This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives.
STORAGE NAME: h0257.HRS
DATE: 1/16/2024
HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: HB 257 Autonomous Practice by a Certified Registered Nurse Anesthetist
SPONSOR(S): Giallombardo
TIED BILLS: IDEN./SIM. BILLS:
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY
CHIEF
1) Healthcare Regulation Subcommittee Osborne McElroy
2) Health Care Appropriations Subcommittee
3) Health & Human Services Committee
SUMMARY ANALYSIS
An advanced practice registered nurse (APRN) is a licensed professional nurse who is additionally licensed in an
advanced nursing practice, including certified nurse midwives, certified nurse practitioners, certified registered nurse
anesthetists (CRNAs), clinical nurse specialists, and psychiatric nurses. Each specialty requires training and education
specific to the specialty area and certification with a national board that has been approved by the Board of Nursing.
Currently, there are 62,545 APRNs licensed to practice in Florida.
APRNs are generally required to practice under a supervising physician’s protocol and only to the extent that the written
protocol allows. In 2020, the Legislature passed legislation authorizing APRNs meeting certain criteria to practice
“autonomously,” or without physician supervision or a supervisory protocol, in specified settings. The Council on
Advanced Practice Registered Nurse Autonomous Practice was established to recommend standards of practice for
autonomous APRNs to the Board of Nursing. APRNs registered for autonomous practice may only provide “primary care”
services and limited acts related to their respective specialty without a physician’s supervisory protocol. Currently, 11,201
APRNs are registered for autonomous practice.
CRNAs provide pain medication, specifically anesthesia, to patients before, during, and after surgery. CRNAs must
operate under an established supervisory protocol to perform acts related to the administration of anesthesia. CRNAs
may register for autonomous practice, however, they may only autonomously provide primary care services. There are
7,567 CRNAs currently registered to practice in Florida, of which 72 are registered for primary care autonomous practice.
HB 257 authorizes autonomous CRNAs to perform CRNA-specific acts, such as conduct a pre-anesthesia evaluation,
order and administer the anesthetic as determined appropriate, monitor and interpret the patient’s vital signs, and manage
the patient during surgery and in recovery, without an established supervisory protocol. The bill exempts autonomous
CRNAs practicing in certain licensed facilities from the requirement that they only administer anesthesia under onsite
physician or dentist supervision and within an established protocol, unless such facility chooses to require such a protocol.
The bill adds anesthesia to the list of primary care practices that an APRN may engage in autonomously and adds
anesthesia to the list of primary care specialties that an autonomous APRN may be practicing in to be eligible for the
Medical Education Reimbursement and Loan Repayment Program.
The bill repeals the Council on Advanced Practice Registered Nurse Autonomous Practice effective of July 1, 2025.
The bill has an indeterminate, insignificant negative fiscal impact on DOH which can be absorbed within current
resources. The bill has no fiscal impact on local governments.
The bill provides an effective date of July 1, 2024.
FULL ANALYSIS STORAGE NAME: h0257.HRS PAGE: 2
DATE: 1/16/2024
I. SUBSTANTIVE ANALYSIS
A. EFFECT OF PROPOSED CHANGES:
Background
Advanced Practice Registered Nurses
An advanced practice registered nurse (APRN) is a licensed professional nurse who is additionally
licensed in an advanced nursing practice, including certified nurse midwives, certified nurse
practitioners, certified registered nurse anesthetists, clinical nurse specialists, and psychiatric nurses.
1
Currently, there are 62,545 APRNs licensed to practice in Florida.
2
APRNs are regulated under part I of ch. 464, F.S., the Nurse Practice Act. The Board of Nursing
(Board), housed within the Department of Health (DOH), is responsible for establishing by rule the
eligibility criteria for applicants to be licensed as APRNs and the applicable regulatory standards for
APRN nursing practices.
3
The Board is also responsible for disciplining an APRN who violates the
practice act.
4
To be eligible for licensure as an APRN, an applicant must be licensed as a registered
nurse, have a master’s degree in a nursing clinical specialty area with preparation in specialized
practitioner skills, and submit proof that the applicant holds a current national advanced practice
certification from a Board-approved nursing specialty board.
5
In addition to the practice of professional nursing,
6
APRNs perform advanced-level nursing acts
approved by the Board as appropriate for APRNs to perform by virtue of their post-basic, specialized
education, training, and experience. Advanced or specialized nursing acts may only be performed if
authorized under a supervising physician’s protocol.
