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S.B. 45 Enrolled

             1     

NURSING AMENDMENTS

             2     
2007 GENERAL SESSION

             3     
STATE OF UTAH

             4     
Chief Sponsor: Peter C. Knudson

             5     
House Sponsor: Bradley G. Last

             6     
             7      LONG TITLE
             8      General Description:
             9          This bill amends the Nurse Practice Act, the Advanced Practice Registered Nurse
             10      Compact, and the Nurse Midwife Practice Act.
             11      Highlighted Provisions:
             12          This bill:
             13          .    removes the definition of "practice of nurse anesthesia";
             14          .    removes the license classification of certified registered nurse anesthesia;
             15          .    creates the license classification of advanced practice registered nurse - without
             16      prescriptive authority;
             17          .    changes the license category for licensed nurse anesthetist to advanced practice
             18      registered nurse without prescriptive authority;
             19          .    makes technical amendments necessary to remove references to licensed nurse
             20      anesthetists;
             21          .    adds certified nurse midwives to the list of APRN subject to the Advanced Practice
             22      Registered Nurse Compact; and
             23          .     beginning July 2010, amends the qualifications for licensure as a nurse midwife.
             24      Monies Appropriated in this Bill:
             25          None
             26      Other Special Clauses:
             27          None
             28      Utah Code Sections Affected:
             29      AMENDS:


             30          58-31b-102, as last amended by Chapter 291, Laws of Utah 2006
             31          58-31b-301, as last amended by Chapter 291, Laws of Utah 2006
             32          58-31b-302, as last amended by Chapter 291, Laws of Utah 2006
             33          58-31b-305, as last amended by Chapter 291, Laws of Utah 2006
             34          58-31d-103, as last amended by Chapter 291, Laws of Utah 2006
             35          58-44a-302, as last amended by Chapter 288, Laws of Utah 1998
             36     
             37      Be it enacted by the Legislature of the state of Utah:
             38          Section 1. Section 58-31b-102 is amended to read:
             39           58-31b-102. Definitions.
             40          In addition to the definitions in Section 58-1-102 , as used in this chapter:
             41          (1) "Administrative penalty" means a monetary fine imposed by the division for acts or
             42      omissions determined to constitute unprofessional or unlawful conduct in accordance with a
             43      fine schedule established by rule and as a result of an adjudicative proceeding conducted in
             44      accordance with Title 63, Chapter 46b, Administrative Procedures Act.
             45          (2) "Applicant" means a person who applies for licensure or certification under this
             46      chapter by submitting a completed application for licensure or certification and the required
             47      fees to the department.
             48          (3) "Approved education program" means a nursing education program that meets the
             49      minimum standards for educational programs established under this chapter and by division
             50      rule in collaboration with the board.
             51          (4) "Board" means the Board of Nursing created in Section 58-31b-201 .
             52          (5) "Consultation and referral plan" means a written plan jointly developed by an
             53      advanced practice registered nurse and a consulting physician that permits the advanced
             54      practice registered nurse to prescribe schedule II-III controlled substances in consultation with
             55      the consulting physician.
             56          (6) "Consulting physician" means a physician and surgeon or osteopathic physician and
             57      surgeon licensed in accordance with this title who has agreed to consult with an advanced


             58      practice registered nurse with a controlled substance license, a DEA registration number, and
             59      who will be prescribing schedule II-III controlled substances.
             60          (7) "Diagnosis" means the identification of and discrimination between physical and
             61      psychosocial signs and symptoms essential to the effective execution and management of
             62      health care.
             63          (8) "Examinee" means a person who applies to take or does take any examination
             64      required under this chapter for licensure.
             65          (9) "Licensee" means a person who is licensed or certified under this chapter.
             66          (10) "Long-term care facility" means any of the following facilities licensed by the
             67      Department of Health pursuant to Title 26, Chapter 21, Health Care Facility Licensing and
             68      Inspection Act:
             69          (a) a nursing care facility;
             70          (b) a small health care facility;
             71          (c) an intermediate care facility for the mentally retarded;
             72          (d) an assisted living facility Type I or II; or
             73          (e) a designated swing bed unit in a general hospital.
             74          (11) "Medication aide certified" means a certified nurse aide who:
             75          (a) has a minimum of 2,000 hours experience working as a certified nurse aide;
             76          (b) has received a minimum of 40 hours of classroom and 20 hours of practical training
             77      that is approved by the division in collaboration with the board, in administering routine
             78      medications to patients or residents of long-term care facilities; and
             79          (c) is certified by the division as a medication aide certified.
             80          (12) (a) "Practice as a medication aide certified" means the limited practice of nursing
             81      under the supervision, as defined by the division by administrative rule, of a licensed nurse,
             82      involving routine patient care that requires minimal or limited specialized or general
             83      knowledge, judgment, and skill, to an individual who is ill, injured, infirm, developmentally or
             84      physically disabled, mentally disabled, or mentally retarded, and who is in a regulated
             85      long-term care facility.


