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Practice - Guidelines and Interpretive Guidelines


Rules and Guidelines Governing the Graduate Vocational and Registered Nurse Candidates or Newly Licensed Vocational or Registered Nurse

The Board's mission is to protect and promote the welfare of the people of Texas by ensuring that each person holding a license as a nurse in the State of Texas is competent to practice safely. This mission, derived from the Nursing Practice Act, supersedes the interest of any individual, the nursing profession, or any special interest group. Adherence to the NPA, Rules, and Guidelines related to GVNs, GNs and newly licensed LVNs and RNs will help assure the safety of the clients these novice nurses encounter, as well as supplying the necessary support and guidance to the next generation of licensed nurses in Texas.

Requirements for Graduate Nurse Candidates to Practice Under Temporary Authorization:

In accordance with Rule 217.3(a): "A new graduate who completes an accredited basic nursing education program within the United States, its Territories, or Possessions and who applies for initial licensure by examination in Texas may be temporarily authorized to practice nursing as a graduate nurse (GN) or graduate vocational nurse (GVN) pending the results of the licensing examination." This temporary authorization is not renewable and will expire the earliest date of any of the following: (1) when the candidate passes the NCLEX-PN® or NCLEX-RN® test; (2) when the candidate fails the NCLEX-PN® or NCLEX-RN® test; (3) or on the 75th day following the effective date of the temporary authorization [217.3(2)].

Candidates graduating from nursing programs outside of the United States jurisdiction who are seeking Texas licensure through examination are not eligible for temporary authorization [Rule 217.4]. Licensure candidates who have previously failed the NCLEX-PN® or NCLEX-RN® are also ineligible for temporary permission to practice. A graduate of a nursing program within the United States jurisdiction may be deemed ineligible for temporary permission to practice based upon a Board determination under NPA Section 301.257 and Rule 213.30 relating to Declaratory Order of Eligibility for Licensure.

Verification of Temporary "Permission to Practice"

Effective January 1, 2006, a licensure candidate (GVN or GN) who meets Board requirements will be issued a temporary "permission to practice" via the Board's web site at www.bon.state.tx.us. Potential employers must verify that a licensure candidate has current temporary "permission to practice" via the web page or by phoning the Board at (512) 305-7400. Hard-copy (paper) temporary permits are no longer issued.

Expired or Invalid "Permission to Practice"

New graduates may not continue to practice as GVNs or GNs after failing the NCLEX-RN® or NCLEX-PN® , even if the expiration date of the temporary permission to practice has not expired. Employers must follow-up on the results of the new graduate’s test results, either by asking to see the new graduate’s test results, monitoring the issuance of a license using the automated phone line (512/305-7400), or utilizing the on-line licensure verification process on the Board’s web page. If the new graduate is allowed to continue to practice after receiving notice of failing the NCLEX-RN® or NCLEX-PN® , both the nurse manager and the new graduate may be subject to disciplinary action by the Board.

The Board will not issue a GVN or GN permission to practice until all application processes are complete, enabling the new graduate to be deemed eligible to sit for the NCLEX-PN® or NCLEX-RN® exam. The new graduate should schedule to sit for the applicable licensure exam as soon as possible because his/her Authorization To Test (ATT) is only active for a period of 75 days. If the new graduate does not test in time to receive a nursing license before the date that the permission to practice expires, the GVN or GN must cease practicing as a graduate nurse. There are no extensions for the temporary permission to practice as a GVN or GN based on failure to schedule the licensing examination.

