Upon successful completion of this course, continuing education hours will be awarded as follows:Nurses: 2 Contact Hours**Western Schools is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Texas Nursing Jurisprudence and Ethics

2nd Edition

By

Leanna Marchand, BSN, RN, JD

P.O. Box 1930Brockton, MA 02303800-438-8888

Nurse Planner: Deborah A. Bauer, BSN, MSN, RNThe planner who worked on this continuing education activity has disclosed that she has no significant financial or other conflicts of interest pertaining to this course book.

Copy Editor: Jo-Ann ParksProofreader: Graphic World, Inc.

Western Schools’ courses are designed to provide healthcare professionals with the educational information they need to enhance their career development as well as to work collaboratively on improving patient care. The information provided within these course materials is the result of research and consultation with prominent healthcare authorities and is, to the best of our knowledge, current and accurate at the time of printing. However, course materials are provided with the understanding that Western Schools is not engaged in offering legal, medical, or other professional advice.

Western Schools’ courses and course materials are not meant to act as a substitute for seeking professional advice or conducting individual research. When the information provided in course materials is applied to individual cases, all recom-mendations must be considered in light of each case’s unique circumstances.

Western Schools’ course materials are intended solely for your use and not for the purpose of providing advice or recom-mendations to third parties. Western Schools absolves itself of any responsibility for adverse consequences resulting from the failure to seek medical, or other professional advice. Western Schools further absolves itself of any responsibility for updat-ing or revising any programs or publications presented, published, distributed, or sponsored by Western Schools unless other-wise agreed to as part of an individual purchase contract.

Products (including brand names) mentioned or pictured in Western Schools’ courses are not endorsed by Western Schools, any of its accrediting organizations, or any state licensing board.

ISBN: 978-1-68041-459-2

COPYRIGHT© 2018—S.C. Publishing. All Rights Reserved. No part(s) of this material may be reprinted, reproduced, transmitted, stored in a retrieval system, or otherwise utilized, in any form or by any means electronic or mechanical, including photocopying or recording, now existing or hereinafter invented, nor may any part of this course be used for teaching without written permission from the publisher.

ii

ABOUT THE AUTHORLeanna Marchand, BSN, RN, JD, is a partner in Marchand & Rossi, LLP, in Dallas, Texas. She handles civil litigation, including healthcare, personal injury, and guardianship law. Mrs. Marchand rep-resents healthcare providers before their respective boards and in peer review matters. She is an author and has presented nationally on topics related to healthcare. Mrs. Marchand is member of the American Association of Nurse Attorneys and the Texas and American Nurses Association, and serves as director on the board of TeamConnor Childhood Cancer Foundation.

Leanna Marchand has disclosed that she has no significant financial or other conflicts of interest pertaining to this course book.

ABOUT THE PEER REVIEWERMable H. Smith, PhD, JD, MN, NEA-BC, is the dean of the College of Nursing and Public Health at South University. Dr. Smith has been in education for more than 25 years and has taught at all academic levels, including undergraduate courses in professional nursing, leadership and management, role tran-sition, legal/ethical aspects of practice, healthcare policies, and adult health/critical care nursing. Dr. Smith has published and presented in numerous arenas on legal and ethical issues in nursing education and in nursing/healthcare, and she is the author of The Legal, Ethical and Professional Dimension of Nursing Education, Second Edition. Dr. Smith earned a BSN from Florida State University (FSU) and an MN from Emory University, with an emphasis in education. She obtained a PhD in Higher Education Administration and JD from FSU.

Mable H. Smith has disclosed that she has no significant financial or other conflicts of interest per-taining to this course book.

FP1017WS

iii

COURSE INSTRUCTIONSIMPORTANT: Read these instructions BEFORE proceeding!

HOW TO EARN CONTINUING EDUCATION CREDIT

To successfully complete this course you must: 1)Read the entire course 2)Pass the final exam with a score of 75% or higher* 3)Complete the course evaluation

*You have three attempts to pass the exam. If you take the exam online, and fail to receive a passing grade, select “Retake Exam.” If you submit the exam by mail or fax and you fail to receive a passing grade, you will be notified by mail and receive an additional answer sheet.

Final exams must be received at Western Schools before the Complete By date located at the top of the FasTrax answer sheet enclosed with your course.

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Complete the FasTrax Answer Sheet using blue or black ink only. If you make an error use correction fluid. If the exam has fewer than 100 questions, leave any remaining answer circles blank. Respond to the evaluation questions under the heading “Evaluation,” found on the right-hand side of the FasTrax answer sheet. See the FasTrax Exam Grading & Certificate Issue Options enclosed with your course order for further instructions.

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WESTERN SCHOOLSP.O. Box 1930, Brockton, MA 02303

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WESTERN SCHOOLSCOURSE EVALUATION

TEXAS NURSING JURISPRUDENCE AND ETHICSINSTRUCTIONS: Using the scale below, please respond to the following evaluation statements. All responses should be recorded in the right-hand column of the FasTrax answer sheet, in the section marked “Evaluation.” Be sure to fill in each corresponding answer circle completely using blue or black ink. Leave any remaining answer circles blank.

A B C D

Agree Agree Disagree Disagree Strongly Somewhat Somewhat Strongly

OUTCOMES: After completing this course, I am able to: 1. List the laws that regulate nursing practice in Texas.

