Nursing Jurisprudence and Ethics for Texas
Standards of Nursing Practice

LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this course, you will be prepared to comply with the ethics, laws, and rules that govern nursing practice in the state of Texas, including those from the Texas Statutes (Occupations Code), the Texas Board of Nursing Rules (Administrative Code), and Texas Board of Nursing position statements. Specific learning objectives to address potential knowledge gaps include:

• Discuss the Texas Board of Nursing and the Texas Nursing Practice Act.
• Identify the levels of nursing practice in Texas.
• Discuss the factors for safe delegation to unlicensed assistive personnel.
• Define the standards and scope of nursing practice in Texas.
• Discuss Texas nursing law violations and disciplinary actions.
• Summarize the principles of nursing ethics.
• Describe professional boundaries as related to nursing practice.

TEXAS BOARD OF NURSING AND NURSING PRACTICE ACT

"All states and territories legislate a nurse practice act (NPA) which establishes a board of nursing (BON) with the authority to develop administrative rules or regulations to clarify or make the law more specific. Rules and regulations must be consistent with the NPA and cannot go beyond it. These rules and regulations undergo a process of public review before enactment. Once enacted, rules and regulations have the full force and effect of law." (NCSBN, 2023)

The purpose of nurse practice acts is to:

• Outline guiding principles to which nursing regulations refer
• Define terminology used in the law
• Describe what type of members should serve on the board
• Outline standards for nursing school education programs
• Delineate the scope of nursing practice
• Regulate the process of licensure
• Outline reasons for disciplinary action
  (Boehning & Haddad, 2022)

Texas Board of Nursing

The Texas Nursing Practice Act (NPA) defines responsibilities of the Texas Board of Nursing (BON) for regulating nursing education, licensure, and practice. Chapters of the Texas Occupational Code define nursing practice and give the BON the authority to make rules that implement and interpret the NPA. The BON makes rule changes as needed to assist in the application of the NPA to evolving practice conditions and settings. These rules may be found in the Texas Administrative Code, Title 22, Part 11 (TX BON, 2019a).

The purpose of the Board (Texas Board of Nursing, or BON) is to protect and promote the welfare of the people of Texas. This purpose supersedes the interest of any individual, the nursing profession, or any special interest group. The board fulfills its mission through two principle areas of responsibility, regulation of the practice of professional and vocational nursing and the accreditation of schools of nursing (TX SOS, n.d.-a).

The BON is funded and supported by mandatory licensure fees paid by nurses wishing to practice legally in the state of Texas.

Texas Nursing Laws and Rules

In Texas, nursing standards are codified in the Texas Statutes, a permanent collection of state laws. Only the Legislature can change the NPA, so statutory changes only occur every two years.

The Texas Occupations Code (TOC) is updated by laws that create, amend, transfer, or repeal statutory material. The TOC has three chapters related to nursing. These chapters define nursing practice and give the BON the authority to make rules that implement and interpret the NPA.

• Chapter 301, Nursing Practice Act (NPA)
• Chapter 303, Nursing Peer Review
• Chapter 304, Nursing Licensure Compact
  (TX BON, 2019a)

The Texas Administrative Code (TAC) is the official compilation of all state agency rules for Texas. The Office of the Secretary of State oversees the publishing of the TAC. Title 22, Part 11, of the TAC outlines rules related to nursing (TX SOS, n.d.-b).

LEVELS OF NURSING PRACTICE IN TEXAS

Licensed Vocational Nursing

[This section is abridged from Texas Board of Nursing Position Statements, 15.27, The Licensed Vocational Nurse Scope of Practice (TX BON, 2023).]

The Texas NPA and the Board’s Rules and Regulations define the legal scope of practice for the licensed vocational nurse (LVN). The LVN, with a focus on patient safety, is required to function within the parameters of the legal scope of practice and in accordance with the federal, state, and local laws, rules, and regulations, as well as the policies, procedures, and guidelines of the employing healthcare institution or practice setting. The LVN is responsible for providing safe, compassionate, and focused nursing care to assigned patients with predictable healthcare needs.

LVN SCOPE OF PRACTICE

The LVN uses a systematic problem-solving process in the care of multiple patients with predictable healthcare needs to provide individualized, goal-directed nursing care. LVNs may contribute to the plan of care by collaborating with interdisciplinary team members, the patient, and the patient’s family. LVN scope of practice does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures.

