Applying Rule 217.19, What, If Any, Violations Of The Rule Occurred In The Above Scenario?

About this course:

This module aims to satisfy the requirements of the Texas Nursing Practice Act (NPA) by increasing understanding of nursing jurisprudence and ethics through study of the most current text of the Texas Board of Nursing Rules and Regulations, Chapter 301, 303, and 304 of the Texas Occupations Code.

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This module aims to satisfy the requirements of the Texas Nursing Practice Act (NPA) by increasing understanding of nursing jurisprudence and ethics through the study of the current text of the Texas Board of Nursing Administration Code Chapters 301, 303, and 304 of the Texas Occupations Code.

    By the completion of this module, the nurse should be able to:

• discuss the Texas Board of Nursing Administration Code
• describe the current text of Chapters 301, 303, and 304 of the Texas Occupations Code: Nurse Practice Act
• discuss the principles of nursing ethics
• describe the regulation, licensure, and practice of nursing in Texas
• discuss board position statements on professional boundaries

Nursing as a profession has gone through a process of change and growth, especially with respect to practice requirements. In the early 1900s, legislative acts requiring registration were passed, and in 1938, the major goal was mandatory licensure in all states for employed nurses. Since then, states have revised their nurse practice acts individually (Bullough, 1976). These NPAs have evolved and continue to change (Martin, 2020). Nursing licensure is permission from the state government to practice nursing; therefore, the state's laws and rules direct the nursing practice (Russell, 2017). Many states specify continuing education requirements that the nurse must fulfill for license renewal. For example, Texas (TX) requires nurses to complete their license renewal every 2 years. The original NPA of Texas was passed on March 28, 1909 (Texas Board of Nursing [BON], 2020a). Continuing education regarding the current laws and rules is mandated by the Texas Administrative Code to renew a nursing license. This continuing education course meets those requirements and is appropriate for registered nurses (RNs), licensed vocational nurses (LVNs), clinical nurse specialists (CNS), and advanced practice registered nurses (APRNs) in Texas.

Texas Board of Nursing

The stated purpose of the BON is to protect and promote the welfare of the people of Texas. This purpose supersedes the interest of any individual, nurse, the profession of nursing, or special interest group. To this end, the BON regulates the practice of professional and vocational nursing and the accreditation of nursing schools. The BON writes and then interprets the NPA and Administration Code based on the statutes passed by the Texas State Legislature. It receives complaints and investigates possible violations of the NPA. Violators of the NPA are disciplined through the BON. The BON also grants licensure through established standards and recommends appropriate changes to the legislature (Texas Administrative Code [TAC], n.d.).

NPA of Texas

The mission statement of the Texas Board of Nursing is as follows:

To protect and promote the welfare of the people of Texas by ensuring that each person holding a license as a nurse in the State of Texas is competent to practice safely. The Board fulfills its mission through the regulation of the practice of nursing and the approval of nursing education programs. This mission, derived from the Nursing Practice Act, supersedes the interest of any individual, the nursing profession, or any special interest group. (NPA, 2013)

The Texas Occupations Code operationalizes or amends material in the Texas Statutes. The Texas Occupations Code contains 3 chapters related to nursing. These chapters define nursing practice and appropriate authority to the BON and consist of Chapter 301, the NPA; Chapter 303, Nursing Peer Review; and Chapter 304, Nursing Licensure Compact (Texas Board of Nursing [BON], 2019).

Chapter 301: The Nurse Practice Act

Chapter 301, also known as the NPA, contains information on the regulation of nursing licensure in Texas. Disciplinary actions are also discussed in Chapter 301. Chapter 301 is comprised of subchapters A through N. Each subchapter is summarized below, with a special focus on those pertinent to nursing jurisprudence.

Subchapter A: General Provisions

In Subchapter A, Chapter 301, the following definitions are given:

A nurse is a person who is required to be licensed to engage in professional or vocational nursing.

Nursing means professional or vocational nursing.

Professional nursing is the performance of an act that requires substantial specialized judgment and skill. Nursing judgment and skill are based on the knowledge and application of principles of biological, physical, and social sciences acquired by completed courses in an approved school of professional nursing. The term excludes acts of medical diagnosis or prescription of therapeutic or corrective measures (BON, 2019).

Professional nursing practice involves the observation, assessment, intervention, evaluation, care, and health teaching of patients who are ill, injured, infirmed, or experiencing a change in normal health. It also includes the maintenance of health or prevention of illness, as well as the administration of a medication or treatment. Other practices include the supervision or teaching of nursing; the administration, supervision, and evaluation of practices, policies, and procedures; and the development of the nursing care plan (BON, 2019).

