Nursing Jurisprudence and Ethics for Texas
Standards of Nursing
Online Continuing Education Course
MANDATORY TEXAS NURSING CEU. Fulfills Texas BON requirement for continuing education on nursing jurisprudence and nursing ethics. 2 contact hour CNE course covers standards of nursing practice in Texas, nurse practice act, and ethics, laws, and rules.
Course Price: $20.00
Contact Hours: 2
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This course fulfills the Texas Board of Nursing requirement for 2 hours of continuing nursing education (CNE) relating to nursing jurisprudence and ethics.
Nursing Jurisprudence and Ethics for Texas
Standards of Nursing
Copyright © 2017 Wild Iris Medical Education, Inc. All Rights Reserved.
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 objectives include:
- Describe the Texas Board of Nursing.
- Identify the levels of nursing practice in Texas.
- Discuss the factors for safe delegation to unlicensed assistive personnel.
- Define the standards of nursing practice in Texas.
- Identify the steps in the Six-Step Decision-Making Model for Determining Nursing Scope of Practice.
- Explain the requirements for renewing a nursing license in Texas.
- Differentiate between ethical and legal issues.
- Describe professional boundaries as related to nursing practice.
- Discuss Texas nursing law violations and disciplinary actions.
TABLE OF CONTENTS
- Texas Nursing Laws and Rules
- Levels of Nursing Practice in Texas
- Delegation to Unlicensed Personnel
- Standards of Nursing Practice
- Six-Step Decision-Making Model
- Texas Nursing Licensure Renewal Requirements
- Ethics Versus Laws
- Discipline Related to Nursing Practice
“The practice of nursing requires specialized knowledge, skill, and independent decision-making… . Because nursing care poses a risk of harm to the public if practiced by professionals who are unprepared or incompetent, the state, through its police powers, is required to protect its citizens from harm. That protection is in the form of reasonable laws to regulate nursing… .
“All [U.S.] states and territories have enacted a nurse practice act (NPA). Each state’s NPA is enacted by the state’s legislature. The NPA itself is insufficient to provide the necessary guidance for the nursing profession; therefore, each NPA establishes a board of nursing (BON) that has the authority to develop administrative rules or regulations to clarify or make the law more specific…
“All NPAs include:
- Authority, power, and composition of a board of nursing
- Education program standards
- Standards and scope of nursing practice
- Types of titles and licenses
- Requirements for licensure
- Grounds for disciplinary action, other violations, and possible remedies”
Currently in each U.S. state and territory, a law known as a nurse practice act designates an authoritative body that defines and regulates the nursing practice of every nurse in every role. This authoritative body, known as a board of nursing, is responsible for ensuring that nurses who practice in that state are competent, safe, skilled, and knowledgeable about the standards set forth in that state’s scope of practice for nurses.
This course discusses the standards for the safe practice of nursing in the state of Texas as written by the Texas Board of Nursing in accordance with the Texas Statutes.
TEXAS NURSING LAWS AND RULES
Texas Nursing Practice Act
In Texas, nursing standards are codified in the Texas Statutes. The Texas Statutes are a permanent collection of state laws organized by subject area into a code made up of titles, subtitles, chapters, subchapters, parts, and sections. The Texas Occupations Code is updated by laws that create, amend, transfer, or repeal statutory material.
The Texas Occupations Code has four parts related to nursing:
- Chapter 301, Nursing Practice Act (NPA)
- Chapter 303, Nursing Peer Review
- Chapter 304, Nursing Licensure Compact
- Chapter 305, Advanced Practice Registered Nurse Compact
(Texas Legislature, 2013)
TEXAS NURSING PRACTICE ACT
- General Provisions
- Texas Board of Nursing
- Executive Director and Personnel
- General Powers and Duties of Board
- Public Interest Information and Complaint Procedures
- License Requirements
- License Renewal
- Practice by License Holder
- Reporting Violations and Patient Care Concerns
- Prohibited Practices and Disciplinary Actions
- Administrative Penalty
- Other Penalties and Enforcement Provisions
- Anesthesia in Outpatient Setting
- Corrective Action Proceeding and Deferred Action
Source: Texas Legislature, 2013.
Texas Board of Nursing
The practice of nursing in Texas is licensed by the Texas Board of Nursing (BON). The BON is funded and supported by mandatory licensure fees paid by nurses wishing to practice legally in the state of Texas.
The Texas Board of Nursing consists of 13 members appointed by the governor with the advice and consent of the senate for terms of six years as follows:
- Six nurse members, including:
- One advanced practice nurse
- Two registered nurses who are not advanced practice nurses or members of a nurse faculty
- Three vocational nurses who are not members of a nurse faculty
- Three members who are nurse faculty members of schools of nursing:
- One of whom is a nurse faculty member of a school of nursing offering a baccalaureate degree program in preparing registered nurses
- One of whom is a nurse faculty member of a school of nursing offering an associate degree program in preparing registered nurses
- One of whom is a nurse faculty member of a school of nursing at an institution of higher education preparing vocational nurses
- Four members who represent the public
(Texas Legislature, 2013)
A person is not eligible for appointment as a registered nurse or vocational nurse member of the board unless the person has practiced nursing in the role for which the member was appointed for at least three of the five years preceding the date of appointment.
