Frequently Asked Questions - Nursing Practice
Workplace and Employment — General Information
What is the BON Proposed Nursing Work Hours Position Statement?
BON Proposed Nursing Work Hours Position Statement. The Texas Board of Nursing's (BON) Nursing Practice Advisory Committee (NPAC) initiated an online survey concerning nursing work hours which was conducted on the BON web site. The survey was developed in response to research...
done by the Institute of Medicine which showed that working shifts longer than 12.5 hours per day and more than 60 hours per week may cause increased incidence of nursing errors and diminished patient safety. A public hearing was held to solicit further public feedback concerning nursing work hours on April 18, 2007. Feedback obtained from the public hearing, as well as from the BON survey data, was considered by the Board concerning adoption of a proposed position statement (included in the January, 2007, Texas Board of Nursing Bulletin) relating to nursing work hours. The Board voted to send the proposed position statement back to the NPAC for further consideration. The linked document below was taken from the April 2007 Texas Board of Nursing's Bulletin Nursing Work Hours Summary Document PDF. (See more, below.)
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Mandatory Overtime/Consecutive Shifts
Can an employer require a nurse to work longer than scheduled, or to work overtime?
How many consecutive hours or shifts can a nurse work?
The Texas Board of Nursing (BON) does not have authority over work-place issues, such as schedules or number of hours worked, either consecutively, in a given time period or "on-call". In 2009, during the 81st Legislative Session, SB 476 made changes to the Nursing Practice Act (NPA) and the Health & Safety Code. SB 476 applies to hospitals and nurses working in hospital settings only.
As a result of SB 476, the NPA was amended to include Section 301.356
, Retaliation Prohibited.
Section 301.356 states that, "the refusal by a nurse to work mandatory overtime as authorized by Chapter 258, Health and Safety Code, does not constitute patient abandonment or neglect." However, this does not diminish the duty of each individual nurse to always act in the best interest of the patient and provide for their safety. If a nurse knows, or should have known, that a patient was potentially in danger by being left unattended the nurse's duty is always to act in the best interest of the patient.
In relation to overtime and or consecutive hours worked, the nurse has a duty to recognize when he or she is unfit to practice secondary to physical, mental, and or emotional fatigue [217.11(1)(T)]. Nursing judgment and provision of nursing care may be impaired if a nurse is physically, mentally, or emotionally exhausted, which could lead to nursing errors Nurses must "know and conform" with the NPA and Board Rules as well as all the laws, rules, and regulations for their particular practice setting [217.11(1)(A)]. The NPA and Board Rules have the force of law for nurses; any nurse who violates some part(s) of the NPA or Board Rules is subject to possible reporting to the Board and possible disciplinary action on his or her license. While the BON does not have authority in employment situations, there are protections in both the NPA and the Texas Administrative Code Rule 217.20, Safe Harbor Peer Review for Nurses and Whistleblower Protections for a nurse who refuses mandatory overtime and declares safe harbor in good faith. If adverse employment action was taken against a nurse, then the nurse may choose to seek private legal counsel in an effort to civilly secure these whistleblower protections. Rule 217.20 (e) outlines the requirements the nurse must meet in order to secure the protections, what the protections are, and where they are listed in the Texas Occupations Code, Nursing Peer Review, Section 303.005.
Additional resources and contact information to guide nurses as they implement the new laws are:
Nurses, who practice in hospital settings, may wish to contact the Texas Department of State Health Services (DSHS) http://www.dshs.texas.gov/ or call 1-888-973-0022 for specific guidance related to the regulations for the official nurse staffing policies and plans that took effect on September 1, 2009.
Nursing specialty organizations, such as the Texas Nurses Association at www.texasnurses.org or 512-452-0645 may have additional information.
A Nurse Staffing Law Toolkit developed by The Texas Hospital Association at www.tha.org or 512-465-1000 may also be available.
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Is there a law regarding how many patients (nurse: patient ratio) a nurse can be assigned to care for in Texas?
The Texas Board of Nursing (BON) has no authority over workplace or employment issues, such as staffing ratios. The Nursing Practice Act (NPA) Nursing Practice Act and Board Rules are written broadly to apply to nursing practice by all nurses (LVNs, RNs, & APRNs) in any practice setting. Board Rule 217.11, Standards of Nursing Practice provides the minimum standards nurses must meet in accepting any assignment, including floating, working with inadequate staffing and other practice situations, specifically:
- Standard 217.11(1) (B) requires the nurse to maintain a safe environment for the patient. This requirement supersedes any agency policy or physician order.
- Standard 217.11(1) (T) holds the nurse accountable to accept only those assignments that are within the nurse's education, training, and experience, as well as his or her physical and emotional ability. If a licensed nurse accepts an assignment, he or she is responsible for the care delivered.
- Standard 217.11(1) (S) applies to charge nurses or nurses who are in management positions. This standard is the "companion" standard to (1) (T), as it requires the nurse who is supervising other nurses to "make assignments" that take into account the educational preparation, knowledge, skills, and physical, mental and emotional abilities of the nurses for whom the supervisor is administratively responsible. This does not mean other nurses are working under the supervisor's license, or that the supervisor is responsible for every aspect of care delivered by other staff nurses. Assignments made to other licensed nurses do require forethought and adequate supervision.
- Standard 217.11(1) (U) holds supervisors responsible to oversee the nursing care provided by others for whom the supervisor is professionally responsible, from a licensure standpoint, the responsibility for overall patient care is the responsibility of the staff nurse accepting the assignment.
During the 2009, 81st Legislative Session, Senate Bill 476 was enacted and this changed the Health & Safety Code. If the nurse practices in a hospital, he or she may wish to contact the Department of State Health Services (DSHS) - Health Facility Program at 1-888-973-0022 or http://www.dshs.texas.gov/facilities/hospitals/laws-rules about the regulations for the official nurse staffing policies and plans that took effect on September 1, 2009. To view the actual law, please go to http://www.legis.stte.tx.us/tlodocs/81R/billtext/html/SB00476F.HTM
The nurse may also wish to contact various nursing specialty organizations, such as the Texas Nurses Association at 512-452-0645 or www.texasnurses.org. While the Board cannot address employment issues, specialty nursing organizations exist to serve their members and may be able to provide the nurse with additional guidance. The Texas Hospital Association has developed a Nurse Staffing Law Toolkit (available for purchase) that may provide nurses and hospitals with additional resource information ( www.tha.org or 512-465-1000)
If the nurse believes that he or she is being asked to accept an assignment that would cause the nurse to violate the NPA or Board rules, especially any of the standards of practice in Board Rule 217.11, the nurse may wish to review the NPA Section 301.352 Protection for Refusal to Engage in Certain Conduct. If the facility or employer routinely utilizes at least 10 nurses, 5 of which are RNs, the nurse may wish to consider invoking Safe Harbor found in Board Rule 217.20. While the BON does not have authority over workplace issues, such as determining nurse to patient ratios, there are protections in both the NPA and the Safe Harbor Rule for a nurse who invokes Safe Harbor in good faith. If adverse employment action was taken against a nurse, then the nurse may choose to seek private legal counsel. Board Rule 217.20 (e) outlines the requirements the nurse must meet in order to secure the protections, what the protections are, and where they are listed in the Texas Occupations Code, Section 303.005.
Revised October 2009
Revised August 2014
Revised July 2016
Senate Bill 476
Nursing Practice Act
Texas Board of Nursing Rules
Texas Occupations Code, Section 303.005
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Floating to Unfamiliar Practice Settings
Question: I Nurses in my facility are often required to float from their home unit to other care units where they do not have clinical competence and/or clinical experience. What is the duty of the nurse when it comes to floating to different clinical units (adults, pediatric, ER, etc.)?. Can a nurse invoke Safe Harbor? If so, how do nurses invoke Safe Harbor?
Answer: The Nursing Practice Act (NPA) Nursing Practice Act and Board rules Board Rules are written broadly to apply to nursing practice in any setting. Although the Board of Nursing (BON) has no authority over workplace policies, such as floating or staffing ratios, nurse staffing was addressed in SB 476 during the 81st Legislative Session in 2009.
If you work in a hospital, this law is applicable to you and requires hospitals to have a nurse staffing committee, policy and plan to ensure that an adequate number and skill mix of nurses are available to meet the level of patient care needed. The law further states that the staffing plan must include a method for adjusting the staffing plan for each patient care unit to provide staffing flexibility to meet patient needs; and include a contingency plan when patient care needs unexpectedly exceed direct patient care staff resources. “Floating”is a staffing strategy that involves sending a nurse from his/her permanently assigned unit, or home unit, to a unit that needs staff.” (JONA, 2011). Floating can be the strategy that meets the intent of the law.
- Nurses are required to "know and conform" to the NPA and Board Rules, both of which have the force of law for licensed nurses (LVN, RN, or APRN). Nurses that may be required to float to assist another unit or confronted with a potentially unsafe practice situation should be familiar with the Standards of Nursing Practice, found in Board Rule 217.11, specifically:Standard (1) (B) requires the nurse to maintain a safe environment for the patient. This requirement supersedes any agency policy or physician order; also see Position Statement 15.14: Duty of a Nurse in Any Practice Setting.
- Standard (1) (P), in situations where nurses are floating, working double or extra shifts, taking charge duties, or working short-staffed, clear communication between staff and supervisors is essential to manage patient care and decrease conflict in the work setting. A nurse may also seek opportunities in his or her practice setting to become involved with committees or other facility-based efforts in developing staffing strategies that comply with the nurse’s scope of practice and that balance the needs of the facility with the requirements for safe patient care.
- Standard(1)(S) applies to charge nurses or nurses who are in management positions. This standard requires the nurse who is supervising other nurses to make assignments that take into account the educational preparation, knowledge, skills, physical, mental and emotional abilities of the nurses for whom the supervisor is administratively responsible. This does not mean other nurses are working under the supervisor's license, or that the supervisor is responsible for every aspect of care delivered by other staff nurses.
- Standard (1)(T) holds the nurse accountable to accept only those assignments that are within the nurse’s education, training, or experience, as well as his or her physical and emotional ability. If the nurse accepts an assignment, then they are responsible for the nursing actions and care delivered.
- Standard (1)(U) holds supervisors responsible to oversee the nursing care provided by others for whom the supervisor is professionally responsible.
If a nurse believes they are being asked to accept an assignment that would cause the nurse to violate the NPA or rules, especially any of the standards of practice in Board Rule 217.11, the nurse will want to refer to Section 301.352 of the NPA or the Frequently Asked Question: Safe Harbor Peer Review which address the nurse's right to refuse an assignment. The Request for Peer Review Determination or Safe Harbor originates from this statute. Safe Harbor protects the nurse from potential action against the nurse’s nursing license and retaliatory action from the employer when the procedure is correctly followed. Safe Harbor ensures that a group of nursing peers examines the assignment the nurse was asked to accept and determines whether the nurse was being asked to accept an assignment that was unsafe and or outside of his or her knowledge, skills, and physical or emotional abilities. Safe Harbor is invoked at the time the nurse is asked to engage in an activity or an assignment that the nurse believes is not safe for patients. Safe Harbor cannot be invoked after a patient has been hurt or after the shift is over and done.
Safe Harbor Peer Review is an internal process, between the nurse and the employer. Safe Harbor must be invoked prior to engaging in the conduct or assignment. The nurse may use the Safe Harbor Quick Request Form available at www.bon.texas.gov, or may choose to capture the required information in another format. The required information is then submitted to the nurse manager. Board staff recommends that the nurse invoking Safe Harbor keep a copy for future reference. In addition to the Quick Request Form, the nurse must complete the Comprehensive Written Request for Safe Harbor Peer Review before leaving the work setting at the end of the work period. See Board Rule 217.20(d)(4) for complete information. The BON does not get involved with Safe Harbor Peer Review, but may be involved after-the-fact if peer review is not conducted in good faith. The nurse may wish to seek legal counsel for advice on employment issues. The BON cannot provide legal advice, and has no authority in civil matters.
Safe Harbor promotes patient safety and collaborative problem solving. The Peer Review Committee can be a catalyst for positive changes, resulting in improved staffing systems. Safe Harbor can be found in Board Rule 217.20. Additional information, Safe Harbor forms and a Frequently Asked Question (FAQ) are resources available on the Board’s website Practice: Peer Review: Incident-Based or Safe Harbor that will assist the nurse if he or she chooses to invoke Safe Harbor.