2. Describe the purpose, functions, and structure of the Texas Board of Nursing.

3. Discuss licensure, certifications, and nursing scope of practice.

4. Explain different types of nursing peer review.

5. Identify unprofessional conduct and the disciplinary process.

6. Discuss nursing ethics including professional boundaries and the use of social media.

COURSE CONTENT 7. The course content was presented in a well-organized and clearly written manner.

8. The course content was presented in a fair, unbiased, and balanced manner.

9. The course content presented current developments in the field.

10. The course was relevant to my professional practice or interests.

11. The final examination was at an appropriate level for the content of the course.

12. The course expanded my knowledge and enhanced my skills related to the subject matter.

13. I intend to apply the knowledge and skills I’ve learned to my practice.

A. Yes B. Unsure C. No D. Not Applicable

CUSTOMER SERVICEThe following section addresses your experience in interacting with Western Schools. Use the scale below to respond to the statements in this section.

A. Yes B. No C. Not Applicable 14. Western Schools staff was responsive to my request for disability accommodations. 15. The Western Schools website was informative and easy to navigate. 16. The process of ordering was easy and efficient. 17. Western Schools staff was knowledgeable and helpful in addressing my questions or problems.

ATTESTATION

18. I certify that I have read the course materials and personally completed the final examination based on the material presented. Mark “A” for Agree and “B” for Disagree.

vcontinued on next page

Course Evaluation— vi Texas Nursing Jurisprudence and Ethics

COURSE RATING

19. My overall rating for this course is

A. Poor B. Below Average C. Average D. Good E. Excellent

You may be contacted within 3 to 6 months of completing this course to participate in a brief survey to evaluate the impact of this course on your clinical practice and patient/client outcomes.

Note: To provide additional feedback regarding this course and Western Schools services, or to suggest new course topics, use the space provided on the Important Information form found on the back of the FasTrax instruction sheet included with your course.

C O N T E N T SCourse Evaluation ....................................................................................................................................................vFigures and Tables ..................................................................................................................................ixPretest .......................................................................................................................................................xiIntroduction ...........................................................................................................................................xiii

Course Objectives .......................................................................................................................xiii

Learning Outcome ......................................................................................................................xiii

Overview .....................................................................................................................................xiiiTexas Nursing Jurisprudence and Ethics ..............................................................................................1

Types of Law .................................................................................................................................1

Criminal and Civil Law ...........................................................................................................1

Statutory Law and the Nurse Practice Act ...............................................................................2

Administrative Law and the Texas Board of Nursing .............................................................2

Professional Organizations ......................................................................................................3

Texas Board of Nursing .................................................................................................................3

Overview ..................................................................................................................................3

Purpose .....................................................................................................................................3

Functions and Structure ...........................................................................................................3

Licensure, Certifications, and Practice Requirements ...................................................................4

Overview ..................................................................................................................................4

Vocational Nurse (LVN or VN) ..............................................................................................5

Professional Nurse (RN) ..........................................................................................................5

Advanced Practice Registered Nurse (APRN) ..................................................................6

Certifications ......................................................................................................................6

Continuing Competency ..........................................................................................................6

Licensure Renewal ...................................................................................................................8

Nurse Licensure Compact Act .................................................................................................9

Nursing Scope and Standards of Practice ......................................................................................9

Overview ..................................................................................................................................9

Duties of a Nurse .....................................................................................................................9

Vocational Nursing ................................................................................................................10

Professional Nursing ..............................................................................................................11

Advance Practice Registered Nursing ...................................................................................11

Prescriptive Authority ......................................................................................................12

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Contents— viii Texas Nursing Jurisprudence and Ethics

Nursing Peer Review ...................................................................................................................12

Overview ................................................................................................................................12

Incident-Based Peer Review ..................................................................................................12

Safe Harbor Peer Review .......................................................................................................13

Whistleblower Protections .....................................................................................................14

Unprofessional Conduct ...............................................................................................................14

Overview ................................................................................................................................14

Behaviors ...............................................................................................................................14

Reporting ................................................................................................................................15

Disciplinary Process .....................................................................................................................16

Overview ................................................................................................................................16

Disciplinary Sanction Policies and Guidelines ......................................................................16

Disciplinary Matrix ................................................................................................................18

Mitigating or Aggravating Circumstances .............................................................................19

Nursing Ethics ..............................................................................................................................19

Overview ................................................................................................................................19

Professional Boundaries .........................................................................................................19

Social Media ..........................................................................................................................20

Summary ......................................................................................................................................21Exam Questions ......................................................................................................................................23Appendix A .............................................................................................................................................27Appendix B .............................................................................................................................................31Appendix C .............................................................................................................................................35Resources ................................................................................................................................................53References ...............................................................................................................................................55

F I G U R E S A N D T A B L E S

Table 1: Nursing Certifications ..................................................................................................................7

Table 2: Thirteen Behavior Categories.....................................................................................................15

Figure 1: BON Investigation and Disciplinary Process ...........................................................................17

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xi

P R E T E S T1. Begin this course by taking the pretest. Circle the answers to the questions on this page, or write the

answers on a separate sheet of paper. Do not log answers to the pretest questions on the FasTrax test sheet included with the course.

2. Compare your answers to the answers in the PRETEST KEY located at the end of the pretest. The pretest key indicates the page where the content of that question is discussed. Make note of the ques-tions you missed, so that you can focus on those areas as you complete the course.

