Eliminates certain practice restrictions for advanced practice nurses, the official text

SENATE, No. 2996

STATE OF NEW JERSEY

222nd LEGISLATURE

PRE-FILED FOR INTRODUCTION IN THE 2026 SESSION

Sponsored by:

Senator JOSEPH F. VITALE

District 19 (Middlesex)

Senator TROY SINGLETON

District 7 (Burlington)

Co-Sponsored by:

Senators Diegnan, Zwicker, Cryan, Stack, Cruz-Perez, Beach,
Johnson, Turner, O'Scanlon, Greenstein, Ruiz, Burgess, Holzapfel, Steinhardt,
Testa, McKnight, Timberlake, McKeon, Moriarty, Corrado, Henry, Wimberly, Space,
Amato and Mukherji

SYNOPSIS

Eliminates certain practice restrictions for advanced
practice nurses.

CURRENT VERSION OF TEXT

Introduced Pending Technical Review by Legislative
Counsel.

An Act concerning advanced practice nurses, revising
various parts of the statutory law, and supplementing P.L.1991, c.377
(C.45:11-45 et al.).

Be It
Enacted by the Senate and General Assembly of
the State of New Jersey:

1.    (New section) The
Legislature finds and declares that:

a.     Advanced practice
nurses are registered nurses who are certified to provide an advanced level of
health care to patients that exceeds the standard scope of nursing practice.

b.    Advanced practice nurses
augment the system of care in New Jersey and nationwide by providing treatment
services at a level that can relieve some of the demand on physicians, of whom
there is a chronic shortage, and expedite access to care for patients, including
those in medically underserved areas and among medically underserved
populations.

c.     Studies suggest that
approximately one quarter of the population of the United States lives in an
area with a shortage of primary care professionals.  Limited access to care is
frequently worse among racial and ethnic minorities, people with low incomes,
and individuals for whom a lack of transportation creates logistical barriers
to health care.

d.    One way to reduce gaps
in health care access is to allow full practice authority for advanced practice
nurses, over 75 percent of whom are educated in a primary care specialty and
can directly improve access to both primary care services and specialty care
services.

e.     Currently, 24 states,
the District of Columbia, and two U.S. territories have adopted full practice
authority for advanced practice nurses.  The requirement to practice in
collaboration with a physician limits the ability of advanced practice nurses
to provide primary care and specialty care services, and has been associated
with advanced practice nurses leaving New Jersey for other jurisdictions with
fewer practice restrictions.

f.     It has been estimated
that removing practice restrictions for advanced practice nurses has the
potential to reduce health care access disparities by a factor of more than 38
percent.

g.    In response to the
coronavirus disease 2019 (COVID-19) pandemic, Governor Murphy issued Executive
Order No. 112, which, among other things, directly and through waivers issued
pursuant to its authority, waived existing practice restrictions for advanced
practice nurses, including joint protocol and supervision requirements.

h.    According to surveys,
over 45 percent of advanced practice nurses in New Jersey reported working
without practice restrictions as authorized under Executive Order No. 112 and
the waivers issued pursuant to the executive order.  No adverse incidents were reported
during the waiver period involving advanced practice nurses practicing without
practice restrictions.

i.     Given the need for
expanded access to care, it is necessary and appropriate to take steps to
remove practice restrictions that serve as a barrier for advanced practice
nurses to practice in New Jersey to the full extent of their education,
clinical training, and national certification.

2.    Section 1 of P.L.1947,
c.262 (C.45:11-23) is amended to read as follows:

1.    As used in this act:

a.     The words "the
board" mean the New Jersey Board of Nursing created by this act.

b.    The practice of nursing
as a registered professional nurse is defined as diagnosing and treating human
responses to actual or potential physical and emotional health problems,
through such services as casefinding, health teaching, health counseling, and provision
of care supportive to or restorative of life and well-being, and executing
medical regimens as prescribed by a licensed or otherwise legally authorized
physician or dentist. Diagnosing in the context of nursing practice means the
identification of and discrimination between physical and psychosocial signs
and symptoms essential to effective execution and management of the nursing
regimen within the scope of practice of the registered professional nurse.
Such diagnostic privilege is distinct from a medical diagnosis.  Treating means
selection and performance of those therapeutic measures essential to the
effective management and execution of the nursing regimen.  Human responses
means those signs, symptoms, and processes which denote the individual's health
need or reaction to an actual or potential health problem.

