Can psychiatric nurse practitioners practice independently in florida

1. UNDERSTANDING AUTONOMOUS PRACTICE FOR FLORIDA APRNS
2.  NOW IS THE TIME TO APPLY FOR YOUR AUTONOMOUS APRN LICENSE!
3. After many years of working to obtain Autonomous Practice in Florida, this opportunity has finally come to fruition for many, but not all. The new law, initially called the Direct Care Workers bill  provides for Autonomous APRN Practice effective 07/01/2020 and ONLY includes advanced practice registered nurses practicing in primary care in the following settings:

1. Family Medicine
2. General Pediatrics
3. General Internal Medicine; and
4. Certified Nurse Midwives (requires a written patient transfer agreement)

1. Unfortunately, the bill did not include CRNAs and Specialty APRNs. The first Autonomous APRN licenses were issued in October 2020 and there are currently over 3000 APRNs that now hold this new license. We need to see these numbers increase. The first two APRNs to obtain this long-awaited status were members of FNPN who fought hard to pass this law. We are sharing this information to give our members updated information and encourage all APRNs to apply. It does take time to gather your CE/Course Work information to provide to the BON.
2. This should help you prepare to do so.
3. ** Remember: ANY Florida licensed APRN can apply to be Autonomous APRN**
4. You may be approved but need to make sure that you ONLY practice autonomously in the above primary care areas. It is important that you consider applying for Autonomous practice if you can meet the requirements set forth in the statute, even if you may not use it now and you continue to practice as you currently do under a protocol. By applying and receiving your Autonomous practice license it increases the number in the state and helps us to obtain data on a larger group of licensees as we move forward with future legislation to include all specialty groups. Without this data we may have a harder time. Remember success comes in numbers and we need autonomous numbers! Apply today!  
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6. WHAT IS THE PROCESS TO APPLY FOR THE AUTONOMOUS APRN LICENSE?
7. There is a separate application process when submitting your application for autonomous practice to the BON. Any nurse practitioner that meets the requirements for autonomous practice may apply and may be issued an autonomous practice license. It is up to the individual licensee to know if their education, training, and board certification enables them to practice in the above approved settings as an autonomous APRN in the primary care setting. There is no added fee to apply for Autonomous APRN licensure.
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9. For Registration as an Autonomous Advanced Practice Registered Nurse, the requirements are as follows and can be found in Section 464.0123, F.S. (From BON Website)
10. You must hold a Clear, Active, Florida APRN License.
11. You must have completed at least 3000 clinical hours under the supervision of an allopathic or osteopathic physician within the past 5 years.  These hours may include clinical instructional hours.  See 464.123(1)(c), F.S. for complete requirements.
12. You must submit proof of three graduate-level semester hours (or the equivalent) in Differential Diagnosis, and three graduate-level semester hours (or the equivalent) in Pharmacology completed within the last five years. Please click herefor a description of equivalent courses.
13. You must not have been subject to disciplinary action as specified in s. 456.072, F.S. or s. 464.018, F.S., or any similar disciplinary action in any state or jurisdiction within the past five years.
14. Applications are valid for (1) year, so if incomplete or pending you can continue to fulfill the accepted courses required. After that time, the application will be expired if not approved. Once an application is expired a new paper application may be submitted. PDF versions of applications can be found at https://floridasnursing.gov/resources/.
