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Jurisprudence and Ethics for Nurses Licensed in Texas

2.00 Contact Hours
A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Author:    Julia Tortorice (RN, MBA, MSN, NEA-BC, CPHQ)

Outcomes

The purpose of this course is to prepare nurses licensed in Texas to practice within the perimeters of the Texas Nurse Practice Act.

Objectives

After completing this course the learner will be able to:

  • discuss the Texas nursing practice act
  • describe the Texas Board of nursing rules and regulations, including BON ruled 217. 11
  • apply standards of nursing practice
  • locate Texas Board of Nursing position statements
  • apply principles of nursing ethics
  • describe professional boundaries

If the font is in blue, it is a link to a website. Hold the ctrl button and click on the name to be taken to the site.

Introduction

Jurisprudence is the science or philosophy of law. The Texas Nurse Practice Act and the Texas Board of Nursing Rules and Regulations Relating to Nurse Education, Licensure, and Practice are the laws that govern the practice of nursing practice in Texas. Your nursing practice is directly affected by your ability to make informed decision within the parameters of these laws.  You need to know how the rules apply to you, and then apply them in your nursing practice.

The Texas Nurse Practice Act (NPA) is composed of statutes passed by the Texas State Legislature. The NPA grants the Texas board of nursing (BON) the authority to regulate nursing applicants and licensed nurses; provides broad statements of duties; and specifies how BON members are appointed.

Texas Board of Nursing Rules and Regulations relating to Nurse Education, Licensure, and Practice are regulations passed by the BON to clarify the nurse practice act. Rules and regulations are administrative law.

Statues plus Rules and Regulations define the responsibility of the BON and licensed nurses. You can find the Nurse Practice Act and Rules and Regulations by going to the Texas BON website at www. http://www.bne.state.tx.us/ and click on Laws & Rules. Below is a screenshot of the homepage showing the drop-down menu for laws and rules.


Texas Board of Nursing

Statutes and rules and regulations have complex numbering systems. You do not need to know that numbering system, because you can always look up the information by subject. The nursing rules and regulations is one chapter of a comprehensive document relating to other licensed professions. Each section is called a subchapter. So, the use of the word chapter in this course or in the rules and regulations   applies to the entire nursing rules and regulations.

Check the website regularly to keep up with any changes or additions that will affect your nursing practice. Make sure your contact information is up-to-date otherwise the license renewal notice will go to the wrong place.

The BON represents the people of Texas by ensuring that licensed nurses meet minimum standards of safe practice. The following is the BON Mission Statement: 1

Mission Statement: The mission of the Texas Board of Nursing 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. 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.

Licensure of nurses is a requirement to protect the people of Texas and ensure safe nursing care. The NPA stipulates that you cannot call yourself a nurse nor practice in the state of Texas without a license.

The BON DOES NOT:

  • answer questions about employment issues such as salaries, staffing ratios, or other workplace concerns
  • regulate practice settings or environments
  • protect or advocate for nurses
  • make decisions for you

The BON can help you understand how to practice safely and within the rules and regulations set up in the state of Texas.

Professional nursing associations DO:

  • represent their members in legislative, political, and policy matters
  • provide leadership in other areas, such as efforts to improve working conditions and benefits for nurses.

Texas Board of Nursing

The BON members are appointed by the governor. Membership includes:

  • one APRN
  • two RNs who are not APRN's nor faculty
  • three vocational nurses who are not faculty
  • three members who are nursing faculty for schools of nursing
  • one from a baccalaureate program
  • one from an associate program
  • one from a vocational nurse program
  • four members represent the public

The appointment terms are staggered six-year terms so that one third of the members are expired on January 31 of each odd-numbered year. The section goes on to define eligibility for membership in eligibility for membership removal from the BON.

License Requirements

Using the title of registered or licensed nurse is restricted to those with a license. This restriction exists to assure the public that the licensed nurse has specialized knowledge which is graduation from an approved nursing program and passing the licensure exam.

