Texas Jurisprudence

https://www.bon.texas.gov/about_site_map.asp
https://www.bon.texas.gov/faq_peer_review.asp
https://www.bon.texas.gov/forms_safe_harbor.asp
http://www.bne.state.tx.us/practice_bon_position_statements_content.asp#15.28

Nursing Practice Act

https://www.ncsbn.org/nurse-practice-act.htm

Mission of the Board of Nursing is to protect the welfare of the people of Texas. The Board does that by helping
nurses stay in the know about their duty to provide safe, competent care to patients and by making sure each
nurse who holds a license to practice is competent to practice safely.

The Board represents the people of Texas by ensuring that licensed nurses meet minimum standards of safe
practice. Professional nursing associations represent their members in legislative, political, and policy matters.
Nursing associations also provide leadership in other areas, such as efforts to improve working conditions and
benefits for nurses.

The Board does not answer questions about employment issues such as salaries, staffing ratios, or other workplace
concerns. The Board does not regulate practice settings or environments; it regulates nurses.

The Board does not protect or advocate for nurses; it protects the public. But it can help you understand how to
practice safely and within the rules and regulations set up in the state of Texas. It's an important resource for your
practice. services are offered by the Texas Board of Nursing – licensing, enforcement services, audit of continuing
competency, information services - and what services the Board does not provide- job referral, legal referral,
salary question, co-worker dispute.

The accepted standard of practice may vary by specialty and by task; some specialty areas require certification,
while others simply require post-licensure continuing education to establish competency to perform the necessary
skills safely.

Board staff cannot provide detailed recommendations because of all of the differences in nurses and nursing
practice settings.

Nursing practice is directly affected by your ability to make informed decisions. You need to know how the rules
apply to you, and then apply them in your nursing practice.

The Board of Nursing is subject to the legislature. The legislature makes the act, and then the Board makes the
rules and regulations to carry out the act.

The legislature gives the Board the authority to make rules and regulations. But keep in mind that the Board serves
the legislature; it does not and cannot lobby the legislature.

The legislature creates the Nursing Practice Act, or NPA, which grants authority to the Board of Nursing and
defines its responsibility. Nurses must be familiar with both the NPA and the Board's rules.

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NPA and Board rules are organized by a numbering system. You won't need to memorize many numbers, though,
as you can always look up rules by their titles. 217.11 Standards of Nursing Practice.

the Board provides information about and enforcement of the Board's rules and regulations, in addition to
licensing nurses.

Licensure is implemented by the Board to protect the people of Texas and ensure safe nursing care. According to
the NPA, you can't call yourself a nurse or practice in the state of Texas without a license. NPA 301.251, License
Required.

additional statutes and rules that protect the title "nurse." The title needs protection to make sure the public
knows that only properly licensed practitioners can use it.

There are a few specific requirements for what must appear on your badge, and your employer's policy might have
specific requirements for how you write your name. Jeffrey Nas RN - While all of these items are allowed, Rule
217.10(b) states that only two items are required: name and licensure level.

New graduates, temporary permits expire after 75 calendar days, or when you pass or fail the National Council
Licensure Examination (NCLEX) exam. For people who are already licensed, temporary licenses expire after 120
days.

Wall certificates will still be sent with initial licensure. But the whole world is going paperless, and nursing is no
exception. Going paperless is safer and more effective, but it will affect how you present your license to potential
employers.

Verifying your license is easier than ever, and a potential employer has two ways to choose from: on the
computer- An employer can verify your license at the Board of Nursing website, which is available 24 hours a day.
or by phone - Verification can be done by phone during regular business hours by contacting the Board of Nursing
customer service department.

HAPPY BIRTHDAY - keep your contact info up-to-date! Sixty days prior to your license expiration, the Board will
mail you a postcard reminder to renew online. For information on renewals, consult NPA 301.301, 301.3011,
301.302, and Rule 217.6

Nurse obligation for continuing competency (CE). All nurses with an active Texas license are required to
demonstrate continuing competency for relicensure. Each nurse reactiviating an inactive or delinquent license
must also submit verification of 20 hours of CE completed in the two years prior to reactivation. The Board does
not approve CE, but it does require nurses to have it and it does audit them to ensure they obtain it. The
continuing competency rules for license renewal are found in Rule 216.

