Anticipating the Future Maintaining Your License

By Charlene Morris, RN, MSN

Texas Occupations Code

• • •

Governs many occupations Chapter 301 - Law that establishes & empowers Board of Nursing for the State

•

of Texas

• Contains the

Nurse Practice Act Contains law setting up rules and regulations for nursing practice in Texas – Defines the SCOPE of PRACTICE Texas Administrative Code

– Provides more detail on how the requirements of the Occupations Code are to be carried out.

– Appointment of members, meetings, proceedings, investigations, disciplinary actions, etc.

Texas Occupations Code

• Chapter 301: Nursing Practice Act • Chapter 303: Nursing Peer Review • Chapter 304: Nurse Licensure Compact • Chapter 305: Advanced Practice Registered Nurse Licensure Compact

TEXAS OCCUPATIONS CODE AND STATUTES REGULATING THE PRACTICE OF NURSING As Amended September, 2005 AGENCY MISSION The mission of the Texas Board of Nursing (BON) 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 practice safely.

competent

to This mission, derived from the Nursing Practice Act,

supersedes the interest of any individual, the nursing profession, or any special interest group

.

Protecting the People of Texas

Texas Administrative Code

BOARD OF NURSING

Purpose and Functions Purpose

.

The board fulfills its mission through two principle areas of responsibility:

(1) regulation of the practice of professional and vocational nursing (2) accreditation of schools of nursing.

Texas Administrative Code Functions of BOARD OF NURSING

The board shall perform the following functions as outlined in Texas Occupations Code chapters 301, 303, 304, & 305. ( 1) Establish standards and regulate the practice of professional and vocational nursing. (2) Interpret the Nursing Practice Act and Regulations Relating to: Nurse Education Licensure and Practice to nurses Employers Public to ensure informed professionals, allied health professionals, and consumers.

Texas Administrative Code Functions of

BOARD OF NURSING The board shall perform the following functions as outlined in Texas Occupations Code chapters 301, 303, 304, & 305. (3) Receive complaints and investigate possible violations.

(4) Discipline violators through appropriate legal action.

(5) Provide a mechanism for public comment and by which the rules and regulations are modified when appropriate.

(6) Examine and license qualified applicants and recognize qualified applicants for advanced practice nursing as minimally competent. (7) Grant licensure by endorsement and grant recognition of advanced practice nurses from other states. (8) Recommend to legislature appropriate changes in the Nursing Practice Act (9) Establish standards for nursing education and accredit or deny accreditation of schools.

(10) Monitor the examination results of applicants for variances in the level of educational effectiveness.

(11) Consultation and guidance to nurse schools for self-study, evaluation, and the development of effective education programs.

(12) Provide advice to the faculty, staff of health care agencies utilizing nursing services, and practitioners of nursing to improve professional service. (13) Implement and manage all other programs and responsibilities as authorized and mandated by the Texas Legislature.

Source Note:

The provisions of this §211.2 adopted to be effective March 31, 2002, 27 TexReg 2236; amended to be effective May 17, 2004, 29 TexReg 4884

Standards of Nursing Practice in the state of Texas

Texas Administrative Code Chapter 217 Rule 217.11 Standards of Nursing Practice in the state of Texas • Know and conform to Nurse Practice Act & Rules • Promote safe environment • Know rationale & effects of meds & treatments Administer them safely, stabilize pts. and question orders PRN • Accurately document/report assessments and response to care and pt. status as well as contacts with other health care team members • Respect patient’s right to privacy – confidentiality • Provide education/counseling to client, family, etc. & referrals

Texas Administrative Code Chapter 217 Rule 217.11 Standards of Nursing Practice in the state of Texas cont.

• Obtain appropriate supervision, orientation, in service info, & CE’s • Accept responsibility for competence & growth • Notify supervisor when leaving nursing assignment • Maintain professional boundaries • Comply with reporting requirements • Provide care without discrimination & within own abilities and those of others you are supervising • Implement measures to stabilize clients and prevent complications • Implement measures to prevent exposure to infectious disease

Texas Administrative Code Chapter 217 Rule 217.11 Standards of Nursing Practice in the state of Texas cont.

• Clarify any order or treatment that may be inaccurate, non-efficacious or contraindicated by consulting the appropriate licensed practitioner and notifying the ordering practitioner when deciding not to administer the medication or treatment • Collaborate with the client, care team, and when appropriate the client’s family to provide optimal care.

• Make appropriate referrals for continuity of care.

Texas Administrative Code Chapter 217 Rule 217.11 Standards of Nursing Practice in the state of Texas cont.

