Dear Board of Nursing and Medicine

I have over 8 years of experience as a certified nurse practitioner. I have only been in my current job for 5 months, however, in the last 5 years I have worked at two other offices. When the law is implemented will a clause be placed in the requirements that multiple collaborative physicians can attest to the years worked under them to total the 5 years requirement?

How is attestation done?  Is MD required to "Attest" to the 5 years of experience of the NP?  If so, would rather just have the NP attest to the experience.  What are the "attestation" barriers the NP could face at the 5 year mark, if any?

Dear Boards of Medicine and Nursing,

I respectfully request that the Joint Boards consider that the General Assembly overwhelmingly approved the fundamental concepts of nurse practitioner (NP) transition to practice with the five-year post-licensure compromise. Any obstacles that limit these fundamental concepts should be minimized as they would not be consistent with the spirit of the legislation and bipartisan will of General Assembly.

The NP community acknowledges that the five-year post-licensure transition to practice requirement resulted from political compromise and is not based on any evidence. NPs are prepared at the graduate level and are deemed competent clinicians upon graduation and passage of national certification. Policy development without supporting evidence, results in variability as evidenced by the significant inconsistency between the transition to practice time requirements from state to state. Virginia is the outlier among all other states in the nation and as such will be in the spotlight as regulations are being promulgated.

It is requested that the Joint Boards bear in mind that NPs have unique skills and expertise that are complimentary to the physician and other team members on the patient care team. It is therefore not reasonable to expect that there would be an absolute overlay of the physician's area of practice and the NPs licensure and certification. We work in many settings with MDs, DOs and DPMs to illustrate this point. A broad interpretation of basic internal medicine education of any specialist physician must be considered sufficient to meet the requirement for practice in a patient population and practice area that the NP is licensed and certified.    

The board must consider the portability of professionals and that an NPs may have had several collaborating physicians during the required 5-year transition period. Therefore, the attestation needs to accommodate the names of several physicians and/or other evidence from entities such as practice administrators, employers, or credentialing documents, etc. based on individual circumstances. It is suggested that the boards consider formatting the attestation in a check list format for physicians to check the requirements specified in the law.  

For example:

• physician has served with the NP pursuant on a practice agreement
• physician routinely practiced with a patient population and practice area for which the NP is certified and licensed
• physician practiced with NP from ____________date to ___________date

It is also suggested that the boards consider that NPs in any state or working for U.S. Armed Forces, U.S. Veterans Administration or the Public Health Service be able to submit evidence of the five-year equivalent post-licensure practice requirement with signature from an employer, a physician, a practice administrator, etc. when coming from another state to practice in Virginia. This will prevent bottlenecks to building the necessary provider workforce and equitable distribution in primary care delivery for underserved and vulnerable populations.

Thank you for considering my comments for promulgation of regulations for NPs in Virginia.

Respectfully,

Cynthia M. Fagan, MSN, RN, FNP-BC

Dear Sir/Madam,

I am in full support of this legislation because I am a family nurse practitioner and I know the experiece, knowledge, and services they provide will make a huge difference in medical care.  Further, for the past 23 years, my "doctors" have all been nurse practitioners.  You would have to experiece the difference to know the difference.

Sincerely,

Jane Miller, MS, FNP-BC, RD, CDE

The five-year post-licensure “transition to practice” requirement is the result of political compromise with no evidence to support the regulatory mandate.  This has created variability from state to state, making Virginia an outlier with the most arduous practice environment in the nation for NPs.

The Virginia Association of Clinical Nurse Specialists (VaCNS) supports full practice authority for nurse practitioners (NP) in order to fulfill the need for increased primary care services across Virginia, in both rural and metropolitan areas, so all Virginias have access to healthcare. Advanced Practice Registered Nurses, inclusive of NPs, provide excellent nursing care through demonstrated patient outcomes. VaCNS notes that the evidence neither supports: 1) the stipulation that NPs work for 10,000 hours (5 years) before competence is demonstrated; or 2) physician supervision/oversight provides protection for the public. Professional nurses remain the most trusted profession in the US for a reason!

As a recently retired military NP, I'm concerned how we provide "attestation of practice" since moving all over the world for the last 18 years of my practice. Therefore I request that an NP in any state or working for U.S. Armed Forces, U.S. Veterans Administration or the Public Health Service submit evidence that the five-year full-time equivalent collaborative requirements have been met with signature from employer, physician, practice administrator, etc. Thank you for your attention to this specifically.

Sandra Hearn DNP-c, CPNP

Chief Nursing Officer, ESRH

I suggest that the NP attestation NOT require any signatures except that of the NP.  If an NP is untruthful about her/his hours, they would risk losing their license -- incentive enough, no?  The attestation should be subject to audit, just as it is when I renew my NP certification (via the American Academy of Nurse Practitioners).  

As a nurse educator and administrator with experience working in multiple states with NP programs, I fully endorse the VA legislation to move independent practice for NPs forward.  It is regretful that political motives added yet another restriction of delaying such independence. NPs move to other states in order to practice independently. There should be no roadblocks in assuring the citizens of Virginia have quick and proper access to Advance Practice Nurses in a timely, effective manner.  Any barriers to prevent such access should be removed. I commend the legislative movement and fully support the direction. 

