Effective Date of Rule: January 1, 2011.

     Purpose: The purpose of the changes to chapter 246-840 WAC is to establish continuing competency mechanisms for nurses under the statutory authority of RCW 18.79.010 and 18.79.110. The new rules create requirements for documentation of continuing competency, components of active practice and continuing education, and auditing. Four existing rules were amended to include references to the new rules.

     Citation of Existing Rules Affected by this Order: Amending WAC 246-840-010, 246-840-020, 246-840-111, and 246-840-120.

     Statutory Authority for Adoption: RCW 18.79.010 and 18.79.110.

      Adopted under notice filed as WSR 10-16-117 on August 2, 2010.

     Changes Other than Editing from Proposed to Adopted Version: Changes were made to make the rules clear and consistent. All changes were editing and did not change the content of the rule. A section was deleted that appeared in WAC 246-840-204 and 246-840-205. This section referenced nursing practice in United States jurisdictions. The commission decided that practice occurs anywhere and is not limited to United States jurisdictions.

     A final cost-benefit analysis is available by contacting Terry J. West, Department of Health, P.O. Box 47864, Olympia, WA 98504, phone (360) 236-4712, fax (360) 236-4738, e-mail terry.west@doh.wa.gov.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 4, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 4, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 4, Repealed 0.

     Date Adopted: September 10, 2010.

Paula R. Meyer, MSN, RN

Executive Director

OTS-3139.3

AMENDATORY SECTION(Amending WSR 08-11-019, filed 5/12/08, effective 6/12/08)

WAC 246-840-010   Definitions.   (1) An "advanced registered nurse practitioner (ARNP)" is a registered nurse who has had formal graduate education and has achieved national specialty certification for the nurse practitioner, nurse anesthetist, or nurse midwife role. A nurse with this preparation may qualify as an ARNP as described in WAC 246-840-300.

     (2) "Advanced nursing practice" is the delivery of nursing care by registered nurses who have acquired experience and formal education that prepares them for independent practice.

     (3) "Client advocate" means a licensed registered nurse or practical nurse who actively supports client's rights and choices, including the client's right to receive safe, high quality care, and who facilitates the client's ability to exercise those rights and/or choices by providing the client ((has)) with adequate information about their care and options.

     (4) "Commission" means the Washington state nursing care quality assurance commission.

     (5) "Competency" means demonstrated knowledge, skill and ability in the practice of nursing.

     (6) "Conditional approval" of a school of nursing is the approval given a school of nursing that has not met the requirements of the law and the rules and regulations of the commission; conditions are specified that must be met within a designated time to rectify the deficiency.

     (7) "Delegation" means the licensed practical nurse or registered nurse transfers the performance of selected nursing tasks to competent individuals in selected situations. The licensed practical nurse or registered nurse delegating the task retains the responsibility and accountability for the nursing care of the client. The licensed practical nurse or registered nurse delegating the task supervises the performance of the unlicensed person. Delegation in community and in-home care settings is defined by WAC 246-840-910 through 246-840-970.

     (a) Nursing acts delegated by the licensed practical nurse or registered nurse shall:

     (i) Be within the area of responsibility of the licensed practical nurse or registered nurse delegating the act;

     (ii) Be such that, in the opinion of the licensed practical nurse or registered nurse, it can be properly and safely performed by the unlicensed person without jeopardizing the patient welfare;

     (iii) Be acts that a reasonable and prudent licensed practical nurse or registered nurse would find are within the scope of sound nursing judgment.

     (b) Nursing acts delegated by the licensed practical nurse or registered nurse shall not require the unlicensed person to exercise nursing judgment nor perform acts which must only be performed by a licensed practical nurse or registered nurse, except in an emergency situation (RCW 18.79.240 (1)(b) and (2)(b)).