Licensure by Examination

Applicants for initial licensure must submit the following Rules and Regulations 217,2:,

  • a completed application containing all the data requested
  • verification of completion of all requirements for graduation from an approved nursing education program are certification from the nursing program director of us completion
  • pass the appropriate NCLEX exam within four years of completion of requirements for graduation
  • LVN applicants must hold a high school diploma or GED
    • if graduated from another US jurisdiction, the education program must satisfy the complete curriculum comparable to the Texas programs
  • FBI fingerprint print card provided by the board for a complete criminal background check
  • passage jurisprudence exam approved by the board

Graduates from Foreign Nursing Programs have additional verification processes. These requirements can be found under rules and regulations 217.4 regulations for initial licensure by examination for nurses who graduated from nursing education programs outside of United States to jurisdiction

Temporary Authorization to Practice

A new graduate who completes an approved 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 as a graduate nurse (GRN) or graduate vocational nurse (GVN) pending results of examination rules and regulations 217.3. To receive temporary authorization of practice the following must be submitted.

  • completed application
  • have no outstanding eligibility issues
  • have never taken the appropriate NCLEX
  • have registered to take the NCLEX

The temporary permit is valid for six months and cannot be renewed.

Graduate nurses who have already failed the NCLEX will not be granted temporary authorization to practice. Nurses who have not practice nursing for four more years may be issued a temporary permit for the limited period of completing a refresher course, or extended orientation. A nurse’s license that has been suspended, revoked, or surrendered due to action by the board may be issued a temporary permit for the limited purpose of meeting any requirements imposed by the board to have the license reissued Rules and Regulations 217.3.

Licensure by Endorsement

A practicing nurse from another state can apply for permanent licensure and a temporary permit that is valid for 120 days, and is not renewable, by doing the following: 

  • must have worked as a nurse in another state within the four years immediately preceding the request for licensure
  • graduated from an approved nursing program
  • satisfactory completion of the licensure examination according to the board establish minimum passing scores
  • licensure by another US jurisdiction
  • the complete application for temporary licensure/endorsement
  • pay nonrefundable application fee
  • submit fingerprints for complete criminal background check
  • pass jurisprudence examination

A nurse, who has not practiced nursing in another state within the four years immediately preceding their request for licensure by endorsement, must first complete a refresher course or extensive orientation. Graduates from Foreign Nursing Programs have additional verification processes. These requirements can be found under rules and regulations 217.4 and 217.5 (4).

There are situational rules for renewing a license when the license has lapsed is in Rules and Regulations Failure to Renew License 217.6.

License Renewal

The BON will send to license renewal notice at least 30 days before the license expires. Make sure your address and contact information is correct, to receive the renewal notice. You cannot renew more than two months before the expiration date. An unexpired license can be renewed by payment to the BON before the expiration date of the license. Rules and Regulation 301.3 explains renewal of an expired license.

A renewed license card must be available for employer inspection by January 1 of the new license period. It is illegal to practice nursing after your license has expired.

Continuing competency requirements must be completed within the last two years before the before the expiration date of the license. Those requirements will be discussed in detail later in this course.

When you apply for or renew your license, you are required to report any criminal behavior in your past and any pending criminal charges against you, including adjudicated or probationary action. While some criminal incidents don't result in a conviction, the incident should still be reported to the BON. A minor Class C traffic violation does not need to be reported. You can refer to the BON rules to determine what counts as a crime. Falsifying information to the BON can be more damaging than the original criminal behavior.

Some nurses will be selected to be audited for compliance with continuing nursing education requirements or a criminal background check. The proof of CNE must be received in the office and the background check must be completed before the license can be renewed.

You can renew online at the BON website https://txapps.texas.gov/NASApp/bnexam/BNExamManager. If your license has expired or you are not eligible for online renewal you can download a paper form at the BON website http://www.bon.state.tx.us/licensure_renewal.asp#timely. You are not eligible to renew online if any of the following conditions are met:2

  • The Nurse has defaulted on a Texas guaranteed student loan.
  • The Nurse has not met the mandatory continuing nursing education (CNE) requirements and/or has been selected for a CNE Audit. Proof of continuing nursing education must be received in our office for the license to be released or renewed.
  • The Nurse has been selected for a Criminal Background Check and the process has not been completed.
  • The Nurse is recognized as an Advanced Practice Registered Nurse and has not met the mandatory APRN audit requirements. Proof of current national certification for each type of approved recognition must be received in our office for the license to be released for renewal.
  • The Nurse's primary state of residence is a compact state other than Texas. Check here to see more information regarding the Nurse Licensure Compact and to check if your state is included.
  • The license number and/or last four digits of the Social Security Number entered do not match the information on the Boards files.