The practice of vocational nursing is a directed scope of nursing practice and requires appropriate supervision of a registered nurse, advanced practice registered nurse, physician, physician assistant, dentist, or podiatrist. The LVN may not practice in a completely independent manner, but direct and on-site supervision of the LVN may not be required in all settings or patient care situations.

Determining the degree of proximity of an appropriate clinical supervisor, whether the supervisor is available by phone or actually physically present, should be made by the LVN and the LVN’s clinical supervisor. An appropriate clinical supervisor may need to be physically available to assist the LVN.

The setting in which the LVN provides nursing care should have well-defined policies, procedures, and guidelines and be one in which assistance and support are available from an appropriate clinical supervisor.

NURSING PROCESS FOR THE LICENSED VOCATIONAL NURSE

Assessment

The LVN assists in determining the physical and mental health status, needs, and preferences of culturally, ethnically, and socially diverse patients and their families. The LVN collects data and information, recognizes changes in conditions, and reports this to the registered nurse (RN) supervisor or another appropriate clinical supervisor. The LVN cannot perform independent assessments.

The LVN’s role in the nursing process is to appraise the patient’s status or the situation at hand. Also known as a focused assessment, this appraisal may be considered a component of a more comprehensive assessment performed by an RN or another appropriate clinical supervisor. The LVN reports the information that is collected either verbally or in writing. Written documentation must be accurate and complete.

Patient Diagnosis / Problem Identification

The second step in the nursing process is analyzing data gathered during the assessment and the identification of problems. The role of the LVN is to report data to assist in the identification of problems and the formulation of goals/outcomes and patient-centered plans of care in collaboration with patients, their families, and the interdisciplinary healthcare team.

Planning

The third step in the nursing process is planning nursing care needs of patients. The LVN participates by reporting data and other information to the appropriate clinical supervisor, such as the RN. The LVN participates in the development and revision of the nursing care plan, but the RN has the responsibility for plan development as well as the overall responsibility to coordinate nursing care for patients.

Implementation

Implementing the plan of care is the fourth step in the nursing process. The LVN is responsible for providing safe, compassionate, and focused nursing care to assigned patients by implementing aspects of the plan of care within legal, ethical, and regulatory parameters.

Delegating tasks to unlicensed assistive personnel (UAPs) is beyond the scope of practice for LVNs; however, LVNs may make appropriate assignments to other LVNs and UAPs according to Rule 217.11(2).

The RN is generally responsible and accountable for supervising not only the LVN’s practice but the UAP’s performance of tasks as well. For example, the RN may have trained, verified competency, and delegated tasks to a UAP, and the LVN may then proceed to assign those same tasks that need to be accomplished for that day to a UAP.

In addition, LVNs can participate in implementing established teaching plans for patients and their families with common health problems and well-defined health learning needs.

Evaluation

A critical and final step in the nursing process is evaluation. The LVN participates in the evaluation process by identifying and reporting any alterations in patient responses to therapeutic interventions in comparison to expected outcomes. The LVN may contribute to the evaluation phase by suggesting any necessary modifications to the plan of care and making appropriate referrals to facilitate continuity of care.

IV THERAPY

[This section is taken from Texas Board of Nursing Position Statement, 15.3, LVNs Engaging in Intravenous Therapy, Venipuncture, or PICC Lines (TX BON, 2021).]

Basic competency in management of intravenous (IV) lines and/or intravenous therapy is not a given for any specific LVN licensee. Instruction and skill evaluation relating to LVNs performing insertion of peripheral IV catheters and/or administering IV fluids and medications as prescribed by an authorized practitioner may allow an LVN to expand their scope of practice to include intravenous therapy.

It is the opinion of the Board that the LVN shall not engage in IV therapy and/or administration of IV push medications until successful completion of a validation course that instructs the LVN in the knowledge and skills applicable to the LVN’s IV therapy practice. The LVN who chooses to engage in IV therapy must first have been instructed in the principles of IV therapy congruent with prevailing nursing practice standards.

Professional Nursing

[This section is taken from Texas Board of Nursing Position Statements, 15.28, The Registered Nurse Scope of Practice; TAC Title 22, Part 11, §217.11. Standards of Nursing Practice; and TOC, Ch. 301.002. Definitions.]

A registered nurse (RN) is any person licensed in Texas to practice professional nursing. The practice of professional nursing means the performance of an act that requires substantial specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of professional nursing.