3. Read the entire course and complete the exam questions at the end of the course. Answers to the exam questions should be logged on the FasTrax test sheet included with the course.

Note: Choose the one option that BEST answers each question.

1. The primary purpose of the Nurse Practice Act is to

a. advocate for nurses.

b. lobby the legislature.

c. protect the public.

d. promote the practice of nursing.

2. A function of the Texas Board of Nursing is to

a. establish standards of nursing practice.

b. file criminal charges against nurses.

c. lobby the legislature.

d. establish hourly wages for nurses.

3. Nurses must complete a nursing jurisprudence and ethics course

a. before the end of every two-year licensing period.

b. every four years.

c. only once in their career.

d. before the end of every third two-year licensing period.

4. Renewal of a license requires

a. designation of the nurse’s home state.

b. disclosure of deferred adjudication.

c. affidavits of good character.

d. a notarized statement of completed continuing education requirements.

5. A licensed vocational nurse may

a. perform a comprehensive assessment.

b. delegate to unlicensed personnel.

c. peripherally insert a central catheter line.

d. supervise unlicensed personnel.

PRETEST KEY1. C page 22. A page 33. D page 64. A page 85. B page 10

xiii

I N T R O D U C T I O N

COURSE OBJECTIVESAfter completing this course, the learner will be able to:

1. List the laws that regulate nursing practice in Texas.

2. Describe the purpose, functions, and structure of the Texas Board of Nursing.

3. Discuss licensure, certifications, and nursing scope of practice.

4. Explain different types of nursing peer review.

5. Identify unprofessional conduct and the disciplinary process.

6. Discuss nursing ethics including professional boundaries and the use of social media.

LEARNING OUTCOME

After completing this course, the learner will be able to describe the requirements of the Texas Nurse Practice Act, the role of the Texas Board of Nursing, the duties and scope of nursing prac-

tice in Texas, and the principles of nursing ethics and professional boundaries.

OVERVIEW

In Texas, formal nursing education began in 1890 followed by the first Texas college degree program in 1923 (Crowder, 2010). In 1909, the Texas legislature enacted the first Nurse Practice Act (NPA).

Today, nursing is a tightly regulated profession of well-educated, organized, and dedicated nursing pro-fessionals who provide a variety of nursing services in numerous healthcare settings (Whelan, 2014). A nurse is required to know and abide by the laws and rules pertaining to the nursing profession. This course is specific to nursing jurisprudence and nursing ethics in the state of Texas. In 2013, the 83rd Regular Session of the Texas legislature amended the NPA to require every nurse licensed in Texas to complete at least two hours of continuing education related to nursing jurisprudence and nursing ethics before the end of every third two-year licensing period (Tex. Occ. Code §301.305). The Texas Board of Nursing (the Board) amended its rules and regulations to comply with these requirements (22 Tex. Admin. Code §216). The requirement is applicable to the licensing period that began on or after January 1, 2014.

This course includes information regarding the NPA; nursing peer review; the nurse licensure com-pact; Board rules and regulations, including sections 217.11 (Standards of Nursing Practice) and 217.12 (Unprofessional Conduct); Board Position Statements and Guidelines; and principles of nursing ethics and professional boundaries. This course is not a comprehensive review of all laws and regulations that may affect the practice of nursing and is not to be construed as offering legal advice. Because laws and regula-tions are always changing, it is imperative that nurses maintain knowledge about all applicable current laws and regulations in order to comply with them. Nurses should be familiar with the Board’s website and other sources that can assist the nurse in safe practice.

Introduction— xiv Texas Nursing Jurisprudence and Ethics

ANA: American Nurses Association

APRN: Advanced practice registered nurse

Board: Texas Board of Nursing

BON: board of nursing

CNE: continuing nursing education

CNM: certified nurse midwife

CNS: clinical nurse specialist

CRNA: certified registered nurse anesthetist

LVN: licensed vocational nurse

NCSBN: National Council of State Boards of Nursing

NPA: nurse practice act

RN: registered nurse

TBON: Texas Board of Nursing

TNA: Texas Nurses Association

VN: vocational nurse

ABBREVIATIONS

T E X A S N U R S I N G J U R I S P R U D E N C E

A N D E T H I C STYPES OF LAW

There are four basic sources of law: (1) fed-eral and state constitutional law, (2) fed-

eral and state legislative law, (3) common law, and (4) administrative rules and regulations. Regardless of the type of law, a nurse must be familiar with and follow the law. Constitutional law provides the nurse with rights to due pro-cess, including notice requirements and the right to consult an attorney. Laws passed by the leg-islature are called statutes. In Texas, the statutes are grouped into subparts called Codes, such as the penal code (criminal laws) and the occupa-tions code (Nurse Practice Act or NPA). Within the statutes, state agencies, such as the Board, are given the authority to make administrative rules and regulations. The court system devel-ops the common law by interpreting the laws passed by the legislature and the administrative bodies of government.

Criminal and Civil LawEither criminal or civil action (or inaction)

affects the ability of the nurse to obtain and maintain a license. Nurses care for patients and their families in settings in which the patient is vulnerable, ill, sedated, impaired, or disabled. Nursing is a profession that requires the high-est level of trust, honesty, integrity, account-ability, and reliability (22 Tex. Admin. Code §213.27(a)), and nurses are entrusted with the health care of the public and must at all times

put the health and safety of the patient above all else. Review of a nurse’s fitness to practice does not stop upon obtaining his or her initial license; rather, licensure is an ongoing process. Commission of a crime that violates such pro-fessional principles raises concern about the nurse’s ability to render nursing care safely.