The practice of nursing as a
licensed practical nurse is defined as performing tasks and responsibilities
within the framework of casefinding; reinforcing the patient and family
teaching program through health teaching, health counseling and provision of
supportive and restorative care, under the direction of a registered nurse or
licensed or otherwise legally authorized physician or dentist.

The terms "nursing,"
"professional nursing," and "practical nursing" as used in
this act shall not be construed to include nursing by students enrolled in a
school of nursing accredited or approved by the board performed in the
prescribed course of study and training, nor nursing performed in hospitals,
institutions and agencies approved by the board for this purpose by graduates
of such schools pending the results of the first licensing examination
scheduled by the board following completion of a course of study and training
and the attaining of age qualification for examination, or thereafter with the
approval of the board in the case of each individual pending results of
subsequent examinations; nor shall any of said terms be construed to include
nursing performed for a period not exceeding 12 months unless the board shall
approve a longer period, in hospitals, institutions or agencies by a nurse
legally qualified under the laws of another state or country, pending results
of an application for licensing under this act, if such nurse does not
represent or hold himself or herself out as a nurse licensed to practice under
this act; nor shall any of said terms be construed to include the practice of
nursing in this State by any legally qualified nurse of another state whose
engagement made outside of this State requires such nurse to accompany and care
for the patient while in this State during the period of such engagement, not
to exceed six months in this State, if such nurse does not represent or hold himself
or herself out as a nurse licensed to practice in this State; nor shall any of
said terms be construed to include nursing performed by employees or officers
of the United States Government or any agency or service thereof while in the
discharge of his or her official duties; nor shall any of said terms be
construed to include services performed by nurses aides, attendants, orderlies
and ward helpers in hospitals, institutions and agencies or by technicians,
physiotherapists, or medical secretaries, and such duties performed by said
persons aforementioned shall not be subject to rules or regulations which the
board may prescribe concerning nursing; nor shall any of said terms be
construed to include first aid nursing assistance, or gratuitous care by friends
or members of the family of a sick or infirm person, or incidental care of the
sick by a person employed primarily as a domestic or housekeeper,
notwithstanding that the occasion for such employment may be sickness, if such
incidental care does not constitute professional nursing and such person does
not claim or purport to be a licensed nurse; nor shall any of said terms be
construed to include services rendered in accordance with the practice of the
religious tenets of any well-recognized church or denomination which subscribes
to the art of healing by prayer.  A person who is otherwise qualified shall not
be denied licensure as a professional nurse or practical nurse by reason of the
circumstances that such person is in religious life and has taken a vow of
poverty.

c.     "Homemaker-home
health aide" means a person who is employed by a home care services agency
and who is performing delegated nursing regimens or nursing tasks delegated
through the authority of a duly licensed registered professional nurse.  No homemaker-home
health aide shall follow a delegated nursing regimen or perform tasks which are
delegated unless the homemaker-home health aide is under the supervision of a
duly licensed registered professional nurse provided by the home care services
agency that directly employs the homemaker-home health aide. "Home care
services agency" means home health agencies, assisted living residences,
comprehensive personal care homes, assisted living programs or alternate family
care sponsor agencies licensed by the Department of Health pursuant to
P.L.1971, c.136 (C.26:2H-1 et al.), nonprofit homemaker-home health aide
agencies, and health care service firms regulated by the Director of the
Division of Consumer Affairs in the Department of Law and Public Safety and the
Attorney General pursuant to P.L.1989, c.331 (C.34:8-43 et seq.) and P.L.1960,
c.39 (C.56:8-1 et seq.) respectively, which are engaged in the business of
procuring or offering to procure employment for homemaker-home health aides,
where a fee may be exacted, charged or received directly or indirectly for
procuring or offering to procure that employment.

