Source: http://bon.texas.gov/practice_guidelines.asp
Timestamp: 2019-04-18 10:36:37+00:00

Document:
The Board's mission is 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. This mission, derived from the Nursing Practice Act, supersedes the interest of any individual, the nursing profession, or any special interest group. Adherence to the NPA, Rules, and Guidelines related to GVNs, GNs and newly licensed LVNs and RNs will help assure the safety of the clients these novice nurses encounter, as well as supplying the necessary support and guidance to the next generation of licensed nurses in Texas.
In accordance with Rule 217.3(a): "A new graduate who completes an accredited basic nursing education program within the United States, its Territories, or Possessions and who applies for initial licensure by examination in Texas may be temporarily authorized to practice nursing as a graduate nurse (GN) or graduate vocational nurse (GVN) pending the results of the licensing examination." This temporary authorization is not renewable and will expire the earliest date of any of the following: (1) when the candidate passes the NCLEX-PN® or NCLEX-RN® test; (2) when the candidate fails the NCLEX-PN® or NCLEX-RN® test; (3) or on the 75th day following the effective date of the temporary authorization [217.3(2)].
Candidates graduating from nursing programs outside of the United States jurisdiction who are seeking Texas licensure through examination are not eligible for temporary authorization [Rule 217.4]. Licensure candidates who have previously failed the NCLEX-PN® or NCLEX-RN® are also ineligible for temporary permission to practice. A graduate of a nursing program within the United States jurisdiction may be deemed ineligible for temporary permission to practice based upon a Board determination under NPA Section 301.257 and Rule 213.30 relating to Declaratory Order of Eligibility for Licensure.
Verification of Temporary "Permission to Practice"
Effective January 1, 2006, a licensure candidate (GVN or GN) who meets Board requirements will be issued a temporary "permission to practice" via the Board's web site at www.bon.state.tx.us. Potential employers must verify that a licensure candidate has current temporary "permission to practice" via the web page or by phoning the Board at (512) 305-7400. Hard-copy (paper) temporary permits are no longer issued.
Expired or Invalid "Permission to Practice"
New graduates may not continue to practice as GVNs or GNs after failing the NCLEX-RN® or NCLEX-PN® , even if the expiration date of the temporary permission to practice has not expired. Employers must follow-up on the results of the new graduate’s test results, either by asking to see the new graduate’s test results, monitoring the issuance of a license using the automated phone line (512/305-7400), or utilizing the on-line licensure verification process on the Board’s web page. If the new graduate is allowed to continue to practice after receiving notice of failing the NCLEX-RN® or NCLEX-PN® , both the nurse manager and the new graduate may be subject to disciplinary action by the Board.
The Board will not issue a GVN or GN permission to practice until all application processes are complete, enabling the new graduate to be deemed eligible to sit for the NCLEX-PN® or NCLEX-RN® exam. The new graduate should schedule to sit for the applicable licensure exam as soon as possible because his/her Authorization To Test (ATT) is only active for a period of 75 days. If the new graduate does not test in time to receive a nursing license before the date that the permission to practice expires, the GVN or GN must cease practicing as a graduate nurse. There are no extensions for the temporary permission to practice as a GVN or GN based on failure to schedule the licensing examination.
In accordance with Texas Occupations Code §301.254 (Nursing Practice Act), results of NCLEX-PN® or NCLEX-RN® are mailed to applicants within 30 days of testing. The new graduate may choose to participate in obtaining "quick results" from the test vendor (NCS Pearson) within 48 hours of testing; however, these quick results are unofficial and cannot be considered as evidence of successful exam completion until verified directly from NCS Pearson/VUE to the Board. Employers and/or candidates may use either the on-line licensure verification system or the automated phone line (512/305-7400) to verify whether the GVN or GN has been issued a license by using the licensure candidate's social security number. Please be aware that both the automated phone line and on-line verification systems will only verify that a license has been issued. Neither system will inform the caller about failure to pass the examination; therefore, absence of the GVN or GN on the applicable registry means only that a license has not been issued as of the date of inquiry. IT DOES NOT NECESSARILY MEAN THAT THE GVN or GN HAS FAILED THE LICENSURE EXAM. Please do not call the Board office to inquire about examination results. Staff cannot release results over the telephone until at least 21 days after testing have elapsed.