The Texas legislature mandated that crimi-nal background checks be conducted for appli-cation and renewal of a nursing license (Tex. Occ. Code §301.3011). The effect that a viola-tion of the law has on a nurse’s license is not limited to the practice setting. For example, criminal and civil actions, such as failure to repay student loans, failure to pay child sup-port, and drug use outside the practice setting, are indicators of the nurse’s fitness to pro-vide safe care (22 Tex. Admin. Code §§213.27 and 217.12). In the practice setting, actions can manifest in a myriad of situations, includ-ing, but not limited to, falsification of records, theft, murder, elder abuse, Medicare fraud, and nursing negligence (22 Tex. Admin. Code §213.28). The Board must review convictions or deferred adjudication of offenses against the person and property, those involving fraud, deception, lying, and falsification, as well as crimes related to drug use (22 Tex. Admin. Code §213.28(b)). The disciplinary process, penalties, and mitigating circumstances will be discussed below.

1

2 Texas Nursing Jurisprudence and Ethics

In civil litigation, a nurse might be a fact witness, a defendant, or an expert witness, or the nurse could be the person who is filing suit (i.e., the plaintiff). For example, an emergency department nurse could be called to testify as a fact witness in a family law case involving abuse and neglect. Nursing malpractice or nurs-ing negligence is handled in civil courts. In determining negligence, the jury will consider information from the medical records, testi-mony, evidence, and all the standards, compe-tencies, rules, regulations, and policies by which the nurse is required to abide under the cir-cumstances. Although employer policies and procedures are not law, they may be used to determine the nursing standard of care.

Statutory Law and the Nurse Practice Act

The Texas legislature meets every two years and may amend, repeal, or promulgate laws, including those affecting the nursing pro-fession. To address the education and prac-tice of nursing, the Texas legislature enacted Texas Occupations Code Chapters 301 (Nurse Practice Act), 303 (Nursing Peer Review), and 304 (Nurse Licensure Compact; Tex. Occ. Code §301, 2017a; Tex. Occ. Code §303, 2017b; Tex. Occ. Code §304, 2017c). Although the legislature titled only chapter 301 as the Nurse Practice Act, in practice these codes are referred to collectively as the NPA. Full copies of each may be found at http://www.statutes.legis.state.tx.us. The legislature also gave the Board access to information relat-ing to criminal history in order to assist in the determination of fitness to practice nursing (Tex. Gov’t. Code §411.125) and outlined the consequences of criminal convictions (Tex. Occ. Code §53). Nursing statutes are for the protection and welfare of the citizens of Texas and to ensure the education and competency of nurses practicing in Texas. Within the NPA,

the Texas legislature created the Board, a regu-latory agency tasked with administering the intent of the statutes and performing the func-tions outlined by the legislature.

Administrative Law and the Texas Board of Nursing

The administrative or regulatory rules gov-erning nurses are those promulgated by the Board with the authority of the Texas leg-islature. The Board must act only within the scope authorized by the legislature. The Administrative Codes, commonly called the Board rules and regulations, can be found in the Texas Administrative Codes §211 to §228 (https://www.sos.state.tx.us/tac/index.shtml). Both the occupation and administra-tive codes pertaining to nursing education and practice are accessible on the Board’s web-site (www.bon.texas.gov). The tab labeled Laws & Rules links to the NPA, including the Nurse Peer Review Act and Nurse Licensure Compact Act, the rules and regulations, and rule changes. The Board meets regularly and the meetings are open to the public. Although statutes change only every two years, the administrative regulations may be changed, updated, or repealed on a regular basis or as needed. The proposed changes, along with the comment period, and any new rule issues are published on the Board’s website and in the Texas Register, and listed in the Board’s pub-lication, the Texas Board of Nursing Bulletin. The Bulletin is mailed to all nurses within the state every quarter and is also found on the Board website. The online version of the Bulletin contains more information and any updated material that occurs between the quar-terly publications. It is important to read the Bulletin and frequent the Board’s website to stay abreast of the current law. The Board’s website is of great support to the nurse, pro-viding user-friendly content and a plethora of

Texas Nursing Jurisprudence and Ethics 3

information for nurses as well as the public. In addition, the Board has a mobile application to allow on-the-go access, which may be help-ful in situations in which a form is needed to invoke safe harbor or to verify a license. In the mobile application, the Continuing Education link will take the user directly to the Board’s website. Board position statements and guide-lines are not law. They are advisory opinions and guidance for the nurse or the public and will be discussed more fully below.

Professional OrganizationsProfessional nursing organizations influence

the statutory and administrative laws. These groups advocate for the safety and advance-ment of nursing practice. Professional orga-nizations tackle a variety of issues, such as workplace violence protections, expansion of advanced practice registered nurse (APRN) authority, whistleblower protections, and work-place staffing. The Texas Nurses Association (TNA), the American Nurses Association (ANA), the American Association of Nurse Attorneys (TAANA), the American Assembly of Men in Nursing (AAMN), and the National Council of State Boards of Nursing (NCSBN), as well as other organizations specific to spe-cialty areas, lobby legislatures on behalf of nurses and for quality health care, some of which are listed in the Resources. The purpose of these professional nursing organizations is to promote the practice of nursing, lobby the legislature, provide input into rules proposed by the Board, and provide educational resources. These organizations often have position state-ments or papers for guidance. The guidelines may be referred to when determining the stan-dard of care in a particular nursing specialty. Every nurse should be a member of at least one professional organization.

