I am a practicing Clinical Nurse Specialist with decades of experience delivering high-quality diabetes and endocrine care. In Virginia, my prescriptive authority depends on a collaborative agreement with a physician. My most recent physician collaborator fulfilled the required review of medical records but never questioned my clinical decision-making. This reflects my expertise and competence in providing specialty nursing care, including medication prescribing and adjustment.

A 2021 report on APRN oversight, commissioned by the Virginia General Assembly, recommended aligning state laws and regulations with the APRN Consensus Model. This would grant all APRNs in Virginia independent practice and prescriptive authority, while placing regulatory authority solely under the Virginia Board of Nursing. The report also noted that 34 jurisdictions across the United States allow Clinical Nurse Specialists to practice independently, without evidence of reduced quality of care or breaches in scope of practice. Claims by organizations such as the American Medical Association and the Medical Society of Virginia that APRNs require physician oversight are not supported by evidence. Despite this, the report’s recommendations have not been implemented.

I believe the Virginia Board of Nursing is fully equipped to regulate professional nursing practice.

In my work, I provide expert nursing care, education, and support for individuals living with diabetes. I do not seek to function as a physician. Instead, I approach patient care through a nursing lens—focusing on therapeutic communication, assessment of physical and psychological status, and consideration of socioeconomic challenges. My goal is to improve health outcomes through timely care, ongoing support, and a whole-person approach that identifies and addresses gaps in self-management.

This perspective differs from the traditional physician model, which emphasizes diagnosis, medication management, and procedural interventions. Both roles are essential but distinct.

From a workforce standpoint, there are simply not enough endocrinologists—293 as of 2026—to meet the needs of the 733,302 Virginians living with diabetes (2021 data). As the healthcare workforce ages, this gap is likely to widen.

Finally, nursing has been ranked the most trusted profession for 23 consecutive years. This trust reflects the public’s confidence in nurses’ honesty and ethical standards. Nursing should regulate nursing, and physicians should regulate physicians.

I am an advanced practice registered nurse - clinical nurse specialist (APRN-CNS) practicing in Virginia in a non-prescribing role focused on patient safety and the prevention of hospital-acquired conditions. I appreciate the opportunity to comment on the periodic review of 18 VAC 90-30.

Regulations should protect patient safety while recognizing APRN-CNS advanced education, national certification, and specialized expertise. Duplicative supervision or joint regulation delays CNS-led interventions without improving safety. CNSs have consistently demonstrated safe patient care and outcomes, are trained and educated by nurses, and as such, should be regulated by nurses rather than physicians. This model has been proven to be safe and effective in the majority of states.

CNSs who desire prescriptive authority should have a clear, structured pathway to independent practice following 1,000 hours of supervised practice by experienced prescribing CNSs or physicians. I respectfully urge modernization of APRN-related regulations to support safe, efficient, and effective patient care across Virginia.

I am a Virginia?licensed Advanced Practice Registered Nurse (APRN)–Clinical Nurse Specialist (CNS) and appreciate the opportunity to comment on the periodic review of 18 VAC 90?30 pursuant to Executive Order 19. My comments address public health and safety, economic impact, and regulatory clarity as they relate to CNS practice within hospital?based pressure injury prevention programs.

Public Health and Safety:
Wound Care Clinical Nurse Specialists play a critical role in hospital?based pressure injury prevention through risk assessment, staff education, protocol development, product evaluation, and oversight of prevention and early intervention strategies. CNS?led programs are central to reducing hospital?acquired pressure injuries (HAPIs), improving patient outcomes, and supporting evidence?based practice. Regulations should protect patient safety while recognizing CNS advanced education, specialty certification, and clinical leadership. The role of CNS specifically focuses on secondary prevention and chronic disease management. The CNS role was specifically designed to improve patient outcomes that are impacted by NURSING interventions. Requirements that do not add clear safety benefit delay prevention efforts and consultation.

Economic Impact and Regulatory Burden:
Pressure injuries are associated with increased length of stay, higher treatment costs, and negative quality outcomes. Regulatory barriers that delay or limit CNS practice—such as duplicative supervision or joint regulation by the Board of Nursing and Board of Medicine— undermine prevention efforts and increase avoidable costs. Streamlined, nurse?led regulation supports efficiency and high?value care.