Kathleen B. LaSala, PhD, RN, former PNP,

Dean and Professor, Eleanor Wade Custer School of Nursing, Shenandoah University,

There is no evidence to support the need for the five-year post-licensure “transition to practice” requirement.  However, this has been agreed upon in order to have a political compromise that would allow at least some NPs to practice independently.  This mandate is unnecessarily and sets the stage for Virginia havng the most arduous practice environment in the nation for NPs.  This requirement continues to create an access barrier to care for the states underserved populations.

In a safety net clinic setting, nurse practitioners present an excellent means of delivering economically affordable quality care to the uninsured and underinsured patients we serve. We commend this bill for expanding the ability of nurse practitioners to function in this setting. We believe attestation by the nurse practitioner is appropriate, and would favor recognizing experience gained in other states.

I graduated from UVA in 2003 and moved to California and practiced in San Diego for the first 4 years, then moved back to Virginia and practiced 2 more years with a residential program that folded because of economic crash and lack of insurance reimbursement on this coast.  Then transitioned to a Free Clinic which was first to provide psych services full-time with grant from VHCF.  My concern.....locating the physicians who could attest to my competence.  Please make this realistic for those of us who have been out there a long time and have moved.  It would be realistic to get the companies human resources departments attestation to my employment and time with them; but much harder to get the actual physician at the time.  Please take this into consideration.  Also, we already pay many licensure fees.  I'm not sure why a fee would be necessary for this transition to practice.  Thank you and looking forward to the transition!

NPs are prepared at the graduate level and are deemed competent clinicians upon graduation and passage of national certification. There is no evidence to support the need for additional post-licensure supervision of NPs’ practice beyond current educational and certification standards.

The education provided to Nurse Practitioner students in Virginia's Schools of Nursing is outstanding and we routinely graduate competent individuals willing and able to provide healthcare in communities where there are precious few healthcare providers. Restricting independent practice restricts access to care for Virginia's citizens who all deserve better.

Julie Sanford, DNS, RN, FAAN

Director, School of Nursing

James Madison University

Harrisonburg, Virginia

Dear Joint Boards of Medicine and Nursing and Advisory Commitee,

We've established that APRNs provide safe quality healthcare and I'm thankful that Virginia has recognized this by passing legislation that makes us one step closer to FPA. When formulating regulations to implement HB793, I propose that we adopt a similar regulation to the proposed one below:

The board shall grant recognition as an advanced practice registered nurse without a practice agreement to a nurse who has: (1) A current, unencumbered license as a registered nurse in this State; (2) An unencumbered license as a registered nurse in all other states in which the nurse has a current and active license; (3) An unencumbered recognition as an advanced practice registered nurse with an equivalent of at least 5 years of physician lead collaboration in a similar field as the nurse practitioner is certified. Similar field is defined as graduate level generalized training/residency or clinical practice in the area of certification as the APRN. Five years of experience is defined as a total length of certification, by an acceptable certifying body, as an APRN to include practice among any state in the U.S. and it's territories. (4) Acquired clinical experience of sufficient depth and breadth to reflect the intended license as evidenced by meeting all of the criteria above and presents a letter of attestation from one collaborating physician during the 5 year reporting period. A letter of attestation is defined as a standardized form that outlines the APRNs length of practice, current certification, current unencumbered liscensure as an APRN and RN in the state of practice. (5) Paid the appropriate fees to issue a new liscense to reflect a registered nurse practitioner or other APRN to practice without a practice agreeement. Appropriate fees is defined as a one time free initial liscense and then a 2 year renewal to match the current renewal liscensure fees.

Thank you for your time to read this and your consideration.

Jessica Ruff, FNP-C

I am disappointed in the outcome of this bill.  I feel that VCNP has settled for an 'anything is better than nothing' approach and has caved to the political pressure of the organization not in support of autonomous practice for NP's.  I would hope that VCNP would continue to pressure for ammendments that lift restrictions.  I do agree that there should be a waiting period for new graduate NP's especially for those with limited nursing experience.  Five years, I feel is excessive.  I feel that Virginia continues to remain an outlier with this bill.  

Dear Boards of Medicine and Nursing:

I respectfully ask that you would approach the regulatory process with the same bipartisan spirit that overwhelmingly approved the proposed legislature.  Nurse practitioners (NPs )have unique skills and expertise that are a compliment to the health care team caring for all of the citizens of Virginia.  The result of the five-year transition to practice requirement is the result of compromise in the political arena and there is no evidence to support the regulations proposed.  Moreover, this distinguishes Virginia with the most arduous practice environment in the nation for NPs. I have practiced in this state for over twenty years and I am devoted to the patients that I have had the honor to serve. NPs are prepared at the graduate level and are deemed competent clinicians upon graduation and subsequent passage of the national board certification.   I ask you to make the process fair, succint and timely.  I would like for you all to consider a simple attestation form that may include the patient care physician (MD, DO or DPM) that has practiced with the NP for the equivalent of at least five years.  Moreover, please consider allowing office adminstrators, health system administrators, credentialing documentation to also be used as evidence.  Please also consider that any NP in any state working for the United States (U.S.) Armed Forces, U.S.  Veterans Administration or the Public Health Services submit evidence that the five year full time equivalent collaborate requirements have been met with signature from the employer, physician, or practice administrator.  Sincerely, Barbara G. Schimming FNP-BC 

