Texas Nursing Jurisprudence and Ethics

Course Description

Credit Hours: 2 Authors: Kevin Arnold, DNP, MSN, BBA, BS, BSN, RN

Texas nurses should be familiar with nursing ethics and professional boundaries. This course meets the continuing education requirement on the laws, rules, and ethics related to the practice of nursing in Texas for all levels of nursing, including registered nurse (RN), licensed vocational nurse (LVN), registered nurse first assistant (RNFA), and advanced practice registered nurse (APRN).

Accreditation Information: KLA Education Services LLC is accredited by the State of California Board of Registered Nursing, Provider # CEP16145.

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Course Objectives

Upon completion of this course, the course participant will be able to:

Define jurisprudence and ethics.
Discuss standards of nursing practice.
Understand the Texas BON position statement.
Discuss the Texas Nursing Practice Act.
Define licensed vocational and professional nursing.
Identify advanced practice registered nurses (APRNs).
Identify Texas nursing practice rules.
Discuss principles of nursing ethics and professional boundaries.
Recognize misconducts in nursing practice.
Define the use of social media and rules for nursing practice.

Course Content

Introduction

Health care is one of the critical fields where human lives are directly concerned and dealt with. Governments enact rules and laws in order to pursue standards of health practices. In United States, medical or health enactment started in early 1900s. In 1909, nurses around the state struggled and advocated for the establishment of a nursing board and nursing legislation to offer standard nursing care to people the state [1]. In 1907, an early version of Nursing Practice Act passed the Texas legislature which led the foundation of Board of Nursing (BON) in 2007 [2]. From 2007, Texas Nursing Practice Acts has undergone extensive modifications in terms of changing standards of practice and public safety. Chapter 301 of Texas Occupations Code (TOC) covers all the rules and laws regarding nursing education, license and practice issues. Texas Board of Nursing has authority adopt and modify rules, programs, and standards of nursing. It has authority to control nurses who violate the enacted rules and laws.

Other chapters of TOC like 303, 304 and 305 have full guide on nursing practice, licensure and Advanced Practice Registered Nurse (APRN) respectively. Nurses practicing in the state of Texas must have license and are bound to follow the rules and laws mentioned in chapters 301, 303, 304 and 305 of TOC along with guidelines given by BON. Moreover, Texas BON Position Statements guides and demonstrates patients’ care and safety, scope of practice and other issues such as nursing ethics and professional boundaries.

Figure 1: Board of Nursing Texas (Source: www.bon.texas.gov)

This nursing course provides reading on the current standards of jurisprudence and ethics in terms of nursing legislation, practice and advancing trends in nursing field in the Texas state. It offers guidelines for all levels of nursing such as registered nurses (RNs), licensed vocational nurses (LVNs), registered nurse first assistants (RNFAs) and APRNs. The course includes current information about the Texas Nursing Practice Act, the BON rules, standards of nursing practice, the Texas BON position statements, principles of nursing ethics and professional boundaries for nurses.

Jurisprudence

Derived from a Latin word “juris prudential”, jurisprudence refers to “the study, knowledge or science of law”. In United States, it means philosophy of law. Nursing jurisprudence in health means the rules or laws which are applied to the education, practice and standards of health delivery to the public by nurses. In Texas, all the nurses must have a license and all the license holders are to complete at least 2 hours of continuing education relating to nursing jurisprudence and nursing ethics before the end of every third two-year licensing period [3]. BON and chapters 301, 303, 304 and 305 of TOC demonstrate jurisprudence for nurses.

Figure 2: Nursing jurisprudence

(Source: http://www.acenursingeducation.com)

Ethics

Ethics refers to rules of conduct. Nursing ethics means how a nurse should perform his or her activities or duties. Nursing ethics is a branch of applied ethics that include beneficence, non-maleficence and assurance of autonomy. Simply, it is "the ethics of caring." Nursing ethics is more concerned with care and nature than cure of illness. BON has addressed several issued of nursing ethics for the reason and provision of best possible health services.

