AN ACT to define the practice of nursing for advanced practice registered nurses: Nurse practitioners (NP), certified nurse midwives (CNM), certified REGISTERED nurse anesthetists (crna), and clinical nurse specialists (CNS).

Whereas, North Carolina is expected to be the seventh largest state in the nation by 2035 and demand for health care will continue to increase; and

Whereas, North Carolina has provided over 628,000 North Carolinians access to insurance through Medicaid expansion but lacks the health care providers to ensure their access to care; and

Whereas, APRNs are registered nurses with master's or doctorate degrees and advanced education and training; and

Whereas, North Carolina has over 20,000 advanced practice registered nurses (APRNs) who have been educated and licensed to practice to their full scope; and

Whereas, more than three decades of research demonstrates that APRNs improve access to safe, high‑quality, cost‑effective, patient‑centered health care; and

Whereas, the Institute of Medicine (IOM) has called for states to allow APRNs to practice to the full extent of their licensure and education since the 2010 release of the IOM Report on the Future of Nursing; and

Whereas, health care costs in North Carolina are among the highest in the nation; and

Whereas, a recent report by a Ph.D. health care economist at Duke University estimates savings of at least $700 million annually for North Carolina patients, employers, and taxpayers by removing unnecessary and antiquated government regulations; and

Whereas, 36 other states have rolled back these costly and burdensome government regulations on advanced practice registered nurses over the past 31 years with no evidence of negative effects on patient safety, and indeed positive impact on patient care, according to numerous studies; and

Whereas, no state has enacted these reforms and later reversed course to reinstate these government regulations; and

Whereas, the APRN role has existed for over a half century but remains undefined in North Carolina statute; and

Whereas, North Carolina's courts and executive branch have called on the legislature, the body of the people, to remove the ambiguity surrounding APRN practice by clearly defining it in statute; Now, therefore,

The General Assembly of North Carolina enacts:

SECTION 1.  G.S. 90‑171.20 reads as rewritten:

§ 90‑171.20.  Definitions.

As used in this Article, unless the context requires otherwise:

(1)        Advanced assessment. – The taking by an advanced practice registered nurse of the history, physical, and psychological assessment of a patient's signs, symptoms, pathophysiologic status, and psychosocial variations in the determination of differential diagnoses and treatment.

(1a)      Advanced practice registered nurse or APRN. – An individual licensed by the Board as an advanced practice registered nurse within one of the following four roles:

a.         Certified nurse practitioner or CNP.

b.         Certified nurse midwife or CNM.

c.         Clinical nurse specialist or CNS.

d.         Certified registered nurse anesthetist or CRNA.

(1b)      Board means the Board. – The North Carolina Board of Nursing.

(2)        Health care provider means any Health care provider. – Any licensed health care professional and any agent or employee of any health care institution, health care insurer, health care professional school, or a member of any allied health profession. For purposes of this Article, a person enrolled in a program that prepares the person to be a licensed health care professional or an allied health professional shall be deemed a health care provider.

(3)        License means a License. – A permit issued by the Board to practice nursing as an advanced practice registered nurse, as a registered nurse nurse, or as a licensed practical nurse, including a renewal or reinstatement thereof.

(3a)      Licensee means any Licensee. – Any person issued a license by the Board, whether the license is active or inactive, including an inactive license by means of surrender.

(4)        Nursing is a Nursing. – A dynamic discipline which includes the assessing, caring, counseling, teaching, referring and implementing of prescribed treatment in the maintenance of health, prevention and management of illness, injury, disability or the achievement of a dignified death. It is ministering to; assisting; and sustained, vigilant, and continuous care of those acutely or chronically ill; supervising patients during convalescence and rehabilitation; the supportive and restorative care given to maintain the optimum health level of individuals, groups, and communities; the supervision, teaching, and evaluation of those who perform or are preparing to perform these functions; and the administration of nursing programs and nursing services. For purposes of this Article, the administration of required lethal substances or any assistance whatsoever rendered with an execution under Article 19 of Chapter 15 of the General Statutes does not constitute nursing.

(5)        Nursing program means any Nursing program. – Any educational program in North Carolina offering to prepare persons to meet the educational requirements for licensure under this Article.Article as a registered nurse or a licensed practical nurse.

(6)        Person means an Person. – An individual, corporation, partnership, association, unit of government, or other legal entity.