I've been employed in adult/geriatric care for over 18 years as an APN. The patient care teams I've collaborated with have been respectful of nursing philosophy and the professionlism of care experienced APN's bring to the health care industry. Medical schools have been embracing medical student collaboration and respect of APN colleagues, for over a decade. It is timely for the full scope of medical community and nursing profession grant independent practice to experienced Advance Nurse Practitioners.

It is requested that the Joint Boards recognize ANPs have unique skills and expertise, complimentary to the physician and other diverse members on the patient care team. Therefore it is reasonable to expect there will be overlap of the various consulting physician's area of practice and the ANP's. Our expertise and clinical experience is validated by our licensure and certification. The Veteran's administration as well as 23 other states recognize practice and licensure laws providing for all nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments—including prescribing medications and controlled substances—under the exclusive licensure authority of the state board of nursing.

We work in many settings with MDs, DOs and DPMs to illustrate this point. A broad interpretation of basic internal medicine education of any specialist physician is considered sufficient to meet the requirement for practice in the medical profession for a patient population. The practice area of the ANP licensed and certified by our national board meets requirements to practice within our profession. It is timely for the Commonwealth of Virginia to retire barriers to patient choices and practice restrictions. I applaud promulgation of emergency regulations to implement HB 793. This legistative is timely and well needed.

I am a family nurse practitioner student at James Madison University, and I will be graduating in May 2019, thus these regulations will impact my future practice.  The FNP program at JMU is rigorous with both classroom and clinical applications.  We are instructed on using the most current guidelines and evidence when treating our patients, as well as seeking answers from specialist consultants when faced with a complicated cases.  This ensures safe, high quality care for our patients.  For these reasons, nurse practitioners are prepared for independent practice because of this commitment to changing practice based on evidence based research and using the most current resources to guide care.  I support this bill, and I do feel that my education will prepare me for independent practice.  

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Esteemed colleagues thank you for your consideration of public comment regarding the promulgation of HB 793.

Promulgating HB 793 will provide an excellent opportunity for Virginia to transition nearly 50% of licensed nurse practitioners to independent practice. This will increase access to care in our Commonwealth and is a demonstration of compromise between nursing and medicine.

The five year full time equivalence period is the longest in the nation; however, there are many examples of transitional licensing approaches in other states. Connecticut,  Delaware, Maine, Maryland, Minnesota, South Dakota and Vermont all use a transition to independent practice model, however, none of these states require an attestation. Nebraska requires a transition to practice agreement for the first 2,000 hour of nurse practitioner practice; there is no mention of an attestation. New York allows transition after 3,600 hours at which time nurse practitioners attest that a collaborating physician is available to them. Virginia’s attestation requirement seems arduous; it would be a travesty to create an unbearable work burden for the Joint Boards.

The current nurse practitioner workforce in Virginia operates under collaborative agreements that are regulated by the Joint Boards. These collaborative agreements should be honored when considering the five year work equivalence. The boards should not have to redefine who is an acceptable collaborator simply because new legislation was passed. This creates unnecessary work and would unduly penalize our current workforce; thereby, defeating expansion of access to care.  Therefore, it seems reasonable that the Joint Boards can create a simple attestation form that acknowledges the prior collaborative agreements between nurse practitioner and physician. The physician would simply verify that the nurse practitioner collaborated under the pre-existing contract for at least five years full time work equivalence.

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Please remove the website with my information about my military dependent license as an RN and ANP from the State of Virginia. The license was not renewed and expired back 18 years ago. I was a USMC dependent wife stationed in Northern Virginia and have not lived or been in the State of Virginia since 2000. I am an original and permanent resident of the State of Minnesota and have never been a resident of Virginia. I was only there as a military dependent on USMC military orders of my former husband and in military sponsored housing. The Adult Nurse Practitioners are not licensed anywhere in the United States as our programs were eliminated from the Schools of Nursing in 2015. Therefore this information is not accurate. If you have any doubts - contact Nicholas Liensch JD with the Minnesota State Attorney General's Office. Ann McTernan 

I appreciate the opportunity to make public comment to the Boards of Medicine and Nursing promulgation of regulations to implement HB793.  I encourage the Boards to hold true to the intent of the General Assembly and the Governor in their passage of this legislation.  Because of this legislation Nurse Practitioners are enabled to practice more independently and thus the citizens of the Commonwealth have increased access to health care providers.  As a Licensed Clinical Social Worker with 43 years of clinical practice in a more rural area of Virginia I am familiar with the difficulty my clients experienced gaining access to Psychiatrist for their medication needs.  Nurse Practitioners are more widely distributed across the Commonwealth and have prescribing authority.  This legislation is intended to extend the delivery of health care services and it is my hope that the Boards do not promulgate regulations that make any narrow interpretation of the legislation that in any manner inhibits this extension of service delivery.