Unless licensed as an advanced practice registered nurse (see “Advanced Practice Nursing” below), the RN scope of practice does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures.

NURSING PROCESS FOR THE REGISTERED NURSE

Assessment

The comprehensive assessment is the first step and lays the foundation for the nursing process. Nursing judgment is based on the assessment findings. The RN uses clinical reasoning and knowledge, evidence-based outcomes, and research as the basis for decision-making and comprehensive care.

Based upon the comprehensive assessment, the RN determines the physical and mental health status, needs, and preferences of culturally, ethnically, and socially diverse patients and their families using evidence-based health data and a synthesis of knowledge.

Patient Diagnosis / Problem Identification

The second step in the nursing process is analyzing data gathered during the assessment and problem identification. The role of the RN is to synthesize comprehensive assessment data to identify problems, formulate goals/outcomes, and develop plans of care for patients, families, populations, and communities using information from evidence-based practice and published research in collaboration with these groups and the interdisciplinary healthcare team.

Planning

The third step in the nursing process is planning. The RN synthesizes the data collected during the comprehensive assessment to identify problems, participate in the patient diagnoses, and formulate goals, teaching plans, and outcomes. A nursing plan of care for patients is developed by the RN, who has the overall responsibility to coordinate nursing care for patients.

Implementation

Implementing the plan of care is the fourth step in the nursing process. The RN may begin, deliver, assign, or delegate certain nursing tasks within the plan of care for patients within legal, ethical, and regulatory parameters and in consideration of health restoration, disease prevention, wellness, and promotion of healthy lifestyles.

The RN’s duty to patient safety when making assignments to other nurses or when delegating tasks to unlicensed staff is to consider the education, training, skill, competence, and physical and emotional abilities of those to whom the assignments or delegation is made. The RN is responsible for reasonable and prudent decisions regarding assignments and delegation.

The RN may determine when it is appropriate to delegate tasks to unlicensed personnel and maintains accountability for how the unlicensed personnel perform the tasks (see also “Delegation to Unlicensed Personnel” below). The RN is responsible for supervising the unlicensed personnel when tasks are delegated.

Evaluation and Reassessment

A critical and final step in the nursing process is evaluation. The RN evaluates and reports patient outcomes and responses to therapeutic interventions in comparison to benchmarks from evidence-based practice and research findings. Revisions to the plan of care may be made as needed as well as plans for follow-up care and appropriate referrals.

Advanced Practice Nursing

[This section is taken from TOC Ch. 301.152 and Ch. 301.354; §219.2. Definitions, §221.12. Scope of Practice, and §221.13. Core Standards for Advanced Practice.]

ADVANCED PRACTICE REGISTERED NURSE

An advanced practice registered nurse (APRN) is a registered nurse licensed by the Texas Board of Nursing to practice as an advanced practice registered nurse on the basis of completion of an advanced educational program. The term APRN refers to a nurse practitioner, nurse midwife, nurse anesthetist, and clinical nurse specialist.

The advanced practice nurse practices in an expanded role to provide a broad range of health services, the scope of which shall be based upon educational preparation and the accepted scope of professional practice of the particular specialty area.

Scope of Practice

The advanced practice nurse may perform only those functions that are within that scope of practice and that are consistent with the Nursing Practice Act, Board rules, and other applicable laws and regulations affecting their practice in Texas.

The advanced practice nurse’s scope of practice shall be in addition to the scope of practice permitted a registered nurse and does not prohibit the advanced practice nurse from practicing in those areas deemed to be within the scope of practice of a registered nurse. The advanced practice nurse acts independently and/or in collaboration with the healthcare team.

Protocols

When providing medical aspects of care, advanced practice nurses shall utilize mechanisms that provide authority for that care. Protocols or other written authorization shall promote the exercise of professional judgment by the advanced practice nurse commensurate with their education and experience. The degree of detail within protocols/policies/practice guidelines/clinical practice privileges may vary in relation to the complexity of the situations covered by such protocols, the advanced specialty area of practice, the advanced educational preparation of the individual, and the experience level of the individual advanced practice nurse.