Verification of Licensure

In accordance with Texas Occupations Code §301.254 (Nursing Practice Act), results of NCLEX-PN® or NCLEX-RN® are mailed to applicants within 30 days of testing. The new graduate may choose to participate in obtaining "quick results" from the test vendor (NCS Pearson) within 48 hours of testing; however, these quick results are unofficial and cannot be considered as evidence of successful exam completion until verified directly from NCS Pearson/VUE to the Board. Employers and/or candidates may use either the on-line licensure verification system or the automated phone line (512/305-7400) to verify whether the GVN or GN has been issued a license by using the licensure candidate's social security number. Please be aware that both the automated phone line and on-line verification systems will only verify that a license has been issued. Neither system will inform the caller about failure to pass the examination; therefore, absence of the GVN or GN on the applicable registry means only that a license has not been issued as of the date of inquiry. IT DOES NOT NECESSARILY MEAN THAT THE GVN or GN HAS FAILED THE LICENSURE EXAM. Please do not call the Board office to inquire about examination results. Staff cannot release results over the telephone until at least 21 days after testing have elapsed.

Nursing Law Basics

Each licensure candidate as well as each newly licensed nurse in Texas is responsible to know and comply with the current Nursing Practice Act (NPA) and the Board Rules and Regulations. We recommend starting with the definitions of professional and vocational nursing in the NPA §301.002(2) and (5), and §301.353 relating to vocational nurse supervision. The two rules most often applied to nursing practice in any setting should also be studied: Rule 217.11, Standards of Nursing Practice, and Rule 217.12, Unprofessional Conduct. Both the NPA and Rules may be viewed in their entirety on the Board’s web page at www.bon.state.tx.us, or hard copies may be purchased.

It is also the responsibility of each licensed nurse to maintain his/her knowledge of the most current NPA and Rules. The most current regulations can be found on our website. Updates are also printed in the Board's quarterly newsletter, the Texas Board of Nursing Bulletin, that is mailed to all current licensees who live within the United States. Archived issues of the Bulletin are also on the Board’s website.

Integration of the GVN, GN, or Newly Licensed Nurse Into Practice

Both the graduate nurse (GVN or GN) and the newly licensed nurse are in a transitional process from student to professional. As a novice practitioner, the GVN, GN or new LVN or RN is inexperienced and not fully integrated into his/her professional nursing role and setting. The Board believes it is essential during this transitional period for the new graduate or newly licenced nurse to seek and receive direction, supervision, consultation and collaboration from experienced nurses.

Rule 217.3(a)(3), Temporary Authorization to Practice, mandates that the new graduate who has been authorized to practice as either a GVN or GN pending the results of the licensing examination must work under the direct supervision of a licensed nurse. Vocational nursing graduates must work under the direct supervision of either a LVN or RN; registered professional nursing graduates must work under the direct supervision of a RN. "Direct supervision" means the licensed nurse is physically present in the facility or practice setting and is readily available to the GVN or GN for consultation and assistance. If the facility is organized into multiple units that are geographically distanced from each other, then the supervising nurse must be working on the same unit to which the new graduate is assigned.

A graduate nurse (GVN or GN) is not yet "licensed," and thus shall not be placed in supervisory or charge positions and shall not work in independent practice settings, such as home health. A licensure candidate (GVN or GN) must first achieve nursing licensure through passing the NCLEX-PN® or NCLEX-RN® prior to any consideration of employment involving charge nurse/nurse manager responsibilities or nursing in independent practice settings.

In addition to the rule language noted above, the Board provides the following guidance to employers of recent graduates of LVN or RN programs:

  1. 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 independently should be mutually determined by the new graduate and the supervising nurse and should be demonstrated and supported by documentation.
  2. New graduates 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.
  3. 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.
  4. It is recommended that a newly licensed nurse not practice in independent settings, such as home health, for a period of 12-18 months post-licensure to allow the new nurse sufficient practice experience in more structured settings in order to assimilate knowledge learned in school consistently into practice.
  5. In any practice setting where new graduates are employed, experienced nurses should be willing to supervise and mentor the new graduate.

