Course Description

MANDATORY TEXAS NURSING CEU. This 2 contact hour course meets Texas BON requirement for continuing education on nursing jurisprudence and nursing ethics. This course covers the following topics:

• Texas Nursing Practice Act

• Board's rules (including §217.11, Standards of Nursing Practice),

• Board's position statements,

• principles of nursing ethics

• professional boundaries

Introduction

This comprehensive course provides an in-depth exploration of the legal and ethical frameworks governing nursing practice in Texas. By understanding the Texas Nursing Practice Act, the Board's rules, and position statements, nurses can ensure they uphold the highest standards of professional conduct and patient care. The course places a strong emphasis on the principles of nursing ethics, which guide nurses in making sound, ethical decisions in their daily practice. Additionally, the course addresses the concept of professional boundaries, helping nurses navigate the complexities of maintaining appropriate relationships with patients and colleagues.

Texas Nursing Practice Act

Mission

The mission of the Texas Board of Nursing (BON or Board) is to protect and promote the welfare of the people of Texas by ensuring that each person holding a license as a nurse in this state is competent to practice safely. The Board fulfills its mission through the regulation of the practice of nursing and the approval of nursing educational programs. This mission, derived from the Nursing Practice Act, supersedes the interest of any individual, the nursing profession, or any special interest group.

Overview of Texas Nursing Practice Act

The Texas Nursing Practice Act is a set of laws and regulations that govern the practice of nursing in the state of Texas. It outlines the scope of practice for nurses, as well as the standards of care that must be followed. Understanding the Nursing Practice Act is essential for all nurses working in Texas, as it ensures that they are providing safe and competent care to their patients.

Any person practicing or offering to practice nursing in the state of Texas is required to have a license. Your license must be renewed every two years in order to continue practicing in Texas. Once licensed, you are authorized to use the title “RN” or “LVN” and are required to wear a name tag identifying yourself as a “RN” or “LVN” while providing patient care. 

You must keep the Board informed of your current address at all times. Changes to your address or a name change must be submitted in the Texas Nurse Portal accessible through the Board’s website (see 22 TAC 217.7). Failure to do so can result in a lapse of your license and potential disciplinary action. Nurses practicing in this state are expected to know and practice in compliance with chapters 301, 303, and 304 of the TOC and with the Board’s Rules. 

Chapter 301 of the Texas Nursing Practice Act sets forth the definitions and foundational concepts that are pivotal to understanding and regulating the practice of nursing within the state. It delineates the roles, responsibilities, and scope of practice for nursing professionals, ensuring that all actions taken are in alignment with established standards of care and patient safety protocols. This chapter critically defines key terms such as the Texas Board of Nursing, the chief nursing officer, and the patient safety committee, each playing an integral role in maintaining and enhancing the quality of nursing services provided. It also outlines what constitutes professional nursing, emphasizing the importance of specialized judgment, skill, and knowledge in undertaking nursing duties.

Sec. 301.002 Definitions

1. Board means the Texas Board of Nursing. The chief nursing officer means the registered nurse who is administratively responsible for the nursing services at a facility. The patient safety committee means a committee established by an association, school, agency, health care facility, or other organization to address issues relating to patient safety, including: 

(A) the entity’s medical staff composed of individuals licensed under Subtitle B; or 

(B) a medical committee under Subchapter D, Chapter 161, Health and Safety Code (Sec 303.001).

2. Professional nursing means the performance of an act that requires substantial specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of professional nursing. The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures. 

Professional nursing involves:

(A) the observation, assessment, intervention, evaluation, rehabilitation, care and counsel, or health teachings of a person who is ill, injured, infirm, or experiencing a change in normal health processes.

 (B) the maintenance of health or prevention of illness.

(C) the administration of a medication or treatment as ordered by a physician, podiatrist, or dentist.

(D) the supervision or teaching of nursing.

(E) the administration, supervision, and evaluation of nursing practices, policies, and procedures. 

(F) the requesting, receiving, signing for, and distribution of prescription drug samples to patients at practices at which an advanced practice registered nurse is authorized to sign prescription drug orders as provided by Subchapter B, Chapter 157.

(G) the performance of an act delegated by a physician under Section 157.0512, 157.054, 157.058, or 157.059; and 

(H) the development of the nursing care plan.

3. Nurse means a person required to be licensed under this chapter to engage in professional or vocational nursing.

4. Nursing means professional or vocational nursing. 

5. Vocational nursing means a directed scope of nursing practice, including the performance of an act that requires specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of vocational nursing. The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures. 

Vocational nursing involves: 

(A) collecting data and performing focused nursing assessments of the health status of an individual;

(B) participating in the planning of the nursing care needs of an individual;

 (C) participating in the development and modification of the nursing care plan; 

(D) participating in health teaching and counseling to promote, attain, and maintain the optimum health level of an individual; 

(E) assisting in the evaluation of an individual’s response to a nursing intervention and the identification of an individual’s needs; and

(F) engaging in other acts that require education and training, as prescribed by board rules and policies, commensurate with the nurse’s experience, continuing education, and demonstrated competency

Sec. 301.051. 

