2013 -- S 0197

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LC00576

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STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2013

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A N A C T

RELATING TO BUSINESSES AND PROFESSIONS - NURSES AND NURSE

ANESTHETISTS

     Introduced By: Senators Doyle, Lynch, Gallo, and Cool Rumsey

     Date Introduced: February 06, 2013

     Referred To: Senate Health & Human Services

It is enacted by the General Assembly as follows:

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     SECTION 1. Sections 5-34-3, 5-34-4, 5-34-7, 5-34-35, 5-34-36, 5-34-36, 5-34-37, 5-34-

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38, 5-34-39, 5-34-40 and 5-34-42 of the General Laws in Chapter 5-34 entitled “Nurses” are

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hereby amended to read as follows:

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     5-34-3. Definitions. -- As used in this chapter:

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     (1) "Advanced practice nurse" means the status of qualified individuals who hold an

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active license as a registered nurse and an active license as a nurse in an advanced role as defined

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under the provisions of this chapter or chapter 5-34.2.

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     (2) "Approval" means the process where the board of nursing evaluates and grants

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official recognition to basic nursing education programs meeting established criteria and

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standards.

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     (3) "Certified registered nurse practitioner" “Advanced Practice Registered Nurse

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(APRN) (including Certified Nurse Practitioner (CNP); Certified Registered Nurse Anesthetist

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(CRNA); Certified Clinical Nurse Specialist, (CNS))” is an advanced practice nurse utilizing

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independent knowledge of physical assessment and management of health care and illnesses. The

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practice may include includes prescriptive privileges. The practice includes collaboration with

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other licensed health care professionals including, but not limited to, physicians, pharmacists,

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podiatrists, dentists and nurses. Practice as an APRN means an expanded scope of nursing in a

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role and population focus accepted by the BON with or without compensation or personal profit,

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and includes the RN scope of practice. The scope of an APRN includes, but is not limited to,

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performing acts of advanced assessment, diagnosing, prescribing and ordering. APRNs may serve

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as primary care providers of record.

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     APRNs are expected to practice as licensed practitioners within their scope of practice

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recognized by the BON or state statute. Each APRN is accountable to patients, the nursing

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profession and the BON for complying with the requirements of this section and the quality of

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advanced nursing care rendered; for recognizing limits of knowledge and experience; planning

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for the management of situations beyond the APRN’s expertise; and for consulting with or

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referring patients to other health care providers as appropriate.

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     (4) "Department" means the department of health.

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     (5) "Health" means optimum well-being.

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     (6) "Healthcare" means those services provided to promote the optimum well-being of

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individuals.

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     (7) "Licensed" means the status of qualified individuals who have completed a designated

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process by which the board of nursing grants permission to individuals accountable and/or

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responsible for the practice of nursing and to engage in that practice, prohibiting all others from

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legally doing so.

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     (8) "Nursing" means the provision of services that are essential to the promotion,

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maintenance, and restoration of health throughout the continuum of life. It provides care and

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support of individuals and families during periods of wellness, illness, and injury, and

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incorporates the appropriate medical plan of care prescribed by a licensed physician, dentist, or

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podiatrist. It is a distinct component of health services. Nursing practice is based on specialized

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knowledge, judgment, and nursing skills acquired through educational preparation in nursing and

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in the biological, physical, social, and behavioral sciences.

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     (9) "Practical nursing" is practiced by licensed practical nurses (L.P.N.s). It is an integral

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part of nursing based on a knowledge and skill level commensurate with education. It includes

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promotion, maintenance, and restoration of health and utilizes standardized procedures leading to

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predictable outcomes, which are in accord with the professional nurse regimen under the direction

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of a registered nurse. In situations where registered nurses are not employed, the licensed

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practical nurse functions under the direction of a licensed physician, dentist, podiatrist or other

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licensed health care providers authorized by law to prescribe. Each L.P.N. is responsible for the

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nursing care rendered.

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     (10) "Professional nursing" is practiced by registered nurses (R.N.s). The practice of

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professional nursing is a dynamic process of assessment of an individual's health status,

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identification of health care needs, determination of health care goals with the individual and/or

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family participation and the development of a plan of nursing care to achieve these goals. Nursing

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actions, including teaching and counseling, are directed toward the promotion, maintenance, and

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restoration of health and evaluation of the individual's response to nursing actions and the

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medical regimen of care. The professional nurse provides care and support of individuals and

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families during periods of wellness and injury, and incorporates where appropriate, the medical

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plan of care as prescribed by a licensed physician, dentist or podiatrist or other licensed health

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care providers authorized by law to prescribe. Each R.N. is directly accountable and responsible

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to the consumer for the nursing care rendered.