Thank you for the opportunity to provide public comment. I have been a nurse practitioner (NP) for 13 years practicing in family Practice setting in Virginia Beach county/city. Completion of graduate education and national board certification deem that I am a competent clinician. Please keep this in mind as rules are being promulgated.

Thank you for the opportunity to provide public comment. I have been a nurse practitioner (NP) for 13 years practicing on the Eastern Shore of Virginia.  We are an underserved, low socioecomonic community. As physician retirements  increase, the use of locum tenens has become the norm.  This practice limits the ability for NPs in this area to identify an active physician with whom they have practiced for 5 years.  An employer or health system  however, could verify practice length and status. I would ask that you make this process flexible to accomodate those of us who serve in underserved communities where physician turnover is high and the use of locum tenems is the norm.

  Thank you for allowing me to comment on the above Bill and its implementation period.I have been a Nurse Practitioner in the Fairfax County section of Northern Virginia for almost 25 years.I fully agree with a five-year period of experience in collaboration with a physician colleague. The mentorship which I obtained from my physician colleagues was invaluable.  I agree with others who have recommended that the process of documenting and attesting to the five years of experience not be overly difficult, especially for our colleagues who have traveled from other states or who have worked with the government and with the military  during that five-year timeperiod. I disagree with the use of practice administrators, corporate or hospital administrators or other non-medical people giving any type of input which could affect our attestation period.  Again, thank you for considering my comments.

Dear Boards of Nursing and Medicine,

Thank you for the opportunity to provide public professional advisement on the promulgation of HB 793. I have been a board certified adult nurse practitioner for 25 years, practicing in various primary care facilities,  have taught at the graduate level for 23 years and have recently returned for a post-doctoral certification as a psychiatric mental health NP. I will complete my program of study in May of 2019. I am not starting over, I am adding to my current credentials. The catalyst is to provide integrative holistic care to my primary care patients and to prepare my NP/DNP students to do the same. I am blessed to have been "raised and mentored" by both nurse and physician educators and I want to pay that forward. 

I respectfully request the joint boards to consider the near unanimous support of this bill by the General Assembly as decisions on regulations are made to promote the health of Virginians, some of which are our most vulnerable and underserved citizens. The testimony of our competency is far greater than a signature by a physician colleague.  Neither should it change the collegial relationship between two professional groups who are working for the same cause, best patient outcomes.  The evidence of education, certification, licensure, annual continuing education credits, employment records/agreements, involvement in local, state and national organizations and most certainly evidence of patient outcomes are but a few of the cumulative attestations of our competency, professionalism and commitment to being  providers of Primum non nocere "do no harm".    I advocate for diverse attestations that will qualify and quantify the competency of the nurse practitioner.   Specific to additional certifications and endorsements, I ask the board to acknowledge and waive any additional 5 year period requirement for second certifications. We need our experienced NPs to return for additional credentialing in order to provide augmented care to population health, especially in the area of mental and behavioral health. I believe our physician colleagues who acquire additional "training" have no "wait period" in executing a new skill or procedure and their licensure and certification suffice. 

I appreciate your task at hand and I look forward to the outcomes that will bring us closer to the professional parity that we deserve.

With much gratitude,

Dr. Rosie Taylor-Lewis, DNP, ANP-BC, GNP

Thank you for the opportunity to comment. Reducing barriers to practice for Nurse Practitioners to practice is one way Virginia can increase accessibility to health care for Virginians. The requirement of five years full time practice to reach the goal of practice without a practice agreement with a patient care physician is already significantly out of line with what most states require and increases barriers to practice and care I Virginia.

  I would recommend that the process be a simple and straightforward as possible. I have worked seven years in primary care, then seven years in public health. During my time at public health I have had three medical directors. It would be difficult track down former physician team leaders. It would be uncomfortable to ask the person who worked the most consistently with me to sign a form, because I worked with him more than 7 years ago. While my physician team leaders will probably be willing to sign, the one I work with now, I have worked with less than two years. Should she sign and take my word? Wouldn’t it be better cutting out the middle man?

 Consider the individual physician team leaders. What if they personally disagree with nurse practitioners being granted the authority to practice to the full extent of their training? A Virginia Nurse practitioner should not have to stalk former physician team leaders or be at the mercy of a current physician team leader for permission to work to the full extent of her training and certification.

To prevent increased tensions and waste of time, I recommend that nurse practitioners be allowed to attest to their own work history. Nurses are consistently voted the most trusted profession and are no more likely to tell an untruth than a physician.

Thank you.