Figure 3: Ethics of nursing (Source: www.slideshare.net)

Standards of Nursing Practice

Standard of nursing practice throws light on how nurses perform their activities and offer care services to the patients in the state of Texas. Nurses are not only to receive standard and up-to-date education and care procedures but also to apply knowledge and struggle for the prevention of any misconduct, inappropriate, unauthorized, illegal and intentional nonperformance of care services. Nursing Practice Act governs all levels of nursing practice. LVNs may only practice vocational nursing while RNs, APRNs, and RNFAs can perform professional and specialized nursing [4]. Nurses are accountable for their actions in terms of patients’ care.

Standard of nursing.jpg

Figure 4: Nursing care (Source: www.utexas.edu)

Texas BON Position Statement

BON position statement does not enforces a law, but it provides directions for nursing practice in order to protect the public and reach provision of a quality health care system in Texas. BON position statement is reviewed and revised every year in terms of relevance, accuracy, board rules and nursing practice act. BON position statements are given below in the table-1 (The table is referemced from the website):

Table-1: BON Position Statements (Source: www.bon.texas.gov)

#	Title	Description Summary
15.1	Nurses Carrying out Orders from Physician’s Assistants	Nurses may carry out physician orders relayed by a PA and/or which originate from a protocol between the PA and the physician. The nurse is expected to clarify any order he/she questions by communicating with the PA or the physician.
15.2	Role of the Licensed Vocational Nurse in the Pronouncement of Death	Laws regarding the pronouncement of death are not in the NPA or Board Rules. LVNs cannot pronounce death. LVNs must initiate CPR in the absence of a clear do-not-resuscitate (DNR) order. The LVN may accept a physician’s order regarding post-mortem care, but cannot accept a verbal order to pronounce death.
15.3	LVNs Engaging in IV Therapy, Venipuncture, or PICC Lines	LVN must complete post-licensure training to engage in IV Therapy/Venipuncture (not typically included in LVN curriculum). Insertion of PICC lines is beyond the scope of practice for LVN.
15.4	Educational Mobility	The Board supports educational mobility for nurse’s prepared at LVN, ADN, Diploma, and BSN levels without needless repetition of clinical experiences or time penalties
15.5	Nurses with Responsibility for Initiating Physician Standing Orders	Nurses may initiate physician’s standing medical orders or standing delegation orders by selecting specific tasks or functions for patient management. The nurse is accountable to assure his/her actions are within the NPA and Board Rules, including that the standing orders do not require the nurse to engage in independent medical judgment. NOTE: RN’s who lack Advanced Practice authorization and LVNs may not utilize “protocols” intended for use by APRN’s or PA’s (see definitions of protocols from the Texas Medical Board in this position statement).
15.6	Board Rules Associated with Alleged Patient “Abandonment”	This position statement differentiates employment vs. licensure issues; addresses relevant Board rules when a nurse engages in unprofessional conduct with regard to being unavailable to provide care to assigned patients (such as sleeping on the job).
15.7	The Role of LVNs & RNs in Management and/or Administration of Medications via Epidural or Intrathecal Catheter Routes	LVNs may provide nursing care to patients with epidural or intrathecal catheters, but should not be responsible for catheter management, including administration of drugs via these routes. Epidural & Intrathecal catheter management is within the RN’s scope of practice if the RN has current competency in both the knowledge and skills required, with certain limitations recommended in the Obstetrical setting. Appropriate nursing policies and procedures must also be in place.
15.8	The Role of the Nurse in Moderate Sedation	LVNs cannot administer to or monitor patients receiving moderate sedation. The administration of drugs and monitoring of patients for moderate sedation can be within the RN’s scope of practice. If an RN elects to engage in administration of pharmacologic agents classified as “anesthetic” agents to induce moderate sedation, the RN should either be skilled in, or have immediate availability of other practitioners skilled in advanced airway management along with appropriate equipment that might be necessary to rescue a patient from unintended deep sedation. The facility or physician’s office needs to have policies and procedures to guide the RN. See evidence based practice standards of professional anesthesia association guidelines listed in the position statement.
15.9	Performance of Laser Therapy by RN’s or LVNs	A nurse must have the appropriate education, knowledge, and experience to engage in laser therapy. There are criteria to be followed by the nurse who accepts physician delegation in the use of nonablative laser therapy.
15.10	Continuing Education: Limitations for Expanding Scope of Practice	Clarifies that expansion of an individual nurse’s scope of practice has licensure-related limitations. Informal continuing nursing education or on-the job training cannot be substituted for formal education leading to the next level of practice/licensure or authorization.
15.11	Delegated Medical Acts	Specifies criteria which must be met for a nurse to carry out a delegated medical act. This includes documentation of individual training and competency, procedures to be performed, physician order to initiate, and appropriate medical and nursing back up.
15.12	Use of American Psychiatric Association Diagnoses by LVN, RNs, or APNs	LVNs and RNs cannot determine Medical Diagnoses. Use of these multi-disciplinary psychiatric diagnoses is permitted by advanced practice nurses designated as Clinical Nurse Specialists (CNS) or Nurse Practitioners (NP’s) whose specialty area is psych/mental health. Patient problems beyond the scope of training and education of the CNS/NP are to be referred to an appropriate medical provider.
15.13	Role of LVNs and RNs in School Health	Discusses the role of the LVN and RN as a school nurse. RN may delegate routine, repetitive tasks in the school setting in compliance with the BON’s Delegation Rules (§224 & §225). Also addresses RN’s relationship to LVNs who provide nursing in a school setting.