Vocational nursing is a directed scope of nursing practice, which includes the performance of an act that requires specialized judgment and skill, the proper performance of which is based on the 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 (BON, 2019).

The following exclusions are included in the general provisions:

• nursing care of the sick provided by a friend
• nursing care provided during a disaster under the state emergency management plan
• nursing care where treatment is solely by prayer or spiritual means
• an act performed by a person under the delegated authority of a provider licensed by the Texas Medical Board
• an act performed by a person licensed by another state agency, except if that person also holds a Texas license
• the practice of nursing incidental to a program of study in a nursing education program for initial licensure
• the practice of nursing by a person licensed in another state for up to 72 hours (BON, 2019)

Subchapter B: Texas Board of Nursing

The Texas BON is made of 13 members appointed by the governor. The BON includes 6 nurses, 3 nurse faculty members, and 4 members of the public. A nurse appointed to the board must have practiced nursing for at least 3 of the 5 years preceding the date of appointment. Nurses are represented by a single APRN, 2 RNs (not licensed as an APRN or working as nurse faculty), and 3 LVNs. A person representing a member of the public must not work in health care or have a vested interest in the health care industry. They also cannot be registered as a lobbyist. Members of the board serve 6-year terms. The board members must attend at least half of the scheduled meetings and are paid on a per-diem basis. Board members are offered a training program that covers laws, operations, programs, functions, rules, and budgets (BON, 2019).

Subchapter C: Executive Director and Personnel

The BON employs an executive director (ED) who may not be a member of the BON. The ED keeps a record of meetings and a registry of each nurse registered. The BON also employs other people to conduct the work of the board. The salaries of these employees are set by the board (BON, 2019).

Subchapter D: General Powers and Duties of the Board

The BON

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has general rulemaking authority and may adopt and enforce rules as outlined in Chapter 301. The BON determines whether acts constitute the practice of professional or vocational nursing. Rules regarding specialized training are adopted by the BON, such as for APRN, nurse first assistants, and certain nurses assisting in surgery. The BON also licenses an RN as an APRN and outlines any specialized education or training that is required to prescribe or order medications (BON, 2019).

Other rules made by the BON include those regarding advertising and competitive bidding (301.153), the delegation of certain medical acts (301.154), and consequences of a criminal conviction or deferred adjudication (301.1545). The BON establishes fees necessary to cover the cost of carrying out the duties outlined in the NPA, as well as a newsletter to disseminate new information to license holders (BON, 2019).

The BON recognizes three types of programs of study for initial licensure as an RN. These include a baccalaureate degree program, an associate degree program, and a diploma program. The BON approves two types of programs that prepare students for initial licensure as an LVN. These programs are conducted by education units in hospitals and within the structure of a school. The minimum course of study is prescribed by the BON (BON, 2019).

Disciplinary action may be posted on the nurse licensure verification page of the BON website. The BON may remove a disciplinary action from the verification page if the discipline is the only action taken against the nurse, was not related to the practice of nursing, or did not result in suspension or revocation of the license; the BON may also remove the action if the nurse has completed requirements related to the disciplinary action (BON, 2019).

The BON aids in the enforcement of disciplinary action as laid out in Chapter 301. The BON may issue a subpoena, compel a witness, administer an oath for testimony, and cause the prosecution of violators. Legal assistance can be provided to the BON by the Attorney General of Texas. The BON has the authority to establish a criminal investigation due to suspected criminal acts related to the practice of nursing. The BON may also assist federal, state, or local law enforcement agencies in the investigation and prosecution of crimes related to the practice of nursing (BON, 2019).

The BON has the authority to request and receive criminal history records from the Federal Bureau of Investigation. A criminal history received by the BON may be used only by the board and is privileged information. The BON may deny the application for a license or refuse to renew a license based on an applicant's criminal history (BON, 2019).

When the BON receives a complaint, it will promptly and efficiently act. The BON will notify the parties of the complaint about the schedule and the projected time requirements. Dismissed complaints will be reported at each public meeting. The BON allows the public a reasonable opportunity to speak before the BON about any issue related to nursing practice (BON, 2019).

Subchapter E: Public Interest Information and Complaint Procedures

The board will prepare information for the public describing the functions of the board and how to file complaints. The board will have established measures for consumers to make complaints via mail or telephone. The board will maintain a toll-free telephone number to be called for complaints about a health professional. The board will ensure that complaints are given appropriate consideration before being dismissed. If a complaint is dismissed, the person making the complaint will be sent a letter explaining actions taken. These complaints will be managed in a timely manner.  The public will also be given the opportunity to appear before the board to speak upon matters under the board's jurisdiction (BON, 2019).