(6a)      Population focus. – With respect to APRN practice, includes one of the following areas of focus:

a.         The family or the individual across the life span.

b.         Adult/gerontology.

c.         Neonatal.

d.         Pediatrics.

e.         Women's health or gender‑related issues.

f.          Psychiatric mental health.

(6b)      Practice of nursing as a certified nurse midwife or CNM. – In addition to the RN scope of practice and APRN role and population foci, also consists of the following four components:

a.         The management, diagnosis, and treatment of primary sexual and reproductive health care, including primary, preconception, gynecologic/reproductive/sexual health, antepartum, intrapartum, neonatal, and post‑pregnancy care.

b.         Ordering, performing, supervising, and interpreting diagnostic studies.

c.         Prescribing pharmacologic and nonpharmacologic therapies.

d.         Consulting with or referring to other health care providers as warranted by the needs of the patient.

(6c)      Practice of nursing as a certified nurse practitioner or CNP. – In addition to the RN scope of practice and APRN role and population foci, also consists of the following six components:

a.         Health promotion, disease prevention, health education, and counseling.

b.         Providing health assessment and screening activities.

c.         Diagnosing, treating, and facilitating patients' management of their acute and chronic illnesses and diseases.

d.         Ordering, performing, supervising, and interpreting diagnostic studies.

e.         Prescribing pharmacologic and nonpharmacologic therapies.

f.          Consulting with or referring to other health care providers as warranted by the needs of the patient.

(6d)     Practice of nursing as a certified registered nurse anesthetist or CRNA. – In addition to the RN scope of practice and within the APRN role and population foci, also consists of the following:

a.         Selecting, ordering, procuring, prescribing, and administering drugs and therapeutic devices to facilitate diagnostic, therapeutic, and surgical procedures.

b.         Ordering, prescribing, performing, supervising, and interpreting diagnostic studies, procedures, and interventions.

c.         Consulting with or referring to other health care providers as warranted by the needs of the patient.

(6e)      Practice of nursing as a clinical nurse specialist or CNS. – In addition to the RN scope of practice and APRN role and population foci, also consists of the following eight components:

a.         The diagnosis and treatment of health and illness states.

b.         Disease management.

c.         Prescribing pharmacologic and nonpharmacologic therapies.

d.         Ordering, performing, supervising, and interpreting diagnostic studies.

e.         Preventing of illness and risk behaviors.

f.          Nursing care for individuals, families, and communities.

g.         Integrating care across the continuum to improve patient outcomes.

h.         Consulting with or referring to other health care providers as warranted by the needs of the patient.

(6f)      Practice of nursing as an advanced practice registered nurse or APRN. – In addition to the RN scope of practice and within the APRN role and population foci, also consists of the following six components:

a.         Conducting an advanced assessment.

b.         Delegating and assigning therapeutic measures to assistive personnel.

c.         Performing other acts that require education and training consistent with professional standards and commensurate with the APRN's education, certification, demonstrated competencies, and experience.

d.         Complying with the requirements of this Article and rendering quality advanced nursing care.

e.         Recognizing limits of knowledge and experience.

f.          Planning for the management of situations beyond the APRN's expertise.

(7)        The practice of nursing by a registered nurse consists Practice of nursing by a registered nurse. – Consists of the following 10 components:

a.         Assessing the patient's physical and mental health, including the patient's reaction to illnesses and treatment regimens.

b.         Recording and reporting the results of the nursing assessment.

c.         Planning, initiating, delivering, and evaluating appropriate nursing acts.

d.         Teaching, assigning, delegating to or supervising other personnel in implementing the treatment regimen.

e.         Collaborating with other health care providers in determining the appropriate health care for a patient but, subject to the provisions of G.S. 90‑18.2, not prescribing a medical treatment regimen or making a medical diagnosis, except under supervision of a licensed physician.patient.

f.          Implementing the treatment and pharmaceutical regimen prescribed or ordered by any person authorized by State law to prescribe or order the regimen.

g.         Providing teaching and counseling about the patient's health.

h.         Reporting and recording the plan for care, nursing care given, and the patient's response to that care.

i.          Supervising, teaching, and evaluating those who perform or are preparing to perform nursing functions and administering nursing programs and nursing services.

j.          Providing for the maintenance of safe and effective nursing care, whether rendered directly or indirectly.