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Guidelines for Transitioning of the Experienced Nurse back into Clinical Practice or into a New Practice Setting

Nurses in the State of Texas may interrupt their practice or change their primary area of practice for a variety of reasons. The impact that a change of practice area or lack of continuity in practice may have on the competence of the nurse is of concern to the Texas Board of Nursing, as either situation may affect the nurse's ability to provide safe and effective nursing care that complies with the Nursing Practice Act (NPA) and Board Rules. A nurse who has not practiced and is re-entering the work force after a period of four or more years may not be current in his/her knowledge base of new drugs, current therapies, and/or changes in technology. A nurse who is transitioning into a practice setting that differs greatly from the nurse's previous experience may also lack the necessary knowledge to immediately assume responsibility for patient care. In 1994, a study conducted by the Board and Lamar University identified that nurses who fit into one of the above two categories were at highest risk for committing practice errors that resulted in Board discipline against the nurse's license. The Board, therefore, believes it is essential that during the transitional period, either back into practice or into a new practice area, that the nurse seek and receive appropriate orientation, direction, supervision, consultation and collaboration from nurses who possess current skills and knowledge of the particular practice environment.

Rule 217.11, Standards of Nursing Practice, requires that when assignments are made, both the charge nurse and the staff nurse take into consideration client safety, as well as the educational preparation, knowledge, skills, and physical and emotional abilities of the individual licensed nurse to whom a given assignment is being made.

Applicable standards in Rule 217.11 include (but are not limited to):
(1)(B): Implement measures to promote a safe environment for clients and others;
(1)(G): Obtain instruction and supervision as necessary when implementing nursing procedures or practices;
(1)(H): Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations;
(1)(T): 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.

Guidance for the Nurse:

The Board recommends that a nurse returning to the work force after a period of four or more years or changing his/her primary area of practice consider the following recommendations:

  1. Direct supervision should be continued for a period mutually determined by the nurse and his/her supervisor/nurse preceptor. Competence to perform safely and independently should be one of the determining factors. Direct supervision means an experienced nurse (minimum 2 years experience) is immediately available on site to coordinate, direct and observe at firsthand another individual for whom the nurse is responsible.
  2. The nurse should be permitted to perform any function that falls within the scope of nursing practice for which he/she has received educational preparation and has demonstrated minimal competency.
  3. The nurse who is returning to the work force or transitioning to a new primary practice area should neither act as charge nurse nor hold any similar position for a period of at least six months, unless a lesser time period is agreed upon by the nurse and his/her supervisor based upon documented competency of the nurse.
  4. Staff nurses should be willing to supervise, collaborate with, and/or mentor nurses returning to work or changing their practice area or role.

Guidance for Employers:

In order to promote a successful transition of the nurse into the new practice setting, it is recommended that the employer:

  1. Establish policies and procedures for incorporating the transitioning nurse into specific roles and staffing patterns;
  2. Develop preceptors who are willing to assume the role of direct supervisor and mentor for transitioning nurses;
  3. Assign a consistent preceptor who is willing to supervise and offer ongoing constructive evaluation of the skills, judgment and knowledge of the transitioning nurse. Alignment with Board Rule 217.11, Standards of Nursing Practice, as well as any practice-specific national nursing care standards is recommended to promote practice that meets at least the minimally safe level required. Length and depth of orientation should be individualized to meet the needs of the transitioning nurse within a reasonable time period established by the employer; and
  4. Evaluate each nurse on an ongoing basis, (not to exceed six months in accordance with §217.3), in order to determine the competence of the nurse to perform at a minimally safe level commensurate with the nurse's licensure.

The following nurses who have completed a formal educational program that includes a clinical practicum are excluded from these guidelines when entering into advanced practice in their newly-educated and authorized advanced role and specialty:

  • Clinical Nurse Specialists;
  • Nurse Practitioners;
  • Nurse Anesthetists; and
  • Nurse Midwives.

The Board provides these guidelines to assist employers and nurses to safely integrate into the current role and functions of licensed vocational or professional nursing as applicable.

4/2006

Footnotes

  1. 22 Texas Administrative Code, §217.11
  2. A.Green et al. (1994). Disciplined Professional Nurses in the State of Texas.
  3. A.Green et al. (1995). "Are you at risk for disciplinary action?" American Journal of Nursing. 95(7), 37-41.