Subchapter F: License Requirements

A license is required to practice professional or vocational nursing in the state of Texas. Unless a license is held, a person cannot use the title of "Registered Nurse," "Professional Nurse," "Licensed Vocational Nurse," "Vocational Nurse," "Licensed Practical Nurse," "Practical Nurse," "Graduate Nurse," or any abbreviation of these titles. In order to obtain licensure, an applicant must submit to the BON a set of fingerprints and a form from the BON to obtain a criminal history record. The BON may deny a license applicant for not complying with this requirement. Each applicant must submit to the BON an application and evidence that the applicant has a good professional character, successfully completion of a program of professional or vocational nursing, and evidence of passing the jurisprudence examination provided by the BON. The jurisprudence exam is conducted on licensing requirements, rules, regulations, and other laws related to the nursing profession in Texas (BON, 2019).

An applicant is required to take the examination prescribed by the BON—currently, the National Council for Licensure Examination [NCLEX] is used in Texas—as long as the applicant meets the qualifications and pays the fees required. The examination must be prepared by a national testing service or the BON. The exam is designed to determine the competence of the applicant and their ability to practice professional or vocational nursing. The BON determines what constitutes a passing score on the examination, but the requirements will not exceed those required by the majority of states. The BON will notify the examinee of the results of the exam. If the applicant fails the exam, the BON will establish conditions for the applicant to retake the exam. For an applicant who fails twice or more, the BON may require the applicant to take additional educational requirements or deny the applicant the opportunity to retake the exam. Pending the results of the exam, the BON may issue a permit to practice professional nursing under the direct supervision of an RN or to practice vocational nursing under the direct supervision of an RN or LVN. The permit expires upon the receipt of a permanent license or 6 months after the date the permit was issued. Applicants who have previously failed the exam cannot obtain a temporary permit (BON, 2019).

An applicant who is licensed as an RN or LVN in another state may qualify for a temporary license to practice in Texas by submitting an endorsement fee, a completed sworn application, evidence that they possess the qualifications for licensing in Texas, and proof of initial license by examination. The applicant must have no history of suspension or restriction of their license (BON, 2019).

Nurses not actively engaged in professional or vocational nursing may have their license placed on inactive status by the BON. This is done after the licensee submits a written request to the BON. A person with a license on inactive status may reactivate the license by requesting the BON to remove the inactive status, pay a fee, and meet requirements determined by the BON (2019).

Subchapter G: License Renewal

A person may renew an unexpired license with payment of a renewal fee to the BON before the expiration date and compliance with any other renewal requirements. Texas has a 2-year licensure period. A person who has a licensed that is expired for 90 days or less may renew that license by paying the required fee and a late fee. For licenses that have been expired for over 90 days but less than 1 year, a renewal will require payment of renewal fees and a late fee that is twice the original late fee. Practicing professional or vocational nursing after the expiration date is illegal and may cause the license to be revoked or suspended. If the nurse has an expired Texas license but has been practicing nursing in another state for the 2 years preceding the application, they may renew an expired Texas license by paying for an initial license fee and a renewal fee (BON, 2019).

The BON requires continuing competency as a condition of license renewal. The BON may not require more than 20 hours of continuing education in 2 years (BON, 2019). The current recommendations and requirements for TX licensees are listed in Table 1.

Subchapter H: Practice by License Holder

When practicing nursing for the general public, a nurse is expected to wear a clearly legible insignia with their nursing designation identified. The insignia may not contain information other than the RN/LVN designation, the nurse's name, certifications, degrees, position, employer, or picture. A nurse cannot be suspended, terminated, disciplined, or discriminated against for refusing to engage in an act or omission of patient care that would constitute grounds for being reported or a violation of the NPA. Nurses may not be penalized for refusing to work mandatory overtime, as this does not constitute patient abandonment or neglect. The practice of vocational nursing must be performed under the supervision of an RN, a physician, a physician assistant, a podiatrist, or a dentist (BON, 2019).

Subchapter I: Reporting Violations and Patient Care Concerns

A report is considered to be made in good faith if the nurse making the report believes (a) it is required or authorized and (b) there is a reasonable legal basis for that belief. A nurse must report another nurse if they have a reasonable cause to suspect that the other nurse has engaged in conduct that is subject to reporting, is a student unable to perform services of the nursing profession, or is impaired by chemical dependency. The report must be written and signed. A nurse may report a practitioner, agency, or facility if the nurse has reasonable cause to believe they have exposed a patient to a substantial risk of harm. The BON also states that it is the duty of peer review committees, nursing education programs, employers, professional associations, state agencies, and liability insurers to report a licensed nurse or nursing student for conduct subject to review, termination, or suspension, chemical abuse, or failing to provide nursing care. Prosecuting attorneys should forward to the BON a court record of any convictions of a felony, misdemeanor involving moral turpitude, violation of narcotic or controlled substance laws, Medicare or Medicaid fraud or abuse, or finding that the nurse is mentally ill or incompetent. The nurse will receive notice of what was reported to the board and be given a chance to submit a written rebuttal. If the BON determines it is necessary, an investigation will occur. The BON will decide if the licensee's continued practice of nursing poses a risk of harm. If the BON decides not to investigate, they will maintain a record of the report. These reports may be investigated if there are two or more similar reports in 5 years (BON, 2019).