(8)        The practice of nursing by a licensed practical nurse consists of the following seven components:

a.         Participating in the assessment of the patient's physical and mental health, including the patient's reaction to illnesses and treatment regimens.

b.         Recording and reporting the results of the nursing assessment.

c.         Participating in implementing the health care plan developed by the registered nurse and/or prescribed by any person authorized by State law to prescribe such a plan, by performing tasks assigned or delegated by and performed under the supervision or under orders or directions of a registered nurse, physician licensed to practice medicine, dentist, or other person authorized by State law to provide the supervision.

c1.       Assigning or delegating nursing interventions to other qualified personnel under the supervision of the registered nurse.

d.         Participating in the teaching and counseling of patients as assigned by a registered nurse, physician, or other qualified professional licensed to practice in North Carolina.

e.         Reporting and recording the nursing care rendered and the patient's response to that care.

f.          Maintaining safe and effective nursing care, whether rendered directly or indirectly.

SECTION 2.  G.S. 90‑18(c) reads as rewritten:

(c)      The following shall not constitute practicing medicine or surgery as defined in this Article:

…

(7)        The practice of midwifery as defined in G.S. 90‑178.2.

…

(14)      The practice of nursing by a an advanced practice registered nurse engaged in the practice of nursing and the performance of acts otherwise constituting medical practice by a registered nurse when performed in accordance with rules and regulations developed by a joint subcommittee of the North Carolina Medical Board and the Board of Nursing and adopted by both boards.as defined in Article 9A of this Chapter.

….

SECTION 3.(a)  G.S. 90‑18.2 is repealed.

SECTION 3.(b)  G.S. 90‑2(a) reads as rewritten:

(a)      There is established the North Carolina Medical Board to regulate the practice of medicine and surgery for the benefit and protection of the people of North Carolina. The Board shall consist of 13 members:

…

(2)        Five members shall all be appointed by the Governor as follows:

…

d.         One shall be a certified nurse practitioner as defined in G.S. 90‑18.2 as recommended by the Review Panel pursuant to G.S. 90‑3.

….

SECTION 3.(c)  G.S. 90‑18.3(a) reads as rewritten:

(a)      Whenever a statute or State agency rule requires that a medical or physical examination shall be conducted by a physician, the examination may be conducted and the form signed by a certified nurse practitioner or a physician assistant, and a physician need not be present. Nothing in this section shall otherwise change the scope of practice of a certified nurse practitioner or a physician assistant, as defined by G.S. 90‑18.1 and G.S. 90‑18.2, respectively.assistant.

SECTION 3.(d)  G.S. 90‑85.24(a) reads as rewritten:

(a)      The Board of Pharmacy shall be entitled to charge and collect not more than the following fees:

…

(13)      For annual registration as a dispensing nurse practitioner under G.S. 90‑18.2, practitioner, seventy‑five dollars ($75.00);

….

SECTION 3.(e)  G.S. 90‑85.34A reads as rewritten:

§ 90‑85.34A.  Public health pharmacy practice.

…

(c)        This section does not affect the practice of certified nurse practitioners pursuant to G.S. 90‑18.2 or of physician assistants pursuant to G.S. 90‑18.1.

SECTION 4.  G.S. 90‑29(b) reads as rewritten:

(b)      A person shall be deemed to be practicing dentistry in this State who does, undertakes or attempts to do, or claims the ability to do any one or more of the following acts or things which, for the purposes of this Article, constitute the practice of dentistry:

…

(6)        Administers an anesthetic of any kind in the treatment of dental or oral diseases or physical conditions, or in preparation for or incident to any operation within the oral cavity; provided, however, that this subsection shall not apply to a lawfully qualified certified registered nurse anesthetist who administers such anesthetic under the supervision and direction of a licensed dentist or physician, anesthetic, or to a registered dental hygienist qualified to administer local anesthetics.

….

SECTION 5.  G.S. 90‑171.23(b) reads as rewritten:

(b)      Duties, powers. The Board is empowered to:

…

(14)      Appoint and maintain a subcommittee of the Board to work jointly with the subcommittee of the North Carolina Medical Board to develop rules and regulations to govern the performance of medical acts by registered nurses and to determine reasonable fees to accompany an application for approval or renewal of such approval as provided in G.S. 90‑8.2. The fees and rules developed by this subcommittee shall govern the performance of medical acts by registered nurses and shall become effective when they have been adopted by both Boards.Grant prescribing, ordering, dispensing, and furnishing authority to holders of the advanced practice registered nurse license pursuant to G.S. 90‑171.20.

….

SECTION 6.  G.S. 90‑171.27(b) reads as rewritten:

§ 90‑171.27.  Expenses payable from fees collected by Board.

