Florida Senate - 2019 SB 972
By Senator Brandes
1 A bill to be entitled
2 An act relating to innovation in the advanced practice
3 registered nursing workforce; amending s. 464.003,
4 F.S.; revising the definition of the term “advanced or
5 specialized nursing practice” to expand the scope of
6 practice; amending s. 464.012, F.S.; authorizing an
7 advanced practice registered nurse to perform certain
8 functions and acts within his or her specialty without
9 a protocol agreement or supervision if specified
10 requirements are met; creating s. 464.0125, F.S.;
11 providing requirements for advanced practice
12 registered nurses to practice without a protocol
13 agreement or supervision; requiring the Department of
14 Health to notify an advanced practice registered nurse
15 who submits a satisfactory form that he or she is
16 qualified to practice without a protocol agreement or
17 supervision; requiring the department to update such
18 practitioner’s profile; authorizing a qualified
19 advanced practice registered nurse to admit, manage
20 care for, and discharge certain patients and to
21 provide an endorsement that is otherwise required to
22 be provided by a physician; requiring the Board of
23 Nursing to adopt a certain form by rule; providing
24 construction; creating s. 464.0155, F.S.; requiring an
25 advanced practice registered nurse practicing without
26 a protocol agreement or supervision to report adverse
27 incidents to the department; defining the term
28 “adverse incident”; requiring a such report to be made
29 in writing and sent by certified mail within a
30 specified timeframe; requiring the department to
31 review adverse incident reports to make a certain
32 determination; authorizing the board to take
33 disciplinary action against the advanced practice
34 registered nurse if the department makes a certain
35 determination; amending s. 395.0191, F.S.; conforming
36 a provision to changes made by the act; providing an
37 effective date.
39 Be It Enacted by the Legislature of the State of Florida:
41 Section 1. Subsection (2) of section 464.003, Florida
42 Statutes, is amended to read:
43 464.003 Definitions.—As used in this part, the term:
44 (2) “Advanced or specialized nursing practice” means, in
45 addition to the practice of professional nursing, the
46 performance of advanced-level nursing acts approved by the board
47 which, by virtue of postbasic specialized education, training,
48 and experience, are appropriately performed by an advanced
49 practice registered nurse. Within the context of advanced or
50 specialized nursing practice, the advanced practice registered
51 nurse may perform acts of nursing diagnosis and nursing
52 treatment of alterations of the health status. The advanced
53 practice registered nurse may also perform acts of medical
54 diagnosis and treatment, prescription, and operation as
55 authorized within the framework of an established supervisory
56 protocol or without a protocol agreement or supervision pursuant
57 to s. 464.0125. The department may, by rule, require that a copy
58 of the protocol be filed with the department along with the
59 notice required by s. 458.348.
60 Section 2. Subsections (3) and (4) of section 464.012,
61 Florida Statutes, are amended to read:
62 464.012 Licensure of advanced practice registered nurses;
63 fees; controlled substance prescribing.—
64 (3) An advanced practice registered nurse shall perform
65 those functions authorized in this section within the framework
66 of an established protocol that must be maintained on site at
67 the location or locations at which an advanced practice
68 registered nurse practices and may practice without a protocol
69 agreement or supervision pursuant to s. 464.0125. In the case of
70 multiple supervising physicians in the same group, an advanced
71 practice registered nurse must enter into a supervisory protocol
72 with at least one physician within the physician group practice.
73 A practitioner currently licensed under chapter 458, chapter
74 459, or chapter 466 shall maintain supervision for directing the
75 specific course of medical treatment. Within the established
76 framework, or pursuant to s. 464.0125, an advanced practice
77 registered nurse may:
78 (a) Prescribe, dispense, administer, or order any drug;
79 however, an advanced practice registered nurse may prescribe or
80 dispense a controlled substance as defined in s. 893.03 only if
81 the advanced practice registered nurse has graduated from a
82 program leading to a master’s or doctoral degree in a clinical
83 nursing specialty area with training in specialized practitioner
85 (b) Initiate appropriate therapies for certain conditions.
86 (c) Perform additional functions as may be determined by
87 rule in accordance with s. 464.003(2).
88 (d) Order diagnostic tests and physical and occupational
90 (e) Order any medication for administration to a patient in
91 a facility licensed under chapter 395 or part II of chapter 400,
92 notwithstanding any provisions in chapter 465 or chapter 893.