The NPA defines the BON’s responsibility 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 (Texas Secretary of State, n.d.-a).
The mission of the Texas Board of Nursing is to protect and promote the welfare of the people of Texas by ensuring that each person holding a license as a nurse in this state is competent to practice safely. The Board fulfills its mission through the regulation of the practice of nursing and the approval of nursing educational programs. This mission, derived from the Nursing Practice Act, supersedes the interest of any individual, the nursing profession, or any special interest group (TX BON, 2016).
Texas Nursing Rules
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 (Texas Secretary of State, n.d.-b). Title 22, Part 11, of the TAC outlines rules related to nursing.
TEXAS ADMINISTRATIVE CODE, TITLE 22, PART 11, TEXAS BOARD OF NURSING
- 211.1–211.9 General Provisions
- 213.1–213.34 Practice and Procedure
- 214.1–214.13 Vocational Nursing Education
- 215.1–215.13 Professional Nurse Education
- 216.1–216.11 Continuing Competency
- 217.1–217.22 Licensure, Peer Assistance and Practice
- 219.1–219.13 Advanced Practice Nurse Education
- 220.1–220.4 Nurse Licensure Compact
- 221.1–221.17 Advanced Practice Nurses
- 222.1–222.10 Advanced Practice Registered Nurses with Prescriptive Authority
- 223.1–223.2 Fees
- 224.1–224.11 Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments
- 225.1–225.14 RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions
- 226.1–226.7 Patient Safety Pilot Programs on Nurse Reporting Systems
- 227.1–227.6 Pilot Programs for Innovative Applications to Professional Nursing Education
- 228.1 Pain Management
Source: Texas Secretary of State, n.d.-a.
LEVELS OF NURSING PRACTICE IN TEXAS
The mission of the Texas Board of Nursing is to protect and promote the welfare of the people of Texas by ensuring that each person holding a license as a nurse in the State of Texas is competent to practice safely. The Board fulfills its mission through the regulation of the practice of nursing and the approval of nursing education programs. This mission, derived from the Nursing Practice Act, supersedes the interest of any individual, the nursing profession, or any special interest group (TXBON, n.d.-a).
[This section is taken from Board Position Statements 15.23. The Use of Complementary Modalities by the LVN or RN and 15.27. The Licensed Vocational Nurse Scope of Practice (TX BON, 2017). TAC Title 22, Part 11, §217.11 Standards of Nursing Practice (TX BON, 2016). Texas Occupations Code, Ch. 301.002. Definitions. Ch. 301.353. Supervision of Vocational Nurse (Texas Legislature, 2013).]
The licensed vocational nurse (LVN) and the professional, or registered, nurse have different roles within the nursing process. The nursing practice of an LVN requires supervision with oversight from a registered nurse (RN), advanced practice registered nurse, physician, physician assistant, podiatrist, or dentist. The LVN collects data and information, recognizes changes in conditions and reports this to the RN supervisor or another appropriate clinical supervisor to assist in the identification of problems and contributes to care planning, interventions, and evaluations. The RN is responsible for the overall coordination of care and performs comprehensive assessments, initiates the nursing care plan, and implements and evaluates care of the client or patient (TX BON, 2017).
THE PRACTICE OF VOCATIONAL NURSING
A licensed vocational nurse means any person licensed in Texas to practice vocational nursing. The practice of vocational nursing is a directed scope of nursing practice, including the performance of an act that requires 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 vocational nursing.
The LVN is an advocate for the patient and the patient’s family and promotes safety by practicing within the NPA and the BON Rules and Regulations. LVN scope of practice does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures. The LVN is precluded from practicing in a completely independent manner; however, direct and on-site supervision may not be required in all settings or patient-care situations.
Supervision is defined as the active process of directing, guiding, and influencing the outcome of an individual’s performance of an activity.
Oversight includes determining the degree of proximity of an appropriate clinical supervisor. This includes identifying whether the supervisor is available by phone or actually physically present. This decision should be made by the LVN and the LVN’s clinical supervisor after evaluating the specific situation and taking into consideration patient conditions and the level of skill, training, and competence of the LVN. An appropriate clinical supervisor may need to be physically available to assist the LVN should emergent situations arise.
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.
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.
NURSING PROCESS FOR THE LICENSED VOCATIONAL NURSE
The LVN assists in determining the physical and mental health status, needs, and preferences of culturally, ethnically, and socially diverse patients and their families based on interpretation of health-related data. The LVN collects data and information, recognizes changes in conditions, and reports this to the RN supervisor or another appropriate clinical supervisor to assist in the identification of problems and formulation of goals, outcomes, and patient-centered plans of care that are developed in collaboration with patients, their families, and the interdisciplinary healthcare team.