…

(b)        The schedule of fees shall not exceed the following rates:

Application for license as advanced practice registered nurse........................... $100.00

Renewal of license to practice as advanced practice registered nurse (two‑year period)..................................................................................................................... 100.00

Reinstatement of lapsed license to practice as advanced practice registered nurse and renewal fee................................................................................................... 180.00

…

Reasonable charge for duplication services and materials.

A fee for an item listed in this schedule shall not increase from one year to the next by more than twenty percent (20%).

SECTION 7.(a)  Article 9A of Chapter 90 of the General Statutes is amended by adding the following new sections to read:

§ 90‑171.36B.  Advanced practice registered nurse licensure.

(a)        No advanced practice registered nurse shall practice as an advanced practice registered nurse unless the nurse is licensed by the Board under this section.

(b)        An applicant for a license to practice as an APRN shall apply to the Board in a format prescribed by the Board and pay a fee in an amount determined under G.S. 90‑171.27.

(c)        The Board shall adopt rules, not inconsistent with this Article, which identify the criteria which must be met by an applicant in order to be issued a license.

§ 90‑171.36C.  Advanced practice registered nurse licensure; grandfathering exceptions.

(a)        The Board shall issue an APRN license to any person recognized by the Board as an APRN or approved to practice as an APRN in this State on or before the date that this section becomes law.

(b)        An advanced practice registered nurse licensed under this section shall maintain all practice privileges provided to licensed advanced practice registered nurses under this Chapter.

§ 90‑171.36D.  Advanced practice registered nurse licensure renewal; reinstatement.

(a)        An applicant for renewal of an APRN license issued under this Article shall apply for licensure renewal according to the frequency and schedule established by the Board and pay the required fee.

(b)        Failure to renew the APRN license before the expiration date shall result in automatic forfeiture of the right to practice nursing as an APRN in North Carolina until such time as the license has been reinstated.

(c)        An APRN licensee who has allowed his or her license to lapse by failure to renew may apply for reinstatement in a manner prescribed by the Board and pay the required fee.

(d)       The Board shall adopt rules, not inconsistent with this Article, which identify the criteria which must be met by an applicant for APRN license renewal or reinstatement.

SECTION 7.(b)  G.S. 90‑171.37(b) is repealed.

SECTION 8.  G.S. 90‑171.43 reads as rewritten:

§ 90‑171.43.  License required.

(a)        No person shall practice or offer to practice as a an advanced practice registered nurse, registered nurse nurse, or licensed practical nurse, or use the word nurse as a title for herself or himself, or use an abbreviation to indicate that the person is a an advanced practice registered nurse, registered nurse nurse, or licensed practical nurse, unless the person is currently licensed as a an advanced practice registered nurse, registered nurse nurse, or licensed practical nurse as provided by this Article. If the word nurse is part of a longer title, such as nurse's aide, a person who is entitled to use that title shall use the entire title and may not abbreviate the title to nurse. This Article shall not, however, be construed to prohibit or limit the following:

(1)        The performance by any person of any act for which that person holds a license issued pursuant to North Carolina law;law.

(2)        The clinical practice by students enrolled in approved nursing programs, continuing education programs, or refresher courses under the supervision of qualified faculty;faculty.

(3)        The performance of nursing performed by persons who hold a temporary license issued pursuant to G.S. 90‑171.33;G.S. 90‑171.33.

(4)        The delegation to any person, including a member of the patient's family, by a physician licensed to practice medicine in North Carolina, a licensed dentist or registered nurse of those patient‑care services which are routine, repetitive, limited in scope that do not require the professional judgment of a registered nurse or licensed practical nurse;nurse.

(5)        Assistance by any person in the case of emergency.

Any person permitted to practice nursing without a license as provided in subdivision (2) (a)(2) or (3) (a)(3) of this section shall be held to the same standard of care as any licensed nurse.

(a1)      The abbreviations for the APRN designation of a certified nurse midwife, a clinical nurse specialist, a certified registered nurse anesthetist, and a certified nurse practitioner shall be APRN, plus the role title, i.e., CNM, CNS, CRNA, and CNP.

(a2)      It shall be unlawful for any person to use the title APRN or APRN plus their respective role titles, the role title alone, authorized abbreviations, or any other title that would lead a person to believe the individual is an APRN, unless permitted by this act.

….

