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Frequently Asked Questions - Nursing Practice

Topics
BON Rules and Regulations Relating to Telenursing/Telehealth LVNs Performing Triage/Telephonic Nursing/Being On-Call
Competency LVNs "Supervision of Practice"
Co-signature on Documentation Mandatory Overtime/Consecutive Shifts
Co-signature on LVN Actions/Documentation Nurse Admitted As Patient Under the Influence
Cosmetic Procedures for APRNs Nurses Have a Duty to Report Confidential Health Information
Cosmetic Procedures for LVNs Nurses Performing Radiologic Procedures
Cosmetic Procedures for RNs Nurse's Role with the Emergency Medical Treatment & Labor Act: Performance of Medical Screening Exams
Decision Making for Determining Nursing Scope of Practice Off Label Use of Medications
Delegation Practice Recommendations for Newly Licensed Nurses
Differentiating the Role of the Texas Board of Nursing from the Role of Profession Nursing Assoications. Regarding Position Statements 15.27, The LVN Scope of Practice and 15.28, The RN Scope of Practice
Doctoral Degree in Nursing and Using the Title "Doctor" RN Pronouncement of Death
Floating to Unfamiliar Practice Settings Role of the School Nurse With Unlicensed Diabetes Care Assistants (UDCAs) (HB984)
Forensic Evidence Collection Safe Harbor Peer Review
GNs, GVNs, and Newly Licensed Nurses Practicing in Home Health Settings Scope of Practice
Initiation of CPR - A Nurse's Duty to Initiate Seasonal Influenza and Vaccinations
LVNs and Nursing Care Plans Staffing Ratios
LVNs Performing Initial Assessments When Does a Nurse's Duty to a Patient Begin and End?
Workplace and Employment — General Information

Workplace and Employment — General Information

What is the BON Proposed Nursing Work Hours Position Statement?

BON Proposed Nursing Work Hours Position Statement. The Texas Board of Nursing's (BON) Nursing Practice Advisory Committee (NPAC) initiated an online survey concerning nursing work hours which was conducted on the BON web site. The survey was developed in response to research...Toggle Expand/Collapse Text

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Mandatory Overtime/Consecutive Shifts

Can an employer require a nurse to work longer than scheduled, or to work overtime?

How many consecutive hours or shifts can a nurse work?

The Texas Board of Nursing (BON) does not have authority over work-place issues, such as schedules or number of hours worked, either consecutively, in a given time period or "on-call". In 2009, during the 81st Legislative Session, SB 476 made changes to the Nursing Practice Act (NPA) and the Health & Safety Code. SB 476 applies to hospitals and nurses working in hospital settings only. Toggle Expand/Collapse Text

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Staffing Ratios

Is there a law regarding how many patients (nurse: patient ratio) a nurse can be assigned to care for in Texas?

The Texas Board of Nursing (BON) has no authority over workplace or employment issues, such as staffing ratios. The Nursing Practice Act (NPA) Nursing Practice Act  and Board Rules are written broadly to apply to nursing practice by all nurses (LVNs, RNs, & APRNs) in any practice setting. Board Rule 217.11, Standards of Nursing Practice provides the minimum standards nurses must meet in accepting any assignment, including floating, working with inadequate staffing and other practice situations, specifically: Toggle Expand/Collapse Text

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Floating to Unfamiliar Practice Settings

Question: I Nurses in my facility are often required to float from their home unit to other care units where they do not have clinical competence and/or clinical experience. What is the duty of the nurse  when it comes to floating to different clinical units (adults, pediatric, ER, etc.)?.  Can a nurse invoke Safe Harbor? If so, how do nurses invoke Safe Harbor?

Answer: The Nursing Practice Act (NPA) Nursing Practice Act and Board rules Board Rules are written broadly to apply to nursing practice in any setting.  Although the Board of Nursing (BON) has no authority over workplace policies, such as floating or staffing ratios, nurse staffing was addressed in SB 476 during the 81st Legislative Session in 2009. Toggle Expand/Collapse Text

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When Does a Nurse's Duty to a Patient Begin and End?

Employment versus Licensure

There is no routine answer to the question, “When does the nurse’s duty to a patient begin?” A nurse's duty is not defined by any single event such as clocking in, or taking report. From a Board of Nursing standpoint, the focus is on the relationship and responsibility of the nurse to the patient(s), not to the nurse's employer or employment.Toggle Expand/Collapse Text

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Safe Harbor Peer Review

What is Safe Harbor Peer Review?
Safe Harbor is a process that protects a nurse from employer retaliation, suspension, termination, discipline, discrimination, and licensure sanction when a nurse makes a good faith request for peer review of an assignment or conduct the nurse is requested to perform and that the nurse believes could result in a violation of the NPA or Board rules. Toggle Expand/Collapse Text

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A Nurse's Duty Not Limited to Assignment:

All nurses, regardless of practice setting, position, title or role, are required to adhere to the NPA and other statutes, as well as the Board Rules. Two of the main rules that relate to nursing practice are Texas Administrative Code, Rule §217.11 Standards of Nursing Practice,...Toggle Expand/Collapse Text

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Decision Making for Determining Nursing Scope of Practice.

Where can I find a list of tasks that LVNs and/or RNs can or cannot do in the State of Texas?

The Nursing Practice Act (NPA) and Board Rules are written broadly so that they can apply to nursing practice in any setting. As such, the BON does not provide lists of tasks or step-by-step procedures of how certain tasks are to be carried out by the nurse. Toggle Expand/Collapse Text

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Nurses Have a Duty to Report Confidential Health Information

Do nurses have a duty to report confidential health information to administrators, law enforcement of to a patient's family?

Nurses have a duty to report patient information, including mental health information, to members of law enforcement, a patient's family and others when a patient is a serious danger to himself or others. Toggle Expand/Collapse Text

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Nurse Admitted As Patient Under the Influence

I currently work in an ICU. I had an opportunity to care for a patient/nurse (who was a nurse at another facility) who overdosed. She was transferred, when stable, to a treatment center by court order. I was told we cannot report her to the board due to HIPAA. My question is, "How do we plan to handle this type of incident in the future?" "Will there be any specific changes made to address problems like this in the future?" I understand with the renewal of our license we must answer the question of treatment for use of "alcohol or any other drug." But if there is no report of her being in the hospital for treatment, due to HIPAA, it's possible that she may not answer the question truthfully. Can you please help with these questions. I appreciate your time.

