Attorney General: Janice Thibodeau, R.N. , Board of Examiners for Nursing , 1994-004 Formal Opinion, Attorney General of Connecticut

Attorney General's Opinion

Attorney General Richard Blumenthal  

February 16, 1994

Janice Thibodeau, R.N.
Chairperson
Board of Examiners for Nursing
Department of Public Health and Addiction Services
150 Washington Street
Hartford, CT 06106

Dear Ms. Thibodeau:

This is in response to an October 19, 1993 request for an opinion regarding the prescriptive authority of advanced practice registered nurses ("APRNs"), which request was generated by Marie Hilliard, the Board's Executive Officer. The question is whether APRNs have prescriptive authority in a private practice setting. The answer is that APRNs may exercise prescriptive authority only in the settings specified in Conn.Gen.Stat.  20-87a(1) through (4), unless and until the Department promulgates regulations specifically permitting APRNs to prescribe medication in a private practice setting.

As Dr. Hilliard noted in her letter, the legislature has prescribed four specific practice settings in which APRNs may prescribe medication, as well as "any other settings that may be prescribed by regulations adopted pursuant to"  20-99a of the statutes. Conn.Gen.Stat.  20-87a(b).1 The only pertinent regulation promulgated by the Department is Connecticut Agencies Reg.  20-87a-1, which provides:


Except as provided in subsection (b) of this section, an Advanced Practice Registered Nurse who performs advanced level nursing practice activities shall do so in a manner that is consistent with the provisions of chapter 378 of the general statutes and sections 2 through 6, inclusive, of these regulations in any setting, including a setting that is not already set forth in subsection (b) of section 20-87a. (Emphasis added).

The APRNs urge a broad reading of this regulation, so that they would be permitted to prescribe medication in any setting. However, this interpretation of the regulation is untenable. This regulation merely states that, in whatever setting APRNs exercise prescriptive authority, they must do so in a manner that is consistent with the relevant statutes. Conn. Agencies Reg.  20-87a-1. It is not sufficiently specific to expand the settings in which APRNs may prescribe medication. This requirement of specificity is derived from the statute and by application of the rules of statutory construction. In general, statutes should be construed so as to give effect to the intent of the legislature. State v. Parmalee, 197 Conn. 158, 161, 496 A.2d 186 (1985) (citation omitted); Nationwide Mut. Ins. Co. v. Pasion, 219 Conn. 764, 768-69, 594 A.2d 468 (1991) (citing Sanzone v. Board of Police Commissioners, 219 Conn. 179, 186, 592 A.2d 912 (1991)). "When the words of a statute are plain and unambiguous, we need look no further for interpretive guidance because we assume that the words themselves express the intention of the legislature." Rhodes v. Hartford, 201 Conn. 89, 93, 513 A.2d 124 (1986) (citation omitted). Here, the statutes clearly delegate to the Department the authority to define the settings in which APRNs may exercise prescriptive authority. Conn.Gen.Stat.  20-87a(b), 20-99a.2 Section 20-87a(b) itself states that APRNs shall have prescriptive authority in "any other settings that may be prescribed by regulations...." Conn.Gen.Stat.  20-87a(b). The legislature delegated broad discretion to the Department in defining the settings in which APRNs could practice.3 However, the Department cannot be said to have enumerated any settings other than those set forth in Conn.Gen.Stat.  20-87a(1) through (4). "Under the maxim of 'noscitur a socis,' the meaning of a particular word or phrase in a statute is ascertained by reference to those words or phrases with which it is associated." Staples v. Palten, 214 Conn. 195, 199, 571 A.2d 97 (1990) (citing Schreiber v. Burlington Northern, Inc., 472 U.S. 1, 8, 105 S.Ct. 2548, 86 L.Ed.2d 1 (1985) (other citations omitted)). The statute itself sets forth four specific places or environments in which APRNs may prescribe medication, and then provides the Department with the authority to identify other specific "settings" if it chooses to do so. Conn.Gen.Stat.  20-87a(5). The legislature's list of specific places or environments indicates that the word "settings" in Conn.Gen.Stat.  20-87a(5) refers to other specific places or environments which might be designated by the Department in regulations promulgated pursuant to Conn.Gen.Stat.  20-87a(b) and 20-99a. Thus, Conn. Agencies Reg.  20-87a-1 does not expand the settings in which APRNs may exercise prescriptive authority because it lists no other specific places or environments in which APRNs may prescribe medication. Although the legislature delegated to the Department the authority to promulgate regulations identifying settings other than those listed in Conn.Gen.Stat.  20-87a, the Department has not done so. Conn. Agencies Reg.  20-87a-1 sets forth no specific places or environments in which APRNs may prescribe medication. As such, the Department cannot be said to have identified any other settings in which APRNs may practice. Thus, APRNs may prescribe medication only in those settings set forth in Conn.Gen.Stat.  20-87a(1) through (4), unless and until the Department promulgates appropriate regulations in which such settings are specified.

Very truly yours,

Richard Blumenthal
Attorney General

Jennifer C. Jaff
Assistant Attorney General

RB/JCJ


Footnote:

1 Conn.Gen.Stat.  20-87a(b) provides in full:


Advanced nursing practice is defined as the performance of advanced level nursing practice activities which, by virtue of postbasic specialized education and experience, are appropriate to and may be performed by an advanced practice registered nurse. The advanced practice registered nurse performs acts of diagnosis and treatment of alterations in health status, as described in subsection (a) of this section. The advanced practice registered nurse may, under the direction of a physician licensed to practice medicine in this state and in accordance with written protocols, and if practicing in (1) an institution licensed pursuant to subsection (a) of  19a-491 as a hospital, home for the aged, health care facility for the handicapped, nursing home, rest home, mental health facility, substance abuse treatment facility, infirmary operated by an educational institution for the care of students enrolled in, and faculty and staff of, such institution, or facility operated and maintained by any state agency and providing services for the prevention, diagnosis and treatment or care of human health conditions, or (2) an industrial health facility licensed pursuant to subsection (h) of  31-374 which serves at least two thousand employees, or (3) a clinic operated by a state agency, municipality, or private nonprofit corporation, or (4) a clinic operated by any educational institution prescribed by regulations adopted pursuant to  20-99a, or (5) any other settings that may be prescribed by regulations adopted pursuant to said section, prescribe, dispense, and administer medical therapeutics and corrective measures, except that an advanced practice registered nurse licensed pursuant to  20-94a and maintaining current certification from the American Association of Nurse Anesthetists who is prescribing and administering medical therapeutics during surgery may only do so if the physician who is medically directing the prescriptive activity is physically present in the institution, clinic, or other prescribed setting where such surgery is being performed. (Emphasis added).

2 Conn.Gen.Stat.  20-99a provides that "[t]he department of public health and addiction services shall, with the advice and assistance of the board, adopt regulations necessary for the implementation of this chapter."

3 Of course, the Department is limited by the other legislative provisions relating to APRNs, as well as to nurses in general. Conn.Gen.Stat.  20-87a et seq.


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