Protocols or other written authorization:

• Should be jointly developed by the advanced practice nurse and the appropriate physician(s)
• Shall be signed by both the advanced practice nurse and the physician(s)
• Shall be reviewed and re-signed at least annually
• Shall be maintained in the practice setting of the advanced practice nurse
• Shall be made available as necessary to verify authority to provide medical aspects of care

REGISTERED NURSE FIRST ASSISTANT

Nurse first assistant means a registered nurse who has passed a nurse first assistant educational program approved or recognized by an organization recognized by the Board and is either:

• Certified in perioperative nursing by an organization recognized by the Board, or
• Recognized by the Board as an advanced practice nurse and qualified by education, training, or experience to perform the tasks involved in perioperative nursing

DELEGATION TO UNLICENSED PERSONNEL

[This section is taken from TAC Title 22, Part 11, §224. Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments.]

Registered nurses must follow the rules from the Texas Administrative Code when delegating tasks to unlicensed personnel. Delegation is defined as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. It does not include situations in which an unlicensed person is directly assisting an RN by carrying out nursing tasks in the presence of a RN.

An unlicensed person is an individual not licensed as a healthcare provider:

• Who is monetarily compensated to provide certain health-related tasks and functions in a complementary or assistive role to the RN in providing direct client care or carrying out common nursing functions (e.g., nurse aides, orderlies, assistants, etc.)

or

• Who is a professional nursing student, not licensed as a RN or LVN, providing care for monetary compensation and not as part of their formal educational program

The full utilization of the services of a RN may require delegation of selected nursing tasks to unlicensed personnel. The scope of delegation and the level of supervision by the RN may vary depending on the setting, task, skills, and experience of the unlicensed person and the client’s physical and mental status.

The following pertains to delegation for acute care clients or in an acute care environment where nursing services are continuously provided. (For information regarding delegation and tasks not requiring delegation in independent living environments for clients with stable and predictable conditions, see TAC Title 22, Part 11, section 225.)

General Criteria for Delegation

The following standards must be met before the RN delegates nursing tasks to unlicensed persons. These criteria apply to all instances of RN delegation.

• The RN must make an assessment of the client’s nursing care needs in collaboration with the client and family as appropriate prior to delegating nursing tasks.
• The nursing task must be one that a reasonable and prudent RN would find is within the scope of sound nursing judgment to delegate. The RN should consider the five “rights” of delegation: the right task, the right person to whom the delegation is made, the right circumstances, the right direction and communication by the RN, and the right supervision as determined by the RN.
• The nursing task must be one that, in the opinion of the delegating RN, can be properly and safely performed by the unlicensed person involved without jeopardizing the client’s welfare.
• The nursing task must not require the unlicensed person to exercise professional nursing judgment, but may involve any action that a reasonable, prudent, nonhealthcare professional would take in an emergency situation.
• The unlicensed person to whom the nursing task is delegated must be adequately identified. The identification may be by individual or, if appropriate, by training, education, and/or certification/permit of the unlicensed person.
• The RN shall have either instructed the unlicensed person in the delegated task or verified the unlicensed person’s competency to perform the nursing task.
• The RN shall adequately supervise the performance of the delegated nursing task in accordance with the requirements of nursing supervision (see below).
• If the delegation continues over time, the RN shall periodically evaluate the delegation of tasks.

Supervision Criteria

The registered professional nurse shall provide supervision of all nursing tasks delegated to unlicensed persons in accordance with the following conditions. These supervision criteria apply to all instances of RN delegation for clients with acute conditions or in acute care environments. The degree of supervision required shall be determined by the RN after an evaluation of appropriate factors involved, including, but not limited to, the following:

• Stability of the client’s status in relation to the task(s) to be delegated
• Training, experience, and capability of the unlicensed person to whom the nursing task is delegated
• Nature of the nursing task being delegated
• Proximity and availability of the RN to the unlicensed person when the nursing task will be performed

The RN shall be available in person or by telecommunications and shall make decisions about appropriate levels of supervision.