Your eligibility to renew your license may be impaired for any criminal offense, including those pending appeal. This may include but is not limited to:2

  • Been convicted of a misdemeanor?
  • Been convicted of a felony?
  • Pled nolo contendere, no contest, or guilty?
  • Received deferred adjudication?
  • Been placed on community supervision or court-ordered probation, whether adjudicated guilty?
  • Been sentenced to serve jail or prison time or court-ordered confinement?
  • Been granted pre-trial diversion?
  • Been arrested or have any pending criminal charges?
  • Been cited or charged with any violation of the law?
  • Been subject of a court-martial; Article 15 violation; or received any form of military judgment, punishment, or action?

You do not report Class C misdemeanor traffic violations nor offenses previously disclosed to the BON.

Continuing Competency

The purpose of continuing competency is to ensure that nurses (Rules and Regulations, 216.2)

  • stay current with industry practices,
  • enhance their professional competence,
  • learn new technology and treatment regimens, and
  • update clinical skills.

Noncompliance with continuing competency requirements, will result in a denial to renew a nursing license.

Options to document continuing competency for all nurses, including ARPNs are Rules and Regulation, 216.3:

Complete 20 contact hours of continuing nursing education (CNE) within the two years immediately preceding license renewal

OR

Achieve, maintain or renew an approved national nursing certification in the nurse's area of practice

All nurses, including APRNs, must complete at least two hours of CNE relating to Nursing Jurisprudence and Nursing Ethics before the end of every third licensing period. Certification does not meet this CNE requirement, but it is counted toward the total of 20 CNE (Rules and Regulation, 216.3(g).

All nurses, including APRNs, whose practice includes older adults or geriatric populations must complete at least two hours of CNE every renewal period. These hours count toward the 20 CNE. This CNE shall include information relating to Rules and Regulation, 216.3(h):

  • elder abuse,
  • age related memory changes and diseases processes, including chronic and end of life issues,
  • health maintenance and health promotion of the older adult or geriatric populations

Certification related to the older adult or geriatric populations that is approved by the BON will fulfill this requirement.

APRNs with prescriptive authority must complete an additional five contact hours in pharmacology. Beginning January 2015, APRN who prescribe controlled substances must complete an additional three contact hours related to prescribing controlled substances. CNE or Category I Continuing Medical Education (CME) meets these requirements Rules and Regulation, 216.3(c). Additional contact hours means this education is not counted toward the 20 hours of CNE and cannot be met with certification.

APRNs who perform a forensic examination on sexual assault victims must complete basic forensic evidence collection training, or the equivalent education before performing an examination. This is a one-time requirements. If CME is used to complete this requirement, it must have been approved the Texas Medical Board to specifically meet the forensic evidence collection requirement Rules and Regulation, 216.3(d).

Nurses with a Texas license, who practice in an emergency department must complete two hours CNE related to forensic evidence collections within two years of the initial date of the nurse's employment in an emergency department. Additional information about this requirement can be found in Rules and Regulation, 216.3(d).

A retired nurse who practices as a volunteer has special continuing competency requirements found in Rules and Regulation, 216.3(e).

APRNs whose practice includes tick borne diseases are encouraged to get CNE related to tick borne diseases.

Acceptable CNE

The nurse is responsible to participate in and maintain proof of successful completion of continuing competency that meets rules and regulations chapter 21.6. Continuing Competency. Detail is available at the BON website.

CNE program must be approved by one of the following BON recognized credentialing agency or an affiliated entity :

Proof that a course provider is approved by one of these credentialing agencies should be readily apparent on any course advertisement or on the website if on the internet. Proof of successful completion of CNE must be maintained for six years.

Academic education courses that are part of a curriculum that leads to an academic degree in nursing or a course directly relevant to the licensee's area of nursing practice can be used to meet CNE. Proof of successful completion is an official transcript showing a grade of C or better or a pass on a pass/fail grading system Rules and Regulation, 216.5.