Each licensure candidate as well as each newly licensed nurse in Texas is responsible to know and comply with the current Nursing Practice Act (NPA) and the Board Rules and Regulations. We recommend starting with the definitions of professional and vocational nursing in the NPA §301.002(2) and (5), and §301.353 relating to vocational nurse supervision. The two rules most often applied to nursing practice in any setting should also be studied: Rule 217.11, Standards of Nursing Practice, and Rule 217.12, Unprofessional Conduct. Both the NPA and Rules may be viewed in their entirety on the Board’s web page at www.bon.state.tx.us, or hard copies may be purchased.
It is also the responsibility of each licensed nurse to maintain his/her knowledge of the most current NPA and Rules. The most current regulations can be found on our website. Updates are also printed in the Board's quarterly newsletter, the Texas Board of Nursing Bulletin, that is mailed to all current licensees who live within the United States. Archived issues of the Bulletin are also on the Board’s website.
Both the graduate nurse (GVN or GN) and the newly licensed nurse are in a transitional process from student to professional. As a novice practitioner, the GVN, GN or new LVN or RN is inexperienced and not fully integrated into his/her professional nursing role and setting. The Board believes it is essential during this transitional period for the new graduate or newly licenced nurse to seek and receive direction, supervision, consultation and collaboration from experienced nurses.
Rule 217.3(a)(3), Temporary Authorization to Practice, mandates that the new graduate who has been authorized to practice as either a GVN or GN pending the results of the licensing examination must work under the direct supervision of a licensed nurse. Vocational nursing graduates must work under the direct supervision of either a LVN or RN; registered professional nursing graduates must work under the direct supervision of a RN. "Direct supervision" means the licensed nurse is physically present in the facility or practice setting and is readily available to the GVN or GN for consultation and assistance. If the facility is organized into multiple units that are geographically distanced from each other, then the supervising nurse must be working on the same unit to which the new graduate is assigned.
A graduate nurse (GVN or GN) is not yet "licensed," and thus shall not be placed in supervisory or charge positions and shall not work in independent practice settings, such as home health. A licensure candidate (GVN or GN) must first achieve nursing licensure through passing the NCLEX-PN® or NCLEX-RN® prior to any consideration of employment involving charge nurse/nurse manager responsibilities or nursing in independent practice settings.
Once licensed, direct supervision should be continued for a period of six months, or a 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 documentation.
New graduates are permitted to perform any function that falls within the scope of nursing practice for which they have received educational preparation and have demonstrated minimal competency.
It is recommended that a newly licensed nurse not hold a position as a charge nurse or nurse manager for a period of six (6) months, unless a lesser time period is mutually agreed upon by the newly licensed nurse and the supervising nurse based upon the evaluation of competency of the newly licensed LVN or RN.
It is recommended that a newly licensed nurse not practice in independent settings, such as home health, for a period of 12-18 months post-licensure to allow the new nurse sufficient practice experience in more structured settings in order to assimilate knowledge learned in school consistently into practice.
In any practice setting where new graduates are employed, experienced nurses should be willing to supervise and mentor the new graduate.
Nurses in the State of Texas may interrupt their practice or change their primary area of practice for a variety of reasons. The impact that a change of practice area or lack of continuity in practice may have on the competence of the nurse is of concern to the Texas Board of Nursing, as either situation may affect the nurse's ability to provide safe and effective nursing care that complies with the Nursing Practice Act (NPA) and Board Rules. A nurse who has not practiced and is re-entering the work force after a period of four or more years may not be current in his/her knowledge base of new drugs, current therapies, and/or changes in technology. A nurse who is transitioning into a practice setting that differs greatly from the nurse's previous experience may also lack the necessary knowledge to immediately assume responsibility for patient care. In 1994, a study conducted by the Board and Lamar University identified that nurses who fit into one of the above two categories were at highest risk for committing practice errors that resulted in Board discipline against the nurse's license. The Board, therefore, believes it is essential that during the transitional period, either back into practice or into a new practice area, that the nurse seek and receive appropriate orientation, direction, supervision, consultation and collaboration from nurses who possess current skills and knowledge of the particular practice environment.
Rule 217.11, Standards of Nursing Practice, requires that when assignments are made, both the charge nurse and the staff nurse take into consideration client safety, as well as the educational preparation, knowledge, skills, and physical and emotional abilities of the individual licensed nurse to whom a given assignment is being made.