• Make appropriate/safe assignments based on ability and client’s needs • Accept only those assignments that you can do safely.

• Supervise those for whom they are responsible.

• Ensure verification of current licensure or compact privilege when administratively responsible

Texas Administrative Code Chapter 217 Rule 217.11 Standards of Nursing Practice in the state of Texas – just for RN’s.

• Use systematic approach to provide individualized, goal directed nursing care based on nursing process.

• Delegate tasks to unlicensed personnel in compliance with Chapter 224 (acute care settings) and Chapter 225 (independent living environments) with stable and predictable conditions.

Contacting the Texas Board of Nursing

Location of Board’s office: 333 Guadalupe, 3-460 Austin, Texas 78701 Telephone: 512/305-7400 Web page: http://www.bon.state.tx.us/contact /

Contact Person:

Katherine Thomas, MN, RN, Executive Director

Texas Licensure

Assuring Competence

• NCLEX-RN – assures knowledge base & decision-making ability • Graduation from accredited school – – Psychomotor/technical skill safety – Legal/ethical knowledge & values – Interpersonal skills – Decision-making skills • Basis for school’s evaluation criteria from BON Rules & Regulations – “Standards of Nursing Practice in Texas” – “Unprofessional Conduct”

Applying for your License

• See the http://www.ncsbn.org/ and www.pearsonvue.com/nclex web sites • See check list at end of application – BON Application • 2 FBI finger print cards • $139.00 fee BNE application • 2x2 passport photo, signature, date taken – Registration for NCLEX-RN Exam • NCLEX-RN Examination application form • $200 NCLEX Registration – Affidavit of Graduation from Nursing Program

NCLEX Test Plan

4 categories of client needs

• Safe & effective care environment – Management of care – 13-19% • Providing and directing care enhancing care and protection of client – Safety and infection control – 8-14% • Protection from environmental hazards • Health Promotion & Maintenance – 6-12% • Growth and development, prevention, early detection, health promotion • Psychosocial Integrity – 6-12% • Care supporting emotional, mental, and social wellbeing in stressful events • Physiologic Integrity – Basic care and comfort – 6-12% • Activities of daily living – Pharmacological & parenteral therapies – 13-19% • Care related to medication and blood/blood product administration – Reduction of risk potential – 13-19% • Decreasing risk of complications of illness or treatments – Physiological adaptation – 11-17% • Care for clients with acute. Chronic, and life threatening illnesses

Test Plan cont

.

Processes integrated into the previous categories • Nursing Process • Caring – Nurse and patient interaction – Collaborative environment • Communication & documentation • Teaching/Learning • Life span in various settings Some questions will apply knowledge from 2 different categories

Type of Testing

• CAT – Computer Adaptive Testing • Identifies 95% chance of safe practice – Various types of questions • Pictures, fill in the blank, multiple answer, etc.

– Don’t make wild guesses to finish items – Each test is different • Computer selects items for candidate’s skill level • Level of question based on answer to previous question • Different questions each time applicant tests – Contains some items that are not graded – Instructions, sample items, and breaks are included in testing time period allowed www.pearsonvue.com/nclex

NCLEX-RN Success

• Web sites • HESI exam as predictor – danger < 850 • Review course or review books • Level 4 exam scores predictor of specific areas

Test Taking Tips

• Study & practice (1 question per 60 to 70 seconds) • Plan – Austin testing sites – Pearson Professional Centers-Austin, TX 301 Congress Avenue Suite 565 Austin,Texas78701 512-469-0276 – Schedule carefully – Sleep, eat, take precautions to promote calm • Strengthen testing strategies – Read carefully (1 to 2 min./item) – Think through but don’t read into question – Remember entry level for LVN and/or CNA or UAP – Text book not the patient you saw in clinical – Use your breaks to rest www.pearsonvue.com/nclex

What to Expect/Prepare

• Arrive 30 minutes early , if you are more than 30 min. late for testing, you will need to be rescheduled and pay fee again • Come alone no children/family/friends waiting or calling • No hats, scarves, coats, calculators, pencils, etc. permitted in testing area • Bring – Authorization to Test (ATT) form – needed to schedule testing session – Name same as on ID – Valid non-expired Photo ID with your signature – Finger/palm print, photo, & signature will be taken on admission to test and after breaks

What to Expect/Prepare • May take up to 6 hours to complete test raise hand don’t get up – First optional break after 2 hrs. – fingerprinting before and after breaks – Second is 90 minutes after test resumes • Must use computer calculator • 75 to 265 questions

– 15 unscored

• Number of questions does not predict Pass/Fail – 75 high pass or fail as computer determines trends • Must answer each item to continue the test after (ENTER), can’t go back

What to Expect/Prepare • Official results come from BON- up to 14 days after BON receives scores – Pay a small fee to get preliminary results in 24 hours.

