APRNs practice in one of 4 roles – nurse practitioner (NP), certified registered nurse anesthetist (CRNA), certified nurse midwife (CNM), or clinical nurse specialist (CNS). They are jointly regulated by the Boards of Nursing and Medicine in Virginia. In its 2023 session, the Virginia General Assembly amended the Code replacing the umbrella title of “nurse practitioner” with “advanced practice registered nurse” bringing Virginia statute further into alignment with the 2008 Consensus Model for APRN Regulation.
The regulations governing APRNs were initially promulgated in 1975 and included supervision of NP and CRNA practice. The following year, regulations for CNMs were added. By 1986, Virginia certified CRNAs, CNMs, and NPs by population focus. Shortly thereafter in 1988, the status of APRNs changed from certified to licensed, and regulations were amended modifying the definition of supervision. In 1989, Virginia began registering CNSs. Notably, common functional role competencies for CNS practice were not delineated nationally until 1998, which may explain the delay on the part of Virginia in shifting CNS regulation from certification to full licensure in 2021.
The Virginia General Assembly has incrementally expanded APRN practice through amendments to the Virginia Code. From provisional practice status to legal changes enabling insurance reimbursement and Schedule II-VI prescriptive authority to granting full practice authority to NPs and CNMs when criteria are met, the Commonwealth has incrementally grown closer to alignment with the APRN Consensus Model.
The Committee of the Joint Boards of Nursing and Medicine (CJB) schedules five business meetings per year to administer the Regulations Governing the Licensure of Nurse Practitioners (18VAC90-30-10 et seq.). The CJB is comprised of 6 members, 3 members from each of the Boards of Nursing and Medicine, appointed by the respective board presidents. The CJB, at its discretion, has appointed an advisory committee comprised of four licensed APRNs and four licensed physicians. This advisory committee is tasked with advising on matters related to the current NP practice environment, providing a specialty perspective, weighing in on regulatory matters, and informing the CJB on state and national professional trends.
Virginia APRNs are licensed consistent with their education and certification in a specialty (population focus) as follows (see 18VAC90-30-70):
APRNs may apply for initial licensure (18VAC90-30-80) or for licensure by endorsement if licensed as an NP in another state (18VAC90-30-85). While waiting to sit for the certifying examination, provisional licensure is also an option (see 18VAC90-30-80(B))
The criteria for APRN licensure (18VAC90-30-80) include:
All laws pertaining to APRN practice are provided in Chapter 29 of the Virginia Code
(Medicine and Other Healing Arts – §54.1-2900 et seq), with regulations in the Board of Nursing.
The scopes of practice of each of the 4 APRN roles are outlined below.
In Virginia, unlike the CNM, CRNA, and CNS roles which are specifically defined in Virginia Code according to education and certification, referring to the traditional NP role requires the use of qualifiers by exception -- “a nurse practitioner, other than a CRNA, CNM or CNS”.
Practice. NPs with fewer than 9,000 practice hours (5 years) must enter into a practice agreement with a patient care team physician defined in Virginia Code as "a physician who is actively licensed to practice medicine in the Commonwealth, who regularly practices medicine in the Commonwealth, and who provides management and leadership in the care of patients as part of a patient care team.” See Guidance Document 90-56 for a summary of practice agreement requirements.
A periodic chart review by the patient care team physician is required. However, the NP laws and regulations do not specify the time period or the number of chart reviews to be performed: 54.1-2957(D) - ". . . Practice agreements shall include provisions for (i) periodic review of health records, which may include visits to the site where health care is delivered, in the manner and at the frequency determined by the nurse practitioner and the patient care team physician and (ii) input from appropriate health care providers in complex clinical cases and patient emergencies and for referrals. . . .” The NP and physician agree on a periodic review schedule which is included in the practice agreement that is maintained by the NP. Should a complaint on the licensee come to the Board, the licensee may be requested to submit a copy of the practice agreement and documentation of the periodic review.