             86          (b) "Practice as a medication aide certified" includes:
             87          (i) providing direct personal assistance or care; and
             88          (ii) administering routine medications to patients in accordance with a formulary and
             89      protocols to be defined by the division by rule.
             90          (13) "Practice of advanced practice registered nursing" means the practice of nursing
             91      within the generally recognized scope and standards of advanced practice registered nursing as
             92      defined by rule and consistent with professionally recognized preparation and education
             93      standards of an advanced practice registered nurse by a person licensed under this chapter as an
             94      advanced practice registered nurse. Advanced practice registered nursing includes:
             95          (a) maintenance and promotion of health and prevention of disease;
             96          (b) diagnosis, treatment, correction, consultation, and referral for common health
             97      problems; [and]
             98          (c) prescription or administration of prescription drugs or devices including:
             99          (i) local anesthesia;
             100          (ii) schedule IV-V controlled substances; and
             101          (iii) schedule II-III controlled substances in accordance with a consultation and referral
             102      plan[.]; or
             103          (d) the provision of preoperative, intraoperative, and postoperative anesthesia care and
             104      related services upon the request of a licensed health care professional by an advanced practice
             105      registered nurse specializing as a certified registered nurse anesthetist, including:
             106          (i) preanesthesia preparation and evaluation including:
             107          (A) performing a preanesthetic assessment of the patient;
             108          (B) ordering and evaluating appropriate lab and other studies to determine the health of
             109      the patient; and
             110          (C) selecting, ordering, or administering appropriate medications;
             111          (ii) anesthesia induction, maintenance, and emergence, including:
             112          (A) selecting and initiating the planned anesthetic technique;
             113          (B) selecting and administering anesthetics and adjunct drugs and fluids; and


             114          (C) administering general, regional, and local anesthesia;
             115          (iii) postanesthesia follow-up care, including:
             116          (A) evaluating the patient's response to anesthesia and implementing corrective
             117      actions; and
             118          (B) selecting, ordering, or administering the medications and studies listed in
             119      Subsection (13)(d); and
             120          (iv) other related services within the scope of practice of a certified registered nurse
             121      anesthetist, including:
             122          (A) emergency airway management;
             123          (B) advanced cardiac life support; and
             124          (C) the establishment of peripheral, central, and arterial invasive lines; and
             125          (v) for purposes of Subsection (13)(d), "upon the request of a licensed health care
             126      professional":
             127          (A) means a health care professional practicing within the scope of the health care
             128      professional's license, requests anesthesia services for a specific patient; and
             129          (B) does not require an advanced practice registered nurse specializing as a certified
             130      registered nurse anesthetist to enter into a consultation and referral plan or obtain additional
             131      authority to select, administer, or provide preoperative, intraoperative, or postoperative
             132      anesthesia care and services.
             133          [(14) (a) "Practice of nurse anesthesia" means the practice of nursing related to the
             134      provision of preoperative, intraoperative, and postoperative anesthesia care and related services
             135      upon the request of a physician, surgeon, or other licensed professional, who is acting within
             136      the scope of their practice, by a person licensed under this chapter as a certified registered nurse
             137      anesthetist and includes:]
             138          [(i) preanesthesia preparation and evaluation including:]
             139          [(A) performing a preanesthetic assessment of the patient;]
             140          [(B) ordering and evaluating appropriate lab and other studies to determine the health
             141      of the patient; and]