• Retest every 45/90 days for 4 years in Texas • Sec. 301.255 Re-examination. (Texas Occupations Code- BON

may

require additional educational requirements or deny retesting if test is failed 2 or more times.

)

Jurisprudence Exam

• Students applying for licensure after 9/1/08 or having to retake the NCLEX-RN • You must take the exam and pass it once to become an RN.

• Cost of exam will be part of application and will be taken on your computer from the BON website.

• You may take it as many times as you need to for a passing score – q 7 days.

Exam cont.

• You will know if you passed upon completion – 75% is a passing score. • It will be open book from the NPA and it will be timed – 2 hours.

• 50 Questions and will be knowledge and application. (Will not ask for specific section numbers of Nurse Practice Act but will test for understanding)

Test Blueprint

• 5 subject areas with weight • A. Nursing Licensure & Regulation in Texas –15% • B. Nursing Ethics –20% • C. Nursing Practice - 30% • D. Nursing Peer Review- 15% • E. Disciplinary Action – 20% Topic areas to guide review of content are available on the BON website.

Test Review

  BON has developed an online Test Review/Prep Workshop which costs about $25 and takes about 2 hours to complete.   This course is accessed on the BON website after applying and obtaining a pin number from the BON.

• • •

Guidelines for New Graduates & New RN’s

What are the requirements that must be met to obtain a GN Verification Letter?

Once granted, what are the limitations of practice placed on a GN using this privilege?

Compare these limitations to those that the BON recommends for newly licensed RN’s.

Guidelines for New Graduate’s Employment

• GN verification letter issued after: – Completion of application for licensure – Criminal checks complete – Affidavit of graduation – Received your Authorization to Test – Registered with Pearson – NCLEX testing date set • • No outstanding eligibility issues

75 day period

specified on GN Verification letter

results of first NCLEX attempt or

•

If first NCLEX is failed MUST stop GN practice

• Must know and follow Nurse Practice Act – Rules and Regulations

Graduate Nurse Requirements

• Temporary Authorization to Practice • Must work under direct supervision of RN – RN physically available – RN at same site • May not be in charge or supervising • May not function in an independent setting • May perform any function that falls within the scope of practice for which they have educational preparation and demonstrated minimal competency

BON Rule 217.3 Recommendations After Licensure

These are for your protection •

Direct supervision for 6 months

or less if agreed upon by new graduate and supervising RN – Competence agreed upon by both – Successful completion of orientation requirements • Newly licensed should not be in charge for 6 months unless agreed upon by grad & RN

Newly Licensed Nurse

• Guideline: – Amount of supervision and charge positions should be mutually agreed upon – 12-18 months experience in a structured setting before practicing in independent living environment

Continuing Competency

• • • • Identify how competency is maintained and validated. How are CE’s approved? What type of learning experiences can be counted as CE credit toward license renewal? What learning experiences are not acceptable? Describe required record keeping related to CE’s.

Continuing Competency (Sec. 301.303 – Occupations Code

• Completion of targeted cont. ed. Programs • Professional portfolio including certifications • May not require more than 20 hours CE per 2 year period • Specific State Requirements – Hepatitis C between June 2002 – June 2004 – Bioterrorism Response was a one time requirement – Forensic Evidence Collection – 2 hrs. for ER nurses by Sept. 1, 2008

Texas Administrative Code (216.1) - 2005

• All CE’s – To count toward licensure renewal, a program must have been approved by one of the credentialing agencies recognized by the Board. The credentialing agencies have met nationally predetermined criteria to approve programs and providers of CE. – RN planner – Approved by accepted credentialing agency – Class or individualized home study/programmed instruction • A 3hr. academic nursing course (part of a degree plan taken for credit with grade C or better or a pass of pass/fail) counts for 15 hours • ACLS, ATLS, and PALS, or national certification in a non-advanced nursing practice specialty (i.e. CCRN, RNFA, CWOCN, etc.) may be counted for CE credit • In-services, CPR, Refresher courses do not count.

• Keep records for 4 years • One CE hour = 60 minutes not 50 as in the past

License Renewal

• • • Describe the license renewal process for new RN’s and experienced RN’s. What criteria must be met for standard renewal? What are the requirements for reactivation when the license was in an official inactive status for more than 4 years? What are the requirements for licensure for retired RN’s who volunteer their service at a community agency?