If a nurse has concerns about staffing patterns or floating on a daily basis and the potential for patient harm, the nurse may wish to consider speaking with the nurse manager for collaborative problem solving before an untoward event occurs. It helpful to utilize some of the information requested on the safe harbor form to initiate discussion surrounding the concerns about floating to areas outside of the clinical expertise and or area of competence. Board staff recommends that nurses active engage in collaborative problem solving, generating ideas and solutions that promote flexible staffing without jeopardizing patient safety or pose the potential for nursing licenses. Board staff recommends consulting the nursing literature for published evidence- based staffing strategies that promote patient safety.
If a nurse practices in a hospital, they may wish to contact the Department of State Health Services (DSHS) - Health Facility Program at 1-888-973-0022 or http://www.dshs.state.tx.us/hfp/default.shtm about the regulations for the official nurse staffing policies and plans that took effect on September 1, 2009.
Nursing specialty organizations, such as the Texas Nurses Association at 512-452-0645 or www.texasnurses.org, can also offer additional information and advocacy related to nurse staffing. While the Board cannot address employment issues, specialty nursing organizations exist to serve their members and may be able to provide the nurse with additional guidance. The Texas Hospital Association at www.tha.org or 512-465-1000 has developed a Nurse Staffing Law Toolkit that may provide nurses and hospitals with additional resource information.
Cita, B. (2010). Top ten tips for fearless floating. Nursing2010, 40, 57-58.
Good, E & Bishop, P. (2011). Willing to walk: a creative strategy to minimize stress related to floating. Journal of Nursing Administration, 41, 5, 231-234.
Texas Senate Bill 476, chapter 257a Retrieved from http://www.legis.state.tx.us/tlodocs/81R/billtext/html/SB00476F.htm
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When Does a Nurse's Duty to a Patient Begin and End?
Employment versus Licensure
There is no routine answer to the question, “When does the nurse’s duty to a patient begin?” A nurse's duty is not defined by any single event such as clocking in, or taking report. From a Board of Nursing standpoint, the focus is on the relationship and responsibility of the nurse to the patient(s), not to the nurse's employer or employment.
For example a nurse notifies his or her employer that he or she is quitting a job at the end of an assigned shift. Board Position Statement 15.6 Board Rules Associated with Alleged Patient Abandonment explains that typically this is an employment, not a licensure issue when a nurse decides to quit his or her job, with or without notice, provided the nurse does not have responsibility for patients at the time. If the employer has a policy that "requires a two-week notice," this may be an employment issue, but not a violation of the Nursing Practice Act (NPA) or Board Rules and Regulations.
It should also be noted that Texas Administrative Code, Rule §217.12 Unprofessional Conduct regarding leaving a nursing assignment does not apply to the situation where the nurse completes his or her scheduled shift, and then turns in notification of job resignation.
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Safe Harbor Peer Review
What is Safe Harbor Peer Review?
Safe Harbor is a process that protects a nurse from employer retaliation, suspension, termination, discipline, discrimination, and licensure sanction when a nurse makes a good faith request for peer review of an assignment or conduct the nurse is requested to perform and that the nurse believes could result in a violation of the NPA or Board rules.
The BON has no authority over employment issues, but a nurse does have civil recourse in matters where the nurse’s decision to invoke Safe Harbor was made in good faith, but negative employment action occurred as a result of the nurse's request. A nurse also has whistleblower protections when the nurse reports a facility, physician, or other entity for violations of laws relating to patient care and or illegal acts, such as fraud, see Nursing Practice Act, Section 301.4025 and Section 303.005 and Texas Administrative Code, Rule §217.20 Safe Harbor Peer Review for Nurses and Whistleblower Protections. You may wish to also seek your own legal counsel for advice. The BON cannot provide legal advice, and has no authority in civil matters.
When is a request for Safe Harbor Peer Review made?
Safe Harbor must be invoked prior to engaging in the conduct or assignment and at any of the following times:
- When the conduct is requested or assignment made;
- When changes occur in the request or assignment that so modify the level of nursing care or supervision required compared to what was originally requested or assigned that a nurse believes in good faith that patient harm may result; or
- When the nurse refuses to engage in the requested conduct or assignment.
How does a nurse invoke Safe Harbor?
The nurse must notify the supervisor requesting the conduct or assignment in writing that the nurse is invoking Safe Harbor. The content of this notification must meet the minimum requirements outlined below. This information is also contained in the Quick Request Form found HERE . The Quick Request must contain:
- The nurse(s) name making the safe harbor request and his/her signature
- The date and time of the request
- The location of where the conduct or assignment is to be completed;
- The name of the person requesting the conduct or making the assignment; and
- A brief explanation of why safe harbor is being requested.
At the end of the shift, the nurse must supplement the initial written request and complete a more thorough, descriptive and comprehensive written request for Safe Harbor prior to leaving the work setting at the end of the work period. The content of the comprehensive written request must include the minimum requirements outlined below. This information is also contained in the Comprehensive Written Request Form found HERE . The Comprehensive Request must contain:
- The conduct assigned or requested, including the name and title of the person making the assignment or request;
- A description of the practice setting, e.g., the nurse’s responsibilities, resources available, extenuating or contributing circumstances impacting the situation;
- A detailed description of how the requested conduct or assignment would have violated the nurse’s duty to a patient or any other provision of the NPA and Board Rules
- If applicable, the rationale for the nurse’s not engaging in the requested conduct or assignment awaiting the nursing peer review committee’s determination as to the nurse’s duty.
- Nay other copies of pertinent documentation available at the time. Additional documents may be submitted to the committee when available at a later time; and
- The nurse’s name, title, and relationship to the supervisor making the assignment or request.
The nurse invoking Safe Harbor is responsible for keeping a copy of the request.
For complete information on Safe Harbor, go to: Safe Harbor
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A Nurse's Duty Not Limited to Assignment:
All nurses, regardless of practice setting, position, title or role, are required to adhere to the NPA and other statutes, as well as the Board Rules. Two of the main rules that relate to nursing practice are Texas Administrative Code, Rule §217.11 Standards of Nursing Practice,...
and Texas Administrative Code, Rule §217.12 Unprofessional Conduct. The standard that serves as the foundation for all other standards is Rule 217.11(1) (B)"...maintain a safe environment for clients and others." This standard supersedes any physician order, facility policy, or administrative directive. The concept of the nurse's duty to maintain client safety also serves as the basis for behavior that could be considered unprofessional conduct by a nurse.
BON Position Statement 15.14, Duty of a Nurse in Any Setting, explains the nurse's duty that was established by a landmark case, Lunsford v. Board of Nurse Examiners, 648 S.W. 2d 391 (Tex. App. — Austin 1983). As the case of Lunsford points out, when a nurse knows, or should have known that a situation potentially places a patient at risk of harm, the nurse has a duty to intervene. The nurse's knowledge based on educational preparation, experience, and licensure as a nurse establishes that the nurse understands the minimum standards of care and has the ability and duty to recognize potentially harmful situations for the patient.
This is why the nurse's duty does not incur solely based on a nurse being "assigned" to provide nursing care to a patient. A nurse who has knowledge that a situation places a patient at risk of harm has a duty to the patient or potential patient, as in Lunsford.
Rule 217.11(1)(S) relates to nurses who supervise other staff. This standard requires nurses in supervisory positions to "make assignments to others that take into consideration client safety and which are commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the persons to whom the assignments are made." Likewise, staff nurses are required to accept assignments within the nurse's educational preparation, experience, knowledge, and physical and emotional ability Rule 217.11(1) (T). The standards do not exist or apply in isolation, but complement each other; thus, all applicable standards should be considered by a nurse in determining the most appropriate course of action. (See Safe Harbor, above.)
Revised October 2009
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Decision Making for Determining Nursing Scope of Practice.
Where can I find a list of tasks that LVNs and/or RNs can or cannot do in the State of Texas?
The Nursing Practice Act (NPA) and Board Rules are written broadly so that they can apply to nursing practice in any setting. As such, the BON does not provide lists of tasks or step-by-step procedures of how certain tasks are to be carried out by the nurse.
It is up to the individual nurse whether LVN or RN, to utilize good professional judgement in accepting any given assignment and when performing a given procedure. The BON has no jurisdiction over facility policies, nor can we speak to civil liability issues.
One of the primary rules that apply to a nurse's clinical practice is Rule 217.11 Standards of Nursing Practice. This rule, along with the Nursing Practice Act and all Board Rules may be viewed on our web site at www.bon.texas.gov. The standards that apply to nearly every situation include (1)(B)- "maintaining a safe environment for patients..," and Standard (1)(T) which states that nurses must accept only those nursing assignments that take into consideration client safety and that are commensurate with the nurse’s educational preparation, experience, knowledge, and physical and emotional ability. Other standards may apply depending on the situation.
In relation to nurses, the NPA section 301.002 "definition of professional nursing" states that professional nursing does not include "medical diagnosis or prescription of therapeutic or corrective measures." (i.e.: the RN may not engage in activities that require the use of independent medical judgement). Vocational nursing is a “directed scope of nursing practice, and does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures.”
In addition to reviewing Rule 217.11, you may wish to look at the board's "Six Step Decision Making Model for Determining Nursing Scope of Practice" and the "LVN Six Step Decision Making Model for Determining Nursing Scope of Practice" The steps in the six step model combine BON references and resources with additional references and resources (policies and procedures from the employment setting, and nursing and healthcare research, and literature) and uses reflective questions to guide a nurse's practice decisions.
One of the questions in the six step decision making model asks if there is precedent for RNs or LVNs engaging in a given practice. You may wish to check the nursing literature, as well as contacting the national nursing organization related to the specialty nursing area in question to verify if there is guidance regarding the current standard of care within that specialty area that endorses RN's and/or LVNs engaging in a given practice.
In addition, some acts may be performed as Delegated Medical Acts. The rules related to this are in the Board of Medical Examiner's Rule 193 and summarized in part in Position Statement 15.11 "Delegated Medical Acts." Your facility's policy and procedure would also have to permit a given practice.
Neither facility policy nor MD order can discharge the nurse's responsibility for assuring patient safety, or for complying with all of the other rules and requirements in the Nursing Practice Act. A nurse may refuse to engage in any activity that the nurse, in good faith, believes may cause him/her to violate one or more provisions of the NPA and board rules (NPA, Section 301.352). Also see the "Safe Harbor" forms on our Peer Review web page and Rule 217.20 for more information.
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Nurses Have a Duty to Report Confidential Health Information
Do nurses have a duty to report confidential health information to administrators, law enforcement of to a patient's family?
Nurses have a duty to report patient information, including mental health information, to members of law enforcement, a patient's family and others when a patient is a serious danger to himself or others.
The confidentiality rule also known as the Health Insurance Portability and Accountability Act (HIPAA) does not prevent nurses, when acting in "good faith", from reporting necessary information about a patient to those who may be able to prevent or lessen a danger to a patient or the public. The confidentiality rule is balanced to protect a patient's health information while allowing information to be disclosed that could protect both the public and a patient from harm. Board Rule 217.11(1)(E),
requires nurses to respect the client’s right to privacy by protecting confidential information unless required or allowed by law to disclose the information.
In January 2013, the U.S. Department of Health and Human Services - Office for Civil Rights issued clarification regarding the Health Insurance Portability and Accountability Act (HIPAA) titled, Message to Our Nation's Health Care Providers. The message can be found at https://www.hhs.gov/hipaa/for-professionals/index.html
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Nurse Admitted As Patient Under the Influence
I currently work in an ICU. I had an opportunity to care for a patient/nurse (who was a nurse at another facility) who
overdosed. She was transferred, when stable, to a treatment center by court order. I was told we cannot report her to the board
due to HIPAA. My question is, "How do we plan to handle this type of incident in the future?" "Will there be any specific changes
made to address problems like this in the future?" I understand with the renewal of our license we must answer the question of treatment
for use of "alcohol or any other drug." But if there is no report of her being in the hospital for treatment, due to HIPAA,
it's possible that she may not answer the question truthfully. Can you please help with these questions. I appreciate your time.
Whether a nurse is admitted for an overdose of a substance, or admitted secondary to some type of accident related to being
under the influence of any mind-altering substance, the answer would remain the same....