The following activities do not meet continuing education requirements for licensure renewal Rules and Regulation, 216.6:

  (1) Basic Life Support (BLS) or cardiopulmonary resuscitation (CPR) courses.

  (3) Nursing refresher courses. Programs designed to up-date knowledge or current nursing theory and clinical practice, which consist of a didactic and clinical component to ensure entry level competencies into nursing practice are not accepted for CNE credit.

  (4) Orientation programs. A program designed to introduce employees to the philosophy, goals, policies, procedures, role expectations and physical facilities of a specific work place are not acceptable for CNE credit.

  (5) Courses which focus upon self-improvement, changes in attitude, self-therapy, self-awareness, weight loss, and yoga.

  (6) Economic courses for financial gain, e.g., investments, retirement, preparing resumes, and techniques for job interview.

  (7) Courses which focus on personal appearance in nursing.

  (8) Liberal art courses in music, art, philosophy, and others when unrelated to patient/client care.

  (9) Courses designed for lay people.

  (10)Self-directed study is an educational activity wherein the learner takes the initiative and the responsibility for assessing, planning, implementing and evaluating the activity including, but not limited to:

 (A) academic courses that are audited, or that are not directly relevant to a licensee's area of nursing practice, or that are prerequisite courses such as mathematics, physiology, biology, government, or other similar courses are not acceptable; and

(B) authorship.

(11) Continuing Medical Education (CME), unless completed by an APRN in the APRN's role and population focus area of licensure. One contact hour equals 50 minutes of education and 0.5 contact hours equals 25 minutes. A contact hour is not equivalent to a continuing education unit (CEU). Contact hour is the current term of measure for CNE. You might find the old term CEU used occasionally.

One contact hour equals 0.1 CEU and 10 contact hours equals one CEU. Courses that may be included for APRN's who prescribed medication will be noted as having pharmacology hours.

Practice by License Holder

You can find Scope and Practice information and position statements by going to the Texas BON of nursing website and click on Practice. Below is a screenshot of the BON homepage showing the practice drop-down menu.

Key to your practice is the difference between professional and vocational nursing.

Professional Nursing Involves (RN, APRN)Vocational Nursing Involves (LVN)
Observation, assessment, intervention, evaluation, rehabilitation, care and counsel, or health teachings of a person who is ill, injured, infirmed, or experiencing a change in normal healthCollect data and perform focused nursing assessments of the health status of an individual
Assist in the evaluation of an individual's response to a nursing intervention and the identification of the individual's needs
Maintenance of help or prevention of illness 
Administration of medications or treatments as ordered by a physician, podiatrist, or dentistsEngage in other acts commensurate with the nurses experience, continuing education, and demonstrate competency as prescribed by the BON
Supervision or teaching of nursingParticipate in health teaching and counseling of an individual
Administration, supervision, and evaluation of nursing practices, policies, and procedures. 
APN's can request, receive, signed for, the and distribute prescription drug samples to patients at practices where they are authorized to sign prescription drug orders 
Perform an act delegated by physician 
Develop the nursing care planParticipate in the planning or modification of the nursing care of an individual

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.

The BON provides a Six-Step Decision-Making Model for determining nursing scope of practice. Each step is in the form of a question you ask yourself. If you answer yes to continue to the next question. If you answered no 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.

  1. Is the activity consistent with the NPA and BON rules and regulations?
  2. Is the activity appropriately authorized?
  3. Is it supported by nursing research or scope of practice statements by national nursing organizations?
  4. Do you possess the required knowledge and competency to carry out the act?
  5. Would a reasonable and prudent nurse perform this activity in this setting?
  6. Are you prepared to assume accountability for the patient's safe care and outcome?

The BON establishes minimal acceptable levels of nursing practice in all settings for every level of nursing and advanced practice authorization. Failure to meet minimal standards may result in action against a nurse's license, even if there is no patient injury.