Whether a nurse is admitted for an overdose of a substance, or admitted secondary to some type of accident related to being under the influence of any mind-altering substance, the answer would remain the same....Toggle Expand/Collapse Text

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CPR - A Nurse's Duty to Initiate

Is current CPR certification a licensure requirement for nurses?

No. The Texas Board of Nursing (Board or BON) does not require CPR for licensure renewal; however, employers may have specific requirements for maintaining current CPR status as a condition of employment.Toggle Expand/Collapse Text


GNs, GVNs, and Newly Licensed Nurses Practicing in Home Health Settings

I will be graduating from a vocational nurse training program in a few months, and am beginning to seek out employment options once I graduate. I am attracted to the area of home health nursing, and I wondered if LVNs can work in home health settings? (Note: The same answer applies to graduates of registered nurse training programs).

As a newly graduated LVN (or RN), I am interested in home health nursing.  Should I work in this environment as a new nurse?

When you graduate from your vocational training program or your professional nursing program, you will likely be eligible for a temporary permit to practice as a Graduate Vocational Nurse (GVN) or Graduate Nurse (GN).  Board Rule §217.3 prohibits GVNs and GNs from working in "independent practice settings", which includes home health settings.Toggle Expand/Collapse Text

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Practice Recommendations for Newly Licensed Nurses

Does the Board of Nursing (BON) have any recommendations for newly licensed LVNs or RNs as they begin their nursing practice?

The newly licensed nurse is in a transitional process and as a novice practitioner, the new LVN or RN is inexperienced and not fully integrated into his/her nursing role and setting. Based on this belief, the Board provides the following guidance to newly licensed LVNs or RNs: Toggle Expand/Collapse Text

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Regarding Position Statements 15.27, The LVN Scope of Practice and 15.28, The RN Scope of Practice

Position Statements 15.27 and 15.28 state that it is the LVN's responsibility to ensure appropriate supervision.  What is appropriate supervision?

Each LVN is required to ensure that he or she has the appropriate supervisor prior to accepting an assignment, a position, or employment. The Nursing Practice Act (NPA) Section 301.353 states that "the practice of vocational nursing must be performed under the supervision of a registered nurse, physician, physician assistant, podiatrist, or dentist." Rule 217.11, Standards of Nursing Practice, subsection (2) further clarifies that “the licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity."
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FAQ - LVNs Performing Initial Assessments

Can an LVN perform an “initial” assessment?

Board Rule 217.11, Standards of Nursing Practice, refers to focused assessments performed by LVNs [Board Rule 217.11(2)(A)] and comprehensive assessments performed by RNs [Board Rule 217.11(3)(A)]. Toggle Expand/Collapse Text

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LVNs and Nursing Care Plans

Can an LVN initiate/develop the nursing care plan?

LVNs may not initiate care plans; however, they may contribute to the planning and implementation of the nursing care plan.  Only the RN may develop the initial nursing care plan and make nursing diagnoses [Board Rule 217.11(3)(A)(ii) & (iii)]. Toggle Expand/Collapse Text

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LVNs Performing Triage/Telephonic Nursing/Being On-Call

Can LVNs in any practice setting be "on-call" to deal with after-hours issues?

Can an LVN perform "triage" duties (either telephone triage such as for home health or on-site such as an Emergency Room)?

Triage is defined as the sorting of patients and prioritizing of care based on the degree of urgency and complexity of patient conditions. Telephone triage is the practice of performing a verbal interview and making a telephonic assessment with regard to the health status of the caller. As the caller may not accurately describe symptoms, and/or may not accurately perceive or communicate the urgency of the situation or condition prompting the call, nurses who perform these functions must have specific educational preparation, as the consequences of inadequate triage can be devastating.1 Toggle Expand/Collapse Text

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LVNs "Supervision of Practice"

Describe what "supervision of practice" means in relation to an LVN functioning with a directed scope of practice “under the supervision of. . . .”

The LVN’s scope of practice requires that his or her nursing practice be directed by an appropriately licensed supervisor, e.g. registered nurse, advanced practice registered nurse, physician, physician assistant, podiatrist or dentist [Nursing Practice Act (NPA) Sections 301.002(5), 301.353 and Board Rule 217.11(2)]. Toggle Expand/Collapse Text

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Nurse's Role with the Emergency Medical Treatment & Labor Act: Performance of Medical Screening Exams

Background Information:

The Emergency Medical Treatment and Active Labor Act (EMTALA) is a federal law established in 1986 that requires hospitals or other acute care facilities who offer emergency services to provide a medical screening examination to each person presenting to the emergency department. Toggle Expand/Collapse Text


Seasonal Influenza and other Vaccinations

What are the requirements for a nurse to give flu injections?

Although the laws regarding immunizations are not within the BON's authority, an Attorney General opinion in 1981 (MW-318) determined immunizations are preventative, thus no medical diagnosis is required or made when a person receives an immunization. Board staff recommends that a facility have standing physician delegation orders that guide the nurse when to give pneumococcal or influenza vaccines. Position Statement 15.5, Nurses with Responsibility for Initiating Physician Standing Orders, references the Texas Medical Board rules applicable to these types of orders, and provides guidance to nurses and employers on important components to include in standing delegation orders.Toggle Expand/Collapse Text

Role of the School Nurse With Unlicensed Diabetes Care Assistants (UDCAs) (HB984)

What is the BON' recommendation?

BON Position Statement 15.13, Role of LVNs and RNs as School Nurses, recommends that the school nurse be an RN, but does not absolutely preclude an LVN with appropriate...Toggle Expand/Collapse Text

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Can an LVN be a school nurse? Can an LVN train Unlicensed Diabetes Care Assistants (UDCAs) or serve in other roles (consultative relationship, administratively responsible)?

The BON does not preclude LVNs from being employed in school settings; however, the BON has no jurisdiction over employment practices or facility policies.  The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nursed, physician’s assistant, physician, podiatrist, or dentist (Board Rule 217.11(2).  Additionally, the LVN contributes to the development and implementation of teaching plans for patients and their families with common health problems and well-defined health needs.  LVNs may teach from a developed education plan as well as contribute to its development.

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Who is responsible for determining which school employees will be trained as Unlicensed Diabetes Care Assistants (UDCAs)?

NThe training of Unlicensed Diabetes Care Assistants in Texas public schools is not within the BON's jurisdiction...Toggle Expand/Collapse Text

Who is responsible for training the Unlicensed Diabetes Care Assistants (UDCAs) in schools? Can a healthcare provider with expertise in diabetic care be contracted to do all of the training for an individual school or a school district?