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     (11) "Psychiatric and mental health nurse clinical specialist" is an advanced practice

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nurse utilizing independent knowledge and management of mental health and illnesses. The

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practice may include prescription privileges of certain legend medications, controlled substances

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from Schedule II classified as stimulants, and controlled substances from Schedule IV within the

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scope of their practice. The practice may include collaboration with other licensed health care

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professionals, including, but not limited to, psychiatrists, psychologists, physicians, pharmacists,

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and nurses. The psychiatric and mental health clinical specialist holds the qualifications defined

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in § 5-34-40.1.

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     5-34-4. Board of nursing – Establishment – Composition – Appointment, terms, and

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removal of members – Director of nurse registration and nursing education. -- (a) Within the

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division of professional regulation, pursuant to chapter 26 of this title, there is a board of nurse

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registration and nursing education. The board shall be composed of fifteen (15) members. The

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term of office shall be for three (3) years. No member shall serve more than two (2) consecutive

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terms. The member shall serve until a qualified successor is appointed to serve. In making those

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appointments, the director of the department of health shall consider persons suggested by

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professional nurse organizations and the practical nurse's association.

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     (b) Present members of the board holding office under the provisions of this chapter shall

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serve as members of the board until the expiration of their terms or until qualified successors are

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appointed. The fifteen (15) member board shall include: eleven (11) professional nurses, two (2)

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practical nurses appointed by the director of health and approved by the governor and two (2)

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members of the general public appointed by the governor. Three (3) professional nurses shall be

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from different basic education programs preparing students to become nurses; one professional

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nurse shall be from a nursing service administration; four (4) professional non-administrative,

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clinical nurses not licensed as advanced practice nurses, and three (3) professional advanced

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practice nurses, one who holds a license as a certified registered nurse anesthetist, one who holds

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a license as a certified registered nurse practitioner, and one who holds a license as a psychiatric

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and mental health nurse clinical nurse specialist. No educational program or cooperating agency

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shall have more than one representative on the board.

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     (c) The director of health may remove any member from the board for cause including,

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but not limited to, neglect of any duty required by law, or incompetence, or unprofessional

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conduct, or willful misconduct. A member subject to disciplinary proceedings shall be

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disqualified from board business until the charge is adjudicated. There shall also be a director of

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nurse registration and nursing education appointed by the director of health in accordance with

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the provisions of chapter 4 of title 36.

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     5-34-7. Board of nursing – General powers. -- The board of nurse registration and

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nursing education is authorized, subject to the approval of the director of the department of

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health, to:

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     (1) Adopt, review, or revise rules, and regulations consistent with the law that may be

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necessary to effect provisions of the chapter;

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     (2) Approve nursing education programs according to the rules established by the board;

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     (3) Require standards for nursing practice within organized nursing services and the

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individual practice of licensees;

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     (4) Approve the examinations for licensure;

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     (5) Establish requirements to validate competence for reinstatement to the active list;

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     (6) Conduct hearings upon charges calling for discipline of a licensee or revocation of a

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license;

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     (7) Issue subpoenas to, compel the attendance of witnesses at, and administer oaths to

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persons giving testimony at hearings;

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     (8) Cause the prosecution or enjoinder of all persons violating this chapter;

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     (9) Maintain a record of all its proceedings;

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     (10) Submit an annual report to the director of the department of health;

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     (11) Utilize other persons that may be necessary to carry on the work of the board;

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     (12) Conduct public hearings, investigations, and studies of nursing practice, nursing

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education, and related matters and prepare and issue publications that, in the judgment of the

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board, allow the nursing profession to provide safe, effective nursing services to the public;

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     (13) Determine qualifications necessary for prescriptive privileges for certified registered

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nurse practitioners APRNs;

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     (14) Grant certified registered nurse practitioners APRNs prescriptive privileges;

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     (15) Determine qualification necessary for the prescriptive privileges for psychiatric and

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mental health clinical nurse specialists; and

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     (16) Grant certified psychiatric and mental health clinical nurse specialists prescriptive

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privileges.