(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.
Direct supervision should be continued for a period mutually determined by the nurse and his/her supervisor/nurse preceptor. Competence to perform safely and independently should be one of the determining factors. Direct supervision means an experienced nurse (minimum 2 years experience) is immediately available on site to coordinate, direct and observe at firsthand another individual for whom the nurse is responsible.
The nurse should be permitted to perform any function that falls within the scope of nursing practice for which he/she has received educational preparation and has demonstrated minimal competency.
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 six months, unless a lesser time period is agreed upon by the nurse and his/her supervisor based upon documented competency of the nurse.
Staff nurses should be willing to supervise, collaborate with, and/or mentor nurses returning to work or changing their practice area or role.
Evaluate each nurse on an ongoing basis, (not to exceed six months in accordance with §217.3), in order to determine the competence of the nurse to perform at a minimally safe level commensurate with the nurse's licensure.
The Board provides these guidelines to assist employers and nurses to safely integrate into the current role and functions of licensed vocational or professional nursing as applicable.
A.Green et al. (1994). Disciplined Professional Nurses in the State of Texas.
A.Green et al. (1995). "Are you at risk for disciplinary action?" American Journal of Nursing. 95(7), 37-41.
The Texas Board of Nursing recognizes that advanced nursing practice is dynamic. The scope of advanced practice evolves through experience, acquisition of knowledge, evidence-based practice, technology development and changes in the health care delivery system. Therefore, advanced practice nurses may need to practice in new settings, perform new procedures, and develop new skills during their professional careers. It is common for the Board of Nurse Examiners to receive questions such as, "Can an advanced practice nurse treat a patient with that condition?", or "Is it within the scope of practice of an advanced practice nurse to perform that procedure?"
Scope of practice is defined as the activities that an individual health care provider performs in the delivery of patient care. Scope of practice reflects the types of patients for whom the advanced practice nurse can care; what procedures/activities the advanced practice nurse can perform; and influences the ability of the advanced practice nurse to seek reimbursement for services provided.
Both professional and individual scopes of practice exist. Professional scopes of practice are derived from professional specialty and advanced practice nursing organizations. An individual advanced practice nurse may or may not practice the full scope of the professional role and specialty. Decisions regarding individual scope of practice are complex and related to an advanced practice nurse's knowledge, skills and competencies. Each advanced practice nurse must practice within his/her individual scope.
National professional specialty and advanced practice nursing organizations broadly define scope of practice for each role. These documents address role, function, population served, and practice setting. They offer advanced practice nurses the broadest parameters for scope of practice. Therefore, professional scopes of practice are recommended as the initial resource in defining an individual's scope of practice.
Formal advanced practice nursing education is the foundation for the individual's scope of practice and evolves over the professional lifetime of the individual. Clinical experience in various settings, continuing education, formal course work and developments in healthcare all impact individual scope of practice. However, there are finite limits to expansion of scope of practice without completing additional formal education. Advanced practice nurses cannot change their legally recognized titles or designations through experience or continuing education; these changes may only be achieved through additional formal educational preparation and meeting all legal requirements to use that title and practice in that specialty set forth by the BON.
Is it consistent with one's professional scope of practice?
Is it consistent with statutory or regulatory laws?
Is it consistent with one's education in the role and specialty?
Is it consistent with the scope of one's recognized title or does it evolve into another	advanced practice title recognized by the board requiring additional formal education	and legal recognition?
Is it consistent with the Standards of Nursing Practice outlined in Board Rule 217.11?
Is it consistent with evidence-based care?
Is it consistent with reasonable and prudent practice?
Are you willing to accept accountability and liability for the activity and outcomes?
Identify the benefit for a new patient care activity, taking into consideration	consumer demand, standards for safe practice, and interest of the advanced	practice nurse.
Ensure that state or federal statutes and regulations do not constrain the advanced	practice nurse from incorporating the activity into practice.
Identify established professional standards, if available, supporting the performance	of the new activity.
Establish goals and methods for learning that encompass knowledge and skills	acquisition through which competence is attained.
Demonstrate competent performance of the procedure/activity.
Maintain records that reflect the acquisition and maintenance of competency.