Subchapters J-L: Prohibited Practices, Disciplinary Actions, and Penalties

A person is subject to license refusal or disciplinary action for the following reasons:

• a violation of this chapter, a rule or regulation not inconsistent with this chapter, or an order issued under this chapter;
• fraud or deceit in procuring or attempting to procure a license to practice professional nursing or vocational nursing;
• a conviction for, or placement on deferred adjudication community supervision or deferred disposition for, a felony or for a misdemeanor involving moral turpitude;
• conduct that results in the revocation of probation imposed because of conviction for a felony or a misdemeanor involving moral turpitude;
• use of a nursing license, diploma, or permit, or the transcript of such a document, that has been fraudulently purchased, issued, counterfeited, or materially altered;
• impersonating or acting as a proxy for another person in the licensing examination required under section 301.253 or 301.255;
• directly or indirectly aiding or abetting an unlicensed person in connection with the unauthorized practice of nursing;
• revocation, suspension, or denial of, or any other action relating to, the person's license or privilege to practice nursing in another jurisdiction or under federal law;
• intemperate use of alcohol or drugs that the board determines endangers or could endanger a patient;
• unprofessional conduct in the practice of nursing that is likely to deceive, defraud, or injure a patient or the public;
• adjudication of mental incompetency;
• a lack of fitness to practice because of a mental or physical health condition that could result in injury to a patient or the public; or
• failure to care adequately for a patient or to conform to the minimum standards of acceptable nursing practice in a manner that, in the board's opinion, exposes a patient or another person unnecessarily to risk of harm (BON, 2019).

A person may also be refused admission to the licensing examination for the above-listed behaviors. The board may require a nurse or an applicant to submit to a physical or psychological evaluation only if the BON has probable cause to believe they have a physical or mental impairment or chemical dependency that would affect the care of patients. The BON will also temporarily suspend the license of a nurse if the nurse tests positive for alcohol or a prohibited drug, refuses to comply with the BON for a drug or alcohol test, or fails to participate in the peer assistance program or if the program issues a letter of dismissal (BON, 2019).

The decision by the BON to suspend or restrict a license is determined by a simple majority vote of the BON based on the evidence presented. A proceeding is initiated with a complaint filed in writing. A preliminary investigation will be done. If probable cause is found, the BON will file formal charges against the nurse. The BON will determine whether there exists a continuing and imminent threat to public welfare if the nurse continues to practice. The nurse will be required to appear in person or by counsel to a formal hearing. If the BON determines that cause for disciplinary action is present, one or more of the following will be imposed:

• denial of an application for a license or renewal
• written warning
• public reprimand
• limitation or restriction of license
• suspension of license
• revocation of license
• monetary fine or administrative penalty (BON, 2019)

If the BON decides on disciplinary action, including warnings and reprimands, the BON will send a copy of the final order to the nurse and the last known employer of the nurse. If the BON suspends or revokes a license, or the nurse surrenders their license, the BON may impose conditions for reinstatement that must be satisfied before issuing a new license. For administrative penalties, the person can pay the penalty or file a petition for judicial review to appeal the decision. If the court rules that the penalty is not sustained, the court will order that the penalty is not owed. Administrative penalties do accrue interest. If a person is found in violation of the NPA, they may be liable for a civil or criminal penalty, depending on the violation (BON, 2019).

Subchapter M: Anesthesia in the Outpatient Setting

The BON establishes minimum standards for anesthesia services. These rules are designed to protect the health, safety, and welfare of the public. These rules do not apply to local anesthesia or peripheral nerve blocks, a licensed hospital, a licensed ambulatory surgical center, a clinic on Native North American land, a state or local government-owned facility, or an outpatient setting accredited by other accrediting bodies. Any certified registered nurse anesthetist providing anesthesia services in an outpatient setting shall comply with the rules adopted by the BON. The nurse anesthetist will also be required to register biennially and pay a fee. The BON may conduct inspections to enforce these rules (BON, 2019).