The LVN participates in the nursing process by appraising the individual patient’s status or situation at hand. Also known as a focused assessment, this appraisal may be considered a component of a more comprehensive assessment performed by a RN or another appropriate clinical supervisor. For example, a RN may utilize the data and information collected and reported by the LVN in the formation of the nursing process; however, the RN’s comprehensive assessment lays the foundation for the nursing process. The LVN reports the data and information collected either verbally or in writing. Written documentation must be accurate and complete and according to policies, procedures, and guidelines for the employment setting.
The second step in which the LVN participates and contributes to the nursing process is planning. After the focused assessment, the LVN reports data and other information such as changes in patient conditions to the appropriate clinical supervisor, such as an RN. This information may be considered in planning, problem identification, nursing diagnoses, and formulation of goals, teaching plans, and outcomes by the RN supervisor or another appropriate clinical supervisor. A nursing plan of care for patients is developed by the RN, and thus the RN has the overall responsibility to coordinate nursing care for patients.
Implementing the plan of care is the third step in the nursing process. The LVN is responsible for providing safe, compassionate, and focused nursing care to assigned patients with predictable healthcare needs. The LVN may implement aspects of the plan of care within legal, ethical, and regulatory parameters and in consideration of patient factors. The LVN organizes aspects of patient care based on identified priorities.
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), which states that the LVN 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.
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 the tasks to a UAP, and the LVN may then proceed to assign those tasks that need to be accomplished for that day.
Teaching and counseling are interwoven throughout the implementation phase of the nursing process, and LVNs can participate in implementing established teaching plans for patients and their families with common health problems and well-defined health learning needs.
A critical and fourth 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 modifications to the plan of care that may be necessary and making appropriate referrals to facilitate continuity of care.
[This section is taken from Board Position Statement 15.3. LVNs Engaging in Intravenous Therapy, Venipuncture, or PICC Lines (TXBON, 2017).]
The basic educational curriculum for LVNs does not mandate teaching of principles and techniques of insertion for peripheral intravenous catheters or the administration of fluids and medications via the intravenous route. Knowledge and skills relating to maintaining patency and performing dressing changes of central line intravenous catheters is also not mandated as part of basic LVN education. As such, basic competency in management of intravenous lines/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 a LVN to expand his/her scope of practice to include intravenous therapy.
It is the opinion of the Board that the LVN shall not engage in IV therapy related to either peripheral or central venous catheters, including venipuncture, administration of IV fluids, 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 BON does not define or set qualifications for an “IV Validation Course” or for “LVN IV certification.” The LVN who chooses to engage in intravenous therapy must first have been instructed in the principles of intravenous therapy congruent with prevailing nursing practice standards.
The ability of a LVN to administer specific IV fluids or drugs, to prepare and/or administer IV “piggy-back” or IV “push” medications, or to monitor and titrate IV drip medications of any kind is up to facility policy. The LVN’s practice relative to IV therapy must also comply with any other regulations that may exist under the jurisdiction of other regulatory agencies or entities.
[This section is taken from Board Position Statement 15.28. The Registered Nurse Scope of Practice (TXBON, 2017); TAC Title 22, Part 11, §217.11. Standards of Nursing Practice (TX BON, 2016); and Texas Occupations Code, Ch. 301.002. Definitions (Texas Legislature, 2013).]
A registered nurse (RN) means 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.
The professional registered nurse is an advocate for the patient and the patient’s family and promotes safety by practicing within the NPA and the BON Rules and Regulations.
Unless licensed as an advanced practice registered nurse, the RN scope of practice does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures. RNs utilize the nursing process to establish the plan of care in which nursing services are delivered to patients. The level and impact of the nursing process differs between the RN and LVN.
NURSING PROCESS FOR THE REGISTERED NURSE
The comprehensive assessment is the first step and lays the foundation for the nursing process. It consists of the initial and ongoing extensive collection, analysis, and interpretation of data. Nursing judgment is based on the assessment process. 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. Surveillance is an essential step in the comprehensive assessment process. The RN must anticipate and recognize changes in patient conditions and determine when reassessments are needed.
The second step in the nursing process is planning. The RN synthesizes the data collected during the comprehensive assessment to identify problems, make nursing 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. Teaching plans address health promotion, maintenance, restoration, and prevention of risk factors. The RN utilizes evidence-based practice, published research, and information from patients and the interdisciplinary healthcare team during the planning process.
Implementing the plan of care is the third step in the nursing process. The RN may begin, deliver, assign, or delegate certain interventions 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 scope of practice may include the supervision of LVNs. Supervision of LVN staff is defined as the process of directing, guiding, and influencing the outcome of an individual’s performance and activity. The RN may have to directly observe and evaluate the nursing care provided depending on the LVN’s skills and competence, patient conditions, and emergent situations.