Board Membership:

The Texas Board of Nursing consists of 13 members appointed by the governor with the advice and consent of the senate as follows: 

(1) Six nurse members, including: one advanced practice nurse, two registered nurses who are not advanced practice nurses or members of a nurse faculty, and three vocational nurses who are not members of a nurse faculty.

(2) Three members who are nurse faculty members of schools of nursing. One of whom is a nurse faculty member of a school of nursing offering a baccalaureate degree program in preparing registered nurses, one of whom is a nurse faculty member of a school of nursing offering an associate degree program in preparing registered nurses, and one of whom is a nurse faculty member of a school of nursing at an institution of higher education preparing vocational nurses. 

(3) Four members who represent the public. Appointments to the Board shall be made without regard to the race, color, disability, sex, religion, age, or national origin of the appointee.

General Powers and Duties of Board 

Sec. 301.151.: General Rulemaking Authority.

 The Board may adopt and enforce rules consistent with this chapter and necessary to: 

(1) perform its duties and conduct proceedings before the Board; 

(2) regulate the practice of professional nursing and vocational nursing; 

(3) establish standards of professional conduct for license holders under this chapter; and

 (4) determine whether an act constitutes the practice of professional nursing or vocational nursing.

Sec. 301.152. Rules Regarding Specialized Training

(a) In this section, “advanced practice registered nurse” means a registered nurse licensed by the board to practice as an advanced practice registered nurse on the basis of completion of an advanced educational program. The term includes a nurse practitioner, nurse midwife, nurse anesthetist, and clinical nurse specialist. The term is synonymous with “advanced nurse practitioner” and “advanced practice nurse.”

(b) The board shall adopt rules to: 

(1) license a registered nurse as an advanced practice registered nurse; 

(2) establish: 

(A) any specialized education or training, including pharmacology, that an advanced practice registered nurse must have to prescribe or order a drug or device as delegated by a physician under Section 157.0512 or 157.054; 

(B) a system for approving an advanced practice registered nurse to prescribe or order a drug or device as delegated by a physician under Section 157.0512 or 157.054 on the receipt of evidence of completing the specialized education and training requirement under Paragraph (A); and 

(C) a system for issuing a prescription authorization number to an advanced practice registered nurse approved under Paragraph (B); and 

(3) concurrently renew any license or approval granted to an advanced practice registered nurse under this subsection and a license renewed by the advanced practice registered nurse under Section 301.301. 

(c) At a minimum, the rules adopted under Subsection (b)(2) must: 

(1) require completion of pharmacology and related pathophysiology education for initial approval; and 

(2) require continuing education in clinical pharmacology and related pathophysiology in addition to any continuing education otherwise required under Section 301.303. 

(d) The signature of an advanced practice registered nurse attesting to the provision of a legally authorized service by the advanced practice registered nurse satisfies any documentation requirement for that service established by a state agency.

License Requirements 

Sec. 301.251. License Required. 

(a) A person may not practice or offer to practice professional nursing or vocational nursing in this state unless the person is licensed as provided by this chapter. 

(b) Unless the person holds a license under this chapter, a person may not use, in connection with the person’s name: 

(1) the title “Registered Nurse,” “Professional Nurse,” “Licensed Vocational Nurse,” “Vocational Nurse,” “Licensed Practical Nurse,” “Practical Nurse,” or “Graduate Nurse”; 

(2) the abbreviation “R.N.,” “L.V.N.,” “V.N.,” “L.P.N.,” or “P.N.”; or 

(3) any other designation tending to imply that the person is a licensed registered nurse or vocational nurse. 

(c) This section does not apply to a person entitled to practice nursing in this state under Chapter 304. 

(d) Unless the person holds a license under this chapter, a person may not use, in connection with the person’s name: 

(1) the title nurse; or 

(2) any other designation tending to imply that the person is licensed to provide nursing care.

Sec. 301.2511. Criminal History Record Information for License Applicants. 

(a) An applicant for a vocational nurse license, registered nurse license, or advanced practice registered nurse must submit to the Board, in addition to satisfying the other requirements of this subchapter, a complete and legible set of fingerprints, on a form prescribed by the Board, for the purpose of obtaining criminal history record information from the Department of Public Safety and the Federal Bureau of Investigation. 

(b) The Board may deny a license to an applicant who does not comply with the requirement of Subsection (a). Issuance of a license by the Board is conditioned on the Board obtaining the applicant’s criminal history record information under this section. 