The nurse licensure compact is an agreement between states to recognize each other’s' licensees. It increases
nurse mobility and facilitates innovative and cooperative health care. Find more information on the licensure
compact in NPA 304 and Rule 220.

NURSING ETHICS

Objectives: criminal behavior disclosure, categories of ethical conduct, guidelines for recognizing good professional
character, and professional boundaries.

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Apply for or renew your license required to report any criminal behavior in your past and any pending criminal
charges against you, including adjudicated or probationary action. anything beyond a minor Class C traffic violation
does need to be disclosed.

Some criminal incidents don't result in a conviction, they are likely still relevant to the Board! Always refer to Board
rules to determine what counts as a crime. Keep in mind that falsifying information to the Board can be more
damaging than the original criminal behavior.

Must be disclosed when applying for or renewing a license: Convictions, Deferred adjudications, Probated
sentences, Domestic offenses.

Ethical conduct is important. The Board has rules to identify behavior that is likely to deceive, defraud, or injure
clients or the public. Nursing is one of the most trusted professions, and it's important to maintain that level of
trust so that we can practice efficiently.

Category of TRUST:
Honesty -Accurate and reliable documentation of patient care and interventions
Accountability- Knowing the rationale for administered medications and clarifying doctors' orders
Trustworthiness - Following proper procedures in securing patient valuables and ensuring their return
Reliability - Keeping up with continuing competency and professional growth
Integrity - Accepting responsibility for actions or inactions in providing nursing care and refusing to document
something you don’t witness.

Disciplinary actions that can result, ranging from remedial education to revocation of license, depending on the
seriousness of the incident. Revocation of a license is uncommon. Situations are evaluated on a case-by-case basis.

Rule 213.27 - good professional character

Factors apply – distinguish right from wrong, keep promises and honor obligations, accountable for one’s own
behavior, think and act rationally, Practice nursing in an autonomous role with patients, family and members of
the public who are or who may become physically, emotionally or financially vulnerable, Proptly and fully self-
disclose facts, circumstances, events, errors and omissions when such disclosure could enhance the health status
of patient or the public or could protect patients or public from unnecessary risk of harm.
The nurse's golden rule is duty to the patient - that's the highest level of responsibility. Employers, other health
care providers, and the nurse's personal interests do not outweigh this very important responsibility. Nurses must
be aware of their actions and feelings within the therapeutic relationship, identify the invisible boundaries, and act
in the best interest of the patient.

Nursing is a position of power. It's important that we are able to practice nursing in an autonomous role with
patients, their families, significant others, and members of the public during difficult times in their lives.

A nurse is in a trusted position, but the nurse is also human. That's why the nurse must be able to promptly and
fully self-disclose facts, circumstances, events, errors, and omissions when such disclosure could enhance the
health status of patients or the public, or could protect patients or the public from unnecessary risk of harm.

The Board takes into consideration academic history, experience level, and job history in order to establish
sufficient evidence that the individual can consistently act in the best interest of patients and the public in any
practice setting.

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Rule 217.12 (6)(D) and Rule 217.11 (1)(J), a nurse has an important role in maintaining professional boundaries,
and must be able to know, recognize, and maintain professional boundaries of the nurse-client relationship.
Violating professional boundaries of the nurse-client relationship includes but is not limited to physical, sexual,
emotional, or financial exploitation of the client or the client's significant other.

Rule 217.11 (1) (Q): Consult with, utilize, and make referrals to appropriate community agencies and health care
resources to provide continuity of care.

Over-involvement is use of the patient's financial information for personal reasons. A nurse commits a boundary
violation when he or she uses a patient's personal information, with or without their knowledge, for the personal
benefit of the nurse.

Continuum of Professional Behavior – Under-involved, zone of helpfulness, over involved.

Boundary violation could be described as any of the following kinds of behaviors: selective communication,
secretive behavior, flirtations, or "you and me against the world" behavior.
Rule 217.12 – Unprofessional Conduct - improper management of patient records and falsifying reports.

