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Jurisprudence and Ethics for Nurses Licensed in Texas

2 Contact Hours
This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Nurse Midwife, Certified Nurse Practitioner, Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Nursing Student, Registered Nurse (RN), Registered Nurse Practitioner
This course will be updated or discontinued on or before Tuesday, April 30, 2024

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


Outcomes

≥ 92% of nurses licensed in Texas will know how to practice within the perimeters of the Texas Nurse Practice Act.

Objectives

After completing this course, the learner will be able to:

  1. Discuss the Texas nursing practice act (NPA).
  2. Describe the Texas Board of Nursing rules (BON) and regulations, including BON, rule 217.11.
  3. Apply standards of nursing practice.
  4. Locate Texas Board of Nursing position statements.
  5. Apply principles of nursing ethics.
  6. Describe professional boundaries.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Julia Tortorice (RN, MBA, MSN, NEA-BC, CPHQ)

Introduction

Jurisprudence is the science or philosophy of law. The Texas Nurse Practice Act and the Texas Board of Nursing (BON) Rules and Regulations Relating to Nurse Education, Licensure, and Practice are the laws that govern the practice of nursing practice in Texas. The BON represents the people of Texas by ensuring that licensed nurses meet minimum standards of safe practice. The licensure of nurses is a requirement to protect the people of Texas and ensure safe nursing care. Your nursing practice is directly affected by your ability to make an informed decision within the parameters of these laws. You can find the Nurse Practice Act and Rules and Regulations by going to the Texas BON website and clicking on the menu item Laws & Rules. The NPA stipulates that you cannot call yourself a nurse or practice in Texas without a license.

Scope of Practice

You can find the Scope and Practice information and BON position statements by going to the Texas BON of nursing website and clicking on practice. The difference between professional and vocational nursing is detailed in Table 1(NPA, 2021).

Table of Practice Differences

Table1: Professional vs Vocational Nursing
Professional Nursing (RN, APRN)Vocational Nursing (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 health.Collect data and perform focused nursing assessments of the health status of an individual.
Assist in the evaluation of an individual's response to nursing intervention and the identification of the individual's needs.
Maintenance of health or prevention of illness
Administration of medications or treatments as ordered by a physician, podiatrist, or dentistEngage in other acts commensurate with the nurse's 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
APNs can request, receive, sign for, and distribute prescription drug samples to clients at practices where they are authorized to sign prescription drug orders
Perform an act delegated by a physician

Develop the nursing care plan

Participate 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 require post-licensure continuing education to establish competency to perform the necessary skills safely.

Six-Step Decision-Making Model

The BON provides a Six-Step Decision-Making Model for determining the nursing scope of practice. Each step is in the form of a question. If you answer yes, continue to the next question. If you answered no, stop. If you continue to the end, you can feel confident about the act fitting within your scope of practice. If you stop, you know the act is not within your scope of practice (TBN, 2019). This model includes questions like:

  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 conduct the act?
  5. Would a reasonable and prudent nurse perform this activity in this setting?
  6. Are you prepared to assume accountability for the client's safe care and outcome?

The BON establishes minimally 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 client injury.

Minimal Standards for all Nurses

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

  • Promoting a safe environment
  • Knowing the rationale and effects of medications and treatments
  • Accurately and completely reporting and documenting
  • Protecting confidential information
  • Promoting and participating in education and counseling
  • Obtaining instructions and supervision when necessary
  • Making a reasonable effort to obtain orientation and training for competency with new equipment, technology, or unfamiliar care situations
  • Notifying the supervisor when leaving a nursing assignment
  • Maintaining professional boundaries
  • Complying with mandatory reporting requirements
  • Providing nursing services without discrimination
  • Instituting nursing interventions to stabilize the client's condition or preventing complications
  • Clarifying orders and treatment that the nurse may believe is inaccurate, non-efficacious, or contraindicated
  • Preventing exposure to infectious pathogens and communicable conditions

LVN Scope of Practice

Vocational nursing practice is a directed scope of nursing under the supervision of an 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 the predictable healthcare needs of clients within healthcare settings (Rules and Regulations, 217.11 (2)). Minimal standards specific to vocational nurses include:

  • Utilizing a systematic approach to provide individualized, goal-driven nursing care by:
    • collecting data and performing focused nursing assessments
    • participating in the planning of nursing care needs
    • participating in developing a modification of the nursing care plan
    • implementing appropriate care within the vocational nurses' scope of practice
    • assisting in the evaluation of the client's responses to nursing interventions and identification of client needs
  • Assigning 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
  • Performing other acts that require education and training as prescribed by BON rules and regulations commensurate with the vocational nurse's experience, continuing education, and demonstrated competencies (Rules and Regulations, 217.11 (2)).

RN Scope of Practice

Minimal Standards Specific to RNs (Rules and Regulations, 217.11) include:

  • Utilizing a systematic approach to provide individualized, goal-driven nursing care by:
    • performing comprehensive nursing assessments
    • making a nursing diagnosis that serves as the basis for a strategy of care
    • developing a plan of care based on assessment and nursing diagnosis
    • implementing care
  • Evaluating client's responses to nursing interventions
  • Delegating tasks to unlicensed personnel in compliance with BON rules and regulations

APRN Scope of Practice

Minimal Standards Specific to RNs with Advanced Practice Authorization (Rules and Regulations, 217. 11) include:

  • Practicing in an advanced nursing practice role in a specialty under authorization granted under BON rules chapter 221
  • Prescribing medications under 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 the United States Drug Enforcement Administration (DEA) registration number may register to use the Prescription Monitoring Program (PMP) through the Texas State Board of Pharmacy's (TSBP's) website. AWARxE is a PMP that allows health care providers to query client reports of controlled substance prescriptions to help them safely prescribe controlled substances. The PMP allows prescribers to 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 prescribing practices. This query allows a prescriber to confirm that a prescriber wrote all prescriptions for controlled substances linked to the provider's prescriber identification. To register for the PMP, please visit the TSBP's website (NPA, 2021).