(c) The board by rule shall develop a system for obtaining criminal history record information for a person accepted for enrollment in a nursing educational program that prepares the person for licensure as a vocational nurse, registered, or advanced practice registered nurse by requiring the person to submit to the board a set of fingerprints that meets the requirements of Subsection (a). The board may develop a similar system for an applicant for enrollment in a nursing educational program. The board may require payment of a fee by a person who is required to submit a set of fingerprints under this subsection.

Sec. 301.252. License Application. 

(a) Each applicant for a registered nurse license or a vocational nurse license must submit to the board a sworn application that demonstrates the applicant’s qualifications under this chapter, accompanied by evidence that the applicant: 

(1) has good professional character related to the practice of nursing; 

(2) has successfully completed a program of professional or vocational nursing education approved under Section 301.157(d); and 

(3) has passed the jurisprudence examination approved by the board as provided by Subsection (a-1). 

(a-1) The jurisprudence examination shall be conducted on the licensing requirements under this chapter and board rules and other laws, rules, or regulations applicable to the nursing profession in this state. The board shall adopt rules for the jurisprudence examination under Subsection (a)(3) regarding: 

(1) the development of the examination; 17 

(2) applicable fees; 

(3) administration of the examination; 

(4) reexamination procedures; 

(5) grading procedures; and 

(6) notice of results.

(a-2) An applicant who provides satisfactory evidence that the applicant has not committed a violation of this chapter or a rule adopted under this chapter is considered to have good professional character related to the practice of nursing. A determination by the board that an applicant does not have good professional character related to the practice of nursing must be based on a showing by the board of a clear and rational connection between a violation of this chapter or a rule adopted under this chapter and the applicant’s ability to effectively practice nursing. 

(b) The board may waive the requirement of Subsection (a)(2) for a vocational nurse applicant if the applicant provides satisfactory sworn evidence that the applicant has completed an acceptable level of education in: 

(1) a professional nursing school approved under Section 301.157(d); or 

(2) a school of professional nurse education located in another state or a foreign country. 

(c) The board by rule shall determine acceptable levels of education under Subsection (b).

Examination & Results

An applicant is entitled to take the examination prescribed by the Board if the Board determines that the applicant meets the qualifications required and the applicant pays the fees required by the Board. Each examination administered under this section must be prepared by a national testing service or the board. The examination shall be designed to determine the fitness of the applicant to practice professional nursing or vocational nursing. The Board shall determine the criteria that determine a passing score on the examination. The criteria may not exceed those required by the majority of the states. A written examination prepared, approved, or offered by the Board, including a standardized national examination, must be validated by an independent testing professional. The Board shall notify each examinee of the results of the examination not later than the 30th day after the date the examination is administered. If an examination is graded or reviewed by a national testing service, the Board shall notify each examinee of the results of the examination not later than the 14th day after the date the Board receives the results from the testing service. If the notice of the examination results graded or reviewed by a national testing service will be delayed for longer than 90 days after the examination date, the Board shall notify each examinee of the reason for the delay before the 90th day. If requested in writing by a person who fails an examination, the Board shall provide the person an analysis of the person’s performance on the examination.

Reexamination

The Board by rule shall establish conditions under which an applicant who fails an examination may retake the examination. For an applicant who fails the examination two or more times, the Board may require the applicant to fulfill additional educational requirements or deny the applicant the opportunity to retake the examination.

License Renewal 

(a) The Board by rule may adopt a system under which licenses expire on various dates during the year. 

(b) A person may renew an unexpired license issued under this chapter on payment to the board of the required renewal fee before the expiration date of the license and compliance with any other renewal requirements adopted by the board. A person whose license has expired may not engage in activities that require a license until the license has been renewed. 

(c) A person whose license has been expired for 90 days or less may renew the license by paying to the Board the required renewal fee and a late fee in the amount considered appropriate by the board to encourage timely renewal. 

(c-1) A person whose license has been expired for more than 90 days but less than one year may renew the license by paying to the Board all unpaid renewal fees and a late fee that is equal to twice the amount of a late fee under Subsection (c). 

(d) The Board by rule shall set a length of time beyond which an expired license may not be renewed. The Board by rule may establish additional requirements that apply to the renewal of a license that has been expired for more than one year but less than the time limit set by the Board beyond which a license may not be renewed. The person may obtain a new license by submitting to reexamination and complying with the requirements and procedures for obtaining an original license. 

(e) At least 30 days before the expiration of the person’s license, the Board shall send written notice of the impending license expiration to the person at the person’s last known address according to the records of the Board. 

(f) A registered nurse who practices professional nursing or a vocational nurse who practices vocational nursing after the expiration of the nurse’s license is an illegal practitioner whose license may be revoked or suspended

Continuing Competency. 

(a) The Board may recognize, prepare, or implement continuing competency programs for license holders under this chapter and may require participation in continuing competency programs as a condition of renewal of a license. The programs may allow a license holder to demonstrate competency through various methods, including: 

(1) completion of targeted continuing education programs; and 

(2) consideration of a license holder’s professional portfolio, including certifications held by the license holder. 