The license renewal form for both LVNs and RNs includes a question that asks "In the past 5 years have you been addicted or
treated for the use of alcohol or any other drug?” A nurse or any other person who is treated for an overdose or any kind
is not necessarily suffering from a substance "addiction" and would not, therefore, need "treatment" for an addiction. There
could be a psychological issue underlying the OD, such as depression, which would also not require the nurse to reveal anything
to the Board since one of the other renewal questions asks "In the past 5 years, have you been diagnosed with or treated or
hospitalized for schizophrenia or other psychotic disorder, bipolar disorder, paranoid personality disorder, antisocial
personality disorder, or borderline personality disorder?" Even if the nurse in question was "transferred for treatment" related
to an overdose, he/she would still not be reportable because they are a patient in this situation---not a practicing nurse who
is being compensated.
As with the nurse admitted due to an overdose on a substance, a nurse admitted for treatment as a patient for any reason
secondary to being found "under the influence" is also not reportable to the board. Should the nurse's conduct lead
to a criminal conviction, including an adjudicated or probated sentence, this would be self-reportable (or could be reported by
another entity, such as law enforcement authority). A question regarding criminal conduct is also on the renewal form. In
addition, the Board has Disciplinary Sanction Polices on "Substance Abuse, Misuse, Substance Dependency, or other Substance Use Disorder" as well as "Lying and Falsification" that may
be helpful for you to review.
The plan for the future will be to continue to comply with the Federal HIPAA law that mandates adherence to certain patient
privacy rights in relation to a person's medical records and information. The BON would have no grounds under NPA Sections
301.401 to take action against a nurse who is being treated as a patient for any health problem. Occasionally nurses have,
currently can, and probably will continue to lie on occasion about being treated or diagnosed with a reportable condition.
Any nurse who falsifies information relating to the practice of nursing or nursing licensure runs the risk of being "caught"–
possibly years in the future, should the nurse be reported to the Board and investigated for possible practice violations.
Nurses face stiffer sanctions from the Board when it is discovered that a nurse falsified information to the BON. You may wish
to review the Board's various Disciplinary Sanction Policies (4 in total) that explain why the Board is concerned about certain
actions/behaviors of nurses and how the Board typically acts in these situations.
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CPR - A Nurse's Duty to Initiate
Is current CPR certification a licensure requirement for nurses?
No. The Texas Board of Nursing (Board or BON) does not require CPR for licensure renewal; however, employers may have specific requirements for maintaining current CPR status as a condition of employment.
Nurses should use their professional judgment when deciding to maintain current CPR certification, taking into consideration whether they are employed in patient care settings in which CPR may be necessary to resuscitate and stabilize a client condition [(217.11(1)(M)]. Nurses have a responsibility to maintain continuing competence in nursing practice through educational opportunities that promote individual professional growth (Board Rule 217.11(1)(G)(H)(R).
Do all nurses have an obligation to initiate CPR for a client? Does the Texas Board of Nursing have rules that establish a nurse’s duty to initiate CPR?
Yes. All nurses have an obligation or duty to initiate CPR for clients who require resuscitative measures [217.11(1)(M)]. In all healthcare settings, nurses must initiate CPR immediately in the absence of a client’s do-not-resuscitate/out of hospital do-not-resuscitate order. A do-not-resuscitate/out of hospital do-not-resuscitate order is a medical order that must be given by a physician and in the absence thereof; it is generally outside the standard of nursing practice to determine that CPR will not be initiated. The initiation of CPR does not require a physician’s order in the absence of do-not-resuscitate/out of hospital do-not-resuscitate order..
In general, the Texas Nursing Practice Act and Board Rules and Regulations establish a nurse’s duty to initiate CPR and require every nurse, regardless of expertise, specialty, or practice setting to provide safe and effective care for clients [Board Rule 217.11(1)(B)]. Licensure laws and rules do not specifically require a nurse to have a current CPR card in order to perform CPR or utilize other life-saving interventions for a client. Instead, the minimum standards of nursing practice addressed in Board Rule 217.11 require a nurse to “implement measures to promote a safe environment for clients and others” as well as “institute appropriate nursing interventions that might be required to stabilize a client’s condition and/or prevent complications.”
What is the role of the licensed vocational nurse (LVN), registered nurse (RN), and advanced practice registered nurse (APRN) in initiating CPR in a witnessed arrest?
In the absence of a do-not-resuscitate/out of hospital do-not-resuscitate order from a physician, all nurses should initiate CPR immediately in a witnessed arrest, regardless of healthcare setting. CPR should continue and the physician should be notified of the client’s change in condition to include current life-saving interventions being provided to the client.
Does the BON have a position statement that addresses the RN’s role in the management of an unwitnessed cardiac or respiratory arrest in a long-term care facility?
Yes, Position Statement 15.20, Registered Nurses in the Management of an Unwitnessed Arrest in a Resident in a Long-Term Care Facility. The purpose of this position statement is to provide recommendations and guidance to clarify issues for compassionate end-of-life care for residents residing in long-term care facilities only. This position statement is specific to long-term care facilities and is not to be construed as applicable to other healthcare settings in which nurses are employed.
After assessment of the resident is completed and appropriate interventions are implemented, documentation of the circumstances and the assessment of the resident in the medical record are required.
Are nurses expected to perform CPR on clients with obvious clinical signs of irreversible death?
Board Rule 217.11(1)(A) requires all nurses to know and conform to the Texas Nursing Practice Act and Board rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurses’ current area of nursing practice. Additionally, nurses should know and follow their facility, agency or employer’s policies.
The American Heart Association recommends that all clients receive CPR immediately unless attempts at CPR would be futile; such as when clients exhibit obvious clinical signs of irreversible death. Obvious clinical signs of irreversible death include decapitation (separation of head from body), decomposition (putrefactive process; decay), dependent lividity (dark blue staining of the dependent surface of a cadaver, resulting from blood pooling and congestion), transection, or rigor mortis (body stiffness that occurs within two to four hours after death and may take 12 hours to fully develop).
Does the Texas Board of Nursing have purview over the pronouncement of death?
No. The Board of Nursing does not have purview over physician practice, employer policies, or the laws regulating the pronouncement of death in Texas. Additional information on Texas regulations regarding pronouncement of death may be found in the Texas Health and Safety Code Chapter 671.
Is there a difference between the decision to initiate CPR and the decision to pronounce death?
Yes. The decision to initiate CPR for all nurses should be a spontaneous clinical decision and nursing intervention for a client in cardiac or respiratory arrest. Delay in initiating CPR can be critical to the outcome of CPR. CPR should not be delayed to review the client’s medical record or chart to determine the client’s wishes or search physician orders for do-not-resuscitate/out of hospital do-not-resuscitate documentation. Employers and nurses should take a proactive approach to ensure that healthcare setting policies are in place to ascertain a physician’s order for resuscitative status upon admission and to update the plan of care to anticipate the immediate need to access a client’s current resuscitation status physician’s order so that CPR is initiated appropriately and without delay.
Can an RN or an APRN pronounce death?
Texas Statutes and Rules and Regulations outside of the nursing licensure laws and rules govern who can pronounce death, and only those legally authorized to pronounce death may do so (i.e., physician, justice of the peace). Texas regulations regarding pronouncement of death may be found in Texas Health and Safety Code Chapter 671 and Texas Administrative Code Chapter 193 (Texas Administrative Code, Title 22, Part 9, Chapter 193.18)
The Texas Health and Safety Code chapter 671 requires that in order for an RN to pronounce death, the facility, institution, or entity must have a written policy which is jointly developed and approved by the medical staff or medical consultant and the nursing staff, specifying under what circumstances an RN can make a pronouncement of death.
An RN and/or an APRN can pronounce death when a client has executed a properly documented do-not-resuscitate/out of hospital do-not-resuscitate physician orders and when the employer has policies and procedures in place to acknowledge that the RN and/or APRN may pronounce death. Neither an RN nor an APRN may sign the death certificate under any circumstances.
Can LVNs pronounce death or accept an order to pronounce death in Texas?
No. The Board of Nursing Position Statement 15.2 addresses the Role of The Licensed Vocational Nurse in the Pronouncement of Death. LVNs have a directed scope of practice under the supervision of RNs, APRNs, PAs, Physicians, Dentists, and Podiatrists. LVNs conduct focused assessments that include making nursing observations and recognizing significant changes in a client’s condition. These observations and changes in condition are reported to the physician. LVNs may not accept an order to pronounce death; however, after LVNs communicate their findings which include presumptive and/or obvious clinical signs of irreversible death to the physician and in accordance with facility policy, the LVN may accept a reasonable physician’s order regarding the care of the client (i.e., notification of family and funeral home and postmortem care). TMB Rule 193.18 requires LVNs to inform physicians of the following minimum findings:
- Absence of palpable pulse for a minimum of 60 seconds;
- Absence of discernible blood pressure for a minimum of 60 seconds;
- Absence of evidence of respiration for a minimum of 60 seconds;
- Absence of evidence of heartbeat for a minimum of 60 seconds; and
- Other information as the physician may require.
It is imperative that LVNs document their focused assessment findings, nursing interventions, and communication with physician and physician’s orders.
What additional references are available should be considered when establishing policies and procedures for nursing staff in my facility?
In addition to the current American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, the Board website (www.bon.texas.gov) may provide assistance and serve as a resource in developing policies and procedures to further support safe practice with regard to CPR. The Board recommends employers consider the following references when establishing policies and procedures in the healthcare setting....
GNs, GVNs, and Newly Licensed Nurses Practicing in Home Health Settings
I will be graduating from a vocational nurse training program in a few months, and am beginning to seek out employment options once I graduate. I am attracted to the area of home health nursing, and I wondered if LVNs can work in home health settings? (Note: The same answer applies to graduates of registered nurse training programs).
As a newly graduated LVN (or RN), I am interested in home health nursing. Should I work in this environment as a new nurse?
When you graduate from your vocational training program or your professional nursing program, you will likely be eligible for a temporary permit to practice as a Graduate Vocational Nurse (GVN) or Graduate Nurse (GN). Board Rule §217.3 prohibits GVNs and GNs from working in "independent practice settings", which includes home health settings.
Once you receive confirmation from the BON that you have passed your NCLEX-PN (or NCLEX-RN) licensure exam, you will be entitled to hold yourself out as a Licensed Vocational Nurse (LVN) or Licensed Registered Nurse (RN) as applicable, with all of the privileges and responsibilities that go along with each license. The Board strongly discourages newly licensed nurses from accepting employment in any independent living environment setting until the new nurse achieves twelve (12) to eighteen (18) months of nursing experience in an acute health care setting (such as a hospital).
The Board believes that the newly licensed nurse (LVN or RN) needs adequate time to apply newly learned nursing knowledge and clinical skills, as well as time to develop clinical judgment and decision-making skills. Further, the Board believes that this process occurs most effectively in a structured health care environment where resources and supervision are immediately available to the new nurse. Once licensed, you are required to “know and comply with” the Nursing Practice Act (NPA) and Board Rules, as the content of each has the force of law with regard to nursing practice in Texas. The NPA and rules may be viewed in their entirety on this site.
Board Rule 217.11 Standards of Nursing Practice is the heart of nursing practice and applies to all nurses. Specifically, Board Rule 217.11(1)(B) requires nurses to always maintain client safety and Board Rule 217.11(1)(T) requires nurses to accept only those assignments that are commensurate with the nurse’s education, licensure, experience, and abilities. If a newly-licensed nurse decides to work in home health, and is subsequently reported to the Board for possible violations of the Board Rules, the nurse would likely be asked to explain his/her rationale for accepting employment in a home health setting, particularly when the Board expressly cautions new nurses against working in this environment.
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Practice Recommendations for Newly Licensed Nurses
Does the Board of Nursing (BON) have any recommendations for newly licensed LVNs or RNs as they begin their nursing practice?
The newly licensed nurse is in a transitional process and as a novice practitioner, the new LVN or RN is inexperienced and not fully integrated into his/her nursing role and setting. Based on this belief, the Board provides the following guidance to newly licensed LVNs or RNs:
- The newly licensed LVN must ensure that he or she has appropriate supervision. The LVN has a directed scope of practice, which means the LVN must have a registered nurse, advanced practice registered nurse, physician, physician assistant, dentist or podiatrist as a supervisor of his or her clinical nursing practice.
- It is recommended that a newly licensed nurse not practice in independent settings, such as group homes, assisted living facilities and home or school health, where access to a clinical supervisor is limited for a period of 12-18 months post-licensure. This allows the newly licensed nurse sufficient practice experience in more structured settings and the opportunity to assimilate knowledge learned in school consistently into practice.
- It is recommended that a newly licensed nurse not hold a position as a charge nurse or nurse manager for a period of six (6) months, unless a lesser time period is mutually agreed upon by the newly licensed nurse and the supervising nurse based upon the evaluation of competency of the newly licensed LVN or RN.