7
In addition to advanced or specialized nursing
practices, APRNs are authorized to practice certain medical acts, as opposed to nursing acts, as
authorized within the framework of an established supervisory protocol of a physician or dentist.
8
APRNs may only perform advanced nursing and medical acts to the extent that the written protocol
allows, unless the APRN is registered for autonomous practice under s. 464.0123, F.S.
9
Certified Registered Nurse Anesthetists (CRNA)
An APRN may be certified in one of five specialty roles: a certified nurse practitioner (CNP), certified
nurse midwife (CNM), clinical nurse specialist (CNS), certified registered nurse anesthetist (CRNA), or
psychiatric nurse.
10
To practice as an APRN in any of these specialties, an individual must have a
masters’ degree or post-master’s certificate in the respective nursing clinical specialty area and national
1
S. 464.003(3), F.S. In 2018, the Florida Legislature enacted a law which changed the occupational title from “Advanced Registered
Nurse Practitioner (APRN)” to “Advanced Practice Registered Nurse (APRN),” and also reclassified a Clinical Nurse Specialist as a
type of APRN instead of a stand-alone occupation (see ch. 2018-106, Laws of Fla.).
2
Email from Daniel Leyte-Vidal, Deputy Legislative Planning Director, Florida Department of Health, RE: Information Request,
December 14, 2023. On file with the Healthcare Regulation Subcommittee.
3
S. 464.004, F.S.
4
S. 464.018, F.S.
5
S. 464.012(1), F.S., and Rule 64B9-4.002, F.A.C.
6
“Practice of professional nursing” means the performance of those acts requiring substantial specialized knowledge, judgment, and
nursing skill based upon applied principles of psychological, biological, physical, and social sciences. See s. 464.003(19), F.S.
7
S. 464.012(3)-(4), F.S.
8
S. 464.003, F.S., and s. 464.012(3), F.S.
9
S. 464.012, F.S.
10
S. 464.012(4), F.S. STORAGE NAME: h0257.HRS PAGE: 3
DATE: 1/16/2024
advanced practice certification from an approved nursing specialty board,
11
in addition to being licensed
as a professional nurse.
12
To practice as a CRNA, a nurse must be certified by the appropriate specialty board,
13
which is the
National Board of Certification & Recertification for Nurse Anesthetists (NBCRNA).
14
Certification by the
NBCRNA requires a nurse to practice full-time as a licensed registered nurse for at least one year
before attending an accredited nurse anesthesia educational program.
15
Nurse anesthesia education
programs range from 24 to 42 months in length.
16
After completing an accredited nurse anesthesia
educational program, the nurse is eligible for the NBCRNA certification exam.
17
Once NBCRNA
certified, a nurse is eligible for licensure as a CRNA.
CRNAs provide pain medication, specifically anesthesia, to patients before, during, and after surgery.
CRNAs are required to operate under an established protocol approved by the medical staff of the
facility in which the CRNA is practicing. Within the limitations of the protocol, a CRNA may:
18
Determine the health status of the patient as it relates to the risk factors and to the anesthetic
management of the patient through the performance of the general functions;
Based on history, physical assessment, and supplemental laboratory results, determine, with
the consent of the responsible physician, the appropriate type of anesthesia;
Order preanesthetic medication;
Perform procedures commonly used to render the patient insensible to pain during the
performance of surgical, obstetrical, therapeutic, or diagnostic clinical procedures;
19
Order or perform monitoring procedures indicated as pertinent to the anesthetic health care
management of the patient;
Support life functions during anesthesia health care, including induction and intubation
procedures, the use of appropriate mechanical supportive devices, and the management of
fluid, electrolyte, and blood component balances;
Recognize and take appropriate corrective action for abnormal patient responses to anesthesia,
adjunctive medication, or other forms of therapy;
Recognize and treat a cardiac arrhythmia while the patient is under anesthetic care;
Participate in management of the patient while in the post-anesthesia recovery area, including
ordering the administration of fluids and drugs; and
Place special peripheral and central venous and arterial lines for blood sampling and monitoring
as appropriate.
Autonomous APRN Practice
11
See Rule 64B9-4.002 Requirements for Licensure for the list of Board approved specialty boards.
12
Florida Board of Nursing, Advanced Practice Registered Nurse (APRN). Available at https://floridasnursing.gov/nursing-
faqs/advanced-practice-registered-nurse-aprn/ (last visited December 13, 2023).
13
S. 464.012(1)(a), F.S.
14
Rule 64B9-4.002, F.A.C. See also, National Board of Certification & Recertification website for more information. Available at
https://www.nbcrna.com/home (last visited December 13, 2023).