Rhonda Arthur DNP, CNM, 
WHNP-BC, FNP-BC

Thank you for the opportunity to provide public comment. I have been a nurse practitioner (NP) for 18 years practicing in acute, outpatient, geriatric and Integrative Medicine settings in the greater Richmond area. Completion of graduate education and national board certification deem that I am a competent clinician. Please keep this in mind as rules are being promulgated. I am board certified as an Adult Acute Care NP, but after working in an acute setting, mostly Cardiac Surgery at 2 hospitals in Ricmond for 8 years, I transitioned to outpatient in Gastroenterology, then Endocrinology. In 2010, I began an 2-year fellowship in Integrative Medicine at the University of Arizona. After completeion of that, I opened my own practice in Integrative Medicine, mostly managing chronic disease. I request that the requirement for "Routine practice in a practice area included within the category for which the NP was certified and licensed" be examined. As, I have 8 years of practice in the field in which I was board certified, that is not the area I'm practicing now. I am fully trained via a 2-year fellowship, as well as many other training programs and CME conferences, I would not want this bill to prohibit my ability to practice practice without a practice agreement with a patient care team physician. I would like consideration for NPs such as myself who have worked in other practice settings in which they are fully competent to do so. The regulations should not be written in a restrictive manner. 

Additionally, NPs already pay fees associated with RN, NP, and prescribing licenses. Any additional fees associated with submission of attestation and issuance of autonomous designation should not create a financial barrier for qualified NPs to practice. There is also no need for additional requirements on the attestation beyond what is listed in HB 793. It should be used to doucment clinical experience under a sworn statement and meets the requirments of the law. Both the NP and the patient care team physician should be appropriately disciplined for falsifying docments of attestation or other docments presented to the Board. 

Sincerely, 

Kristin Andrs, NP

Even in reviewing this small comment section, one can see the various challenges that NPs may face with the attestation process. I look forward to completing my Doctor of Advanced Nursing Practice in 2020. Currently, I am a resident of northern Virginia, but I hope to move to a more rural area in the future to bring primary care to underserved populations. I sincerely hope the attestation process is made simple, allowing the heart of the bill the shine. If we make the process of submitting for independent licensure overly complex, then we are missing the point of what this legislation is trying to achieve. I, respectively, urge the board to honor the heart of the law by developing a common-sense attestation policy.

Dear colleagues on the Boards of Nursing and Medicine,

Thank you for the opportunity to comment on Bill 793.  It is gratifying to see that Virginia is finally recognizing that the evidence shows nurse practitioners are educated and highly qualified to provide healthcare to the citizens of Virginia. I would request that you make attestation for the independent practice a simple process that can be completed by the NP.  As many of the comments note requiring physician attestation may be a burden for many NPs and violates the spirit of the bill for access to healthcare for many Virginians. This is our opportunity to show the collegueality between all members of the healthcare team.

Sincerely,

Sharon Zook, DNP, FNP-BC, Professor JMU

5 yrs experience in practice is reasonable.   We all need experience to be our best!  The attestation to meet this requirement should be allowed to come from any physician in any specialty, as all are physicians, specialties should not be excluded.  I don't feel we should have to pay to be noted as being "FPA", our licensure fees should cover this.

I have worked as a NP for 13 years.  The last 4 of those years I owned my own house calls practice.  Unfortunately, I closed that practice in December due to excessive costs of running the business in relation to Medicare reimbursements. A major cost for me was paying a monthly fee for a collaborating physician.  I am very happy that we are in the process of reducing this barrier to practice, but as many know we still have a ways to go.  

I ask the boards to consider the inconvenience and expense (time and/or money) in chasing down former physician employers to sign a permission slip to allow experienced NPs to practice without a collaborative agreement. And to that, what are the requirements for the physician? Is it possible a physician would chose to not sign, not because the NP is incompetent, but that they don't want the liability of "vouching" for the NP. What exactly would the board ask the physician to attest to?  Is it a simple yes/no and signature?  What, if any, are the implications of the signing physician in the event the NP does violate standards of the profession?  One would not think this would be fair or reasonable.  However, the concern of some physicians is that it would imply liability for the NP just as many fear collaborating with NPs for the same reason (even though the law states otherwise). 

As another NP stated in comments earlier, the NP is the only person who should have to attest to their 5 years of experience.  If the board has reason to believe (or a complaint is filed) that a NP has falsified that attestation then a formal review/investigation would be appropriate and a better use of time and money for the joint boards. 

I thank you for the opportunity to comment on this issue. Please consider keeping this process as basic and paperless as possible.  

Jennifer Fellman DNP, FNP-C

The legislation passed that allows nurse practitioners to engage in independent practice is long overdue.  However, the five year full time equivalence period is too long.  I understand the reasoning behind this requirement, but the proposed time frame is excessive, the longest in the nation, and negatively impacts efforts to increase access to health providers in underserved areas of the Commonwealth.  Schools of Nursing that educate nurse practitioners meet strict academic and clinical standards to assure that graduates are able to practice competently and safely within this advanced practice role.  Graduates of medical education programs complete residencies and fellowships over several years before launching into independent sub-specialty practice, and yet technically, in most states (but not all) medical school graduates are required to complete only a one-year internship before engaging in independent practice.  Why should this be different for nurse practitioners who likely have had 2 or more years of practice in the RN role before earning certification as a NP, whereas medical graduates have had no prior experience in the provider role. The Boards must take care not to get caught implementing a double standard.