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. The proximity of supervision is dependent upon patient conditions and skill level of the unlicensed personnel. In addition, teaching and counseling are interwoven throughout the implementation phase of the nursing process.
Evaluation and Reassessment
A critical and fourth 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, and plans any follow-up care and referrals to appropriate resources that may be needed. The evaluation phase is one of the times when the RN reassesses patient conditions and determines if interventions were effective and if any modifications to the plan of care are necessary.
[This section is taken from Texas Occupations Code, Ch. 301.152 and Ch. 301.354 (Texas Legislature, 2013) and TAC Title 22, Part 11, §217.18. Assisting at Surgery, §219.2. Definitions, §221.12. Scope of Practice, and §221.13. Core Standards for Advanced Practice (TX BON, 2016).]
ADVANCED REGISTERED NURSE PRACTITIONER
An advanced registered nurse practitioner (ARNP) means 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 includes a nurse practitioner, nurse midwife, nurse anesthetist, and clinical nurse specialist.
The advanced practice nurse provides a broad range of health services, the scope of which shall be based upon educational preparation, continued advanced practice experience, and the accepted scope of professional practice of the particular specialty area. Advanced practice nurses practice in a variety of settings, and according to their practice specialty and role, they provide a broad range of healthcare services to a variety of patient populations.
Scope of Practice
The scope of practice of particular specialty areas shall be defined by national professional specialty organizations or advanced practice nursing organizations recognized by the Texas Board of Nursing. 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 laws and regulations of the state of 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 health team in the observation, assessment, diagnosis, intervention, evaluation, rehabilitation, care and counsel, and health teachings of persons who are ill, injured, or infirm or experiencing changes in normal health processes; and in the promotion and maintenance of health or prevention of illness.
When providing medical aspects of care, advanced practice nurses shall utilize mechanisms that provide authority for that care. These mechanisms may include, but are not limited to, protocols or other written authorization. This shall not be construed as requiring authority for nursing aspects of care.
Protocols or other written authorization shall promote the exercise of professional judgment by the advanced practice nurse commensurate with his/her 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 directly 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 (TX BON, 2016).]
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 a 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 including, but not limited to, nurse aides, orderlies, assistants, attendants, technicians, home health aides, medication aides permitted by a state agency, and other individuals providing personal care/assistance of health-related services; 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 school 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, the complexity of the task, the 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. (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. The RN should, when the client’s status allows, consult with the client and, when appropriate, the client’s family and/or significant other(s) to identify the client’s nursing needs 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; however, the unlicensed person may take any action that a reasonable, prudent non-healthcare 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 verification of competence may be done by the RN making the decision to delegate or, if appropriate, by training, education, experience, and/or certification/permit of the unlicensed person.
- 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. For example, the evaluation would be appropriate when the client’s nursing care plan is reviewed and revised. The RN’s evaluation of a delegated task(s) will be incorporated into the client’s nursing care plan.
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
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 for sugar and stool test for occult blood results
- 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 which 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 which require professional nursing judgment or intervention
- Responsibility and accountability for client health teaching and health counseling which 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)
Sabrina is an RN in a busy medical-surgical department at a hospital in Austin. She is in the middle of passing morning medications when her new post-op patient, Mr. Winters, rings in complaining of severe pain. When she arrives to Mr. Winters’ room, Sabrina performs a focused assessment of his surgical dressing and finds everything within normal limits. Sabrina consults the electronic medication administration record (eMAR) and sees that Mr. Winters has IV morphine ordered for severe pain. She also recalls the report from the PACU nurse stating that Mr. Winters’ blood pressure was running low.
In reviewing the tasks at hand, Sabrina knows she needs to continue with medications for her other patients, to get a new set of vitals on Mr. Winters to be sure his blood pressure won’t drop with a new dose of IV morphine, and then to administer the pain medication to Mr. Winters. In order to accomplish her tasks in a timely manner, Sabrina determines that it is necessary to delegate something to the appropriate assistive personnel. She remembers that Martha, a nurse aide, has also been assigned to her patients.
Sabrina contacts Martha to see if she is available to take Mr. Winters’ blood pressure, knowing that taking patients’ vitals is within Martha’s education and training and is part of her normal assignment as an aide. Sabrina indicates to Martha that she will continue passing medications while Martha gets the patient’s vitals, which she should carry out right away. Sabrina informs Martha that she will be with the patient in the next room by the time Martha has the vital signs. Martha agrees and begins to take Mr. Winters’ blood pressure.
Martha finds Sabrina as she is coming out of the room next door and reports that Mr. Winters’ blood pressure is 118/58, which Sabrina knows presents no contraindication to administering the IV morphine. Sabrina goes to the department’s med room to obtain the pain medication and administers the morphine, relieving Mr. Winters’ pain. She thanks Martha for her help and then returns to her other patients.