Unprofessional Conduct
 Fraud or deceit in procuring license
 Improper using a nursing license
 Impersonating another person in examination
 Aiding and abetting someone in unlawful practice
 Failing to cooperate with a lawful investigation
 Behaving in threatening or violent manner in the workplace
 Offering giving soliciting or receiving or agreeing to receive directly or indirectly, any fee or other
consideration to or from a third party for the referral of a client in connection documentation with the
performance of professional services

Rule 217.12 (6)(H) and (I) - fraud answer. NPA 301.452 (b)(5) and (10) –altering and attempting to pass off another
RN license as his own. This is Board reportable conduct that may result in action against the nurse’s license.

Nursing Practice

Scope of practice and standards of practice, rules of supervision, the nurse's duty to the patient, position
statements, and preventing human error.
Nursing processes for vocational nursing and professional nursing. Refer to NPA 301.002 and Rules 217.11 (2)(A)
and 217.11 (3)(A)
Rule 217.11 is Standards of Nursing Practice - This rule is at the very heart of your nursing practice. It covers
standards of nursing practice that apply to all nurses, including RNs, LVNs, and APRNs.

Rules applies to ALL NURSES

 Know and conform to board rules
 Promote safe environment

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 Ensure accurate documentation
 Institute interventions to stabilize client condition
 Clarify orders
 Accept assignment safely
 Know about and correctly administer medication
 Respect patient right to privacy
 Know and maintain professional boundaries.

Standards apply to LVN: Vocational Nursing

 Use systematic approach to collect data
 Participate in the planning of nursing care for patients
 Implement appropriate aspects of nursing care
 Complete focused nursing assessments
 Assist in evaluating patient response to treatment
Role of LVN:
 Direct scope of practice that must be supervised
 Educated to care for clients with stable and predictable conditions
 Educated to to hands-on assessments using their senses

Standards apply to RN: Professional Nursing

 Make nursing diagnosis that serve as a basis for care
 Developing ncp
 Implement ncp
 Perform comprehensive nursing assessment
 Evaluate patient response to nursing intervention
 Delegate task to unlicensed personnel
Role of RN:
 Works in both structured and unstructured health care environments
 Responsible for well-being of all patients
 Functions independently within the scope of the NPA and board rules

Standards apply to Advance Practice RN:

 Practice in an advanced nursing role and specialty
 Prescribe medications in accordance with prescriptive authority

NPA 301.353, Supervision of Vocational Nurse, the practice of vocational nursing must be performed under the
supervision of a registered nurse, physician, physician assistant, podiatrist, or dentist.

The Board's position statements are there to provide you with extra guidance and direction. They don't have the
force of law, but the Board strongly encourages nurses to choose those position statements that are applicable to
their practice setting and incorporate them into their daily practice to assure patient safety.

Position Statement 15.14, Duty of a Nurse in any Practice Setting. Fulfilling its mission to protect the health,
safety, and welfare of the people of Texas through the regulation of nurses, the Board of Nursing, through the
Nursing Practice Act and Board rules, emphasizes the nurse's responsibility and duty to the client or patient to

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provide safe, effective, nursing care. Lunsford v. Board of Nurse Examiners, the court held that a nurse's duty to
the patient ranks higher than hospital policy or a physician's order.

You only have one nursing license. The nurse, by virtue of a rigorous process of education and examination leading
to either LVN or RN licensure, is accountable to the Board to ensure that nursing care meets standards of safety
and effectiveness.

Kinds of Nurses:

Graduate nurses – once licensed, direct supervision should be continued for a period of 6 mos, or lesser time
period if agreed upon by the newly licensed nurse and the supervising nurse. Competence to perform
independently should be mutually determined by the new graduate and the supervising nurse and should be
demonstrated and supported by the documentation. In any practice setting where the new graduates are
employed, experience nurses should be willing to supervise and mentor the new graduate.

Nursing transitioning back to practice – the nurse who is returning to the work force or transitioning to a new
primary practice area should neither act as charge nurse nor hold any similar position for a period of at least 6
mos, unless a lesser time period is agreed upon by the nurse and his/her supervisor based upon documented
competency of the nurse.

Six-Step Decision-Making Model for Determining Nursing Scope of Practice. each step is in the form of a question
you ask yourself, and depending on your answer to the question, you either continue or stop. If you continue all
the way to the end, then you can feel confident about the act fitting within your scope of practice. If you stop, then
you know the act is not within your scope of practice.

