Our friend, Gale Adcock, FNP, joins us again for another guest blog titled Nurse Practitioner Regulation. This is part one of a three blog series by Representative Adcock. A big thank you again to Rep. Adcock for helping spread knowledge to our nurses and nurse practitioners throughout this great state.
It’s important that nurse practitioners (NPs) know who regulates their practice and the avenues available to improve the practice environment and remove barriers to NP care.
Who regulates NP practice?
Unless an NP is active military or employed by a federal agency such as the Veterans Administration, their practice is regulated by the state where they work. A few states have advanced practice registered nurse (APRN) regulatory boards that are distinct from the state board of nursing (BON), but most states have a single regulatory board that regulates the practice of registered nurses, licensed practical nurses and APRNs.
Then there’s North Carolina.
North Carolina is one of only a few states where nursing and medicine jointly regulate some or all of NP practice.
A 1970s amendment to the state medical practice act authorized the first North Carolina NPs to practice. The new law established a 6 member joint subcommittee (JSC), mandated physician supervision, protected the title ‘nurse practitioner’ and granted prescriptive authority. It did not describe exactly what physician supervision or prescriptive authority would look like. These details (and many others) are in regulations included in the North Carolina Administrative Code (NCAC), and referred to colloquially as NP Rules. Regulations cannot deviate from the law on which they are based. In the case of NP Rules, changes to a fundamental tenet of the establishing law (such as physician supervision) require legislation to repeal it. (More about this in Part 3).
The JSC is responsible for proposing changes to NP Rules. It has 3 BON members and 3 Medical Board (MB) members. Having a JSC means that both boards are responsible for oversight of NP practice. This is why identically worded NP Rule language appears in two different NCAC chapters—21 NCAC 36.0800 [the BON chapter] and 21 NCAC 32M [the MB chapter]. Often only one of these chapters is cited when NP Rules are discussed or written about. When the MB refers to NP Rules they reference 32M. When the BON does so, they reference 36.0800. Both boards are correct, yet this can be confusing.
How are NP Rules changed?
There is an established and uniform procedure for making changes to any part of the NCAC. A formal comprehensive description is at NC Office of Administrative Hearings.
This is a streamlined NP-friendly version:
- A majority of the 6-member JSC must agree to change the rules and on the language to be used.
- The proposed rule changes/language must then be approved by members of the BON and members of the MB. The boards decide which will be the ‘initiating board’.
- A notice of intent to change the rules is published in the NC Register.
- Proposed rule language along with public comment and public hearing information, are posted on the initiating board’s website.
- Written feedback (during a 60 day public comment period) and verbal feedback (during the public hearing) must be considered by the initiating board before proposed rules are submitted to the NC Rules Review Commission (RRC).
- After RRC review and approval (but before the effective date), any 10 individuals may make a written request for legislative review.
- The legislature can review the rules and take no action to stop them (meaning the rules will become effective on the date previously set by RRC) or it can propose a bill to prevent the new rules from taking effect. If the bill passes, the new rules are dead.
The rulemaking process can take a few months if changes seem simple; a year or more if changes are considered controversial. A request for legislative review is a strategy used by opponents of new rules to stop their implementation.
One license…or two?
Again, North Carolina is unique. Rather than a single license that encompasses the RN and NP/APRN roles (as some states like Texas do), our NPs get an RN license first and then complete an additional step for authorization to practice as an NP. This step is called approval to practice. To be approved to practice, NPs must meet certain education and certification requirements, have a designated primary supervising physician and a signed collaborative practice agreement (CPA). Other requirements to maintain approval to practice are detailed in NP Rules. Approval to practice is renewed annually; an RN license is renewed every 2 years.
In NP Regulation Part 2, we’ll take a look back at significant NP Rule changes in the 1990s, considered progressive at the time, and their impacts today. Part 3 will be a deep dive into how our 50 year old law and current NP Rules create barriers to NP practice and restrict access to care.