Minimal standards for all nurses includes (Rules and Regulations, 217.11):

  • promote safe environment
  • know the rationale and effects of medications and treatments
  • accurately and completely report and document
  • protect confidential information
  • promote and participate in education and counseling
  • obtain instructions and supervision when necessary
  • make a reasonable effort to obtain orientation and training for competency with new equipment, technology, or unfamiliar care situations
  • notify supervisor when leaving nursing assignment
  • maintain professional boundaries
  • comply with mandatory reporting requirements
  • provide nursing services without discrimination
  • Institute nursing interventions to stabilize the patient's condition or prevent complications
  • clarify orders and treatment that the nurse may believe is inaccurate, non-efficacious, or contraindicated
  • prevent exposure to infectious pathogens and communicable conditions

Vocational nursing practice is a directed scope of nursing under the supervision of a RN, ARNP, PA, physician, podiatrist, or dentist. Supervision is defined as the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The vocational nurse will assist in the determination of predictable healthcare needs of clients within healthcare settings. Minimal standards specific to vocational nurses (Rules and Regulations, 217.12 (2)):

  • utilized a systematic approach to provide individualized, goal driven nursing care by
    • collecting data and performing focused nursing assessments,
    • participate in planning of nursing care needs
    • participate in developing modification of nursing care plan
    • implement appropriate care within the vocational nurses' scope of practice
    • Assisting in evaluation of the clients responses to nursing interventions and identification of client needs
  • assign specific tasks, activities, and functions to unlicensed personnel commensurate with their education, experience, knowledge, and physical/emotional ability of the person to whom the assignments are made and maintain appropriate supervision of unlicensed personnel
  • perform other acts that require education and training as prescribed by BON rules and regulations commensurate with the vocational nurses experience, continuing education, and demonstrated competencies

Minimal Standards Specific to RNs (Rules and Regulations, 217.12 (3):

  • utilized a systematic approach to provide individualized, goal driven nursing care by
    • collecting data and performing focused nursing assessments,
    • utilize a systematic approach to provide individualized, goal directed nursing care by
  • performing comprehensive nursing assessments
  • make nursing diagnosis that serve as the basis for strategy of care
  • develop a plan of care based on assessment and nursing diagnosis
  • implement cared
  • evaluate clients response to nursing interventions
    • delegate tasks to unlicensed personnel in compliance with BON rules and regulations

Minimal Standards Specific to RNs with Advanced Practice Authorization (Rules and Regulations, 217. 12 (4):

  • practice in an advanced nursing practice role in specialty in accordance with authorization granted under BON rules chapter 221
  • prescribed medications in accordance with prescriptive authority granted under BON rules and regulations chapter 222

Standardized procedures are specific to the scope of practice for nurses working in a facility. The standardized procedure approval is not transferable to another facility.

All APRNs who have prescriptive authority and a United States Drug Enforcement Administration (DEA) registration number may register to use the PMP through the Texas State Board of Pharmacy’s (TSBP’s) website. AWARxE is a PMP that allows health care providers to query patient reports of controlled substance prescriptions in an effort to help them safely prescribe controlled substances. The PMP helps prescribers avoid practices such as polypharmacy in which duplicate prescriptions may be issued for the same drug by multiple providers. APRNs and other prescribers may also query the PMP to evaluate their own prescribing practices. This allows a prescriber to confirm that all prescriptions for controlled substances linked to the provider’s prescriber identification were written by that prescriber. To register for the PMP, please visit the TSBP’s website at www.pharmacy.texas.gov/PMP. 2

Delegation

Delegation can to be a perplexing concept with multiple nuances. RNs can delegate. LVNs can supervise or assign, but they cannot delegate. APRNs must delegate tasks just as other RNs would. APRNs may not delegate like physicians do. Training is not the same as delegation. Your responsibility to a trainee ends when his or her training is complete.

The BON provides a lot of resources about delegation on the Texas Board of Nursing website. The following is a flow chart of decision-making about delegation by RNs to unlicensed personnel for clients with acute conditions or acute care environments.

PDF Delegation-rule224

The following is a flowchart of decision-making about delegation by RNs to unlicensed personal and tasks not requiring delegation in independent living environment for clients with stable and predictable conditions.