Prescriptive Authority. According to § 54.1-2957.01, NPs have the authority to prescribe Schedule II through Schedule VI controlled substances and devices as set forth in Chapter 34 (§ 54.1-3400 et seq.). This same Code section limits the number of practice agreements a patient care team physician may enter into with nurse practitioners as follows:
E(2). Physicians shall not serve as a patient care team physician on a patient care team or enter into a practice agreement with more than six nurse practitioners at any one time, except that a physician may serve as a patient care team physician on a patient care team with up to 10 nurse practitioners licensed in the category of psychiatric-mental health nurse practitioner.
Full Practice Authority OR Practicing Without a Practice Agreement. In January 2019, the Virginia General Assembly enacted legislation allowing NPs with the equivalent of 5 years of clinical experience to apply for the autonomous practice designation on their licenses which enables them to practice without a practice agreement. During the COVID pandemic, NPs with 2 or more years of clinical experience were permitted to practice without a practice agreement by Executive Order. In response, the General Assembly enacted legislation in spring of 2021 reducing the clinical experience requirement from 5 years to 2 years. Due to a “sunset” provision on the 2021 legislation, the law reverted back to the 5-year clinical experience requirement in July 2022.
Practice. CNMs specialize in women's reproductive health and childbirth, caring for women during their pregnancies, childbirth, and postpartum, performing things like gynecological check-ups, family planning, assisting physicians during C-section births. They practice in accordance with the Standards for the Practice of Midwifery set by the American College of Nurse-Midwives.
In Virginia, a CNM who has practiced fewer than 1,000 hours shall enter into a practice agreement with a CNM who has practiced for at least two years prior to entering into the practice agreement OR a licensed physician. Such practice agreement shall address the availability of the CNM OR licensed physician for routine and urgent consultation on patient care. Evidence of the practice agreement shall be maintained by the CNM and provided to the Boards upon request. See Guidance Document 90-56 for a summary of practice agreement requirements.
Prescriptive Authority. According to § 54.1-2957.01, CNMs have the authority to prescribe Schedule II through Schedule VI controlled substances and devices as set forth in Chapter 34 (§ 54.1-3400 et seq.).
Full Practice Authority OR Practicing Without a Practice Agreement. In July 2021, legislation was enacted in Virginia permitting CNMs to practice without a practice agreement after completion of 1,000 hours of clinical experience attested to by an experienced CNM or physician who supervised such experience. The Board of Nursing does not have the authority to place an autonomous practice designation on CNM licenses. The CNM need only have the receipt of attestation documenting having met the 1,000-hour practice requirement. (Note: The autonomous practice attestation fee in the fee schedule does not apply to CNMs.)
See the full statute at § 54.1-2957(H).
Practice. CRNAs provide the full spectrum of anesthesia care and anesthesia-related care for individuals across the lifespan, whose health status may range from healthy through all recognized levels of acuity, including persons with immediate, severe, or life-threatening illnesses or injury. This care is provided in diverse settings, including hospital surgical suites and obstetrical delivery rooms; critical access hospitals; acute care; pain management centers; ambulatory surgical centers; and the offices of practitioners such as surgeons, dentists, podiatrists and ophthalmologists.
Certified registered nurse anesthetist is defined as an APRN who is “certified in the specialty of nurse anesthesia, who is jointly licensed by the Boards of Medicine and Nursing as a nurse practitioner pursuant to § 54.1-2957, and who practices under the supervision of a doctor of medicine, osteopathy, podiatry, or dentistry but is not subject to the practice agreement requirement described in § 54.1-2957.” This definition comes from Chapter 29 of the Virginia Code (Medicine and Other Healing Arts), while regulations reside with the Board of Nursing.
As noted in the statute above, Virginia CRNAs are supervised; however, “supervision” is not specifically defined in the laws or regulations regarding CRNA practice thus leaving it open to interpretation. It is important to note that Virginia laws and regulations do not specify that a supervisor, anesthesiologist or not, be on site.
Prescriptive Authority: According to § 54.1-2957.01(H), CRNAs have the authority to prescribe Schedule II through Schedule VI controlled substances and devices as set forth in Chapter 34 (§ 54.1-3400 et seq.) to a patient requiring anesthesia, as part of the periprocedural care of such patient. As used in this subsection, "periprocedural" means the period beginning prior to a procedure and ending at the time the patient is discharged.
Full Practice Authority OR Practicing Without a Practice Agreement. CRNAs do not have independent practice or independent prescriptive authority in Virginia due to the supervisory requirement.