TEXAS BOARD OF NURSING

OverviewPrior to February 2004, there were two sepa-

rate statutes and governing bodies for registered nurses (RNs) and licensed vocational nurses (LVNs). Today, one Board governs both voca-tional and professional nursing, and includes APRNs (Tex. Occ. Code §301.002).

PurposeA common misperception about the Board

is that its purpose is to advocate for Texas nurses. However, its “purpose is to protect and promote the welfare of the people of Texas. This purpose supersedes the interest of any individual, the nursing profession, or any spe-cial interest group” (22 Tex. Admin. Code §211.2(a)). The Board cannot lobby the legis-lature, negotiate pay raises with employers, or handle workplace disputes. Advocacy is a vital part of the profession and is the reason that the Board and other nursing organizations engage in activities to protect the public and promote safety in nursing practice.

Functions and StructureThe Board is tasked by the legislature with

a broad range of functions, including the prom-ulgation of rules and regulations to carry out the intent of the NPA; establishing standards of nursing practice and formal nursing education for each level of nurse licensure; approval or denial of nursing school accreditation, examina-tion, and licensure; and establishing complaint, investigation, and disciplinary processes (22 Tex. Admin. Code §211.2(b)).

The Board is comprised of 13 members appointed by the governor with consent of the state senate (22 Tex. Admin. Code §211.3(a)). The 13 members represent all areas of nursing as well as four non-nursing public members who

4 Texas Nursing Jurisprudence and Ethics

represent the public (Tex. Occ. Code §301.051). There are six nurse members: one APRN, two RNs who are neither an APRN nor a nursing faculty member, and three LVNs who are not nursing faculty. In addition, there are three nurs-ing faculty members actively employed in a nursing school (Tex. Occ. Code §301.051(1)). Of these nursing faculty members, there must be one bachelor of science in nursing, one asso-ciate degree in nursing (ADN), and one LVN. The Board appoints members to the Standing and Advisory Committees to assist the Board. The committees also include a public member. Decisions of the committees are advisory alone (22 Tex. Admin. Code §211.6). The Board has an executive director, an attorney who advises the Board, and various support personnel.

A number of resources are available to assist nurses and the public with interpreting the rules and regulations. The Board provides a Delegation Resource Packet (Texas Board of Nursing [TBON], 2017d), posts answers to fre-quently asked questions (FAQs), provides the Bulletin with articles affecting nursing practice, and sometimes answers questions via e-mail. In addition, the Board writes numerous position statements, guidelines, and interpretive state-ments to help clarify the NPA. Although posi-tion statements and guidelines are not law, a prudent nurse should read these statements and guidelines and apply them to practice. To find these statements on the Board’s website, go to the Practice tab and then click on BON Position Statements. At the time of publication, 28 posi-tion statements were on the site. For example, by statute, a nurse may administer medications only if ordered by a physician, podiatrist, or dentist (Tex. Occ. Code §301.002 (2)(C)). However, Position Statement 15.1 clarifies that a nurse may carry out the orders of a physician assistant (PA; TBON, 2017i). If an order from a PA is

questioned, the nurse must clarify the order with the PA or the physician.

LICENSURE, CERTIFICATIONS,

AND PRACTICE REQUIREMENTS

OverviewThere are two types of nurses in Texas,

pro fessional and vocational (Tex. Occ. Code §301.002(2)-(5)), and three types of licensure, RN, LVN, and APRN, each requiring a dif-ferent level of education as described below. This is especially important to a nurse when delegating or supervising in the healthcare set-ting. Information regarding inactive and retired status may be found in the Texas Administrative Codes (22 Tex. Admin. Code §217.9). Additionally, for a nurse re-entering the work-force after four years, or any time the nurse changes practice settings, he or she should com-ply with Board Guidelines for Transitioning of the Experienced Nurse Back Into Clinical Practice or Into a New Practice Setting (TBON, 2017g) and comply with Rule 217.11.

When acting in the capacity of a nurse, you are required to display your name and your applicable designation of RN or voca-tional nurse (LVN or VN) clearly and legibly on an identification badge (Tex. Occ. Code §301.351(a-b)); in addition, you may not dis-play anything other than certifications, aca-demic degrees, practice positions, the name of the facility or employer, and a photo (Tex. Occ. Code §301.351(c)). No other information is allowed on the badge or insignia (22 Tex. Admin. Code §217.10(B)). These rules ensure that the title of nurse and his or her licensure are protected. Each year, the nurse must show continuing nursing competency as described

Texas Nursing Jurisprudence and Ethics 5

below. It is recommended by the Board that a new nurse or a nurse changing specialties have six months of direct supervision.

All nurses must know the definitions of each type of licensure. These definitions determine the scope of practice of each nurse, decision-making processes, and the parameters of delega-tion authority.

Vocational Nurse (LVN or VN)The legislature has defined vocational nursing

as “a directed scope of nursing practice, including the performance of an act that requires special-ized 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” (Tex. Occ. Code §301.002(5)). Further, “voca-tional nursing involves

a. collecting data and performing focused nurs-ing 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 modifi-cation of the nursing care plan;

d. participating in health teaching and counsel-ing to promote, attain, and maintain the opti-mum 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 dem-onstrated competency.”

