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Nurse Licensure and NP Approval to Practice in North Carolina Eileen C. Kugler RN MSN MPH FNP MANAGER - PRACTICE May 15, 2009 Workshop Objectives Compare scopes of nursing practice for RN, LPN, NP Discuss NP scope of practice

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nurse licensure and np approval to practice in north carolina

Nurse Licensure andNP Approval to Practicein North Carolina

Eileen C. Kugler RN MSN MPH FNP


May 15, 2009

workshop objectives
Workshop Objectives
  • Compare scopes of nursing practice for RN, LPN, NP
  • Discuss NP scope of practice
  • Describe the application and approval process for NPs in North Carolina
  • Identify documentation required at the practice site
regulatory authority
Regulatory Authority
  • Purpose of Regulation – PROTECTION OF THE PUBLIC
  • Occupational regulation based upon state’s rights to protect citizens and hold providers accountable
  • Mandate to Regulate Nursing and Medical Practice – authority derived from legislative action
  • Rules and Regulations promulgated through NC Administrative Code
compact states as of feb 2009
Compact States as of Feb. 2009
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • North Carolina  
  • North Dakota
  • Rhode Island  
  • South Carolina
  • Virginia  
  • Wisconsin 
  • Arizona 
  • Arkansas 
  • Colorado
  • Delaware 
  • Idaho  
  • Iowa 
  • Kentucky
  • Maine
  • Maryland  
  • Mississippi 
  • Nebraska
  • New Hampshire 
  • New Mexico
what defines scope of practice
What defines scope of practice?
  • Nursing Practice Act - Law
  • NC Administrative Code - Rules
  • Level of Licensure
  • Board Position/Advisory Statements and Opinions
  • Agency Policy/Procedure-can restrict, but not expand scope
what defines scope of practice8
  • Nursing Practice Act - NC G.S. 90-171
  • Level of License: Components of practice defined under G.S.90-171.20 (7) & (8)
  • NC Administrative Code - Rules for Occupational Licensing Boards
    • 21 NCAC 36.0224 “Components of Nursing Practice for the Registered Nurse”
    • 21 NCAC 36.0800 “Approval and Practice Parameters for Nurse Practitioners”
    • 21 NCAC 36.0226 “Nurse Anesthesia Practice”
comparison of scopes
Comparison of Scopes
  • Advanced Practice Nurse
  • Registered Nurse
  • Licensed Practical Nurse
npa statute g s 90 171 20
NPA STATUTE G.S. 90-171.20
  • In North Carolina, the RN has an INDEPENDENT role
  • In North Carolina, the LPN has a DEPENDENT role.
scopes of practice for rn and lpn
Scopes of Practice for RN and LPN
  • GS. 90-171.20 (7)
  • Ten components of practice by the RN

Does not require the RN to have nursing

activities assigned to them nor be supervised by anyone.

  • GS. 90-171.20 (8)
  • Seven components of practice by the LPN

Requires the LPN to have assignment and supervision by the RN or physician or other duly authorized person.

registered nurse
Registered Nurse
  • full scope of nursing, comprehensive care for all clients in all settings
  • teaching theory and practice of nursing, managing nursing personnel, and administering nursing services
licensed practical nurse
Licensed Practical Nurse
  • directed scope of nursing, under supervision of RN, APRN, MD or other authorized provider
  • collect focused data
  • contribute to and participate in the comprehensive care of clients
advanced practice registered nurses
Advanced Practice Registered Nurses
  • expanded scope of nursing practice
  • graduate degree with advanced knowledge of theory, assessment, interventions, and management of health care
nursing practice act administrative rule 21 ncac 36 0226
Nursing Practice ActAdministrative Rule: 21 NCAC 36 .0226

The CRNA “may perform nurse anesthesia activities in collaboration with a physician, dentist, podiatrist, or other qualified health care provider, but may not prescribe a medical treatment regimen or make a medical diagnosis except under the supervision of a licensed physician.”


Supervision vs Collaboration

Is it lawful for CRNAs in NC to practice without Physician Supervision?

The NCBON explicitly distinguishes “nurse anesthesia activities” that are performed “in collaboration with… from prescribing a “medical treatment regimen” or making a “medical diagnosis”, which are performed “under the supervision of a licensed physician”

crna recognition process

On 7/01/03, the North Carolina Board of Nursing initiated the process for verifying that nurse anesthetists meet the requirements to practice in NC.

recognition process
  • CRNAs Practicing in North Carolina
  • Nurse Anesthetists Endorsing into North Carolina
nurse anesthetist nc school information
Nurse AnesthetistNC School Information

Nurse anesthetist students

graduating from anesthesia school (not yet certified)

