Texas Nursing Ethics and Jurisprudence

Function

The Texas Nursing Practice Act (NPA, Chapter 301)

Chapter 301 of the Texas Occupations Code, commonly referred to as the NPA, serves as the primary set of regulations governing nursing practice in Texas. It establishes the Texas BON and delineates its responsibilities for overseeing CNE, licensure, and practice. The NPA accomplishes this by establishing criteria for licensure, defining the scope of practice for Registered Nurses (RNs) and Licensed Vocational Nurses (LVNs), outlining ethical conduct and professional boundaries, setting requirements for continuing competency, and outlining disciplinary measures in case of non-compliance with these regulations. The main objective of this act is to ensure public safety and the delivery of high-quality nursing care. While the NPA can change every 2 years, such changes require approval from the Texas legislature. On the other hand, the Texas BON may revise its regulations more frequently, given the continuously evolving nature of nursing practice. As a result, nurses are mandated to stay updated on the provisions of the NPA [bon.texas.gov, 2019].

The NPA encompasses several key sections, including:

• The composition, organization, powers, and duties of the Texas BON.
• Procedures for handling public interest information and complaint procedures.
• Requirements for obtaining and renewing licensure.
• Guidelines for practice under the license, including the supervision of LVNs.
• Reporting obligations for violations and concerns related to patient care to the BON.
• Prohibited practices and disciplinary actions for non-compliance.
• Enforcement mechanisms, penalties for violations, corrective actions, and deferred actions.
• Guidelines and provisions specific to anesthesia in the outpatient setting.

The following are the key aspects of the NPA: 

Definitions

The initial segment of the NPA provides definitions for each nursing role governed by the Texas BON.

Chief Nursing Officers

They are RNs responsible for administrative duties pertaining to nursing services at a facility [TOC Sec. 301.002. bon.texas.gov, 2019].

Nurses

They are individuals required to possess a license from the Texas BON to practice professional or vocational nursing [TOC Sec. 301.002. bon.texas.gov, 2019].

Registered Nurses (RNs, Professional Nursing)

• The provision of medical care or education necessitates the use of specialized judgment, skill, and the application of acquired concepts from an approved nursing school, including:
  • Assessment, intervention, care, counseling, or health education for individuals experiencing a decline in normal health processes.
  • Health maintenance and prevention of illness. 
  • Administration of medications and/or treatments as prescribed by clinicians, podiatrists, or dentists. 
  • Training or supervision of nursing personnel.
  • Administration, supervision, and evaluation of nursing practices, policies, and procedures. 
  • Handling and/or distributing prescription drug samples to patients by authorized advanced practice RNs (APRNs).
  • Carrying out physicians’ orders as specified in Section 157.0512, 157.054, 157.058, or 157.059. 
  • Development of nursing care plans [TOC Sec. 301.002. bon.texas.gov, 2019].
• Medical diagnosis and the prescription of therapeutic measures are not considered a part of professional nursing [TOC Sec. 301.002. bon.texas.gov, 2019]. 
• As stated in the Texas BON Position Statements, the scope of practice for RNs encompasses the following activities:
  • Preparedness for working in various healthcare settings.
  • Ability to independently perform nursing practice without supervision from other healthcare providers. 
  • Commitment to prioritizing patient safety while adhering to the legal scope of practice and complying with federal, state, and local laws, rules, and regulations. 
  • Compliance with the policies, procedures, and guidelines established by their employing healthcare institution or practice setting. 
  • Responsibility for delivering safe, compassionate, and comprehensive nursing care to patients and their families, particularly those with more complex healthcare needs [bon_position_statements].

Licensed Vocational Nurses (LVNs, Vocational Nursing)

• Supervised medical care by LVNs requires applying concepts, judgment, and specialized training acquired through the completion of an approved vocational nursing school. 
• Medical diagnosis and prescription of therapeutic measures are not considered a part of vocational nursing practice. 
• The key responsibilities of LVNs include the following: 
  • Collecting data and performing focused nursing assessments on patients.
  • Partaking in the planning, developing, and modifying the nursing care plan.
  • Participating in patient health education and counseling. 
  • Assisting in the evaluation of patients’ responses following nursing interventions.
  • Performing any other acts that require education and training as specified by the Board’s rules and policies [TOC Sec. 301.002. bon.texas.gov, 2019].
• LVNs are required by the Texas BON to work under the supervision of RNs, APRNs, physicians, physician assistants (PAs), dentists, or podiatrists [Sec. 301.353. bon.texas.gov, 2019].

Advanced Practice Registered Nurses (APRNs)

An RN, upon successful completion of an advanced educational program, may obtain licensure from the Board to practice as an APRN. Common examples of APRN roles include:

• Nurse Practitioner
• Nurse Midwife
• Nurse Anesthetist
• Clinical Nurse Specialist [TOC Sec. 301.002. bon.texas.gov, 2019]

Nursing Care Not Governed by the Texas BON

The Texas BON does not govern the following aspects of nursing care:

• Care provided by a friend to a sick individual.
• Care delivered during a disaster by the state emergency management plan.
• Treatment based on prayer or spiritual methods exclusively.
• Actions performed under the delegated authority of a provider licensed by the Texas Medical Board.
• Care provided by an individual licensed by another state agency unless they also hold a nursing license issued by Texas.
• Care delivered as part of a nursing education program to obtain initial licensure.
• Care provided by a nurse licensed in another state who is in Texas for a maximum of 72 hours to transport a patient, offers consulting services, or attends a continuing medical education (CME) event [TOC Sec. 301.004. bon.texas.gov, 2019].

Membership and Duties of the Texas BON

Here are the key points regarding the Board’s composition and duties of the Texas BON. Please refer to the Texas NPA [bon.texas.gov, 2019] for more comprehensive information.

Board Appointments

The Texas BON consists of 13 members appointed by the Governor with the advice and consent of the Senate.

The composition of the Board is as follows:

• Six nurse members comprise the professions below.
  • One APRN.
  • Two RNs (who are not APRNs or nurse faculty members).
  • Three LVNs (who are not nurse faculty members).
• Three nurse faculty members from a school of nursing represent different types of nursing programs, as mentioned below. 
  • One nurse faculty member from a school offering a Baccalaureate degree program for RNs. 
  • One nurse faculty member from a school offering an Associate degree program for RNs.
  • One nurse faculty member from a school for LVNs.
• Four members from the general public selected without considering race, color, disability, sex, religion, age, or national origin [TOC Sec. 301.051. bon.texas.gov, 2019]. 