Case Studies

Sue works the evening shift at a nursing home at 3:30. Sue receives a call from her child's care provider, and her child is sick. She asks the charge nurses if she could check on her child. This situation conflicts with Sue's value of her child's health and her professional, ethical responsibility of fidelity in doing one's duty. If the charge nurse allows Sue to 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 client education related to his diet and medication. Physical therapy is also ordered. Mr. X allows the nurse to come but refuses physical therapy. After Mr. X refused to open the door for the therapist, the nurse and therapists arranged to go together. Mr. X continues to refuse to participate in the physical therapy regimen. This situation is an ethical conflict between fidelity and beneficence in doing one's duty to conduct a beneficial client care order and the client's autonomy in his right to choose.

Sam is a 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 source of support, but she disagrees with this decision. She is convinced that improving Sam's depression will change his mind. She demands that everything be done for her brother. This situation is the conflict between Nonmaleficence in avoiding harm to the client and autonomy in the client's right to choose.

Professional Boundaries

A nurse must maintain a therapeutic relationship with clients. The boundaries of this relationship include physical, sexual, emotional, or financial exploitation of the client or their family members. Because nursing involves caring for clients who may not be fully dressed, it puts them in a vulnerable situation. A nurse must promote the client's dignity, independence, and best interests. Personal gain at a client's expense is unacceptable and may be a crime (rules and regulations, 217.2).

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
OR
Reflect on Practice ImpactDescribe how this course will impact your practice.   (No Test)

Delegation

Delegation can 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 but may not delegate as physicians do. Training is different from delegation. Your responsibility to a trainee ends when their training is complete.


The BON provides many 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

PDF Delegation-rule225

Delegation Resources Links

Reporting Violations and Patient Care Concerns

Consumers and other professionals can make complaints. Nurses have the mandated responsibility to submit a written, signed report to the BON when they have cause to suspect violations of the rules and regulations. This report may include but is not limited to:

  • behaviors that may expose clients or others to unnecessary risk of harm
  • unprofessional conduct by a nurse
  • failure to adequately care for a 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 nursing incident-based peer review committee report satisfies the nurse's duty to report to the BON. Complaints must be in writing and signed by the complainant.

This website link 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)-305-7400
  • mailing a complaint to the Texas board of nursing, enforcement, Suite 3406, 333 Guadalupe St., Austin, TX 78701.

Reporting minor Incidents does not enhance public protection; therefore, they should not be reported. The definition of minor incidents is in NPA 301.401 (2) and includes "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 and means conduct by a nurse that may violate the Texas Nursing Practice Act or a Board rule but does not indicate the nurse's continued practice poses a risk of harm to a client or another person. However, any error contributing to client death or serious harm is never classified as a minor incident.

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

  • failure to report is a violation of the mandatory reporting requirement
  • the first duty is to the clients
  • the nurse may get the help they need

If you submit a complaint, you will receive periodic updates and be notified of the results.

Ethics

A nurse is trusted, 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 clients or the public or could protect clients or the public from unnecessary risk of harm.

Nurses have a duty to the client - that's the highest level of responsibility. Employers, other health care providers, and the nurse's interests do not outweigh this especially important responsibility. Nurses must be aware of their actions and feelings within the therapeutic relationship, identify the invisible boundaries, and act in the client's best interest.

Nursing is a position of power. We must practice nursing in an autonomous role with clients, their families, significant others, and public members during challenging times in their lives. Nurses can take advantage of vulnerable people, and we have to arm ourselves against any abuse of trust.

A nurse has a vital role in maintaining professional boundaries and must know, recognize, and maintain the 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.

Principles

Table 2: Ethical Principles Affecting Nursing Practice

Autonomy

  • self-governance
  • the right to make an informed decision
  • the right to determine a course

Beneficence

  • one 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

Justice

  • equal access
  • equal, equitable distribution
  • a 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

Fidelity

  • doing one's duty
  • keeping one's word
  • faithfulness

Nonmaleficence

  • do no harm
  • avoid harm

Morality is social conventions about right and wrong agreed upon amongst the population. Values include your beliefs, likes, dislikes, and preferences. 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 ethics and values affect your practice. Value and ethical conflict occur if you fail to recognize that values and beliefs are different for individuals of different cultures and within a culture.

Sources of professional values:

  • professional organizations
  • state nurse practice act

References

  • Nursing practice act, and nursing peer-reviewed, and nursing licensure compact. Texas occupations code and statutes regulating the practice of nursing as amended September 2021. Visit Source.
  • TBN Texas Board of Nursing Rules and Regulations relating to Nurse Education, Licensure, and Practice (December 2021). Visit Source.
  • TBN Texas Board of Nursing. 2019. Scope of Practice Decision‐Making Model. Visit Source.