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     5-34-35. Qualifications of a certified registered nurse practitioner applicant

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Qualifications of an APRN applicant. -- (a) An applicant for licensure to practice as a certified

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registered nurse practitioner APRN shall submit to the board of nurse registration and nursing

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education written evidence on forms furnished by the division of professional regulation, verified

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by oath, that:

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     (1) The applicant is a registered nurse who has completed an accredited educational

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program resulting in a master's degree, and/or a doctoral degree, in nursing and/or an approved

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nurse practitioner APRN course of study. This curriculum must include both a didactic

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component and supervised clinical experience that includes nationally recognized education

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standards and core competencies for programs preparing individuals in the role. Effective January

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1, 2004 2015, all applicants for initial licensure must complete an accredited educational program

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resulting in a master's degree with a major in nursing.

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     (2) The applicant passed a national qualifying examination recognized by the board of

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nurse registration and nursing education.

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     (b) A license to practice as a certified registered nurse practitioner an APRN may be

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issued to an applicant who is licensed by examination or endorsement as a certified registered

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nurse practitioner an APRN under the laws of another state or territory if, in the opinion of the

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board, the applicant meets the qualifications required of certified registered nurse practitioners

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APRNs in this state.

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     5-34-36. Licensing of certified registered nurse practitioners. Licensing of APRN --

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A license to practice as a certified nurse practitioner an APRN shall be issued if the applicant

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meets the qualifications for the certified registered nurse practitioner (R.N.P.) APRN license.

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Persons who meet the qualifications of a certified registered nurse practitioner, as stated in § 5-

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34-35, and are currently licensed as certified registered nurse practitioners by examination or

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endorsement under the laws of another state of the United States and/or the District of Columbia

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shall be allowed to practice as certified registered nurse practitioners in this state for a period not

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to exceed ninety (90) days from the date of clearance by the board of nurse registration and

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nursing education of the department of health, provided that they are licensed in this state within

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ninety (90) days. The original privilege to work ninety (90) days from the date of clearance shall

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not be extended or renewed.

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     5-34-37. Application fee for certified registered nurse practitioners Application fee

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for APRN. -- The initial application fee for licensure as a certified registered nurse practitioner

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an APRN, the renewal fee for certified registered nurse practitioner an APRN, and the fee for

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application for prescriptive privileges shall be as set forth in section 23-1-54.

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     5-34-38. Right to use certified registered nurse practitioner title. Right to use

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advanced practice registered nurse title – Any person who holds a license to practice as a

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certified registered nurse practitioner an APRN in this state has the right to use the title certified

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registered nurse practitioner an advanced practice registered nurse and use the abbreviation

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"R.N.P". "APRN". No other person may assume that title or use that abbreviation or any other

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words or letters, signs, figures, or devices to indicate that the person using it is a certified

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registered nurse practitioner an advanced practice registered nurse.

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     Individuals are licensed or granted privilege to practice as APRNs in the roles of

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Certified Registered Nurse Anesthetist (CRNA), Certified Clinical Nurse Specialist (CNS), and

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Certified Nurse Practitioner (CNP), and in the population foci of family/individual across the

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lifespan, adult-gerontology, neonatal, pediatrics, women’s health/gender-related, or psychiatric/

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mental health.

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     Each APRN shall use the designation “APRN” plus role title as a minimum for purposes

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of identification and documentation. When providing nursing care, the APRN shall provide clear

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identification that indicates his/her APRN designation. The APRN with an earned doctorate in

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nursing may use the term doctor or abbreviation “Dr.” when providing nursing care.

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     5-34-39. Process for prescriptive privileges of certified registered nurse. Process for

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prescriptive privileges of APRN. -- (a) Prescriptive privileges for the certified registered nurse

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practitioner APRN:

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     (1) Shall be granted under the governance and supervision of the department, board of

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nurse registration and nurse education; and

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     (2) Shall include prescription of legend medications and prescription of controlled

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substances from schedules II, III, IV and V that are established in regulation; and

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     (3) Must not include controlled substances from Schedule I.

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     (b) To qualify for prescriptive privileges an applicant must submit on forms provided by

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the board of nurse registration and nursing education, verified by oath, that the applicant has

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evidence of completion of thirty (30) hours of education in pharmacology within the three (3)

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year period immediately prior to date of application. To maintain prescriptive privileges the

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certified registered nurse practitioner (R.N.P.) must submit upon request of the board of nurse

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registration and nursing education evidence of thirty (30) hours continuing education in

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pharmacology every six (6) years.