NThe training of Unlicensed Diabetes Care Assistants in Texas public schools is not within the BON's jurisdiction...Toggle Expand/Collapse Text

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 A school nurse is assigned to 3 different elementary schools within one district and rotates between the schools. The schools’ principles assign who will be trained as Unlicensed Diabetes Care Assistants (UDCAs). The principals also assume administrative responsibility for these staff whether they are functioning within their job descriptions or in the "extra" role of UDCA. Working with the principals at all 3 schools, the RN coordinates training of all UDCAs through another RN with expertise in all aspects of the care of children with diabetes.

Given the situation, as described above, what is the role of the RN with the Unlicensed Diabetes Care Assistants (UDCAs) from a BON standpoint?

According to the Health & Safety Code, Chapter 168, if a school nurse is assigned to a campus, the school nurse shall coordinate the training of school employees acting as unlicensed diabetes care assistants.

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How does the RN provide adequate communication and information to the UDCAs at each school related to the diabetic care needs of each child?

Congruent with the diabetes management and treatment plan and the individualized health plan for each child with diabetes, the RN can develop information sheets with emergency contact numbers, reportable conditions, and how to intervene in a number of possible emergency situations that could occur with each child.  Health and Safety Code, Section 168 and school policy mandate that this information be given to any school employee transporting a child or supervising a child during an off-campus activity.  The school principal and the school nurse, if a school nurse is assigned to the school, shall develop a student’s individualized health plan in collaboration with the student’s parent or guardian and, to the extent practicable, the physician responsible for the student’s diabetes treatment and one or more of the student’s teachers (Health and Safety Code Sec 168.003.) The Nursing Practice Act Sec.301.002(5) (NPA) defines the licensed vocational nurse (LVN) scope of practice as a directed scope of nursing practice and specifically states that LVNs participate in the development and modification of the nursing care plan, whereas the registered nurse (RN) is responsible for the development of the nursing care plan. The LVN may assist with the development of the IHP but is not permitted to write it independently.

Can the LVN develop the Individualized Health Plan (IHP)?
No. This would be in violation of, Texas Health and Safety Code §168.003 that defines the IHP as a "coordinated plan of care" developed by the principal and the school nurse (RN) in collaboration with the student’s parent/guardian and the student’s physician, if possible. Developing or initiating a student’s IHP would also be beyond the LVN’s scope of practice as defined by the BON in Rule 217.11(2)(A).

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Health and Safety Code §168.008 mandates schools to permit and encourage students' abilities to engage in self-care. Occasionally, used supplies, such as insulin syringes or blood-stained gauze, may not be disposed of properly, exposing other children to potentially hazardous bodily fluids/blood that could carry HIV or Hepatitis.  Does HB984 mandate that a child always be permitted to engage in the self-management of diabetes anywhere on the campus, regardless of the health threat posed on other students if a given student isn't capable of disposing of used supplies and cleaning the testing area in a responsible manner? Must a student who is not capable, either by age, maturity or both, of appropriately maintaining supplies and equipment (not losing his/her glucometer, leaving used supplies where others could be exposed to blood, used sharps, etc.) be permitted to self-manage?

The Standards of Nursing Practice (Rule 217.11) require all nurses to prevent exposure of clients (students) to infectious pathogens and communicable conditions. The language in ...Toggle Expand/Collapse Text

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Does the LVN have to report signs and symptoms or changes in the student's health status to the school nurse (RN)?

LVNs and RNs are responsible for the assignments that they make or accept, and for complying with the NPA and Rules as outlined in Rule 217.11, Standards of Nursing Practice...Toggle Expand/Collapse Text

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What if the principal refuses to act on a school nurse’s report that the Unlicensed Diabetes Care Assistant (UDCA) is unable or unwilling to carry out applicable duties?

The BON has no jurisdiction over employment issues; however, the nurse should consider reporting up the chain of command, or if necessary, reporting to the Texas Education Agency (TEA), http://www.tea.state.tx.us/. The nurse always has a duty to provide a safe environment for the client, which may include advocating for the client through other channels to prevent harm. (Position Statement 15.14, Duty of Nurse in Any Practice Setting.) Failure to do so may result in the reporting of the nurse to the BON with a subsequent investigation and possible sanctions on the nurse’s license for failing to intervene in the client’s best interest. The BON staff encourage nurses to utilize the chain of command within their employment setting. If unable to reach a resolution, then ultimately the nurse may have to choose between changing employment settings or risking action on his/her nursing license.

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Is it within the RN’s scope of practice to train the Unlicensed Diabetes Care Assistant (UDCA)?

Though all RNs receive both knowledge and skills training in care of clients with diabetes across the life span, this does not necessarily mean that every RN is capable of effectively training a UDCA...Toggle Expand/Collapse Text

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Can a nurse train Unlicensed Diabetes Care Assistants (UDCAs), teachers, and other school personnel in the administration of glucagon?

While the BON has no jurisdiction over school district policies, nurses do have the obligation to promote a safe environment for students and staff [Rule 217.11(1) (B)] and to institute appropriate nursing interventions to stabilize a client's condition and prevent complications [Rule 217.11 (1) (M)]. Glucagon is prescribed to thousands of students with diabetes. Both students and their parents or guardians are instructed by providers and pharmacists on administration of glucagon should a hypoglycemic reaction occur.

Chapter 224 becomes applicable in the ISD setting when acute health conditions arise and patients become unstable or unpredictable, i.e., an emergency situation.  Section 224.6, General Criteria for Delegation, outlines the standards that must be met before an RN can delegate nursing tasks to unlicensed persons.  In the ISD setting even during an emergency situation, the RN cannot delegate tasks that require unlicensed persons to exercise professional nursing judgment; but, the unlicensed person may take any action that a reasonable, prudent non-health care professional would take in an emergency situation.  This forms the basis for the Frequently Asked Question from the Board’s  Delegation Resource Packet online entitled Medications or Procedures in an Emergency Situation, which might provide more clarification.  Each nurse will need to exercise nursing judgment to decide when it is appropriate and safe to delegate in emergency situations, remembering the supervision requirements of delegation.

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Other Resources

Acknowledgments

The BON wishes to thank Anita Wheeler, MSN, RN, Texas School Health Network Administrator and School Nurse Consultant at the Texas Department of State Health Services, and Susan Young, MSN, RN, former Nurse Consultant for the Diabetes Program at the Texas Department of State Health Services, for their assistance in the development of this document.

