Nursing License Requirements and Scope of Practice in Massachusetts

Although one of the smallest states in the US, Massachusetts is one of the best-paying of all the states for all classes of nursing personnel. The US Bureau of Labor Statistics (BLS) reports that in 2018, 39,100 certified nursing assistants (CNAs) and16,220 licensed practical nurses (LPNS) were employed in Massachusetts. Nursing personnel also included 80,630 registered nurses (RNs) and more than 7,200 advanced practice registered nurses (APRNs). While the class of APRN known as clinical nurse specialists (CNSs) is included in the total of the RN group, the BLS notes that Massachusetts employed 810 certified registered nurse anesthetists (CRNAs), 6,200 nurse practitioners (NPs) and 250 certified nurse-midwives (CNMs) in 2018.

The Nurse Aide Registry Program, under the auspices of the Bureau of Health Care Safety and Quality, governs licensing for CNAs in Massachusetts. LPNs, RNs, and APRNs fall under the jurisdiction of the Massachusetts Board of Registration in Nursing (MBRN).

Massachusetts is not a nursing compact state. States that belong to the Nursing Licensure Compact (NLC) allow nurses with a license in one state to practice in all other compact states.

Initial Licensure

Certified Nurse Aides (CNA)

Applicants have two options. The first is to complete an approved training program. These are offered by a number of organizations and educational institutions as well as the American Red Cross. The second is to receive on the job training in a long-term care facility; the training allows the nurse aide to take the competency evaluation test and become certified. The evaluation includes both written testing and skills testing. Fees are required for testing and certification. Once certified, the CNA is placed on the nurse aide registry. Candidates have four attempts at the written test and three at the skills test. Applications are mailed to the Division of Health Care Quality in Boston.

The Massachusetts Medication Administration Program (MAP), jointly regulated by the Departments of Public Health, Mental Health, and Mental Retardation, allows CNAs to become certified medication aides in community programs. The CNA must complete additional training and become certified through examination.

Licensed Practical Nurses (LPN)

Applicants must complete an approved and accredited practical nursing program, which typically takes about 12 months. The applicant must also pass the NCLEX-PN examination, submit fingerprints and pass a criminal background check. CPR certification is also required. Fees are required for testing and licensure.

Registered Nurses (RN)

To become a registered nurse in Massachusetts, an applicant must complete a nursing diploma, associate or bachelor’s degree in nursing and submit to fingerprinting and a criminal background check. Passing the NCLEX-RN is required, as are fees for testing and actual licensure.

Advanced Practice Registered Nurses (APRN)

APRNs in Massachusetts must first be licensed as RNs. The applicant must complete a master’s or doctoral degree in nursing. National certification is required. Massachusetts recognizes five categories of APRNs: CRNAs, CNMs, NPs, CNSs and psychiatric mental health clinical nurse specialists (PCNSs).

Fees are required for certification and licensing.

License Renewal

Massachusetts does not issue paper licenses or certificates in any category. The state has only two categories of license – current and expired; there is no option to allow a license to become inactive.

CNA – a CNA who has worked at least eight hours in the previous two-year period is eligible to renew. Documentation must be completed by the employer. The new certification will expire two years from the last documented date of employment.

LPN – to renew an LPN license, the applicant must have completed a minimum of 15 hours of continuing education. Applicants must also attest to being of good moral character (as defined by state law) and to comply with mandatory abuse reporting laws. LPNs renew in odd-numbered years; the expiration date is the LPN’s birthday.

RN – requirements are the same as those for LPNs. RNs renew in even-numbered years; the expiration date is the RN’s birthday.

APRN – APRNs must meet the requirements for RNs. In addition, an APRN must attest to meeting prescriber training requirements and submit proof of national certification in his or her specialty and proof of enrollment in MassHealth. The applicant must have a National Provider Identifier to enrolled in MassHealth. APRNs can renew as an RN only if they want to allow the APRN designation to lapse.

Other Methods of Licensure

Home health aides who completed training within the preceding five years are eligible to take the nurse aide competency examination and skills test.

Nursing students can become CNAs if they have completed at least 75 hours of training in the program of a nursing school in Massachusetts that qualifies graduates to sit for the NCLEX examinations.

Endorsement/Reciprocity – nursing personnel who are currently licensed in another state may become licensed in Massachusetts. A CNA must hold a current certification in good standing in another state and have never been certified in Massachusetts. An LPN must hold a current license in good standing in another state. RNs and APRNs must hold licenses in good standing and the APRN must be nationally certified.

LPNs, RNs, and APRNs previously licensed in Massachusetts must renew the expired license rather than apply for a new license.