SECTION 9.  G.S. 90‑171.43A reads as rewritten:

§ 90‑171.43A.  Mandatory employer verification of licensure status.

(a)        Before hiring an advanced practice registered nurse, a registered nurse nurse, or a licensed practical nurse in North Carolina, a health care facility shall verify that the applicant has a current, valid license to practice nursing pursuant to G.S. 90‑171.43.

(b)        For purposes of this section, health care facility means:

(1)        Facilities described in G.S. 131E‑256(b).

(2)        Public health departments, physicians' offices, ambulatory care facilities, and rural health clinics.

SECTION 10.  G.S. 90‑171.44 reads as rewritten:

§ 90‑171.44.  Prohibited acts.

It shall be a violation of this Article, and subject to action under G.S. 90‑171.37, for any person to:

(1)        Sell, fraudulently obtain, or fraudulently furnish any nursing diploma or aid or abet therein.

(2)        Practice nursing under cover of any fraudulently obtained license.

(3)        Practice nursing without a license. This subdivision shall not be construed to prohibit any licensed registered nurse who has successfully completed a program established under G.S. 90‑171.38(b) from conducting medical examinations or performing procedures to collect evidence from the victims of offenses described in that subsection.

(3a)      Refer to himself or herself as an advanced practice registered nurse; or refer to himself or herself as any of the four roles of advanced practice registered nurses, a registered nurse, or a licensed practical nurse; or use the abbreviations APRN, CNM, CNS, CRNA, CNP, RN, and LPN.

(4)        Conduct a nursing program or a refresher course for activation of a license, that is not approved by the Board.

(5)        Employ unlicensed persons to practice nursing.

SECTION 11.(a)  Article 10A of Chapter 90 of the General Statutes is repealed.

SECTION 11.(b)  G.S. 90‑21.11 reads as rewritten:

§ 90‑21.11.  Definitions.

The following definitions apply in this Article:

(1)        Health care provider. – Without limitation, any of the following:

a.         A person who pursuant to the provisions of Chapter 90 of the General Statutes is licensed, or is otherwise registered or certified to engage in the practice of or otherwise performs duties associated with any of the following: medicine, surgery, dentistry, pharmacy, optometry, midwifery, osteopathy, podiatry, chiropractic, radiology, nursing, physiotherapy, pathology, anesthesiology, anesthesia, laboratory analysis, rendering assistance to a physician, dental hygiene, psychiatry, or psychology.

….

SECTION 11.(c)  G.S. 115C‑407.57(b)(2) reads as rewritten:

(2)      If a student participating in an interscholastic athletic activity exhibits signs or symptoms consistent with a concussion, the student shall be removed from the activity at that time and shall not be allowed to return to play or practice that day. The student shall not return to play or practice on a subsequent day until the student is evaluated by and receives written clearance for such participation from one of the following:

…

e.         A certified nurse practitioner, consistent with the limitations of G.S. 90‑18.2.provisions of Article 9A of Chapter 90 of the General Statutes.

SECTION 12.(a)  No later than 30 calendar days after this act becomes law, the Governor shall submit to the Centers for Medicare and Medicaid Services an opt‑out letter requesting an exemption under 42 C.F.R. § 482.52(c) that allows hospitals, ambulatory surgical centers, critical access hospitals, and rural hospitals in this State the maximum flexibility to obtain Medicare reimbursement for anesthesia services in a manner that best serves each facility and the patients and communities the facility serves.

SECTION 12.(b)  This section is effective when it becomes law.

SECTION 13.(a)  The North Carolina Board of Nursing, the North Carolina Medical Board, and the North Carolina State Board of Dental Examiners shall adopt rules to implement the provisions of this act.

SECTION 13.(b)  This section is effective when it becomes law.

SECTION 14.  The Revisor of Statutes shall change all references to nurse practitioners to instead be references to certified nurse practitioners and shall change all references to the abbreviation NP to instead be references to the abbreviation CNP, wherever those terms appear in the following statutes: G.S. 15‑190, 20‑37.6(c1), 55B‑14(c), 58‑3‑169, 58‑50‑30, 58‑51‑45, 90‑1.1, 90‑3, 90‑21.17, 90‑21.81, 90‑171.21, 90‑724, 108A‑77.1, 115C‑323, 115C‑375.2A, 122C‑263.1, 122C‑465, 130A‑115, 130A‑440.1, and 131D‑4.8.

SECTION 15.  Except as otherwise provided, this act is effective 90 days after it becomes law.