(b) The Board may not require participation in more than a total of 20 hours of continuing education in a two-year licensing period. 

(c) If the Board requires participation in continuing education programs as a condition of license renewal, the Board by rule shall establish a system for the approval of programs and providers of continuing education. 

(d) [Repealed by Acts 2007.] 

(e) The Board may adopt other rules as necessary to implement this section. 

(f) The Board may assess each program and provider under this section a fee in an amount that is reasonable and necessary to defray the costs incurred in approving programs and providers. 

(g) The Board by rule may establish guidelines for targeted continuing education required under this chapter. The rules adopted under this subsection must address:  

(1) the nurses who are required to complete the targeted continuing education program;

(2) the type of courses that satisfy the targeted continuing education requirement;

(3) the time in which a nurse is required to complete the targeted continuing education; 

(4) the frequency with which a nurse is required to meet the targeted continuing education requirement; and 

(5) any other requirement considered necessary by the Board.

Continuing Education in Tick-Borne Diseases. (a) As part of the continuing education requirements under Section 301.303, a license holder whose practice includes the treatment of tick-borne diseases shall be encouraged to participate, during each two-year licensing period, in continuing education relating to the treatment of tick-borne diseases. Rules adopted under this section must provide that continuing education courses representing an appropriate spectrum of relevant medical clinical treatment relating to tick-borne diseases qualify as approved continuing education courses for license renewal. 

Continuing Education in Nursing Jurisprudence and Nursing Ethics.

 As part of a continuing competency program under Section 301.303, a license holder shall complete at least two hours of continuing education relating to nursing jurisprudence and nursing ethics before the end of every third two-year licensing period. The board may not require a license holder to complete more than four hours of continuing education under this section.  

Forensic Evidence Collection Component in Continuing Education. 

As part of continuing education requirements under Section 301.303, a license holder who is employed to work in an emergency room setting and who is required under Board rules to comply with this section shall complete at least two hours of continuing education relating to forensic evidence collection not later than: (1) September 1, 2008; or (2) the second anniversary of the initial issuance of a license under this chapter to the license holder. The continuing education required under Subsection (a) must be part of a program approved under Section 301.303(c).

Continuing Education in Older Adult or Geriatric Care.

 As part of a continuing competency program under Section 301.303, a license holder whose practice includes older adult or geriatric populations shall complete at least two hours of continuing education relating to older adult or geriatric populations or maintain certification in an area of practice relating to older adult or geriatric populations. The board may not require a license holder to complete more than six hours of continuing education under this section. 

Continuing Education in Human Trafficking Prevention. 

 As part of a continuing competency program under Section 301.303, a license holder who provides direct patient care shall complete a human trafficking prevention course approved by the executive commissioner of the Health and Human Services Commission under Section 116.002. 

Protection for Refusal to Engage in Certain Conduct

(a) A person may not suspend, terminate, or otherwise discipline, discriminate against, or retaliate against: 

(1) a nurse who refuses to engage in an act or omission as provided by Subsection (a-1); or

 (2) a person who advises a nurse of the nurse’s rights under this section. 

(a-1) A nurse may refuse to engage in an act or omission relating to patient care that would constitute grounds for reporting the nurse to the Board under Subchapter I, that constitutes a minor incident, or that violates this chapter or a board rule if the nurse notifies the person at the time of the refusal that the reason for refusing is that the act or omission: 

(1) constitutes grounds for reporting the nurse to the Board; or 

(2) is a violation of this chapter or a rule of the Board. 

(b) An act by a person under Subsection (a) does not constitute a violation of this section if a nursing peer review committee under Chapter 303 determines:

 (1) that the act or omission the nurse refused to engage in was not: 

(A) conduct reportable to the board under Section 301.403; 

(B) a minor incident; or 

(C) a violation of this chapter or a board rule; or 

(2) that: 

(A) the act or omission in which the nurse refused to engage was conduct reportable to the board, a minor incident, or a violation of this chapter or a board rule; and 

(B) the person: 

(i) rescinds any disciplinary or discriminatory action taken against the nurse;

(ii) compensates the nurse for lost wages; and 

(iii) restores to the nurse any lost benefits. 

(c) A nurse’s rights under this section may not be nullified by a contract. 

(d) An appropriate licensing agency may take action against a person who violates this section. 

(e) [Repealed by Acts 2007] 

(f) A violation of this section is subject to Section 301.413. 

 301.353. Supervision of Vocational Nurse.

 The practice of vocational nursing must be performed under the supervision of a registered nurse, physician, physician assistant, podiatrist, or dentist.

Reporting Violations and Patient Care Concerns 

Sec. 301.401. Definitions. 