Nursing Tasks Commonly Delegated

By way of example, and not in limitation, the following nursing tasks are ones that are most commonly the type of tasks within the scope of sound professional nursing practice to be considered for delegation, regardless of the setting, provided the delegation is in compliance with TAC Title 22, Part 11, §224.6 (relating to General Criteria for Delegation) and the level of supervision required is determined by the RN in accordance with §224.7 of the same title (relating to Supervision):

• Noninvasive and nonsterile treatments
• Collecting, reporting, and documentation of data, including, but not limited to:
  • Vital signs, height, weight, intake and output, capillary blood, and urine test
  • Environmental situations
  • Client or family comments relating to the client’s care
  • Behaviors related to the plan of care
• Ambulation, positioning, and turning
• Transportation of the client within a facility
• Personal hygiene and elimination, including vaginal irrigations and cleansing enemas
• Feeding, cutting up of food, or placing of meal trays
• Socialization activities
• Activities of daily living
• Reinforcement of health teaching planned and/or provided by the registered nurse

Nursing Tasks Prohibited from Delegation

By way of example, and not in limitation, the following are nursing tasks that are not within the scope of sound professional nursing judgment to delegate:

• Physical, psychological, and social assessment that requires professional nursing judgment, intervention, referral, or follow-up
• Formulation of the nursing care plan and evaluation of the client’s response to the care rendered
• Specific tasks involved in the implementation of the care plan that require professional nursing judgment or intervention
• Responsibility and accountability for client health teaching and health counseling that promotes client education and involves the client’s significant others in accomplishing health goals
• Administration of medications, including intravenous fluids, except by medication aides as permitted under §224.9 of this title (relating to the Medication Aide Permit Holder)

STANDARDS OF NURSING PRACTICE

[This section is taken from TAC Title 22, Part 11, §217.11. Standards of Nursing Practice.]

The Texas Board of Nursing is responsible for regulating the practice of nursing within the state of Texas for vocational nurses, registered nurses, and registered nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse’s license even if no actual patient injury resulted.

Standards Applicable to All Nurses

The Texas Administrative Code gives standards for all vocational nurses, registered nurses, and registered nurses with advanced practice authorization. The standards include:

• Know and conform to the Texas Nursing Practice Act and the Board’s rules and regulations as well as all federal, state, or local laws, rules, or regulations affecting the nurse’s current area of nursing practice
• Implement measures to promote a safe environment for clients and others
• Know the rationale for and the effects of medications and treatments and correctly administer the same
• Accurately and completely report and document:
  • Client’s status, including signs and symptoms
  • Nursing care rendered
  • Physician, dentist, or podiatrist orders
  • Administration of medications and treatments
  • Client response(s)
  • Contacts with other healthcare team members concerning significant events regarding client’s status
• Respect the client’s right to privacy by protecting confidential information unless required or allowed by law to disclose the information
• Promote and participate in education and counseling to a client(s) and family as appropriate
• Obtain instruction and supervision as necessary
• Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations
• Notify the appropriate supervisor when leaving a nursing assignment
• Know, recognize, and maintain professional boundaries of the nurse-client relationship
• Comply with mandatory reporting requirements of Texas Occupations Code, Chapter 301 (Nursing Practice Act), Subchapter I, which include reporting a nurse:
  • Who violates the Nursing Practice Act or a Board rule and contributed to the death or serious injury of a patient
  • Whose conduct causes a person to suspect that the nurse’s practice is impaired by chemical dependency or drug or alcohol abuse
  • Whose actions constitute abuse, exploitation, fraud, or a violation of professional boundaries
  • Whose actions indicate that the nurse lacks knowledge, skill, judgment, or conscientiousness to such an extent that the nurse’s continued practice in nursing could reasonably be expected to pose a risk of harm to a patient or another person, regardless of whether the conduct consists of a single incident or a pattern of behavior
  • Except for minor incidents (Texas Occupations Code §§301.401[2], 301.419, 22 TAC §217.16), peer review (Texas Occupations Code §§301.403, 303.007, 22 TAC §217.19), or peer assistance if no practice violation (Texas Occupations Code §301.410) as stated in the Nursing Practice Act and Board rules (22 TAC Chapter 217)
• Provide nursing services without discrimination regardless of the age, disability, economic status, gender, national origin, race, religion, health problems, or sexual orientation of the client served
• Institute appropriate nursing interventions that might be required to stabilize a client’s condition and/or prevent complications
• Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, nonefficacious, or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment
• Implement measures to prevent exposure to infectious pathogens and communicable conditions
• Collaborate with the client, members of the healthcare team, and when appropriate, the client’s significant other(s) in the interest of the client’s healthcare
• Consult with, utilize, and make referrals to appropriate community agencies and healthcare resources to provide continuity of care
• Be responsible for one’s own continuing competence in nursing practice and individual professional growth
• Make assignments to others that take into consideration client safety and that are commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made
• Accept only those nursing assignments that take into consideration client safety and that are commensurate with the nurse’s educational preparation, experience, knowledge, and physical and emotional ability
• Supervise nursing care provided by others for whom the nurse is professionally responsible
• Ensure the verification of current Texas licensure or other Compact State licensure privilege and credentials of personnel for whom the nurse is administratively responsible, when acting in the role of nurse administrator