Revised 2017

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Off Label Use of Medication

May I administer a medication if the use is considered to be off label?

The Nursing Practice Act or NPA (Texas Occupations Code, Chapter 301) and Board Rules are written broadly so they can be applied by every nurse to all of the many different practice settings and specialty areas in nursing across Texas. The BON does not have a list of tasks that nurses can perform because each nurse has a different background, knowledge and level of competence. Determinations of a nurse's scope of practice are often complex and it is up to the individual nurse to utilize sound professional judgment in accepting any given assignment and/or performing any given procedure.

Off label use indicates that the medication is being used in a way not specified in the FDA’s approved packaging label, or insert. All prescription drugs marketed in the U.S. have an FDA-approved label.  Toggle Expand/Collapse Text

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Nurses Performing Radiologic Procedures

Are there rules regarding nurses performing radiologic procedures?

Yes, BON Rule 217.14, Registered Nurses Performing Radiologic Procedures.Toggle Expand/Collapse Text

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RN Pronouncement of Death

Texas Senate Bill 823 (1991) amended Section 671.001 of the Texas Health and Safety Code and gave RNs the legal authority to assess a patient/client and make a determination of death, unless the pronouncement is clearly prohibited under the Health and Safety Code (such as when an inquest is required). The bill specifically requires the RNs employing agency/facility to have written policies jointly developed and approved by the nursing and medical staff to direct the practice. Toggle Expand/Collapse Text

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BON Rules and Regulations Relating to Telenursing/Telehealth

What are the Texas Board of Nursing (BON) Rules and Regulations Relating to Telenursing/Telehealth?

Telenursing involves nursing practice via any electronic means such as telephone or computer. Examples of telenursing practice may include (but are not limited to) teaching, consulting, triaging, advising, or providing direct services.
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Forensic Evidence Collection

Who is required to have forensic evidence collection continuing education?

Pursuant to the Health and Safety Code §323.004 and §323.0045, a nurse licensed in Texas or holding a privilege to practice in Texas, including an APRN, who performs a forensic examination on a sexual assault survivor must have basic forensic evidence collection training or the equivalent education prior to performing the examination.  This is a onetime requirement. Toggle Expand/Collapse Text

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Co-signature on Documentation

When a Graduate Nurse (GN) or Graduate Vocational Nurse (GVN) has completed all requirements for the nursing program attended, and has received permission to test for nursing boards, must the preceptor co-sign the nursing assessment, medication administration, and other records for patients assigned to the GN/GVN?

Besides obtaining approval to sit for the NCLEX, a student who has successfully completed a nursing program must also hold a current valid temporary permit from the Board to practice as a GN or GVN in the state of Texas. Toggle Expand/Collapse Text

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Co-signature on LVN Actions/Documentation

Must an RN sign behind or "co-sign" nursing actions performed by an LVN?

In general, BON staff does not recommend a nurse co-sign anything unless he/she has directly witnessed an act (such as narcotic wastage) or has gone behind another nurse and personally performed the same assessment with the same findings. Toggle Expand/Collapse Text

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FAQ - Differentiating the Role of the Texas Board of Nursing from the Role of Professional Nursing Associations

What is the difference between the Texas Board of Nursing and professional nursing organizations?

Although the Texas Board of Nursing and professional nursing associations are both involved in the arena of nursing, nursing associations serve a different purpose and provide different services to their nursing membership and the public. Toggle Expand/Collapse Text

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FAQ – Doctoral Degrees in Nursing and Using the Title “Doctor”

Question: I am a nurse in Texas and recently graduated with a Doctor of Nursing Practice (DNP). Can I use the title “Doctor” when I work with patients and other healthcare providers?

Answer:

One of the hallmarks of nursing is the approach to lifelong learning. As nurses earn advanced degrees, the number of nurses earning doctoral degrees is increasing....Toggle Expand/Collapse Text


FAQ - Cosmetic Procedures for LVNs

The Board receives questions frequently about whether cosmetic procedures are within the scope of practice for a licensed vocational nurse (LVN). Because each nurse has a different background, knowledge, and level of competence, the Board does not have an all-purpose list of tasks that every nurse can or cannot perform, and it is up to each individual nurse to use sound judgment when deciding whether or not to perform any particular procedure or act.
The following resources, however, are intended to provide you guidance in determining if cosmetic procedures are within your scope of practice.

What is the LVN scope of practice in regards to cosmetic procedures?

Vocational nursing is 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:

  1. collecting data and performing focused nursing assessments of the health status of an individual;
  2. participating in the planning of the nursing care needs of an individual;
  3. participating in the development and modification of the nursing care plan;
  4. participating in health teaching and counseling to promote, attain, and maintain the optimum health level of an individual;
  5. assisting in the evaluation of an individual’s response to a nursing intervention and the identification of an individual’s needs; and
  6. 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 [Tex. Occ. Code §§301.002(5)].

Additionally, Vocational nursing must be performed under the supervision of a registered nurse, advanced practice registered nurse, physician assistant, physician, dentist, or podiatrist [Tex. Occ. Code §301.353].

Regardless of the setting or practice area, the NPA and Board Rules and Regulations prevent LVNs from practicing in a completely independent manner. Vocational nursing requires the acts/procedures being performed be within the scope of the LVN’s practice and appropriate orders be in place. While the NPA and Board rules do not specifically address cosmetic procedures, when a medication has been appropriately ordered for a specific client by a provider who has authorization to order such treatments, each nurse would need to individually determine whether or not that specific act is within his/her scope of practice. Each LVN would need to individually apply the Board’s Six-Step Decision-Making Model for Determining the LVN Scope of Practice, a step-by-step tool designed to assist LVNs in determining whether a task or procedure is within his/her scope of practice. Note that two LVNs could both utilize the Six-Step Model and come to differing answers of whether or not the same given task is within their respective scopes of practice because each nurse has his/her own individual knowledge, experience, training, etc.