Board Member Eligibility

To be eligible for appointment to the Texas BON, individuals should meet the following criteria: 

• RNs or LVNs must have practiced nursing for a minimum of 3 years (out of the past 5 years) before their date of appointment [TOC Sec. 301.052. bon.texas.gov, 2019]. 
• Regarding public members, they are considered ineligible for appointment if they or their spouse meet any of the following criteria:
  • Registered, certified, or licensed by an occupational regulatory healthcare agency.
  • Connected financially to any agency related to health care, healthcare facility, or insurer.
  • Regulated by or receives financial benefits or services from the Board, except for authorized compensation or reimbursement [TOC Sec. 301.051. bon.texas.gov, 2019].

Board Membership Terms

The terms for the Texas BON membership are as follows: 

• Each member is appointed to serve a 6-year term.
• Each term will be staggered, with one-third of the member’s terms expiring on January 31 of every odd-numbered year [TOC Sec. 301.053. bon.texas.gov, 2019]. 

Officers 

Regarding the Texas BON, the following arrangements are made for Officers:

• The Governor appoints the presiding members of the Board.
• The Board itself appoints other Officers from its members. 
• The presiding Officer has the authority to convene a special Board meeting upon receiving a written request from at least 2 Board members [TOC Sec. 301.056. bon.texas.gov, 2019]. 

Grounds for Removal From the Board 

A member of the Texas BON may face removal from the Board for the following reasons:

• Failure to possess or maintain the qualifications required by the Board or being ineligible for membership.
• Inability to perform the member’s duties for a significant portion of their term.
• Unexcused absence from more than half of the regularly scheduled Board meetings [TOC Sec. 301.055. bon.texas.gov, 2019].

Per Diem Reimbursement: Each member of the Texas BON is eligible to receive a per diem allowance and reimbursement for travel expenses when engaged in official board activities [TOC Sec. 301.056. bon.texas.gov, 2019]. 

Executive Director of the Board 

• The Board appoints the Executive Director of the Texas BON but does not hold the position of a Board member.  
• The Executive Director is responsible for various duties, including:
  • Recording and maintaining a comprehensive record of each board meeting.
  • Maintaining a registry accessible to the public that contains the names of all registered nurses [TOC Sec. 301.101. bon.texas.gov, 2019]. 

General Powers and Duties of the Board 

General Rulemaking Authority

The Texas BON possesses the authority to exercise general rulemaking powers and duties. The Board can adopt and enforce rules that are necessary for:

• Performing duties and conducting proceedings before the Board.
• Regulating the practice of professional nursing and vocational nursing.
• Establishing standards of professional conduct for licensed nurses.
• Determining the scope and activities that constitute the practice of professional nursing or vocational nursing [TOC Sec. 301.151. bon.texas.gov, 2019].

Responsibilities for Specialized Training  

The Texas BON has specific duties and powers concerning specialized training for APRNs, which include:

• Adoption of rules to grant an RN the licensure as an APRN [TOC Sec. 301.152. bon.texas.gov, 2019].
• Establishment of specialized training requirements, including pharmacology, for APRNs to prescribe or order delegated treatments from a clinician.
• Implementation of an approval system to verify completion of the specialized education and training requirements.
• Implementation of a system to issue a prescription authorization number to approved APRNs [TOC Sec. 301.151. bon.texas.gov, 2019].
• Responsibility for renewing licenses and approvals granted to APRNs concurrently.
• Requirement for completion of pharmacology and related pathophysiology education as part of initial approval.
• A mandate for continuing education in clinical pharmacology and related pathophysiology, in addition to any other required continuing education, for APRNs [TOC Sec. 301.151. bon.texas.gov, 2019].
• Recognition that the signature of an APRN fulfills any documentation requirements for services established by a state agency [TOC Sec. 301.151. bon.texas.gov, 2019].

Nursing Licensure in Texas

In Texas, a valid nursing license is required to practice nursing. It is crucial to note that without a license, an individual is prohibited from using the title of a “Nurse” or suggesting that they are licensed to provide nursing care [TOC Sec. 301.251. bon.texas.gov, 2019].

An individual must hold a valid license to use any of the following designations (or their respective abbreviations):

• A Registered Nurse (RN) or Professional Nurse.
• Licensed Vocational Nurse (LVN) or Vocational Nurse (VN).
• Licensed Practical Nurse (LPN), Practical Nurse (PN), or Graduate Nurse [TOC Sec. 301.251. bon.texas.gov, 2019].

Initial Licensure by Examination for US Graduates

For graduates of nursing education programs in the United States who apply for initial licensure through LVN or RN examination in Texas, the following requirements must be fulfilled:

• Consent to a criminal background check.
• Submission of a duly sworn application and the required fee.
• Verification of completion of the degree from an approved nursing education program.
• Successfully passed the NCLEX-PN (National Council Licensure Examination for Practical Nurses) or NCLEX-RN (National Council Licensure Examination for Registered Nurses) examination.
• Successfully passed the Texas Nursing Jurisprudence and Ethics examination. (“TAC” refers to Texas Administrative Code.) [TAC 217.2]

New graduates who have not previously failed their examinations can apply for and receive temporary authorization to practice as a Graduate Nurse or Graduate VN while awaiting examination results.[TAC 217.3]

Initial Licensure by Examination of Nursing Program Graduates Outside the United States 

For graduates of nursing education programs outside the United States who apply for initial licensure as LVNs or RNs must complete the following steps:  

• Consent to a criminal background check.
• Submission of a duly sworn application along with the required fee.
• Deliver a complete education course-by-course report from a credential evaluation service and demonstrate English proficiency through an acceptable test recognized by the Texas BON.
• Successfully passed the NCLEX-PN or NCLEX-RN examination.
• Successfully passed the Texas Nursing Jurisprudence and Ethics examination.[TAC 217.4]

Applicants who fulfill the specified requirements outlined in the rules are eligible to apply for an accustomization permit, granting them the opportunity to practice nursing under direct supervision.[TAC 217.4]

 Licensure by Endorsement 

Nurses who have practiced in another state within the 4 years preceding their licensure application may request and obtain a temporary license (valid for 120 days) and/or a permanent license by endorsement. This process also allows them to obtain a non-renewable temporary license.[TAC 217.5]

Nurses must meet the following requirements to be eligible for licensure by endorsement.