(Tex. Occ. Code §301.002(5))

A vocational nurse may use the designation LVN or VN. Vocational nurses must complete a 1-year nursing program in an accredited school of nursing. Vocational nurses use a directed scope of practice and must be supervised by a RN, an APRN, physician, PA, dentist, or podiatrist (22 Tex. Admin. Code §217.11(2)). A vocational nurse is educated to care for patients with stable and predictable outcomes and to per-form hands-on assessments using their senses. A systematic nursing process is utilized by the vocational nurse in which the nurse collects data, participates in the planning of nursing care, implements appropriate aspects of nursing care, completes focused nursing assessments, and participates in teaching and counseling (22 Tex. Admin. Code §§214.2(41) and 217.11(2). Refer to the Nursing Scope and Standards of Practice section.

Professional Nurse (RN)The legislature has defined professional nurs-

ing as “the performance of an act that requires substantial specialized judgment and skill, the proper performance of which is based on knowl-edge and application of the principles of biologi-cal, 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 as defined by the legislature 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 treat-ment as ordered by a physician, podiatrist, or dentist;

6 Texas Nursing Jurisprudence and Ethics

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.”

(Tex. Occ. Code §301.002(2))

Registered nurses are required to have a 2-year minimum education in nursing at an accredited school of professional nursing. The associate degree in nursing (ADN) is a 2-year program, whereas the bachelor of science in nursing (BSN) is a 4-year program. After com-pletion of either program, the applicant applies to take the NCLEX-RN exam to become a reg-istered nurse (RN). RNs can function indepen-dently within the scope of the NPA and the Board rules in structured and unstructured envi-ronments. They are educated to make nursing diagnoses, prepare nursing care plans, perform comprehensive assessments, make evaluations, and institute interventions (22 Tex. Admin. Code §217.11(3)).

Advanced Practice Registered Nurse (APRN)

An advanced practice registered nurse (APRN) is a professional nurse with a bach-elor’s degree, advanced education in his or her specialty area, and authority beyond that of an RN. APRNs include nurse practitioners (NPs), nurse midwives (CNMs), nurse anesthetists (CRNAs), and clinical nurse specialists (CNSs; Tex. Occ. Code §301.152(a)). An APRN has passed a national examination, is prepared to

perform in a greater autonomous role, and has the education to dispense and manage medica-tions, as allowed by law (22 Tex. Admin. Code §216.1(2)). They must be licensed by the Board to act in this role and to display this title (22 Tex. Admin. Code §221.2).

Certifications

In addition to the above designations, a nurse may become certified in their field of practice. The additional designations may be utilized only after completion of all the require-ments for certification. The available certifica-tions may be found in Table 1.

Continuing CompetencyThe Board requires 20 hours of continuing

nursing education (CNE) every two years. The requirements for CNE are listed in Rule 216. Nurses cannot simply complete 20 generic CNE hours to meet the Board’s requirements. The Board provides several resources for spe-cific questions related to CNE, including (1) a brochure on continuing competency, (2) infor-mation on its website under the Education and FAQs tabs, and (3) through various educa-tional programs.

CNE hours are required to be from a Board-approved agency, which includes national nursing certification, or an authorized academic program. The hours must be in the nurse’s “area of prac-tice” and a certain number of those hours may be required in particular subjects (22 Tex. Admin. Code §216.3(a)). Area of practice is defined as including “any activity, assignment, or task by the nurse that utilizes nursing knowledge, judge-ment, or skill” (22 Tex. Admin. Code §216.1(4)). For example, the previously required biohazard education has been repealed and the legislature recently added two hours of required education in nursing jurisprudence and ethics for every third two-year license renewal period for all nurses (22 Tex. Admin. Code §216.3(c)). Furthermore, there

Texas Nursing Jurisprudence and Ethics 7

are specific continuing education requirements for nurses who (1) work with older adults and geri-atric populations, (2) perform forensic evidence collection, (3) work in emergency department settings, (4) hold an APRN license, or (5) hold a volunteer retired RN license (22 Tex. Admin. Code §216.3). Proof of completion must contain the name of the program, the hours per topic, date, location, provider number, and credentialing agency. The Board will not accept basic life sup-port certification, cardiopulmonary resuscitation classes, orientation programs, refresher courses,

or self-improvement courses toward the required 20 hours. Employer in-service programs will not suffice unless the content covers nursing care and the employer acts as an approved provider. In-service education on workplace policies is also not considered toward the required hours. It is the nurse’s responsibility to ensure that the hours meet the Board requirements and to maintain the required record of CNE hours for a minimum of three consecutive renewal periods (six years; 22 Tex. Admin. Code §216.7). Additionally, you must have the certificate of completion for each

TABLE 1: NURSING CERTIFICATIONS

• Clinical Nurse Specialist in Adult Health Nursing

• Clinical Nurse Specialist in Adult/Gerontology Nursing

• Acute Care Nurse Practitioner (ACNP)

• Acute Care Adult/Gerontology Nurse Practitioner (A/GACNP)

• Adult/Gerontology Nurse Practitioner (A/GNP)

• Neonatal Nurse Practitioner (NNP)

• Women’s Health Nurse Practitioner (WHNP)

• AACN-CC: Acute/Critical Care Knowledge Professional (CCRN-K)

• ABOHN: Certified Occupational Health Nurse (COHN)

• NCC: Maternal Newborn Nursing (RNC-MNN)

