SB 166-BOARD OF NURSING; NURSES  3:46:31 PM CHAIR OLSON announced that the next order of business would be CS FOR SENATE BILL NO. 166(FIN), "An Act relating to nursing and to the Board of Nursing." 3:46:35 PM SENATOR CATHY GIESSEL, Alaska State Legislature, stated that she holds two licenses under the jurisdictions of the Board of Nursing (BON), as a registered nurse (RN) and as an advanced nurse practitioner (ANP). She has served two terms on the BON, serving five years as chair. She said SB 166 is a "clean-up" or "revisor's" bill. The Legislative Legal Services doesn't do revisor's bills for professional boards due to the technical nature. 3:47:38 PM SENATOR GIESSEL stated that this bill revises the board member qualifications, requiring that licensed practical nurses have at least two years of clinical practice before being appointed to the BON. The registered nurse or nurse educator on the BON can also be working in a program that provides graduate, bachelor's, or associate degrees, noting that, previously, the requirement was for a minimum of a bachelor's degree. The advanced nurse practitioner must have at a minimum of four years of advanced practice prior to being appointed to the board. Additionally, the bill establishes a retired nurse status and "cleans up" some practical nurse education program criteria. She noted that the qualifications and duties of the executive administrator have been revised. The term has changed from executive secretary to administrator and requires the person to have a minimum education of a Masters' degree in Nursing. 3:48:55 PM SENATOR GIESSEL said that this has been raised in other committees so she elaborated that holding an advance degree is rather common, and there are over 900 advanced nurse practitioners (ANPs) in Alaska. She commented that this represents the minimal level of entry for an ANP. She related that for the past 25 years, the executive administrator has had either a masters' degree or a doctorate. In fact, the current administrator holds a Ph.D., she said. She explained the changes made for testing, such that SB 166 removes the requirement for written exams since electronic exams are administered. The bill would repeal language that allows licensing through the Canadian Nurses Association testing examination, which is no longer considered valid for licensure in the U.S. The bill removes an obsolete term, licensed vocational nurse. Under the bill, the board would continue to do background checks and competency requirements to reinstate lapsed licenses. The board allows a physician's assistant to be authorized to supervise a licensed practical nurse and would add a new section that requires an employer to report to the BON when a nurse or nurse aide is fired or suspended. She explained the reporting is no longer required to be done under oath. It would also provide protection for nurses that may refuse to delegate a task if the person delegated to lacks sufficient training. The reporting was deemed important since it may require disciplinary action be taken by the BON. 3:50:56 PM SENATOR GIESSEL related the committee hearings raised some issues. One concern related to the criminal background checks, noting that the BON has performed criminal background checks for a number of years. Health care professionals have very intimate contact with their patients and Alaska is an "end of the road" jurisdiction so criminal background checks have been very important to ensure public safety. In fact, the BON's mission is to ensure safety through the regulation of safe nursing practices. In 2009, someone asked the executive director why barrier crimes were being imposed on nurses practicing in their facilities. It turns out that the federal government had placed a restriction on any health care facility receiving federal funds. The BON does not have any barrier crimes to licensure. It has conducted background checks; however, any questionable criminal background is reviewed individually by the BON. She acknowledged that for the most part, the BON continues to license the individual unless the crime is egregious, such as a murder conviction. Since the federal government created barrier crimes and required a second background check, some duplication exists. The BON has contacted the Federal Executive Institute (FEI) on numerous occasions and has been advised that the federal administrative procedure restricts the sharing of a criminal background check by one entity with another. 3:52:53 PM SENATOR GIESSEL referred to an audit performed by the Division of Legislative Audit. She pointed out that the BON was in compliance for the authorized use of criminal background checks, but were found out of compliance since the board stores its records for license applications in the Alaska archives. She characterized this as being a "ding" by the FBI, which shows how stringent the agency is in terms of sharing the document. She referred to page 3 of the audit that showed the BON was in compliance in having a reason to request the information. She said these audits are "very real," and the FBI takes its jurisdiction and prevention of sharing background checks seriously. Some health care providers finish their education, seek licensure, and must submit to a criminal background check for the BON for licensure. She related a scenario in which a nurse then applies for work at a hospital in Bethel. The nurse must submit to a second background check. On March 21, 2014, the BON formulated a subcommittee that plans to meet this summer with Alaska State Hospital and Nursing Home Association (ASHNA) and the FBI to discuss and find solutions for the duplicate requirements and associated costs to new employees. 