                                 CODE OF VIRGINIA

LICENSURE AND PRACTICE OF ADVANCED PRACTICE REGISTERED NURSES; CERTIFIED NURSE
MIDWIVES; INDEPENDENT PRACTICE OF CERTIFIED NURSE MIDWIVES (§ 54.1-2957)

A. As used in this section, &#8220;clinical experience&#8221; means the
postgraduate delivery of health care directly to patients pursuant to a practice
agreement with a patient care team physician.

B. The Board of Medicine and the Board of Nursing shall jointly prescribe the
regulations governing the licensure of advanced practice registered nurses. It
is unlawful for a person to practice as an advanced practice registered nurse in
the Commonwealth unless he holds such a joint license.

C. Every nurse practitioner who does not meet the requirements of subsection I
shall maintain appropriate collaboration and consultation, as evidenced in a
written or electronic practice agreement, with at least one patient care team
physician. A nurse practitioner who meets the requirements of subsection I may
practice without a written or electronic practice agreement. A certified nurse
midwife shall practice pursuant to subsection H. A clinical nurse specialist
shall practice pursuant to subsection J. A certified registered nurse
anesthetist shall practice under the supervision of a licensed doctor of
medicine, osteopathy, podiatry, or dentistry. An advanced practice registered
nurse who is appointed as a medical examiner pursuant to &#xA7; 32.1-282 shall
practice in collaboration with a licensed doctor of medicine or osteopathic
medicine who has been appointed to serve as a medical examiner pursuant to
&#xA7; 32.1-282. Collaboration and consultation among advanced practice
registered nurses and patient care team physicians may be provided through
telemedicine as described in &#xA7; 38.2-3418.16.
			Physicians on patient care teams may require that an advanced practice
registered nurse be covered by a professional liability insurance policy with
limits equal to the current limitation on damages set forth in &#xA7;
8.01-581.15.
			Service on a patient care team by a patient care team member shall not, by
the existence of such service alone, establish or create liability for the
actions or inactions of other team members.

D. The Boards of Medicine and Nursing shall jointly promulgate regulations
specifying collaboration and consultation among physicians and advanced practice
registered nurses working as part of patient care teams that shall include the
development of, and periodic review and revision of, a written or electronic
practice agreement; guidelines for availability and ongoing communications that
define consultation among the collaborating parties and the patient; and
periodic joint evaluation of the services delivered. 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 advanced practice registered nurse and the patient
care team physician and (ii) input from appropriate health care providers in
complex clinical cases and patient emergencies and for referrals. Evidence of a
practice agreement shall be maintained by an advanced practice registered nurse
and provided to the Boards upon request. For advanced practice registered nurses
providing care to patients within a hospital or health care system, the practice
agreement may be included as part of documents delineating the advanced practice
registered nurse&#8217;s clinical privileges or the electronic or written
delineation of duties and responsibilities in collaboration and consultation
with a patient care team physician.

E. The Boards of Medicine and Nursing may issue a license by endorsement to an
applicant to practice as an advanced practice registered nurse if the applicant
has been licensed as an advanced practice registered nurse under the laws of
another state and, pursuant to regulations of the Boards, the applicant meets
the qualifications for licensure required of advanced practice registered nurses
in the Commonwealth. An advanced practice registered nurse to whom a license is
issued by endorsement may practice without a practice agreement with a patient
care team physician pursuant to subsection I if such application provides an
attestation to the Boards that the applicant has completed the equivalent of at
least three years of full-time experience, as determined by the Boards, in
accordance with the laws of the state in which the nurse practitioner was
licensed.

F. Pending the outcome of the next National Specialty Examination, the Boards
may jointly grant temporary licensure to advanced practice registered nurses.

G. In the event a physician who is serving as a patient care team physician
dies, becomes disabled, retires from active practice, surrenders his license or
has it suspended or revoked by the Board, or relocates his practice such that he
is no longer able to serve, or for other good cause, and an advanced practice
registered nurse is unable to enter into a new practice agreement with another
patient care team physician, the advanced practice registered nurse may continue
to practice upon notification to the designee or his alternate of the Boards and
receipt of such notification. Such advanced practice registered nurse may
continue to treat patients without a patient care team physician for an initial
period not to exceed 60 days, provided that the advanced practice registered
nurse continues to prescribe only those drugs previously authorized by the
practice agreement with such physician and to have access to appropriate input
from appropriate health care providers in complex clinical cases and patient
emergencies and for referrals. The designee or his alternate of the Boards shall
grant permission for the advanced practice registered nurse to continue practice
under this subsection for another 60 days, provided that the advanced practice
registered nurse provides evidence of efforts made to secure another patient
care team physician and of access to physician input. At the conclusion of the
second 60-day period, provided that the advanced practice registered nurse
provides evidence of the continued efforts to secure another patient care team
physician and of access to physician input, the designee or his alternate of the
Boards may grant permission for the advanced practice registered nurse to
continue practicing under the management and leadership of a nurse practitioner
licensed by the Boards of Medicine and Nursing who (i) meets the requirements of
subsection I, (ii) routinely practiced with a patient population and in a
practice area within the category for which the advanced practice registered
nurse was certified and licensed, and (iii) has been authorized to practice
without a written or electronic practice agreement for at least three years.