• Graduation from an approved nursing education program.
• A passing score on the NCLEX-PN or NCLEX-RN examination.
• Licensure in another jurisdiction within the United States.
• For graduates of nursing education programs outside the United States, verification of licensure from the country of education or submission of a complete education course-by-course report from a credential evaluation service.
• Payment of the application fee.
• Submission of a completed application form for Temporary License/Endorsement, which requires the below details:
  • Personal identification
  • Verification of required information
  • Attestation of meeting current Texas licensure requirements and having no disciplinary action against any license in any jurisdiction
  • Attestation of providing complete and accurate information
  • Fingerprints for a criminal background check
  • A passing score on the Texas Nursing Jurisprudence and Ethics examination.[TAC 217.5]

Types of Licensure Status Under the Texas BON 

• Active status 
• Inactive and retired status
• Volunteer retired status [TAC 217.9] 

Nursing License Renewal

Here are the key points regarding the license renewal for RNs and LVNs:

• The duration of the license renewal period ranges from 6 to 29 months, depending on the month and year of birth and license Board requirements.
• Licensees born in even-numbered years must renew their licenses in even-numbered years.
• Licensees born in odd-numbered years must renew their licenses in odd-numbered years.[TAC 217] 

CNE Requirements for License Renewal

Nurses must fulfill the requirements below for CNE when renewing their licenses.

• Nurses must attest that they have completed the mandatory CNE requirements or have obtained and maintained a national nursing specialty certification from an accredited organization.
• Nurses are responsible for maintaining their own CNE records. The Texas BON conducts random audits, and selected nurses must provide their completion records for verification.[TAC 216.3]
• CNE requirements must meet the following criteria:
  • They must be met within the 2 years preceding the license renewal.
  • They must be pertinent to the nurse’s area of practice.
  • They must provide evidence to demonstrate obtaining, maintaining, or renewing a Board-approved national nursing certification within the nurse’s practice area.
  • Include a minimum of 20 hours of approved CNE.[TAC 216.3]
• Academic education in nursing or relevant to the nurse’s specialty can also satisfy CNE requirements. Prerequisite courses, however, are not acceptable.
  • One academic semester hour is equivalent to 15 contact hours
  • One academic quarter hour is equivalent to 10 contact hours
• Nurses licensed by examination or endorsement are exempt from the CNE or certification requirement during their first license renewal period.[TAC 216.3]

CNE Jurisprudence Requirements

The following topics must be included in the CNE course to meet the Jurisprudence requirements:

• Nurses must complete a 2-contact-hour CNE course on Texas Nursing Jurisprudence and Ethics during every third license renewal period. This course counts toward the total requirement of 20 hours of CNE.[TAC 216.3]
• It is important to note that certification does not fulfill this specific requirement.[TAC 216.3]
• The CNE courses must include the requirements listed below. 
  • The Texas NPA
  • The rules and regulations established by the Texas BON, including the Standards of Nursing Practice
  • The BON’s Position Statements
  • Principles of Nursing Ethics
  • Professional boundaries [TAC 216.3]

Practice Specific Requirements for CNE

Depending on a nurse’s specific practice area, they may need to fulfill additional CNE requirements to maintain licensure.[TAC 216.3] The table below summarizes these requirements specified by the Texas BON.[TAC 216.3] 

Nursing Peer Review (Chapter 303)

Chapter 303 of the Texas Occupations Code focuses on Nursing Peer Review committees, specifying the nursing employers required to establish them and the policies and procedures governing their operations. The primary objective of these committees is to assess the quality of patient care delivered by nurses, evaluate the validity of complaints against nurses, and provide recommendations pertaining to those complaints. In addition, peer review committees are responsible for identifying and reporting incidents to the Texas BON [TOC Sec. 303.003. bon.texas.gov, 2019]. 

General Provisions for Nursing Peer Review Committees

Employers are required to establish a Peer Review committee under the following conditions: 

• For LVNs, if there are 8 or more LVNs employed.
• For Professional Nurses, if there are 8 or more employed, with at least 4 RNs [TOC Sec. 303.002. bon.texas.gov, 2019].

Furthermore, the employer must develop policies and procedures governing the nursing peer review process [TOC Sec. 303.002. bon.texas.gov, 2019].

The Nursing Peer Review Committee must afford any nurse undergoing review with appropriate due process, including timely notice of the complaint and the opportunity for a fair and impartial hearing [TOC Sec. 303.002. bon.texas.gov, 2019].

Peer Review Committee Requirements

A Nursing Peer Review committee must adhere to the following requirements:

• The committee must consist of nurses who constitute three-fourths of its members. 
• The committee should include LVNs as members to the extent feasible, and only RNs and LVNs may serve as voting members.
• The committee must have RNs comprising two-thirds of its members, and only RNs may be voting members.
• The committee must include at least 1 nurse familiar with the work performed in the specific area of nursing practiced by the nurse under review [TOC Sec. 303.002. bon.texas.gov, 2019]. 

Confidentiality of Peer Review Proceedings

All proceedings within a nursing peer review are strictly confidential. Any communication made to a review committee is privileged unless requested by the following entities:

• A licensing authority of any state.
• A law enforcement agency investigating a criminal matter [TOC Section 303.006-007. bon.texas.gov, 2019].

The peer review committee determines whether an incident should be reported to the Nurse’s Licensing Board [TOC Section 303.003. bon.texas.gov, 2019].

Nursing Peer Review Procedures 

The Texas BON rule 217.19 of the TAC should be utilized by individuals responsible for conducting nursing peer reviews. This rule outlines the following procedures:[TAC 217.19]

• Incident-based peer review is the process for evaluating reported complaints concerning nurses.
  • Anyone can submit complaints to the peer review committee.
  • A nurse’s report of an incident to the peer review committee satisfies the duty to report the incident as required.[TAC 217.19]

• Protections during incident-based peer reviews are provided to ensure fairness and safety.
  • Safe Harbor
  • Whistleblower protection [TAC 217.19]

Safe Harbor

Safe Harbor is a protective process that safeguards Nurses from employer retaliation or disciplinary action when they believe they have been assigned to unsafe assignments, asked to engage in activities beyond their scope of practice, or instructed to participate in unprofessional or illegal conduct. The procedure for requesting a Safe Harbor entails the following steps:

• The nurse must inform the shift supervisor before accepting or performing the assignment. 
• The nurse must complete a detailed written statement outlining the concerns and submit it to the supervisor before the end of their work period. The forms specified in Rule 217.19 may be used. The nurse should retain a copy of the statement for their records. 
• The Peer Review Committee will review the incident and the nurse’s Safe Harbor request.[TAC 217.20] 