15.14	Duty of a Nurse in any Practice Setting	Establishes, through the NPA and Board Rules, that a nurse has a responsibility and duty to a client/patient to provide and coordinate the delivery of safe, effective nursing care. This duty supersedes any facility policy or physician order.
15.15	Board's Jurisdiction over a Nurse's Practice in Any Role and Use of the Nursing Title	If a RN or LVN functions in role of lower than that which for which each is licensed, or in another area with an overlapping scope of practice, the nurse is still held to the level of education and competency of their highest licensure. Also restricts use of the titles LVN or RN or any designation implying nursing licensure by non-nurses (Rule 217.10 and NPA Section 301.351)
15.16	Development of Nursing Education Programs	Judicious development of new nursing programs is urged as adding programs alone will not address the growing nursing shortage. Key considerations are delineated.
15.17	BON/ Board of Pharmacy Joint Position Statement on Medication Errors	Stresses the current trend to look at “systems” and not just “individual competency” in determining root causes of medication errors and implementing strategies to effectively reduce errors, thus better protecting the public.
15.18	Nurses Carrying Out Orders from Advanced Practice Registered Nurses (APRN)	As in PS 15.1, nurses may carry out orders issued by APRN’s as long as the orders are within the APRN’s scope of practice in their role and specialty. The nurse is expected to question orders they believe are non-efficacious or contraindicated by consulting with the APRN or the physician.
15.19	Nurses Carrying Out Orders from Pharmacists for Drug Therapy Management	There are current rules that permit pharmacists to write orders for Drug Therapy Management (DTM) while working under physician delegation. A nurse may carry out these orders provided the orders originate from a written protocol authorized by a physician. The nurse is responsible and accountable for his/her actions as with any physician order.
15.20	Nurses In The Management Of An Unwitnessed Arrest In A Resident In A Long Term Care Facility	Guidance is provided concerning the appropriateness of initiating cardiopulmonary resuscitation (CPR) when the RN encounters an unwitnessed resident arrest without a do not resuscitate (DNR) order in the long term care setting. Presumptive and conclusive signs of death are delineated, to assist the RN in making a decision that CPR would be futile. Documentation, RN obligation to the patient, care planning/advanced directives, and RN pronouncement of death are also discussed.
15.21	[Deleted 01/2005]	[Deleted 01/2005]
15.22	APRNs Providing Medical Aspects of Care for Individuals whom there is a Close Personal Relationship	The BON is concerned that when APRNs provide medical aspects of care for themselves or other individuals with whom they have a close personal relationship the APRNs risk allowing their personal feelings to cloud their professional judgment. Thus APRNs should not provide medical treatment or prescribe medications for themselves or any other individual with whom they have a close personal relationship.
15.23	The Use of Complementary Modalities by the LVN or RN	Regardless of practice setting, RNs who incorporate complementary modalities into their practice are accountable and responsible for adherence to the NPA and BON Rules and Regulations. Specific regulations of particular relevance are identified in the position statement, including a reference to the BON’s Six Step Decision- Making Model for Determining Nursing Scope of Practice. Also, a list of criteria is included in order for RNs to show accountability for the care they provide. Lastly, RNs are accountable to hold proper credentials (e.g., license, certification, registration) to safely engage in specific practices, where applicable.
15.24	Nurses Engaging In Reinsertion of Permanently Placed Feeding Tubes	LVNs & RNs should receive post-licensure training and demonstrate competency in reinsertion of a displaced permanently placed feeding tube prior to engaging in this activity. Verification of correct placement is essential to prevent life-threatening complications. Reinsertion by a nurse is not recommended prior to 8-12 weeks post-initial insertion; specific physician orders must be obtained regarding reinsertion by a nurse.
15.25	Administration of Medication & Treatments by LVNs	LVNs are educationally prepared to administer medications and treatments as ordered by a physician, podiatrist, dentist or any practitioner legally authorized to prescribe the ordered medication. LVNs may administer medications and treatments ordered by physician assistants (PS 15.1) and advanced practice registered nurses (PS 15.18). Also see NPA 301.002 (5), the definition of vocational nursing.
15.26	Simulation in Prelicensure Nursing Education	While the benefits of simulation are known, limitations to simulation do exist. Guidance is provided to clarify the role and limitation of simulation in prelicensure nursing education programs (Rule §214 and Rule §215). BON recommends adherence to the guidelines contained in the position statement to ensure that students receive optimal learning experiences.
15.27	The Licensed Vocational Nurse Scope of Practice	The LVN scope of practice is a directed scope of practice and requires appropriate supervision. The LVN is responsible for providing safe, compassionate and focused nursing care to assigned patients with predictable health care needs.
15.28	The Registered Nurse Scope of Practice	The RN takes responsibility and accepts accountability for practicing within the legal scope of practice and is prepared to work in all health care settings, and may engage in independent nursing practice without supervision by another health care provider. The RN is responsible for providing safe, compassionate, and comprehensive nursing care to patients and their families with complex healthcare needs.
15.29	Use of Social Media by Nurses	The use of social media can be of tremendous benefit to nurses and patients alike. However, nurses must be aware of the potential consequences of disclosing patient-related information via social media. Nurses must always maintain professional standards, boundaries, and compliance with state and federal laws as stated in Board Rule 217.11(A). All nurses have an obligation to protect their patient’s privacy and confidentiality [as required by Board Rule 217.11(E)] which extends to all environments, including the social media environment.