     (c) When delegating a nursing act to an unlicensed person it is the licensed practical nurse or the registered nurse who shall:

     (i) Make an assessment of the patient's nursing care need before delegating the task;

     (ii) Instruct the unlicensed person in the delegated task or verify competency to perform or be assured that the person is competent to perform the nursing task as a result of the systems in place by the health care agency;

     (iii) Recognize that some nursing interventions require nursing knowledge, judgment, and skill and therefore may not lawfully be delegated to unlicensed persons.

     (8) "Faculty" means persons who are responsible for the educational nursing program and who hold faculty appointment in the school.

     (9) "Full approval" of a school of nursing is the approval signifying that a nursing program meets the requirements of the law and the rules and regulations of the commission.

     (10) "Good cause" as used in WAC 246-840-860 for extension of a nurse technician registration means that the nurse technician has had undue hardship such as difficulty scheduling the examination through no fault of their own, receipt of the examination results after thirty days after the nurse technician's date of graduation, or an unexpected family crisis which caused him or her to delay sitting for the examination. Failure of the examination is not "good cause."

     (11) "Good standing" as applied to a nursing technician, means the nursing technician is enrolled in a registered nursing program approved by the commission and is successfully meeting all program requirements.

     (12) "Immediately available" as applied to nursing technicians, means that a registered nurse who has agreed to act as supervisor is on the premises and is within audible range and available for immediate response as needed. This may include the use of two-way communication devices which allow conversation between the nursing technician and a registered nurse who has agreed to act as supervisor.

     (a) In a hospital setting, a registered nurse who has agreed to act as supervisor is on the same patient care unit as the nursing technician and the patient has been assessed by the registered nurse prior to the delegation of duties to the nursing technician.

     (b) In a nursing home setting, a registered nurse who has agreed to act as supervisor is in the same building and on the same floor as the nursing technician and the patient has been assessed by the registered nurse prior to the delegation of duties to the nursing technician.

     (13) "Initial approval" of nursing programs is the approval given a new nursing program based on its proposal prior to the graduation of its first class.

     (14) "Limited educational authorization" is an authorization to perform clinical training through a commission approved refresher course. This authorization does not permit practice for employment. A limited educational authorization may be issued to:

     (a) A person whose Washington state license has been expired or inactive for three years or more and who applies for reinstatement and enrolls in a refresher course; or

     (b) An applicant endorsing from another state or territory if the applicant's license from that jurisdiction is on inactive or expired status. The applicant must be enrolled in a refresher course.

     (15) "Minimum standards of competency" means the knowledge, skills and abilities that are expected of the beginning practitioner.

     (16) "Nontraditional program of nursing" means a school that has a curriculum which does not include a faculty supervised teaching/learning component in clinical settings.

     (17) "Nurse administrator" is an individual who meets the qualifications contained in WAC 246-840-555 and who has been designated as the person primarily responsible for the direction of the program in nursing. Titles for this position may include, among others, dean, director, coordinator or chairperson.

     (18) "Nursing technician" means a nursing student preparing for registered nurse licensure who is employed in a hospital licensed under chapter 70.41 RCW or a nursing home licensed under chapter 18.51 RCW, and who:

     (a) Is currently enrolled in good standing and attending a nursing program approved by the commission and has not graduated; or

     (b) Is a graduate of a nursing program approved by the commission who graduated:

     (i) Within the past thirty days; or

     (ii) Within the past sixty days and has received a determination that there is good cause to continue the registration period.

     (c) Approved schools for nursing technicians include the list of registered nursing programs (schools) approved by state boards of nursing as preparation for the NCLEX registered nurse examination, and listed in the NCLEX bulletin as meeting minimum standards. Approved schools do not include nontraditional schools as defined in subsection (16) of this section.

     (19) "Philosophy" means the beliefs and principles upon which the curriculum is based.

     (20) "Program" means a division or department within a state supported educational institution, or other institution of higher learning charged with the responsibility of preparing persons to qualify for the licensing examination.

     (21) "Registered nurse" as used in these rules shall mean a nurse as defined by RCW 18.79.030(1).