Subchapter N: Corrective Action Proceeding and Deferred Action

Corrective action is a fine, remedial education, or a combination of both that is imposed upon the licensee. It is not considered a disciplinary action and is subject to disclosure similarly to a complaint. Deferred action is an action against a licensee that is deferred to a later time. The BON may defer the final action if the person conforms to the conditions imposed by the BON. The BON may also dismiss the complaint if the licensee successfully meets the imposed conditions (BON, 2019).

Chapter 303: Nursing Peer Review

The nursing peer review committee (NPRC) is established under the authority of a governing body to conduct peer reviews of nurse employees. The governing body can be a nurse association, an agency, a nursing home, a health care facility, etc. A peer review consists of the evaluation of nursing services, the qualifications of a nurse, the quality of patient care, or the merits of complaints. The committee will give the nurse being reviewed due process, including notice and opportunity for a hearing, and then make recommendations regarding complaints. An NPRC must have nurses as three-fourths of its members. An NPRC that reviews VNs must have VNs as its members. An NPRC that conducts peer reviews on RNs must have RNs as two-thirds of its members. An NPRC is a confidential proceeding, and all communication is privileged. The NPRC will evaluate a nurse's conduct and decide the extent to which a deficiency in care was the result of deficiencies in the nurse's judgment, knowledge, training, or skill. A nurse who requests a peer review in good faith cannot be disciplined or retaliated against (BON, 2019).

Chapter 304: Nurse License Compact

Nurses who hold multistate licenses can practice in other states listed as Nurse Licensure Compact States. A multistate license to practice registered or practical nursing issued by a home state will be recognized by each state under the multistate licensure privilege and allow the nurse to practice as an RN or VN, according to the license. A nurse practicing in a state under the multistate license must comply with the state practice act where the patient is receiving treatment at the time service is provided. If the party-state takes action against the nurse, the home state will be contacted. The licensee's home state will take action against the nurse. The Texas BON will take action against a nurse with the same procedures for taking action against nurses practicing in Texas. If a nurse moves to another party state, the nurse must apply for licensure in the new home state, and the license issued by the old state will be deactivated (BON, 2019).

Texas Board of Nursing Administrative Code

The Texas BON Administration Code governs nursing practice, education, licensure, safety, reporting, and pain management. This module portion will focus on the chapters discussing nursing practice, ethics, and disciplinary action (NPA, 2020a).

Chapter 217.11: Standards of Practice

The Texas BON has standards of practice that establish a minimum acceptable level of nursing. Failure to meet these standards can result in action taken against the licensee, even if no patient injury occurred. The standards that apply to all nurses as listed in Chapter 217.11 include:

• know and conform to the Texas NPA and the BON'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;
• implement measures to promote a safe environment for clients and others;
• know the rationale for and the effects of medications and treatments and correctly administer the same;
• accurately and completely report and document:
  • the client's status, including signs and symptoms;
  • nursing care rendered;
  • physician, dentist, or podiatrist orders;
  • administration of medications and treatments;
  • client response(s); and
  • contacts with other health care team members concerning significant events regarding the client's status;
• respect the client's right to privacy by protecting confidential information unless required or allowed by law to disclose the information;
• promote and participate in education and counseling to a client(s) and, where applicable, the family/significant other(s) based on health needs;
• obtain instruction and supervision as necessary when implementing nursing procedures or practices;
• make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations;
• notify the appropriate supervisor when leaving a nursing assignment;
• know, recognize, and maintain professional boundaries of the nurse-client relationship;
• comply with mandatory reporting requirements of the Texas Occupations Code Chapter 301 (NPA), Subchapter I, which include reporting a nurse:
  • who violates the NPA or a board rule and consequently contributed to the death or serious injury of a patient;
  • whose conduct causes a person to suspect that the nurse's practice is impaired by chemical dependency or drug or alcohol abuse;
  • whose actions constitute abuse, exploitation, fraud, or a violation of professional boundaries; or
  • whose actions indicate that the nurse lacks knowledge, skill, judgment, or conscientiousness to such an extent that the nurse's continued practice could reasonably be expected to pose a risk of harm to a patient or another person, regardless of whether the conduct consists of a single incident or a pattern of behavior;
  • except for minor incidents, peer review, or peer assistance if no practice violation has occurred, as stated in the NPA and board rules;
• provide, without discrimination, nursing services regardless of the age, disability, economic status, gender, national origin, race, religion, health problems, or sexual orientation of the client served;
• institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications;
• clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious, or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment;
• implement measures to prevent exposure to infectious pathogens and communicable conditions;
• collaborate with the client, members of the health care team, and, when appropriate, the client's significant other(s) in the interest of the client's health care;
• consult with, utilize, and make referrals to appropriate community agencies and health care resources to provide continuity of care;
• be responsible for one's continuing competence in nursing practice and individual professional growth;
• make assignments to others that take into consideration client safety and that are commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made;
• 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;
• supervise nursing care provided by others for whom the nurse is professionally responsible; and
• ensure the verification of current Texas licensure or other compact state licensure privilege and credentials of personnel for whom the nurse is administratively responsible when acting in the role of a nurse administrator (TAC, n.d.).