Below are some examples of what you should consider when evaluating whether a cosmetic procedure is within your scope of practice:

    1. Whether you have the necessary educational preparation and knowledge to perform the task safely.
      1. Was the procedure taught to you as a part of your formal educational curriculum in a school of vocational nursing?
      2. Do you know what complications and/or untoward effects may result from the task or procedure?
      3. Does the task or procedure require a higher level of licensure or a different level of authorization?
    2. Whether you have the competency and skill to safely perform the task or procedure.
      1. Have you obtained additional training or continuing education specific to the cosmetic procedure?
        1. Keep in mind that continuing education and on-the-job training may expand competency at the current level of licensure but CANNOT qualify a LVN to perform the same level of care as an RN or APRN.
      2. In the event of complications and/or untoward effects, are you able to respond appropriately?
    3. Whether there is an appropriate order from a provider authorized to prescribe such treatments
      1. For administration of drugs, such as Botox, does the order contain all pertinent information, such as dose, strength, route, etc.?
      2. Do you have a standing delegation order, if applicable?
    4. Whether there is appropriate nursing and medical supervision available.
      1. Is the supervising RN on-site?
      2. Is the ordering provider on-site?

An LVN should not perform a cosmetic procedure if the LVN lacks the necessary educational preparation, knowledge, competency, or skill to safely perform the procedure; lacks an order for the procedure; or lacks appropriate supervision.

To further assist you in determining whether a cosmetic procedure is within your scope of practice, Board Staff recommend review of several resources available on the Texas BON website. These resources include:

  • Tex. Admin. Code §217.11 (Standards of Nursing Practice) outlines the minimum standards of nursing care at all licensure levels (LVN, RN, APRN). Specific subsections of this rule can be directly applied to this situation and should be considered. All nurses must:
    • (1)(A)- know and conform to the Texas NPA 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;
    • (1)(B)- implement measures to promote a safe environment for clients and others;
    • (1)(C)- know the rationale for and the effects of medications and treatments and correctly administer the same;
    • (1)(G)- obtain instruction and supervision as necessary when implementing nursing procedures or practices;
    • (1)(H)- make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations;
    • (1)(M)- institute appropriate nursing interventions that might be required to stabilize a client’s condition and/or prevent complications;
    • (1)(O)- implement measures to prevent exposure to infectious pathogens and communicable conditions;
    • (1)(R)- be responsible for one’s own continuing competence in nursing practice and individual professional growth; and
    • (1)(T)- accept only those nursing assignments that take into consideration client safety and that are commensurate with the nurse’s educational preparation, experience, knowledge, and physical and emotional ability.
  • Position Statement 15.9 (Performance of Laser Therapy by RNs or LVNs)
  • Position Statement 15.23 (The Use of Complementary Modalities by the LVN or RN)
  • Position Statement 15.11 (Delegated Medical Acts) - specifically addresses the nurse’s role with delegated medical acts. Board staff recommend caution when performing a delegated medical act, as delegated medical acts do not diminish the responsibility of the nurse in any way to adhere to the Board's Standards of Nursing Practice, Tex. Admin. Code §217.11. Nurses function under their own licenses and assume responsibility and accountability for quality, safe care in accordance with all applicable laws/rules/regulations; nurses do not practice under a physician’s license.
  • Position Statement 15.14 (Duty of a Nurse in any Practice Setting) - discusses a landmark court case which demonstrates how every nurse has a duty to promote patient safety and that duty to a patient supersedes any physician order or facility policy.
  • Position Statement 15.10 (Continuing Education: Limitations for Expanding Scope of Practice) - clarifies that expansion of an individual nurse’s scope of practice has licensure-related limitations and that informal continuing nursing education or on-the job training cannot be substituted for formal education leading to the next level of practice/licensure or authorization.

Board Staff also recommend review of the Texas Medical Board Rule 193.17, entitled Nonsurgical Medical Cosmetic Procedures, that addresses the rules related to physician delegation of nonsurgical medical cosmetic procedures. In addition, depending on the range of services you plan to provide, there may be specific licensure requirements including, but not limited to, Cosmetology Licensing. Having a nursing license authorizes you to practice nursing within your licensure level and scope of practice but not to do other things that require separate licensure/certification. You can find additional regulations related to cosmetologists/practicing cosmetology from the agency that regulates cosmetologists, the Texas Department of Licensing and Regulation. Additionally, there may be applicable regulations related to the practice setting; e.g., a private physician office might have further laws and rules from the American Board of Medical Specialties. Beyond following all applicable laws, rules and regulations regarding the acts/tasks and the setting, the nurse would need to practice consistently with the employer’s policies, assuming these policies promote patient safety (refer back to Position Statement 15.14 if necessary).

If a license is obtained via another agency or regulatory body to perform duties and tasks in another setting, for example a medical spa, the Board considers persons who hold nursing licensure accountable for acts within the practice of nursing even if these acts are performed ‘off duty’ or in another setting [Tex. Occ. Code §301.004(a)(5)]. One example of this may be performing a lower leg wax for a client who has diabetes and peripheral neuropathy; this client may not be able to feel if the wax is too hot and there may be associated burns and a poor outcome. In this example, you would be held responsible for applying your nursing knowledge and judgment with this particular client. There is also a Frequently Asked Question which relates to this discussion (Practice of Nursing). Position Statement 15.15 (Board’s Jurisdiction Over a Nurse’s Practice in Any Role and Use of the Nursing Title) reiterates that any licensed nurse in Texas is responsible to and accountable to adhere to both the NPA and Board Rules and Regulations when practicing nursing, which have the force of law [Tex. Admin. Code §217.11(1)(A)].

Food for Thought

It is important to remember that there is more to this topic than simply learning how to perform a particular procedure. Patient selection criteria, underlying physiology and/or pathophysiology, as well as indications for and contraindications to the procedure are among the many concepts that are fundamental to learning a new procedure. You must also learn to respond to and manage (as appropriate) untoward events/adverse reactions/complications that may occur as a result of the procedure. In many cases, on-the-job training will not include this type of content. If you are ever required to defend your practice for any reason (whether to the BON or any other entity), you will likely be required to provide evidence of education/training and documentation of competence related to the specific service you provided.

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FAQ - Cosmetic Procedures for RNs

The Board receives questions frequently about whether cosmetic procedures are within the scope of practice for a registered nurse (RN). Because each nurse has a different background, knowledge, and level of competence, the Board does not have an all-purpose list of tasks that every nurse can or cannot perform, and it is up to each individual nurse to use sound judgment when deciding whether or not to perform any particular procedure or act.

The following resources, however, are intended to provide you guidance in determining if cosmetic procedures are within your scope of practice.

What is the RN scope of practice in regards to cosmetic procedures?