First, ask yourself if the activity is consistent with the NPA and Board rules. Second: Is the activity appropriately
authorized? Third: Is it supported by nursing research or scope of practice statements by national nursing
organizations? Fourth: Do you possess the required knowledge and competency to carry out the act? Fifth: Would
a reasonable and prudent nurse perform this activity in this setting? And sixth: Are you prepared to assume
accountability for the patient's safe care and outcome?

Common areas for error are look-alike medication labels and lack of attention to repetitive tasks. And let's not
forget about the errors that can result from fatigue. Distractions, poor lighting, and interruptions by staff and
clients are other possible sources of nursing errors.

Preventing nursing errors is an ongoing process for you to remain aware of;
https://www.jointcommission.org/
http://www.rxlist.com/script/main/notfoundstatic.asp - most prescribed meds 2005
http://www.ismp.org/ - preventing medication errors

RN license is required for delegation.

Rule 225 RN delegation to unlicensed personnel and tasks not requiring delegation independent living
environments for clients with stable and predictable conditions. Training (demonstrate) is not the same as
delegation. Your responsibility to a trainee ends when his or her training is complete. RNs can delegate (direct the
aide). LVNs can supervise or assign, but they cannot delegate. Supervision (ensure).

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APRNs must delegate tasks just as other RNs would. After all, APRNs are nurses, not doctors, and they have to
follow nursing rules. APRNs may not delegate like physicians do.

Nursing Peer Review

history, purpose, and importance of nursing peer review. The peer review rules are among the most difficult for a
nurse to understand. To give you a little history, peer review is a rule that's been in effect since 1987. It was
started because nurses wanted the opportunity to monitor themselves, apart from and before the Board's review.
Peer review is separate from Board review, and it's confidential. See revised Rules 217.19 and 217.20.

Two kinds of peer review:

Incident-Based Peer Review relates to an incident reported after the fact by a nurse or facility, incident-based
peer review is initiated by a nurse or a facility, association, school, agency or any other setting that utilizes the
services of at least 10 nurses.
Safe Harbor Peer Review relates to an application made by a nurse to seek safe harbor before he or she accepts
an assignment. SHPR maybe initiated by a nurse prior to accepting an assignment or engaging in requested
conduct that the nurse believes would place vpatients at risk of harm. SH protects the nurse from action by the
board and retaliatory action by the employer.

The rules state that a nurse has the responsibility to submit a written, signed report to the Board when he or she
has cause to suspect violations of the rules and regulations by another nurse. If you fail to report, it's a violation of
NPA 301.402 (b) and Rule 217.19 (j).

NPA 303.001 (5), the Peer Review Committee evaluates the nurse and his or her qualifications and quality of
patient care. The Committee also evaluates the merits of a complaint and makes recommendations regarding the
complaint.

The Board recognizes that the protection of the public is not enhanced by the reporting of every minor incident. So
it's important to define a minor incident, and to understand when a minor incident needs to be reported to the
Board and when it does not.

Minor incidents in NPA 301.401 (2): "conduct that does not indicate that the continuing practice of nursing by an
affected nurse poses a risk of harm to the client or other person." And information guiding which incidents need to
be reported to the Board is contained in Rule 217.16, regarding "Minor Incidents."- no harm, normal.

error contributing to patient death or serious harm is never classified as a minor incident. Criminal conduct as
defined in NPA 301.4535, serious violation of the boards unprofessional conduct rule 217.12 (fraud, theft, patient
abuse, patient exploitation), practice related violation involving impairment or suspected impairment.

Board reportable, follow Rule 217.16, which states that a nurse involved in a minor incident need not be reported
to the Board unless the conduct creates a significant risk of physical, emotional, or financial harm to the patient,
indicates a lack of a conscientious approach, indicates the nurse lacks knowledge or competencies, or indicates a
pattern of multiple minor incidents.

Due process rights in Incident-Based Peer Review, facility must have policies in place about peer review, and that
the Peer Review Committee must comply with requirements. Furthermore, a nurse must receive notice regarding

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the review, and the nurse will have opportunity to respond to that notice. And finally, a nurse may hire his or her
own attorney, will get feedback after the decision, and will have a chance to respond to the decision.