The forms that are available on the Texas BON website include the following: 

• Quick Request for Safe Harbor [QuickRequest]
• Comprehensive Request for Safe Harbor [CompRequest]
• Safe Harbor Request to Question Medical Reasonableness of a Physician’s Order [MDOrder]

Whistleblower Protection 

Whistleblower protection is granted to nurses who invoke Safe Harbor or refuse to perform a nursing care act that would violate the NPA or BON rules. It ensures that an employer cannot engage in actions such as suspension, termination, discipline, retaliation, or discrimination against a nurse who, in good faith, reports an incident or informs another nurse about their rights and obligations as per the regulations.[TAC 217.19]

The Nurse Licensure Compact (NLC, Chapter 304)

The NLC aims to facilitate the nursing regulation and licensure process for nurses across multiple member states that are part of the compact. Since its enactment on December 31, 2018, the NLC legally authorizes RNs and LPNs/VNs to practice nursing in other compact states. This compact ensures compliance with nursing laws in each participating state and enables the exchange of information between states [TOC Section 304.0015. bon.texas.gov, 2019].

The NLC consists of various articles that outline its enforcement powers and the establishment of the Interstate Commission of NLC Administrators. The following is a summary of the key sections, while further details can be found in Chapter 304 of the Texas Occupations Code [bon.texas.gov, 2019].

General Provisions of the NLC

• A multistate license to practice registered or licensed vocational nursing, issued by the applicant’s state of residence, will be recognized by each member state, granting the applicant the authority to practice as an RN or LVN in those states. 
• States that authorize initial multistate nursing licenses or licensure by endorsement must establish procedures for reviewing the criminal history records of nursing applicants. This may involve the submission of fingerprints or other biometric-based information to access data from the Federal Bureau of Investigation (FBI) and the agency responsible for maintaining criminal records within that particular state. 
• To obtain or retain a multistate license in their home state, applicants must fulfill the following requirements in each member state: 
  • Meet the licensure qualifications and renewal criteria set by the home state and comply with all other applicable state laws.
  • Have successfully graduated from an RN or LVN prelicensure education program approved by the licensing board or be eligible for graduation from such a program.
  • Achieve a passing score on the NCLEX-RN or NCLEX-PN examination.
  • Possess an active, unencumbered license.
  • Submit fingerprints or other biometric data for obtaining criminal history record information from the FBI and the agency responsible for maintaining the state’s criminal records.
  • Not have been convicted or found guilty of a felony offense.
  • Not have been convicted or found guilty of a misdemeanor offense related to nursing.
  • Not be currently enrolled in an alternative program and comply with self-disclosure requirements regarding participation in an alternative program.
  • Hold a valid Social Security Number in the United States.
  • For foreign applicants, 
    • Graduation from an authorized RN/LVN prelicensure education program verified as a comparable program by an independent credentials review agency.
    • Obtain a passing score on an English proficiency examination if the prelicensure program was not conducted in English or if English is not the individual’s native language [TOC 304.001. bon.texas.gov, 2019].
• All member states have the authority, by their respective state due process laws, to restrict a nurse’s authorization to practice under a multistate licensure privilege such as revocation, suspension, or probation. 
• If a member state takes disciplinary action against a nurse, they must promptly notify the administrator of the coordinated licensure information system, who will then inform the nurse’s home state. 
• Nurses practicing under a multistate license must comply with the nurse practice laws of the state where the patient they are providing care to resides. They are subject to the jurisdiction of the licensing Board, the Courts, and the state's laws where the patient resided at the time of service. 
• The NLC does not affect the requirements established by a member state for issuing a single-state license. 
• If a nurse changes their primary state of residence after the effective date of the compact, they must fulfill all applicable requirements to obtain a multistate license from their new home state.
• Failure to meet the specified requirements can result in the revocation of the multistate license [TOC Section 304.001.3. bon.texas.gov, 2019].

 Applications for Licensure in Texas

• When a Texas resident applies for a multistate license, the Texas Licensing Board is responsible for verifying the following details:
  • Determine whether the applicant holds or has ever held a license issued by any other state.
  • Assess whether there are any encumbrances on any licenses held by the applicant.
  • Evaluate whether any disciplinary actions have been taken against the applicant.
  • Confirm whether the applicant participates in an alternative program [TOC Section 304.001.4. bon.texas.gov, 2019].
• A nurse can only possess a multistate license, issued by their home state, in only one member state at a time. 
• If a nurse relocates from one compact state to another, they must apply for licensure in the new home state, and their previous multistate license will be deactivated. 
• A nurse should apply for their licensure in the new state before the relocation. Proof of residency may be required. 
• The issuance of a new multistate license from the applicant’s new home state will only occur when all the applicable requirements for obtaining a multistate license in that state are fulfilled.
• If a nurse changes their primary state of residence to a noncompact state, the multistate license issued by their former home state will convert to a single-state license valid solely in the former home state [TOC Section 304.001.4. bon.texas.gov, 2019]. 

Issues of Concern

The Texas Standards of Nursing Practice (TAC 217.11)

Nurses should be familiar with the Texas Standards of Nursing Practice, which establish the minimum acceptable level of nursing practice for each level of nursing licensure or advanced practice authorization across various healthcare settings.[TAC 217.11] Failure to meet these standards may result in disciplinary action against the nurse’s license, even if no patient injury occurred.[TAC 217.11]

The Texas Standards of Nursing Practice contains 4 main sections:

1. Standards Applicable to All Nurses
2. Standards Specific to LVNs
3. Standards Specific to RNs
4. Standards Specific to APRNs 

Standards Applicable to All Nurses

Irrespective of their specific level of nursing practice (including LVNs, RNs, and APRNs), all nurses are required to fulfill the following requirements as part of their nursing practice [TOC Sec. 301.419. bon.texas.gov, 2019]:

• They must understand and conform to the rules and regulations of the Texas NPA and Texas BON and all relevant federal, state, or local laws and regulations applicable to their current practice area.
• They must take necessary measures to promote a safe environment for clients and others.
• They must comprehend the rationale for and the effects of medications and treatments and their correct administration [TOC Sec. 301.419. bon.texas.gov, 2019].
• They are responsible for accurately reporting and documenting various aspects of patient care, as listed below. 
  • Patient’s current status, including signs and symptoms.
  • Details of the nursing care provided.
  • Orders received from physicians, dentists, or podiatrists.
  • Administration of medications and treatments.
  • Patient’s responses to interventions or treatments.
  • Significant events and communication with other healthcare team members regarding the patient’s condition [TOC Sec. 301.419. bon.texas.gov, 2019].
• They must respect a patient’s right to privacy by safeguarding confidential information, unless required or permitted by law to disclose such information [TOC Sec. 301.419. bon.texas.gov, 2019].
• They must promote and participate in education and counseling for patients and their families or significant other(s) whenever necessary. 
• They must seek appropriate instruction and supervision as needed [TOC Sec. 301.419. bon.texas.gov, 2019].
• They should make reasonable efforts to acquire orientation and training to maintain competency when encountering new or unfamiliar care situations [TOC Sec. 301.419. bon.texas.gov, 2019].
• Inform the relevant supervisor when concluding a nursing assignment [TOC Sec. 301.419. bon.texas.gov, 2019].
• They should understand, identify, and maintain appropriate professional boundaries with patients [TOC Sec. 301.419. bon.texas.gov, 2019].
• They must adhere to the mandatory reporting requirements outlined in the Texas NPA, Subchapter I, which entails reporting a nurse in the circumstances mentioned below. 
  • Violation of the NPA or a Board rule that contributes to the death or severe injury of a patient [TOC Sec. 301.419. bon.texas.gov, 2019].
  • Suspected impairment of a nurse’s practice due to substance abuse.
  • Actions that encompass abuse, exploitation, fraud, or a breach of professional boundaries.
  • Actions that indicate a lack of knowledge, skill, judgment, or conscientiousness to the extent that the nurse’s continued practice could harm a patient or another individual, excluding minor incidents that pose a risk of harm with their ongoing practice [TOC Sec. 301.419. bon.texas.gov, 2019].  
• They must provide nursing services without discrimination, irrespective of the patient’s age, disability, economic status, gender, national origin, race, religion, health problems, or sexual orientation [TOC Sec. 301.419. bon.texas.gov, 2019].
• They must initiate necessary actions to stabilize a patient’s condition and prevent complications [TOC Sec. 301.419. bon.texas.gov, 2019].
• They must seek clarification from the appropriate licensed practitioner regarding any order or treatment regimen they suspect to be inaccurate, ineffective, or contraindicated. They should also inform the ordering practitioner when deciding not to administer medication or treatment [TOC Sec. 301.419. bon.texas.gov, 2019].
• They must implement measures to prevent exposure to infectious pathogens and communicable conditions [TOC Sec. 301.419. bon.texas.gov, 2019].
• They should collaborate with the healthcare team members and the patient or their significant other(s) when appropriate, focusing on the patient’s healthcare needs [TOC Sec. 301.419. bon.texas.gov, 2019].
• They should consult, utilize, and refer to appropriate community agencies and healthcare resources to ensure continuity of care [TOC Sec. 301.419. bon.texas.gov, 2019]. 
• They should continually maintain competence in nursing practice and actively pursue professional growth [TOC Sec. 301.419. bon.texas.gov, 2019].
• They should make assignments for others considering patient safety, the nurse’s educational preparation, experience, knowledge, and physical and emotional capabilities [TOC Sec. 301.419. bon.texas.gov, 2019]. 
• They must accept only those nursing assignments that prioritize patient safety and are appropriate based on the nurse’s educational preparation, experience, knowledge, and physical and emotional capabilities [TOC Sec. 301.419. bon.texas.gov, 2019].
• They should supervise the care provided by others for whom they hold professional responsibility [TOC Sec. 301.419. bon.texas.gov, 2019].
• They should verify the current Texas licensure or other licensure privileges and credentials of personnel for whom they hold administrative responsibility when acting in that role [TOC Sec. 301.419. bon.texas.gov, 2019].

Nursing Standards Specific to LVNs

LVN practice is conducted under supervision and guidance from an RN, APRN, physician’s assistant, physician, podiatrist, or dentist. Supervision is defined as the process of directing, guiding, and influencing the outcomes of an individual’s performance.[TAC 217.11]

LVNs are responsible for assisting in determining the healthcare needs of patients and performing the following tasks: 

• Utilizing a systematic approach to provide individualized, goal-directed nursing care, including: 
  • Collecting data and performing focused nursing assessments.
  • Participating in the planning of nursing care needs.
  • Assisting in developing and modifying comprehensive nursing care plans for assigned patients.
  • Implementing appropriate aspects of care within the LVN’s scope of practice.
  • Assisting in evaluating patients' responses to nursing interventions and identifying their needs.[TAC 217.11]
• Assigning specific tasks, activities, and functions to unlicensed personnel, considering their education, experience, physical abilities, and emotional capacity, while maintaining appropriate supervision.[TAC 217.11]
• Performing additional activities that align with the education and training required by the Texas Board rules, commensurate with the LVN’s experience, continuing education, and demonstrated competencies as an LVN.[TAC 217.11] 

Nursing Standards Specific to RNs

RNs play a crucial role in assisting and determining the healthcare needs of patients and delivering individualized nursing care through a systematic approach. Their responsibilities include: 

• Conducting comprehensive nursing assessments to evaluate the health status of a patient.
• Establishing nursing diagnoses that form the foundation for the care strategy.
• Developing a care plan based on the assessment and nursing diagnosis.
• Implementing nursing care interventions.
• Evaluating patients’ responses to nursing interventions.[TAC 217.11]

In addition, RNs are also expected to delegate tasks to unlicensed personnel per the following guidelines: 

• TAC Chapter 224, which pertains to patients with acute conditions or in acute care environments.
• TAC Chapter 225, which addresses independent living environments for patients with stable and predictable conditions.[TAC 217.11]

Nursing Standards Specific to APRNs

The standards specific to the APRNs’ role and specialty take precedence over those for RNs in case of conflicts. In addition to complying with the standards applicable to all nurses and standards specific to RNs, APRNs are expected to perform the following duties:[TAC 217.11]

• Practice in an advanced nursing practice role and specialty within the parameters established by the authorization granted under TAC Chapter 221 pertains to practicing in an APRN role. It encompasses the standards outlined in that chapter.[TAC 217.11]
• Prescribe medications within their prescriptive authority granted under Texas Board Rule 222. They must adhere to the nursing standards for nursing and comply with state and federal laws and regulations governing the prescription of dangerous drugs and controlled substances.[TAC 217.11]

Clinical Significance

The state of Texas mandates the NPA, Standards of Nursing Practice, Texas BON Position statements, and Nursing Code of Ethics due to their clinical significance. Healthcare holds immense importance in the lives of those receiving it, emphasizing the necessity of delivering care professionally, compassionately, and ethically. Upholding a consistent standard for all nurses ensures that only licensed individuals who meet these standards can practice nursing. The NPA grants authority to the Texas BON to regulate nursing practices and establish minimum standards for nursing education programs. This regulatory role safeguards the public by ensuring that those providing care are adequately qualified.