Standards Specific to LVNs

The LVN practice is a directed scope of nursing practice under the supervision of an RN, APRN, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of a performance of an activity. The LVN shall assist in the determination of predictable health care needs of clients within health care settings and perform the standards applicable to vocational nurses. As listed in Chapter 217.11, an LVN:

• shall utilize a systematic approach to provide individualized, goal-directed nursing care by:
  • collecting data and performing focused nursing assessments,
  • participating in the planning of nursing care needs for clients,
  • participating in the development and modification of the comprehensive nursing care plan for assigned clients,
  • implementing appropriate aspects of care within the LVN's scope of practice, and
  • assisting in the evaluation of the client's responses to nursing interventions and the identification of client needs;
• shall assign specific tasks, activities, and functions to unlicensed personnel commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made and shall maintain appropriate supervision of unlicensed personnel; and
• may perform other acts that require education and training as prescribed by board rules and policies, commensurate with the licensed vocational nurse's experience, continuing education, and demonstrated licensed vocational nurse competencies (TAC, n.d.).

Standards Specific to RNs

The RN shall assist in the determination of clients' health care needs and perform the standards applicable to registered nurses. As listed in Chapter 217.11, an RN shall:

• utilize a systematic approach to provide individualized, goal-directed nursing care by:
  • performing comprehensive nursing assessments regarding the health status of the client,
  • making nursing diagnoses that serve as the basis for the strategy of care,
  • developing a plan of care based on the assessment and nursing diagnosis,
  • implementing nursing care, and
  • evaluating the client's responses to nursing interventions; and
• delegate tasks to unlicensed personnel in compliance with Chapter 224 of this title, relating to clients with acute conditions or in acute care environments, and Chapter 225 of this title, relating to independent living environments for clients with stable and predictable conditions (TAC, n.d.).

Standards Specific to RNs with Advanced Practice Authorization

Standards for a specific role and specialty of advanced practice nurse supersede standards for RNs if a conflict between the standards arises. In addition to paragraphs 1 and 3 of this subsection, an RN who holds authorization to practice as an APRN shall perform the standards as listed in Chapter 217.11:

• practice in an advanced nursing practice role and specialty in accordance with the authorization granted by the board; and
• prescribe medications in accordance with the prescriptive authority granted under the board with standards set by the NPA and in compliance with state and federal laws and regulations relating to the prescription of dangerous drugs and controlled substances (TAC, n.d.).

Chapter 217.12: Unprofessional Conduct

Nursing has been voted the most honest and ethical profession in the United States for the past 19 years (American Nurses Association [ANA], 2020). Nurses have a code of ethics that guides the members of the profession. The nursing code of ethics was established by the ANA and state boards of nursing (ANA, 2015).

There are four main principles of the nursing code of ethics that nurses should be aware of in their daily practice. These principles are:

• autonomy – recognizing each individual's right to self-determination and decision making
• beneficence – acting for the good and welfare of others with attributes such as kindness and charity, also defined as actions guided by compassion
• justice – having an element of fairness in all medical and nursing decisions and care
• non-maleficence – doing no harm by selecting interventions that will cause the least harm to the patient (ANA, 2015)

There are nine main provisions in the ANA's nursing code of ethics. This code of ethics includes an interpretive statement that provides more specific guidance for a nurse's practice. These provisions of the nursing code of ethics are as follows (ANA, 2015):

1. The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.
2. The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population.
3. The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.
4. The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to provide optimal patient care.
5. The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.
6. The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.
7. The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.
8. The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.
9. The profession of nursing, collectively through its professional organization, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

Safe and ethical nursing practice requires knowledge of the laws that govern nursing and avoidance of unprofessional conduct. The following rules, found in Chapter 217.12, are used by the Texas Secretary of State to identify behaviors in the practice of nursing that are likely to deceive, defraud, or injure patients or the public.