d.    "Advanced practice
nurse" means a person who holds a certification in accordance with section
8 or 9 of P.L.1991, c.377 (C.45:11-47 or 45:11-48).

e.     "Collaborating [physician] provider"
means a [person] physician
licensed to practice medicine and surgery pursuant to chapter 9 of Title 45 of
the Revised Statutes [who
agrees to work with]
or an advanced practice nurse issued a certification pursuant to
section 8 or 9 of P.L.1991, c.377 (C.45:11-47 or C.45:11-48) with more than 24
months or 2,400 hours of licensed, active, advanced nursing practice in an
initial role.

f.     “APN-Anesthesia” or
“Certified Registered Nurse Anesthetist” means an advanced practice nurse licensed
to practice as an APN-Anesthesia in accordance with the requirements
established by the board for licensure as an APN-Anesthesia.

Nothing in this act shall
confer the authority to a person licensed to practice nursing to practice
another health profession as currently defined in Title 45 of the Revised
Statutes.

(cf: P.L.2019, c.48, s.2)

3.    Section 10 of P.L.1991,
c.377 (C.45:11-49) is amended to read as follows:

10.  a. In addition to all
other tasks which a registered professional nurse may, by law, perform, an
advanced practice nurse may manage preventive care services [and] ,
diagnose, monitor, and manage deviations from wellness and long-term
illnesses, and administer local anesthesia and conscious sedation,
consistent with the needs of the patient and within the defined scope of
practice of [the] that
advanced practice nurse, by:

(1)   initiating laboratory
and other diagnostic tests;

(2)   prescribing,
authorizing, or ordering medications and devices, as authorized by
subsections [b.
and c.]
g. or h. of this section; [and]

(3)   prescribing or ordering
treatments, including referrals to other licensed health care professionals,
and performing specific procedures in accordance with the provisions of this [subsection] section;
and

(4)   administering general
anesthesia, major regional anesthesia, neuraxial anesthesia, and minor
conduction blocks, within the specific scope of practice of APN-Anesthesia, as
authorized by subsection i. of this section.

b.    [An advanced
practice nurse may order medications and devices in the inpatient setting,
subject to the following conditions:

(1)   the collaborating
physician and advanced practice nurse shall address in the joint protocols
whether prior consultation with the collaborating physician is required to
initiate an order for a controlled dangerous substance;

(2)   the order is written in
accordance with standing orders or joint protocols developed in agreement
between a collaborating physician and the advanced practice nurse, or pursuant
to the specific direction of a physician;

(3)   the advanced practice
nurse authorizes the order by signing the nurse's own name, printing the name
and certification number, and printing the collaborating physician's name;

(4)   the physician is present
or readily available through electronic communications;

(5)   the charts and records
of the patients treated by the advanced practice nurse are reviewed by the
collaborating physician and the advanced practice nurse within the period of
time specified by rules adopted by the Commissioner of Health pursuant to section
13 of P.L.1991, c.377 (C.45:11-52);

(6)   the joint protocols
developed by the collaborating physician and the advanced practice nurse are
reviewed, updated, and signed at least annually by both parties; and

(7)   the advanced practice
nurse has completed six contact hours of continuing professional education in
pharmacology related to controlled substances, including pharmacologic therapy,
addiction prevention and management, and issues concerning prescription opioid
drugs, including responsible prescribing practices, alternatives to opioids for
managing and treating pain, and the risks and signs of opioid abuse, addiction,
and diversion, in accordance with regulations adopted by the New Jersey Board
of Nursing.  The six contact hours shall be in addition to New Jersey Board of
Nursing pharmacology education requirements for advanced practice nurses
related to initial certification and recertification of an advanced practice
nurse as set forth in N.J.A.C.13:37-7.2.]
(Deleted by amendment, P.L.    , c.    ) (pending before the Legislature as
this bill)

c.     [An advanced
practice nurse may prescribe medications and devices in all other medically
appropriate settings, subject to the following conditions:

(1)   the collaborating
physician and advanced practice nurse shall address in the joint protocols
whether prior consultation with the collaborating physician is required to
initiate a prescription for a controlled dangerous substance;