3:54:56 PM SENATOR GIESSEL next referred to an issue raised by the Christian Science Committee on Publication for Alaska. She stated that as a religious community, the Christian Science community has religious ministers that the community refers to as "nurses." She explained that these ministers go into homes and provide services such as cooking, bathing, housekeeping, encouragement, and spiritual guidance. These services are all non-medical. She noted that the Christian Science Community has come to the BON on numerous occasions requesting an exemption to use the protected term "nurse" for their church members who are preforming these services. The board has repeatedly denied this exemption since "nurse" is a protected term. She referred to a letter [dated September 3, 2013] from the Department of Law that limits the term of "nurse" since AS 08.68.340 (a)(4) identifies a nurse as a medical health care provider and it would be inappropriate to make an exemption. Also, the BON recognizes that the public assigns a certain identity to the term "nurse." 3:56:17 PM REPRESENTATIVE JOSEPHSON asked about notice to the board of a termination of a nurse. He asked whether that is done in other professions. SENATOR GIESSEL answered yes, that the BON provisions are modeled after the state medical profession statutes. REPRESENTATIVE JOSEPHSON surmised that the BON would make a distinction for personality conflicts and not much more would happen. SENATOR GIESSEL answered that would raise other questions about fair employment practices. She clarified that these are related to professional conduct and competency. 3:57:17 PM REPRESENTATIVE JOSEPHSON referred to the Christian Science Committee on Publication letter in members' packets that read, "Notably, the Alaska Medical Practice Act already has a religious exception in place." He asked whether any analogy exists. SENATOR GIESSEL said she has reviewed the medical statutes and the statement exists; however, she recalled the next section of statutes relates to the definitions and it is very clear that the term "physician" and "doctor" are protected terms under the medical statutes. The medial board does not allow other people to use the terms, "physician" or "medical doctor" unless they are scientifically and medically trained physicians. CHAIR OLSON remarked that the committee has seen naturopath issues that have arisen in terms of the title "doctor." REPRESENTATIVE JOSEPHSON recalled that naturopaths advertise themselves in that manner. CHAIR OLSON responded that the naturopaths advertise themselves as being "naturopathic doctors" or "NDs." He asked the sponsor if the BON has had that experience. SENATOR GIESSEL agreed he is correct. 3:58:58 PM REPRESENTATIVE JOSEPHSON asked whether some compromise could be reached in which the Christian Science community could use a term other than "nurse" or term that said "pastoral nurse." He further asked whether that has been discussed. SENATOR GIESSEL said it has and the Christian Science community wants to use the term "nurse." She explained that the BON does not have any opposition to the services provided by the spiritual guides but the term "nurse" is protected. She offered her belief that Alaska's citizens believe that a "nurse" represents a medically trained individual. 3:59:59 PM REPRESENTATIVE SADDLER asked for the reason that the Christian Science community has for using the term "nurse" and if it is motivated by respect, professional standing, or additional billing status. SENATOR GIESSEL answered that using the term would enable them to advertise and to be reimbursed by insurance for services. 4:00:38 PM REPRESENTATIVE SADDLER referred to page 4, line 2, to paragraph (3), to the required education for a practical nurse. He related his understanding that if a registered nurse fails the exam, the individual could be licensed as a practical nurse. SENATOR GIESSEL agreed. This is something the board would review before licensure. She deferred to the executive administrator to provide more details. 