• unsafe practice – actions or conduct including, but not limited to:
  • carelessly failing, repeatedly failing, or exhibiting an inability to perform vocational, registered, or advanced practice nursing in conformity with the standards of a minimum acceptable level of nursing practice set out in §217.11 of this chapter;
  • failing to conform to generally accepted nursing standards in applicable practice settings;
  • improper management of client records;
  • delegating or assigning nursing functions or a prescribed health function when the delegation or assignment could reasonably be expected to result in unsafe or ineffective client care;
  • accepting the assignment of nursing functions or a prescribed health function when the acceptance of the assignment could be reasonably expected to result in unsafe or ineffective client care; or
  • failing to supervise the performance of tasks by any individual working pursuant to the nurse's delegation or assignment;
• failure of a clinical nursing instructor to supervise or to assure adequate supervision of student experiences;
• failure of a chief administrative nurse to follow standards and guidelines required by federal or state law or regulation or by facility policy in providing oversight of the nursing organization and nursing services for which the nurse is administratively responsible;
• failure to practice within a modified scope of practice or with the required accommodations, as specified by the board, in granting an encumbered license or any stipulated agreement with the board;
• conduct that may endanger a client's life, health, or safety;
• inability to practice safely – a demonstration of actual or potential inability to practice nursing with reasonable skill and safety to clients because of illness, use of alcohol, drugs, chemicals, or any other mood-altering substances, or as a result of any mental or physical condition;
• misconduct – actions or conduct that include, but are not limited to:
  • falsifying reports, client documentation, agency records, or other documents;
  • failing to cooperate with a lawful investigation conducted by the board;
  • causing or permitting physical, emotional, or verbal abuse or injury or neglect to the client or the public, or failing to report same to the employer, appropriate legal authority, and/or licensing board;
  • violating professional boundaries of the nurse/client relationship, including but not limited to physical, sexual, emotional, or financial exploitation of the client or the client's significant other(s);
  • engaging in sexual conduct with a client, touching a client in a sexual manner, requesting or offering sexual favors, or demonstrating language or behavior suggestive of the same;
  • threatening or violent behavior in the workplace;
  • misappropriating, in connection with the practice of nursing, anything of value or benefit, including, but not limited to, any property—real or personal—of the client, employer, or any other person or entity, or failing to take precautions to prevent such misappropriation;
  • providing information that was false, deceptive, or misleading in connection with the practice of nursing;
  • failing to answer specific questions or providing false or misleading answers in a licensure or employment matter that could reasonably affect the decision to license, employ, certify, or otherwise utilize a nurse; or
  • 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 with the performance of professional services;
• failure to pay child support payments as required by the Texas Family Code;
• drug diversion – the diversion or attempts to divert drugs or controlled substances;
• dismissal from a board-approved peer assistance program for noncompliance and referral by that program to the board;
• other drug-related actions or conduct that include, but are not limited to:
  • use of any controlled substance or any drug, prescribed or unprescribed, or device or alcoholic beverages while on duty or on call and to the extent that such use may impair the nurse's ability to conduct safely to the public the practice authorized by the nurse's license;
  • falsification of or making incorrect, inconsistent, or unintelligible entries in any agency, client, or other record pertaining to drugs or controlled substances;
  • failing to follow the policy and procedure in place for the wastage of medications at the facility where the nurse was employed or working at the time of the incident(s);
  • a positive drug screen for which there is no lawful prescription; or
  • obtaining or attempting to obtain or deliver medication(s) through means of misrepresentation, fraud, forgery, deception, and/or subterfuge;
• unlawful practice – actions or conduct that include, but are not limited to:
  • knowingly aiding, assisting, advising, or allowing an unlicensed person to engage in the unlawful practice of vocational, registered, or advanced practice nursing;
  • violating an order of the board, carelessly or repetitively violating a state or federal law relating to the practice of vocational, registered, or advanced practice nursing, or violating a state or federal narcotics or controlled substance law;
  • aiding, assisting, advising, or allowing a nurse under board order to violate the conditions set forth in the order; or
  • failing to report violations of the Nursing Practice Act and/or the board's rules and regulations;
• leaving a nursing assignment, including a supervisory assignment, without notifying the appropriate personnel (TAC, n.d.).

Board of Nursing Position Statements

The BON uses position statements to give an expert opinion on issues that affect its members. These position statements provide guidance with the most relevant information; however, they are not legally enforceable. The Texas BON reviews its position statements and updates them when needed. There are 28 position statements, and these are advised to be reviewed. As an example, this module will highlight the position statement related to professional boundaries (TX BON, 2020b).