Standards Specific to Vocational Nurses

The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician’s assistant, physician, podiatrist, or dentist. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and:

• Shall utilize a systematic approach to provide individualized, goal-directed nursing care by:
  • Collecting data and performing focused nursing assessments
  • Participating in the planning of nursing care needs for clients
  • Participating in the development and modification of the comprehensive nursing care plan for assigned clients
  • Implementing appropriate aspects of care within the LVN’s scope of practice
  • Assisting in the evaluation of the client’s responses to nursing interventions and the identification of client needs
• Shall assign specific tasks, activities, and functions to unlicensed personnel commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made and shall maintain appropriate supervision of unlicensed personnel
• May perform other acts that require education and training as prescribed by Board rules and policies, commensurate with the licensed vocational nurse’s experience, continuing education, and demonstrated licensed vocational nurse competencies

Standards Specific to Registered Nurses

The registered nurse shall assist in the determination of healthcare needs of clients and shall:

• Utilize a systematic approach to provide individualized, goal-directed nursing care by:
• Performing comprehensive nursing assessments regarding the health status of the client
• Making nursing diagnoses that serve as the basis for the strategy of care
• Developing a plan of care based on the assessment and nursing diagnosis
• Implementing nursing care
• Evaluating the client’s responses to nursing interventions
• Delegate tasks to unlicensed personnel in compliance with TAC Title 22, Part 11, Chapter 224, relating to clients with acute conditions or in acute care environments, and Chapter 225 of the same title, relating to independent living environments for clients with stable and predictable conditions

Standards Specific to Registered Nurses with Advanced Practice Authorization

Standards for a specific role and specialty of advanced practice nurses supersede standards for registered nurses where conflict between the standards, if any, exist. In addition to the standards specific to all nurses and registered nurses, a registered nurse who holds authorization to practice as an advanced practice nurse (APN) shall:

• Practice in an advanced nursing practice role and specialty in accordance with authorization granted under Board Rule Chapter 221 of this title (relating to practicing in an APN role; 22 TAC Chapter 221) and standards set out in that chapter
• Prescribe medications in accordance with prescriptive authority granted under Board Rule Chapter 222 of this title (relating to APNs prescribing; 22 TAC Chapter 222) and standards set out in that chapter and in compliance with state and federal laws and regulations relating to prescription of dangerous drugs and controlled substances

(The latest details on standards of practice may be found in the current edition of Texas Board of Nursing Rules and Regulations Relating to Nursing Education, Licensure, and Practice, available on the TX BON website. See “Resources” at the end of this course.)

PEER REVIEW AND DISCIPLINE RELATED TO NURSING PRACTICE

[This section is taken from Texas Occupations Code, Ch. 303, Nursing Peer Review, and Texas Occupations Code, Ch. 301, Nurses.]

The Texas BON “has the authority and power to regulate nursing practice utilizing the language stipulated in the Nurse Practice Act. It is also the responsibility of the BON to protect (Texas) citizens’ health, safety, and welfare against substandard nursing care.” The Texas Board of Nursing protects the public’s health and welfare by overseeing and ensuring the safe practice of nursing. It regulates and oversees nursing practice by enforcing the nursing laws of Texas (Boehning & Haddad, 2022).

Violations of Texas laws related to nursing (TAC Title 22, Part 11, and TOC Chapters 301–305) are serious and may result in complaints being filed and in discipline by the Board of Nursing. Violations of nursing laws and rules can result in written warnings, public reprimands, fines, limitations or restrictions on the person’s license, citations, denial, revocation, or suspension of licenses.

Nursing Peer Review

Peer review means the evaluation of nursing services, the qualifications of a nurse, the quality of patient care rendered by a nurse, the merits of a complaint concerning a nurse or nursing care, and a determination or recommendation regarding a complaint.