15
The Council on Accreditation of Nurse Anesthesia Educational Programs is the recognized accrediting body for nurse anesthesia
education programs in the US. See, US Department of Education, Accreditation in the United State. Available at
https://www2.ed.gov/admins/finaid/accred/accreditation_pg4.html#National_Institutional (last visited January 11, 2024).
16
Florida Association of Nurse Anesthesiology. “What is a Nurse Anesthetist?” Available at https://www.fana.org/what-is-a-nurse-
anesthetist- (last visited January 11, 2024).
17
National Board of Certification & Recertification for Nurse Anesthetists. Student Information: National Certification Examination
(NCE). Available at https://www.nbcrna.com/initial-certification/students (last visited January 11, 2024).
18
s. 464.012(4)(b), F.S.
19
These procedures include ordering and administering regional, spinal, and general anesthesia; inhalation agents and techniques;
intravenous agents and techniques; and techniques of hypnosis; see, s. 464.012(4)(b), F.S. STORAGE NAME: h0257.HRS PAGE: 4
DATE: 1/16/2024
Current law authorizes an APRN who meets certain eligibility criteria to engage in autonomous practice
only in primary care, which includes family medicine, general pediatrics, and general internal medicine,
without a supervising physician or written protocol with a physician.
20
The Board has defined primary
care by rule to include the “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 conditions.”
21
An autonomous APRN may
not perform any surgical procedures except subcutaneous surgical procedures.
22
To engage in autonomous practice, an APRN must hold active and unencumbered Florida or multi-
state license and have:
23
Completed at least 3,000 clinical practice hours or clinical instructional hours
supervised by a
physician with an active license within the five-year period immediately preceding the
registration request;
Not have been subject to any disciplinary action during the five years immediately preceding the
application;
Completed three graduate-level semester hours, or the equivalent, in pharmacology and three
graduate-level semester hours, or the equivalent, in differential diagnosis within the five-year
period preceding the registration request;
24
and
Any other registration requirements provided by Board rule.
The registration must be renewed biennially and the renewal coincides with the licensure renewal
period for the APRN. To maintain registration, an APRN must complete at least 10 hours of continuing
education approved by the Board for each biennial renewal in addition to the 30 hours of continuing
education required for renewal of the APRN license.
25
There are currently 11,201 APRNs registered
for autonomous practice in Florida.
26
CRNAs may register for autonomous practice, however, they may only autonomously provide primary
care-related services and must still adhere to an established supervisory protocol when performing
acts related to the administration of anesthesia.
27
There are 7,567 CRNAs currently registered to
practice in Florida, of which 72 are registered for primary care autonomous practice.
28
Medical Education Reimbursement and Loan Repayment Program
In 2002, the Legislature created the Medical Education Reimbursement and Loan Repayment Program
(program) within DOH, to encourage health care professionals to practice in underserved areas where
there are shortages of such personnel.
29
The program makes payments to offset loans and educational
expenses incurred in education or licensure. Health care professionals eligible to participate in the
program include:
30
20
S. 464.0123(3)(a)1., F.S.
21
Rule 64B9-4.001(12), F.A.C.
22
S. 464.0123(3)(c), F.S.
23
S. 464.0123(1)-(2), F.S.
24
See Rule 64B9-4.020(3), F.A.C.; The BON has defined the equivalent of three graduate-level semester hours in pharmacology and
the equivalent of three graduate-level semester hours in differential diagnosis as equal to forty-five (45) Continuing Education credits
offered in those areas by the entities set forth in Section 464.013(3)(b), F.S. and Fla. Admin. Code R. 64B9-4.002(2), (2023).
25
S. 464.0123(5), F.S.
26
Supra, note 2.
27
See, ss. 395.0191(2)(b), 464.012(4)(b), and 464.0123(3)(a), F.S.
28
Supra, note 2.
29
S. 1009.65(1), F.S.
30
Id. Primary care specialties for physicians include obstetrics, gynecology, general and family practice, internal medicine, pediatrics,
and other specialties identified by DOH. STORAGE NAME: h0257.HRS PAGE: 5
DATE: 1/16/2024
Allopathic physicians with primary care specialties;
Osteopathic physicians with primary care specialties;
Physician assistants;
Autonomous APRNs with primary care specialties;
Licensed practical nurses;
Registered nurses; and
APRNs.
As funds are available, DOH may award up to $15,000 per year for autonomous APRNs with primary
care specialties and up to $10,000 per year for APRNs.