4:01:24 PM CHAIR OLSON suggested that the Christian Science community may wish to seek a separate bill to address their issue since it would raise several other concerns. REPRESENTATIVE HERRON referred to page 3, paragraph (10) of Section 2. He commended Dr. Nancy Sanders, who was helpful with respect to nurse aide classes in rural Alaska. He said that she helped foster a solution for the Bethel Health Center. He said he was considering an amendment. He asked whether the existing AS 08.68.101 could be amended to allow, but not require, a criminal background check previously ordered by the department. REPRESENTATIVE HERRON appreciated hearing that the administrator, Dr. Nancy Sanders, will convene a workgroup to work with all the parties with respect to the FBI ruling on criminal background checks. He suggested that this would give the board an opportunity to use the background check working group in anticipation that the legislature could address the law next session. In this way the working group could work on a solution, totally within their purview, but come to the legislature next session. 4:04:31 PM SENATOR GIESSEL acknowledged this is the reason the board has convened the subcommittee; however, she expressed concern about inserting permissive language in the event a potential licensee contests the board saying it could have used another criminal background check. [Referring to the 2/11/14 letter from the executive administrator, Nancy Sanders, that under AS 08.68.344] the Board of Nursing may deny a certification or impose a disciplinary sanction. She hoped the FBI will be helpful in finding a solution, although she did find letters dating back to 2007 denying the double use. Thus, she was unsure of the FBI's outcome and how quickly it might act. She offered her belief that it is possible to more quickly address the issue next session based on the interim work. At that point the BON will know if it has permission to use the background check for two different facilities; however, currently it may just add confusion to the administration of the licensing procedures. She deferred to the executive administrator. 4:06:10 PM REPRESENTATIVE HERRON asked whether the FBI's initial concern was about a Department of Health and Social Services (DHSS) requested background check. SENATOR GIESSEL answered yes. She read [from a U.S. Department of Justice] letter dated July 5, 2005, which read, in part, "Criminal history information obtained under this authority may be used solely for the purpose requested and cannot be disseminated outside the receiving departments, related agencies, or other authorized entities." 4:07:18 PM REPRESENTATIVE HERRON looked forward to the outcome of the working group. He referred to proposed language [in members' packets, not yet offered] that would amend AS 08.68.101 to allow, but not require, use of a background check previously ordered by the department. He asked whether his proposed language would help, in advance of the working group's solution. NANCY SANDERS, Ph.D., RN; Executive Administrator, Board of Nursing, Department of Commerce, Community & Economic Development answered that she thought it would be premature to do so. She suggested some decisions need to be made. The BON asked for background checks to make a decision about licensing. The DHSS asked for an employment background check, which are two very separate purposes. In terms of putting in proposed language changes, the BON does not currently have a process since the FBI will not allow sharing the criminal background information. She understood the DHSS could not share with the Board of Nursing and hoped more information would be forthcoming via the work group to figure out how to streamline this. 4:10:34 PM REPRESENTATIVE HERRON asked what talent and skill sets Dr. Sanders will bring to the work group. DR. SANDERS envisioned a representative from DHSS would serve on the work group. She also hoped she would serve, as well as a member from the Alaska State Hospital and Nursing Home Association. She suggested that someone from the FBI should provide consultation and added that the full complement of people to serve has not yet been identified. 4:11:30 PM REPRESENTATIVE HERRON asked whether she would consider adding someone from the Kuskokwim Health Corporation to participate in the work group. MS. SANDERS answered she would entertain that idea; however, she said that the proposed language would not just affect nurse aides but would affect everyone licensed by the BON, including registered nurses, licensed practical nurses, and certified nurse assistants. She suggested she would like a broad representation, including someone from a rural setting such as the Yukon Kuskokwim Delta. 4:12:43 PM CHAIR OLSON suggested the language could affect 16,000 people. DR. SANDERS acknowledged that's the current number, but it also would affect those applying to be licensed or certified as well as those seeking reinstatement. It might be 1,000 to 1,300 more per year, she said. CHAIR OLSON noted that was a significant number. REPRESENTATIVE HERRON asked to put on record that he would like the FBI involved in the work group. SENATOR GIESSEL answered that she believed that was the intent. She also appreciated the suggestion to have a rural facility represented. She acknowledged that the board seeks geographic distribution in its composition, too. CHAIR OLSON asked whether she would work with Representative Herron on a letter of intent to SB 166. SENATOR GIESSEL answered that she would be happy to do so 4:14:38 PM REPRESENTATIVE SADDLER referred to page 2, line 16, which adds retired nurse status. He asked what activities a retired nurse would be allowed. DR. SANDERS answered that this category of licensure is one the BON is continually asked to issue. This does not allow nurses to continue to work, even in a voluntary capacity. She characterized it as keeping an honorarium since nurses worked hard for their licenses and would like to be recognized as nurses. 