Peer review includes:

• The evaluation of the accuracy of a nursing assessment and observation and the appropriateness and quality of the care rendered by a nurse
• A report made to a nursing peer review committee concerning an activity under the committee’s review authority
• A report made by a nursing peer review committee to another committee or to the Board as permitted or required by law
• Implementation of a duty of a nursing peer review committee by a member, an agent, or an employee of the committee
• The provision of information, advice, and assistance to nurses and other persons relating to:
  • The rights and obligations of and protections for nurses who raise care concerns or report under Chapter 301 or other state or federal law
  • The rights and obligations of and protections for nurses who request nursing peer review under this chapter
  • Nursing practice and patient care concerns
  • The resolution of workplace and practice questions relating to nursing and patient care
(TX BON, 2019a)

There two distinct types of nursing peer review, the incident-based nursing peer review and safe harbor nursing peer review:

• Incident-based nursing peer review is conducted to find out if a nurse’s singular or repetitive action needs to be reported to the Board or if it can be disciplined by the facility.
• Safe harbor nursing peer review is when a nurse makes a request in good faith for nursing peer review for a task the nurse has been asked to do that the nurse believes could be a violation of the NPA or Board rules. Nurses who request safe harbor nursing peer review are protected from discipline and discrimination for making the request and may engage in the requested conduct pending the peer review.
  (TX BON, 2022; TX BON, 2019a)

Grounds for Disciplinary Action

Violations of Texas law that are grounds for disciplinary action include, but are not limited to:

• Violation of the Texas Nursing Practice Act, a rule or regulation not inconsistent with the Act, or an order issued under the Act
• Fraud or deceit in procuring or attempting to procure a license to practice professional nursing or vocational nursing
• Conviction for, or placement on deferred adjudication community supervision or deferred disposition for, a felony or a misdemeanor involving moral turpitude
• Conduct that results in the revocation of probation imposed because of conviction for a felony or for a misdemeanor involving moral turpitude
• Use of a nursing license, diploma, or permit, or the transcript of such a document, that has been fraudulently purchased, issued, counterfeited, or materially altered
• Impersonating or acting as a proxy for another person in the licensing examination required under Sections 301.253 or 301.255
• Directly or indirectly aiding or abetting an unlicensed person in connection with the unauthorized practice of nursing
• Revocation, suspension, or denial of, or any other action relating to, the person’s license or privilege to practice nursing in another jurisdiction or under federal law
• Intemperate use of alcohol or drugs that the Board determines endangers or could endanger a patient
• Unprofessional or dishonorable conduct that, in the Board’s opinion, is likely to deceive, defraud, or injure a patient or the public
• Adjudication of mental incompetency
• Lack of fitness to practice because of a mental or physical health condition that could result in injury to a patient or the public
• Failure to care adequately for a patient or to conform to the minimum standards of acceptable nursing practice in a manner that, in the Board’s opinion, exposes a patient or other person unnecessarily to risk of harm

Required Suspension, Revocation, or Refusal of a License

The Board shall suspend a nurse’s license or refuse to issue a license to an applicant on proof that the nurse or applicant has been initially convicted of:

• Murder, capital murder, or manslaughter
• Kidnapping or unlawful restraint
• Sexual assault
• Aggravated sexual assault
• Continuous sexual abuse of a young child or children or indecency with a child
• Aggravated assault
• Intentionally, knowingly, or recklessly injuring a child, elderly individual, or disabled individual
• Intentionally, knowingly, or recklessly abandoning or endangering a child
• Aiding suicide
• An offense involving a violation of certain court orders or conditions of bond punished as a felony
• An agreement to abduct a child from custody
• The sale or purchase of a child
• Robbery
• Aggravated robbery
• An offense for which a defendant is required to register as a sex offender
• An offense under the law of another state, federal law, or the Uniform Code of Military Justice that contains elements that are substantially similar to the elements of an offense listed above

NURSING ETHICS

The terms laws and ethics are distinct from one another, although some individuals mistakenly assume they mean the same thing. In the United States, law refers to “any rule that, if broken, subjects a party to criminal punishment or civil liability” (The Free Dictionary, 2023a). Nurses must practice according to the laws that govern their society as well as their nursing practice.

Ethics refers to a system or set of moral principles that govern behavior, including job performance. Ethics includes beliefs about the “rightness” and “wrongness” of actions as well as the “goodness” and “badness” of motives and outcomes (The Free Dictionary, 2023b). Nurses must practice according to the ethical principles of their profession.

Code of Ethics for Nurses

Codes of ethics are formal statements that set forth standards of ethical behavior for members of a group. In fact, one of the hallmarks of a profession is that its members subscribe to a code of ethics. Every member of a profession is expected to read, understand, and abide by the ethical standards of their occupation.