H. Every certified nurse midwife shall practice in accordance with regulations
adopted by the Boards and consistent with the Standards for the Practice of
Midwifery set by the American College of Nurse-Midwives governing such practice.
A certified nurse midwife who has practiced fewer than 1,000 hours shall
practice in consultation with a licensed physician or an independent practice
midwife, in accordance with a practice agreement. Such practice agreement shall
address the availability of the licensed physician or independent practice
midwife for routine and urgent consultation on patient care. Evidence of the
practice agreement shall be maintained by the certified nurse midwife and
provided to the Boards upon request. A certified nurse midwife who has completed
1,000 hours of practice as a certified nurse midwife may practice without a
practice agreement upon receipt by the certified nurse midwife of an attestation
from the licensed physician or independent practice midwife with whom the
certified nurse midwife has entered into a practice agreement stating (i) that
such licensed physician or independent practice midwife has provided
consultation to the certified nurse midwife pursuant to a practice agreement
meeting the requirements of this section and (ii) the period of time for which
such licensed physician or independent practice midwife practiced in
collaboration and consultation with the certified nurse midwife pursuant to the
practice agreement. A certified nurse midwife authorized to practice without a
practice agreement shall consult and collaborate with and refer patients to such
other health care providers as may be appropriate for the care of the patient.
			For the purposes of this subsection, &#8220;independent practice
midwife&#8221; means a licensed certified midwife who is authorized to practice
without a practice agreement pursuant subsection D of &#xA7; 54.1-2957.04 and
has practiced independently for two years or a certified nurse midwife who is
authorized to practice without a practice agreement pursuant to this subsection
and has practiced independently for two years.

I. A nurse practitioner who has completed the equivalent of at least three years
of full-time clinical experience, as determined by the Boards, may practice in
the practice category in which he is certified and licensed without a written or
electronic practice agreement upon receipt by the nurse practitioner of an
attestation from either (i) the patient care team physician or (ii) an attesting
nurse practitioner who assumed management and leadership of a nurse practitioner
pursuant to subsection G and has met the requirements of this subsection for at
least three years stating (a) that the patient care team physician or attesting
nurse practitioner has served as a patient care team physician or attesting
nurse practitioner, respectively, on a patient care team with the nurse
practitioner pursuant to a practice agreement meeting the requirements of this
section and &#xA7; 54.1-2957.01; (b) that while a party to such practice
agreement, the patient care team physician or attesting nurse practitioner
routinely practiced with a patient population and in a practice area included
within the category for which the nurse practitioner was certified and licensed;
and (c) the period of time for which the patient care team physician or
attesting nurse practitioner practiced with the nurse practitioner under such a
practice agreement. A copy of such attestation shall be submitted to the Boards
together with a fee established by the Boards. Upon receipt of such attestation
and verification that a nurse practitioner satisfies the requirements of this
subsection, the Boards shall issue to the nurse practitioner a new license that
includes a designation indicating that the nurse practitioner is authorized to
practice without a practice agreement. In the event that a nurse practitioner is
unable to obtain the attestation required by this subsection, the Boards may
accept other evidence demonstrating that the applicant has met the requirements
of this subsection in accordance with regulations adopted by the Boards.
			A nurse practitioner authorized to practice without a practice agreement
pursuant to this subsection shall (1) only practice within the scope of his
clinical and professional training and limits of his knowledge and experience
and consistent with the applicable standards of care, (2) consult and
collaborate with other health care providers based on the clinical conditions of
the patient to whom health care is provided, and (3) establish a plan for
referral of complex medical cases and emergencies to physicians or other
appropriate health care providers.

J. A clinical nurse specialist licensed by the Boards of Medicine and Nursing
who does not prescribe controlled substances or devices may practice in the
practice category in which he is certified and licensed without a written or
electronic practice agreement. Such clinical nurse specialist shall (i) only
practice within the scope of his clinical and professional training and limits
of his knowledge and experience and consistent with the applicable standards of
care, (ii) consult and collaborate with other health care providers based on the
clinical condition of the patient to whom health care is provided, and (iii)
establish a plan for referral of complex medical cases and emergencies to
physicians or other appropriate health care providers.
			A clinical nurse specialist licensed by the Boards who prescribes controlled
substances or devices shall practice in consultation with a licensed physician
in accordance with a practice agreement between the clinical nurse specialist
and the licensed physician. Such practice agreement shall address the
availability of the physician for routine and urgent consultation on patient
care. Evidence of a practice agreement shall be maintained by a clinical nurse
specialist and provided to the Boards upon request. The practice of clinical
nurse specialists shall be consistent with the standards of care for the
profession and with applicable laws and regulations.

HISTORY: Code 1950, § 54-274; 1950, p. 98; 1958, c. 161; 1962, c. 127; 1966, c.
657; 1970, c. 69; 1973, cc. 105, 514, 529; 1975, c. 508; 1976, c. 15; 1980, c.
157; 1982, c. 220; 1985, cc. 303, 347; 1986, c. 377; 1988, c. 765; 2006, c. 750;
2012, c. 213; 2015, c. 107; 2016, cc. 308, 409, 495; 2018, c. 776; 2019, cc. 92,
137; 2021, Sp. Sess. I, cc. 1, 157, 396; 2022, cc. 197, 563; 2023, c. 183; 2024,
c. 404; 2025, cc. 544, 557.