             142          [(C) selecting, ordering, or administering appropriate medications;]
             143          [(ii) anesthesia induction, maintenance, and emergence, including:]
             144          [(A) selecting and initiating the planned anesthetic technique;]
             145          [(B) selecting and administering anesthetics and adjunct drugs and fluids; and]
             146          [(C) administering general, regional, and local anesthesia;]
             147          [(iii) postanesthesia follow-up care, including:]
             148          [(A) evaluating the patient's response to anesthesia and implementing corrective
             149      actions; and]
             150          [(B) selecting, ordering, or administering the above medications and studies; and]
             151          [(iv) other related services within the scope of practice of a certified registered nurse
             152      anesthetist, including:]
             153          [(A) emergency airway management;]
             154          [(B) advanced cardiac life support; and]
             155          [(C) the establishment of peripheral, central, and arterial invasive lines.]
             156          [(b) Nothing in this section shall be construed as to require a certified registered nurse
             157      anesthetist to obtain an advance practice registered nurse license in order to select, administer,
             158      or provide preoperative, intraoperative, or postoperative anesthesia care and services.]
             159          [(15)] (14) "Practice of nursing" means assisting individuals or groups to maintain or
             160      attain optimal health, implementing a strategy of care to accomplish defined goals and
             161      evaluating responses to care and treatment. The practice of nursing requires substantial
             162      specialized or general knowledge, judgment, and skill based upon principles of the biological,
             163      physical, behavioral, and social sciences, and includes:
             164          (a) initiating and maintaining comfort measures;
             165          (b) promoting and supporting human functions and responses;
             166          (c) establishing an environment conducive to well-being;
             167          (d) providing health counseling and teaching;
             168          (e) collaborating with health care professionals on aspects of the health care regimen;
             169          (f) performing delegated procedures only within the education, knowledge, judgment,


             170      and skill of the licensee; and
             171          (g) delegating nurse interventions that may be performed by others and are not in
             172      conflict with this chapter.
             173          [(16)] (15) "Practice of practical nursing" means the performance of nursing acts in the
             174      generally recognized scope of practice of licensed practical nurses as defined by rule and as
             175      provided in this Subsection [(16)] (15) by a person licensed under this chapter as a licensed
             176      practical nurse and under the direction of a registered nurse, licensed physician, or other
             177      specified health care professional as defined by rule. Practical nursing acts include:
             178          (a) contributing to the assessment of the health status of individuals and groups;
             179          (b) participating in the development and modification of the strategy of care;
             180          (c) implementing appropriate aspects of the strategy of care;
             181          (d) maintaining safe and effective nursing care rendered to a patient directly or
             182      indirectly; and
             183          (e) participating in the evaluation of responses to interventions.
             184          [(17)] (16) "Practice of registered nursing" means performing acts of nursing as
             185      provided in this Subsection [(17)] (16) by a person licensed under this chapter as a registered
             186      nurse within the generally recognized scope of practice of registered nurses as defined by rule.
             187      Registered nursing acts include:
             188          (a) assessing the health status of individuals and groups;
             189          (b) identifying health care needs;
             190          (c) establishing goals to meet identified health care needs;
             191          (d) planning a strategy of care;
             192          (e) prescribing nursing interventions to implement the strategy of care;
             193          (f) implementing the strategy of care;
             194          (g) maintaining safe and effective nursing care that is rendered to a patient directly or
             195      indirectly;
             196          (h) evaluating responses to interventions;
             197          (i) teaching the theory and practice of nursing; and


             198          (j) managing and supervising the practice of nursing.
             199          [(18)] (17) "Routine medications":
             200          (a) means established medications administered to a medically stable individual as
             201      determined by a licensed health care practitioner or in consultation with a licensed medical
             202      practitioner; and
             203          (b) is limited to medications that are administered by the following routes:
             204          (i) oral;
             205          (ii) sublingual;
             206          (iii) buccal;
             207          (iv) eye;
             208          (v) ear;
             209          (vi) nasal;
             210          (vii) rectal;
             211          (viii) vaginal;
             212          (ix) skin ointments, topical including patches and transdermal;
             213          (x) gastronomy or jejunostomy tubes;
             214          (xi) premeasured medication delivered by aerosol/nebulizer; and
             215          (xii) medications delivered by metered hand-held inhalers.
             216          [(19)] (18) "Unlawful conduct" is as defined in Sections 58-1-501 and 58-31b-501 .
             217          [(20)] (19) "Unlicensed assistive personnel" means any unlicensed person, regardless
             218      of title, to whom tasks are delegated by a licensed nurse as permitted by rule and in accordance
             219      with the standards of the profession.
             220          [(21)] (20) "Unprofessional conduct" is as defined in Sections 58-1-501 and
             221      58-31b-502 and as may be further defined by rule.
             222          Section 2. Section 58-31b-301 is amended to read:
             223           58-31b-301. License or certification required -- Classifications.
             224          (1) A license is required to engage in the practice of nursing, except as specifically
             225      provided in Sections 58-1-307 and 58-31b-308 .