Graduate nurses – some states allow graduate nurses to work in their field with an interim permit prior to passing the NCLEX-RN or NCLEX-PN examination. Massachusetts does not have a graduate nurse option.

Foreign-educated nurses who apply for licensure by reciprocity or exam must submit an evaluation report from the Commission on Graduates of Foreign Nursing Schools (CGFNS).

Veterans who completed military health care training such as medical corpsman programs are not eligible to become nursing personnel in any category in Massachusetts without additional training and examinations.

Criminal History Reports

The MBRN has the responsibility to determine whether applicants for initial licensure or renewal pose an unacceptable risk to public health. Specifically, the board uses evidence of past and present conduct to determine what it defines as good moral character: “… the ability to practice nursing in a safe and competent manner and without risk to the public health, safety or welfare.” At the time of application or renewal, candidates must answer specific questions related to criminal and/or disciplinary history. An open criminal matter or any criminal conviction which has not been closed for at least one year from completion of all conditions will usually result in denial of a license. The applicant bears the entire responsibility for submitting all necessary documents; the board does not communicate with third-party entities such as nursing schools, employers or the courts. Permanent license revocation typically occurs in cases involving a violent crime against a person that involves extreme disregard against human life, trafficking in or manufacturing illegal substances, or exploitation of or criminal mistreatment of a vulnerable individual. Nurses who have substance abuse problems may be eligible for the Substance Abuse Rehabilitation Program (SARP), a voluntary abstinence program that may allow them to maintain licensure.

Disciplinary Actions

In the interests of protecting the public welfare, the MBRN may take disciplinary action against a nursing practitioner. Such action is usually taken based on findings of malpractice, abuse or substance abuse. Other possible reasons for disciplinary action include patient abandonment, negligence, acting outside of the scope of practice, fraud or sexual misconduct.

All disciplinary action is on a case-by-case basis. The board will investigate, review the evidence and consider mitigating factors. It will also take into account whether the applicant has completed a prison sentence or substance abuse program. The various options for the board include the following:

Dismissal – a case outside of the board’s jurisdiction, or one in which there is insufficient evidence, may be dismissed. Other reasons for dismissal include that the conduct complained of does not warrant discipline or the nurse has successfully completed the SARP program.
Reprimand – the board provides a written statement on the way(s) in which a nurse has failed to comply with the law and/or regulation. A reprimand does not limit what the practitioner can do but serves as notice of wrongdoing.
Probation – the board allows a nurse to continue to practice subject to certain terms and conditions.
Suspension – temporary denial of the right to practice. The individual is not allowed to represent him- or herself as a licensed nurse.
Stayed Suspension – the board will not activate the suspension as long as the nurse doesn’t comply with terms and conditions set forth by the board (often used in substance abuse cases).
Surrender – the board requires the licensee to surrender his or her license. Surrender means the nurse has permanently lost the right to practice in Massachusetts.

Scope of Practice

Scope of practice determines the tasks, authority, and conditions under which nursing personnel offer their services to the public. Scope of practice is greatest for APRNs and most limited for CNAs. Each level of higher scope includes all the tasks and responsibilities of the levels below it.

CNA – considered dependent practitioners, CNAs must work under the direct supervision of a licensed nurse. Typical CNA tasks include hygiene activities such as bed baths, feeding patients, and helping them ambulate. Certified medication aides may also administer medications.

LPN – also dependent practitioners, LPNs work under licensed nurses and physicians. They are bedside caregivers who perform direct care tasks. This includes medication administration. LPNs in Massachusetts may also insert and remove peripheral intravenous lines, monitor the site, administer blood products or obtain a blood sample.

RN – RNs are responsible for higher-level functions that require additional training and experience, critical thinking skills and assessment and evaluation of the patient. They may perform more specialized tasks such as dialysis or manage central infusion lines.

APRN – the APRN scope of practice is similar to that of physicians, although APRNs cannot perform surgery. They can, however, order laboratory and diagnostic tests, prescribe medications, treatments, and durable medical equipment, and perform procedures such as joint injections or suture lacerations. Massachusetts requires APRNs to have a collaborative agreement with a physician. Most APRNs provide direct care – CRNAs administer anesthesia, CNMs provide prenatal, obstetric and gynecological care and NPs provide primary care. PCNSs provide mental health care. CNSs have advanced education and training in specific populations, settings, disease or medical sub-specialties, types of problems, or types of care – such as psychiatric or rehabilitative care. They provide expertise and support to bedside nurses, drive organizational practice changes and help ensure the use of best practices and evidence-based care through nursing research.