Nurses are responsible for collaborating with the entire healthcare team to ensure optimal care for each patient by coordinating treatment plans and addressing individual dietary preferences. As representatives of the nursing profession, every member must be familiar with ethical standards of conduct, ensuring the fulfillment of nursing duties aligned with the expectations of other healthcare professionals and the general public. Moreover, healthcare professionals from other disciplines may be unfamiliar with the specific educational requirements and responsibilities associated with different levels of nursing licensure. Therefore, nurses should thoroughly understand their practice scope and patient-related responsibilities.

These regulations and codes of ethics provide valuable guidance to nurses in their provision of care, outlining their duties, the scope of their practice, and the expected conduct. Conflicts and errors commonly encountered in healthcare can be mitigated by having clarity on these matters. Familiarity with the laws governing nursing practice in Texas is crucial for nurses to understand the requirements set forth by the state for their employers. Upholding these standards contributes to establishing high-quality nursing care and promotes excellence within the nursing profession. Each member of the nursing profession must remain vigilant in adhering to these rules and regulations, as it enhances the protection of patients who often find themselves in vulnerable situations.

Other Issues

Unprofessional Conduct (TAC 217.12)

The Texas BON has outlined various other issues, including rules that define unprofessional nursing conduct. These rules safeguard the public against nurses who lack competence or act unethically while identifying those who may engage in deception, fraud, or harm toward patients or the general population. Evidence of actual patient injury is not a prerequisite. While the following types of conduct are outlined, the list below is not exhaustive.[TAC 217.12]

• Unsafe practices include actions or conduct such as:  
  • Carelessly failing or demonstrating an inability to meet the minimum standard of care for an LVN, RN, or APRN, as outlined in Chapter 217.11. 
  • Improperly managing patient records. 
  • Delegating or assigning nursing care or healthcare tasks leading to an unsafe or ineffective outcome for patient care. 
  • Accepting a nursing assignment despite knowing that it may reasonably result in unsafe or ineffective patient care. 
  • Failing to supervise the performance of tasks by individuals working under the nurse’s delegation or assignment. 
  • Failing to ensure adequate supervision of a student by a clinical nursing instructor.[TAC 217.12]
• Failure of a Chief Administrative Nurse to adhere to the standards and guidelines mandated by federal or state law, regulations, or facility policies while providing oversight of the nursing organization and nursing services under their administrative responsibility. 
• Failure to practice within a modified scope of nursing practice area or to comply with the required accommodations, as specified by the Board in granting an encumbered license or any stipulated agreement with the Board. 
• Conduct that may pose a potential risk to a patient’s life, health, or safety. 
• Actual or potential inability to provide nursing care with reasonable skill and safety to patients due to illness, substance abuse, or any mental or physical condition. 
• Misconduct encompasses various actions or conduct, such as:  
  • Falsifying reports, patient documentation, agency records, or other documents. 
  • Refusing to cooperate with a lawful investigation conducted by the Board. 
  • Allowing or causing abuse (physical, emotional, or verbal), injury, or neglect toward a patient or the public, and failing to report such incidences to the employer, appropriate legal authorities, and/or the licensing Board. 
  • Violating professional boundaries with a patient, including, but not limited to, physical, sexual, emotional, or financial exploitation of the patient or the patient’s significant other(s). 
  • Engaging in sexual conduct with a patient, sexually touching a patient, requesting or offering sexual favors, or engaging in language or behavior suggesting such actions. 
  • Displaying threatening or violent behavior in the workplace. 
  • Misappropriating anything of value or benefit related to nursing, including property belonging to individuals or entities (such as patients or employers), or failing to take precautions to prevent such misappropriation. 
  • Providing false, deceptive, or misleading information in connection with nursing practice. 
  • Failing to answer specific questions or providing false or misleading answers in matters related to licensure or employment that could impact decisions regarding licensing, employment, certification, or the utilization of a nurse. 
  • Directly or indirectly accepting or offering any fee or consideration from a third party in exchange for patient referrals in connection with the provision of professional services.[TAC 217.12]
• Failure to fulfill child support payment obligations as mandated by the Texas Family Code Sec. 232.001. 
• Engage in drug diversion, which involves the diversion or attempted diversion of drugs or controlled substances. 
• Dismissal from a Board-approved peer-assistance program due to noncompliance and subsequent referral by that program to the Board. 
• Drug-related actions or conduct include:  
  • Using any controlled substance, prescribed or unprescribed, or device, or consuming alcoholic beverages while on duty or call to the extent that such usage impairs the nurse’s ability to safely provide any authorized practice outlined in the nurse’s license to the public. 
  • Falsifying or making incorrect, inconsistent, or unintelligible entries in any record associated with drugs or controlled substances, whether agency, client, or any other relevant documentation. 
  • Failing to adhere to the established policy and procedure for medication wastage at the facility where the nurse was employed or working at the time of the incident(s). 
  • Testing positive on a drug screen without a lawful prescription to justify the results. 
  • Engaging in the illegal or deceptive acquisition or distribution of medication(s) through misrepresentation, fraud, or forgery.[TAC 217.12]
• Unlawful practices encompass actions or conduct such as: 
  • Knowingly aiding, assisting, advising, or permitting an unlicensed individual to engage in the unlawful practice of nursing at any level. 
  • Violating an order issued by the Board, carelessly or repetitively violating state or federal laws concerning nursing practice, or violating state or federal laws regarding narcotics or controlled substances. 
  • Assisting, aiding, advising, or permitting a nurse under Board Order to violate the specified conditions outlined in the Order. 
  • Failing to report violations of the NPA and/or the Board’s rules and regulations. 
• Abandon a nursing assignment, including a supervisory assignment, without notifying the relevant personnel.[TAC 217.12] 

Texas BON Disciplinary Process

Nurses are advised to review the Texas BON Disciplinary Matrix as outlined in section TAC 213.33 to understand the disciplinary steps involved when a review of their conduct is necessary. The disciplinary process considers various factors, including public safety, the seriousness and frequency of the violations, any mitigating circumstances, prior violations, and potential expenses resulting from the violation.[TAC 213.33]

Initiation of the Disciplinary Process

The initiation of the disciplinary process involves the following steps:

• Upon receiving a complaint, the Texas BON will promptly provide written notification to the nurse who is the subject of the claim (referred to as the respondent), informing them about the nature of the complaint.
• The written notice will include a statement detailing the alleged conduct and invite the respondent to demonstrate their compliance with the BON’s rules and legal requirements.
• The respondent is required to submit a written response within 20 days of receiving the notification of the complaint.[TAC 213.14]

Disciplinary Proceedings

Steps within the disciplinary proceedings observed by Texas BON are listed below.