- The Board believes it is essential for newly licensed nurses to seek and receive direction, supervision, consultation and collaboration from experienced nurses during the transition into nursing practice. In any practice setting where newly licensed LVNs and RNs are employed, experienced nurses should be willing to supervise and mentor novice nurses.
- Once licensed, direct supervision should be continued for a period of six months, or a lesser time period if agreed upon by the newly licensed nurse and the supervising nurse. Competence to perform without direct supervision should be mutually determined by the newly licensed nurse and the supervising nurse and should be demonstrated and supported by documentation.
- Newly licensed nurses are permitted to perform any function that falls within the scope of nursing practice for which they have received educational preparation and have demonstrated minimal competency.
- Nursing Practice Act (NPA), Section 301.002(5) (2012).
- Nursing Practice Act (NPA), Section 301.353 (2012).
- Texas Board of Nursing. (2012). Rules and guidelines governing the graduate vocational and registered nurse candidates or the newly licensed vocational or registered nurse. Retrieved on 1/10/12 from http://www.bon.texas.gov/practice/grads.html
- Texas Board of Nursing. (2011). Position statement 15.27, the licensed vocational nurse scope of practice. Retrieved on 1/10/12.
- Texas Board of Nursing. (2011). Position statement 15.28, the registered nurse scope of practice. Retrieved on 1/10/12.
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Regarding Position Statements 15.27, The LVN Scope of Practice and 15.28, The RN Scope of Practice
Position Statements 15.27 and 15.28 state that it is the LVN's responsibility to ensure appropriate supervision. What is appropriate supervision?
Each LVN is required to ensure that he or she has the appropriate supervisor prior to accepting an assignment, a position, or employment. The Nursing Practice Act (NPA) Section 301.353 states that "the practice of vocational nursing must be performed under the supervision of a registered nurse, physician, physician assistant, podiatrist, or dentist." Rule 217.11, Standards of Nursing Practice, subsection (2) further clarifies that “the licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity."
LVNs provide valuable and essential nursing care in different types of health care settings. When LVNs work in settings, such as hospitals, long-term care facilities, rehabilitation centers, or skilled nursing facilities, RNs are likely to serve as the LVN's supervisor. LVNs also work in private physician or dentist offices, where physicians, dentists and podiatrists function as the LVN's supervisor. Because LVNs may practice in these various health care settings, the term “clinical supervisor” is used to describe the different licensed healthcare providers that are authorized in the NPA to supervise and direct the LVN's practice, i.e.: registered nurse, advanced practice registered nurse, physician, physician assistant, podiatrist or dentist. These types of clinical supervisors oversee the nursing practice of an LVN by monitoring the health status of patients and then directing the LVN's actions to ensure the delivery of safe and effective nursing care.
Position Statements 15.27 and 15.28 state that LVNs are responsible for providing safe, compassionate, and focused nursing care to assigned patients with predictable health care needs. What does predictable health care needs mean?
The LVN in Texas provides nursing care to patients with health care needs that are predictable in nature, under the direction and supervision of a registered nurse, advanced practice registered nurse, physician, physician assistant, podiatrist, or dentist. The term “predictable” describes health conditions that behave or occur in an expected way. A predictable health condition does not mean that the patient is always stable. Instead, predictable health conditions follow an expected range or pattern that allows the LVN, with his or her clinical supervisor, to anticipate and appropriately plan for the needs of patients.
For example, it is appropriate for an LVN to care for a patient with a diagnosis of asthma. The disease process for asthma, while sometimes acute in nature, is predictable or well-known, and the symptoms can be anticipated. The LVN assists his or her clinical supervisor in the development of a plan, in which the LVN provides care, prevents possible complications, and stabilizes the symptoms of asthma. In addition, when complications arise or events occur that are outside the predicted range, the LVN must be able to recognize this change in condition and notify his or her clinical supervisor.
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FAQ - LVNs Performing Initial Assessments
Can an LVN perform an “initial” assessment?
Board Rule 217.11, Standards of Nursing Practice, refers to focused assessments performed by LVNs [Board Rule 217.11(2)(A)] and comprehensive assessments performed by RNs [Board Rule 217.11(3)(A)].
Nothing in the Board’s rules refers to initial assessments; therefore, the Texas Board of Nursing does not define nor does it determine whether a LVN may complete an initial assessment. All nurses are required to know and conform to not only the NPA and board rules, but all federal, state and local laws affecting the nurses area of practice [217.11(1)(A)]. As such, Board staff recommends contacting the agency that regulates the specific type of practice setting to determine if other laws and regulations apply to the completion of an initial assessment. For example, acute care facilities such as hospitals are licensed by the Texas Department of State Health Services (www.dshs.state.tx.us) and nursing homes, long term care facilities, and home health are regulated by the Department of Aging & Disabilities Services (www.dads.state.tx.us). If other regulations require that a RN perform the initial patient/client assessment, then the LVN cannot perform the assessment for the RN.
RNs conduct comprehensive health assessments. As defined by the BON, a comprehensive assessment is "An extensive data collection (initial and on-going) for individuals, families, groups and communities addressing anticipated changes in client conditions as well as emergent changes in a client's health status; recognizing alterations to previous conditions; synthesizing the biological, psychological, spiritual and social aspects of the client's condition; and using this broad and complete analysis to make independent decisions and nursing diagnoses; plan nursing interventions, evaluate need for different interventions, and the need to communicate and consult with other health team members (§217.11 (3) (A) (i) and Position Statement 15.28 The RN Scope of Practice.)
Licensed vocational nurses may only conduct focused health assessments .A focused assessment is An appraisal of an individual client's status and situation at hand [what is occurring at that moment], contributing to the comprehensive assessment by the RN, supporting on-going data collection, and deciding who needs to be informed of the information and when to inform (§217.11 (2) (A) (i) and the Position Statement 15.27 LVN Scope of Practice.)
In situations requiring comprehensive assessments by a RN, the LVN cannot begin by performing a focused assessment and have the RN follow up with an assessment of only those parameters not assessed by the LVN. A comprehensive assessment is a different level of assessment requiring that the RN use his/her own independent nursing judgment. Board Rule 217.11(1) (T) clarifies that a nurse is responsible for accepting assignments based on the nurse’s individual educational preparation, experience, knowledge, skills and abilities. Likewise, when a nurse makes assignments to another person(s), the nurse must consider the educational preparation, experience, knowledge, and skills of the person(s) receiving the assignment [Board Rule 217.11(1)(S)].
Texas Board of Nursing Rules & Regulations
Revised August 2013
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LVNs and Nursing Care Plans
Can an LVN initiate/develop the nursing care plan?
LVNs may not initiate care plans; however, they may contribute to the planning and implementation of the nursing care plan. Only the RN may develop the initial nursing care plan and make nursing diagnoses [Board Rule 217.11(3)(A)(ii) & (iii)].
The difference between LVN and RN scope of practice is based on differences in educational preparation of nurses licensed at each level as defined in the Differentiated Essential Competencies of Graduates of Texas Nursing Programs (DECs). The DECs may be viewed in its entirety or downloaded from “Nursing Education”, then “Faculty, Program & Student Information” on the BON website at https://www.bon.texas.gov/education_documents.
Board staff recommends review of Board Rule 217.11, Standards of Nursing Practice, as well as Position Statement 15.27 entitled The LVN Scope of Practice
Board Rule 217.11, Standards of Nursing Practice
Position Statement 15.27, The LVN Scope of Practice
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LVNs Performing Triage/Telephonic Nursing/Being On-Call
Can LVNs in any practice setting be "on-call" to deal with after-hours issues?
Can an LVN perform "triage" duties (either telephone triage such as for home health or on-site such as an Emergency Room)?
Triage is defined as the sorting of patients and prioritizing of care based on the degree of urgency and complexity of patient conditions. Telephone triage is the practice of performing a verbal interview and making a telephonic assessment with regard to the health status of the caller. As the caller may not accurately describe symptoms, and/or may not accurately perceive or communicate the urgency of the situation or condition prompting the call, nurses who perform these functions must have specific educational preparation, as the consequences of inadequate triage can be devastating.1
Though the BON does not regulate employers, and the NPA and rules are not prescriptive to specific practice settings, the Board believes on-call duties, telephonic nursing, and/or being on-call to handle urgent/emergent issues telephonically are all beyond the scope of practice for LVNs. It is in settings where the LVN would be required to independently engage in assessment (either telephonically or face-to-face) for purposes of triaging a patient that are of concern to the Board.
The Board's concerns are based on the fact that LVNs are not educationally prepared to perform triage assessments, either telephonically or in the role of the health care professional initially assessing a client to determine treatment priorities in any setting. The Differentiated Entry Level Competencies of Graduates of Texas Nursing Programs (DECs) states in part that "LVN nursing programs in Texas prepare entry-level bedside nurses to care for acutely and chronically ill patients with predictable health outcomes in structured healthcare delivery settings." The DECs further state that LVNs are educated in basic head-to-toe assessment using the senses of sight, smell, touch, and hearing. In either telephonic or face-to-face triage, the LVN is likely to be dealing with a situation where the client's condition is not predictable.
In alignment with the educational preparation for vocational nursing, Board Rule 217.11, Standards of Nursing Practice, establishes that LVNs "...collect data and perform focused nursing assessments of the health status of individuals"[217.11(2)(A)(I)]. NPA section 301.353 and Rule 217.11(2) further establishes that LVNs have a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist.
Placing an LVN in a position to perform duties requiring comprehensive (versus "focused") assessments of patients potentially experiencing unpredictable changes in health status, as well as making independent nursing judgments (such as would be required for either telephonic or on-site initial triage) may place the LVN in a position that violates the BON's Standards of Nursing Practice.
Both the Interpretive Guideline for LVN Scope of Practice and Position Statement 15.10 Continuing Education: Limitations for Expanding Scope of Practice, further clarify that while LVNs may expand their practice with post-licensure continuing nursing education, this does not permit the LVN to expand his/her practice to a level that requires RN education, training, and licensure (such as comprehensive assessment). This relates to Rule 217.11(1)(B) which holds each nurse accountable to maintain client safety. This standard supersedes any doctor's order or facility policy, thus the nurse cannot avoid his/her "duty" to maintain client safety by placing responsibility for nursing actions on another party. Position Statement 15.14, Duty of a Nurse in Any Practice Setting, further clarifies the nurse's duty, regardless of the type of nursing license held.
It remains the opinion of the Board (consistent with the opinion of the former Board of Vocational Nurse Examiners) that on-site triage and/or telephone triage (by an "on-call" LVN) that requires the LVN to perform a comprehensive assessment and make independent treatment decisions on the basis of information supplied by the client is beyond the scope of practice for an LVN. Triage is not taught in one-year vocational nurse education programs. The LVN has not received education in the complex and finite details of comprehensive assessment as provided in a professional registered nurse education program that would include the knowledge base necessary for on-site and telephone triage.
Can an RN be on "back-up on-call" in case the LVN has questions?
It is not acceptable to have either an RN or advanced practice registered nurse (APRN) on "back-up call" to an LVN who is also responding only telephonically to clients in need. As the LVN's formal education does not prepare the LVN to perform telephonic assessments, the LVN may not be able to determine what information is essential to obtain and then relay to an RN or APRN. In addition, if a client situation is emergent, even if the RN or APRN subsequently call the client back, the delay in securing emergent treatment may result in serious harm or patient death.
Is the RN ultimately responsible?
Regardless of job experience, an LVN does not have the educational background equivalent to that of the RN, and is not educated or trained to analyze and synthesize symptoms or otherwise conduct a comprehensive assessment telephonically with a client. Additionally, if emergent action is needed and the LVN is unable to discern this need due to limited assessment abilities, assistance that may be necessary to save the client's life could be delayed.
The RN cannot under any circumstances assume "ultimate responsibility." RNs do not delegate to other licensed nurses (LVNs or RNs); RNs "make assignments" to other licensed nurses. Each nurse (LVN or RN) is responsible for making and/or accepting of assignments that are within the knowledge, skills, and abilities of the nurse performing the task [217.11(1)(S) and (T)].
"Medical Screening" in the ER
The Emergency Medical Treatment and Active Labor Act (EMTALA) requires every patient who presents to an emergency room to be assessed for the existence of an "emergency medical condition" before the patient can be transferred or discharged from the ER. For more information, you may wish to visit the following web site https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA.