(1) Conduct subject to reporting means conduct by a nurse that: 

(A) violates this chapter or a board rule and contributed to the death or serious injury of a patient; 

(B) causes a person to suspect that the nurse’s practice is impaired by chemical dependency or drug or alcohol abuse; 

(C) constitutes abuse, exploitation, fraud, or a violation of professional boundaries; or 

(D) indicates that the nurse lacks knowledge, skill, judgment, or conscientiousness to such an extent that the nurse’s continued practice of nursing could reasonably be expected to pose a risk of harm to a patient or another person, regardless of whether the conduct consists of a single incident or a pattern of behavior. 

(2) Minor incident means conduct by a nurse that does not indicate that the nurse’s continued practice poses a risk of harm to a patient or another person. This term is synonymous with “minor error” or “minor violation of this chapter or board rule.”

(3) Nursing educational program means an educational program that is considered approved by the Board that may lead to an initial license as a registered nurse or vocational nurse. 

(4) Nursing student means an individual who is enrolled in a nursing educational program

Good Faith Report by Nurse

A report is considered to be made in good faith if the person reporting believed that the report was required or authorized and There was a reasonable factual or legal basis for that belief.

Mandatory Report by Nurse

 A nurse shall report to the Board if the nurse has reasonable cause to suspect that another nurse has engaged in conduct subject to reporting or the ability of a nursing student to perform the services of the nursing profession would be, or would reasonably be expected to be, impaired by chemical dependency.

A report by a nurse must be written and signed and include the identity of the nurse or student and any additional information required by the Board. Instead of reporting to the Board a nurse may make a report to a nursing peer review committee or to the nursing educational program in which the student is enrolled. A person may not suspend or terminate the employment of, or otherwise discipline, discriminate against, or retaliate against, a person who reports in good faith or advises a nurse of the nurse’s rights and obligations under this section.

Effect of Failure to Report.

(a) A person is not liable in a civil action for failure to file a report required by this subchapter.

 (b) The appropriate state licensing agency may take action against a person regulated by the agency for a failure to report as required by this subchapter. 

Nursing Peer Review 

Nursing peer review committee means a committee established under the authority of the governing body of a national, state, or local nursing association, a school of nursing, the nursing staff of a hospital, health science center, nursing home, home health agency, temporary nursing service, or other health care facility, or state agency or political subdivision for the purpose of conducting peer review. The committee includes an employee or agent of the committee, including an assistant, an investigator, an intervenor, an attorney, and any other person who serves the committee in any capacity. 

Patient safety committee means a committee established by an association, school, agency, health care facility, or other organization to address issues relating to patient safety, including: 

(A) the entity’s medical staff composed of individuals licensed under Subtitle B; or 

(B) a medical committee under Subchapter D, Chapter 161, Health and Safety Code.  

Peer review means the evaluation of nursing services, the qualifications of a nurse, the quality of patient care rendered by a nurse, the merits of a complaint concerning a nurse or nursing care, and a determination or recommendation regarding a complaint. The term includes: 

(A) the evaluation of the accuracy of a nursing assessment and observation and the appropriateness and quality of the care rendered by a nurse; 

(B) a report made to a nursing peer review committee concerning an activity under the committee’s review authority; 

(C) a report made by a nursing peer review committee to another committee or to the Board as permitted or required by law; 

(D) implementation of a duty of a nursing peer review committee by a member, an agent, or an employee of the committee; and 

(E) the provision of information, advice, and assistance to nurses and other persons relating to: 

  (i) the rights and obligations of and protections for nurses who raise care concerns     or report under Chapter 301 or other state or federal law; 

  (ii) the rights and obligations of and protections for nurses who request nursing peer review under this chapter;

  (iii) nursing practice and patient care concerns; and

  (iv) the resolution of workplace and practice questions relating to nursing and patient care.

SECTION 217.11. Standards of Nursing Practice

The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted.

(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall:

(A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice;

(B) Implement measures to promote a safe environment for clients and others;

(C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same;

(D) Accurately and completely report and document:

(i) the client's status including signs and symptoms;

(ii) nursing care rendered;

(iii) physician, dentist or podiatrist orders;

(iv) administration of medications and treatments;

(v) client response(s); and

(vi) contacts with other health care team members concerning significant events regarding client's status;

(E) Respect the client's right to privacy by protecting confidential information unless required or allowed by law to disclose the information;

(F) Promote and participate in education and counseling to a client(s) and, where applicable, the family/significant other(s) based on health needs;

(G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices;

(H) Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations;

(I) Notify the appropriate supervisor when leaving a nursing assignment;

(J) Know, recognize, and maintain professional boundaries of the nurse-client relationship;

(K) Comply with mandatory reporting requirements of Texas Occupations Code Chapter 301 (Nursing Practice Act), Subchapter I, which include reporting a nurse:

(i) who violates the Nursing Practice Act or a board rule and contributed to the death or serious injury of a patient;

(ii) whose conduct causes a person to suspect that the nurse's practice is impaired by chemical dependency or drug or alcohol abuse;

(iii) whose actions constitute abuse, exploitation, fraud, or a violation of professional boundaries; or

(iv) whose actions indicate that the nurse lacks knowledge, skill, judgment, or conscientiousness to such an extent that the nurse's continued practice of nursing could reasonably be expected to pose a risk of harm to a patient or another person, regardless of whether the conduct consists of a single incident or a pattern of behavior.