     (22) "Supervision" of licensed or unlicensed nursing personnel means the provision of guidance and evaluation for the accomplishment of a nursing task or activity with the initial direction of the task or activity; periodic inspection of the actual act of accomplishing the task or activity; and the authority to require corrective action.

     (a) "Direct supervision" means the licensed registered nurse who provides guidance to nursing personnel and evaluation of nursing tasks is on the premises, is quickly and easily available, and has assessed the patient prior to the delegation of the duties.

     (b) "Immediate supervision" means the licensed registered nurse who provides guidance to nursing personnel and evaluation of nursing tasks is on the premises, is within audible and visual range of the patient, and has assessed the patient prior to the delegation of duties.

     (c) "Indirect supervision" means the licensed registered nurse who provides guidance to nursing personnel and evaluation of nursing tasks is not on the premises but has given either written or oral instructions for the care and treatment of the patient and the patient has been assessed by the registered nurse prior to the delegation of duties.

     (23) "Traditional program of nursing" means a program that has a curriculum which includes a faculty supervised teaching/learning component in clinical settings.

[Statutory Authority: RCW 18.79.110. 08-11-019, § 246-840-010, filed 5/12/08, effective 6/12/08. Statutory Authority: Chapter 18.79 RCW and 2003 c 258. 04-13-053, § 246-840-010, filed 6/11/04, effective 6/11/04. Statutory Authority: RCW 43.70.280. 98-05-060, § 246-840-010, filed 2/13/98, effective 3/16/98. Statutory Authority: Chapter 18.79 RCW. 97-13-100, § 246-840-010, filed 6/18/97, effective 7/19/97.]

     (1) Active status license. A license is issued upon completion of all requirements for licensure. The license holder may use the title licensed practical nurse or registered nurse and the use of its abbreviation, LPN or RN. The license allows practice as a licensed practical nurse or registered nurse in the state of Washington. See WAC 246-840-201 through 246-840-207 for continuing competency program requirements.

     A student who has graduated from a basic professional nursing course and who is pursuing a baccalaureate degree in nursing, an advanced degree in nursing or an advanced certification in nursing must hold an active Washington RN license before participating in the practice of nursing as required to fulfill the learning objectives in a clinical course.

     (2) Inactive status license. A license issued to a person previously holding an active license in this state, is in good standing, and does not practice in Washington state. Refer to chapter 246-12 WAC, Part 4.

     (3) Advanced registered nurse practitioner (ARNP) license. An ARNP license may be issued to any person who meets the requirements of the commission as contained in WAC 246-840-300 through 246-840-365. Only persons holding this license have the right to use the title "advanced registered nurse practitioner" or the abbreviation "ARNP" or any title or abbreviation which indicates that the person is entitled to practice at an advanced and specialized role as a nurse practitioner, a nurse midwife, or a nurse anesthetist. The ARNP may engage in the scope allowed for his or her area of national certification as approved by the commission. The license is valid only with a current registered nurse license. The ARNP's scope of practice is defined by national certification standards and approved by the commission.

[Statutory Authority: RCW 18.79.110. 08-11-019, § 246-840-020, filed 5/12/08, effective 6/12/08; 99-10-079, § 246-840-020, filed 5/4/99, effective 6/4/99. Statutory Authority: RCW 43.70.280. 98-05-060, § 246-840-020, filed 2/13/98, effective 3/16/98. Statutory Authority: Chapter 18.79 RCW. 97-13-100, § 246-840-020, filed 6/18/97, effective 7/19/97.]

     (2) If the license has expired for more than three years and the practitioner has been in active practice in another United States jurisdiction, the practitioner must:

     (a) Submit verification of active practice from any other United States jurisdiction;

     (b) Meet the requirements of chapter 246-12 WAC, Part 2;

     (c) Meet the continuing competency requirements of WAC 246-840-201 through 246-840-207.

     (3) If the license has expired for more than three years and the practitioner has not been in active practice in another United States jurisdiction, the practitioner must:

     (a) Successfully complete a commission approved refresher course. The practitioner will be issued a limited educational license to enroll in the refresher course. The limited educational license is valid only while working under the direct supervision of a preceptor and is not valid for employment as a licensed practical or registered nurse;

     (b) Meet the requirements of chapter 246-12 WAC, Part 2.