The Board believes that the performance of a medical screening exam is not within the scope of practice for an LVN, regardless of years of experience or post-licensure continuing nursing education at the LVN level. The Board believes that the RN educational preparation and licensure constitutes the minimum acceptable level of competence necessary to conduct a medical screening exam. Even with this minimum licensure, the RN must undergo training and be properly authorized within the setting to conduct the MSE, according to EMTALA rules and requirements. As defined in §217.11(2)(A) the scope of practice for an LVN is limited to performance of a hands-on focused assessment of an individual client. Even if a physician wishes to delegate assessment of medical conditions and/or treatments to an LVN, the LVN is accountable for only accepting those assignments within his/her scope of practice as outlined in the NPA and in Rule 217.11, Standards of Nursing Practice. Position Statement 15.11 Delegated Medical Acts contains additional information on physician delegation to nurses.
Other Practice-Setting Examples (Physician's Office, Call Center)
The Board is aware that LVNs may also practice in "call centers" (such as a poison control center), physician's offices, or other similar settings. In settings where a physician(s) is/are present, there may be a set of standardized guidelines approved by the physician(s) to establish treatment priorities within the office environment under the supervision of the physician(s). Such practice settings may be appropriate for a qualified LVN. See Position Statement 15.5. In call centers, the LVN typically has access to computer systems that guide the LVN in asking specific symptom-driven decision-tree questions that then dictate what action the LVN recommends to the caller.
Evaluation of the system utilized is recommended to assure (1) it is appropriate for the practice setting, (2) that it has an established standardized and valid/reliable decision-making process (preferably determined outside of the institution/facility in which it is used), and (3) that the LVN has access to an appropriate supervisor for situations that might exceed the capabilities of any computer-based algorithm treatment model.
It is not the intent of the Board to preclude LVNs from practicing in settings where the LVN has sufficient guidance/support/supervision to promote both safe LVN practice as well as client safety. The LVN should not practice in settings where he/she is required to perform comprehensive assessments and make independent treatment decisions or establish treatment priorities as described in this statement.
The BON cannot provide legal advice or counsel to nurses; however, a nurse may wish to seek his/her own legal counsel for advice on the best course of action for the individual nurse.
ENA Triage Qualifications and Competency Position Statement 2017: https://www.ena.org/docs/default-source/resource-library/practice-resources/position-statements/triagequalificationscompetency.pdf?sfvrsn=a0bbc268_8
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LVNs "Supervision of Practice"
Describe what "supervision of practice" means in relation to an LVN functioning with a directed scope of practice “under the supervision of. . . .”
The LVN’s scope of practice requires that his or her nursing practice be directed by an appropriately licensed supervisor, e.g. registered nurse, advanced practice registered nurse, physician, physician assistant, podiatrist or dentist [Nursing Practice Act (NPA) Sections 301.002(5), 301.353 and Board Rule 217.11(2)].
The licensed supervisor is responsible for overseeing the LVN’s nursing practice and actively engages in a supervisory process that directs guides and influences the LVN’s performance of an activity. Supervision is the process of directing, guiding, and influencing the outcome of an individual’s performance of an activity Board Rule 217.11(2)].
The NPA and Board rules and regulations prevent a LVN from practicing in a completely independent manner (that is, without a licensed supervisor); however, the NPA and rules are silent as to the proximity of the licensed supervisor. There are many factors to be considered in determining how quickly the licensed supervisor needs to be available to the LVN. Factors to be considered should include: (1) the type of practice setting; (2) the stability of the patient’s condition; (3) the tasks to be performed; (4) the LVN’s experience and (5) any laws and regulations that apply to the specific practice setting. The proximity to the LVN’s practice setting and the type of licensure of the licensed supervisor should be determined on a case-by-case basis with input from the LVN and his/her licensed supervisor. The appropriate licensed supervisor must be accessible to the LVN at least telephonically or by similar means. To illustrate, compare the LVN who performs routine nursing tasks or nursing tasks learned through ongoing continuing education (such as intravenous therapy) with a LVN who performs a delegated medical act (such as Botox administration). These are different situations and will differ in who (RN or physician) is appropriate to supervise the LVN as well as the proximity of the licensed supervisor. Other regulations, such as those related to reimbursement, may also be a factor in the latter situation.
As noted previously, remember that whether a task is a nursing act or a delegated medical act, any nurse (LVN or RN) is responsible for providing a safe environment for patients and for the tasks he/she chooses to perform [Board Rule 217.11(1)(B) & (T)]. Position Statement 15.14, Duty of a Nurse in Any Practice Setting illustrates a nurse’s duty to the patient. This position statement along with other scope of practice documents may be accessed in Nursing Practice, then Scope of Practice on the BON web page. While there are many documents available in the Scope of Practice section, Board staff recommend review of the following documents to assist LVNs and RNs in determining the LVN scope of practice: Position Statement 15.27, The Licensed Vocational Nurse Scope of Practice; Board Rule 217.11, Standards of Nursing Practice; and the Six-Step Decision-Making Model for Determining Nursing Scope of Practice.
National Council State Boards of Nursing Model Act 2010
Texas Board of Nursing Rule 217.11, Standards of Nursing Practice
Position Statement 15.27, The Licensed Vocational Nurse Scope of Practice
Six Step Decision Making Model for Determining Nursing Scope of Practice
Revised August 2013
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Nurse's Role with the Emergency Medical Treatment & Labor Act: Performance of Medical Screening Exams
The Emergency Medical Treatment and Active Labor Act (EMTALA) is a federal law established in 1986 that requires hospitals or other acute care facilities who offer emergency services to provide a medical screening examination to each person presenting to the emergency department.
A medical screening exam is done to determine whether or not an emergency medical, not nursing, condition exists. EMTALA requires the assessment of a patient for the existence of an emergency medical condition before the patient can be transferred or released from the emergency department. An emergency medical condition is defined under federal law, 42CFR §489.24, and may be readily viewed in its entirety at the U.S. Government Publishing Office Electronic Code of federal Regulations. An understanding of what EMTALA is and what is meant by performing a medical screening exam is essential to the RN performing this task.
Can an RN Perform A Medical Screening Exam?
The EMTALA Interpretive Guidelines indicate that a facility may credential specific registered nurses to perform a Medical Screening Exam (MSE) and develop bylaws specifying which RN nursing staff is considered to be "qualified medical personnel" and under what circumstances a physician must be consulted and/or must physically come to the unit/facility. The MSE may be delegated by the physician to other qualified medical personnel according to the physician delegation rules found in the Texas Administrative Code, Chapter 193.
In addition to being permitted by an employing facility, however, the RN must also be competent to carry out the assigned task in a manner that complies with the NPA and board Rules. The Board of Nursing does not have purview over specific employment policies, procedures or site-based requirements. There may be laws, rules, or regulations applicable to your practice setting that may impact your practice. There is broad, general guidance for registered nurses accessible on the Board of Nursing (BON) website in Practice then Scope – Registered Nurse Scope of Practice. This includes Board Rule 217.11, Standards of Nursing Practice, the Board's Six-Step Decision-Making Model for Determining Nursing Scope of Practice, and Position Statement 15.14, Duty of a Nurse in any Practice Setting. The referenced position statement is important for nurses to understand that they must intervene or advocate on behalf of their patients and establishes that a nurse has a responsibility and duty to a patient to provide and coordinate the delivery of safe, effective nursing care, through the NPA and Board Rules. This duty supersedes any facility policy or physician order. The Six-Step Decision-Making Model guides nurses in deciding if a task is within the nurse's scope of practice. The steps combine BON references and resources with additional references and resources (policies and procedures from the employment setting, and nursing and healthcare research and literature) and uses reflective questions to guide a nurse's practice decisions. A "no" answer, on any step, usually means the activity in question is not within the nurse's scope of practice. Each nurse is accountable for the assignments the nurse accepts [Board Rule 217.11 (1)(T)].
An RN may be able to perform a medical screening exam if he/she possesses adequate knowledge and skills and there are adequate support systems and standing orders in place to delegate from the physician this medical aspect of care; however, the RN should always have telephonic access to a physician who is also capable of physically responding to do a hands-on evaluation if needed or requested by the RN. RNs who do not hold advanced practice authorization cannot independently engage in medical diagnosis or prescription of therapeutic or corrective measures, as this is beyond the scope of practice for an RN.
Can an LVN perform a medical screening exam?
The board believes that the performance of a medical screening exam is not within the scope of practice for an LVN, regardless of years of experience or post-licensure continuing nursing education at the LVN level. As defined in §217.11(2)(A) the scope of practice for an LVN is limited to the performance of a focused assessment of an individual client, thus a comprehensive RN nursing assessment is the minimum level of assessment acceptable to conduct a medical screening exam. Even if a physician wishes to delegate assessment of medical conditions and/or treatments to an LVN, the LVN is accountable for only accepting those assignments within his/her scope of practice as outlined in the NPA and in Rule 217.11, Standards of Nursing Practice. Position Statement 15.11 Delegated Medical Acts contains additional information on physician delegation to nurses.
Is a medical screening exam the same as triage?
No, a medical screening exam is not the same as triage. The differentiation is discussed in depth under the EMTALA Interpretive Guidelines EMTALA Interpretive Guidelines for Enforcement for 42CFR §489.24. This guideline to states in part that "individuals coming to the emergency department must be provided a medical screening examination beyond initial triaging. Triage is not equivalent to a medical screening examination. Triage merely determines the order in which patients will be seen, not the presence or absence of an emergency medical condition
How do the NPA and Rules apply to RNs performing medical screening exams under EMTALA?
The definition of "professional nursing" found in Texas Occupation Code §301.002(2) of the Nursing Practice Act (NPA) states that the practice of professional nursing "does not include acts of medical diagnosis or prescription of therapeutic or corrective measures." This means an act must not require the RN to exercise independent medical judgment or medical diagnosis, as this is the practice of medicine, not nursing. Rule 217.11, Standards of Nursing Practice, contains the minimum standards of acceptable nursing practice. Some of the standards in Rule 217.11 that would apply to EMTALA medical screening exams performed by an RN include, but are not limited to, the requirements that an RN must:
- (1)(A) know and conform to the NPA, rules, as well as federal, state, or local laws affecting the nurse’s current area of practice;
- (1)(B) maintain a safe environment for clients and others;
- (1)(D) accurately and completely report and document: (i)-(vi);
- (1)(M) institute appropriate nursing interventions that might be required to stabilize a client’s condition and/or prevent complications;
- (1)(P) collaborate with the client, members of the health care team and, when appropriate, the client's significant other(s) in the interest of the client's health care;
- (1)(T) accept only those nursing assignments that take into consideration patient safety and that are commensurate with one's own educational preparation, experience, knowledge and physical and emotional ability.
- (3)(A)(i) performing comprehensive nursing assessments regarding the health status of the client.
Regardless of practice setting, the nurse's duty to keep patients safe cannot be superseded by physician orders, facility policies, or administrative directives; see Position Statement 15.14 Duty of a Nurse in Any Practice Setting. To assist in determining if a task is within an individual nurse's scope of practice; nurses may utilize the board's "Six-Step Decision-Making Model for Determining Nursing Scope of Practice."
Can an Advanced Practice Registered Nurse Perform A Medical Screening Exam?
Advanced practice registered nurses (APRNs) are RNs who have completed a formalized education program, e.g., Master's or Post-Master's APRN curriculum that enables them to engage in certain aspects of medical diagnosis and medical management within their advanced practice role and population focus. Advanced practice licensure is not sufficient on its own to qualify an APRN to perform all types of medical screening exam. The APRN would have to be licensed in an appropriate role and population focus, e.g., Acute Care Nurse Practitioner, Adult Nurse Practitioner, or Family Nurse Practitioner for evaluation of general medical conditions of adults. The appropriately licensed APRN should have a signed protocol or collaborative agreement with a physician that specifically delegates medical aspects of care to the APRN. Other sources of information on EMTALA include:
Seasonal Influenza and other Vaccinations
What are the requirements for a nurse to give flu injections?
Although the laws regarding immunizations are not within the BON's authority, an Attorney General opinion in 1981 (MW-318) determined immunizations are preventative, thus no medical diagnosis is required or made when a person receives an immunization. Board staff recommends that a facility have standing physician delegation orders that guide the nurse when to give pneumococcal or influenza vaccines. Position Statement 15.5, Nurses with Responsibility for Initiating Physician Standing Orders, references the Texas Medical Board rules applicable to these types of orders, and provides guidance to nurses and employers on important components to include in standing delegation orders.