PDF Delegation-rule225

Reporting Violations and Patient Care Concerns

Complaints can be made by consumers and other professionals. Nurses have the mandated responsibility to submit a written, signed report to the BON when he or she has cause to suspect violations of the rules and regulations. This may include but are not limited to

  • behaviors which may expose patient are others to unnecessary risk of harm
  • unprofessional conduct by a nurse
  • failure to adequate care for client
  • failure to conform to the minimum standards of acceptable nursing practice
  • impairment or likely impairment of a nurses practice by chemical dependency, alcohol or mental illness

A report to a nursing incident-based peer review committee satisfies the nurse's duty to report to the BON. Peer Review will be discussed later in this course.

Complaints must be in writing and signed by the complainant.

The following website provides complaint forms and explains how to file a complaint. You can also file a complaint by:

  • calling the Texas board of nursing at (512)305-6838, or 1-800823205
  • mailing a complaint to the Texas board of nursing, enforcement, Suite 3406, 333 Guadalupe St., Austin, TX 78701.

Reporting Minor Incidents does not enhanced protection of the public; therefore, they should not be reported. The definition of minor incidents is 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." Additional information guiding which incidents need to be reported to the BON is contained in Rule 217.16. However any error contributing to patient death or serious harm is never classified as a minor incident.

The BON receives up to 16,000 complaints per year. Most are not investigated because they are minor instances, the nurse's identity cannot be in determined, or the complaint is outside of the BON's jurisdiction. All complaint information submitted to the Texas BON of Nursing is kept confidential.

A nurse may feel an obligation to a coworker to not report an incident. The reasons to make a report includes but is not limited to the following:

  • failure to report, it is a violation of the mandatory reporting requirement
  • the first duty is to the patients
  • the nurse may get the help he or she needs

All nurse received due process, and very few nurses ever lose their license. If you submit a complaint, you will receive periodic updates and be notified of the results.

Nursing Peer Review

Anyone who regularly employees ten or more nurses must provide for the nursing peer review process. The rules and regulations provide specific committee requirements to ensure that a nurse gets due process. Peer review is separate from BON review, and it's confidential. The peer review committee will investigate reports including input from the accused. If they find that a nurse has violated the rules and regulations the committee will provide a written report to the BON.

There are two types of peer review: 1) Incident-based Peer Review, 2) Safe Harbor Peer Review. Incident-Based Peer Review relates to an incident reported after the fact by a nurse or facility. Safe Harbor Peer Review relates to an application made by a nurse to seek safe harbor before he or she accepts an assignment.

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.

Due process rights include provisions that the 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 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.

Safe Harbor is a process that protects a nurse from employer retaliation, suspension, termination, discipline, discrimination, or licensure sanction when a nurse makes a good faith request in writing for peer review of an assignment or conduct the nurse is requested to perform and that the nurse believes could result in a violation of the NPA or BON rules. 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. Safe Harbor tries to balance duty to the patient with protection of the nurse's license. So the point is, it's better for patients to have a nurse on duty, rather than no nurse on duty because the nurse refuses the assignment out of fear of committing errors. Safe Harbor protects the nurse's license, it does not protect the nurse from civil action.

A nurse also has the right to refuse to engage in conduct related to patient care if they believe the conduct would violate the NPA or any BON rule. 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.

Safe Harbor must be invoked prior to engaging in the conduct or assignment for which peer review is requested, and may be invoked at any time during the work period, when the initial assignment changes (rules and regulations, 217.19 (15). 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.

Complete the "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.

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 BON. 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.

Prohibited Practices and Disciplinary Actions

Your nursing license is a property right and cannot be removed with due process of the law. Due process includes notice of the charges and a hearing on those charges. Either peer review committee or BON review requires the accused nurse be notified of the investigation and invited to respond. If you are investigated, you have several responsibilities, including responding to the investigator's request for information, asking questions, and keeping your contact information current. If you do not respond, the investigation will still proceed. The investigator gathers and reviews evidence. The nurse's response is seriously considered. The investigator forwards the information to the BON for a decision.

Types of unprofessional conduct Rules and Regulations, 217.12.