4:15:41 PM REPRESENTATIVE SADDLER clarified that it doesn't allow them to practice. He asked whether there is any legal status given to retired nurses. DR. SANDERS answered no; it just provides an honorary title. REPRESENTATIVE SADDLER related that he is married to a registered nurse. REPRESENTATIVE SADDLER said the sponsor statement states that this is the first improvement to nursing statutes in 10 years. He asked for any trends in nursing. DR. SANDERS offered her belief that a bill would likely be introduced next year to introduce the advanced practice registered nurses (APRNs) consensus model for advanced practice nurses. Currently a subgroup, the APRN alliance, has been working on the national movement. She envisioned that if nurse practitioners or certified nurse midwives move out of state that their practice would be similar to their practice in Alaska. 4:17:37 PM REPRESENTATIVE SADDLER referred to page 2, line 17, to subparagraph (D), which read, "establishing criteria for  approval of practical nurse education programs that are not  accredited by a national nursing accrediting body;" He asked whether the programs are educational programs in Alaska. DR. SANDERS said that many practical nurse programs throughout the U.S. are not nationally accredited nursing programs through the national nursing accreditation. This would allow the board to consider an applicant's transcript to determine whether the applicant has met the same educational standard as programs in the state. She explained that the regulations in Alaska require the practical nurse program "will" achieve national accreditation, but many programs in the Lower 48 are not nationally accredited. REPRESENTATIVE SADDLER asked whether the BON expects many applicants to come from non-accredited programs. 4:18:57 PM DR. SANDERS said there are a significant number of people who have graduated from these programs that might apply for licensure in Alaska. She was unsure of the percentage, but they may be accredited through a regional accreditation, but not specifically a nursing accreditation. There is one advanced practice nurse program (APN) in Alaska, which is moving towards becoming nationally nursing accredited. 4:19:40 PM REPRESENTATIVE SADDLER asked for an assessment of the quality of education for consumers. DR. SANDERS answered that the BON currently licenses APNs; however, the BON is tightening its regulations about nursing education, regarding the minimum level of education. This would allow the BON to scrutinize their education. Currently, as the administrator, she will go the applicant's home jurisdiction and board site and compare the minimum qualifications for that jurisdiction and compare it to Alaska's requirements to determine equivalency. 4:21:02 PM JANA SHOCKMAN, Registered Nurse, President, Alaska Nurses Association, related that the ANA supports the requirement in this bill for the executive administrator to hold a Master's degree in Nursing as a minimum. This position requires broad knowledge of nursing issues that range from the certified nurse assistant (CNA) level to the advanced practice nurse. Historically, this position has been filled for the past two decades with that background. She reported that there are currently more than 1,000 nurses who meet that qualification in Alaska. The ANA believes that any background check amendment is premature. The plans underway for the work group meeting are also supported by the ANA. She stated that the ANA does not support the Christian Science nurses use of the title "nurse" although it recognizes the value of the services they provide. She pointed out that the Christian Science spiritual guides are not educated as nurses. The use of the title could be confusing to the public. She concluded that the ANA supports SB 166, without any amendments. 4:23:07 PM BETH FARNSTROM, Registered Nurse; Chair, Board of Nursing, Department of Commerce, Community & Economic Development, stated that the BON supports SB 166, without any amendments for the various reasons previously stated. PATRICIA SENNER, Advanced Nurse Practitioner (ANP), asked to speak in support of SB 166 as has been brought to the committee. 