Registered nursing, also known as professional nursing, is 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:

  1. 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;
  2. the maintenance of health or prevention of illness;
  3. the administration of a medication or treatment as ordered by a physician, podiatrist, or dentist;
  4. the supervision or teaching of nursing;
  5. the administration, supervision, and evaluation of nursing practices, policies, and procedures;
  6. 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;
  7. the performance of an act delegated by a physician under Tex. Occ. Code §§157.0512, 157.054, 157.058, or 157.059; and
  8. the development of the nursing care plan [Tex. Occ. Code §301.002(2)].

Professional nursing requires the tasks/procedures/acts being performed be within the scope of the RN’s practice and appropriate orders be in place. While the NPA and Board rules do not specifically address cosmetic procedures, when appropriately ordered for a specific client by a provider who is authorized to prescribe such treatments, each RN would need to individually determine whether or not that specific act is within his/her scope of practice. Each RN would need to individually apply the Board’s Six-Step Decision-Making Model for Determining Nursing Scope of Practice, a step-by-step tool designed to assist a nurse in determining whether a task/procedure/act is within his/her scope of practice. Note that two RNs could both utilize the Six-Step Model and come to differing answers of whether or not the same given task/procedure/act is within their respective scopes of practice because each nurse has his/her own individual knowledge, experience, training, etc.

Below are some examples of what you should consider when evaluating whether a cosmetic procedure is within your scope of practice:

  1. Whether you have the necessary educational preparation and knowledge to perform the task safely.
    1. Was the procedure taught to you as a part of your formal educational curriculum in a school of professional nursing?
    2. Do you know what complications and/or untoward effects may result from the task or procedure?
    3. Does the task or procedure require a higher level of licensure or a different level of authorization?
  2. Whether you have the competency and skill to safely perform the task or procedure.
    1. Have you obtained additional training or continuing education specific to the cosmetic procedure?
      1. Keep in mind that continuing education and on-the-job training may expand competency at the current level of licensure but CANNOT qualify a RN to perform the same level of care as an APRN.
    2. In the event of complications and/or untoward effects, are you able to respond appropriately?
  3. Whether there is an appropriate order from a provider authorized to prescribe such treatments.
    1. For administration of drugs, such as Botox, does the order contain all pertinent information, such as dose, strength, route, etc.?
    2. Do you have a standing delegation order, if applicable?
  4. Whether there is appropriate medical supervision available.
    1. Is the ordering provider on-site?
An RN should not perform a cosmetic procedure if the RN lacks the necessary educational preparation, knowledge, competency or skill to safely perform the procedure; lacks an order for the procedure; or lacks appropriate supervision.

To further assist you in evaluating whether a cosmetic procedure is within your scope of practice, Board Staff recommend review of several resources available on the Texas BON website. These resources include:

  • Tex. Admin. Code §217.11 (Standards of Nursing Practice) outlines the minimum standards of nursing care at all licensure levels (LVN, RN, APRN). Specific subsections of this rule can be directly applied to this situation and should be considered. All nurses must:
    • (1)(A)- know and conform to the Texas NPA 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;
    • (1)(B)- implement measures to promote a safe environment for clients and others;
    • (1)(C)- know the rationale for and the effects of medications and treatments and correctly administer the same;
    • (1)(G)- obtain instruction and supervision as necessary when implementing nursing procedures or practices;
    • (1)(H)- make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations;
    • (1)(M)- institute appropriate nursing interventions that might be required to stabilize a client’s condition and/or prevent complications;
    • (1)(O)- implement measures to prevent exposure to infectious pathogens and communicable conditions;
    • (1)(R)- be responsible for one’s own continuing competence in nursing practice and individual professional growth; and
    • (1)(T)- accept only those nursing assignments that take into consideration client safety and that are commensurate with the nurse’s educational preparation, experience, knowledge, and physical and emotional ability.
  • Position Statement 15.9 (Performance of Laser Therapy by RNs or LVNs)
  • Position Statement 15.23 (The Use of Complementary Modalities by the LVN or RN)
  • Position Statement 15.11 (Delegated Medical Acts) - specifically addresses the nurse’s role with delegated medical acts. Board staff recommend caution when performing a delegated medical act, as delegated medical acts do not diminish the responsibility of the nurse in any way to adhere to the Board's Standards of Nursing Practice, Tex. Admin. Code §217.11. Nurses function under their own licenses and assume responsibility and accountability for quality, safe care in accordance with all applicable laws/rules/regulations; nurses do not practice under a physician’s license.
  • Position Statement 15.14 (Duty of a Nurse in any Practice Setting) - discusses a landmark court case which demonstrates how every nurse has a duty to promote patient safety and that duty to a patient supersedes any physician order or facility policy.
  • Position Statement 15.10 (Continuing Education: Limitations for Expanding Scope of Practice) - clarifies that expansion of an individual nurse’s scope of practice has licensure-related limitations and that informal continuing nursing education or on-the job training cannot be substituted for formal education leading to the next level of practice/licensure or authorization.

Board Staff also recommend review of the Texas Medical Board Rule 193.17, entitled Nonsurgical Medical Cosmetic Procedures, that addresses the rules related to physician delegation of nonsurgical medical cosmetic procedures. In addition, depending on the range of services you plan to provide, there may be specific licensure requirements including, but not limited to, Cosmetology Licensing. Having a nursing license authorizes you to practice nursing within your licensure level and scope of practice but not to do other things that require separate licensure/certification. You can find additional regulations related to cosmetologists/practicing cosmetology from the agency that regulates cosmetologists, the Texas Department of Licensing and Regulation. Additionally, there may be applicable regulations related to the practice setting; e.g., a private physician office might have further laws and rules from the American Board of Medical Specialties. Beyond following all applicable laws, rules and regulations regarding the acts/tasks and the setting, the nurse would need to practice consistently with the employer’s policies, assuming these policies promote patient safety (refer back to Position Statement 15.14 if necessary).

If a license is obtained via another agency or regulatory body to perform duties and tasks in another setting, for example a medical spa, the Board considers persons who hold nursing licensure accountable for acts within the practice of nursing even if these acts are performed ‘off duty’ or in another setting [Tex. Occ. Code §301.004(a)(5)]. One example of this may be performing a lower leg wax for a client who has diabetes and peripheral neuropathy; this client may not be able to feel if the wax is too hot and there may be associated burns and a poor outcome. In this example, you would be held responsible for applying your nursing knowledge and judgment with this particular client. There is also a Frequently Asked Question which relates to this discussion (Practice of Nursing). Position Statement 15.15 (Board’s Jurisdiction Over a Nurse’s Practice in Any Role and Use of the Nursing Title) reiterates that any licensed nurse in Texas is responsible to and accountable to adhere to both the NPA and Board Rules and Regulations when practicing nursing, which have the force of law [Tex. Admin. Code §217.11(1)(A)].