STANDARDS OF NURSING PRACTICE
[This section is taken from TAC Title 22, Part 11, §217.11. Standards of Nursing Practice (TX BON, 2016).]
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, where applicable, the family’s significant other(s) based on health needs
- Obtain instruction and supervision as necessary when implementing nursing procedures and practices
- 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, including 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 caused 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 (age, disability, economic status, gender, national origin, race, religion, health problems, sexual orientation)
- 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, non-efficacious, 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 health care
- Consult with, utilize, and make referrals to appropriate community agencies and health care 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 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. Supervision is the process of directing, guiding, and influencing the outcome of an individual’s performance of an activity. 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
SIX-STEP DECISION-MAKING MODEL
[This section is taken directly from Six-Step Decision-Making Model for Determining Nursing Scope of Practice (TXBON, n.d.-b).]
The Board of Nursing has developed a decision-making flowchart to assist nurses in making good professional judgments about the nursing tasks or procedures they choose to undertake. It references parts of the NPA and Rules and asks the nurse to apply other questions to his/her specific practice situation. These same sections of the nursing laws and targeted questions are tools Board staff utilizes when nurses call and ask, “Is this task/procedure in my scope of practice?”
A nurse always has a duty to his/her patients to assure that they are safe. One of the most important actions a nurse can take toward that goal is making sure that he/she only accepts those assignments for which the nurse has the education, training, and skill competency. Physical and emotional ability can also impact a nurse’s ability to maintain client safety when accepting an assignment.
The BON does not maintain that this is the only model a nurse may use for assistance in determining his/her scope of practice in a given situation; however, all nurses practicing in Texas must comply with the Nursing Practice Act and Board rules as they apply to LVNs, RNs, and/or RNs with advanced practice authorization in a given role and specialty.
- Step 1: Is the act consistent with the Texas Nursing Practice Act, Board rules, and Board position statements and/or guidelines?
- Step 2: Is the activity appropriately authorized by valid order/protocol and in accordance with established policies and procedures?
- Step 3: Is the act supported by either research reported in nursing and health-related literature or in scope of practice statements by national nursing organizations?
- Step 4: Do you possess the required knowledge and have you demonstrated the competency required to carry out this activity safely?
- Step 5: Is the performance of the act within the accepted standard of care that would be provided in similar circumstances by reasonable and prudent nurses who have similar training and experience?
- Step 6: Are you prepared to accept the consequences of your actions?
Each of these steps must be answered with a “yes” before proceeding to the next step. If at any point an answer is “no,” the nurse must not perform the action.
Monica is a licensed vocational nurse (LVN) with five years of experience who has recently moved to Texas. This is her first shift on a surgical floor following orientation, and she is responsible for five patients who are one to four days post-op. Monica sees that her patient, Mr. Hansen, has had a peripheral IV for three days. She knows that at her last hospital job in another state it was a requirement to change the IV sites after three days to help prevent IV-associated infections. She consults with Alice, the charge nurse. Alice thanks her and replies that she will verify the start time of the IV and take the appropriate action.
Monica does not know whether she is permitted to insert a peripheral IV in Texas. On her next day off, she uses the Texas Six-Step Decision-Making Model and consults the Texas Nursing Practice Act, Board rules, and Board position statements to determine if this is within her scope of practice. The position statements explain that venipuncture is not within the education of an LVN but can be performed after an IV validation course is completed. Since she has not yet had an IV validation course in Texas, Monica makes a mental note to discuss with the unit head nurse the possibility of enrolling in the appropriate training that will allow her to perform this task once she has taken and passed the training.
TEXAS NURSING LICENSURE RENEWAL REQUIREMENTS
[This section is taken from TAC Title 22, Part 11, §216. Continuing Competency (TX BON, 2016) and Texas Occupations Code, Ch. 301. 301 Nurses: License Renewal (Texas Legislature, 2013).]
Texas nursing licenses are monitored by the Texas Board of Nursing and are required to be renewed every two years. Licensees must keep the Board informed of their current address at all times. To inform the Board of an address change or a name change, written notice must be sent, clearly marked “change of address” or “name change,” to the Board’s office within ten (10) days of the occurrence. Failure to do so can result in a lapse of the license and potential disciplinary action.
Fees and Status
Fees are due to the BON at the time of renewal. Fee amounts may be found in TAC Title 22, Part 11, §223.1 (TX BON, 2016).
Continuing Nursing Education (CNE)
The purpose of continuing competency is to ensure that nurses stay abreast of current industry practices, enhance their professional competence, learn about new technology and treatment regimens, and update their clinical skills. Continuing education in nursing includes programs beyond the basic preparation that are designed to promote and enrich knowledge, improve skills, and develop attitudes for the enhancement of nursing practice, thus improving healthcare to the public. Nursing certification is another method of demonstrating continuing competence. The Board requires participation in continuing competency activities for license renewal.