Dear Board of Nursing and Board of Medicine: The attestation process should be broad and allow for other avenues in addition to physician declaration. There are many physicians who will not do this and their reasons will be plentiful including a presumed liability and feeling as if they are "releasing" an NP therefore implying that their "certification" on the attestation may imply a possible future liability. Consider that on each bi-annual license renewal, NPs, RNs, etc., already "attest" that they are meeting the continuing education requirements and there is no process for submitting documentation unless audited. A similar process could be done for attestation. Additionally, you could consider other records such as employment records from HR, etc. There are many NPs who have held multiple positions, changed jobs, have more than one job, etc., that will make gathering the "physician signature" a challenge that is against the current of this new law. The "equivanlent of 5 years full time practice" is HUGE, and when an NP finally meets that requirement, it is very likely that they would be able to support their own attestation by other means. The process of only having sworn statements by physicians is burdensome, and worrysome for both NPs and our colleague physicians. Thank you for the opportunity to express our concerns. 

Nurse practitioners are highly educated and committed nurses who work tirelessly to help those in need. Nurse practitioners constantly work to improve the health and wealthfare of their patients and those in the community. They provide excellent care and provide needed services and medical care to those who request care.  Demanding >10,000 hours of supervised oversight is extravagant. Nurse Practitioners work within a framework of a medical team at all times collaborating with team members as needed. A more realistic requirement would be less than 1 year of collaborative practice.  Many nurse practitioners work in practices that they are already working alone or with one MD, should the collaborative physician become ill or incapacitated the patients in that practice would be without medical care.  Studies have shown that Nurse Practitioners provide equal or better care to their patients with chronic illnesses than their physician counterparts. Most nurse practitioners presently work within a medical team  but those who  choose to go out on their own should not face barriers to practice within their scope of practice.  With the expansion of Medicaid more nurse practioner swill be needed to provide care to those in need.

May 2, 2018

To the members of the Committee of the Joint Boards of Nursing and Medicine and it’s Advisory Committee,

I am a nurse practitioner with 13 years experience. I am pleased with the passage of HB793 and the potential for release from the requirement of a collaboration agreement. I own my own practice in southern, central Virginia and in order to maintain a collaborative agreement, my physician collaborator and that of my colleague, expect to be paid for this service. This takes money away from the practice and the services we can offer. I am requesting an expedited process for the promulgation of these regulations so that we can obtain attestation and these funds can be retained in the practice. 

I ask that the fee for attestation be modest and the consideration of adding the letter “A” to the license number to designate those nurse practitioners who have completed attestation. The time frame to complete attestation should be limited to no more than 30 days from the date of the request to avoid delays in the process. The form should be simple, requiring only a check box and signature. The use of electronic signature such as with DocuSign should be considered in addtition to paper forms.

I would add that the skill set of a nurse practitioner has components that are common to any practice site such as taking a history, completing a physical exam and making a treatment plan that reflects current evidence-based guidelines. Therefore, a nurse practitioner with 5 years of experience could easily translate those skills to any setting and should be allowed to proceed with attestation even with a variety of practice sites or specialties during that five year period. Some states do not require that nurse practitioners have experience beyond certification to practice without a practice agreement and those that do, require much less time than Virginia has legislated.

In order to fill the need for health care providers in Virginia, we should readily accept the experience of nurse practitioners outside of the commonwealth for attestation. Some of our colleagues in Northern VA left the state to practice in nearby states and DC to be able to practice to the full scope of their education and training. We would hope to attract them back to Virginia with this new law to improve access to care.

Thank you for your consideration of these comments.

With regards,

Phyllis C Everett, NP-C

Owner, Sapient Health Services, PLLC dba Huddleston Health and Wellness

Thank you for the opportunity to provide public comment regarding HB 793. I have been a NP for 35 years and practice in Virginia. I, as well as my NP peers, have completed Post Graduate Nursing Education & have National board certification.  Please keep in mind that the rules you make will impact quality health care to all Virginians.

•   The five year equivalent experience requirement creates additional barriers to health care across our state.  This is especially true in our rural areas. 
• NPs already pay fees for RN, NP, & Prescriptive Authority licenses.  Any additional fees for attestation should not create a financial barrier for qualified NPs to practice in Virginia.
• There is no demonstrated need for additional requirements on the attestation beyond what is listed in HB 793
• Thank you again, Lydia D. Shelton, WHNP/FNP

Thank you for the opportunity to provide public comment. I have been a nurse practitioner (NP) for one and a half years  practicing in primary care _ setting in Virginia Beach county/city. Completion of graduate education and national board certification deem that I am a competent clinician. Please keep this in mind as rules are being promulgated.”

Dear Members of the Committee of the Joint Boards of Nursing and Medicine,

The American Association of Nurse Practitioners (AANP) appreciates the opportunity to respond to the request by the Boards of Medicine and Nursing for public comment on the promulgation of regulations to implement HB793 (Chapter 776 of 2018 General Assembly). In drafting regulations, AANP would encourage the boards to be as flexible as the new law allows and to avoid adding new requirements or restrictions that are in excess of those required under the previous career-long nurse-physician contracted agreements. AANP looks forward to providing added comment when a copy of proposed rule is available for public comment.