In short, in accordance with BON position statement nurses should follow the following rules:

It is an ethical and legal obligation that nurses must not breach the privacy and confidentiality of the patients at any time.
Nurses must not transmit any image or information that violates patients’ rights, privacy, and confidentiality or embarrasses them.
Nurses are not allowed to post or publish the name or information of the patient that leads to the identification of the patient.
Nurses should not make disparaging remarks about patients, employers and co-workers even if they are not identified.
Nurses are not allowed to take photos or make videos of the patients until they follow the employer policies.
Nurses must establish professional boundaries in terms of communication in online environment.
Nurses must report any breach in privacy or confidentiality of the patients.
Nurses should consult employer policies for work-related postings.

Texas Nursing Practice Act and Board of Nursing (BON)

An early version of Nursing Practice Act passed the Texas legislature and the Board of Nursing (BON) was established in March 28, 1909 [2]. BON is serving and applying Texas Nursing Practice Acts (NPA) for more than 100 years. NPA has undergone extensive modifications in terms of changing standards of practice and public safety. Therefore, it is the dire responsibility of nurses to be aware of the changing rules and regulations of the BON every year. Currently, BON is providing and governing 200 nursing education programs and issues licenses to more than 27000 nurses every year. It offers guidance to 350000 nurses in the state of Texas.