             226          (2) The division shall issue to a person who qualifies under this chapter a license or
             227      certification in the classification of:
             228          (a) licensed practical nurse;
             229          (b) registered nurse;
             230          (c) advanced practice registered nurse intern;
             231          (d) advanced practice registered nurse;
             232          [(e) certified registered nurse anesthetist; and]
             233          (e) advanced practice registered nurse - CRNA without prescriptive practice; and
             234          (f) medication aide certified.
             235          (3) An individual holding an advanced practice registered nurse license as of July 1,
             236      1998, who cannot document the successful completion of advanced course work in patient
             237      assessment, diagnosis and treatment, and pharmacotherapeutics, may not prescribe and shall be
             238      issued an "APRN - without prescriptive practice" license.
             239          (4) The division shall grant an advanced practice registered nurse license to any
             240      licensed advanced practice registered nurse currently holding prescriptive authority under any
             241      predecessor act on July 1, 1998.
             242          (5) An individual holding a certified registered nurse anesthetist license as of July 1,
             243      2007, shall be issued an "APRN - CRNA - without prescriptive practice" license.
             244          Section 3. Section 58-31b-302 is amended to read:
             245           58-31b-302. Qualifications for licensure or certification -- Criminal background
             246      checks.
             247          (1) An applicant for certification as a medication aide shall:
             248          (a) submit an application to the division on a form prescribed by the division;
             249          (b) pay a fee to the division as determined under Section 63-38-3.2 ;
             250          (c) have a high school diploma or its equivalent;
             251          (d) have a current certification as a nurse aide, in good standing, from the Department
             252      of Health;
             253          (e) have a minimum of 2,000 hours of experience within the two years prior to


             254      application, working as a certified nurse aide in a long-term care facility;
             255          (f) obtain letters of recommendation from a long-term care facility administrator and
             256      one licensed nurse familiar with the applicant's work practices as a certified nurse aide;
             257          (g) be in a condition of physical and mental health that will permit the applicant to
             258      practice safely as a medication aide certified;
             259          (h) have completed an approved education program or an equivalent as determined by
             260      the division in collaboration with the board;
             261          (i) have passed the examinations as required by division rule made in collaboration
             262      with the board; and
             263          (j) meet with the board, if requested, to determine the applicant's qualifications for
             264      certification.
             265          (2) An applicant for licensure as a licensed practical nurse shall:
             266          (a) submit to the division an application in a form prescribed by the division;
             267          (b) pay to the division a fee determined under Section 63-38-3.2 ;
             268          (c) have a high school diploma or its equivalent;
             269          (d) be in a condition of physical and mental health that will permit the applicant to
             270      practice safely as a licensed practical nurse;
             271          (e) have completed an approved practical nursing education program or an equivalent
             272      as determined by the board;
             273          (f) have passed the examinations as required by division rule made in collaboration
             274      with the board; and
             275          (g) meet with the board, if requested, to determine the applicant's qualifications for
             276      licensure.
             277          (3) An applicant for licensure as a registered nurse shall:
             278          (a) submit to the division an application form prescribed by the division;
             279          (b) pay to the division a fee determined under Section 63-38-3.2 ;
             280          (c) have a high school diploma or its equivalent;
             281          (d) be in a condition of physical and mental health that will allow the applicant to