4:24:26 PM KAREN PURDUE, President & CEO, Alaska State Hospital Nursing Home Association (ASHNHA), stated that the association supports this bill and is interested in having the background issue addressed. She emphasized that the ASHNHA employs numerous nurses and nursing assistants in their facilities. She said that ASHNHA depends on the BON to maintain a qualified work force. She offered support for rigorous licensing, background checks, and the type of work that the board conducts. She clarified that the complexity of the background check has been added to because the legislature passed another bill in 2008. She recalled that Representative Herron referred to the DHSS background check. Part of the issue arises from the FBI, but also part of it is that the state has a duplicate background check system. Basically, each individual who is working in a facility licensed by the DHSS or paid by the department must submit to a background check conducted by the DHSS. MS. PURDUE offered her belief that this has added thousands of background checks to the process, even though it uses the same seminal information that the licensing board and FBI fingerprinting uses. The ASHNHA questions whether this can be more efficient but not lower the standards or impact the BON's ability to regulate licensees. She further asked if expenses and complexity will be cut. She looked forward to the work group process and to participating vigorously. She closed by saying that the recent focus has been on the CNA, so those individuals have a very short training time and make about $16 per hour. These jobs provide the backbone of the care industry. She emphasized that she is very focused on jobs being available in rural Alaska. Anything that the ASHNHA can do to ensure that those individuals obtain employment is important, which includes background checks, taking timely tests, and ensuring that classes are available. She thanked members and assured them that the ASHNHA is ready to participate in the process. REPRESENTATIVE HERRON noted that she raised a good point that the issue might not rest with the FBI and may rest with [the legislature and the state]. 4:27:36 PM BEVERLY SMITH, Media and Legislative, Christian Science Church, stated that she has no desire to hold up the bill. She has held discussions with the Chair of the Board of Nursing and is willing to work with the board during the interim. First, the Christian Science Nurses refer to themselves only as "Christian Science Nurses" and would never hold themselves out as a "nurse." She explained that they have been in operation for 106 years and there has never been any confusion anywhere in the world with this term. The "Christian Science Nurses" do not advertise in the yellow pages, but do advertise in a religious publication so someone seeking the services of a "Christian Science Nurse" would know where to look for the service. She thinks it is a little strange that a person could live in Michigan and practice this religious practice and use the services of "Christian Science Nurses" but cannot do so in Alaska and thought that there should be some accommodation. She referred to a letter in members' packets from the Christian Science - Committee on Publication for Alaska [dated 4/15/2014]. She pointed out the first amendment issue for practicing one's religion. She mentioned the model nurse practices act, which has a suggested accommodation for caring for the sick in accordance with tenets and practices related to religious denomination that teaches reliance on spiritual means for healing. She reported that most other states in the U.S. and other countries do permit "Christian Science nurses" to practice in their jurisdiction through regulation, statute, or advisory opinion. Again, the Christian Science church is looking for such an accommodation in Alaska so its citizens who are Christian Scientists can practice their religion fully. CHAIR OLSON said that working with the BON is a good start. 4:31:37 PM REPRESENTATIVE SADDLER asked how many Christian Science practitioners are in Alaska. MS. SMITH answered that the practitioners are different than the "Christian Science nurses." She estimated that perhaps five or six practitioners are in the state and fewer "Christian Science nurses" since they currently cannot practice in Alaska. 4:32:06 PM REPRESENTATIVE SADDLER asked how many practice the faith in Alaska. MS. SMITH suggested it is a small group, in the hundreds. She related Christian Science nursing facilities exist in the Lower 48, similar to a hospital, and the services are reimbursed by Medicare and other insurance companies. She anticipated that the potential "Christian Science nurse" would provide home care in Alaska. CHAIR OLSON, after first determining no one else wished to testify, closed public testimony on SB 166. REPRESENTATIVE JOSEPHSON remarked that this is an interesting issue and is something he taught about the constitution. He said if a law has general application then everyone is subject to it. The other theory is that one has to be sensitive to free exercise issues and accommodate those issues in the least restrictive way possible. He said two strains of jurisprudence exist and he has previously represented nurses [as a lawyer], so he understands the need to keep the "nurse" title as privileged. He also recalled that naturopaths called themselves doctors and sometimes the terms are a little confusing. He acknowledged his comments just represent a discussion point. 4:34:57 PM REPRESENTATIVE HERRON moved to report CSSB 166(FIN) out of committee with individual recommendations and the accompanying fiscal notes. There being no objection, CSSB 166(FIN) was reported from the House Labor and Commerce Standing Committee.