The nurse must complete 20 contact hours of continuing nursing education (CNE) within the two years immediately preceding renewal of registration in his or her area of practice. Or a nurse may choose to demonstrate the achievement, maintenance, or renewal of an approved national nursing certification in the nurse’s area of practice for her continuing education requirement.
Those persons licensed by examination within a biennium are exempt from the continuing education requirement for that biennium.
As part of the continuing education requirements, license holders must complete courses related to:
- Two contact hours in nursing jurisprudence and nursing ethics before the end of every third two-year licensing period
- Two contact hours in forensic evidence collection (for those employed to work in an emergency department)
- Two contact hours in care for older adult or geriatric populations (for those who practice with these individuals)
- Content related to treatment of tick-borne diseases (encouraged but not required for APRNs whose practice includes this)
The licensee shall be responsible for maintaining a record of CNE activities. These records shall document attendance as evidenced by original certificates of attendance, contact hour certificates, or academic transcripts, and copies of these shall be submitted to the Board upon audit. These records shall be maintained by the licensee for a minimum of three consecutive renewal periods or six years.
A person whose license has expired may not engage in activities that require a license until the license has been renewed. To renew the license, the licensee must demonstrate completion of all continuing education and must pay a late fee.
A registered nurse who practices professional nursing or a vocational nurse who practices vocational nursing after the expiration of the nurse’s license is an illegal practitioner whose license may be revoked or suspended.
The Board may place on inactive status the license of a person under TAC Title 22, Part 11, Chapter 223, who is not actively engaged in the practice of professional nursing or vocational nursing if the person submits a written request to the Board in the form and manner determined by the Board. The inactive status begins on the expiration date of the person’s license. A person whose license is on inactive status may not perform any professional nursing or vocational nursing service or work. The Board shall remove a person’s license from inactive status if the person requests that the Board remove the person’s license from inactive status, pays each appropriate fee, and meets the requirements determined by the Board.
ETHICS VERSUS LAWS
Nurses practice within a society governed by laws. Nurses also follow ethical standards of care at all times. Thus, nurses need to understand the basis of law (jurisprudence) in the United States and the relationship of law to ethics in the practice of nursing.
Ethical principles serve as general guides for behavior. In contrast, laws flow from ethical principles and consist of rules about specific situations. These rules are enforced by an authority with the power to see that they are obeyed.
Many people are uncomfortable when they hear the word ethics, viewing it as too controversial or too complex to discuss freely. However, ethics is a significant concern of thinking, caring persons, especially healthcare providers such as nurses.
Ethics is a branch of philosophy concerned with the nature of values in regards to matters of human conduct. Ethical theory guides a practitioner in determining right and wrong action in a situation and provides a moral compass. A profession’s ethical code establishes the values used when making practice decisions.
NURSING ETHICAL PERSPECTIVE: VIRTUE ETHICS
Nursing is defined as “the protection, promotion, and optimization of health and abilities; prevention of illness and injury; facilitation of healing; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, family, groups, communities, and populations” (ANA, 2015c, p. 1).
The virtue of caring is prominent in this definition. Virtue-based ethics is particularly suited to nursing practice, as it emphasizes a nurse’s obligations to the patient and the principles on which nursing practice are based (ANA, 2015b). Virtue ethics emphasizes a person’s character rather than rules or consequences in determining right action.
THREE MAJOR ETHICAL APPROACHES
Deontological. Actions are guided by what a person ought to do rather than by what the outcome will be. Duty determines what is morally right.
Teleological. Also called consequentialism. A behavior is morally right depending on the outcome, or consequences, of that action.
Virtue ethics. A values-based approach that emphasizes the application of character traits as the basis for moral action. Rightness of action is based on implementation of key virtues such as honesty or benevolence.
Source: Adapted from Stanford Encyclopedia of Philosophy, 2016.
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 its occupation.
In order to make explicit the values and standards of nurses, the American Nurses Association (ANA) publishes the Code of Ethics for Nurses with Interpretive Statements. This document is regularly revised and updated by ANA, with the latest update to the code made in 2015 (see box).
PROVISIONS OF THE CODE OF ETHICS FOR 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 healthcare.
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.
Source: ANA, 2015a.