Clarity and Structured Practice Pathways:
Clear, CNS?specific regulatory language and alignment between 18 VAC 90?30 and 18 VAC 90?40, particularly regarding prescriptive authority, are essential. A defined, competency?based transition to independent practice is appropriate when prior inpatient and prevention experience is recognized.

Conclusion:
I urge modernization of APRN?related regulations to that will only serve to improve patient safety and financial burden across Virginia’s health systems.

I am a Virginia-licensed registered nurse who hopes to undertake Advanced Practice Registered Nursing and appreciate the opportunity to comment on the periodic review of 18 VAC 90?30 pursuant to Executive Order 19. My comments address public safety, economic impact, and regulatory clarity as they relate to CNS practice.

CNSs are graduate?educated, nationally certified APRNs who provide high?quality, evidence?based care within defined populations and specialties. Regulations should continue to protect public health while recognizing CNS education, training, and competencies. Requirements that do not meaningfully improve patient safety unnecessarily limit access to care, particularly in specialty and underserved settings.

Duplicative or prolonged supervision and joint regulation by both the Board of Nursing and the Board of Medicine imposes avoidable administrative and financial burdens without clear benefit. Streamlined, nurse?led regulation supports workforce stability, employer efficiency, and patient access while maintaining safety standards.

Clear, CNS?specific regulatory language would improve understanding and compliance. Greater consistency between 18 VAC 90?30 and 18 VAC 90?40, particularly regarding prescriptive authority, would reduce confusion and support effective implementation.

A defined, time?limited transition period—such as the proposed 1,000 supervised hours—may be reasonable if it is competency?based, recognizes prior experience, and allows supervision by experienced prescribing CNSs or physicians. Clear criteria for completion and progression to independent practice are essential.

I respectfully urge the Department of Health Professions and the Board of Nursing to modernize CNS?related regulations by reducing unnecessary burden, clarifying requirements, and supporting a fair, competency?based pathway to independent practice while maintaining patient safety.

I am a Virginia-licensed Advanced Practice Registered Nurse (APRN)-Clinical Nurse Specialist (CNS) and appreciate this opportunity to comment on the periodic review of 18 VAC 90?30 pursuant to Executive Order 19. My comments address public safety, economic impact, and regulatory clarity as they relate to CNS practice.

Public Health and Safety:
CNSs are graduate?educated, nationally certified APRNs who provide high?quality, evidence?based care within defined populations and specialties. Regulations should continue to protect public health while recognizing CNS education, training, and competencies. Requirements that do not meaningfully improve patient safety unnecessarily limit access to care, particularly in specialty and in Virginia's multiple underserved settings - rural, semi-rural and urban areas.

Economic Impact and Regulatory Burden:
Duplicative or prolonged supervision and joint regulation by both the Board of Nursing and the Board of Medicine imposes avoidable administrative and financial burdens without clear benefit. Modernized, streamlined, nurse?led regulations support workforce stability, employer efficiency, and patient access while maintaining safety and care standards.

Clarity and Readability:
Clear, CNS?specific regulatory language would improve understanding and compliance. Greater consistency between 18 VAC 90?30 and 18 VAC 90?40, particularly regarding prescriptive authority, would reduce confusion and support effective implementation of the standards of care and needed CNS-led interventions.

Structured Pathway to Independent Practice (SB 811):
A defined, time?limited transition period—such as the proposed 1,000 supervised hours—may be reasonable when it is competency?based, recognizes prior experience, and allows supervision by experienced prescribing CNSs or physicians. Clear criteria for completion and progression to independent practice are essential.

Conclusion

I respectfully urge the Department of Health Professions and the Board of Nursing to modernize CNS?related regulations by reducing unnecessary burden, clarifying requirements, and supporting a fair, competency?based pathway to independent practice while maintaining patient safety.

Thank you,

Jennifer H. Matthews, Ph.D, APRN-CNS, FAAN

I am a Virginia?licensed Advanced Practice Registered Nurse (APRN)–Clinical Nurse Specialist (CNS) and appreciate the opportunity to comment on the periodic review of 18 VAC 90?30 pursuant to Executive Order 19.

