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ND Board of Nursing and ND Medical Imaging and Radiation Therapy Board Joint Position Statement: Advanced Practice Registered Nurses Supervising/Performing Fluoroscopy

Guidance regarding the interpretation and application of the Nurse Practices Act (NPA) may be adopted by the ND Board of Nursing (Board) as a means of providing direction to licensees and stakeholders who seek to ensure safe nursing practice and to address issues of concern relevant to public protection. (North Dakota Century Code (NDCC) 43-12.1-08(2)(p)).

Board approved practice guidance does not carry the force and effect of the law/rules. Each licensed nurse (nurse) is “responsible and accountable to practice according to the standards of practice prescribed by the board and the profession”; and must “accept responsibility for judgments, individual nursing actions, competence, decisions, and behavior in the course of nursing practice.” (Standards of Practice, North Dakota Administrative Code (NDAC) 54-05-01-07 and 54-05-02-04). “Competence": means the application and integration of knowledge, skills, ability, and judgment necessary to meet standards. (NDAC 54-01-03-01(16)).

Background/Significance

In April 2021, the NDBON endorsed the ND Medical Imaging and Radiation Therapy Board (NDMIRTB) position statement related to APRNs and the supervising/performing of fluoroscopy. The position statement encompasses both boards, as APRNs are exempt per NDCC 43-62-03; and the scope and standards of practice for the APRN is under the jurisdiction of the NDBON per NDCC 43-12.1. Therefore, after further deliberation, the NDMIRTB and NDBON collaborated to provide a joint statement which supersedes the original position statement adopted by NDMIRTB in January 2022. The ND Department of Environmental Quality (DEQ) has authority over sources of ionizing radiation and registrants, including fluoroscopy devices under NDCC 23.1-03. The DEQ provided a statement in November 2021 supporting the educational framework and certification in this joint position statement for the APRN supervising or performing fluoroscopy procedures.

• Position statement regarding a concern for the proper specialized, comprehensive, and accredited training to include both didactic and clinical components. There is a competency skill assessment and validation by a nationally recognized written examination for fluoroscopy before the APRN independently supervises/performs the practice of fluoroscopy. The supervision/performance of fluoroscopy is considered an advancement of the APRN scope of practice.
• Position statement to assist APRNs with the ability to safely and competently supervise/perform fluoroscopy with an ongoing process of evaluation and assessment. The APRN must have appropriate knowledge and skills in fluoroscopy before accepting fluoroscopy responsibilities. Accepting and supervising/performing fluoroscopy without the appropriate knowledge and skills places the recipient/patient and others in jeopardy, as well as the APRN.

An educational framework provides a cognitive base supporting the development of knowledge and skills for an APRN who supervises/performs fluoroscopic guidance in their practice. This educational framework is intended for use by the APRN only and does not apply to the RN or LPN.

The APRN is expected to supervise/perform each examination in a safe and competent manner. The APRN must understand the rationale of the exam purpose and how it fits into the continuum of patient care. The APRN is encouraged to monitor their progress in the development of such competency.

Knowledge and skills required, but not limited to, are radiation safety, production and those characteristics, radiobiology, contrast media, health physics, fluoroscopic unit operation, safety, and image correlation with anatomy, physiology, and pathology. This education must include hands-on training.

The APRN must work closely with a medical physicist, radiologist, or other properly trained and licensed medical provider with specialized training in fluoroscopy to gain competence in each area of training.

The recommended educational framework is divided into didactic and clinical sections.  Additionally, the APRN must meet the requirement of passing a nationally recognized fluoroscopic examination, such as the American Registry of Radiologic Technologists (ARRT) fluoroscopic examination.