             282      practice safely as a registered nurse;
             283          (e) have completed an approved registered nursing education program;
             284          (f) have passed the examinations as required by division rule made in collaboration
             285      with the board; and
             286          (g) meet with the board, if requested, to determine the applicant's qualifications for
             287      licensure.
             288          (4) Applicants for licensure as an advanced practice registered nurse shall:
             289          (a) submit to the division an application on a form prescribed by the division;
             290          (b) pay to the division a fee determined under Section 63-38-3.2 ;
             291          (c) be in a condition of physical and mental health which will allow the applicant to
             292      practice safely as an advanced practice registered nurse;
             293          (d) hold a current registered nurse license in good standing issued by the state or be
             294      qualified at the time for licensure as a registered nurse;
             295          (e) (i) have earned a graduate degree in:
             296          (A) an advanced practice registered nurse nursing education program; or
             297          (B) a related area of specialized knowledge as determined appropriate by the division
             298      in collaboration with the board; or
             299          (ii) have completed a nurse anesthesia program in accordance with Subsection
             300      (4)(f)(ii);
             301          (f) have completed:
             302          (i) course work in patient assessment, diagnosis and treatment, and
             303      pharmacotherapeutics from an education program approved by the division in collaboration
             304      with the board; or
             305          (ii) a nurse anesthesia program which is approved by the Council on Accreditation of
             306      Nurse Anesthesia Educational Programs;
             307          (g) have successfully completed clinical practice in psychiatric and mental health
             308      nursing, including psychotherapy as defined by division rule, after completion of the masters
             309      degree required for licensure, to practice within the psychiatric and mental health nursing


             310      specialty;
             311          (h) have passed the examinations as required by division rule made in collaboration
             312      with the board;
             313          (i) be currently certified by a program approved by the division in collaboration with
             314      the board and submit evidence satisfactory to the division of the certification; and
             315          (j) meet with the board, if requested, to determine the applicant's qualifications for
             316      licensure.
             317          [(5) An applicant for licensure as a certified registered nurse anesthetist shall:]
             318          [(a) submit to the division an application on a form prescribed by the division;]
             319          [(b) pay to the division a fee determined under Section 63-38-3.2 ;]
             320          [(c) be in a condition of physical and mental health which will allow the applicant to
             321      practice safely as a certified registered nurse anesthetist;]
             322          [(d) hold a current registered nurse license in good standing issued by the state or be
             323      qualified at the time for licensure as a registered nurse;]
             324          [(e) complete a nurse anesthesia program which is approved by the Council on
             325      Accreditation of Nurse Anesthesia Educational Programs;]
             326          [(f) be currently certified by a program approved by the division in collaboration with
             327      the board and submit evidence satisfactory to the division of the certification; and]
             328          [(g) meet with the board, if requested, to determine the applicant's qualifications for
             329      licensure.]
             330          [(6)] (5) An applicant for licensure or certification under this chapter:
             331          (a) (i) shall submit fingerprint cards in a form acceptable to the division at the time the
             332      license application is filed and shall consent to a fingerprint background check by the Utah
             333      Bureau of Criminal Identification and the Federal Bureau of Investigation regarding the
             334      application; and
             335          (ii) the division shall request the Department of Public Safety to complete a Federal
             336      Bureau of Investigation criminal background check for each applicant through the national
             337      criminal history system (NCIC) or any successor system; and


             338          (b) if convicted of one or more felonies, must receive an absolute discharge from the
             339      sentences for all felony convictions five or more years prior to the date of filing an application
             340      for licensure or certification under this chapter.
             341          [(7)] (6) For purposes of conducting the criminal background checks required in
             342      Subsection [(6)] (5), the division shall have direct access to criminal background information
             343      maintained pursuant to Title 53, Chapter 10, Part 2, Bureau of Criminal Identification.
             344          [(8)] (7) (a) (i) Any new nurse license or certification issued under this section shall be
             345      conditional, pending completion of the criminal background check.
             346          (ii) If the criminal background check discloses the applicant has failed to accurately
             347      disclose a criminal history, the license or certification shall be immediately and automatically
             348      revoked.
             349          (b) (i) Any person whose conditional license or certification has been revoked under
             350      Subsection [(8)] (7)(a) shall be entitled to a postrevocation hearing to challenge the revocation.
             351          (ii) The hearing shall be conducted in accordance with Title 63, Chapter 46b,
             352      Administrative Procedures Act.
             353          Section 4. Section 58-31b-305 is amended to read:
             354           58-31b-305. Term of license -- Expiration -- Renewal.
             355          (1) The division shall issue each license or certification under this chapter in
             356      accordance with a two-year renewal cycle established by rule. The division may by rule extend
             357      or shorten a renewal period by as much as one year to stagger the renewal cycles it administers.
             358          (2) At the time of renewal, the licensee or person certified under this chapter shall
             359      show satisfactory evidence of each of the following renewal requirements:
             360          (a) complete and submit an application for renewal in a form prescribed by the division
             361      and pay the renewal fee determined under Section 63-38-3.2 ; and
             362          (b) meet continuing competency requirements as established by rule, which shall
             363      include continuing education requirements for medication aide certified established by the
             364      board and adopted by the division by rule.
             365          (3) In addition to the renewal requirements under Subsection (2), a person licensed as a