In addition to abiding by the laws established in the Nursing Practice Act, every member of the nursing profession is expected to read, understand, and abide by the ethical standards of their occupation. In the case of nursing, the American Nurses Association (2015) publishes the Code of Ethics for Nurses with Interpretive Statements to guide nurses’ professional practice. The following provisions of the code broadly describe the ethical obligations of nurses:

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

Nursing Ethical Principles

Ethical principles are fundamental concepts by which people make decisions. Four ethical principles mark the practice of professional nursing and are inherent in the Code of Ethics for Nurses (Haddad & Geiger, 2022).

Autonomy is the belief that patients have the right to make their own decisions based on their own beliefs and values. For example, patients have the right to refuse treatment regardless of what benefit may come from it.

Beneficence refers to a particular type of treatment. Nurses have a duty to abstain from maltreatment, minimize harm, and promote the good of the patient. For example, nurses have the responsibility to administer medications accurately, safely, and in a timely manner.

Justice means that all patients have the right to be treated fairly and equally. For example, patients who live in areas that do not have adequate healthcare services are not treated equally compared to those who are able to access (and afford) adequate treatment.

Nonmaleficence mandates that nurses do not cause harm to patients. This particular principle may be the most challenging to adhere to. For example, patients may refuse medication that is essential to their health and well-being. Although the patient has a right to refuse this medication, the nurse might be concerned that without the medication the patient may become dangerously ill and even die. Nurses must ensure that patients have all of the information they need to make an informed decision. Even with such information, the patient may decide to refuse the medication, and the nurse must support the patient’s decision (autonomy).

Ethical Dilemmas

An ethical dilemma is a conflict between choices that, no matter which choice is made, some ethical principle will be compromised. Resolution of ethical dilemmas requires careful evaluation of all the facts of a case, including applicable laws, consultation with all concerned parties, and appraisal of the decision makers’ ethical philosophies.

In order to resolve an ethical dilemma in the best possible way, several steps should be taken. These include:

1. Consider the consequences of both choices, particularly the positive and negative results from each.
2. Consider the actions of those choices. Do one’s actions line up with the moral principles regarding honesty, fairness, and respect for other people?
3. Decide what to do and explain one’s reasoning to those who are affected by the decision.
   (Hegde, 2021)

PROFESSIONAL BOUNDARIES

Professional boundaries are the appropriate limits that should be established by the nurse in the nurse/patient relationship due to the nurse’s power and the patient’s vulnerability. Working within professional boundaries refers to the provision of nursing services within the limits of the nurse/patient relationship. However, nurses who display one or more of the following behaviors should examine their patient relationships for possible boundary crossings or violations:

• Excessive self-disclosure. The nurse discusses personal problems, feelings of sexual attraction, or aspects of their intimate life with the patient.
• Secretive behavior. The nurse keeps secrets with the patient and/or becomes guarded or defensive when someone questions their interaction.
• “Super nurse” behavior. The nurse believes that they are immune from fostering a nontherapeutic relationship and that only they understand and can meet the patient’s needs.
• Displays of favoritism. The nurse spends inappropriate amounts of time with a particular patient, visits the patient when off-duty, or trades assignments to be with the patient. This form of treatment may also be reversed, with the patient paying special attention to the nurse (e.g., giving gifts to the nurse). If a nurse is receiving this type of attention from a patient, it is advisable for the nurse to seek the guidance of the supervisor.
• Selective communication. The nurse fails to explain actions and aspects of care, reports only some aspects of the patient’s behavior, or gives double messages.
• Flirtations. The nurse communicates in a flirtatious manner, perhaps employing sexual innuendo, “off-color” jokes, or offensive language.
• “You and me against the world” behavior. The nurse views the patient in a protective manner, tends not to accept the patient as merely a patient, or sides with the patient’s position regardless of the situation.
  (NCSBN, 2018)

CONCLUSION

The Texas Nursing Practice Act defines the rules for the state Board of Nursing, which then, along with the law itself, sets the standards of competent nursing practice and standards for promoting patient safety by all nurses who practice in the state. Competent nursing practice includes providing care according to ethical as well as legal standards. By ensuring that all nurses adhere to these standards, the mission of the Board of Nursing to safeguard and advance the health of Texan citizens through safe nursing practice is achieved.