Practice. Virginia began registering CNSs in 1989 and only began licensing CNSs in July 2021. A “clinical nurse specialist” is an APRN who is certified in the specialty of clinical nurse specialist and who is jointly licensed by the Boards of Medicine and Nursing pursuant to § 54.1-2957. A CNS who does not prescribe may practice without a practice agreement.
CNSs integrate care across the continuum and through three spheres of influence: patient, nurse, system. The three spheres are overlapping and interrelated, but each sphere possesses a distinctive focus. In each of the spheres of influence, the primary goal of the CNS is continuous improvement of patient outcomes and nursing care. Key elements of CNS practice are to create environments through mentoring and system changes that empower nurses to develop caring, evidence-based practices to alleviate patient distress, facilitate ethical decision-making, and respond to diversity.
Prescriptive Authority. CNSs must obtain prescriptive authority in order to prescribe Schedules II through VI controlled substances. Once prescriptive authority is obtained, the CNS is required in statute (§ 54.1-2957(J)) to practice in consultation with a licensed physician in accordance with a practice agreement. Such practice agreement shall address the availability of the physician for routine and urgent consultation on patient care. There is no mechanism for CNSs to independently prescribe.
Full Practice Authority OR Practicing Without a Practice Agreement. CNSs may practice independently without a practice agreement unless they obtain prescriptive authority.
A bona fide practitioner-patient relationship must be established prior to issuing any controlled substance (all prescribed medications are considered “controlled substances” in Virginia). According to § 54.1-3303(B), a bona fide practitioner-patient relationship exists when the prescriber has:
Except in cases involving a medical emergency, the examination required in 3 above shall be performed by the practitioner prescribing the controlled substance, a practitioner who practices in the same group as the practitioner prescribing the controlled substance, or a consulting practitioner. Additional requirements including modalities for establishing a practitioner-patient relationship are outlined later in this section of Virginia Code.
Although several Virginia statutes address telemedicine, the Board of Nursing concurs with the guidance document adopted by the Board of Medicine regarding the practice of telemedicine in Virginia. A common question is – “what are the licensure requirements to provide healthcare via telehealth to patients in Virginia?” In order to provide care via telemedicine, providers must be licensed in both the state where they are located and the state where the patient is located as fully described in Guidance Document 90-64:
“The practice of medicine occurs where the patient is located at the time telemedicine services are used, and insurers may issue reimbursements based on where the practitioner is located. Therefore, a practitioner must be licensed by, or under the jurisdiction of, the regulatory board of the state where the patient is located and the state where the practitioner is located. Practitioners who treat or prescribe through online service sites must possess appropriate licensure in all jurisdictions where patients receive care. To ensure appropriate insurance coverage, practitioners must make certain that they are compliant with federal and state laws and policies regarding reimbursements.”
Out-of-state Providers, In order to ensure continuity of care, an exception to Chapter 29 – Medicine and Other Healing Arts – was adopted in 2023 expanding the ability of other members of a provider group to provide care when a member of the group who has established a bona fide practitioner-provider relationship is unavailable:
Any doctor of medicine or osteopathy, physician assistant, respiratory therapist, occupational therapist, or nurse practitioner who would otherwise be subject to licensure by the Board who holds an active, unrestricted license in another state or the District of Columbia and who is in good standing with the applicable regulatory agency in that state or the District of Columbia from engaging in the practice of that profession in the Commonwealth with a patient located in the Commonwealth when (i) such practice is for the purpose of providing continuity of care through the use of telemedicine services as defined in § 38.2-3418.16 and (ii) the patient is a current patient of the practitioner with whom the practitioner has previously established a practitioner-patient relationship and the practitioner has performed an in-person examination of the patient within the previous 12 months.