(2)   the prescription is
written in accordance with standing orders or joint protocols developed in
agreement between a collaborating physician and the advanced practice nurse, or
pursuant to the specific direction of a physician;

(3)   the advanced practice
nurse writes the prescription on a New Jersey Prescription Blank pursuant to
P.L.2003, c.280 (C.45:14-40 et seq.), signs the nurse's own name to the
prescription and prints the nurse's name and certification number;

(4)   the prescription is
dated and includes the name of the patient and the name, address, and telephone
number of the collaborating physician;

(5)   the physician is present
or readily available through electronic communications;

(6)   the charts and records
of the patients treated by the advanced practice nurse are periodically
reviewed by the collaborating physician and the advanced practice nurse;

(7)   the joint protocols
developed by the collaborating physician and the advanced practice nurse are
reviewed, updated, and signed at least annually by both parties; and

(8)   the advanced practice
nurse has completed six contact hours of continuing professional education in
pharmacology related to controlled substances, including pharmacologic therapy,
addiction prevention and management, and issues concerning prescription opioid
drugs, including responsible prescribing practices, alternatives to opioids for
managing and treating pain, and the risks and signs of opioid abuse, addiction,
and diversion, in accordance with regulations adopted by the New Jersey Board
of Nursing.  The six contact hours shall be in addition to New Jersey Board of
Nursing pharmacology education requirements for advanced practice nurses
related to initial certification and recertification of an advanced practice
nurse as set forth in N.J.A.C.13:37-7.2.]
(Deleted by amendment, P.L.    , c.    ) (pending before the Legislature as
this bill)

d.    [The joint
protocols employed pursuant to subsections b. and c. of this section shall
conform with standards adopted by the Director of the Division of Consumer
Affairs pursuant to section 12 of P.L.1991, c.377 (C.45:11-51) or section 10 of
P.L.1999, c.85 (C.45:11-49.2), as applicable.]
(Deleted by amendment, P.L.    , c.    _) (pending before the
Legislature as this bill)

e.     (Deleted by amendment,
P.L.2004, c.122.)

f.     An attending advanced
practice nurse may determine and certify the cause of death of the nurse's
patient and execute the death certification pursuant to R.S.26:6-8 if no [collaborating] physician is
available to do so and the nurse is the patient's primary caregiver.

g.    An advanced practice
nurse may authorize qualifying patients for the medical use of cannabis and
issue written instructions for medical cannabis to registered qualifying
patients, subject to the [following
conditions:

(1)   the collaborating
physician and advanced practice nurse shall address in the joint protocols
whether prior consultation with the collaborating physician is required to
authorize a qualifying patient for the medical use of cannabis or issue written
instructions for medical cannabis;

(2)   the authorization for
the medical use of cannabis or issuance of written instructions for cannabis is
in accordance with standing orders or joint protocols developed in agreement
between a collaborating physician and the advanced practice nurse, or pursuant
to the specific direction of a physician;

(3)   the advanced practice
nurse signs the nurse's own name to the authorization or written instruction
and prints the nurse's name and certification number;

(4)   the authorization or
written instruction is dated and includes the name of the qualifying patient
and the name, address, and telephone number of the collaborating physician;

(5)   the physician is present
or readily available through electronic communications;

(6)   the charts and records
of qualifying patients treated by the advanced practice nurse are periodically
reviewed by the collaborating physician and the advanced practice nurse;

(7)  the joint protocols
developed by the collaborating physician and the advanced practice nurse are
reviewed, updated, and signed at least annually by both parties; and

(8)   the advanced practice
nurse complies with the]
requirements for authorizing qualifying patients for the medical use of
cannabis and for issuing written instructions for medical cannabis established
pursuant to P.L.2009, c.307 (C.24:6I-1 et al.).

h.    An advanced practice
nurse may order medications and devices, subject to the following conditions:

(1)   The advanced practice
nurse shall issue a prescription on a New Jersey Prescription Blank in
accordance with the provisions of P.L.2003, c.280 (C.45:14-40 et seq.), and
include on the prescription blank the advanced practice nurse’s signature,
printed name, certification number, and patient information, and any other
information required pursuant to regulations adopted by the New Jersey Board of
Nursing;