Chapter 301 of Texas Occupations Code (TOC) covers all the rules and laws regarding nursing education, license and practice issues. Texas Board of Nursing has authority to adopt and modify rules, programs, and standards of nursing. It has authority to control nurses who violate the enacted rules and laws. Other chapters of TOC like 303, 304 and 305 have full guide on nursing practice, licensure and Advanced Practice Registered Nurse (APRN) respectively. Nurses practicing in the state of Texas must have license and are bound to follow the rules and laws mentioned in chapters 301, 303, 304 and 305 of TOC along with guidelines given by BON.

Licensed Vocational Nurses (LVNs)

Licensed vocational nurses perform the following activities:

To collect data and perform focused nursing assessment of the patient
To participate in the planning, development and modification of patient care needs of the patients
To participate in the teaching and counseling to promote and maintain an optimum level of health care services.
To assist the evaluation process of the individuals’ responses.
To engage in the activities which need education and training as per ordered by BON.

BON also states that LVNs should be supervised an RN, APRN, physician assistant, physician, dentist, or podiatrist.

Professional Nurses

Professional nurses perform the following duties:

To observation, assess, evaluate, care and counsel and health teachings of the patients as well as to establish intervention and to offer rehabilitation management to the patients.
To follow the treatment as ordered by a physician, podiatrist, or dentist
To maintenance health and to prevent the illness
To perform an act delegated by a physician
To develop the nursing care plan
To supervise or care for nursing teaching
To evaluate nursing practices, policies, rules and procedures
To request, receive, sign for and distribute prescription drug samples to patients at practices where an APRN is authorized to sign prescription drug orders

Advanced Practice Registered Nurses (APRNs)

APRNs refer to the registered nurses who have completed special advanced practice training and internship as authorized by BON [5]. BON specifies that APRNs must work within their scope and advanced practice to offer quality health services to the public. BON has established both professional and individual scope for APRNs. Professional scope offers broadest parameters for scope of practice. Individual scope includes continuing education, formal course of work, developments in health care and experience in different health care settings. However, APRNs can’t change their titles until they achieve further or additional education. The following questions may help whether the new activity or procedure can be incorporated into individual practice or not [5]:

Is it consistent with one's professional scope of practice?
Is it consistent with statutory or regulatory laws?
Is it consistent with one's education in the role and specialty?
Is it consistent with the scope of one's recognized title or does it evolve into another advanced practice title recognized by the board requiring additional formal education and legal recognition?
Is it consistent with the Standards of Nursing Practice outlined in Board Rule 217.11?
Is it consistent with evidence-based care?
Is it consistent with reasonable and prudent practice?
Are you willing to accept accountability and liability for the activity and outcomes?

Texas Nursing Practice Rules

Along with NPA, other chapters of TOC also contain rules and regulations for LVNs, RNs, APRNs, and RNFAs. Texas Administrative Code Rule 217.11 which is “Standards of Nursing Practice” describes minimum acceptable standards for all RNs (given below) and it is the duty of BON to implement all these rules and regulations to all RNs.

Figure 5: APRNs (Source: www.work.chron.com)

Minimum rules that an RN must follow are:

Principles of Nursing Ethics and Professional Boundaries

Along with their legal responsibilities, nurses have to fulfill their ethical obligations as well. Actually, nursing refers to care and ethics for nurses is rendered as “the ethics of caring”. Sometimes, legal and ethical issues become much complex. BON has clearly demonstrated ethical issues in its position statements. Every day, new advancements in health system are introduced; therefore, they should be duly incorporated in terms of legal and ethical responsibilities. The American Nurses Association has established a code of ethics for nurses, which states "a framework for nurses to use in ethical analysis and decision-making" [6].

Some of the major ethical issues include patient-centered care, advocacy, delegation, self-care, confidentiality, privacy, self-determination, and supporting colleagues and the profession. All the nurses must care for accountability, beneficence, competence, non-malfeasance, veracity and social reform. Nurses should care for the following four elements:

The nurse should owe his/her duty to meet standard care.
He/she should not fail to perform the owed duty.
He/she should avoid such failure that may cause injury to the patient.