[Statutory Authority: RCW 43.70.280. 98-05-060, § 246-840-111, filed 2/13/98, effective 3/16/98.]

     (2) Practitioners with an inactive credential for three years or less who wish to return to active status must meet the requirements of chapter 246-12 WAC, Part 4 and WAC 246-840-204.

     (3) Practitioners with an inactive credential for more than three years, who have been in active practice in another United States jurisdiction, and wish to return to active status must:

     (a) Submit verification of active practice from any other United States jurisdiction;

     (b) Meet the requirements of chapter 246-12 WAC, Part 4;

     (c) Meet the requirements of WAC 246-840-201 through 246-840-207.

     (4) Practitioners with an inactive credential for more than three years, who have not been in active practice in another United States jurisdiction, and wish to return to active status must:

     (a) Successfully complete a commission approved refresher course. The practitioner will be issued a limited educational license to enroll in the refresher course. The limited educational license is valid only while working under the direct supervision of a preceptor and is not valid for employment as a licensed practical or registered nurse;

     (b) Meet the requirements of chapter 246-12 WAC, Part 4.

[Statutory Authority: RCW 43.70.280. 98-05-060, § 246-840-120, filed 2/13/98, effective 3/16/98. Statutory Authority: Chapter 18.79 RCW. 97-13-100, § 246-840-120, filed 6/18/97, effective 7/19/97.]

OTS-3009.10

DOCUMENTING CONTINUING COMPETENCY
NEW SECTION
WAC 246-840-201   Continuing competency purpose statement.   Patients, families, and communities expect safe, competent, and compassionate nursing care. These rules establish a self-directed continuing competency program that includes participation in active practice, self-assessment and reflection, and continuing nursing education for registered nurses and licensed practical nurses, as a mechanism to help keep patients safe and improve nursing practice.

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     (1) Active nursing practice means engagement in paid, unpaid, or volunteer activity performing acts requiring a nursing license as described in RCW 18.79.040, 18.79.050, or 18.79.060. Active nursing practice may include working as a nursing administrator, nursing quality manager, nursing policy officer, public health nurse, parish nurse, home health nurse, nursing educator, nursing consultant, nursing regulator or any practice requiring nursing knowledge and a nursing license.

     (2) Attestation means the affirmation by signature of the nurse indicating compliance with the standards and terms of the continuing competency requirements.

     (3) Continuing competency is the ongoing ability of a nurse to maintain, update and demonstrate sufficient knowledge, skills, judgment, and qualifications necessary to practice safely and ethically in a designated role and setting in accordance with the scope of nursing practice. A nurse achieves continuing competency through active practice, self-assessment and reflection, and continuing nursing education.

     (4) Continuing nursing education refers to systematic professional learning experiences obtained after initial licensure designed to augment the knowledge, skills, and judgment of nurses and enrich nurses' contributions to quality health care and his or her pursuit of professional career goals. The education hours should relate to the nurse's area of professional practice or areas identified through self-assessment and reflection for professional growth and development. There are various types of continuing nursing education activities. Some involve participant attendance where the pace of the activity is determined by the provider who plans and schedules the activity. Others are designed for completion by the learner, independently, at the learner's own pace and at a time of the learner's choice. Continuing nursing education hours may be obtained through mentorship, certification, presentations, and specialty certification.

     (5) Review period is three full licensing renewal cycles. For purposes of a compliance audit, the review period will be the three years preceding the audit form due date.

     (6) Self-assessment and reflection means the process of the nurse assessing his or her active nursing practice to determine strengths and opportunities for new learning. The purpose of this process is for the nurse to assess and reflect on:

     (a) Making patient safety a priority;

     (b) Familiarity with current laws and rules related to nursing practice; and

     (c) Existing knowledge and skills (e.g., infection prevention techniques, open communication, and clinical competency). Nurses complete the self-assessment and reflection process when selecting education and training opportunities in his or her nursing careers.