The three-step process is outlined below:

1. The didactic section includes, but is not limited to, patient history, contrast media, operation of the fluoroscopic unit and radiation safety.
   1. Hands-on training is conducted on each model of fluoroscopy equipment the APRN will be utilizing and consists of a minimum of two (2) hours. This hands-on equipment training is considered part of the didactic education. This training may include, but is not limited to, use of controls, activation of various modes of operation, displays, and the effect of different modes of operation on the dose rate. This training may be provided by a medical physicist or a licensed and registered radiologic technologist.
   2. The entire didactic section will comprise a minimum of 40 hours of instruction. (Appendix A provides a list of Didactic Educational Sources)
       
2. The clinical section of the educational framework includes education of all fundamental examinations that the APRN plans to perform. This aspect of training includes individual supervision by a formally trained preceptor, i.e., medical physicist, board certified radiologist, or other properly trained and licensed medical professional to ensure safety for the patient as well as any additional staff in the room while fluoroscopy is utilized.  The content and objectives should be organized to meet the educational needs of the APRN.
   1. Completion of this portion must include written confirmation that the APRN has achieved a level of competency to supervise/perform fluoroscopy independently.  This written confirmation must be signed by the preceptor.
   2. The clinical component encompasses 40 logged and documented fluoroscopy cases (approximately 40 hours). The cases are logged on the appropriate NDBON form and submitted to the NDBON upon completion.
       
3. After completion of the didactic and clinical portions of the training, the APRN must successfully complete a nationally recognized fluoroscopy examination, such as the ARRT Fluoroscopy Examination.
   1. The ARRT Fluoroscopy examination is only available for candidates who have been made eligible by a state agency and was designed for candidates who have relevant foundational qualifications (e.g., physicians, radiological technologists, radiologist assistants, physician extenders, advanced nurse practitioners). The examination is not intended for limited x-ray machine operators, medical assistants, registered/licensed nurses, chiropractic assistants (certified or not), or other ancillary medical personnel.
   2. The APRN must submit evidence to the NDBON of completion of both the didactic and clinical portions of the training to obtain eligibility to complete the exam.
   3. The NDBON will notify the APRN of their fluoroscopy examination results. The APRN must successfully pass the exam with a score of at least 75% within three (3) attempts. After three (3) failed attempts, the APRN cannot function independently in the supervision/performance of fluoroscopy as they have not met criteria for advancement in the scope of practice for fluoroscopy. Further action is at the discretion of the BON.

After successful completion of all requirements, the APRN is considered to have expanded their scope to supervise/perform fluoroscopy.  To continue this advanced scope of practice, the APRN must submit five (5) hours of continuing education relevant to the practice of fluoroscopy safety and radiation protection, upon each renewal cycle.  Continuing education must be recognized continuing education evaluation mechanism (RCEEMs) eligible for consideration of acceptance for continuing education in fluoroscopy. 

An APRN with evidence of proper specialized, comprehensive, and accredited training, both didactic and clinical components, which include fluoroscopy modality must submit portfolios to be considered on a case-by-case basis. Portfolios must include evidence, syllabi, clinical experience, and certifications/fellowships. The portfolios will be jointly reviewed by NDBON, NDMIRTB, and the DEQ (for compliance with NDCC 23.1-03).

If, after reviewing a portfolio, the Board determines that the candidate must complete further education and/or a certifying examination, the candidate must follow the Board requirements within 12 months of the Board decision. The candidate may request, in writing, a one-time extension to this 12 month time frame. An extension request is reviewed by the Board for approval. Failure to follow Board requirements will result in a report to the Compliance Division of the Board, DEQ, and NDMIRTB.

North Dakota Medical Imaging and Radiation Board
North Dakota Board of Nursing

Approved January 2022
Revised: 10/2022, 4/2023

Appendix A

List of Didactic Educational Sources

• AAPA:  Up to 40 hours (https://cme.aapa.org/local/catalog/view/product.php?productid=240)
• ASRT:  up to 12.75 hours (https://www.asrt.org/main/continuing-education/earn-ce/featured-ce/fluoroscopy-ce)
• Fluoroscopy Safety:  up to 10 hours (https://fluorosafety.com/combination-course/)
• Scrubs continuing education:  Up to 39.5 hours (https://www.scrubsce.com/fluoroscopy-ce-courses/)
• Versant Medical Physics:  up to 10 hours (https://versantphysics.com/online-fluoroscopy-course/)

In-Classroom Instruction/discussion: provided by Medical Physicists, 20 hours; dates and location to be determined based on need.