As a  doctoral-educated, nationally certified APRN, I provide high?quality, evidence?based care within the defined populations and specialties for which I am licensed. Regulations should protect public safety while recognizing CNS education, certification, and clinical expertise. Requirements that do not meaningfully improve patient safety, limit access to care, and increase unnecessary regulatory and economic burden.

CNS?specific regulatory language and alignment between 18 VAC 90?30 and 18 VAC 90?40  are essential. A defined pathway to independent practice that recognizes education and advanced healthcare experience is essential. In the 2021 DHP REPORT ON ADVANCED PRACTICE REGISTERED NURSES: 2021 BUDGET BILL, the following actions were supported:

i. Regulation of APRNs according to the National Council of State Boards of Nursing, which presents recommendations for state legislatures and boards regarding the regulatory structure for APRNs (Certified Nurse Practitioners, Certified Nurse Midwives, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists).

ii. Granting all APRNs the ability to practice independently,
iii. Regulate APRNs solely through the Board of Nursing, 
iv. Further recommendations from DHP are:  
       1) Amend statutory and regulatory definitions to conform to those in the APRN Consensus Model;
       2) Consider amending Virginia laws and regulations to align with the APRN Consensus Model; 
       3)  Follow The Future of Nursing: Leading Change, Advancing Health, the Institute of Medicine that recommends nurses practice to the full extent of their education and skills. under the Board of Nursing.

I respectfully urge modernization of APRN ?related regulations to support safe, efficient, and effective patient care across Virginia. APRNs are nurses and regulation should be wholly managed by nurses.

I am a practicing Clinical Nurse Specialist with prescriptive authority that started a rural hospice, a pain management service, and a palliative care service in an acute care setting. In Virginia, my prescriptive authority depends on a collaborative agreement with a physician. I work with countless physicians who all trust my clinical expertise and prescriptive authority competency.

A 2021 report on APRN oversight, commissioned by the Virginia General Assembly, recommended aligning state laws and regulations with the APRN Consensus Model. This would grant all APRNs in Virginia independent practice and prescriptive authority, while placing regulatory authority solely under the Virginia Board of Nursing. The report also noted that 34 jurisdictions across the United States allow Clinical Nurse Specialists to practice independently, without evidence of reduced quality of care or breaches in scope of practice. Claims by organizations such as the American Medical Association and the Medical Society of Virginia that APRNs require physician oversight are not supported by evidence. Despite this, the report’s recommendations have not been implemented.

Palliative care in Virginia's underserved communities faces significant disparities, with minority-serving hospitals showing a 33% lower likelihood of providing these services compared to others. Rural and low-income areas, particularly in Southern Virginia, face high symptom burdens due to limited access and workforce shortages. Patients with metastatic cancer or chronic, life-limiting illnesses in these areas often experience late referrals, impacting their quality of life. There are numerous factors that contribute to Palliative care disparities in Virginia including access barriers. In Virginia, particularly in rural or low-income areas like those in the Southwest or Southern part of the state, access to palliative care is restricted by limited infrastructure and fewer healthcare providers. Furthermore, racial and socioeconomic disparities exist. Patients in primarily minority-serving hospitals are 33% less likely to receive palliative care. Studies also indicate that lower-income zip codes and, in some cases, Hispanic, Black, and American Indian/Alaska Native populations show disparities in utilization. In the Hampton Roads region, while 35.5% of Black Medicare beneficiaries utilized hospice in 2021, disparities in access for palliative services (non-hospice) remain. In Appalachian regions, including parts of Virginia, significant barriers exist regarding geography, workforce shortages, and cultural differences, which hinder timely access to palliative services. Lower-income communities, such as those in the Southern Suffolk Health District (SSHD), often have higher rates of uninsured or underinsured residents, reducing access to specialized care such as palliative care. Patients with Sickle Cell Disease (SCD) or other chronic illnesses, often in underserved communities, frequently lack access to palliative care despite experiencing high symptom burdens.