  • NC schools provide BON with list of names/addresses (including SSN and/or RN cert # for database purposes) of new grads successfully completing program
  • Program Directors work with new grads on completion of online verification form to practice as Graduate Nurse Anesthetists
  • Out-of-State Grads need to provide transcript or letter from program director
grna status and issuance of initial crna recognition
GRNA Status and Issuance of Initial CRNA Recognition
  • GRNA Status
    • Recognition certificate will be issued to Graduate Nurse Anesthetists indicating that they have 18 mos. from time of graduation to pass credentialing exam.
  • Issuance of Initial CRNA Recognition
    • Once certified, Recognition certificate sent from BON as acknowledgement for practice as a Certified Registered Nurse Anesthetist(CRNA).
renewing nc crna recognition
Renewing NC CRNA Recognition
  • Renewal of national certification biennially in July.
  • Board sends recognition renewal notice ~60 days prior to expiration of the national certification with instructions on how to update NCBON recognition.
  • A non-refundable administrative charge of $25.00
nurse practitioner administrative code rules
  • Effective August 1, 2004 New NP Rules
  • NC Board of Nursing Rule: 21 NCAC 36.0800 “Approval and Practice Parameters for Nurse Practitioners”
  • NC Medical Board Rule: 21 NCAC 32M.0101 “Approval of Nurse Practitioners”
np scope of practice
NP Scope of Practice
  • 21 NCAC 36 .0801(4)
  • Definition of Nurse Practitioner
    • Current NC RN license
    • Approved to perform medical acts
    • Consistent with NP academic prep and national certification
    • Collaborative Practice Agreement with licensed physician
scope of np practice
Scope of NP Practice
  • Definition of NP, continued
    • Medical acts are in addition to nursing acts performed by virtue of RN license
    • NP held accountable under RN license for nursing acts performed
scope of np practice26
Scope of NP Practice
  • 21 NCAC 36 .0802
  • Scope of Practice
    • Continuous and comprehensive management of broad range of personal health services
    • Educationally prepared and competency maintained
    • Collaborative Practice Agreement
scope of np practice27
Scope of NP Practice
  • 21 NCAC 36 .0802, continued
  • Services include but not restricted to:
    • Promotion and maintenance of health
    • Prevention of illness and disability
    • Diagnosing, treating and managing acute and chronic illnesses
    • Guidance and counseling individuals and families
scope of np practice28
Scope of NP Practice
  • 21 NCAC 36 .0802, continued
  • Services include but not restricted to
    • Prescribing, administering and dispensing therapeutic measures, tests, procedures and drugs
    • Planning for situations beyond NPs expertise, consulting with and referring to other providers
    • Evaluating health outcomes
np approval to practice
NP Approval to Practice
  • 21 NCAC 36 .0801(6) Definition
  • Approval to practice means
    • Authorization by Medical Board and Board of Nursing for RN to perform medical acts
    • Within area of educational prep and certification
    • Under Collaborative Practice Agreement
np approval to practice requirements
NP Approval to Practice Requirements
  • Authorization by the Medical Board and Board of Nursing to use the title of Nurse Practitioner in accordance with the Rule without having an approval to practice with a supervising physician.
  • All NPs who desire to use the title NP are required to complete the Application for Registration as a Nurse Practitioner.

$25.00 administrative charge.

np approval to practice requirements31
NP Approval to Practice Requirements
  • 21 NCAC 36.0803 (a):

(1) An unrestricted license to practice as a RN in NC and when applicable unrestricted approval, registration or license as a NP in another state, territory, or possession of the US.

(2) Has successfully completed a NP education program as outlined in Rule 21 NCAC 36.0805

np approval to practice requirements32
NP Approval to Practice Requirements


(3) Has supplied information necessary to evaluate the application.

(b) Effective January 1, 2005 new graduates seeking first-time nurse practitioner registration in NC shall: 21 NCAC 36.0803 NURSE PRACTITIONER REGISTRATION – (b)(1)-(3)

np approval to practice requirements33
NP Approval to Practice Requirements


(1) Hold a Master’s Degree in Nursing or related field with primary focus on Nursing

(2) Have successfully completed a graduate level NP education program accredited by a national credentialingbody, and in addition met the criteria as outlined in Rule .0805 (a) and (c) under “Education and Certification for Registration as a NP”.

(3) Provide documentation of certification by a national credentialing body

np approval to practice requirements34
NP Approval to Practice Requirements
  • 1. NOTORIZED letter of verification from the Director of the Nurse Practitioner Program that all the components of the core curriculum and the clinical management of commonhealth problems found in Rule 21 NCAC 36.0805 or 21 NCAC 32M.0105 are met, and the date of completion and type of NP program.
np approval to practice requirements35
NP Approval to Practice Requirements
  • 2. Registration allows the individual to use the title Nurse Practitioner, but does not allow the individual to practice as a NP.
  • 3. An application for approval to practice must be completed and approved by the Boards before the NP may practice.
np approval to practice requirements36
NP Approval to Practice Requirements
  • A separate application for the NP who desires to practice (registration and approval applications may be done online at the same time).
  • A separate application must be completed for each Primary Supervising Physician
  • The NP can have more than one primary supervising physician.
  • With each Primary Supervising Physician there shall be a Collaborative Practice Agreement (CPA).
interim status for nurse practitioner applicant

Shall be granted to:

  • Any registered nurse seeking first-time approval to practice as a NP in NC who
    • meets the NP education and registration requirements, if applicable
    • Interim status allows the NP to practice until the application is approved by the Boards
interim status continued

The following limitations apply: 21 NCAC 36.0804(g)(1)(2)(3)(4)

1. No prescribing privileges

2. Primary or back-up physicians shall be continuously available

3. Countersigning by MD of notations of medical acts in all patient charts within two working days of NP applicant-patient contact

interim status continued39
  • 4. Face to face consultation meetings with the primary supervising physician on a weekly basis with documentation of consultation consistent with Rule .0810(e)(3) (“Quality Assurance Standards for a Collaborative Practice Agreement”).
    • A. Identify clinical issues discussed and action taken,
    • B. Be signed and dated by those who attended; and,
    • C. Be available for review by members or agents of either Board for the previous 5 calendar years and be retained by both the NP and primary supervising physician.