Minimum due process rights grant that you will be notified that your practice is being evaluated by a peer
committee, provided with a description of the events to be evaluated, and given the opportunity to present
testimony and rebut the decision in writing. But there are exclusions to minimum process. Minimum due process
rules still apply if the nurse is a new employee in orientation. apply if the nurse has been reported three or more
times in the past 12 months.

Reason for exclusion- Minimum due process rules do not apply if a nurse’s practice is suspected of being impaired
due to chemical dependency.

The general purpose of Safe Harbor Peer Review is to allow a nurse to accept an assignment when the nurse has
reason to believe the patient is at risk and the nurse needs protection of her license. Safe Harbor protects nurses
while they care for patients in less-than-ideal circumstances. It allows nurses to accept assignments, and do the
best patient care they are capable of, without fear of licensure action by the Board if they accidentally commit a
practice error.

NPA 301.352 gives a nurse the right to refuse to engage in conduct related to patient care if they believe the
conduct would violate the NPA or any Board rule. Safe Harbor protects the nurse's license, it does not protect the
nurse from civil action. So before a nurse considers refusing an assignment altogether, he or she must always
recognize that the patient comes first. All nurses want a hard-and-fast rule about this - whether it begins after a
nurse accepts an assignment, or if they automatically have a duty to accept assignments no matter what.

You may refuse an assignment if you lack the basic knowledge and ability that would be necessary to render the
care, or if the assignment would constitute unprofessional conduct such as fraud, theft, patient abuse,
exploitation, or falsification. Requesting Safe Harbor, you must fill out the Quick Request form before accepting an
assignment.

The "Quick Request for Safe Harbor" must be made before accepting the assignment and the request must be
made in writing. You don't even have to use a form - any written format is acceptable, as long as it contains the
required information. 2nd part "Comprehensive Request for Safe Harbor Nursing Peer Review" by the end of the
work period and before leaving the practice setting. You may include supporting documents at a later time, but the
written comprehensive request must be submitted to a supervisor or designated person by the end of the work
period and prior to leaving the work setting. Remember to keep a copy!

A nurse who has invoked Safe Harbor may not be disciplined or discriminated against by his or her employer, may
engage in the requested conduct pending the peer review, is not subject to the reporting requirement, and may
not be disciplined by the Board for engaging in that conduct while the peer review is pending.

The rules protect a nurse who makes a good faith request for Safe Harbor. But if the nurse refuses to collaborate
with the nursing supervisor or leaves work without collaborating with the nursing supervisor, the nurse may be
acting in bad faith and may be reportable to the Board. And if the nursing supervisor making the assignment
refuses to collaborate with the nurse in a good faith effort to determine if a safe assignment is possible, the
nursing supervisor may be reported to the Board for acting in bad faith. It is always the nurse’s choice whether he
or she wants to withdraw the request or sustain it and have peers look at the situation.

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The Board helps you by providing you with the rules, but the Board can't represent you if your actions have
consequences. However, remember that all nurses have a duty to report unsafe practices. The NPA and the
Board's rules and regulations have several protections in place for nurses who report potential violations. For
instance, you cannot be suspended, terminated, or otherwise disciplined if you properly make a report.

Disciplinary Action
Cover unprofessional conduct, complaints, and the Board's investigatory process, all in relation to disciplinary
action.
Nurses must understand how chemical dependency, alcohol dependency, or mental illness can relate to their
fitness to practice, and how these factors or abuses can lead to disciplinary action.
Fit to Practice – well rested, alert, unimpaired, and stress-free. Not fit to Practice – severe depression, hung over,
on illegal drugs, fatigued.

Prescription drugs can impact your fitness to practice, and their effects must be considered carefully. Nurses must
ensure that their prescribed medications are taken as directed and that the effects and side effects of those
prescribed medications do not interfere with or impede their ability to perform their jobs adequately and, above
all, safely. Fatigue and sickness can have strong consequences on a nurse's ability to perform his or her job, and
these conditions must be evaluated scrupulously.
When making decisions about your own fitness to practice, remember that your duty to the patient is more
important than any other consideration, and that that duty entails being able to perform your job safely and
effectively. Refer to Position Statement 15.14, Duty of a Nurse in any Practice Setting.
Red flags in nurse behaviors and see if they require report to a supervisor for possible violation of Rule 213.29.