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     5-34-40. Advanced practice nurse advisory committee. -- (a) The nine (9) member

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committee consists of two (2) certified registered nurse practitioners, two (2) certified registered

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nurse anesthetists, two (2) psychiatric and mental health certified clinical nurse specialists, one

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physician and two (2) consumers. The director of health shall appoint the committee. In making

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appointments to the committee, the director shall consider persons recommended by professional

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nurse organizations and professional medical associations. The professional members of the

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committee shall be currently engaged in practice. The consumer members shall be: (1)

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knowledgeable in consumer health concerns; (2) a resident of the state; (3) not licensed as a

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health care practitioner; (4) not a parent, spouse, sibling, or child of a person licensed as a health

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care practitioner, and not a student in a professional program; (5) not having a direct financial

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interest in health care services; (6) not a member or an employee of any board of control of any

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public or private health care service.

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     (b) Each member appointment shall be for three (3) years, with no member serving more

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than two (2) consecutive three (3) year terms except that in making the initial appointments the

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director designates: four (4) members for a term of two (2) years; three (3) members for a term of

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three (3) years; and the consumer members for three (3) year terms.

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     (c) This committee must meet not fewer than two (2) times per year. The committee has

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the following functions:

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     (1) To assess advanced nursing practice for the purpose of improving patient care.

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     (2) To review all complaints regarding advanced practice nurses, and recommend any

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and all disciplinary or corrective action that they deem appropriate, including revocation and

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suspension of license, upon proof that an advanced practice nurse has:

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     (A) Aided or abetted an uncertified person to practice as an advanced practice nurse;

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     (B) Become addicted to the use of liquor or controlled substances;

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     (C) Negligently, willfully, or intentionally acted in a manner inconsistent with the health

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and safety of persons entrusted to his or her care;

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     (D) Had his or her authorization to practice as an advanced practice nurse denied,

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revoked or suspended in another state;

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     (E) Engaged in the performance of medical functions beyond the scope of practice

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authorized by the provisions of this chapter;

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     (F) Willfully failed to file or record medical records and reports;

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     (G) Mental incompetence; or

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     (H) Willfully failed to maintain standards established by the nursing profession.

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     (ii) The recommendation shall be submitted to the board of nursing for implementation.

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     (3) To advise periodically to the board of nurse registration and nursing education

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regarding advanced nurse practice.

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     5-34-42.Global signature authority of certified registered nurse. Global signature

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authority of APRN -- Whenever any provision of the general or public law, or regulation

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requires a signature, certification, stamp, verification, affidavit or endorsement by a physician, it

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shall be deemed to include a signature, certification, stamp, verification, affidavit or endorsement

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by a certified registered nurse practitioner an advanced practice registered nurse; provided,

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however, that nothing in this section shall be construed to expand the scope of practice of nurse

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practitioners APRNS.

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     SECTION 2. Sections 5-34-40.1 and 5-34-40.2 of the General Laws in Chapter 5-34

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entitled “Nurses” are hereby repealed in its entirety.

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     5-34-40.1.Qualifications of a psychiatric and mental health clinical nurse specialist

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applicant. -- (a) An applicant for licensure as a psychiatric and mental health clinical nurse

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specialist shall submit to the board written evidence on forms furnished by the department of

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health, verified by oath, that the applicant:

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     (1) Is a registered nurse who has completed an accredited educational program resulting

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in a master's degree in psychiatric and mental health nursing; and/or

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     (2) Passed a national qualifying examination recognized by the board.

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     (b) All persons who are engaged in the practice of a psychiatric and mental health clinical

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nurse specialist on July 1, 2003, who meet the definition in § 5-34-3(i) may be considered to have

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met the qualifications for licensure providing they have three (3) years experience acceptable to

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the board between January 1, 1997, and January 1, 2003. After January 1, 2004, all applicants for

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initial licensure must complete an accredited educational program resulting in a master's degree in

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nursing and must pass a national qualifying examination recognized by the board.

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     5-34-40.2. Licensing of psychiatric and mental health clinical nurse specialists. -- A

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license to practice as a psychiatric clinical nurse specialist shall be issued if the applicant meets

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the qualifications for the psychiatric and mental health clinical nurse specialist. Persons who meet

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the qualifications of a psychiatric and mental health clinical nurse specialist, as stated in § 5-34-

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40.1, and are currently licensed as psychiatric and mental health clinical nurse specialists by

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examination or endorsement under the laws of another state or territory of the United States

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and/or the District of Columbia shall be allowed to practice as psychiatric and mental health

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clinical nurse specialists in this state for a period not to exceed ninety (90) days from the date of

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clearance by the board of nurse registration and nursing education of the Rhode Island department

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of health, provided that they are licensed in this state within ninety (90) days. The original

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privilege to work ninety (90) days from the date of clearance shall not be extended or renewed.