5. Shall not exceed period of six months.

continuing education requirements
Continuing Education Requirements
  • 50 contact hours each year
  • Beginning with the first renewal after initial approval to practice granted
continuing education requiements
Continuing Education Requiements
  • Continuing Education are those hours for which approval has been granted by the:
  • 1. American Nurses Credentialing Center (ANCC)
  • 2. Accreditation Council on Continuing Medical Education (ACCME)
  • 3. Other National Credentialing Body
  • 4. Practice relevant Courses in an Institution of Higher Learning (New Category)
  • 5. Documentation shall be maintained by the NP & made available upon request to either Board.
collaborative practice agreement
  • Definition:“Collaborative Practice Agreement” means the arrangement for nurse practitioner-physician continuous availability to each other for on-going supervision, consultation, collaboration, referral and evaluation of care provided by the nurse practitioner.
collaborative practice agreement43
  • Written Protocols are not mandatory as in the previous NP rules, but the NP may use them AS PART of the COLLABORATIVE PRACTICE AGREEMENT.
collaborative practice agreement44

Discussed in Rules:

  • 21 NCAC 36.080 Definitions (9)
  • 21 NCAC 36 .0804 Process for Approval to Practice (a)(4)
  • 21 NCAC 36 .0809 Prescribing Authority (b)(1)((2)(A)(B)(C)(3)(A)(B)
  • 21 NCAC 36 .0810 QA Standards for a CPA
collaborative practice agreement45

Quality Improvement Process

  • Written Plan for evaluating the quality of care provided for one or more frequently encountered clinical problems
  • The CPA can be more restrictive than Nursing Law just not less.
collaborative practice agreement46

Required Elements in the CPA

CPA must include:

  • How NP and MD are continuously available to each other
  • A pre-determined plan for emergency services
  • Drugs, devices, tests, procedures

No specific format required.

collaborative practice agreement47

What elements to include???

  • Some examples:

1. Practices differ – even if same specialty.

2. What is the Patient Population?

3. Most Common Diagnoses

4. Complexity of care – Client Population

5. Availability of Emergency Services, Diagnostic Centers & Specialists

6. Address components of CPA discussed in the rules mentioned above.

collaborative practice agreement48
  • 7. New graduate, seasoned NP, or seasoned NP & new Primary Supervising Physician
  • 8. When NP & primary supervising physician address how they practice together, completed document will be the nurse practitioner’s collaborative practice agreement.
collaborative practice agreement49
  •, then Practice, APRN, NP, Collaborative Practice Agreement Guidelines
information required

Required to be at each NP practice site:

  • Signed Collaborative Practice Agreement (CPA) (according to NP Rules – 21 NCAC 36 .0810(b)(1)
  • Registration as NP, if applicable
  • Current NP approval
  • Current RN license
  • DEA number, if applicable
information required51

Required to be at each NP practice site:

  • Documentation of QI Process Meetings
  • Copy of Notification of Original Approval to Practice
  • Documentation of Continuing Education:

21 NCAC 36.0807 - Documentation shall be maintained by the NP & made available upon request to either Board

np refresher course
NP Refresher Course
  • 21 NCAC 36.0808 – Inactive Status
  • Refresher Course: Required if inactive NP status greater than 5 years.
  • NP seeking 1st time approval to practice in NC who has not provided direct patient care as an NP in more than 5 years
np refresher course53
NP Refresher Course
  • An unrestricted RN license is required for the NP Refresher Course
  • NP Refresher Course is NCBON approved & consists of common conditions & their management directly related to the NP’s area of education & certification
purpose of compliance reviews
Purpose of Compliance Reviews
  • To provide the opportunity for NP to review rules and regulations
  • To ensure NP and MD meet requirements
compliance review process
Compliance Review Process

Guiding Principles

  • Accountability for requirements in NP Rules
  • Review limited to current approval
  • If >1 approval, only one will be reviewed
  • Acceptable documentation
  • QI framework
compliance review process56
Compliance Review Process


  • Selection Process
  • Site Visits
  • Mail-In Self Assessments
np laws and rules
NP Laws and Rules
  • Laws
    • § 90-18.2 and § 90-18.3
  • Rules
    • 21 NCAC 36.0801 - .0814
    • 21 NCAC 32M.0101 - .0116
questions discussion
  • Website:
  • E-Mail:
  • (919) 782-3211, ext. 255