• NCC: Neonatal Intensive Care Nursing (RNC-NIC)

• NAPNES: Certified in Pharmacology (LVN, NCP)

• Clinical Nurse Specialist in Gerontological Nursing

• Clinical Nurse Specialist in Pediatric Nursing

• Nurse Midwife (CNM)

• Acute Care Pediatric Nurse Practitioner (ACPNP)

• Family Nurse Practitioner (FNP)

• Pediatric Nurse Practitioner (PNP)

• AACN-CC: Acute/Critical Care Nursing (CCRN)

• AACN-CC: Progressive Care Nursing (PCCN)

• ABOHN: Certified Occupational Health Nurse-Specialist (COHN-S)

• NCC: Low Risk Neonatal Nursing (RNC-LRN)

• DDNA: Certified Developmental Disabilities Nurse (RN, CDDN)

• DDNA: Developmental Disability Certified (LVN, DDC)

• Clinical Nurse Specialist in Neonatal Nursing

• Clinical Nurse Specialist in Psychiatric/Mental Health Nursing

• Nurse Anesthetist (CRNA)

• Adult Nurse Practitioner (ANP)

• Gerontological Nurse Practitioner (GNP)

• Psychiatric/Mental Health Nurse Practitioner (PMHNP)

• AACN-CC: Tele-ICU Acute/Critical Care Nursing (CCRN-E)

• AACN-CC: Nurse Manager and Leader (CNML)

• NCC: Inpatient Obstetric Nursing (RNC-OB)

• NCC: Neonatal Intensive Care Nursing (RNC-NIC)

• NAPNES: Certification in Long Term Care (LVN, CLTC)

Note: Adapted from TBON (2017z)

8 Texas Nursing Jurisprudence and Ethics

course. Advanced Cardiac Life Support (ACLS), Advanced Trauma Life Support (ATLS) and Pediatric Advanced Life Support (PALS) may be used for the 20-hour requirement with the cer-tificate of completion. The card provided upon completion will not qualify if you are audited. If selected for an audit, then you will be notified 90 days prior to your renewal month with instruc-tions to assist you in compliance.

Licensure RenewalLicense renewal occurs every two years. A

renewal must be completed within 60 days prior to the expiration date of a license. It is the nurse’s responsibility to comply with all rules and regulations in renewing a license. Thirty days prior to a license renewal, the Board will notify the nurse by mail at the address on file with the Board. Nurses are required to notify the Board in writing within 10 days of a name change or change of address (22 Tex. Admin. Code §217.7). E-mail, fax, or mail is an appropriate means of notification of name change or address. Failure to comply with this requirement subjects the nurse to disciplinary action. Further, if the nurse does not have the current address on file timely, the nurse will not receive notifications, investigation letters, or complaints. You may also take advantage of the Nursys System (https://www.nursys.com), a national database for licensure and discipline for RNs and LVNs that provides e-reminders of license expiration and status updates free of charge (NCSBN, 2015). Renewals may be completed online or by mail. Allowance for the requisite processing time is the responsibility of the nurse.

The Board requires disclosure of certain mental disorders, addictions, and violations of the law, whether those violations are pend-ing or final. These matters reflect on your fit-ness to practice as a nurse; therefore, arrests, pending criminal charges, and convictions of a

mis demeanor or felony, whether you pled guilty, no contest, or innocent, must be reported to the Board. This includes deferred adjudications, pro-bated sentences, community supervision, and courts-martial or military judgments. If you have been cited or charged with any violation of the law or are being investigated by a grand jury or governmental agency, you are required to report this to the Board. Although the fact that a person has been arrested will not be used as grounds for disciplinary action, should the Board’s review of such report indicate a violation of the NPA, the Board may consider this when deciding to impose disciplinary action (22 Tex. Admin. Code §213.28(h)). A statement from the nurse and copies of court documents must be ten-dered with your renewal form. Traffic tickets and some class C misdemeanors may be excluded from the reporting requirements. If a record has been expunged or sealed, you are not required to report this to the Board. However, it is your responsibility to ensure that the record is in fact expunged or sealed. Details regarding minor offenses and discipline will be discussed below.

To renew a license online, the nurse must have completed the applicable CNE require-ments, must not have defaulted on a Texas guar-anteed student loan, and must have his or her designated home state of licensure as the state of Texas; the license must not be delinquent or inactive. In addition, if you have been chosen for an audit for your CNE records or a criminal background check has not yet been completed, you may not renew online. To access the online renewal or download copies of the appropriate renewal form, click on the Licensure tab and then Renewals on the Board’s website.

Renewals sent via mail are processed within approximately 15 business days. If a renewal is not timely completed online or is not post-marked by the last date of the renewal period, then a nurse’s license is delinquent. If this

Texas Nursing Jurisprudence and Ethics 9

happens, then the nurse may not practice nurs-ing until the license is no longer delinquent. In this situation, the nurse must download the Delinquent License Renewal Form, properly complete all requirements, pay an increased fee, and send proof of completed CNE hours with the correct form to the Board. This process may take several weeks. If the license has been expired for more than four years and you have not practiced nursing during that time, then you must apply for a six-month temporary permit, complete a refresher course, attend extensive orientation or a nursing program of study, com-plete the jurisprudence examination, and com-ply with continuing competency requirements (22 Tex. Admin. Code §217.6).