Food for Thought

It is important to remember that there is more to this topic than simply learning how to perform a particular procedure. Patient selection criteria, underlying physiology and/or pathophysiology, as well as indications for and contraindications to the procedure are among the many concepts that are fundamental to learning a new procedure. You must also learn to respond to and manage (as appropriate) untoward events/adverse reactions/complications that may occur as a result of the procedure. In many cases, on-the-job training will not include this type of content. If you are ever required to defend your practice for any reason (whether to the BON or any other entity), you will likely be required to provide evidence of education/training and documentation of competence related to the specific service you provided.

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FAQ - Cosmetic Procedures for APRNs

The Board receives questions frequently about whether cosmetic procedures are within the scope of practice for an advanced practice registered nurse (APRN). Because each nurse has a different background, knowledge, and level of competence, the Board does not have an all-purpose list of tasks that every nurse can or cannot perform, and it is up to each individual nurse to use sound judgment when deciding whether or not to perform any particular procedure or act.

The following resources, however, are intended to provide you guidance in determining if cosmetic procedures are within your scope of practice.

What is the APRN scope of practice in regards to cosmetic procedures?

An advanced practice registered nurse is a registered nurse licensed by the Board to practice as an APRN on the basis of completion of an advanced educational program. The term includes a nurse practitioner, nurse midwife, nurse anesthetist, and clinical nurse specialist [Tex. Occ. Code §301.152.(a)]. The APRN scope of practice is addressed in Tex. Admin. Code §221.12, and may include medical diagnosis and prescriptive authority when properly delegated by a physician. The APRN scope of practice is based upon formal educational preparation, continued advanced practice experience and the accepted scope of professional practice of the particular specialty area. The Core Standards for Advanced Practice found in Tex. Admin. Code §221.13 further clarify that APRNs must function within the advanced role and specialty appropriate to their educational preparation [specifically in Tex. Admin. Code §221.13(b)]. If the APRN has had the formal education to provide a specific service, then this is part of their scope of practice. The APRN must, however, have been educated not only in the provision of the service, but also in the response to and medical management of untoward events/adverse reactions/complications experienced as a result. You may find it helpful to review the Practice-APRN Scope of Practice page on the BON website. The APRN must also have the appropriate physician delegation to engage in these medical aspects of patient care.

Pertaining to cosmetic procedures, the scope of practice of the APRN will, in part, be dependent on the educational component discussed above. When incorporating a new patient care activity or procedure into one's individual scope of practice, the board expects the APRN to verify that the activity or procedure is consistent with the professional scope of practice for the licensed role and population focus and permitted by laws and regulations in effect at the time. If the activity is not consistent with the professional scope of practice for the licensed role and population focus, additional formal education and licensure from the BON in the second role and/or population focus are required. Position Statement 15.10, Continuing Education: Limitations for Expanding Scope of Practice clarifies that expansion of an individual nurse’s scope of practice has licensure-related limitations. Informal continuing nursing education or on-the job training CANNOT be substituted for formal education leading to the next level of practice/licensure.

If an APRN would like to perform medical aspects of care related to cosmetic procedures s/he should first consider whether the medical aspects of care related to cosmetic procedures relate to his/her current licensed role and population focus area. If it does NOT, then the APRN must obtain additional licensure in the appropriate licensed role and population focus area in order to provide medical aspects of care related to cosmetic procedures. If it is within their current licensed role and population focus area, then they should next consider whether they have the appropriate training, knowledge, skills, etc. to safely deliver the medical aspects of care related to the cosmetic procedure. Continuing education may be an adequate method to gain training, knowledge, and skills necessary to safely deliver the medical aspects of care related to cosmetic procedures within the APRN licensed role and population focus area.

An example of an APRN that would be practicing outside his/her licensed scope of practice in delivering medical aspects of care related to cosmetic procedures, is a Nurse Midwife delivering such care as cosmetic procedures are outside the Nurse Midwife’s licensed role. Another example is a Women’s Health Nurse Practitioner (WHNP) delivering such care to men as men are outside the WHNP’s population focus area. Additional formal education and APRN licensure authorizing practice in the pertinent role and population focus would be required in both instances. It is important to remember that the task or procedure must be consistent with both the licensed role and population focus area.

It is important to consider that an APRN who determines that performing medical aspects of cosmetic procedures is not within his/her scope of practice may determine that administration of a medication or performance of a non-invasive treatment is within the individual’s RN scope of practice using the Board’s Six-Step Decision-Making Model for Determining Scope of Practice. For example, the WHNP described above may determine that administration of cosmetic injections ordered by an appropriately licensed provider is within his/her scope of practice as a registered nurse.

Remember that APRNs do not have full practice authority in the state of Texas. The provisions of medical aspects of care, including formulating diagnoses for the appropriate use of cosmetic injections and ordering the drugs themselves, requires delegation from a physician. It is not within the scope of APRN licensure to provide these services independent of a physician. The APRN may only accept physician delegation for those medical aspects of care and prescribing that are within the scope of the role and population focus area of APRN licensure.

It is important to remember that cosmetic procedures involving medications such as Botox or Restylane will require physician delegation as will the administration of local anesthetic blocks. Botox, for example, is considered a dangerous drug, so the prescriptive authority laws and regulations apply. The FDA has limited approved uses for these types of medications. Tex. Admin. Code §222.4(e) permits issuing prescriptions for non-FDA approved uses when the patient is enrolled in an IRB approved clinical research trial. This rule also describes the requirements that must be met when an APRN issues a prescription drug order for an off-label use of a medication. If the intent is to utilize Botox for a non-FDA approved use, one of these other criteria must be met. Additionally, the APRN must meet all other criteria for prescribing medications, including physician delegation and prescriptive authority agreement requirements as specified in Tex. Admin. Code §222.5.