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     SECTION 3. Chapter 5-34 of the General Laws entitled “Nurses” is hereby amended by

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adding thereto the following section:

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     5-34-44. Status of current licensees.-- (a) Any person holding a license to practice

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nursing as a Registered Nurse Practitioner (RNP), Psychiatric Clinical Nurse Specialist, Certified

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Registered Nurse Anesthetist in this state that is valid on December 31, 2014 shall be deemed to

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be licensed as an APRN, with his or her current privileges and shall be eligible for renewal of

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such license as defined under the provisions of this chapter or chapter 5-34.2.

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     (b) Any person holding a valid license to practice nursing, having graduated from an

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accredited course of study, actively practicing in an advanced practice role, and holding national

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certification related to his or her current practice setting, as of Dec. 31, 2014, as defined in

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chapters 5-34 or 5-34.2 shall be deemed to be eligible to license as an APRN.

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     (c) After December 31, 2014, all new applicants for APRN licensure must meet the

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stipulated licensure requirements.

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     (d) An APRN applying for licensure by endorsement in another state would be eligible

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for licensure if he/she demonstrates that the following criteria have been met:

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     (1) Current, active practice in the advanced role; and

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     (2) Current active national certification, or recertification as applicable, in the advanced

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role.

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     SECTION 4. Sections 5-34.2-2 and 5-34.2-3 of the General Laws in Chapter 5-34.2

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entitled “Nurse Anesthetists” are hereby amended to read as follows:

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     5-34.2-2. Definitions. -- (a) "Board" means the board of nurse registration and nurse

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education established in § 5-34-4.

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       (b) "Certified registered nurse anesthetist" (CRNA) means a registered nurse who has

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successfully met the requirements stated in this chapter.

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       (c) "Practice of certified registered nurse anesthesia" means providing certain health

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care services under the supervision of in collaboration with anesthesiologists, licensed physicians,

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or licensed dentists in accordance with § 5-31.1-1(16) which requires substantial specialized

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knowledge, judgment and skill related to the administration of anesthesia, including preoperative

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and postoperative assessment of patients; administering anesthetics; monitoring patients during

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anesthesia; management of fluid in intravenous therapy and management of respiratory care.

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     5-34.2-3. Requirements for licensure of the nurse anesthetist. -- Requirements for

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licensure as a nurse anesthetist shall consist of the following:

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       (1) Current licensure as a professional registered nurse in the state; and

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       (2) Graduation from an educational program accredited by the American Association of

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Nurse Anesthetists council on accreditation of nurse anesthesia educational programs or its

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predecessors or successors, and which has as its objective preparation of nurses to practice nurse

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anesthesia; and

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       (3)(2) Initial certification by the American Association of Nurse Anesthetists council on

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certification of nurse anesthetists and recertification, as applicable by the American Association

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of Nurse Anesthetists council on recertification of nurse anesthetists or their predecessors or

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successors.

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       (4) The requirements stated in subdivision (3) of this section do not apply to a graduate

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nurse anesthetist awaiting initial certification results, providing that initial certification is

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accomplished within ninety (90) days upon completion of an accredited nurse anesthesia

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educational program.

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       (5)(3)The requirements stated in subdivisions (2) and (3) of this section do not apply to

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a professional registered nurse who practices nursing in accordance with the provisions of the

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Nurse Practice Act, chapter 34 of this title, and who is enrolled as a bona fide student in an

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accredited nurse anesthesia program providing nurse anesthesia under the supervision of a

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certified registered nurse anesthetist and anesthesiologist.

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       (6)(4) Beginning July 21, 1992, all nurse anesthetists shall be afforded the same period

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of time to become licensed. Notwithstanding the provisions of this section, no person practicing

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as a nurse anesthetist in Rhode Island on July 1, 1991, shall be required to obtain proper

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certification under this chapter. However, as required by subdivision (3) of this section, persons

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who become certified under this section shall become recertified as applicable.

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     SECTION 2. This act shall take effect upon passage.

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LC00576

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N A C T

RELATING TO BUSINESSES AND PROFESSIONS - NURSES AND NURSE

ANESTHETISTS

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     This act would amend the general laws to recognize the Advanced Practice Registered

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Nurse.

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     This act would take effect upon passage.

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LC00576

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