Texas BON Position Statement on Professional Boundaries

The purpose of this position statement is to offer guidance related to professional boundaries and provide nurses with guidance to prevent violations of these boundaries. Social media is included in this section. The Texas BON holds nurses accountable for knowing, recognizing, and maintaining professional boundaries with patients. Professional boundaries are defined as "appropriate limits which should be established by the nurse in the nurse/patient relationship due to the nurse's power and the patient's vulnerability" (TX BON, 2020b). Professional boundaries include provisions of nursing services that promote each patient's dignity and refrain from inappropriate involvement in each patient's relationships. Professional boundaries also prohibit the nurse's personal gain at the patient's expense. The National Council of State Boards of Nursing (NCSBN) defines professional boundaries as the spaces between the nurse's power and the patient's vulnerability. Nurses have a professional position and access to sensitive personal information. An imbalance of power results from the difference in personal information the nurse knows about the patient compared to what the patient knows about the nurse. Nurses must respect this power imbalance and ensure a patient-centered relationship (TX BON, 2020b).

Patients rely on nurses to have adequate knowledge and to advocate for their patients' health care. The nurse has a duty to protect the patient and recognize that over- and under-involvement can harm the patient. The nurse is responsible for knowing the difference in boundaries for each patient, as each patient is different. Care should be adjusted depending on each patient's needs (TX BON, 2020b).

A violation of professional boundaries is considered conduct subject to reporting. A professional boundary violation is considered unprofessional conduct. Professional boundary violations include physical, sexual, emotional, and financial violations (TX BON, 2020b).

Nurses have access to personal information and play a significant role in the transmission and interpretation of information. As technology and social media continue to expand, rapid information exchange can pose risks to patients and nurses. The BON recognizes that social media can be a valuable tool in health care, but multiple consequences result if it is used inappropriately. Online postings can harm patients if protected health information is disclosed. Social media postings may also reflect negatively on individual nurses, the nursing profession, or employers. The BON has articulated the following position on the use of social media (TX BON, 2020b):

• Nurses have an ethical and legal obligation to maintain patient privacy and confidentiality at all times. When using social media, nurses do not identify patients by name or post or publish information that may lead to the identification of a patient. Limiting access to postings through privacy settings is not sufficient to ensure privacy. Nurses must promptly report any identified breach of confidentiality or privacy.
• Nurses maintain professional boundaries in the use of electronic media. The nurse must establish, communicate, and enforce professional boundaries with patients in the online environment. Nurses do not refer to patients disparagingly, even if the patient is not identified, or transmit information that may be reasonably anticipated to violate patient rights to confidentiality or privacy or otherwise degrade or embarrass the patient.
• Nurses must provide nursing services without discrimination and do not make threatening, harassing, profane, obscene, sexually explicit, racially derogatory, homophobic, or other offensive comments.
• Nurses must be aware of and comply with all laws and rules, including employer policies regarding the use of electronic devices, such as employer-owned computers, cameras, and personal devices in the workplace. In addition, nurses must ensure appropriate and therapeutic use of all patient-related electronic media—including patient-related images, photos, or videos—in accordance with applicable laws, rules, and institutional policies and procedures.

References

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/

American Nurses Association. (2020, January 6). ANA president proud of nurses for maintaining #1 spot in Gallup's 2019 Most Honest and Ethical Professions Poll. [Press release]. https://www.nursingworld.org/news/news-releases/2020/american-nurses-association-president-proud-of-nurses-for-maintaining-1-spot--in-gallups-2019-most-honest-and-ethical-professions-poll/

Bullough, B. (1976). The law and expanding nursing role. American Journal of Public Health, 66(3), 249-254. https://doi.org/10.2105/AJPH.66.3.249

Martin, E., & Zolnierek, C. (2020). Beyond the nurse practice act: Making a difference through advocacy. Online Journal of Issues in Nursing, 25(1).

Russell, K. (2017). Nurse practice acts guide and govern: Update 2017. Journal of Nursing Regulation, 8(3), 18-25. https://doi.org/10.1016/S2155-8256(17)30156-4

Texas Administrative Code, Title 22, Part 11, Chapters 211-228 (n.d.). https://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=3&ti=22&pt=11

Texas Board of Nursing. (2013). Mission and values. https://www.bon.texas.gov/about_mission_and_values.asp

Texas Board of Nursing. (2019). Nursing practice act, nursing peer review, & nurse licensure compact: Texas Occupations Code as amended September 2019. https://www.bon.texas.gov/pdfs/law_rules_pdfs/nursing_practice_act_pdfs/NPA2019.pdf

Texas Board of Nursing. (2020a). Texas Board of Nursing rules and regulations relating to nurse education, licensure, and practice. https://www.bon.texas.gov/laws_and_rules_rules_and_regulations_current.asp

Texas Board of Nursing. (2020b). Texas Board of Nursing position statements. https://www.bon.texas.gov/practice_bon_position_statements_content.asp

Applying Rule 217.19, What, If Any, Violations Of The Rule Occurred In The Above Scenario?

Source: https://www.nursingce.com/ceu-courses/nursing-jurisprudence-and-ethics

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