Sincerely,

Tay Kopanos

Vice President, State Government Affairs

American Association of Nurse Practitioners

Thank you for the opportunity to submit public comments. Please note that I have 8 years of experience providing very competent care to thousands of patients in inpatient and outpatient psychiatry. I currently pay $400 per month to my collaborating physician, $4800.00 per year. This inherently limits the degree of sliding-scale fees I can charge to my indigent clients, of whom there are many. In addition, it limits my ability to take VA DMAS (Medicaid) patients. 

I respectfully request that the Board keep these factors in mind when promulgating rules for HB793 implementation:

• Keep the process as paperless and inexpensive as possible, something that could be completed in a matter of minutes on your existing website;
• Use the most liberal or open standard you can in regards to what constitutes evidence of 5 years of practice;
• Make it clear in any forms you create for physician attestation that there is NO liability ascribed to the signing/attesting physician;
• Impose no extra limitations, rules or other barriers in the regulations that would slow or impede NPs from qualifying; and
• Finally, please always remember that there is no evidence whatsoever that NPs are any less competent in our care nor are we any more likely to cause patient harm than licensed physicians.

Physicians in all states have always been opposed to open access to NPs, strictly out of risks to their financial monopolies over caring for patients. 

Therefore, it is in the rational self-interest of the Virginia Boards of Medicine and Nursing to make rules for HB793 as open and easy as possible for qualified NPs to comply with as quickly as possible with the least amount of expense or burdensome efforts.

Thank you and feel free to contact me if you request more information.

I appreciate the opportunity to comment on this bill and legislation. It may be helpful for lawmakers to realize that many NPs become NPs after having already worked in the medical field as RNs for years. It is not that we know all there is to know about medicine because obviously we can't. However, we are educated enough to know what we know and are confident/competent in diagnosing/treating and what needs to be referred on to a physician or specialist. In my case, for instance, I was a practicing full-time RN for more than 30 years before attending graduate education to become a NP. Therefore, a novice to the medical field, I was not. Neither were many of my classmates and no doubt many of my current fellow NPs today. Therefore, a lengthy time period of NP practice may not always be needed. Therefore, I ask that no unnecessarily burdensome restrictions be placed upon the future of NP practice. Finally, if we are successful in completion of a graduate level NP program (especially in VA) and pass our NP board exam, I believe our competency should not be unduly challenged. Thank you.   

Thank you for the opportunity to provide public comment.  I have been a nurse practitioner (NP) student who will be graduating soon.

I am writing to ask that you minimize the regulatory burden associated with the attestation of practice in to order to avoid what could become a bottleneck compromising access to care.

NPs already pay fees associated with RN, NP, and prescribing licenses.  Any additional fees associated with submission of attestation and issuance of autonomous designation have the potential to create a financial barrier for qualified NPs to practice.

Acceptance of “other evidence” demonstrating that the applicant has met the requirements must be broadly interpreted.  We ask that the Joint boards issue a guidance document listing examples of supporting evidence that they would take into consideration.  For example, administrative and credentialing documents should be accepted as evidence that an applicant has met the necessary requirements.

The Boards should credit applicants by endorsement for all of their time employed and licensed in other states towards calculating their clinical experience requirement for practicing without a practice agreement.

There is no demonstrated need for additional requirements on the attestation in order to protect the public beyond what is listed in HB 793.  The attestation should be used to document clinical experience under a sworn statement that this information is accurate and meets the requirements of the law.

Most, if not all, states requiring attestation of transitional clinical hours are not overly prescriptive in what they require in their regulations or on their attestation forms.  Therefore, in Virginia it should not be necessary to further define what is meant by “the patient care team physician routinely practiced with a patient population and in a practice area included within the category for which the nurse practitioner was certified and licensed.”

Thank you for consideration of my comments and for supporting expanded access to care.

I work in extreme Southwestern Virginia. We are desperately in need of ALL health care providers. HB-793 will help in giving our Nurse Practitioner managed free clinic continued sustainability. As we treat over 10000 patients, it is essential the joint board develop a transition process which most efficiently opens the doors to nurse practitioners to work independently.  As has been started, attestation of clinical hours shokld have inclusions to ensure that hours can be verified in the cases of physician  death, retirement or inability to obtain signtaure. HB 793 while perfect will make an extreme impact in the Commonwealas a multi disciplinary, collaborative approach to patient care is vital to solving the dilemma of healthcare shortage and access to care.

Thank you for the comment period. Please reconsider the five year requirement [at least five years of full-time clinical experience]; it should be less than five years. Many APNs/Nurse Practitioners have considerably more years as registered nurses in practice as they enter graduate school and then exit school and successfully achieve certification. As a Professor in a graduate program preparing nurse practitioners I am well aware of their dedication to being the best practitioners, utilization of their prior skills as expert registered nurses, and expansion of their clinical reasoning and judgment abilities during their journey to certification. A five-year period will limit their ability to care for increasing numbers of individuals needing medical care and may stifle their innovation in developing new models of care delivery. Please consider solutions to aiding Virginia residents in seeking qualified professional care - one means is to facilitate the practice of experienced nurse practitioners.