31
To qualify for reimbursement, a health care practitioner must:
32
Be a U.S. citizen;
Possess a clear active Florida health care professional license;
Provide in-person services to persons in an underserved location;
33
Not have received an award from any other State of Florida-funded student loan repayment
program since July 1 of the previous year; and
Have a qualified loan.
34
An autonomous APRN, in addition to the requirements above, must specifically have active
employment providing primary care services in a practice or public health program that serves Medicaid
and other low-income patients and practice in a location that has a primary care Health Professional
Shortage Area (HPSA)
35
score of at least 18.
36
Effect of the Bill
HB 257 authorizes autonomous CRNAs to perform CRNA-specific acts, such as conduct a pre-
anesthesia evaluation, order and administer the anesthetic as determined appropriate, monitor and
interpret the patient’s vital signs, and manage the patient during surgery and in recovery, without an
established supervisory protocol. The bill specifies that autonomous CRNAs practicing without an
established protocol may only perform acts authorized under the Nurse Practice Act.
37
The bill exempts autonomous CRNAs practicing in a licensed hospital or ambulatory surgical center
from the requirement that anesthesia only be administered under the onsite medical direction of a
physician or dentist and in accordance with an established protocol approved by the medical staff. The
bill allows such facilities to require an autonomous CRNA to operate under an established protocol
approved by the medical staff or the governing board of the facility.
31
S. 1009.65(1), F.S.
32
Rule 64W-4.002(1)(a), F.A.C.
33
Rule 64W-4.001, F.A.C., defines an “underserved location” as a public health program; a correctional facility; a Health Professional
Shortage Area as designated by Federal Health Resources and Services Administration in a primary care discipline; a rural area as
identified by the Federal Office of Rural Health Policy; a rural hospital as defined in s.395.602(2)(b), F.S.; a state hospital; or other state
institutions that employ medical personnel.
34
Rule 64W-4.001, F.A.C., defines a “qualified loan” as a federal and/or private student loan with a US-based lender that has a verified
balance remaining which loan proceeds were used to pay educational expenses.
35
S. 1009.65(1)(b)1., F.S., defines “Primary care health professional shortage area” means a geographic area, an area having a
special population, or a facility with a score of at least 18, as designated and calculated by the Federal Health Resources and Services
Administration or a rural area as defined by the Federal Office of Rural Health Policy.
36
Rule 64W-4.002(1)(b), F.A.C.
37
Ch. 464, F.S., Part I. STORAGE NAME: h0257.HRS PAGE: 6
DATE: 1/16/2024
The bill adds anesthesia to the list of primary care practices that an APRN may engage in
autonomously and adds anesthesia to the list of primary care specialties that an autonomous APRN
may be practicing in to be eligible for the Medical Education Reimbursement and Loan Repayment
Program.
The bill repeals the Council on Advanced Practice Registered Nurse Autonomous Practice effective of
July 1, 2025.
The bill provides an effective date of July 1, 2024.
B. SECTION DIRECTORY:
Section 1: Amends s. 395.0191, F.S., relating to staff membership and clinical privileges.
Section 2: Amends s. 464.012, F.S., relating to licensure of advanced practice registered nurses;
fees; controlled substances prescribing.
Section 3: Amends s. 464.0123, F.S., relating to autonomous practice by an advanced practice
registered nurse.
Section 4: Amends s. 1009.65, F.S., relating to the Medical Education Reimbursement and Loan
Repayment Program.
Section 5: Provides an effective date of July 1, 2024.
II. FISCAL ANALYSIS & ECONOMIC IMPACT STATEMENT
A. FISCAL IMPACT ON STATE GOVERNMENT:
1. Revenues:
None.
2. Expenditures:
The bill has an indeterminate, insignificant negative impact on DOH which is expected to be
absorbed within current resources.
B. FISCAL IMPACT ON LOCAL GOVERNMENTS:
1. Revenues:
None.
2. Expenditures:
None.
C. DIRECT ECONOMIC IMPACT ON PRIVATE SECTOR:
None.
D. FISCAL COMMENTS:
None.
III. COMMENTS
A. CONSTITUTIONAL ISSUES: STORAGE NAME: h0257.HRS PAGE: 7
DATE: 1/16/2024
1. Applicability of Municipality/County Mandates Provision:
Not applicable. The bill does not appear to affect county or municipal governments.
2. Other:
None.
B. RULE-MAKING AUTHORITY:
The Board has sufficient rulemaking authority to implement this bill’s provisions.
C. DRAFTING ISSUES OR OTHER COMMENTS:
None.
IV. AMENDMENTS/COMMITTEE SUBSTITUTE CHANGES