  • unsafe practices
    • carelessly failing, repeatedly failing, or exhibiting the inability to perform in conformity with the standards of a minimal acceptable level of nursing practice
    • careless or repeatedly failing to conform to the generally accepted nursing standards
    • improper management of records
    • delegating or assigning nursing functions that could reasonably be expected to result in unsafe or ineffective client care
    • accepting the assignment of functions when the acceptance would be reasonably expected to result in unsafe or ineffective client care
    • failing to supervise the performance of tasks by an individual pursuant to delegation or assignment
    • failure of clinical nursing instructor to adequately supervise student
  • failure to practice within the modified scope/required accommodations by the board
  • careless or repetitive conduct that may endanger clients life, health, or safety
  • misconduct
    • falsifying reports
    • failing to cooperate with a lawful investigation
    • causing or permitting physical emotional and verbal abuse, injury, or neglect of the client or the public; failing to report the same
    • violating professional boundaries
    • engaging in sexual conduct with the client
    • threatening or violent behavior in the workplace
    • misappropriating or failing to take precautions against misappropriation of anything of value or benefit of the client, employer, or any other person
    • providing false deceptive or misleading information in connection with the practice nursing
    • failure to answer specific questions or providing false or misleading answers that could affect the decision to license, employee, certified, or otherwise utilizes a nurse
    • 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 repay student loans
  • drug diversion
  • dismissal from a peer assistance program
  • other drug-related actions
    • use of controlled substance or alcohol while on duty to the point of impairment
    • falsification, incorrect, inconsistent, or unintelligible entries pertaining to drug controlled substances
    • failing to follow policy and procedure for the wastage of medicine
    • positive drug screen for which there is no lawful prescription
    • obtaining or attempting to obtain or deliver medications through misrepresentation, fraud, forgery, deception, or subterfuge
  • unlawful practice
    • knowingly aiding, assisting, advising, or allowing an unlicensed person to engage in unlawful practice of nursing
    • violating an order of the board, state or federal law relating to the practice of nursing, state or federal narcotics or controlled substance law
    • knowingly aiding, assisting, advising, or allowing a nurse to violate the conditions set forth in a BON order
    • failing to report violations of the nurse practice act or the BON rules and regulations
  • leaving the nursing assignment without notifying appropriate personnel
  • criminal conduct

Unprofessional conduct itself is a violation. Actual injury to a client does not need to occur.

Specific risk factors for addiction to alcohol or drugs for healthcare professionals:

  1. high level of job stress
  2. knowledge of medications
  3. access to controlled substances
  4. tendencies to self-medicate

Behavioral characteristics that may indicate a problem with substances

  1. patient complaints of not getting relief from pain medicines that were charted as given
  2. patient states no pain medicine given even though it is charted
  3. nurse exhibits odd behavior or behaves very differently from usual behavior
  4. narcissism

Methods of procurement of drugs

  • tampering: substituting something else for the substance in the container (saline for liquids, over-the-counter pills for tablets)
  • theft: documenting medication that was not given and taking the medication

Nurses identified as being impaired or suspected of being impaired are to be suspended immediately, pending referral to a peer assistance program. A peer assistance program is available that will identify, monitor, and assist in locating appropriate treatment for those nurses whose practice is impaired or suspected of being impaired by chemical dependency, mental illness, or diminished mental capability. The objective of the program is to return the nurse to practice safe nursing. Participants must follow the program's requirements or they will be subject to disciplinary action.

Disciplinary action

If an Investigation indicates the need for disciplinary action, the accused will be notified. The due process is described in detail in the rules and regulations chapter labeled practice and procedure. The accused may be represented by a lawyer. The BON website also provides information about disciplinary actions, under the tab discipline and complaints.

In making a determination, the BON 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.

A sanction is a BON Order. It can include remedial education, a warning, a reprimand, a suspension, or revocation of the nurse's license. The BON may order certain 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. The BON disciplinary matrix, describing grounds for discipline and disciplinary action.

Cases that result in disciplinary action become public information. The BON is a public entity, and is subject to open record laws. Any cases that result in formal charges become public information at the time the charges are filed, and continue to be public information throughout the remainder of the disciplinary process.

Example: An LVN applies for the position of Director of Nursing at a nursing home. The LVN indicates on his application for employment that he is a RN and had earned a BSN degree in nursing. The LVN submits an altered copy of an RN license that belonged to another RN at the LVN's former place of employment. The LVN's deception is discovered when the employer attempts to verify the RN license number on the employment application. The LVN's action a direct violation of NPA or BON of Nursing rules.