(v) except for minor incidents (Texas Occupations Code §§301.401(2), 301.419, 22 TAC §217.16), peer review (Texas Occupations Code §§301.403, 303.007, 22 TAC §217.19), or peer assistance if no practice violation (Texas Occupations Code §301.410) as stated in the Nursing Practice Act and Board rules (22 TAC Chapter 217).

(L) Provide, without discrimination, nursing services regardless of the age, disability, economic status, gender, national origin, race, religion, health problems, or sexual orientation of the client served;

(M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications;

(N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment;

(O) Implement measures to prevent exposure to infectious pathogens and communicable conditions;

(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;

(Q) Consult with, utilize, and make referrals to appropriate community agencies and health care resources to provide continuity of care;

(R) Be responsible for one's own continuing competence in nursing practice and individual professional growth;

(S) Make assignments to others that take into consideration client safety and that are commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made;

(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;

(U) Supervise nursing care provided by others for whom the nurse is professionally responsible; and

(V) Ensure the verification of current Texas licensure or other Compact State licensure privilege and credentials of personnel for whom the nurse is administratively responsible, when acting in the role of nurse administrator.

(2) Standards Specific to Vocational Nurses. 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. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and:

(A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care by:

(i) collecting data and performing focused nursing assessments;

(ii) participating in the planning of nursing care needs for clients;

(iii) participating in the development and modification of the comprehensive nursing care plan for assigned clients;

(iv) implementing appropriate aspects of care within the LVN's scope of practice; and

(v) assisting in the evaluation of the client's responses to nursing interventions and the identification of client needs;

(B) Shall assign specific tasks, activities and functions to unlicensed personnel commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made and shall maintain appropriate supervision of unlicensed personnel.

(C) May perform other acts that require education and training as prescribed by board rules and policies, commensurate with the licensed vocational nurse's experience, continuing education, and demonstrated licensed vocational nurse competencies.

(3) Standards Specific to Registered Nurses. The registered nurse shall assist in the determination of healthcare needs of clients and shall:

(A) Utilize a systematic approach to provide individualized, goal-directed, nursing care by:

(i) performing comprehensive nursing assessments regarding the health status of the client;

(ii) making nursing diagnoses that serve as the basis for the strategy of care;

(iii) developing a plan of care based on the assessment and nursing diagnosis;

(iv) implementing nursing care; and

(v) evaluating the client's responses to nursing interventions;

(B) Delegate tasks to unlicensed personnel in compliance with Chapter 224 of this title, relating to clients with acute conditions or in acute are environments, and Chapter 225 of this title, relating to independent living environments for clients with stable and predictable conditions.

(4) Standards Specific to Registered Nurses with Advanced Practice Authorization. Standards for a specific role and specialty of advanced practice nurse supersede standards for registered nurses where conflict between the standards, if any, exist. In addition to paragraphs (1) and (3) of this subsection, a registered nurse who holds authorization to practice as an advanced practice nurse (APN) shall:

(A) Practice in an advanced nursing practice role and specialty in accordance with authorization granted under Board Rule Chapter 221 of this title (relating to practicing in an APN role; 22 TAC Chapter 221) and standards set out in that chapter.

(B) Prescribe medications in accordance with prescriptive authority granted under Board Rule Chapter 222 of this title (relating to APNs prescribing; 22 TAC Chapter 222) and standards set out in that chapter and in compliance with state and federal laws and regulations relating to prescription of dangerous drugs and controlled substances.

Source Note: The provisions of this §217.11 adopted to be effective September 28, 2004, 29 TexReg 9192; amended to be effective November 15, 2007, 32 TexReg 8165

Texas Board of Nursing Board Position Statements:

 Board Position Statements do not have the force of law but are a means of providing direction for nurses on issues of concern to the Board relevant to the protection of the public. Each position statement is meant to provide guidance in the context of the totality of the position statement. Board position statements are reviewed annually for relevance and accuracy to current practice, the Nursing Practice Act, and Board rules.

Professional Nursing

A registered nurse (RN) is any person licensed in Texas to practice professional nursing. The practice of professional nursing means the performance of an act that requires substantial specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of professional nursing.

Unless licensed as an advanced practice registered nurse (see “Advanced Practice Nursing” below), the RN scope of practice does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures.