Board staff recommends review of documents located on our web page in Texas Board of Nursing Rules and Regulations. Among the documents in this section are Rule 217.11, Standards of Nursing Practice, the Interpretive Guideline for LVN Scope of Practice Under Rule 217.11, several Frequently Asked Questions that address the LVN practice, and the Six-Step Decision-Making Model for Determining Nursing Scope of Practice.
As the BON does not regulate specific practices or practice settings, you may wish to check with the Department of State Health Services [DSHS]. The number for the Immunizations Branch is 800-252-9152. The DSHS web site is http://www.dshs.state.tx.us.
Can an RN delegate vaccination administration?
Both the advanced practice registered nurse and the registered nurse delegate in the same manner – through the rules in Chapters 224 and 225. The Delegation Resource Packet contains access to the delegation rules in Chapters 224 and 225 as well as other resources related to delegation.
In general, vaccination administration would be prohibited from delegation by an RN to unlicensed assistive personnel (UAP). The delegation rules in Chapter 224 are more restrictive than the rules in Chapter 225. All medication administration and routes of medication administration are prohibited from delegation in the acute delegation rules with the exception of the medication aide permit holder. An RN cannot delegate the injectable route to a medication aide with the exception of insulin in compliance with Rule 224.9. Rule 225.12 (5) specifically prohibits delegation of injectable routes used for vaccination.
RNs may supervise UAPs performing tasks delegated by other licensed healthcare providers. In these situations, an RNs accountability is to verify the training of the UAP, verify the UAP can perform the task safely, and provide adequate supervision of the UAP. If the RN cannot verify all of these responsibilities, the RN must notify the delegating licensed healthcare provider that the UAP is not capable of performing the task (Rule 224.10 or 225.13)
Does a nurse’s scope of practice change in a pandemic?
A nurse’s scope of practice is related to the nurse’s education, experience, knowledge, and physical and emotional ability. In addition, the practice setting of the nurse influences the nurse’s scope of practice through the policies and procedures as these reflect the regulations for the practice setting. Nurses follow the Nursing Practice Act (NPA) and Board Rules as well as any other laws, rules, or regulations affecting the nurse’s area of practice. The Six-Step Decision-Making Model for Determining Nursing Scope of Practice and LVN Six-Step Decision-Making Model for Determining Nursing Scope of Practice guide a nurse in making good judgments about the tasks or procedures a nurse chooses to perform. Nurses have a duty to promote safety for their patients. Position Statement 15.14, Duty of a Nurse in any Practice Setting further explains the responsibility of the nurse to advocate for patient safety.
Can a nurse do a medical screening exam in the ER during a pandemic?
In the definition of nursing, found in the Nursing Practice Act section 301.002, medical diagnosis is excluded from the practice of nursing. If the purpose of a medical screening is to determine a medical diagnosis, this would be beyond the parameters of nursing practice. A nurse is required to implement measures to prevent exposure to infectious or communicable conditions [Rule 217.11 (1) (O)]. One way to accomplish this standard is to identify incoming patients who might be infectious and provide them with a separate waiting area so as not to expose others to communicable conditions. When a physician is delegating to a nurse, the nurse is expected to comply with the Standards of Nursing Practice just as if performing a nursing procedure. Position Statement 15.11, Delegated Medical Acts discusses physician delegation and the role of the nurse.
Is it mandatory for a nurse to receive a flu vaccination?
Nurses may choose to receive a vaccination to prevent exposing patients to the flu and to protect them from possible infection. A person may be contagious prior to developing symptoms with seasonal flu and thus may expose others to the disease. The following web sites have information on the seasonal influenza:
Role of the School Nurse With Unlicensed Diabetes Care Assistants (UDCAs) (HB984)
What is the BON' recommendation?
BON Position Statement 15.13, Role of LVNs and RNs as School Nurses, recommends that the school nurse be an RN, but does not absolutely preclude an LVN with appropriate...
experience and supervision from fulfilling this role. The Texas Diabetes Council training guide for Unlicensed Diabetes Care Assistants (UDCAs), however, defines a school nurse in accordance with 19 Texas Administrative Code (TAC) (Texas Education Agency), 153.1021 (a) (17), as:
(17) School nurse--An educator employed to provide full-time nursing and health care services and who meets all the requirements to practice as a registered nurse (RN) pursuant to the Nursing Practice Act and the rules and regulations relating to professional nurse education, licensure, and practice, and who has been issued a license to practice professional nursing in Texas.
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Can an LVN be a school nurse? Can an LVN train Unlicensed Diabetes Care Assistants (UDCAs) or serve in other roles (consultative relationship, administratively responsible)?
The BON does not preclude LVNs from being employed in school settings; however, the BON has no jurisdiction over employment practices or facility policies. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nursed, physician’s assistant, physician, podiatrist, or dentist (Board Rule 217.11(2). Additionally, the LVN contributes to the development and implementation of teaching plans for patients and their families with common health problems and well-defined health needs. LVNs may teach from a developed education plan as well as contribute to its development.
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Who is responsible for determining which school employees will be trained as Unlicensed Diabetes Care Assistants (UDCAs)?
NThe training of Unlicensed Diabetes Care Assistants in Texas public schools is not within the BON's jurisdiction...
The school principal determines which school personnel are appropriate to be trained to assist students with diabetes if/when a nurse is not available. In schools that do not have a registered nurse, the principal assures that training is provided by a health care professional with expertise in diabetes care. Questions regarding training of UDCAs should be directed to the Texas Diabetes Council/Program.
For complete information, see Health & Safety Code Chapter 168
Who is responsible for training the Unlicensed Diabetes Care Assistants (UDCAs) in schools? Can a healthcare provider with expertise in diabetic care be contracted to do all of the training for an individual school or a school district?
NThe training of Unlicensed Diabetes Care Assistants in Texas public schools is not within the BON's jurisdiction...
The training guide developed by the Texas Diabetes Council defines who can be a healthcare provider for the purposes of training UDCAs within the Glossary. The training guide is located on the Department of State Health Services web page at http://www.dshs.state.tx.us/diabetes/pdf/hb984.pdf
The language in the Health & Safety Code, Chapter 168.005 states that the school nurse will coordinate training. The decision of who provides the training and what the school nurse's role(s) is/are may be negotiated between the nurse and principal and may be incorporated into job descriptions/functions.
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A school nurse is assigned to 3 different elementary schools within one district and rotates between the schools. The schools’ principles assign who will be trained as Unlicensed Diabetes Care Assistants (UDCAs). The principals also assume administrative responsibility for these staff whether they are functioning within their job descriptions or in the "extra" role of UDCA. Working with the principals at all 3 schools, the RN coordinates training of all UDCAs through another RN with expertise in all aspects of the care of children with diabetes.
Given the situation, as described above, what is the role of the RN with the Unlicensed Diabetes Care Assistants (UDCAs) from a BON standpoint?
According to the Health & Safety Code, Chapter 168, if a school nurse is assigned to a campus, the school nurse shall coordinate the training of school employees acting as unlicensed diabetes care assistants.
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How does the RN provide adequate communication and information to the UDCAs at each school related to the diabetic care needs of each child?
Congruent with the diabetes management and treatment plan and the individualized health plan for each child with diabetes, the RN can develop information sheets with emergency contact numbers, reportable conditions, and how to intervene in a number of possible emergency situations that could occur with each child. Health and Safety Code, Section 168 and school policy mandate that this information be given to any school employee transporting a child or supervising a child during an off-campus activity. The school principal and the school nurse, if a school nurse is assigned to the school, shall develop a student’s individualized health plan in collaboration with the student’s parent or guardian and, to the extent practicable, the physician responsible for the student’s diabetes treatment and one or more of the student’s teachers (Health and Safety Code Sec 168.003.) The Nursing Practice Act Sec.301.002(5) (NPA) defines the licensed vocational nurse (LVN) scope of practice as a directed scope of nursing practice and specifically states that LVNs participate in the development and modification of the nursing care plan, whereas the registered nurse (RN) is responsible for the development of the nursing care plan. The LVN may assist with the development of the IHP but is not permitted to write it independently.
Can the LVN develop the Individualized Health Plan (IHP)?
No. This would be in violation of, Texas Health and Safety Code §168.003 that defines the IHP as a "coordinated plan of care" developed by the principal and the school nurse (RN) in collaboration with the student’s parent/guardian and the student’s physician, if possible. Developing or initiating a student’s IHP would also be beyond the LVN’s scope of practice as defined by the BON in Rule 217.11(2)(A).
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Health and Safety Code §168.008 mandates schools to permit and encourage students' abilities to engage in self-care. Occasionally, used supplies, such as insulin syringes or blood-stained gauze, may not be disposed of properly, exposing other children to potentially hazardous bodily fluids/blood that could carry HIV or Hepatitis. Does HB984 mandate that a child always be permitted to engage in the self-management of diabetes anywhere on the campus, regardless of the health threat posed on other students if a given student isn't capable of disposing of used supplies and cleaning the testing area in a responsible manner? Must a student who is not capable, either by age, maturity or both, of appropriately maintaining supplies and equipment (not losing his/her glucometer, leaving used supplies where others could be exposed to blood, used sharps, etc.) be permitted to self-manage?
The Standards of Nursing Practice (Rule 217.11) require all nurses to prevent exposure of clients (students) to infectious pathogens and communicable conditions. The language in ...
HB984 (Section 168.008) prefaces the mandate to permit/encourage self-management with the phrase "in accordance with the student's individualized health plan...".
Based on maturity, intellectual understanding, or other factors, if a student with diabetes is unable to safely accomplish self-management, then the nurse should assure that this issue is addressed in discussions with the principal, parents, physician, and teacher(s) in revising the IHP as necessary to protect both the child with diabetes as well as other children in the school setting. The IHP may require multiple revisions as the child's ability to engage in responsible self-management increases. The School Health Program at the Department of State Health Services may have additional information.
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Does the LVN have to report signs and symptoms or changes in the student's health status to the school nurse (RN)?
LVNs and RNs are responsible for the assignments that they make or accept, and for complying with the NPA and Rules as outlined in Rule 217.11, Standards of Nursing Practice...
There is nothing to preclude an LVN from carrying out appropriate nursing measures to assess and treat a child with diabetes within the LVN's scope of practice. The RN should be at least be available telephonically for consultation as the LVN's supervisor. See Rule 217.11 and the Board’s Guideline on LVN Scope of Practice at Rule 217.11 - Standards of Nursing Practice
and LVN Scope of Practice
for additional information.
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What if the principal refuses to act on a school nurse’s report that the Unlicensed Diabetes Care Assistant (UDCA) is unable or unwilling to carry out applicable duties?
The BON has no jurisdiction over employment issues; however, the nurse should consider reporting up the chain of command, or if necessary, reporting to the Texas Education Agency (TEA), http://www.tea.state.tx.us/. The nurse always has a duty to provide a safe environment for the client, which may include advocating for the client through other channels to prevent harm. (Position Statement 15.14, Duty of Nurse in Any Practice Setting.) Failure to do so may result in the reporting of the nurse to the BON with a subsequent investigation and possible sanctions on the nurse’s license for failing to intervene in the client’s best interest. The BON staff encourage nurses to utilize the chain of command within their employment setting. If unable to reach a resolution, then ultimately the nurse may have to choose between changing employment settings or risking action on his/her nursing license.
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Is it within the RN’s scope of practice to train the Unlicensed Diabetes Care Assistant (UDCA)?
Though all RNs receive both knowledge and skills training in care of clients with diabetes across the life span, this does not necessarily mean that every RN is capable of effectively training a UDCA...
What is within the scope of practice for one RN may not be within the scope of practice for another. See articles on the BON web page under Scope of Practice for specific guidance on how each RN can determine what is within his/her individual scope of practice. The Six-Step Decision-Making Model guides nurses in deciding if a task is within the nurse's scope of practice. The steps combine BON references and resources with additional references and resources (policies and procedures from the employment setting, and nursing and healthcare research and literature) and uses reflective questions to guide a nurse's practice decisions. A "no" answer, on any step, usually means the activity in question is not within the nurse's scope of practice.
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Can a nurse train Unlicensed Diabetes Care Assistants (UDCAs), teachers, and other school personnel in the administration of glucagon?
While the BON has no jurisdiction over school district policies, nurses do have the obligation to promote a safe environment for students and staff [Rule 217.11(1) (B)] and to institute appropriate nursing interventions to stabilize a client's condition and prevent complications [Rule 217.11 (1) (M)]. Glucagon is prescribed to thousands of students with diabetes. Both students and their parents or guardians are instructed by providers and pharmacists on administration of glucagon should a hypoglycemic reaction occur.