Clinical Nurse Specialists can and should address these barriers safely while providing high quality care for seriously ill patients and their families. With autonomous practice after 1000 hours (as approved for nurse midwives last year) of collaborative practice with prescriptive authority, CNSs would be well positioned to care for patients in these underserved areas as described above.

I respectfully urge the Department of Health Professions and the Board of Nursing to modernize CNS related regulations by reducing unnecessary burden, clarifying requirements, and supporting a fair, competency-based pathway to independent practice while maintaining patient safety.

I am a Virginia licensed Advanced Practice Registered Nurse (APRN)–Clinical Nurse Specialist (CNS) and appreciate the opportunity to comment on the periodic review of 18 VAC 90?30 pursuant to Executive Order 19.

As a  doctoral-educated, nationally certified APRN, and Nurse Manager with over 20 years of healthcare experience and a deep passion for nursing—particularly in serving vulnerable populations I’ve gained valuable insight into the barriers that impact both patient outcomes, nursing practice and organizations.

Regulation of APRNs according to the National Council of State Boards of Nursing, and CNS specific regulatory language and alignment between 18 VAC 90?30 and 18 VAC 90?40  are essential. In the 2021 DHP REPORT ON ADVANCED PRACTICE REGISTERED NURSES: 2021 BUDGET BILL, supported the following actions:

(for the full list of supported actions, see this link, pg. 17) https://rga.lis.virginia.gov/Published/2021/HD18/PDF

-Granting all APRNs the ability to practice independently, 

-Regulate APRNs solely through the Board of Nursing

-Pursue participation in the APRN Licensure Compact

These are essential to improve access to care in an already overwhelmed healthcare environment with decreased providers. 

Public Comment on 18 VAC 90?30

Regulations Governing the Licensure of Advanced Practice Registered Nurses

Comment

I am a Virginia-licensed Advanced Practice Registered Nurse (APRN)-Clinical Nurse Specialist (CNS) and appreciate the opportunity to comment on the periodic review of 18 VAC 90?30 pursuant to Executive Order 19. My comments address public safety, economic impact, and regulatory clarity as they relate to CNS practice.

Public Health and Safety:
CNSs are graduate?educated, nationally certified APRNs who provide high?quality, evidence?based care within defined populations and specialties. Regulations should continue to protect public health while recognizing CNS education, training, and competencies. Requirements that do not meaningfully improve patient safety unnecessarily limit access to care, particularly in specialty and underserved settings. The population I care for, those living with diabetes, need an APRN-CNS who is trained and certified to care for them while they are hospitalized without barriers to independent practice.  

Economic Impact and Regulatory Burden:
Duplicative or prolonged supervision and joint regulation by both the Board of Nursing and the Board of Medicine imposes avoidable administrative and financial burdens without clear benefit. Streamlined, nurse?led regulation supports workforce stability, employer efficiency, and patient access while maintaining safety standards.

Clarity and Readability:
Clear, CNS?specific regulatory language would improve understanding and compliance. Greater consistency between 18 VAC 90?30 and 18 VAC 90?40, particularly regarding prescriptive authority, would reduce confusion and support effective implementation.

Structured Pathway to Independent Practice (SB 811):
A defined, time?limited transition period—such as the proposed 1,000 supervised hours—may be reasonable if it is competency?based, recognizes prior experience, and allows supervision by experienced prescribing CNSs or physicians. Clear criteria for completion and progression to independent practice are essential.

Conclusion

I respectfully urge the Department of Health Professions and the Board of Nursing to modernize CNS?related regulations by reducing unnecessary burden, clarifying requirements, and supporting a fair, competency?based pathway to independent practice while maintaining patient safety.

Public Comment on 18 VAC 9030

I am a Virginia-licensed Advanced Practice Registered Nurse (APRN)-Clinical Nurse Specialist (CNS) and appreciate the opportunity to comment on the periodic review of 18 VAC 9030pursuant to Executive Order 19. My comments address public safety, economic impact, and regulatory clarity as they relate to CNS practice.

Public Health and Safety:
CNSs are graduate educated, nationally certified APRNs who provide high quality, evidence based care within defined populations and specialties. Regulations should continue to protect public health while recognizing CNS education, training, and competencies. Requirements that do not meaningfully improve patient safety unnecessarily limit access to care, particularly in specialty and underserved settings.

