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.