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16. CLINICAL HOURS REQUIREMENT
    You must have completed 3000 hours of clinical practice in the past 5 years under protocol with a physician to apply for Autonomous APRN practice. If you are moving to Florida from an independent practice state and have not had a protocol you will not be able to apply for autonomous practice until you complete 3000 hours under the supervision of an allopathic or osteopathic physician These hours may include clinical instructional hours. (If you are moving from a state where you had a protocol with a physician, then you will need to provide proof of 3000 hours in the past 5 years under protocol in the state you are leaving.)
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18. EDUCATIONAL REQUIREMENTS:  Section 464.0123, F.S.
19. You must have proof of the mandatory graduate education level (3 credit hours) or the equivalent CE hours (45 CEs) in each of the following: Pharmacology and Differential Diagnosis.
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21. When sending in the mandatory CE or university semester course documentation for the Pharmacology and Differential Diagnosis requirements, it may help to send in your CE certificates that includes the course name, as well as the course description and course objectives for the CE/Course you have taken. Many have used a spreadsheet format to attach and send in to help the board staff make the decision on whether the course work submitted has met the requirements. This may help prevent denials of your application and resubmission of documents. When looking for CE courses to take it is recommended that you look for the words-management, treatment, diagnosis, etc. in the course objectives and description.
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23. COUNCIL ON AUTONOMOUS ADVANCED PRACTICE REGISTERED NURSES
24. The Board of Nursing and the Board of Medicine were required by statute to form a Council to make recommendations for the Standards of Practice for Autonomous APRNs. The Council has been appointed by the BON & BOM as follows:
25. Board of Nursing
26. Vicky Stone-Gale, DNP, APRN, FNP (4-year term)
27. Charrita Ernewein, DNP, APRN, FNP (2-year term)
28. Mary Kay Miller, APRN, CNM (3-year term)
29. Kathleen Wilson, PhD, APRN, FNP (2-year term)
30. Board of Medicine
31. Shailesh Gupta, MD (3-year term)
32. Hector Vila, MD (4-year term)
33. Board of Osteopathic Medicine
34. Michelle Mendez, DO (4-year term)
35. Joel Rose, DO (2-year term)
36. Cassandra G. Pasley, BSN, JD, Director of the Division of Medical Quality Assurance, will serve as Chair of the Council as the State Surgeon General’s designee
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38. The Standards of Practice recommended to the BON and accepted state:
    Advanced practice registered nurses who are registered pursuant to Section 464.0123, F.S., shall engage in autonomous practice only in a manner that meets the General Standard of Practice. The General Standard of Practice shall be that standard of practice, care, skill, and treatment which, considering all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similarly licensed and educated advanced practice registered nurses.
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40. Florida Board of Nursing definition of Primary Care for Autonomous APRNs
    Primary care practice – includes physical and mental health promotion, assessment, evaluation, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses, inclusive of behavioral and mental health. 
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    What does the Autonomous APRN qualification provide as compared to an APRN under Physician supervision?