Nurse Licensure Compact

The nurse licensure compact is an agreement between states to recognize each other's licenses in temporary assignments, like travel assignments. It increases nurse mobility and facilitates innovative and cooperative health care. Find more information on the licensure compact in NPA.

Effective January 19, 2018, Texas licensed nurses shall comply with rules adopted by the Interstate Commission of Nurse Licensure Compact Administrators (Commission). (Chapter 304, Nurse Licensure Compact, of the Nursing Practice Act (Tex. Occ. Code §304.0015, Art.VIII).2

Ethics

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.

Nurses have a 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. Nurses are in a position to take advantage of vulnerable people, and we have to arm ourselves against any abuse of trust.

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.

Ethical Principles affecting Nursing Practice
Autonomyself-governance
the right to make an informed decision
the right to determine course
Beneficenceone ought to do or promote good
positive benefits are what the health care providers are obligated to seek
act for the good of the individual
Justiceequal access
equal equitable distribution
fair share of resources
wide range in theories of fairness and veracity
truthfulness
the duty of a nurse to tell the truth
veracity
truthfulness
the duty of the nurse to tell the truth
Fidelitydoing one's duty
keeping one's word
faithfulness
Nonmaleficencedo no harm
avoid harm

Morality is social conventions about right and wrong agreed upon amongst the population.

Values includes your beliefs, likes, dislikes, and preferences. Things that determine personal values are educational background, life experience, cultural beliefs, family beliefs, and religious beliefs. Different people have different values. Different cultures have different values and values are different even within cultures. Values change over time and in different situations.

Personal ethics and values differ from professional ethics and values. Your personal ethics and values affect your practice. Value and ethical conflict occurs if you fail to recognize that values and beliefs are different for individuals of different cultures and within culture.

Sources of professional values:

  • professional organizations
  • state nurse practice act

Case studies

Sue works the evening shift at a nursing home at 3:30 Sue receives a call for her child's care provider and her child is sick. She asks the charge nurses if she could go check on her child. This is the conflict between Sue's personal value of her child's health and her professional ethical responsibility of Fidelity's in doing one's duty. If the charge nurse allows Sue go home this resolves her conflict. If the charge nurse does not allow Sue to go home the conflict remains unresolved.

Mr. X's physician has asked home health care to evaluate him for home health services. It is determined that Mr. X requires patient education related to his diet and medication. Physical therapy is also order. Mr. X allows the nurse to come but refuses physical therapy. After Mr. X refuses to open the door for the therapist the nurse and therapists arranged to come together. Mr. X continues refuse to participate with the physical therapy regimen. This is an ethical conflict between fidelity and beneficence in doing one's duty to carry out a beneficial patient care order and the patient's autonomy in his right to choose.

Sam is the 34-year-old man with end-stage complications due to AIDs. He has been undergoing peritoneal dialysis. Recently he has decided to stop dialysis. He has informed his care providers of his decision. Sam's sister has been the strongest sources support; but, she does not agree with this decision. She is convinced that improving Sam's depressed will change his mind. She demands that everything be done for her brother. This is the conflict between Nonmaleficence in avoiding harm to the patient and autonomy in the patient's right to choose.

References

1. Texas Board of Nursing Rules and Regulations relating to Nurse Education, Licensure, and Practice (February 2018). Retrieved on April 27, 2018 from http://www.bne.state.tx.us/pdfs/law_rules_pdfs/rules_regulations_pdfs/bon_rr_Feb2018.pdf

2. Nursing practice act, and nursing peer-reviewed, and nursing licensure compact. Texas occupations code and statues regulating the practice of nursing as amended September 2017. Retrieved on April 27, 2018 from http://www.bne.state.tx.us/pdfs/law_rules_pdfs/nursing_practice_act_pdfs/NURSINGPRACTICEACT2017.pdf


This course is applicable for the following professions:

Advanced Registered Nurse Practitioner (ARNP), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Registered Nurse (RN)

Topics:

CPD: Promote Professionalism and Trust, Legal & Regulatory, Texas Requirements/Recommendations


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