For purposes of this subdivision, if such practitioner with whom the patient has previously established a practitioner-patient relationship is unavailable at the time in which the patient seeks continuity of care, another practitioner of the same subspecialty at the same practice group with access to the patient's treatment history may provide continuity of care using telemedicine services until the practitioner with whom the patient has a previously established practitioner-patient relationship becomes available. For purposes of this subdivision, "practitioner of the same subspecialty" means a practitioner who utilizes the same subspecialty taxonomy code designation for claims processing. (§ 54.1-2901 (35))
Bona fide practitioner-provider relationship via telemedicine. According to § 54.1-3303(B), A prescriber may establish a bona fide practitioner-patient relationship for the purpose of prescribing Schedule II through VI controlled substances by an examination through face-to-face interactive, two-way, real-time communications services or store-and-forward technologies when all of the following conditions are met:
(a) the patient has provided a medical history that is available for review by the prescriber;
(b) the prescriber obtains an updated medical history at the time of prescribing;
(c) the prescriber makes a diagnosis at the time of prescribing;
(d) the prescriber conforms to the standard of care expected of in-person care as appropriate to the patient's age and presenting condition, including when the standard of care requires the use of diagnostic testing and performance of a physical examination, which may be carried out through the use of peripheral devices appropriate to the patient's condition;
(e) the prescriber is actively licensed in the Commonwealth and authorized to prescribe;
(f) if the patient is a member or enrollee of a health plan or carrier, the prescriber has been credentialed by the health plan or carrier as a participating provider and the diagnosing and prescribing meets the qualifications for reimbursement by the health plan or carrier pursuant to § 38.2-3418.16;
(g) upon request, the prescriber provides patient records in a timely manner in accordance with the provisions of § 32.1-127.1:03 and all other state and federal laws and regulations;
(h) the establishment of a bona fide practitioner-patient relationship via telemedicine is consistent with the standard of care, and the standard of care does not require an in-person examination for the purpose of diagnosis; and
(i) the establishment of a bona fide practitioner patient relationship via telemedicine is consistent with federal law and regulations and any waiver thereof.
Nothing in this paragraph shall apply to
(1) a prescriber providing on-call coverage per an agreement with another prescriber or his prescriber's professional entity or employer;
(2) a prescriber consulting with another prescriber regarding a patient's care; or
(3) orders of prescribers for hospital out-patients or in-patients.
A side-by-side comparison is provided below. You may download a PDF of the APRN/LNP Side-by-Side Comparison Chart.
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Virginia APRN/LNP Side-by-Side Comparison | ||||
|---|---|---|---|---|
|
|
NP |
CRNA |
CNM |
CNS |
|
Joint licensure by BON & BOM
|
Yes
|
Yes
|
Yes
|
Yes
|
|
Collaboration/Consultation/ Supervision requirement |
Collaboration and consultation with at least one licensed patient care team physician |
Under supervision of a licensed doctor of medicine, osteopathy, podiatry, or dentistry. |
< 1,000 hours - Consultation with a CNM with 2+ years of practice or a licensed physician |
Consultation with licensed physician only if granted Rx authority |
|
Practice Agreement
|
Yes, if no autonomous practice designation |
No |
Yes, prior to completion of 1,000 hours and receipt of attestation of completion from CNM or physician |
Only if granted Rx authority |
|
Practice Agreement Criteria See GD 90-56 |
-Periodic chart review -Consultation & referrals -Drug categories & devices -PCT physician availability & define consultation -Periodic joint evaluation of services provided -Periodic review & revision of practice agreement -Signature/name of PCT physician clearly stated |
N/A |
-Shall address the availability of the consulting CNM or the licensed physician for routine and urgent consultation on patient care -Prescribing shall also be in accordance with any prescriptive authority included in a such practice agreement |
-Shall address the availability of the physician for routine and urgent consultation on patient care. -Medications if prescribing Schedule II-V |
|
Practice without a Practice Agreement
|
Yes, if granted autonomous practice designation after 5 years of clinical experience |
Yes |
Yes, if CNM receives attestation from CNM or physician at completion of 1,000 hours |
Yes, if CNS does not prescribe |
|
Rx authority |
Schedule II – VI |
Schedule II – VI* |
Schedule II – VI |
Schedule II – VI |
|
* May prescribe to a patient requiring anesthesia, as part of the periprocedural care of such patient. "Periprocedural" means the period beginning prior to a procedure and ending at the time the patient is discharged (§ 54.1-2957.01(H)) |
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Virginia Board of Nursing
Jay P. Douglas, MSM, RN, CSAC, FRE, Executive Director
Cynthia M. Swineford, MSN, RN, CNE, President