• The BON proceeds by filing formal charges if the complaint cannot be resolved informally.
• The respondent is officially served with a copy of the charges, which includes recommended penalty by the Texas BON, and is instructed to submit a response to the charges.
• The parties involved may resolve through an agreement at any point.[TAC 213.15]
• Failure of the respondent to file a response will result in the case being deemed a default case, indicating that the respondent:
  • Admits to all allegations.
  • Waives the opportunity to provide evidence of compliance, request a hearing, or object to the recommended sanction by the BON.[TAC 213.16]
• The respondent may file a motion for a rehearing if the failure to answer the charges was unintentional.[TAC 213.16]
• Discovery process: The BON has the authority to request relevant information about the complaint from individuals who possess it. These individuals must provide the requested information within 20 days, excluding deposition time.[TAC 213.17]
• Deposition process: The BON may request witnesses to give depositions and may request a witness to provide items, such as records, during the deposition.[TAC 213.18]
• Subpoena process: The BON may issue a subpoena to compel a witness’s presence or the production of evidence.[TAC 213.19]

Informal Proceedings and Alternate Dispute Resolution

The BON has established procedures to facilitate the resolution and early settlement of complaints through informal proceedings or alternative dispute resolution.

• The complainant and the nurse involved are allowed to present their perspectives and be heard.
• Informal proceedings may be conducted in person, with legal representation, or through various forms of communication (eg, electronic or written).
• The nurse involved has the right to be represented by an attorney, and the BON’s counsel or the Assistant Attorney General may participate in the informal proceedings.
• The matter may be resolved at any time by an agreement that satisfies the Executive Director, which is finalized by the Board or a disciplinary committee.[TAC 213.20]
• Mediation allows the parties involved in a complaint to seek a resolution without resorting to an administrative hearing.
  • A mediator assists in facilitating communication and negotiation between the parties.
  • The parties involved have control over whether the dispute is resolved through mediation. The parties may proceed to an administrative hearing if the dispute remains unresolved.[TAC 213.20]

Peer-Assistance Program

The BON may utilize a peer-assistance program as an informal approach to address complaints when a nurse has been reported for impairment due to chemical dependency or mental illness. In such cases, the nurse can submit a written stipulation of impairment, forgo the right to a hearing, and enter into a written contract with the BON to participate in a peer-assistance program.

• The required components of the peer-assistance program are as follows:
  • Undergoing and covering the costs of physical and mental evaluations.
  • Planning, implementing, and adhering to a monitoring plan within a rehabilitation program.
  • Adhering to the provisions outlined in the agreement that define the conditions and timelines for the nurse’s safe return to practice.
• The nurse’s referral to a peer-assistance program will not be reported to the Disciplinary Data Bank of the National Council of State Boards of Nursing (NCSBN).
• In the event of the nurse’s noncompliance with the contract, the nurse will be allowed to respond.
• During an informal proceeding, the Executive Director of the BON may:
  • Modify or extend the existing contract.
  • Declare that the contract has been satisfactorily fulfilled.
  • Impose sanctions that may lead to public disciplinary action against the nurse.
  • Report the nurse to the NCSBN’s Disciplinary Data Bank.[TAC 217.13]

Formal Proceedings

If informal proceedings or alternate dispute resolution fail to resolve, jurisdiction over the complaint is transferred to the State Office of Administrative Hearings (SOAH), which involves the following steps:

• The respondent is provided with a hearing notice and is required to submit a written answer within 20 days from the date of service of the notice.
• If the respondent or their legal representative fails to attend the hearing, the allegations will be considered valid, and the recommended sanctions by the BON will be granted.
• Following the hearing, the judge prepares and serves a statement of their findings and a proposed order to the parties involved, which includes any recommended sanctions, within a reasonable time frame.
• The BON or its Disciplinary Committee decides on the proposed sanctions.
• According to BON rules, there are provisions for presenting additional evidence or an appeal process.[TAC 213.22][TAC 213.23]

Remedial Education Courses

When a nurse exhibits a deficiency in knowledge, judgment, or skills, the BON has the authority to mandate the completion of a remedial education course for the nurse.[TAC 217.21]

Texas BON Position Statements

The Texas BON position statements lack legal authority; however, they serve as valuable guidance for nursing practice, aiming to safeguard the public and ensure high-quality nursing care. Moreover, these statements offer nurses further clarity on applying BON rules in specific scenarios. A summary of the BON position statements can be found in the Table below, while comprehensive details are available on the Texas BON website [bon_position_statements].

The Texas BON Position Statement 15.28—The RN Scope of Practice

As stated in the above Table, the BON recommends that all nurses consult the Scope of Practice DMM-1 to determine whether a job position, policy, or assignment offered by an employer falls within their scope of practice. RNs generally advocate for the patient and the patient’s family and adhere to the Texas NPA and BON. The practice of an RN requires specialized judgment and skills acquired through the completion of an approved program of study at a professional nursing school. It’s important to note that RNs are not authorized to make medical diagnoses or prescribe treatments.[bon_position_statements/15.28]

BON Position Statement 15.28 further provides information on the nursing process, highlighting the variations between RNs and LVNs and among different levels of RN education. The nursing process encompasses assessment, nursing diagnosis, implementation, evaluation, and reevaluation. In addition, this process relies on essential skills such as effective communication, clinical reasoning, and the assessment of practice settings to ensure alignment with their scope of practice. For specific details on the LVN scope of practice, please refer to BON Position Statement 15.27.[bon_position_statements/15.28]

The Nursing Process

Assessment

The initial step of the nursing process is to comprehensively assess and interpret data, which continues throughout a nurse’s care for a patient. After the assessment is complete, the nurse can utilize the findings to make nursing judgments and determine the patient’s physical and mental health status. Furthermore, the RN should also identify the patient’s needs and cultural preferences and be prepared to anticipate and recognize any changes in the patient’s condition.[bon_position_statements/15.28]

Patient Diagnosis/Problem Identification/Planning

The second step in the nursing process is identifying problems from the assessment findings and formulating a care plan for patients, their family members, populations, and communities using evidence-based practice.