     (7) Technical assistance means help provided by commission members or staff based on the needs of the nurse to comply with rules and regulations.

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     (a) Document compliance with the continuing competency requirements every three years. Beginning January 1, 2014, and every three years thereafter, each nurse must sign an attestation on a form provided by the department of health declaring completion of the required active nursing practice and continuing nursing education hours. Each nurse will have a full three years to meet the requirements. The review period begins on the first birth date after receiving the initial license. Nursing practice means the performance of acts requiring substantial specialized nursing knowledge, judgment, and skills described under RCW 18.79.040, 18.79.050, and 18.79.060. For purposes of the continuing competency requirements, the commission recognizes "nursing practice" as being performance in either a paid or unpaid position requiring a nursing license.

     (i) A minimum of five hundred thirty-one hours must be in active nursing practice, which may include working as a nursing administrator, nursing quality manager, nursing policy officer, public health nurse, parish nurse, home health nurse, nursing educator, nursing consultant, nursing regulator or any practice requiring nursing knowledge and a nursing license.

     (ii) A minimum of forty-five hours must be in continuing nursing education.

     (iii) Compliance audit is a review of documents to determine fulfillment of requirements. A continuing competency compliance audit requires a nurse to submit documents demonstrating five hundred thirty-one hours of active nursing practice and forty-five hours of continuing nursing education over a three-year review period.

     (A) Continuing nursing education is defined as systematic professional learning experiences obtained after initial licensure designed to augment the knowledge, skills, and judgment of nurses and enrich nurses' contributions to quality health care and his or her pursuit of professional career goals.

     (B) Continuing nursing education hours should relate to the nurse's area of professional practice or areas identified through reflection and self-assessment for professional growth and development.

     (C) Continuing nursing education hours may be obtained through mentorship, certification, presentations, and specialty certification.

     (D) Complete continuing nursing education. Each nurse must complete a minimum of forty-five hours of continuing nursing education in the previous three-year review period.

     (E) There are various types of continuing nursing education activities. Some involve participant attendance where the pace of the activity is determined by the provider who plans and schedules the activity. Others are designed for completion by the learner, independently, at the learner's own pace and at a time of the learner's choice.

     (F) One quarter credit equals ten to thirty hours. One semester credit equals fifteen to forty-five hours, depending on documentation from the educational institution.

     (b) The hours may be accumulated in a single year or spread throughout the three-year review period.

     (c) Nurses are encouraged to complete the self-assessment and reflection process when selecting education and training opportunities. This assessment and reflection is for the nurses' own professional development and professional competence. The assessment and reflection is not submitted to the commission.

     (2) Failure to complete the attestation every three years may be grounds to deny the license or place the license on expired status according to WAC 246-12-010 (11)(b) and chapter 34.05 RCW.

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     (a) Meet the requirements of WAC 246-12-040.

     (b) Complete an attestation provided by the department indicating the intention to complete a minimum of one hundred seventy-seven hours of active nursing practice and fifteen hours of continuing nursing education within the first year following reactivation.

     (2) A nurse renewing an expired license following a review period of less than three years will be audited at the end of the first year following reactivation and must provide documentation of completion of the one hundred seventy-seven active nursing practice hours and fifteen continuing nursing education hours upon renewal.

     (3) If the practice hours and continuing nursing education hours required in subsection (1)(b) of this section are not completed within one year of reactivation a license will not be renewed without completion of a refresher course as outlined in WAC 246-840-130.

     (4) If a license has expired for more than three years the registered nurse or practical nurse must comply with the requirements of WAC 246-840-111 (2) or (3).

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     (a) Meet the requirement of chapter 246-976 WAC, Part 4;

     (b) Complete an attestation provided by the department indicating the intention to complete a minimum of one hundred seventy-seven practice hours of active nursing practice and fifteen continuing nursing education hours within the first year following reactivation.