Texas Administrative Code (216.1) - 2005

• License Renewal every 2 years - $65 – End of Birth month and odd or even years based on birth year – Receive post card reminder 30 days prior (90 days if CE audit required) – Renew on line at BON

web site

& credit/debit card if meet all criteria • No bars: delinquent student loans/child support, legal issues, Psych illness, drugs, and lack of required CE’s • Application implies legal signature/testimony of meeting criteria and makes nurse legally responsible for accuracy. • First renewal • Continuing education required – not need 20 hours – ER of birth.

Forensic Evidence Collection 2 hours • Six to 29 months after first issued depending on nurses date

Nursing Licensure Compact

• • • States participating in a Licensure Compact accept similar requirements for licensure. What is a nurse’s Home State and how does that relate to licensure? When a nurse practices in a party state whose laws and scope of practice guide the care provided by the nurse? Can the nurse simultaneously hold a home state license in more than one party state? Under what circumstance can the nurse hold a license in more than one state at the same time?

Nursing Licensure Compact

• Chapter 304 • Rule 220

Nurse Licensure Compact

• States agreeing to recognize each others nursing licenses • Texas among the first to adopt this plan - 2000 • Premise: –

Only defines the requirements to hold a license

• Similar licensure requirements in most states – –

Each state defines its own scope of practice States share information related to problems

• Warnings • Suspensions • Licenses that have been revoked • Imposters

Map indicates states that have enacted the RN and LPN/VN Nurse Licensure Compact (NLC).

Last Updated: [July 2008]

Compact Definitions

• Party States – States who have adopted the compact • Primary state of residence –(Home state) – Where you permanently reside or your declared fixed permanent & principal home for legal purposes • Remote state – Where you practice using multistate privilege – Must be a party state

Compact Requirements

• Nurse must: – Maintain home state license – Adhere to practice laws of state in which the patient is located at time of care – Use multi state privilege only in party states – Hold a home state license in only one party state at a time • If permanent home address changes to another party state, relinquishes license of previous state • Applies for & meets requirements for licensure in new Home state (30 day grace period for processing new license)

Practicing in a Different State

1.

How is a nurse’s licensure impacted when he/she changes their permanent address from one state to another? Differentiate between movement from one party state to another as opposed to movement from a party state to a non-party (remote) state? 2. Can a nurse hold permanent residence on a party state and work in a remote state? 3. What are the requirements and limitations of a nurse licensed in a remote state when they wish to obtain a license to practice in Texas?

Practicing in a Non-Party State

• Must obtain a license from the non-party state • May hold both a home state license and a license from the non-party state • If you live in a non-party state – Must obtain a non-resident Texas license to practice in Texas – Lose multistate licensure privilege in other party states

Impact of Licensure Compact

• States share information – Nurses licensed – Disciplinary action • Protects public health and safety • More mobile workforce for employers • Allows nurses to be more mobile • Provides for new forms of practice – Online practice – Telephone practice

Peer Review

Incident-Based Peer Review Rule 217.19

And Safe Harbor Peer Review Rule 217.20

Determine Scope of Practice

•

The Six Step Decision Making Model

found in the back of Nursing Practice Act, Nursing Peer Review, Nurse Licensure Compact

Rule 217.11 and 217.12

• Rule 217.11 Standards of Practice • and 217.12 Unprofessional Conduct – Provide baseline for safe and effective care – Establish minimal acceptable level – Identifies unprofessional behaviors

• • •

Unprofessional Conduct & Peer Review

Discus unprofessional conduct. Describe the types of agencies that must have a Peer Review Committee. Describe an incident based peer review process. Are the findings always reported to the BON? What must be reported? How is it reported?

Incident-Based Nursing Peer Review • Evaluation of – Nursing services – Qualifications of a nurse – Quality of care provided – The merits of a complaint about a nurse – Recommendations about a complaint • Nurse under review given written notice to attend with info about complaint • Fact finding process, analysis studying events that occurred - due process as right to question witnesses and confidentiality • Climate of collegial problem solving • Not a legal proceeding but can have lawyer/peer • If fault is found nurse is subject to Reporting Requirements

Peer Review – RN’s & LVN’s

• Employers of 10 or more licensed nurses must have a Peer Review Committee – Putting a patient or other person at risk of unnecessary harm – Failure to adequately care for a patient – Unprofessional conduct (217.12) – Failure to conform to minimum standards of practice (217.11) – Impairment or likely impairment of the nurse’s practice due to chemical dependency

The Nurse’s Duty to Report

• • •

Licensed care giver, agency, or facility

– Exposing a patient to substantial risk of harm due to lack of minimum standard of nursing care

Another nurse

– Impairment, lack of minimum standard of care, unprofessional conduct, or unnecessary exposure of pt. to risk for harm

Nursing student

– Chemical impairment – Ability to perform professional service within reasonable expectations

Reporting (for Peer Review or BON)

• Must be in writing and signed • Must include name of nurse or student and information required by the Board • May take the report to the employer or school

Action Peer Review Committee/BON

• Problem reported to employer • Proceedings are confidential • If committee finds cause they must report to BON – Identity – Problem – Corrective action taken – Recommendation for BNE action

Minor Incidents - Rule 217.16

• • • • Describe a minor incident. When and how are they reported and to whom? What are the consequences of frequent minor incidents? What types of incidents are considered major?