Nurses Carrying Out Orders from Physician Assistants 

The purpose of this position statement is to provide guidance to nurses with regard to carrying out orders from Physician Assistants (PAs). The Nursing Practice Act (NPA) includes the "administration of medications or treatments ordered by a physician, podiatrist or dentist" as part of the practice of nursing. There are no other healthcare professionals listed thus leading to questions regarding nurses carrying out orders from other licensed healthcare providers. Although PAs are not included in the NPA, the Board recognizes that nurses work collaboratively with PAs to provide patient care in various practice settings. The PA is licensed and regulated by the Texas Physician Assistant Board. PAs may provide medical aspects of care, including ordering or prescribing medications and treatments, as delegated by a physician consistent with laws, rules and regulations applicable to the PAs’ practice including those of the Texas Medical Board (TMB) Chapter 193. A physician is not required to be present at all times at the location where the PA is providing care and orders are not required to be countersigned by the physician. A nurse may carry out these orders. As with any order, the nurse must seek clarification if he/she believes the order or treatment is inaccurate, nonefficacious or contraindicated by consulting with the PA and physician as appropriate. A list of physician assistants credentialed by the medical staff and policies directing their practice should be available to the nursing staff.

IV THERAPY

Basic competency in management of intravenous (IV) lines and/or intravenous therapy is not a given for any specific LVN licensee. Instruction and skill evaluation relating to LVNs performing insertion of peripheral IV catheters and/or administering IV fluids and medications as prescribed by an authorized practitioner may allow an LVN to expand their scope of practice to include intravenous therapy.

It is the opinion of the Board that the LVN shall not engage in IV therapy and/or administration of IV push medications until successful completion of a validation course that instructs the LVN in the knowledge and skills applicable to the LVN’s IV therapy practice. The LVN who chooses to engage in IV therapy must first have been instructed in the principles of IV therapy congruent with prevailing nursing practice standards.

Nursing Ethics

The Difference Between Laws and Ethics in Nursing

While both laws and ethics guide nursing practice, they serve different purposes and operate in distinct ways.

Laws are concrete rules and regulations established by governmental bodies and regulatory agencies. These laws are enforceable by legal means and are designed to protect public health and safety, ensure competent and ethical care, and set standards for nursing education, licensure, and practice. Violating these laws can lead to legal consequences, including fines, loss of licensure, or even criminal charges.

In contrast, ethics in nursing are based on moral principles that govern the behavior and professional conduct of nurses. These principles help nurses determine the rightness or wrongness of their actions, as well as the goodness or badness of their motives and outcomes. Ethical guidelines are not legally enforceable but are critical for ensuring that nurses provide morally sound and respectful care.

Nursing ethics include core principles such as autonomy, beneficence, non-maleficence, and justice. Autonomy respects the patient's right to make informed decisions about their care. Beneficence involves acting in the best interest of the patient, while non-maleficence means avoiding harm. Justice ensures that care is provided fairly and without discrimination.

Adhering to ethical principles helps nurses navigate complex situations, make informed decisions, and maintain the trust and respect of their patients and colleagues. Ethical practice in nursing is essential for delivering high-quality care and fostering a therapeutic and professional environment.

Code of Ethics in Nursing

The Code of Ethics in Nursing is a foundational document that outlines the ethical obligations and duties of every nurse. This code provides a framework for ethical practice and serves as a guide to help nurses navigate the moral complexities of healthcare. It emphasizes the importance of respecting patient rights, maintaining patient confidentiality, and advocating for patient welfare.

Adhering to the Code of Ethics is crucial for fostering a culture of trust, respect, and professionalism in nursing practice. It ensures that nurses are equipped to handle ethical dilemmas and provide compassionate, patient-centered care.

The Nursing Code of Ethics consists of nine provisions designed to guide nurses in their professional conduct. Here are the nine provisions:

1. Respect for Others: Nurses must practice with compassion and respect for the inherent dignity, worth, and unique attributes of every person.

2. Commitment to the Patient: The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population.

3. Advocacy for the Patient: Nurses advocate for the rights, health, and safety of the patient.

4. Authority, Accountability, and Responsibility: Nurses bear the authority, accountability, and responsibility for nursing practice; make decisions; and take action consistent with their obligation to promote health and provide optimal care.

5. Duties to Self and Others: Nurses owe the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.

6. Ethical Environment: Nurses establish, maintain, and improve the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.

7. Advancement of the Profession: Nurses, through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy, advance the profession.

8. Collaboration: Nurses collaborate with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.

9. Social Justice: Nurses must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

These provisions are meant to ensure that nurses uphold the highest ethical standards in their practice, contributing to the overall well-being of patients and the integrity of the nursing profession.