     (2) A nurse reactivating an inactive license following a period of less than three years will be audited and must provide documentation of completion of the one hundred seventy-seven active nursing practice hours and fifteen continuing nursing education hours upon renewal.

     (3) If the practice hours and continuing nursing education hours required in subsection (1)(b) of this section are not completed within one year of reactivation a license will not be renewed without completion of a refresher course as outlined in WAC 246-840-130.

     (4) If a license has been inactive for three years or more the registered nurse or practical nurse must comply with the requirements under RCW 18.79.230 and WAC 246-840-120 (3) or (4).

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     (a) All late renewals; and

     (b) A percentage up to five percent of registered nurses and practical nurses renewing their license.

     (2) The commission will send an audit form to the registered nurse or practical nurse at the address on record with the department.

     (3) A registered nurse or practical nurse being audited will have thirty calendar days to complete and submit to the commission the audit form documenting five hundred thirty-one hours of active practice and forty-five hours of continuing nursing education.

     (4) To document practice hours a licensed registered nurse or licensed practical nurse may provide:

     (a) Verification from employers of hours worked;

     (b) Pay stubs showing hours worked or end of year work hours and payment statements;

     (c) Verification from an appropriate representative of the institution validating the hours by his or her signature;

     (d) A statement including description of the practice setting, whether they were paid or unpaid, a description of duties and responsibilities and the signature of a supervisor. Unpaid practice means providing uncompensated services considered within the scope and domain of the nursing profession. Examples of unpaid practice include: A nurse volunteering time to a church such as a parish nurse or a nurse volunteering nursing services at a community clinic. There is a wide range of opportunities within the nursing profession to participate in unpaid service to the community;

     (e) A log book documenting active nursing practice and the signature of a primary health care practitioner verifying the hours;

     (f) Verification from an appropriate health care provider documenting the number of hours of home care for a friend or family member.

     (5) To document continuing nursing education a registered nurse or a licensed practical nurse may provide:

     (a) Certificates of satisfactory course completion and statement describing relevance to professional development plan goals;

     (b) A current certificate from a nationally recognized certifying body;

     (c) Meeting minutes or meeting attendance rosters documenting participation in professional nursing organizations or employer-sponsored committees;

     (d) A final transcript or transcript of classes documenting current progress towards an advanced degree in a field related to nursing practice;

     (e) Documentation of completion of a nursing research project as the principal investigator, coinvestigator, or project director. Documentation may include summary of findings, thesis, dissertation, abstract, or granting agency summary;

     (f) Publication or submission for publication a health care related article, book chapter, or other scholarly work. Documentation may include a copy of submitted/published article or book chapter and research;

     (g) Presentations on a health care or health care system-related topic. Documentation may include a program brochure, agenda, course syllabi or a letter from the offering provider identifying the nurse's participation;

     (h) Documentation of independent study or research. Documentation may include a list of activities and time spent on completing these activities.

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     (2) The commission will send an audit form requesting documentation of the required continuing competency requirements to the registered nurse or practical nurse being audited at the address on record with the department.

     (3) If the commission does not receive the required documentation within thirty calendar days of the commission's original request for documentation, a second request will be sent by the commission to the nurse at the address of record with the department.

     (4) If the commission does not receive the required documentation within thirty calendar days following the second request, a third request will be sent to the address of record with the department.

     (5) If the commission does not receive the required documentation thirty calendar days following the third letter, the commission shall place the license on inactive status.

     (6) If the nurse's documentation does not match the hours in the attestation, technical assistance will be provided. Technical assistance may include providing information on the web site or at stakeholder meetings, and reviewing materials and offering assistance on the telephone.

     (7) If the nurse cannot provide the required documentation, the nurse may place his or her license on inactive status according to WAC 246-12-090.

     (8) If the nurse repeatedly fails to demonstrate continuing competency according to these rules, the nurse may be charged with unprofessional conduct under RCW 18.130.180, and appropriate disciplinary action will be taken which may include license suspension. License suspension may only occur after a hearing as provided in chapter 34.05 RCW.

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