1. Ability to practice within the scope of an APRN without physician supervision.
2. Ability to sign a Florida Certificate of Death to aid families who otherwise would be delayed.
3. Ability to admit for psychiatric evaluation of a patient deemed in need of involuntary admission.
4. Enter into business agreements with labs.
5. No need to pay a collaborating physician fee.

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2. Challenges with the new law encountered by the Autonomous APRN:

1. Out of state APRNs moving to Florida from a FPA state area may find it a challenge to apply if not supervised in past 5 years under a physician.
2. Able to sign medical documents that a physician might sign including death certificate and DNR.
3. The Autonomous Certified nurse midwives must have a written transfer agreement with a hospital and a written referral agreement with a licensed physician, not required previously. Fla. Stat. § 464.0123(3)(b)
4. Pediatric APRNS who evaluate and work with ADD/ADHD patients still cannot prescribe required drug therapy for ADHD due to Florida APRN Controlled Substance restrictions.

1. FREQUENTLY ASKED QUESTIONS

1. How do I complete the Autonomous APRN application and how do I list my courses for the BON review? 
   1. The BON Registration Form is on BON website available since October 19, 2020.  Get it on site (https://floridasnursing.gov/renewals/autonomous-advanced-practice-registered-nurse/#tab-process3bfc-9c2f).  We recommend you get help from the BON staff if you are not clear on the instructions or ask another FNPN member who has completed the application successfully- just ask us! If you meet all the course requirements when applying, we found simply setting up your documentation on a spreadsheet format is most helpful and attach every CE certificate and add the course or program objectives on the form. 
2. Do I have to become an autonomous APRN to work in Florida? 
   1. No, you can work as an APRN under a general supervisory medical protocol delegating medical acts for the APRN by the physician or DDS. It is not a collaborative agreement and serves as a legal document for your practice. If you choose not to become autonomous nothing changes for you at this time.
3. Will we use AAPRN as our new title?
   1. There is no title change required in statute with Autonomous APRN practice. You will still be titled as APRN
4. Will we receive a new license for Autonomous practice?
   1. You will be issued a new license upon approval of your Autonomous APRN application.
5. I graduated with my advanced practice degree over 10 years ago. This law requires a completion of 3 graduate-level semester hours in Differential Diagnosisand the completion of 3 graduate-level semester hours in Pharmacology. Do I have to go back to a university to take these courses or can I use CE hours?
6. The Board of Nursing voted that an APRN can submit evidence of 45 CE credits in Differential Diagnosis and 45 CE credits in Pharmacology completed in last 5 years to fulfill the statutory requirement of the two 3 credit courses. Please review the BON site for requirements for more information regarding CE courses. The reviewers of the applications have approved courses that compare or are equivalent to Differential Diagnosis terminology. Teaching in a graduate level pharmacology or physical assessment course, being a preceptor, or employment as a clinical instructor will not count toward your required hours.
7. What is the best way to obtain the requirements of 45 CE hours in differential diagnosis and pharmacology? 
   1. There are Florida Board of Nursing CE providers that have approved courses available to meet the CE hours you need. National, regional, and local associations or organizations that offer advanced practice nursing CE hours are usually accepted. AANP hours are often free in the CE Center. FNPN offers a great selection at their conference held every August. Some savvy and respected CE programs and universities had created these DD and Pharma CE bundles to help you. It would be beneficial to weigh the costs of a university 3 credit hour course versus CE courses to receive these hours.
8. Do I need to hold a Doctorate Degree (DNP, PhD, DNS) to become an Autonomous APRN in Florida?
   1. No, but you must hold a Florida APRN license first (even if a new APRNs moving to FL) along with your nationally certification in your practice area.
9. Do Florida APRNs now meet practice requirements to be Independent or Full Practice Authority (FPA) state under this law?  
   1. AANP still designates our state as Restricted- red since there is still the supervisory conditions for APRNs. This is our goal to continue to push for full autonomous practice for all APRN roles.
10. I was initially certified as an FNP but went back to obtain my PMHNP national certification as well. I practice in both areas, but primarily psych/mental health. Are PMHNPs included as a specialty in autonomous practice?  
    1. The BON developed the definition for primary care to read as follows: Primary care practice – includes physical and mental health promotion, assessment, evaluation, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses, inclusive of behavioral and mental health.
    2. If you are an FNP with additional PMHNP certification and you are practicing only in primary care then you would be inclusive in the above definition (Sara Jones, Autonomous FNP, PMHNP, Jones Primary Care Clinic).
    3. If you are practicing solely as a PMHNP you are not able to practice autonomously at this time in your own practice. In other words, you would not be able to hang your shingle and state you are an Autonomous PMHNP (ie. Sarah Jones, Autonomous PMHNP, Jones Mental Health Clinic).
    4. The BON will hear declaratory statements if an AAPRN wants guidance on an interpretation … the law in 464.0123, read along w/ the board’s definition, should give an autonomous APRN what he or she needs to know as to primary care practice.      

1. Questions for Out of State ARPNs:

1. If I completed the 3,000 supervised hours in another state, can I apply for autonomous practice?
   1. You must submit proof of your protocol or supervisory agreement that would cover those hours.
2. What if I am moving from a FPA state with autonomous practice license and I have been practicing autonomously for over six years? Am I eligible for FL Autonomous License now?
   1. You do not meet the supervisory requirement to be supervised under a physician within the past 5 years. You cannot get autonomous practice without having 3,000 supervised hours in the 5 years immediately before applying.