Misconducts in Nursing Practice

Ethical care and practice rules also include professional limits of nurses in terms of nurse-patient relationship. These limits are regulated by Texas law and BON. Major professional violation may include emotional, financial, physical, or sexual exploitation of the patient or the patient's family.

The state of Texas defines professional misconduct as “unprofessional or dishonorable behaviors of a nurse that the Board believes are likely to deceive, defraud, or injure clients or the public" [7]. Professional misconducts include:

Unsafe practice
Failure of chief nurse in the organization of nursing services in order to manage or provide standard nursing care
Failure to practice in accordance with modified nursing scope
Careless or repetitive conduct that may harm client’s health and safety
The nurse is unable to provide safe practice e.g. incompetent, drug abuser or mentally ill
Failure to pay back the guaranteed student loan
Unlawful practice
Criminal conduct
Dismissal from BON approved program
Leaving a nursing assignment without informing the concerned person

Use of Social Media and Rules for Nursing Practice

All the RNs have to follow the rules made by BON in terms of using social media. The nurses should follow the following points:

The nurses are not allowed to take or transmit patient-related images through social media until they follow the employer policy in strict meanings.
Nurses are not allowed to discuss patients or procedures on personal social media.
The nurses should not make disparaging comments about the patients or what may affect the dignity and privacy of the clients.

Summary

BON and Texas State Law or TOC offer complete demonstration and guidelines for all registered nurses. TOC chapters have included all the policy rules and regulations which BON promises to implement by the nurses. All levels of nursing and their professional and individual roles have been specified in the rules and regulations of BON and are updated regularly on its website. For the reason of provision of standard health services to the public and to avoid legal and ethical issues, all RNs should abide by and comply with the BON rules and TOC guidelines.

References

Texas Board of Nursing. History. Available at https://www.bon.texas.gov/history.asp. Last accessed November 25, 2014.
Texas Board of Nursing. Nursing Practice Act, Nursing Peer Review Act, and Nurse Licensure Compact Texas Occupations Code and Rules Regulating the Practice of Nursing: Effective September 2013. Available at https://www.bon.texas.gov/laws_and_rules_nursing_practice_act_2013.asp#Sec.301.002. Last accessed November 25, 2014.
Nursing practice act, nursing peer review, & licensure compact Texas occupations code and statutes regulating the practice of nursing as amended September 2013. Available at: https://www.bon.texas.gov/pdfs/law_rules_pdfs/nursing_practice_act_pdfs/npa2013.pdf. Last accessed November 25, 2014.
Texas Administrative Code. Rule §216.3: Continuing Competency Requirements. Available at http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=5&p_dir=&p_rloc=165947&p_tloc=&p_ploc=&pg=1&p_tac=165947&ti=22&pt=11&ch=216&rl=3. Last accessed August 27, 2014.
Texas Board of Nursing. Practice: APRN Scope of Practice. Available at https://www.bon.texas.gov/practice_scope_of_practice_aprn.asp. Last accessed November 28, 2014.
American Nurses Association. Code of Ethics for Nursing with Interpretive Statements. Available at http://nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.pdf. Last accessed November 28, 2014.
Texas Administrative Code. Rule §217.12: Unprofessional Conduct. Available at http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&ti=22&ch=217&rl=12. Last accessed November 28, 2014.

Introduction
Jurisprudence
Ethics
Standards of Nursing Practice
Texas BON Position Statement
Texas Nursing Practice Act and Board of Nursing (BON)
Licensed Vocational Nurses (LVNs)
Professional Nurses
Advanced Practice Registered Nurses (APRNs)
Texas Nursing Practice Rules
Principles of Nursing Ethics and Professional Boundaries
Misconducts in Nursing Practice
Use of Social Media and Rules for Nursing Practice
Summary
References

Texas Nursing Jurisprudence and Ethics

Texas Nursing Jurisprudence and Ethics

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