Chapter 224 becomes applicable in the ISD setting when acute health conditions arise and patients become unstable or unpredictable, i.e., an emergency situation. Section 224.6, General Criteria for Delegation, outlines the standards that must be met before an RN can delegate nursing tasks to unlicensed persons. In the ISD setting even during an emergency situation, the RN cannot delegate tasks that require unlicensed persons to exercise professional nursing judgment; but, the unlicensed person may take any action that a reasonable, prudent non-health care professional would take in an emergency situation. This forms the basis for the Frequently Asked Question from the Board’s Delegation Resource Packet online entitled Medications or Procedures in an Emergency Situation, which might provide more clarification. Each nurse will need to exercise nursing judgment to decide when it is appropriate and safe to delegate in emergency situations, remembering the supervision requirements of delegation.
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The BON wishes to thank Anita Wheeler, MSN, RN, Texas School Health Network Administrator and School Nurse Consultant at the Texas Department of State Health Services, and Susan Young, MSN, RN, former Nurse Consultant for the Diabetes Program at the Texas Department of State Health Services, for their assistance in the development of this document.
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Off Label Use of Medication
May I administer a medication if the use is considered to be off label?
The Nursing Practice Act or NPA (Texas Occupations Code, Chapter 301) and Board Rules are written broadly so they can be applied by every nurse to all of the many different practice settings and specialty areas in nursing across Texas. The BON does not have a list of tasks that nurses can perform because each nurse has a different background, knowledge and level of competence. Determinations of a nurse's scope of practice are often complex and it is up to the individual nurse to utilize sound professional judgment in accepting any given assignment and/or performing any given procedure.
Off label use indicates that the medication is being used in a way not specified in the FDA’s approved packaging label, or insert. All prescription drugs marketed in the U.S. have an FDA-approved label.
All prescription drugs marketed in the U.S. have an FDA-approved label. The label provides detailed instructions regarding approved uses and doses which are based on the results of clinical studies that have been submitted by the drug maker to the FDA. Off label use of a medication may be supported by research and literature that addresses the necessary knowledge, required safeguards and risks associated with the off label use of the medication.
When a nurse is considering giving a medication, there are documents available on the BON website inNursing Practice then in Scope of Practice to assist the nurse in arriving at a decision. The Board's Six-Step Decision-Making Model for Determining Nursing Scope of Practice and LVN Six-Step Decision-Making Model for Determining Nursing Scope of Practice guide a nurse in deciding if a task is within the nurse's scope of practice. When making these decisions, the model encourages a nurse to consider the six reflective questions using a yes or no answer. If a yes answer is reached on any step, the nurse should proceed to the next step of the decision making model. If the nurse reaches step six with yes answers, then the task is most likely within the nurse's scope of practice. However, if a nurse reaches a no answer on any step the activity is most likely not within the nurse's scope of practice and the nurse should not proceed with the task. Keep in mind, the answer may not be the same for each nurse.
In the Six-Step Model and the LVN Six-Step Model, step one includes references to documents and information on the BON website, including statutes, rules, and position statements. While there is nothing specific in the Nursing Practice Act or Board Rules and Regulations that allows or prohibits the off-label administration of medications, there are laws and rules that licensed vocational nurses (LVN) and registered nurses (RN) should consider in this decision. For example, the LVN has a directed scope of practice under the supervision of a registered nurse, physician, physician assistant, dentist, or podiatrist [(Board Rule 217.11(2)]. The LVN cares for patients whose healthcare needs are predictable. When considering the administration of a medication, the predictability of the patient, the patient's response and the nurse's skill set required to address the needs of the patient must be considered. If any of these cannot be addressed by the LVN, then it would be beyond the scope of practice of the LVN to administer off-label medications. Position Statement 15.25, Administration of Medication & Treatments by LVNs, addresses medication administration; however, if the route of the medication administration is intravenous (IV), then Position Statement 15.3, LVNs Engaging in Intravenous Therapy, Venipuncture, or PICC Lines, must also be considered.
One of the main rules applicable to a nurse's practice is Board Rule 217.11, Standards of Nursing Practice. When a nurse is considering performing a task, such as the off-label administration of medications, several standards in section one of this rule, will apply to all LVNs and RNs. Patient safety must be considered in every assignment a nurse accepts. A nurse must know about the medication, why it is being used, what effects can be expected, and how to administer the medication correctly in order to administer it safely [(Board Rule 271.11(1)(C)]. Some medications may require an assessment, vital signs, and a pain description and level provided by the patient. Certain medications require the presence of equipment or monitoring during and following the medication administration due to the potential or known effects of the medication8. Some medications require the nurse administering the medication to have specific skills and current competencies to include emergency interventions should adverse outcomes occur. Last, but not least, medication administration is not complete without accurate documentation [(Board Rule 217.11(1)(D)].
There are several Position Statements that apply to the off label administration of a medication. Position Statement 15.14, Duty of a Nurse in Any Practice Setting, utilizes a landmark court case to illustrate the responsibility a nurse has to advocate for the patient, thus emphasizing the nurse's critical role in patient safety. Some medication administration is initiated through physician standing orders as addressed in Position Statement 15.5, Nurses with Responsibility for Initiating Physician Standing Orders. Occasionally, a physician delegated act includes medication administration; see Position Statement 15.11, Delegated Medical Acts. There are two position statements that specifically address either the RN or LVN scope of practice in broad terms. These are Position Statements 15.27, The Licensed Vocational Nurse Scope of Practice and 15.28, The Registered Nurse Scope of Practice.
Step two of the Six-Step Model and the LVN Six-Step Model directs nurses to look for a valid order and facility policy support. Facility policy may identify specific levels of licensure for the administration of certain medications, or specific areas or units within the facility where the administration of medications may occur. There may be specific requirements related to current competencies of the personnel who will be administering medications, and for monitoring the patient after the administration of medications. There may be a policy distinction between label uses and off-label uses of medications. When a nurse identifies the safety issues involved in administering any off-label medication correctly, looking for an employer's policy support of the safety measures required may assist a nurse in determining if off-label administration of medications will be safe in a specific setting.
Nurses are required to administer medications correctly, using evidence to support or refute giving a medication. Step three of the Six-Step Model and the LVN Six-Step Model requires "positive and conclusive data from nursing literature, nursing research, and/or research from a health-related field" and does not negate the requirement for nurses to administer medications correctly.
If there is literature to support the safe off-label administration of a medication, a nurse should consider steps four, five, and six of the Six-Step Models. Step four asks if the nurse has the current competencies to perform the task. If a medication is being given via the IV route, having current skills to assess and intervene are important. If a pump is being used to administer the IV medication, then being familiar with the pump is essential. Step five is for the nurse to consider whether a reasonable and prudent nurse of the same or similar education and similar circumstance would administer the off-label medication. Finally, step six is a personal reflective question and asks the nurse to accept accountability for the actions the nurse takes.
Both the mission of the Board and the nurse's duty to the patient align in favor of patient safety. Therefore, a nurse is obligated to make the safest decision for the patient and using the six-step decision making model for determining scope of practice is one tool to help nurses with this decision whether to accept or refuse an assignment related to the off-label administration of medications.
1 Texas Department of State Health Services January 2012 Schedules
2 Ketalar Label from FDA website
3 Tex. Occ. Code 301.002 (5) & 301.353; and 22 Tex. Admin. Code § 217.11 (2)
4 22 Tex. Admin. Code § 217.11 (2)
5 22 Tex. Admin. Code § 217.11 (1) (B) & (1) (T)
6 22 Tex. Admin. Code § 217.11 (1) (C)
7 22 Tex. Admin. Code § 217.11 (2) & (3)
8 22 Tex. Admin. Code § 217.11 (1) (M)
9 22 Tex. Admin. Code § 217.11 (1) (G), (1) (H), (1) (R), & (1) (T)
10 22 Tex. Admin. Code § 217.11 (1) (D)
11 22 Tex. Admin. Code § 217.11 (1) (C)
12 22 Tex. Admin. Code § 217.20 and Tex. Occ. Code, Sec. 301.352
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Nurses Performing Radiologic Procedures
Are there rules regarding nurses performing radiologic procedures?
Yes, BON Rule 217.14, Registered Nurses Performing Radiologic Procedures.
This rule states that a registered nurse who performs radiologic procedures is employed in a practice setting that is not
a Medicare-approved provider or accredited by The Joint Commission, the RN is required to submit an application for registration to the Board. The RN must print out the application for registration form
and submit it to the Board. There is no cost for registering. The RN must notify the Board within 30 days of any changes that render the information provided on the application incorrect, such as new practitioner or director of radiologic services under whose instruction or direction the radiological procedures are performed [BON Rule 217.14
(c)]. If the RN will be performing radiological procedures in a practice setting that is a Medicare-approved provider or accredited by The Joint Commission, then the registration requirement does not apply.
BON Rule 217.14 also references other laws outside of the BON's jurisdiction. These laws require a RN to demonstrate competency in performing radiologic procedures. Some radiologic procedures may be considered delegated medical acts. BON staff recommends caution when performing a task as a delegated medical act and the Board's Position Statement 15.11, Delegated Medical Acts, is a valuable resource for nurses. Delegated medical acts do not diminish the responsibility in any way of the nurse to adhere to the Board's Standards of Nursing Practice, Rule 217.11. Included in BON Rule 217.11 are standards requiring a nurse to know and comply with the Nursing Practice Act (NPA) and Board's Rules and Regulations as well as all federal, state, or local laws, to maintain client safety. Nurses must accept only those assignments that are within the nurse's knowledge, skills, and abilities, and seek instruction as necessary in order to maintain competency when performing tasks in any practice setting [BON Rule 217.11(1): (A), (B), (G), (R) and (T)].
For general information on nurses practicing in the area of radiology, BON staff recommends contacting professional nursing organizations, such as the Radiological Society of North America at http://www.rsna.org or the Association for Radiologic and Imaging Nursing at http://arinursing.org/. Other nursing organizations related to a nurse's specialty practice setting may provide further guidance. In addition to other nursing organizations related to a nurse's specialty practice setting, national patient safety organizations may provide resource information and procedure guidelines for evidence-based practice. Examples include:
How does BON Rule 217.14 apply to LVNs?
BON Rule 217.14 only addresses the RN as well as the Nursing Practice Act and Board Rules and Regulations do not address the LVN performing radiological procedures. Therefore, the LVN would be required to become a certified radiologic technologist/technician in order to perform X-rays.
Revised February 2013
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RN Pronouncement of Death
Texas Senate Bill 823 (1991) amended Section 671.001 of the Texas Health and Safety Code and gave RNs the legal authority to assess a patient/client and make a determination of death, unless the pronouncement is clearly prohibited under the Health and Safety Code (such as when an inquest is required). The bill specifically requires the RNs employing agency/facility to have written policies jointly developed and approved by the nursing and medical staff to direct the practice.
There was legislation some time ago that allowed nurses to pronounce death in long-term care and hospice facilities. Can RNs and APRNs pronounce death in acute care facilities?
During the 1991 Legislative Session, registered nurses were given the legal authority to determine and pronounce a person dead in situations not involving artificial life support, if permitted by written policies of a licensed health care facility, institution, or entity providing services to that person. The statutory authority is set forth in Chapter 671 of the Texas Health and Safety Code. The bill specifically states that if the RN's employing health care facility has an organized nursing staff and an organized medical staff or medical consultant, the nursing staff and medical staff or consultant shall jointly develop and approve those policies.
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BON Rules and Regulations Relating to Telenursing/Telehealth
What are the Texas Board of Nursing (BON) Rules and Regulations Relating to Telenursing/Telehealth?
Telenursing involves nursing practice via any electronic means such as telephone or computer. Examples of telenursing practice may include (but are not limited to) teaching, consulting, triaging, advising, or providing direct services.
All of these actions constitute the practice of nursing, even when there is no face-to-face or physical contact with a person or patient. If a job description requires a person to hold a valid nursing license, then the job duties therein involve the practice of nursing. This means a nurse must comply with the Texas Nursing Practice Act
and Board Rules
in the exercise of his/her practice of nursing. Board Rule 217.11
, Standards of Nursing Practice, is the primary rule applied to nursing practice in any setting.
Telenursing may also involve practicing nursing across state lines. For example:
- A nurse working in an emergency hotline center in Virginia may provide advice to clients in Texas;
- A nursing faculty professor from Arizona may teach nurses enrolled in a graduate (Master's Degree) program in Texas via the internet; or
- An RN working for an insurance company in New York may assess ongoing home healthcare needs of a patient in Texas.