93 (4) In addition to the general functions specified in
94 subsection (3), an advanced practice registered nurse may
95 perform the following acts within his or her specialty:
96 (a) The certified nurse practitioner may perform any or all
97 of the following acts within the framework of established
98 protocol or pursuant to s. 464.0125:
99 1. Manage selected medical problems.
100 2. Order physical and occupational therapy.
101 3. Initiate, monitor, or alter therapies for certain
102 uncomplicated acute illnesses.
103 4. Monitor and manage patients with stable chronic
105 5. Establish behavioral problems and diagnosis and make
106 treatment recommendations.
107 (b) The certified registered nurse anesthetist may, to the
108 extent authorized by established protocol approved by the
109 medical staff of the facility in which the anesthetic service is
110 performed, or pursuant to s. 464.0125, perform any or all of the
112 1. Determine the health status of the patient as it relates
113 to the risk factors and to the anesthetic management of the
114 patient through the performance of the general functions.
115 2. Based on history, physical assessment, and supplemental
116 laboratory results, determine, with the consent of the
117 responsible physician, the appropriate type of anesthesia
118 the framework of the protocol.
119 3. Order under the protocol preanesthetic medication.
120 4. Perform under the protocol procedures commonly used to
121 render the patient insensible to pain during the performance of
122 surgical, obstetrical, therapeutic, or diagnostic clinical
123 procedures. These procedures include ordering and administering
124 regional, spinal, and general anesthesia; inhalation agents and
125 techniques; intravenous agents and techniques; and techniques of
127 5. Order or perform monitoring procedures indicated as
128 pertinent to the anesthetic health care management of the
130 6. Support life functions during anesthesia health care,
131 including induction and intubation procedures, the use of
132 appropriate mechanical supportive devices, and the management of
133 fluid, electrolyte, and blood component balances.
134 7. Recognize and take appropriate corrective action for
135 abnormal patient responses to anesthesia, adjunctive medication,
136 or other forms of therapy.
137 8. Recognize and treat a cardiac arrhythmia while the
138 patient is under anesthetic care.
139 9. Participate in management of the patient while in the
140 postanesthesia recovery area, including ordering the
141 administration of fluids and drugs.
142 10. Place special peripheral and central venous and
143 arterial lines for blood sampling and monitoring as appropriate.
144 (c) The certified nurse midwife may, to the extent
145 authorized by an established protocol which has been approved by
146 the medical staff of the health care facility in which the
147 midwifery services are performed, or approved by the nurse
148 midwife’s physician backup when the delivery is performed in a
149 patient’s home, or pursuant to s. 464.0125, perform any or all
150 of the following:
151 1. Perform superficial minor surgical procedures.
152 2. Manage the patient during labor and delivery to include
153 amniotomy, episiotomy, and repair.
154 3. Order, initiate, and perform appropriate anesthetic
156 4. Perform postpartum examination.
157 5. Order appropriate medications.
158 6. Provide family-planning services and well-woman care.
159 7. Manage the medical care of the normal obstetrical
160 patient and the initial care of a newborn patient.
161 (d) The clinical nurse specialist may perform any or all of
162 the following acts within the framework of established protocol
163 or pursuant to s. 464.0125:
164 1. Assess the health status of individuals and families
165 using methods appropriate to the population and area of
167 2. Diagnose human responses to actual or potential health
169 3. Plan for health promotion, disease prevention, and
170 therapeutic intervention in collaboration with the patient or
172 4. Implement therapeutic interventions based on the nurse
173 specialist’s area of expertise and within the scope of advanced
174 nursing practice, including, but not limited to, direct nursing
175 care, counseling, teaching, and collaboration with other
176 licensed health care providers.
177 5. Coordinate health care as necessary and appropriate and
178 evaluate with the patient or client the effectiveness of care.
179 (e) A psychiatric nurse, who meets the requirements in s.
180 394.455(35), within the framework of an established protocol
181 with a psychiatrist, or pursuant to s. 464.0125, may prescribe
182 psychotropic controlled substances for the treatment of mental
184 Section 3. Section 464.0125, Florida Statutes, is created
185 to read:
186 464.0125 Requirements for advanced practice registered
187 nurses practicing without a protocol agreement or supervision.—
188 (1) To qualify to practice as an advanced practice
189 registered nurse without a protocol agreement or supervision, an
190 advanced practice registered nurse must:
191 (a) Hold an unencumbered license issued under s. 464.012,
192 or an unencumbered license to practice as an advanced practice
193 registered nurse in in another state, jurisdiction, or territory
194 of the United States;
195 (b) Complete at least 2,000 clinical practice hours or
196 clinical instructional hours within the immediately preceding 5
197 year period while practicing as an advanced practice registered
198 nurse; and
199 (c) Submit a form to the board attesting that he or she
200 meets the requirements in paragraphs (a) and (b).