Economic Impact and Regulatory Burden:
Duplicative or prolonged supervision and joint regulation by both the Board of Nursing and the Board of Medicine imposes avoidable administrative and financial burdens without clear benefit. Streamlined, nurse led regulation supports workforce stability, employer efficiency, and patient access while maintaining safety standards.

Clarity and Readability:
Clear, CNSs specific regulatory language would improve understanding and compliance. Greater consistency between 18 VAC 9030 and 18 VAC 9040, particularly regarding prescriptive authority, would reduce confusion and support effective implementation.

Structured Pathway to Independent Practice (SB 811):
A defined, time limited transition period—such as the proposed 1,000 supervised hours—may be reasonable if it is competency based , recognizes prior experience, and allows supervision by experienced prescribing CNSs or physicians. Clear criteria for completion and progression to independent practice are essential.

ConclusionI respectfully urge the Department of Health Professions and the Board of Nursing to modernize CNS related regulations by reducing unnecessary burden, clarifying requirements, and supporting a fair, competency based pathway to independent practice while maintaining patient safety.

I am a Virginia-licensed Advanced Practice Registered Nurse (APRN)-Clinical Nurse Specialist (CNS) and appreciate the opportunity to comment on the periodic review of 18 VAC 90-30 pursuant to Executive Order 19.

CNSs are graduate-educated, nationally certified APRNs who provide high-quality, evidence-based care within defined populations and specialties. Regulations should protect public safety while recognizing CNS education, certification, and clinical expertise. Requirements that do not meaningfully improve patient safety limit access to care and increase unnecessary regulatory and economic burden.

Clear, CNS-specific regulatory language and alignment between 18 VAC 90-30 and 18 VAC 90-40, particularly regarding prescriptive authority, are essential. A defined, competency-based pathway to independent practice that recognizes prior experience is appropriate. In it's landmark report, The Future of Nursing: Leading Change, Advancing Health, the Institute of Medicine recommended that nurses be able to practice to the full extent of their education and skills. Regulatory actions should be managed exclusively by the Board of Nursing. 

I respectfully urge modernization of APRN-related regulations to support safe, efficient, and effective patient care across Virginia. APRNs are nurses and regulation should be wholly managed by nurses.

I am a Virginia-licensed Advanced Practice Registered Nurse (APRN)-Clinical Nurse Specialist (CNS) and appreciate the opportunity to comment on the periodic review of 18 VAC 90?30 pursuant to Executive Order 19. My comments address public safety, economic impact, and regulatory clarity as they relate to CNS practice. My area of clinical practice is neurosciences with a heavy emphasis on the stroke population. There is a significant stroke population in southwest Virginia and access to Neurology services is of ongoing concern.

Public Health and Safety:
CNSs are graduate?educated, nationally certified APRNs who provide high?quality, evidence?based care within defined populations and specialties. Regulations should continue to protect public health while recognizing CNS education, training, and competencies. Requirements that do not meaningfully improve patient safety unnecessarily limit access to care, particularly in specialty and underserved settings.

Economic Impact and Regulatory Burden:
Duplicative or prolonged supervision and joint regulation by both the Board of Nursing and the Board of Medicine imposes avoidable administrative and financial burdens without clear benefit. Streamlined, nurse?led regulation supports workforce stability, employer efficiency, and patient access while maintaining safety standards.

Clarity and Readability:
Clear, CNS?specific regulatory language would improve understanding and compliance. Greater consistency between 18 VAC 90?30 and 18 VAC 90?40, particularly regarding prescriptive authority, would reduce confusion and support effective implementation.

Structured Pathway to Independent Practice (SB 811):
A defined, time?limited transition period—such as the proposed 1,000 supervised hours—may be reasonable if it is competency?based, recognizes prior experience, and allows supervision by experienced prescribing CNSs or physicians. Clear criteria for completion and progression to independent practice are essential.

Conclusion

I respectfully urge the Department of Health Professions and the Board of Nursing to modernize CNS?related regulations by reducing unnecessary burden, clarifying requirements, and supporting a fair, competency?based pathway to independent practice while maintaining patient safety.

Thank you.