To further assist nurses in determining whether a task/procedure/act is within his/her scope of practice, the Board has developed a step-by-step tool, the Six-Step Decision-Making Model for Determining Nursing Scope of Practice. In preparation for any nurse (LVN, RN, or APRN) using the Six-Step Model, Board staff recommend review of several resources available on the Texas BON website to further guide you. These resources include:

  • Tex. Admin. Code §217.11 (Standards of Nursing Practice) outlines the minimum standards of nursing care at all licensure levels (LVN, RN, APRN). Specific subsections of this rule can be directly applied to this situation and should be considered. All nurses must:
    • (1)(A)- know and conform to the Texas NPA 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;
    • (1)(B)- implement measures to promote a safe environment for clients and others;
    • (1)(C)- know the rationale for and the effects of medications and treatments and correctly administer the same;
    • (1)(G)- obtain instruction and supervision as necessary when implementing nursing procedures or practices;
    • (1)(H)- make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations;
    • (1)(M)- institute appropriate nursing interventions that might be required to stabilize a client’s condition and/or prevent complications;
    • (1)(O)- implement measures to prevent exposure to infectious pathogens and communicable conditions;
    • (1)(R)- be responsible for one’s own continuing competence in nursing practice and individual professional growth; and
    • (1)(T)- accept only those nursing assignments that take into consideration client safety and that are commensurate with the nurse’s educational preparation, experience, knowledge, and physical and emotional ability.
  • Position Statement 15.9 (Performance of Laser Therapy by RNs or LVNs)
  • Position Statement 15.23 (The Use of Complementary Modalities by the LVN or RN)
  • Position Statement 15.11 (Delegated Medical Acts) - specifically addresses the nurse’s role with delegated medical acts. Board staff recommend caution when performing a delegated medical act, as delegated medical acts do not diminish the responsibility of the nurse in any way to adhere to the Board's Standards of Nursing Practice, Board Rule 217.11. Nurses function under their own licenses and assume responsibility and accountability for quality, safe care in accordance with all applicable laws/rules/regulations; nurses do not practice under a physician’s license.
  • Position Statement 15.14 (Duty of a Nurse in any Practice Setting) - discusses a landmark court case which demonstrates how every nurse has a duty to promote patient safety and that duty to a patient supersedes any physician order or facility policy.
  • Position Statement 15.10 (Continuing Education: Limitations for Expanding Scope of Practice) - clarifies that expansion of an individual nurse’s scope of practice has licensure-related limitations and that informal continuing nursing education or on-the job training cannot be substituted for formal education leading to the next level of practice/licensure or authorization.

Board staff also recommend review of the Texas Medical Board Rule 193.17, entitled Nonsurgical Medical Cosmetic Procedures, that addresses the rules related to physician delegation of nonsurgical medical cosmetic procedures. In addition, depending on the range of services you plan to provide, there may be specific licensure requirements including, but not limited to, Cosmetology Licensing. Having a nursing license authorizes you to practice nursing within your licensure level and scope of practice but not to do other things that require separate licensure/certification. You can find additional regulations related to cosmetologists/practicing cosmetology from the agency that regulates cosmetologists, the Texas Department of Licensing and Regulation. Additionally, there may be applicable regulations related to the practice setting; e.g., a private physician office might have further laws and rules from the American Board of Medical Specialties. Beyond following all applicable laws, rules and regulations regarding the acts/tasks and the setting, the nurse would need to practice consistently with the employer’s policies, assuming these policies promote patient safety (refer back to Position Statement 15.14 if necessary).

If a license is obtained via another agency or regulatory body to perform duties and tasks in another setting, for example a medical spa, the Board considers persons who hold nursing licensure accountable for acts within the practice of nursing even if these acts are performed ‘off duty’ or in another setting [Tex. Occ. Code §301.004(a)(5)]. One example of this may be performing a lower leg wax for a client who has diabetes and peripheral neuropathy; this client may not be able to feel if the wax is too hot and there may be associated burns and a poor outcome. In this example, you would be held responsible for applying your nursing knowledge and judgment with this particular client. There is also a Frequently Asked Question which relates to this discussion (Practice of Nursing). Position Statement 15.15 (Board’s Jurisdiction Over a Nurse’s Practice in Any Role and Use of the Nursing Title) reiterates that any licensed nurse in Texas is responsible to and accountable to adhere to both the NPA and Board Rules and Regulations when practicing nursing, which have the force of law [Tex. Admin. Code §217.11(1)(A)].

Food for Thought

It is important to remember that there is more to this topic than simply learning how to perform a particular procedure. Patient selection criteria, underlying physiology and/or pathophysiology, as well as indications for and contraindications to the procedure are among the many concepts that are fundamental to learning a new procedure. You must also learn to respond to and manage (as appropriate) untoward events/adverse reactions/complications that may occur as a result of the procedure. In many cases, on-the-job training will not include this type of content. If you are ever required to defend your practice for any reason (whether to the BON or any other entity), you will likely be required to provide evidence of education/training and documentation of competence related to the specific service you provided.

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Scope of APRN Practice

May a nurse practitioner who is educated to practice in a primary care population focus area (e.g., FNP or PNP) practice in a hospital?

The Nursing Practice Act and Board rules are written broadly to apply to all nurses, including advanced practice registered nurses (APRNs), across all practice settings.  Neither are prescriptive to specific tasks or services APRNs may perform or provide.  Likewise, they do not address specific practice settings for specific categories of APRNs. Scope of practice is not specific to a practice setting; rather, it is determined by the patient’s condition and patient care needs at the time services are provided. Board Rules 221.12 and 221.13 clarify that education is the foundation for determining APRN scope of practice.  

When making scope of practice determinations, it is important to consider the patient's condition and patient care needs. Primary care educated APRNs may provide care in the acute care setting for patients with similar patient care needs and diseases and conditions to those they diagnose and manage in the outpatient setting. For example, a family nurse practitioner may be part of a group practice in a specialty such as orthopedics or palliative care and required to round in an inpatient setting in collaboration with the delegating physician. There is nothing in the Nursing Practice Act or Board Rules that prohibits this practice provided management of the patient’s condition is within the scope of the APRN’s educational preparation. 

Although the Board grants APRN licensure titles that are consistent with the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, & Education, it is important to remember that there are APRNs who have been grand-parented under Board Rules. For example, an individual who is licensed as an adult nurse practitioner rather than an adult/gerontology nurse practitioner is still permitted to provide care to geriatric patients based on education in adult health. When reading the Consensus Model, it is important to bear in mind that it contemplates licensure and education based on an APRN role and a population focus. Nothing in the Consensus Model requires scope of practice be specific to a practice setting.

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For more information on these and other topics, use the search field at the top right corner of the page. Should you have further questions or are in need of clarification, please feel free to contact the Board.