(2)   The advanced practice
nurse shall have completed six contact hours of continuing professional
education in pharmacology related to controlled substances, including
pharmacologic therapy and addiction prevention and management, in accordance
with regulations adopted by the New Jersey Board of Nursing.  The six contact
hours shall be in addition to New Jersey Board of Nursing pharmacology
education requirements for advanced practice nurses related to initial
certification and recertification of an advanced practice nurse as set forth in
regulations adopted by the New Jersey Board of Nursing;

(3)   The advance practice
nurse shall have completed 10 contact hours of continuing professional
education in pharmacology each biennial period, in accordance with regulations
adopted by the New Jersey Board of Nursing.  The 10 contact hours shall be in
addition to New Jersey Board of Nursing requirements for renewal of a registered
professional nursing license, as set forth in regulations adopted by the board;
and

(4)   An advanced practice
nurse with fewer than 24 months or 2,400 hours of licensed, active, advanced
nursing practice in an initial role shall have a joint protocol with a
collaborating provider.  The joint protocol shall be required only with respect
to prescribing medications.  An advanced practice nurse subject to this
paragraph shall maintain signed and dated copies of all required joint
protocols, and shall notify the board that the requirements of this paragraph
have been met.

i.     Notwithstanding the provisions of any other law or
regulation to the contrary, an advanced practice
nurse who is an APN-Anesthesia and who has completed either 24 months or 2,400
hours of licensed, active advanced practice nursing practice providing anesthesia services to patients in an initial role shall be authorized to practice as an
APN-Anesthesia to the fullest extent of the
authorized scope of practice for APN-Anesthesia permitted
by the Board of Nursing, without any requirement
for supervision by a licensed physician or dentist and without any requirement that the APN-Anesthesia enter
into joint protocols with a licensed physician or dentist.

j.     Notwithstanding the
provisions of any other law or regulation to the contrary, an advanced practice
nurse with greater than 24 months or 2,400 hours of licensed, active, advanced
nursing practice shall be authorized to practice without a joint protocol with
a collaborating provider.

k.    Any provision of
State law or regulation that requires the signature, stamp, verification,
affidavit, or endorsement of a physician shall be deemed to require the
signature, stamp, verification, affidavit, or endorsement of a physician or an
advanced practice nurse, to the extent consistent with the scope of practice of
an advanced practice nurse.

(cf: P.L.2019, c.153, s.47)

4.    Section 13 of P.L.2017,
c.341 (C.45:11-49.3) is amended to read as follows:

13.  a. Notwithstanding any
other provision of law or regulation to the contrary, an advanced
practice nurse may dispense narcotic drugs for maintenance treatment or
detoxification treatment if the advanced practice nurse has met the training
and registration requirements set forth in subsection (g) of 21 U.S.C. s.823.  [An advanced
practice nurse who is authorized to dispense such drugs may do so regardless of
whether the advanced practice nurse's collaborating physician has met the
training and registration requirements set forth in subsection (g) of 21 U.S.C.
s.823, provided that the joint protocol established by the advanced practice
nurse and the collaborating physician include the collaborating physician's
written approval for the advanced practice nurse to dispense the drugs.]

b.    Notwithstanding any
other provision of law or regulation to the contrary, an advanced
practice nurse [,
under the joint protocol established by the advanced practice nurse and the
collaborating physician,]
may make the determination as to the medical necessity for services for the
treatment of substance use disorder, as provided in P.L.2017, c.28 (C.17:48-6nn
et al.), and may prescribe such services.