Minor Incidents Rule 217.16

• Continued practice doesn’t pose risk of harm to client(s) – Potential risk of harm is very low – Incident is singular – Nurse’s approach to practice is conscientious and accountable – Has knowledge and skill for safe practice • 5 minor incidents in any consecutive 12 month period must be reported to Peer Review Committee – If no Peer Review Committee is available must report to BON

Conduct Assistance

• • • What is unprofessional conduct? Provide examples of this type of problem. What types of problems fall under 217.13? What types of assistance is available to nurses who have these types of problems? What can happen to their license if they can not comply with professional conduct or restrictions of supervision?

217.12 Unprofessional Conduct

• Purpose: – Protect the public from • Incompetent & careless • Unethical • Illegal conduct of nurses – Applies to any licensed nurse

Peer Assistance Rule 217.13

• Required by law • Identifies, assists, and monitors professional colleagues so they can work – Experiencing mental health, alcohol or drug problems – Problems impair or may impair job performance or safe care

Safe Harbor Peer Review

Safe Harbor Peer Review

• Protects nurses asked to engage in conduct which they believe violates duty to patient • “ Duty to Patient ” – means conduct including administrative decisions directly affecting a nurse’s ability to comply with that duty required by: – Standards of practice: “Best Practices” originate from Evidence Based Research – Professional conduct adopted by the Board in Section 303.005 (a) • Required by facilities employing/contracting at least 10 nurses

Safe Harbor Peer Review/Protection

• • • Describe how Safe Harbor Peer Review differs from Incident Based Peer Review.

What is duty to patient? How is the nurse who invokes Safe Harbor protected? When Safe Harbor is invoked, how is the nurse’s accountability for safe patient care impacted? How does a nurse invoke Safe Harbor? Describe the Safe Harbor Peer review process.

Safe Harbor Peer Review Protection

• Nurse may not be disciplined or discriminated against for making the request • May engage in requested conduct pending the peer review • Is not subject to the reporting requirement just presented • May not be disciplined by BON for engaging in conduct while review is pending

Requesting Safe Harbor

• Must be done in good faith • Must notify supervisor making the assignment that he/she is invoking safe harbor • Use form on BON web site – Or include all info. on required form • If used to question a medical order – Medical staff/director will make a determination • Nurse invoking Safe Harbor will get a copy of Peer Review Committee’s determination and the administrator’s review

Entry into Practice Issues

• 1965 ANA paper recommended BSN • 50 + years of debate • Same licensing exam • 2000 ANA reaffirmed it’s recommendation • Public Health Nursing usually requires BSN • Specialist positions may require MSN • Certification

Differentiated Practice

• Structured nursing roles based on: – Education – Experience – Competence • Education based – different prep = different roles • Assessment based – all facets, competency focused

Differentiated Practice Models

• 20+ years of studies – Roles and compensation level delineated according to education level not widely used • Basis of competency models – ANA’s standards of care with levels of practice – Novice to expert (RN 1 to RN 4) – Can be based on job description and evaluation

Regulatory Agencies

• BON • Certification- government standards • Accreditation - non-government standards – Medicare/Medicaid – federal standards – Accreditation – non - government • JCAHO - hospitals • CHAP – Community Health Accreditation Program

Advisory Groups

• Secretary of Health, Congress – National Advisory Council on Nurse Education and Practice – Workforce diversity – Cultural competency – Nursing shortage • JCAHO – Nursing Advisory Council

Examples of Texas Legislation

• Nursing shortage • Hepatitis C & Bioterrorism continuing education requirements

Texas Nurses Association

• Mission: Promote excellence through leadership, advocacy, and innovation • Advocate for nursing in the legislature • Continuing education • • Updates on legal issues and legislation • Interpretation of legal & BON changes www.texasnurses.org

American Nurses Association

• Advocates for Nursing Profession • Defines ethical standards of practice for Profession – General RN – Specialty areas • Provides avenue for nursing to be involved in national level of decision making • AJN

The End