Ethical Dilemmas

Ethical dilemmas in nursing often arise in situations where there are conflicting values, duties, or rights. These dilemmas can challenge a nurse's ability to provide care that is both ethically and legally sound. Common ethical dilemmas include issues related to end-of-life care, patient autonomy versus family wishes, allocation of limited resources, and maintaining patient confidentiality in complex situations.

For example, a nurse might face a dilemma when a patient with a terminal illness refuses life-sustaining treatment, but the patient's family insists on continuing all possible interventions. The nurse must balance respecting the patient's autonomy with considering the family's concerns and the ethical principle of beneficence.

Another dilemma could involve the distribution of scarce resources, such as during a public health crisis. Nurses may have to decide how to allocate limited medical supplies or prioritize patients for treatment, ensuring fairness and justice while striving to provide the best possible care.

In such situations, adhering to the Code of Ethics is crucial for fostering a culture of trust, respect, and professionalism in nursing practice. It ensures that nurses are equipped to handle ethical dilemmas and provide compassionate, patient-centered care.

Steps to Resolve Ethical Dilemmas

Resolving ethical dilemmas in nursing requires a structured approach that ensures comprehensive consideration of all relevant factors. Below are the key steps to help guide nurses through the process:

1. Identify the Dilemma: Clearly define the ethical dilemma. Understand the conflicting values, duties, and rights involved in the situation.

2. Gather Information: Collect all pertinent information, including clinical data, patient preferences, family dynamics, and relevant legal and ethical guidelines.

3. Consider Values and Principles: Reflect on the core nursing values and ethical principles such as autonomy, beneficence, non-maleficence, and justice. Evaluate how these principles apply to the situation.

4. Explore Options: Identify possible courses of action. Consider the potential outcomes and implications of each option for the patient, family, and healthcare team.

5. Consult with Others: Engage in discussions with colleagues, ethics committees, and other healthcare professionals. Diverse perspectives can provide valuable insights and support in decision-making.

6. Make a Decision: Based on the gathered information and consultations, make an informed and ethically sound decision. Ensure that the decision aligns with both professional standards and the patient's best interests.

7. Implement the Decision: Carry out the chosen course of action with compassion and professionalism. Communicate clearly with all parties involved to ensure understanding and cooperation.

8. Evaluate the Outcome: After implementation, assess the outcomes of the decision. Reflect on what was learned from the situation and how it can inform future practice.

9. Document the Process: Thoroughly document the decision-making process, including the rationale for the chosen action, consultations, and the outcomes. This helps maintain transparency and accountability.

By following these steps, nurses can navigate ethical dilemmas with confidence and integrity, ensuring that their actions uphold the highest standards of ethical nursing practice.

Professional Boundaries 

Establishing and maintaining professional boundaries in nursing practice is essential for fostering a therapeutic and trusting relationship between the nurse and the patient. These boundaries define the limits of the nurse-patient relationship and help ensure that care is delivered in a manner that respects the patient's dignity, privacy, and autonomy.

Importance of Professional Boundaries

Professional boundaries serve several critical functions in nursing practice:

• Protection of the Patient: Boundaries protect patients from exploitation, favoritism, and breaches of confidentiality. They ensure that the nurse's actions are always in the patient's best interests.

• Maintaining Professionalism: Adhering to boundaries helps nurses maintain a professional demeanor and avoid behaviors that could be misunderstood or seen as inappropriate.

• Personal Well-being: Boundaries protect nurses from becoming over-involved or emotionally entangled in their patients' lives, which can lead to burnout and compassion fatigue.

Establishing Boundaries

Nurses can establish and maintain professional boundaries by:

• Clear Communication: Communicate openly and honestly with patients about the nature and limits of the nurse-patient relationship.

• Self-awareness: Be aware of personal feelings, biases, and vulnerabilities that might affect interactions with patients.

• Education and Training: Participate in ongoing education and training on professional boundaries and ethical practice.

• Seeking Guidance: When in doubt, seek guidance from colleagues, supervisors, or ethics committees.

Common Boundary Issues

Some common boundary issues in nursing practice include:

• Gift-giving: Accepting or giving gifts can create a sense of obligation and blur the lines of the professional relationship.

• Dual Relationships: Engaging in relationships outside of the nurse-patient context, such as social or financial relationships, can compromise objectivity and professional judgment.

• Personal Disclosures: Sharing too much personal information with patients can shift the focus away from the patient's needs and create confusion about the role of the nurse.

By understanding and adhering to professional boundaries, nurses can provide high-quality, ethical care that prioritizes the well-being of their patients while maintaining their own professional integrity and personal health.

Conclusion

The Texas Nursing Practice Act outlines the regulations for the state Board of Nursing, which, along with the law, establishes the standards for competent nursing practice and promotes patient safety for all nurses practicing in the state. Competent nursing practice involves providing care that meets both ethical and legal standards. By ensuring that all nurses follow these guidelines, the Board of Nursing fulfills its mission to protect and improve the health of all patients and citizens through safe nursing practice.