If a nurse from another state provides nursing to a resident of Texas, except as excluded in the Nursing Practice Act, Section 301.004, Application of Chapter, the nurse must hold a valid Texas nursing license or a valid nursing license in another Compact state in order to practice nursing in the State of Texas and/or with Texas residents. The most current list of states belonging to the Nurse Licensure Compact is located on the web page for the National Council of State Boards of Nursing www.ncsbn.org/nlc.htm. Chapter 304 of the Texas Nursing Practice Act and Rule 220 contain the regulations applicable to the Nurse Licensure Compact in Texas.
Using Nursing Titles Applies to Telephonic Nursing Practice
Any title that would lead a member of the public to believe that a person is licensed as a nurse is prohibited from use unless the person indeed holds a valid nursing license either in Texas or in one of the compact states. This is specified in the Nursing Practice Act, Section 301.4515 and Rule 217.10. This includes titles that apply to advanced practice registered nurses as defined in Rule 221.2 Authorization and Restriction to Use of Advanced Practice Titles.
LVNs and Telephonic Nursing
The documents listed below provide detailed information on how the Texas BON views telephonic nursing in relation to LVN practice. Rule 217.11(2)(A) limits LVN scope with regard to nursing process to "focused" assessments (not comprehensive). The Position Statement 15.27, "The Licensed Vocational Nurse Scope of Practice"provides a brief table of the basic educational preparation for LVNs compared to RNs. This document and the LVN FAQ about LVNS Performing Telenursing/Triage/Being On-call (See below.) explain that whether telephonic or in person, triaging a client requires the ability to perform a comprehensive assessment, which is beyond the scope of practice for a LVN. LVNs Performing Triage/ Telephonic Nursing /Being On-Call — See:
Additional Resource Documents
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Forensic Evidence Collection
Who is required to have forensic evidence collection continuing education?
Pursuant to the Health and Safety Code §323.004 and §323.0045, a nurse licensed in Texas or holding a privilege to practice in Texas, including an APRN, who performs a forensic examination on a sexual assault survivor must have basic forensic evidence collection training or the equivalent education prior to performing the examination. This is a onetime requirement.
A nurse licensed in Texas or holding a privilege to practice in Texas, including an APRN, who is employed in an emergency room setting, must complete a minimum of two hours of CNE relating to forensic evidence collection within two years of the initial date of the nurse’s employment in an ER setting. This is a onetime requirement.
Do nurses who “float” to an Emergency Department need this continuing education?
While some practice settings may have the luxury of always having a specialty certified RN (such as a SANE nurse) available to perform specific types of forensic evidence collection, there will be settings where this is not the case, and where the nurse who "floats" to the emergency department may be the professional responsible for collecting (or assisting with collection of) evidence. Therefore, even if a nurse floats to the ED on rare occasions and is not required by his/her facility to carry out forensic evidence collection, this nurse would have to meet the forensic CNE requirement to comply with the BON rule.
As the Board has no jurisdiction over facilities, the BON has no control over staffing plans, job descriptions, how nurses may or may not be rotated through or floated to the ED, or to establish a minimum number of hours a nurse must work in an ED setting. It would be up to facility or unit policy to determine which nurses will perform forensic evidence collection and how the facility will assure ongoing competency of the nurses engaging in this practice.
What topics need to be included in the continuing education offering?
Continuing education shall include information relevant to forensic evidence collection and age or population-specific nursing interventions that may be required by other laws and/or are necessary in order to assure evidence collection that meets requirements under the Government Code §420.031 regarding use of a service-approved evidence collection kit and protocol. Content may also include, but is not limited to, documentation, history-taking skills, and use of sexual assault kit, survivor symptoms, and emotional and psychological support interventions for victims.
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Co-signature on Documentation
When a Graduate Nurse (GN) or Graduate Vocational Nurse (GVN) has completed all requirements for the nursing program attended, and has received permission to test for nursing boards, must the preceptor co-sign the nursing assessment, medication administration, and other records for patients assigned to the GN/GVN?
Besides obtaining approval to sit for the NCLEX, a student who has successfully completed a nursing program must also hold a current valid temporary permit from the Board to practice as a GN or GVN in the state of Texas.
Assuming the graduate has this, he/she may not practice in an independent setting (such as home care) until licensed; however, the BON has no requirements for co-signatures on anything. In fact, we highly discourage a nurse from co-signing anything he/she did not directly witness or immediately verify personally. Co-signature implies that the signer agrees in total and was either witness to, or went immediately behind the GN/GVN to assess and verify the findings of the GN/GVN.
Co-signatures may be necessary for certain nursing tasks, such as witnessing the wastage of a unit-dosed amount of a narcotic. Such requirements are beyond the jurisdiction of the BON. Contacting the appropriate licensing authority, or an applicable credentialing organization (such as the Joint Commission on Accreditation of Hospitals and Organizations) for any regulations specific to the practice setting, is recommended.
Review Date: 2017
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Co-signature on LVN Actions/Documentation
Must an RN sign behind or "co-sign" nursing actions performed by an LVN?
In general, BON staff does not recommend a nurse co-sign anything unless he/she has directly witnessed an act (such as narcotic wastage) or has gone behind another nurse and personally performed the same assessment with the same findings.
The question of an RN co-signing after an LVN most often arises in situations when an attempt is made to expand the LVN’s scope of practice by holding the RN responsible for expanded tasks performed by the LVN. The RN co-signing for something that is beyond the LVN’s scope of practice does not legitimize the LVN’s actions. A nurse never functions “under the license” of another nurse. Therefore, if a patient requires a comprehensive assessment performed by an RN, the assignment (or a portion thereof) may not be given to an LVN. If such an assignment is inadvertently given to an LVN, he/she is responsible for notifying the nurse who made the assignment that it is beyond his/her scope of practice to perform the assigned task. Each nurse has a duty to maintain client safety [217.11
(1)(B)] that includes communication with appropriate personnel [217.11(1)(P). Position Statement 15.14
, Duty of a Nurse in Any Setting, further explains a nurse’s duty to a client.
As discussed above, each licensed nurse is responsible for accepting assignments that are within the educational preparation, experience, knowledge, and physical and emotional ability of the individual nurse [Rule 217.11(1)(T)]. Both LVNs and RNs are required to document the nursing care they render; each is held accountable for doing it accurately and completely (217.11(1)(D). This is part of a nurse’s duty to a client.
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FAQ - Differentiating the Role of the Texas Board of Nursing from the Role of Professional Nursing Associations
What is the difference between the Texas Board of Nursing and professional nursing organizations?
Although the Texas Board of Nursing and professional nursing associations are both involved in the arena of nursing, nursing associations serve a different purpose and provide different services to their nursing membership and the public.
The mission of the BON is to protect and promote the welfare of the people of Texas by ensuring that each person licensed as a nurse is competent to practice safely. For this purpose, the Texas Board of Nursing (BON) is the State agency empowered by the Texas Legislature with regulating the practice of vocational, professional, and advanced practice nursing.
The Board does not draft legislation, nor can the Board or board staff support or oppose proposed bills during a legislative session. Board Members and Board staff are prohibited from lobbying the legislature regarding any bill that may go before the Texas Legislature and amend the Nursing Practice Act or other statutes, in or outside the authority of the BON, that otherwise impact nurses.
The Nursing Practice Act (Ch. 301), Nursing Peer Review (Ch. 303), Nurse Licensure Compact (Ch. 304), and NCSBN Advanced Practice Registered Nurse Compact (Ch. 305) are all part of the Texas Statutes in the Texas Occupations Code. The Board Rules are part of the Texas Administrative Code (TAC). The Board fulfills its mission of protecting the public by carrying out the applicable statutes in the Occupations Code, and through promulgation of rules in the Administrative Code.
In Texas government, policy making duties are divided between the legislature and the governor. The legislature writes the laws and appropriates the funds for state agency operations. The Governor, the State's Chief Executive Officer, has a major voice in setting the legislative agenda and vetoing bills. However, the legislature and the Governor delegate to state agency boards, like the Board of Nursing, the tasks of carrying out the laws applicable to the profession the agency is responsible for regulating.
The Board meets regularly to execute its responsibilities for administering the law governing nursing practice and education. The Board employs professional and support staff to carry out the provisions of the law along with the policies and regulations established by the Board. The Board pursues its mission by upholding minimum standards for educational programs in nursing educational programs, licensing qualified individuals as nurses, educating licensed nurses regarding changes in the law, investigating alleged violations, and imposing appropriate discipline on the licenses of those found to be in violation of the BON's statutes, rules, and policies.
Unlike the Board of Nursing, a nursing association (also called a professional association) is a private organization whose members must pay dues to enjoy the benefits of membership. One of the primary functions of a nursing association is to represent its members in legislative, political, and practice matters. It provides a central voice for its nurse membership.
A nursing association can lobby the legislature and Governor for the interests of its members and the profession of nursing. A nursing association provides a united voice that can speak out on the issues important to a specific area of nursing practice and/or to the nursing profession as a whole. In addition, a nursing association provides leadership in other areas such as improving working conditions and benefits for nurses. A nursing association also may lead the way in developing public health policies.
The Board and the nursing associations have separate but equally important roles. The nursing associations represent their members; while the Board serves the people of Texas through assuring licensed nurses meet minimum standards of safe practice.
The Board protects the public through ensuring that nurses know and conform to minimum standards through rules that implement the statutes, and through additional resource documents such as position statements, interpretive guidelines, and frequently asked questions available on the web page at http://www.bon.texas.gov.
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FAQ – Doctoral Degrees in Nursing and Using the Title “Doctor”
Question: I am a nurse in Texas and recently graduated with a Doctor of Nursing Practice (DNP). Can I use the title “Doctor” when I work with patients and other healthcare providers?
One of the hallmarks of nursing is the approach to lifelong learning. As nurses earn advanced degrees, the number of nurses earning doctoral degrees is increasing....
The longstanding tradition of addressing a person with an earned doctoral degree as “doctor” began many centuries ago as did the tradition of addressing a physician as “doctor”. The number of healthcare professionals with earned doctoral degrees may contribute to confusion for the public and for members of the healthcare team.
Credentials by Law
Known as the Healing Art Identification Act, Texas Occupations Code, Chapter 104.001 addresses the use of the term doctor. According to TOC Chapter 104.004 a nurse is required to include the degree that gives rise to the use of the title doctor as a credential and indicate the profession being practiced. The Nursing Practice Act and Board Rules mandate that a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN) display a clearly legible insignia specifying name and licensure level (NPA Section 301.351 & Board Rule 217.10). The Advanced Practice Registered Nurse (APRN) is identified both as a RN and uses the appropriate advanced practice title authorized by the Board of Nursing (BON) when providing advanced practice care to patients (Board Rule 221.11). Based on requirements in the referenced Texas laws, doctorally prepared nurses could not simply identify themselves as Dr. _____. The nurse must include the academic credential such as PhD (Doctor of Philosophy), DNS (Doctor of Nursing Science), DNP (Doctor of Nursing Practice), or any other doctoral degree. Nurses must also include licensure level with appropriate APRN title, if applicable.
Communication takes many forms. Some verbal communications occur in person and have associated visual cues such as a name badge. Other verbal communications may occur by telephone, presenting unique challenges in assuring the parties are correctly identified. The information exchanged should include the name and licensure level of the parties involved. Written communications are required to include the name, licensure level, and the appropriate advanced practice title, if applicable, and may include academic degrees and certifications. The academic credential cannot replace the licensure credential. Inadequate identification of a nurse can be confusing to the public. Failure to comply with laws, rules, and regulations can result in disciplinary action. When using a doctoral credential, nurses are obligated to use the term in compliance with the law by identifying the “degree that gives rise to the use of the title” (TOC, Section 104.004)
Additional resources and references related to identification and advanced practice titles include:
- Texas Board of Nursing Bulletin – When the Profession is Nursing and the Title is Dr……, July, 2011, p.4;
- Texas Board of Nursing Bulletin – Use of Advanced Practice Titles, July 2008, p.8; and
- RN Update – RN Identification is Essential in Today’s Health Care Environment, January 1999, p.1.
To access these archived issues on the Board’s website at www.bon.texas.gov click on About then Newsletters.
Board Rule 221.11
Nursing Practice Act (NPA), TOC, Section 301.351 and Board Rule 217.10
Texas Occupations Code (TOC), Section 104.001
Texas Occupations Code, Section 104.004
Original May 2013
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