             366      advanced practice registered nurse shall be currently certified by a program approved by the
             367      division in collaboration with the board and submit evidence satisfactory to the division of that
             368      qualification or if licensed prior to July 1, 1992, meet the requirements established by rule.
             369          [(4) In addition to the renewal requirements under Subsection (2), a person licensed as
             370      a certified registered nurse anesthetist shall be currently certified in anesthesia by a program
             371      approved by the division in collaboration with the board and submit evidence satisfactory to
             372      the division of the certification.]
             373          [(5)] (4) Each license or certification automatically expires on the expiration date
             374      shown on the license or certification unless renewed in accordance with Section 58-1-308 .
             375          Section 5. Section 58-31d-103 is amended to read:
             376           58-31d-103. Rulemaking authority -- Enabling provisions.
             377          (1) The division may adopt rules necessary to implement Section 58-31d-102 .
             378          (2) As used in Article VIII (1) of the Advanced Practice Registered Nurse Compact,
             379      "head of the licensing board" means the executive administrator of the Utah Board of Nursing.
             380          (3) For purposes of the Advanced Practice Registered Nurse Compact, "APRN" as
             381      defined in Article II (1) of the compact includes an individual who is:
             382          (i) licensed to practice under Subsection 58-31b-301 (2) as an advanced practice
             383      registered nurse[.]; or
             384          (ii) licensed to practice under Section 58-44a-301 as a certified nurse midwife.
             385          (4) An APRN practicing in this state under a multistate licensure privilege may only be
             386      granted prescriptive authority if that individual can document completion of graduate level
             387      course work in the following areas:
             388          (a) advanced health assessment;
             389          (b) pharmacotherapeutics; and
             390          (c) diagnosis and treatment.
             391          (5) (a) An APRN practicing in this state under a multistate privilege who seeks to
             392      obtain prescriptive authority must:
             393          (i) meet all the requirements of Subsection (4) and this Subsection (5); and


             394          (ii) be placed on a registry with the division.
             395          (b) To be placed on a registry under Subsection (5)(a)(ii), an APRN must:
             396          (i) submit a form prescribed by the division;
             397          (ii) pay a fee; and
             398          (iii) if prescribing a controlled substance:
             399          (A) obtain a controlled substance license as required under Section 58-37-6 ; and
             400          (B) if prescribing a Schedule II or III controlled substance, have a consultation and
             401      referral plan with a physician licensed in Utah as required under Subsection
             402      58-31b-102 (13)(c)(iii) or 58-44a-102 (8)(b)(iii)(C).
             403          Section 6. Section 58-44a-302 is amended to read:
             404           58-44a-302. Qualifications for licensure.
             405          (1) An applicant for licensure as a nurse midwife shall:
             406          [(1)] (a) submit an application in a form as prescribed by the division;
             407          [(2)] (b) pay a fee as determined by the department under Section 63-38-3.2 ;
             408          [(3)] (c) be of good moral character;
             409          [(4)] (d) at the time of application for licensure hold a license in good standing as a
             410      registered nurse in Utah, or be at that time qualified for a license as a registered nurse under
             411      Title 58, Chapter 31b, Nurse Practice Act;
             412          [(5)] (e) have completed:
             413          [(a)] (i) a certified nurse midwifery education program accredited by the American
             414      College of Nurse Midwives and approved by the division; or
             415          [(b) have completed] (ii) a nurse midwifery education program located outside of the
             416      United States which is approved by the division and is equivalent to a program accredited by
             417      the American College of Nurse Midwives, as demonstrated by a graduate's being accepted to
             418      sit for the national certifying examination administered by the American College of Nurse
             419      Midwives or its designee; and
             420          [(6)] (f) have passed examinations established by the division rule in collaboration with
             421      the board within two years after completion of the approved education program required under


             422      Subsection [(5)] (1)(e).
             423          (2) For purposes of Subsection (1)(e), as of January 1, 2010, the accredited education
             424      program or it's equivalent must grant a graduate degree, including post-master's certificate, in
             425      nurse midwifery.


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