201 (2) Upon satisfactory receipt of such form, the department
203 (a) Notify the advanced practice registered nurse that he
204 or she is qualified to practice without a protocol agreement or
205 supervision pursuant to this section; and
206 (b) Update the practitioner’s profile, as described in s.
207 456.041, to reflect that the advanced practice registered nurse
208 is qualified to practice without a protocol agreement or
209 supervision pursuant to this section.
210 (3) An advanced practice registered nurse qualified to
211 practice without a protocol agreement or supervision may
212 perform, without a protocol agreement or supervision, the
213 functions authorized in s. 464.012(3), the acts within his or
214 her specialty as described in s. 464.012(4), and any of the
216 (a) For a patient being treated at a hospital, long-term
217 care hospital, skilled nursing facility, hospice, or
218 intermediate care facility for the developmentally disabled:
219 1. Admit the patient to the facility;
220 2. Manage the care that the patient receives in the
221 facility; and
222 3. Discharge the patient from the facility, unless
223 prohibited by federal law or rule.
224 (b) Provide a signature, certification, stamp,
225 verification, affidavit, or other endorsement that is otherwise
226 required to be provided by a physician.
227 (4) The board shall adopt a form by rule to be used by
228 advanced practice registered nurses attesting that they have
229 satisfied the criteria in subsection (1) to practice without a
230 protocol agreement or supervision.
231 (5) This section does not prevent an advanced practice
232 registered nurse who satisfies the eligibility requirements in
233 subsection (1) of this section from electing to continue
234 practicing under a protocol agreement as required by s.
236 Section 4. Section 464.0155, Florida Statutes, is created
237 to read:
238 464.0155 Reports of adverse incidents by advanced practice
239 registered nurses practicing without a protocol agreement or
241 (1) An advanced practice registered nurse practicing
242 without a protocol agreement or supervision, pursuant to s.
243 464.0125, shall report any adverse incident to the department.
244 (2) For the purposes of this section, the term “adverse
245 incident” means any of the following events that are reasonably
246 attributable to the prescription of a controlled substance by an
247 advanced practice registered nurse practicing pursuant to s.
249 (a) A condition that requires the transfer of a patient to
250 a hospital licensed under chapter 395.
251 (b) Permanent physical injury to a patient.
252 (c) Death of a patient.
253 (3) An adverse incident report must be in writing, sent to
254 the department by certified mail, and postmarked within 15 days
255 after the date on which the adverse incident occurs if the
256 adverse incident occurs at the office of the advanced practice
257 registered nurse. If the adverse incident occurs when the
258 patient is not at the office of the advanced practice registered
259 nurse, the report must be postmarked within 15 days after the
260 date on which the advanced practice registered nurse discovers
261 or reasonably should have discovered the occurrence of the
262 adverse incident.
263 (4) The department shall review each adverse incident and
264 determine whether the advanced practice registered nurse caused
265 the adverse incident. If the department determines that the
266 advanced practice registered nurse caused the adverse incident,
267 the board may take disciplinary action against the advance
268 practice registered nurse in accordance with s. 456.073.
269 Section 5. Paragraph (b) of subsection (2) of section
270 395.0191, Florida Statutes, is amended to read:
271 395.0191 Staff membership and clinical privileges.—
273 (b) An advanced practice registered nurse who is certified
274 as a registered nurse anesthetist licensed under part I of
275 chapter 464 shall administer anesthesia under the onsite medical
276 direction of a professional licensed under chapter 458, chapter
277 459, or chapter 466, and in accordance with an established
278 protocol approved by the medical staff. The medical direction
279 shall specifically address the needs of the individual patient.
280 This paragraph does not apply to a certified registered nurse
281 anesthetist licensed under part I of chapter 464 who is
282 practicing without a protocol agreement or supervision pursuant
283 to s. 464.0125.
284 Section 6. This act shall take effect July 1, 2019.