1. Questions about specific practice areas:

1. Can I work in Specialty and Primary Care at the same time and hold both APRN with protocol and Autonomous APRN licensure? 
   1. Yes, you can function under a general supervisory medical protocol agreement providing specialty care, and work under the Autonomous license when working in a primary care practice. Many APRNs hold two jobs that benefit from this license opportunity. Do seek legal counsel if you have questions as this is not common practice.
2. Can I work in a Med Spa as an Autonomous practice not under protocol with the Dermatologist?
   1. No. As a specialty, that falls under Dermatology and Plastic Surgery, Florida passed HB699 in 2006 that lends more restriction on this type of practice area and thus has special statutory language. Your collaborative protocol physician must be a dermatologist, a plastic surgeon, or a physician that has received the same training as you have for the procedures you will be doing in the practice. If you want to open a Med Spa, provide aesthetics and injectables or IV hydration, you need a collaborative agreement.  If you must ask yourself if its primary care, then it is probably not. A Med Spa is not considered primary care practice.
3. Can I perform Botox procedures or similar products in a clinic as an Autonomous APRN?
   1. If you are an Autonomous APRN you cannot do cosmetic procedures on patients without a protocol with a physician who is also trained and educated in the same procedures that you will be doing. There is no exception to this if you are autonomous whether you are in primary care or not.
   2. If you work in a Neurology practice and use Botox for migraines, you must have a protocol and would not be autonomous because this is a specialty area.
4. Can an Autonomous APRN now sign certification of death?
   1. Only an APRN who has registered and been approved for autonomous practice can sign a death certificate according to House Bill 607.
   2. The following link will guide you on the process for becoming an online EDRS certifier https://floridasnursing.gov/help-center/can-an-aprn-sign-death-certificates/
5. Is the Autonomous APRN are we now able to sign a DNR form?
   1. No - the Autonomous and the Supervised APRN cannot sign this form at this time. See, Florida Regulations 64J-2.01, December 2004: Do Not Resuscitate Order (DNRO) Form and Patient Identification Device. The person or representative must have the complete yellow signed form in the event of EMS called or transfer to hospital or other health care facility. DH Form 1896.
6. Can the Autonomous APRN pronounce/declare death of the patient?
   1. Yes, also RNs can but usually in nursing care centers or home care situations. Pronouncing death and declaring death are legally different terms. Interesting that in some states a nurse can be the coroner! Medical providers pronounce death but police, EMT or fire fighters are deemed to declare time of death at the scene.
7. A few years ago, there was a law that allowed PHMNPs to admit or release a patient from involuntary hospitalization under the “Baker Act” Can all APRNs do this now under the new Autonomous Law?
   1. If licensed as an Autonomous APRN in practice, you have the signature authority to evoke the Baker Act for involuntary examination or admitting/discharging patients from a facility and “provide a signature, certification, stamp, verification, affidavit, or endorsement that is otherwise required by law to be provided by a physician (except for medical cannabis)".
8. As an Autonomous APRN, may I supervise other APRNs in my workplace?
   1. No, this was not included in the new law.  We are hoping that a future bill addressing this will be able to clarify and addresses this, but until then only physicians, DDS can supervise APRNs.
9. How are Health Care Plans adding Autonomous APRNs to their panels without a supervising physician?
   1. This law is silent of insurance procedures and policies. Some APRNs in practice who moved to Autonomous Licensure have had no problems. Others starting practice may find it not as easy but do able! In Florida, insurance companies cannot force patients to see an NP over a Physician and vice versa, but the patient always has the option to see the provider of request.
10. Can Autonomous APRNs sign home health certifications?
    1. Yes! And APRNs under protocol may also sign. As of April 30, 2020, CMS issued an interim final rule that permanently implements section 3708 of the CARES Act, retroactively effective March 1, 2020. Thanks to AANP and other NP supporters for that national law change that will benefit more patients to remove barriers to care.
11. How does Autonomous APRN Licensure affect my current DEA certificate? 
    1. Nothing has changed. Remember this is a Federal DEA number, not a state. The DEA does not seek your information regarding supervisory protocols or practice agreements. After you apply, the DEA will check with the State BON to confirm you hold a license to prescribe CS and have no disciplinary actions. The DEA in the state offices is primarily to confirm that your license is current, and the number is accurate. The Autonomous law did not change any prescriptive practice for CS for APRNs. Continue to prescribe per current law. APRNs will have to go back to the legislature to amend some barriers here too. Remember you are not able to prescribe medical marijuana whether you are autonomous or not.
12. Can an Autonomous APRN work under sovereign immunity to meet the medical liability requirements when working at academic institutions or volunteering in facilities that have the state agreement?  
    1. Not that we have heard. APRNs are still able to enroll in the organization’s sovereign immunity program as a healthcare provider.
13. Can a hospital or any other nursing facility deny an Autonomous APRN privileges?
    1. Each individual facility can make the decision on who they want to be on staff.
14. If I decide to open my own practice as an Autonomous APRN and I have a doctoral degree, can I post “Doctor” on my signage and documents?
    1. Currently, there is much discussion regarding APRNs using the “Doctor” title and it is highly recommended that you make sure to identify yourself as a nurse practitioner on all your office documents and signage (and even Social Media accounts). For example-Dr. Sara Jones, Family Nurse Practitioner.
    2. You must represent yourself to your patients as a doctoral-prepared nurse practitioner.
    3. The law states you must have identifiers on your lab coat. You do not want to represent yourself as a physician.

1. We recommend that you join Florida Nurse Practitioner Network to keep well informed on regular updates and to get your questions answered.
2. As always, we encourage you to obtain legal counsel for any practice specific areas, especially with this new law that is still “under construction!”  When in doubt seek out legal help and do not put yourself in a situation that could cause you to be reported for practicing out of your scope.
3. File: Website:/Practice/A-APRN2021

UPDATE  8/18/2022 / JA