(cf: P.L.2017, c.341, s.13)

5.    Section 11 of P.L.1991, c.377 (C.45:11-50) is amended
to read as follows:

11.  In
addition to such other powers as it may by law possess, the New Jersey Board of
Nursing shall have the following powers and duties [;] :

a.     To
promulgate, pursuant to the “Administrative Procedure Act,” P.L.1968, c.410
(C.52:14B-1 et seq.), rules and regulations to effectuate the purposes of [this act, except for those subjects of rule-making
authority allocated to the Director of the Division of Consumer Affairs
pursuant to section 12 of P.L.1991, c.377 (C.45:11-51) or to the
Commissioner of Health and Senior Services pursuant to section 13 of P.L.1991,
c.377 (C.45:11-52)] P.L.1991, c.377
(C.45:11-45 et al.);

b.    To
evaluate and pass upon the qualifications of candidates for
certification as advanced practice nurses;

c.     To evaluate and pass
upon national accreditation organizations and the holders of certificates from
those organizations as necessary to award certificates pursuant to section 9 of
P.L.1991, c.377 (C.45:11-48);

d.    To establish specialty
areas of practice for advanced practice nurses;

e.     To take disciplinary
action, in accordance with P.L.1978, c.73 (C.45:1-14 et seq.), against
an advanced practice nurse who violates the provisions of [this act] P.L.1991, c.377 (C.45:11-45 et al.), any
regulation promulgated thereunder, or P.L.1978, c.73 (C.45:1-14 et seq.);

f.     To approve the
examination to be taken by candidates for certification;

g.    To set standards of
professional conduct for advanced practice nurses;

h.    To set fees for
examinations, certification, and other services consistent with section
2 of P.L.1974, c.46 (C.45:1-3.2);

i.     To set standards for
and approve continuing education programs; and

j.     To determine whether
the requirements of another state with respect to certification as an advanced
practice nurse are substantially equivalent to those of this State in
accordance with subsection c. of section 8 of P.L.1991, c.377 (C.45:11-47).

(cf: P.L.1999, c.85, s.8)

6.    (New section)  The Board
of Nursing and the Commissioner of Health shall each adopt, pursuant to the
“Administrative Procedure Act,” P.L.1968, c.410 (C.52:14B-1 et seq.), such
rules and regulations as shall be necessary to implement the provisions of this
act.

7.    The following sections are repealed:

Section
10 of P.L.1999, c.85 (C.45:11-49.2);

Section
12 of P.L.1991, c.377 (C.45:11-51); and

Section
13 of P.L.1991, c.377 (C.45:11-52).

8.    This act shall take effect on the
first day of the fourth month next following the date of enactment.

STATEMENT

This bill eliminates practice restrictions for
advanced practice nurses (APNs), including restrictions that limit the ability
of APNs to prescribe medications and administer anesthesia, and establishes new
requirements for APNs to prescribe medications.

The bill expressly provides that, notwithstanding the
provisions of any other law or regulation to the contrary, an APN with greater
than 24 months or 2,400 hours of licensed, active, advanced nursing practice
will be authorized to practice without a joint protocol with a collaborating
provider.

With regard to prescribing medications, the bill
requires the use of New Jersey Prescription Blanks and satisfying continuing
professional education requirements related to pharmacology and prescribing
controlled substances.  An APN with fewer than 24 months or 2,400 hours of
licensed, active, advanced nursing practice in an initial role will be
permitted to prescribe medication only if a formal joint protocol with a
physician or experienced advanced practice nurse is in place.

The bill revises the requirements for APNs to
authorize patients for medical cannabis and to issue written instructions for
medical cannabis, to provide that the APN will only be required to meet the
requirements set forth under the “Jake Honig Compassionate Use Medical Cannabis
Act,” P.L.2009, c.307 (C.24:6I-1 et al.).  Those requirements include:
possessing active State and federal registrations to prescribe controlled
dangerous substances; being the health care practitioner responsible for the
ongoing treatment of a patient's qualifying medical condition; and complying
with various other requirements for issuing written instructions for medical
cannabis.

The bill further provides that every APN who is an
APN-Anesthesia and who has completed 24 months or 2,400 hours of licensed,
active, advanced nursing practice in an initial role will be authorized to
practice as an APN-Anesthesia to the full scope of practice for
APNs-Anesthesia, without any requirement for supervision by a licensed
physician and without any requirement that the APN-Anesthesia enter into joint
protocols with a licensed physician.

The bill provides that any State law or regulation
that requires the signature or similar endorsement of a physician will be
deemed to require the same of an APN, to the extent consistent with an APN’s
scope of practice.

The bill revises and repeals certain sections of law
that are obviated by the changes made under the bill.