Thank you

Jennifer Matthews, PhD, RN, CNS, FAAN

Professor, Shenandoah University

Thank you for the opportunity to provide public comments on this this extremely important issue of regulating full practice authority for NPs. Many NPs have already been nurses for quite some time. The average NP has already been a nurse for 10 years prior to their NP. It would seem counter intuitive as we strive toward better and expanded access to care to heavily regulate the process of attestation. This gap is especially evident in rural areas. This should be a cumulative 5 years counted toward the attestation with the possibility of having the oversight of multiple physicians during that time. This regulation process should be simple without unreasonable fees attached as NPs already have two licenses to maintain in addition to their DEA license. This process should not be financially burdensome on the NP as they already pay fees for theses aforementioned items. I feel very well prepared to manage complex patients in my current curriculum and have a healthy discretion of when to refer my patients to other specialists as other providers also do. There should not be a limit on the number of NPs whom can attest at the 5 year mark. If they have the experience they should be able to attest. Any NP who has completed a graduate level program should be able to practice to the the full extent of their education without unduly restrictions. As we are always nurses at heart we remain the number one advocate for our patients and supporting their access to care. Make the process of attestation a simplistic one for this reason. 

Thank you for the opportunity to comment on regulatory process related to HB793. As a nurse practitioner with 21 years of experience, I am concerned with the overall implications of this legislation. It is well established that there is absolutely no evidence that any transition to practice period for certified nurse practitioners will improve quality of care or ensure safe practice. With passage of this compromise legislation, Virginia becomes an extreme outlier compared to other states with the longest transition period of 5 years full time practice. Additionally, the attestation process is fully dependent on the physician giving permission for the nurse practitioner to practice without an agreement, not on the nurse practitioner’s competence, and is overshadowed by perceived physician liability. After “transition” the NP must still, by law, consult and collaborate with other health care providers and establish a plan for referral of complex medical cases and emergencies to physicians or other appropriate health care providers. The Joint Board should consider that nurse practitioners are prepared by education and certification to practice, and these restrictions are unnecessary and a restraint of trade.

I would ask that the Joint Board consider the following in promulgation of regulations

1. The 5 year full time practice requirement should be fluid, allowing for nurse practitioners who have worked in a variety of settings during that time to combine years of practice.
2. The attestation document should be simple and not require a physician signature. Naming a physician(s) should be satisfactory. An audit process could satisfy this requirement. It should be established that a physician attestation does not imply liability and that a physician may not require payment for the attestation.
3. Nurse practitioners from out of state should, by the fact of licensure in another state for at least 5 years, qualify for the transition period without an attestation, as this creates an undue hardship and deters nurse practitioners from working in Virginia.
4. There should be a significant effort to collect data for the November 2021 report to the legislature, that will support a decrease in and/or removal of the transition period.

Thank you for the opportunity to provide public comment. I have been a nurse practitioner (NP) for 20 years practicing in a variety of settings in Virginia and overseas.  Completion of graduate education and national board certification deem that I am a competent clinician. As a small business owner in a solo NP practice, implementing the following requirements places a financial burden and hardship on the business as well as barriers to growing the practice and providing patient care.

 Please keep this in mind as rules are being promulgated.

• The five-year equivalent requirement creates a costly bottleneck to building provider workforce and equitable distribution in primary care delivery for underserved and vulnerable populations. Unduly burdensome regulations on top of this requirement will result in additional bottlenecks compromising access to care. 

• NPs already pay fees associated with RN, NP, and prescribing licenses and if they are business owners, pay fees to collaborating physicians. Any additional fees associated with submission of attestation and issuance of autonomous designation should not create a financial barrier for qualified NPs to practice. 

• Acceptance of “other evidence” demonstrating that the applicant has met the requirements must be broadly interpreted. We ask that the Joint boards issue a guidance document listing examples of supporting evidence that they would take into consideration. Office administrators, health system administrators, and credentialing documents should all be accepted as evidence that an applicant has met the necessary requirements.

• The Boards should credit applicants by endorsement for all of their time employed and licensed in other states towards calculating their clinical experience requirement for practicing without a practice agreement.

• NPs in any state or working for U.S. Armed Forces, U.S. Veterans Administration or the Public Health Service should be able to submit evidence that the five-year full-time equivalent collaborative requirements have been met with signature from employer, physician, practice administrator, etc.

• There is no demonstrated need for additional requirements on the attestation in order to protect the public beyond what is listed in HB 793. The attestation should be used to document clinical experience under a sworn statement that this information is accurate and meets the requirements of the law. 

• Most, if not all, states requiring attestation of transitional clinical hours are not overly prescriptive in what they require in their regulations or on their attestation forms. Therefore, in Virginia it should not be necessary to further define what is meant by “the patient care team physician routinely practiced with a patient population and in a practice area included within the category for which the nurse practitioner was certified and licensed.”

• Both the NP and the patient care team physician should be held to disciplinary standards for providing falsified documentation to the Boards.

Thank you,

Nurse Practitioner Buky