The Texas Board of Nursing recognizes that individual scopes of practice will vary and that what is within the individual scope of practice for one advanced practice nurse may not be within the individual scope of practice for another advanced practice nurse authorized to practice in the same role and specialty. However, it is important to keep in mind that the Board holds each advanced practice registered nurse accountable for knowing and practicing within his/her professional and individual scope of practice.
When prescribing controlled substances, all advanced practice registered nurses (APRNs) are required to know and comply with Board Rule 222, relating to Advanced Practice Registered Nurses with Prescriptive Authority. APRNs who are engaged in providing pain management services are also required to comply with Board Rule 228, relating to Pain Management. It is important for all APRNs to know and recognize the challenges associated with prescribing these drugs and be certain they are in compliance with not only Board rules, but also the rules of the Texas State Board of Pharmacy and the US Drug Enforcement Administration (DEA) when writing such prescriptions. The rules of the Texas Medical Board also provide information regarding the practice of pain management. These guidelines are intended to comply with the requirement set forth in Texas Health and Safety Code, §481.0762(a) and to aid APRNs who prescribe opioids, benzodiazepines, barbiturates, and carisoprodol (Soma).
Four types of drugs are known to have significant addictive potential and are prevalent in health care provider disciplinary cases involving non-therapeutic prescribing. These drugs include opioids, benzodiazepines, barbiturates, and carisoprodol (Soma). The incidence of non-therapeutic prescribing of these drugs has significant public health implications. Information reported in the literature typically focuses on the rising number of emergency department visits for opioid-related overdoses and does not include emergency department visits for overdoses involving other categories of drugs, such as benzodiazepines, barbiturates and carisoprodol (Soma). There is also ongoing research regarding the links between the opioid epidemic and infectious diseases, such as hepatitis C and HIV. These implications are receiving attention in Texas and across the nation.
Texas Health and Safety Code, §481.0762 requires all agencies that license providers who have authority to prescribe controlled substances to develop guidelines for responsible prescribing of opioids, benzodiazepines, barbiturates, and carisoprodol (Soma). Although general principles of safe prescribing are applicable to prescribing of these types of drugs, there are additional considerations that providers should recognize.
Texas has a prescription monitoring program (PMP) that collects and monitors prescription data for all controlled substances dispensed by pharmacies in Texas or to Texas residents from a pharmacy that is located in another state. The PMP also allows providers to query their own prescribing history. It is important for all APRNs to recognize the importance of checking the Texas PMP before prescribing any controlled substance. The PMP and information about that program may be found on the Texas State Board of Pharmacy’s website at www.pharmacy.texas.gov/PMP/. Effective September 1, 2019, all APRNs who prescribe opioids, benzodiazepines, barbiturates, or carisoprodol (Soma) are required to access and review the Texas PMP in compliance with Texas Health and Safety Code, §481.0764(a).
When treating patients for pain, it is important for APRNs to recognize that the overarching goal of pain management is to treat the patient’s pain in a manner that provides therapeutic benefit to the patient. The patient’s overall health must be considered, including their level of physical function as well as psychological, social and work-related factors. Treatment plans must be supported by evidence based research and within the current standard of care for the patient’s condition. APRNs must be cautious to ensure that they are treating the patient’s condition and not only the patient’s symptoms.
Consultation and referral are an important part of providing care to patients who are experiencing pain. It is important for APRNs to keep in mind that pain has a physical component as well as a psychological component, and both must be addressed appropriately. Patients who are at risk for or who have known histories of substance use disorder are likely to require consultation and possible referral to providers with significant expertise in addictionology. Likewise, patients with co-existing psychological and/or psychiatric disorders will also require consultation and possible referral to an expert in the treatment of these disorders or conditions. APRNs must be aware of the limitations of their own level of knowledge and expertise and must refer appropriately as indicated.
APRNs must be aware of warnings issued by the FDA when prescribing these drugs. For example, the FDA issued a black box warning regarding issues such as respiratory depression, sleep apnea and even death when taking opioids alongside benzodiazepines or other central nervous system depressants, including alcohol. APRNs have a duty to consider these and other risks and to prescribe these drugs judiciously.
It is important for APRNs to remember that they must comply with the requirements of Board Rule 222.8 when prescribing any controlled substance. For example, testosterone is a Schedule III drug. When prescribing this drug or other controlled substances, all requirements of Board Rule 222.8 must be met, and it would be appropriate for the APRN to review the PMP when writing such prescriptions.

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