NURSING ETHICAL PRINCIPLES
Ethical principles are fundamental concepts by which people make decisions. Five ethical principles mark the practice of professional nursing and are inherent in the Code of Ethics for Nurses:
- Human dignity
- Social justice
Altruism refers to concern for the welfare and well-being of others. Professional nursing is other-focused and patient-centered. Therefore, applying this ethical principle in nursing practice means nurses:
- Involve patients in care decisions
- Consider how an action might affect other team members
- Coordinate care to reduce patient discomfort
- Provide information to reduce patient anxiety
Autonomy is the right of self-determination, independence, and freedom. It is the personal right of individuals to absorb information, comprehend it, make a choice, and carry out that choice. Nurses carry out the principle of autonomy by providing accurate, scientific information to patients and assisting them to understand the information and make decisions based on it. When applied to practice, autonomy means nurses:
- Make sure patients understand available options regarding their treatment
- Respect and accept decisions patients make about their own care or the care of another person for whom they are legally responsible
- Implement and evaluate interventions chosen by patients
- Respect and hold in confidence personal information of patients, divulging it only when patients or their legal guardians give permission
Human dignity is one of the most basic of ethical principles. It is described as “respect for the inherent worth and uniqueness of individuals and populations” (AACN, 2008, p. 26). When applied to nursing, respect for human dignity means nurses:
- Refrain from abuse, harassment, or discrimination
- Respect the personhood, lifestyle, and belief system of patients
- Demonstrate regard for patients’ physical, psychological, and socioeconomic well-being
- Strive to sustain human life and dignity
- Respect and hold in confidence all personal information
- Require specific legal justification for interference with a patient’s civil liberties
Integrity means being truthful in word and deed, even when conveying unwelcome information about a condition or treatment. Nurses must be truthful yet compassionate, withholding information only when the patient is a minor child or an adult with a legal guardian. When applied to practice, integrity means nurses:
- Accurately report and record critical data
- Place the welfare of patients above personal or professional gain
- Keep promises and abide by contracts
- Provide factual, scientific, and relevant information about treatment, including benefits and risks
Social justice implies fairness and equality and requires impartial treatment of patients. Like other ethical principles, social justice is based on respect for human life and dignity. The historic image of justice is a blindfolded woman with a scale, weighing an issue on the basis of objective evidence and judicial precepts. Social justice means that scarce resources will be distributed equally, using the same criteria for everyone. When applied to practice, social justice means nurses:
- Assess all patient needs with equal diligence and professionalism
- Attend to the needs of patients, without prejudice according to their personality, disability, race, religion, gender, age, or lifestyle
- Evaluate and communicate information about plans of care without bias
- Deal fairly and equally with professional supervisors, colleagues, and subordinates
Professional boundaries are the appropriate limits that should be established by the nurse in the nurse/client 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/client relationship that promote the client’s dignity, independence, and best interests and refrain from inappropriate involvement in the client’s personal relationships and/or the obtainment of the nurse’s personal gain at the client’s expense.
Some behavioral indicators can alert nurses to potential boundary issues for which there may be reasonable explanations. 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 his or her 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 he or she is immune from fostering a nontherapeutic relationship and that only he or she understands and can meet the patient’s needs.
- Singled-out patient treatment or patient attention to the nurse. 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 his or her 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. In the reverse, the patient returns repeatedly to the nurse because other staff members are too busy.
- 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.
- Failure to protect patient. The nurse fails to recognize feelings of sexual attraction to the patient, consult with a supervisor or colleague, or transfer care of the patient when needed to support boundaries.
Sources: NCSBN, 2014; TX BON, 2017.
A dilemma is a perplexing problem that requires a choice between conflicting alternatives. An ethical dilemma is a moral problem that requires a choice between two or more opposite actions, each of which is based on an ethical principle.
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.
Ethical dilemmas in healthcare facilities frequently arise when modern medicine keeps hearts and lungs functioning much longer than thinking brains. To help resolve these perplexing issues, many institutions appoint ethics committees made up of healthcare professionals, ethicists, lawyers, and clergy. The task of ethics committees is to help decision makers resolve ethical dilemmas. Often these committees use an ethical decision-making process such as the following:
- Gather relevant facts about the patient’s age, diagnosis, advanced healthcare directive, and applicable laws.
- Identify and clearly state proposed actions together with the ethical principles represented by each proposed action.
- Determine who can make the decision and assist the person or persons to make it.
- Provide emotional support for everyone involved in resolving the dilemma.
ADVANCE HEALTHCARE DIRECTIVES
To reduce the number and complexity of ethical dilemmas, and in support of the ethical principle of autonomy, the Joint Commission (2015) recommends that all adults discuss their wishes regarding extraordinary treatment measures with their families, sign a legal document called an advance healthcare directive, and appoint someone to make healthcare decisions in their stead if they should become incapacitated.
Victoria, a 48-year-old woman with a long-standing manic disorder, built a fire on her living room floor, and when her husband tried to extinguish the fire, she attempted to stab him with a knife. She was taken by police to the emergency department and admitted involuntarily for treatment, where she accepted medications to help her sleep but declined to take any mood-stabilizing drugs. She said, “They make me feel like I’m moving in slow motion, going through Jell-O. I can’t stand them.”
The healthcare team recognized the dilemma between the three ethical principles of altruism (providing treatment), autonomy (right of self-determination), and respect for human dignity (equal treatment).