Nurse Licensure Compact ActTraditionally, nursing was a state-based

activity. Yet, in this new age of advanced tech-nology, it is apparent that the public could be best served by states coming together to efficiently handle licensure and the exchange of information regarding disciplinary action (ANA, 2014). According to the NCSBN, 26 states, including Texas, participate in the Nurse Licensure Compact (NCSBN, 2017). In May 2015, NCSBN adopted an Enhanced Licensure Compact (eNLC; NCSBN, 2017). In July 2017, the Texas legislature adopted the enhanced licensure compact. As of publi-cation, the implementation date has not been determined (TBON, 2017h). Detailed infor-mation regarding the act will be available in Texas Occupations Code §304 and in Section 220 of the Board’s rules. The compact allows a professional or vocational nurse to maintain one license but practice (physically and elec-tronically) in another compact state. There are eleven uniform licensing requirements to obtain licensure to practice interstate (NCSBN, 2017). The nurse must comply with all laws of the state in which the practice takes place.

NURSING SCOPE AND STANDARDS

OF PRACTICE

OverviewThe NPA and the Board Rules and Regula-

tions outline the scope and standards of prac-tice for nurses. The Board identifies the core rules of nursing practice as Rule 22 Texas Administrative Code §217.11, Standards of Nursing Practice, and Rule 22 Texas Administrative Code §217.12, Unprofessional Conduct, along with Position Statement 15.14 (TBON, 2017j). A nurse must promote a safe environment for patients, put the duty to the patient above all else, accept assignments safely, know about and correctly administer medications, and protect the patient’s right to privacy (22 Tex. Admin. Code §217.11(1)).

Duties of a NurseBoth the legislature and the Board have made

clear that a nurse’s primary duty is to provide safe nursing care to the patient (22 Tex. Admin Code §217.11(1)). Position Statement 15.14 pro-vides an excellent summary of nursing duty in any practice setting (TBON, 2017j). In Lunsford v. Board of Nurse Examiners (1983), the court held that a nurse’s duty to a patient was supe-rior to both an employer’s policies and orders of the physician. In making decisions regard-ing patient care, a nurse must consider his or her education, experience, skills, knowledge, and scope of practice, as well as the practice setting and the condition of the patient. The Six-Step Decision-Making Model for Determination of Nursing Scope of Practice (TBON, 2017x), and The Six-Step Decision-Making Model for LVN Scope of Practice (TBON, 2017w) are excel-lent sources for the nurse in determining his or her scope of practice (see Appendixes A and B). Likewise, proper delegation is a duty of the

10 Texas Nursing Jurisprudence and Ethics

nurse. The five rights of delegation model are (1) right task, (2) right circumstances, (3) right person, (4) right direction/communication, and (5) right super vision/ evaluation (TBON, 2017e). The Board’s Delegation Resource Packet con-sists of

1. Conflict Resolution Model (TBON, 2003),

2. Delegation and the Advanced Practice Reg-istered Nurse;

3. Delegation FAQs (TBON, 2017f)

4. Links to Delegation Resources

5. Rule 224: Flow Chart (TBON, 2017s).

6. Rule 225: Flow Sheet (TBON, 2017t).

7. The Five Rights of Delegation (TBON, 2017e)

8. Delegation – Don’ts (TBON, 2017c).

9. Rule 225: Professional Nursing Assessment Grid and Case Examples (TBON, 2017v).

10. Rule 225: Quick Reference Guide (TBON, 2017u).

11. Cooperative Agreement between the Board of Nurse Examiners for the State of Texas & the Department of Aging and Disability Service (TBON, 2017d).

Other factors in determining a nurse’s duty is to provide safe nursing care for patients, and this involves human factors. Is the nurse fatigued, falling asleep on the job, or frequently being interrupted? Commonly, a nurse will fail to provide the proper attention required to repetitive tasks. It is the nurse’s duty to reduce and prevent human error. The Institute for Safe Medication Practices (ISMP) releases high-alert medications and special error alerts along with lists of commonly confused medications (ISMP, 2017). There are standards common to all nurses and include (Tex. Admin. Code §217.11(1)):

• Patient advocacy

• Using proper modes of communication

• Knowing and conforming to rules and regulations

• Ensuring accurate documentation

• Clarifying orders

• Accepting assignments safely

• Knowing and maintaining professional boundaries

• Respecting the patient’s privacy

• Notifying the appropriate supervisor when leaving a nursing assignment

• Complying with the mandatory reporting re-quirements regarding violations of the NPA

• Providing nursing services without dis- crimination

• Making responsible and safe assignments

• Providing proper supervision

• Utilizing community agencies and health-care resources

• Being responsible for continuing compe-tency in the area of practice

The nurse may not exceed the scope delin-eated by his or her license. The types of licensure also have differing scopes of practice. Board Position Statements 15.27, Licensed Vocational Nurse Scope of Practice, and 15.28, Registered Nurse Scope of Practice contain a synopsis of differences in the scope of practice for LVNs as well as associate, diploma, and baccalaureate degree nurses (TBON, 2017m; TBON, 2017n).

Vocational NursingAs discussed, vocational nurses use a

directed scope of practice and must be super-vised by an RN, APRN, physician, PA, dentist, or podiatrist (22 Tex. Admin. Code §217.11(2)). A systematic nursing process is utilized by the vocational nurse in which the nurse collects data, participates in the planning of nursing care, implements appropriate aspects of nursing care, completes focused nursing assessments,