Rule 217.12 - The unprofessional conduct rules protect the public from incompetent, unethical, or illegal conduct
of licensees. These rules help identify what actions are unprofessional or dishonorable and which are likely to
deceive, defraud, or injure clients or the public. The behavior itself is a violation - actual injury to a client need not
be established.
Ex – unsafe practices, criminal conduct, misconduct, failure to repay student loan, drug diversion, drug related
actions, dismissal from peer assistance program, unlawful practice, leaving a nursing assignment without notifying
appropriate personnel.

It affects patients safety, public trust, and what's more, this kind of conduct can affect you as a nurse - any
resulting disciplinary action can have an impact on your nursing practice.

A nurse may not document execution of physician orders or any other nursing care that he or she did not provide.
This would be a violation under the Board’s Unprofessional Conduct rule, 217.12 (6)(A). Possible Board sanctions
for violating this rule could be a reprimand with stipulations.

Investigation process - First, the nurse is notified of the investigation and invited to respond. The investigator
gathers and reviews evidence, and then reviews the nurse's response. Then, a decision is made by the Board.
Nurse responsibilities during an investigation, including responding to the investigator's request for information,
asking questions, and keeping your contact information current, including phone numbers and mailing address. As
always, you want to be sure the Board can reach you as quickly and easily as possible.

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Always open and respond to mail from the Board. If you do not respond, the investigation will still proceed. And
also note that the Board carefully reads and considers nurses' responses - your contribution is an important part of
the investigation. The Board truly listens to you!
Be aware that you can freely contact your investigator, that the investigations can take a long time, and that,
should the investigation result in a decision against you, losing a license is still not common.

Types of Remediation
Remedial education – you may be required to take several extra educational classes specific to your issue.
Supervision – you may be asked to work under direct or indirect supervision of another nurse.
Work environment – you may be directed to work in a stable and consistent environment – ex. Not home health
care for specified period of time.

Constitute possible violations of NPA 301.452 and Rule 217.12.

Misdemeanor assault is a violation of NPA 301.452 (b)(3) and Rule 217.12 (13). A nurse with this criminal
background would likely receive a Board order requiring that his/her nursing practice be monitored, as well as
requiring completion of educational classes or other remediation.

Nurse engaged in unprofessional conduct through diverting narcotics, possibly used drugs that impaired her
practice while on duty, and endangered patients (harm does not have to occur), among other possible violations.
She should be reported to the Board.

Any conduct in violation of the Board's rules must be reported. A report by a nurse must be written and signed, it
must include the identity of the nurse or student being reported, and it must contain any additional information
required by the Board. All complaint information submitted to the Texas Board of Nursing is kept confidential. The
process may take a while, and you will receive periodic updates and be notified of the results.

Two reasons to make sure you report: duty to your patients, and the mandatory reporting requirement. Think of
reporting a nurse as duty to patients and clients - and getting the nurse the help they need, too. Remember, very
few nurses ever lose their license.
Mandatory reporting requirement - The rules state that a nurse has the responsibility to submit a written, signed
report to the Board when he or she has cause to suspect violations of the rules and regulations by another nurse. If
you fail to report, it is a violation of NPA 301.402 (b).
All employer, state agencies, and Peer Review Committees all have a duty to report suspected violations.

REPORTABLE – sexual contact with a patient, falsely documenting patient care, impaired while on duty.
NOT REPORTABLE – time and attendance issues, failed to follow hospital policy documenting with red ink,
arguments between two nurses.

Cases that result in disciplinary action become public information. The Board is a public entity, and as such is
subject to open record laws. Any cases that result in formal charges being filed become public information at the
time the charges are filed, and continue to be public information throughout the remainder of the disciplinary
process. Have to disclose most orders and the sanction. Consider it an opportunity to tell them how the experience
helped you improve your practice.

Sanctions of a Board Order can include remedial education, a warning, a reprimand, a suspension, and, nor
commonly, revocation.

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The Board stipulations, depending on the circumstances, including: various educational courses; general or direct
supervision with reports; notification of employment; limitations on work settings; drug screening; therapy; or
support groups with reports.

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