In Victoria’s case, a crisis situation, it was readily accepted that treatment with medications was clinically indicated and likely to be to her benefit (altruism). They also recognized that Victoria has significant mental illness and her ability to make informed decisions was seriously impaired (autonomy). The decision to involuntarily commit her was based on dangerousness evidenced by the attempt to stab her husband. Equal treatment would require Victoria to be charged with a criminal act (human dignity). Instead, Victoria was court-ordered to be detained and started on lithium, 600 mg per day, in three divided doses.
Laws and Rules
Laws flow from ethical principles and are limited to specific situations and codified by detailed language. Laws establish rules of conduct and are formulated by an authority with power to enforce them. As such, laws change with time and circumstances.
The state of Texas has the power to create and enforce laws governing the profession of nursing, including licensure. In the states, the division of power mirrors that of the federal government:
- The legislative branch makes laws on behalf of the people.
- The judicial branch interprets these laws and adjudicates disputes, fulfilling its purpose to administer justice without partiality.
- The executive branch administers and enforces the laws, using the police power of the state.
|Source||Laws passed by legislative bodies of federal, state, and local governments||Executive powers, delegated by the legislative branch|
|Functions||Protects and provides for the general welfare of society||Carries out special duties of various agencies|
|Example||The Texas legislature passed the Nurse Practice Act, which is outlined in the Texas Occupations Code and Statutes, Title 3, Subtitle E: Regulation of Nursing, Chapter 301: Nurses||The Texas Department of State maintains statewide rules for nurses, which are outlined in the Texas Administrative Code, Title 22, Part 11, Texas Board of Nursing|
DISCIPLINE RELATED TO NURSING PRACTICE
[This section is taken from Texas Occupations Code, Ch. 301. Nurses (Texas Legislature, 2013).]
The BON utilizes its authority to decide whether misconduct or unsafe practice has occurred and what action should be taken. Violations are taken very seriously since they can put patients at risk. This is why every nurse is responsible for understanding his/her scope of practice and other requirements outlined in the law (NCSBN, 2011).
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.
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. Violations of the Texas law related to nursing (TAC Title 22, Part 11, and TOC Chapter 301–305) are serious and may result in complaints being filed and in discipline by the Board of Nursing.
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 this act, or an order issued under this 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
- 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
The Texas laws related to nursing are in place to define the Board of Nursing, which then, along with the law itself, sets the standards of competent nursing practice and standards for promoting patient safety. By so doing, the mission of the Board of Nursing “to protect and promote the welfare of the people of Texas by ensuring that each person holding a license as a nurse in the state of Texas is competent to practice safely” is achieved (Russell, 2012; TX BON, n.d.-a).
NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course.
American Association of Colleges of Nursing (AACN). (2008). The essentials of baccalaureate education for profession nursing practice. Retrieved from http://www.aacn.nche.edu
American Nurses Association (ANA). (2015a). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Author. Retrieved from http://nursingworld.org
American Nurses Association (ANA). (2015b). Guide to the code of ethics for nurses with interpretive statements: development, interpretation, and application (2nd ed.). Silver Spring, MD: Author.
American Nurses Association (ANA). (2015c). Nursing: scope and standards of practice (3rd ed.). Silver Spring, MD: Author.
Joint Commission. (2015). End-of-life care: a patient safety issue. Retrieved from https://www.jointcommission.org
National Council of State Boards of Nursing (NCSBN). (n.d.). Nurse practice act, rules, and regulations. Retrieved from https://www.ncsbn.org
National Council of State Boards of Nursing (NCSBN). (2014). A nurse’s guide to professional boundaries. Retrieved from https://www.ncsbn.org
National Council of State Boards of Nursing (NCSBN). (2011). State and territorial boards of nursing: what every nurse needs to know. Retrieved from https://www.ncsbn.org
Russell KA. (2012). Nurse practice acts guide and govern nursing practice. Journal of Nursing Regulation, 3(3), 36–42. Retrieved from https://www.ncsbn.org
Stanford Encyclopedia of Philosophy. (2016). Ethics. Retrieved from https://plato.stanford.edu
Texas Board of Nursing (TX BON). (n.d.-a). Mission and values. Retrieved from https://www.bon.texas.gov
Texas Board of Nursing (TX BON). (n.d.-b). Six-step decision-making model for determining nursing scope of practice. Retrieved from http://www.bon.texas.gov
Texas Board of Nursing (TX BON). (2017). Texas Board of Nursing position statements. Retrieved from https://www.bon.texas.gov
Texas Board of Nursing (TX BON). (2016). Texas board of nursing: rules and regulations relating to nurse education, licensure and practice. Retrieved from https://www.bon.texas.gov
Texas Legislature. (2013). Texas nursing practice act. Retrieved from http://www.bne.state.tx.us
Texas Secretary of State. (n.d.-a). Texas Administrative Code: Title 22, Part 11. Retrieved from https://texreg.sos.state.tx.us
Texas Secretary of State. (n.d.-b). Welcome to the Texas administrative code. Retrieved from http://www.sos.state.tx.us