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Guidelines for Determining APRN Scope of Practice


The Texas Board of Nursing recognizes that advanced nursing practice is dynamic. The scope of advanced practice evolves through experience, acquisition of knowledge, evidence-based practice, technology development and changes in the health care delivery system. Therefore, advanced practice nurses may need to practice in new settings, perform new procedures, and develop new skills during their professional careers. It is common for the Board of Nurse Examiners to receive questions such as, "Can an advanced practice nurse treat a patient with that condition?", or "Is it within the scope of practice of an advanced practice nurse to perform that procedure?"

Scope of practice is defined as the activities that an individual health care provider performs in the delivery of patient care. Scope of practice reflects the types of patients for whom the advanced practice nurse can care; what procedures/activities the advanced practice nurse can perform; and influences the ability of the advanced practice nurse to seek reimbursement for services provided.

Determining scope of practice includes:

  • Advanced practice education in a role and specialty
  • Legal implications (e.g. compliance with the Nursing Practice Act and Board Rules)
  • Scope of practice statements as published by national professional specialty and advanced practice nursing organizations

Both professional and individual scopes of practice exist. Professional scopes of practice are derived from professional specialty and advanced practice nursing organizations. An individual advanced practice nurse may or may not practice the full scope of the professional role and specialty. Decisions regarding individual scope of practice are complex and related to an advanced practice nurse's knowledge, skills and competencies. Each advanced practice nurse must practice within his/her individual scope.

Professional Scope

National professional specialty and advanced practice nursing organizations broadly define scope of practice for each role. These documents address role, function, population served, and practice setting. They offer advanced practice nurses the broadest parameters for scope of practice. Therefore, professional scopes of practice are recommended as the initial resource in defining an individual's scope of practice.

Individual Scope

Formal advanced practice nursing education is the foundation for the individual's scope of practice and evolves over the professional lifetime of the individual. Clinical experience in various settings, continuing education, formal course work and developments in healthcare all impact individual scope of practice. However, there are finite limits to expansion of scope of practice without completing additional formal education. Advanced practice nurses cannot change their legally recognized titles or designations through experience or continuing education; these changes may only be achieved through additional formal educational preparation and meeting all legal requirements to use that title and practice in that specialty set forth by the BON.

The following questions may help to clarify whether a new activity/procedure can be incorporated into an individual's scope of practice:

  • Is it consistent with one's professional scope of practice?
  • Is it consistent with statutory or regulatory laws?
  • Is it consistent with one's education in the role and specialty?
  • Is it consistent with the scope of one's recognized title or does it evolve into another advanced practice title recognized by the board requiring additional formal education and legal recognition?
  • Is it consistent with the Standards of Nursing Practice outlined in Board Rule 217.11?
  • Is it consistent with evidence-based care?
  • Is it consistent with reasonable and prudent practice?
  • Are you willing to accept accountability and liability for the activity and outcomes?

Adding New Procedures and/or Patient Care Activities

When adding a new procedure or patient care activity, the advanced practice nurse should maintain documentation of additional education and competency. An advanced practice nurse may add new procedures or patient care activities to his/her individual scope of practice by using the following suggestions:

  • Identify the benefit for a new patient care activity, taking into consideration consumer demand, standards for safe practice, and interest of the advanced practice nurse.
  • Ensure that state or federal statutes and regulations do not constrain the advanced practice nurse from incorporating the activity into practice.
  • Identify established professional standards, if available, supporting the performance of the new activity.
  • Establish goals and methods for learning that encompass knowledge and skills acquisition through which competence is attained.
  • Demonstrate competent performance of the procedure/activity.
  • Maintain records that reflect the acquisition and maintenance of competency.

The Texas Board of Nursing recognizes that individual scopes of practice will vary and that what is within the individual scope of practice for one advanced practice nurse may not be within the individual scope of practice for another advanced practice nurse authorized to practice in the same role and specialty. However, it is important to keep in mind that the Board holds each advanced practice registered nurse accountable for knowing and practicing within his/her professional and individual scope of practice.

Adopted by the Texas Board of Nursing, 10/20/2005

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