The third step in the nursing process is planning. RNs synthesize the data collected during the comprehensive assessment to identify problems, participate in the patient diagnoses, and formulate goals. RNs develop a nursing care plan for patients using evidence-based practice.[bon_position_statements/15.28]

Implementation

The fourth step in the nursing process is implementing the plan of care. RNs are responsible for delegating assignments only to individuals with the necessary education, training, skill, competence, and physical and emotional abilities to ensure patients’ safety. In addition, RNs are responsible for supervising LVNs or other RNs, including directing and guiding their performance and activity.

Furthermore, RNs may determine when it is appropriate to delegate tasks to unlicensed individuals, bearing in mind that they are still responsible for supervising the unlicensed person and are accountable for their performance.[bon_position_statements/15.28]

Evaluation and Reassessment

The final step in the nursing process is evaluation, which entails the RN assessing patient outcomes and responses to therapeutic interventions. The RN should compare these responses to benchmarks derived from evidence-based practice and research findings and subsequently plan for follow-up care and/or referrals to relevant resources. RNs should also consistently reassess and report the patient’s condition, determining the effectiveness of interventions and the need to adjust the care plan.

Essential Skills Used in the Nursing Process

Communication

Communication is a fundamental skill used during the nursing process. RNs must effectively communicate verbally, in written form, or electronically with the healthcare team, patients, and their family members in all aspects of patient care. They are responsible for accurately documenting these interactions in the patient record or nursing care plan. Collaboration is essential for RNs, as they plan, coordinate, initiate, and implement a multidisciplinary team approach to patient care. In situations where patient conditions or circumstances surpass an RN’s level of expertise, seeking consultation from other RNs or healthcare providers possessing diverse skill sets is imperative.

Clinical Reasoning 

RNs must utilize critical thinking skills to solve problems and exercise prudent and professional nursing judgment to ensure adherence to nursing practice standards.

Employment Setting

RNs should ensure that they do not exceed the boundaries of their practice, as employers may not be fully aware of an RN’s practice parameters. Before undertaking or accepting an activity or assignment, an RN should assess their capabilities and determine whether they possess the necessary education, training, skills, competence, and physical and emotional capacity to carry out the task safely.

BON Position Statement 15.29—Professional Boundaries—Use of Social Media by Nurses

Professional Boundaries

The Texas BON defines professional boundaries as “the appropriate limits which should be established by the nurse in a relationship with a patient due to the nurse’s power and the patient’s vulnerability.” [bon_position_statements/15.29] Maintaining professional boundaries involves refraining from inappropriate involvement with a patient and avoiding personal gain at the patient’s expense.[TAC 217.1] The NCSBN defines professional boundaries as the distinction between the nurse’s power derived from access to a patient’s personal information and the patient’s vulnerability. This power imbalance stemming from the knowledge of personal information creates an asymmetry between the nurse and the patient. Therefore, the overlying principle for maintaining professional boundaries is that nurses should refrain from any personal gain at the patient’s expense and abstain from any inappropriate involvement with the patient or their family.[bon_position_statements/15.29]

Boundary Violations

Violation of professional nursing boundaries is also considered unprofessional and reportable conduct.[TAC 217.12]. There are various forms of professional boundary violations, such as:

• Physical
• Sexual (eg, engaging in sexual conduct with a patient, sexually touching a patient, requesting or offering sexual favors, or using sexually suggestive language or behavior).[TAC 217.12]
• Emotional
• Financial [bon_position_statements/15.29] 

Social Media Use and Protected Health Information

The Texas BON supports the social media guidelines recommended by the NCSBN and American Nurses Association, which include the following key points:

• Nurses have an ethical and legal obligation to maintain patient privacy and confidentiality consistently in compliance with local, state, and federal laws
• When using social media, nurses must never disclose a patient’s identity, post identifiable patient information, or underestimate the potential consequences of such disclosures.
• Any breaches of confidentiality or privacy must be promptly reported.
• Nurses must establish and maintain professional boundaries with patients online. It is prohibited to reference a patient, even if the patient remains unidentified, or transmit information that could violate the patient’s right to confidentiality or cause embarrassment or degradation.
• Nurses must provide nursing services without discrimination and refrain from making offensive comments (such as threatening, profane, sexually explicit, or racially derogatory comments).
• Nurses must be familiar with and adhere to all applicable laws, regulations, and employer policies concerning the use of electronic devices, including devices owned by the employer.
• Nurses must ensure that any patient-related images, photos, or videos are used appropriately in accordance with relevant laws, regulations, institutional policies, and procedures.[TAC 217.11]  

American Nurses Association Ethical Nursing Provisions

The American Nurses Association has also established a general code of ethics that serves as a fundamental framework for ethical behavior in nursing practice, applicable across all levels. These guidelines emphasize the importance of nurses acting as patient advocates, upholding personal and professional integrity, and continually striving to improve the quality of patient healthcare.

These ethical rules of conduct include:

1. Nurses should practice nursing care with compassion and respect in all professional relationships, acknowledging every individual's inherent dignity, worth, and uniqueness, irrespective of social or economic status, personal attributes, or the nature of health problems.
2. The primary commitment of every nurse is to the patient, whether it be an individual, family, group, or community.
3. Nurses must consistently promote, advocate for, and take necessary measures to safeguard the patient's health, safety, and rights.
4. Nurses are accountable for their actions and should appropriately delegate tasks in alignment with their obligation to provide optimal patient care.
5. Nurses are responsible for preserving their integrity and safety, maintaining competence, and pursuing personal and professional growth.
6. Nurses should actively participate, individually and collectively, in establishing, maintaining, and enhancing healthcare environments and employment conditions that align with the nursing profession's values.
7. Nurses should contribute to nursing practice, education, administration, and knowledge development to advance the profession.
8. Nurses must collaborate with other healthcare professionals and the public to promote healthcare needs and well-being.
9. Members of the nursing profession are responsible for articulating nursing values, maintaining the integrity of the profession and its practice, and influencing social policies.[code-of-ethics-for-nurses]

Enhancing Healthcare Team Outcomes

The Texas NPA and BON rules and regulations play a crucial role in assuring the entire interprofessional healthcare team and the public that nurses providing care are qualified and committed to ethical conduct. The regulations set by the Texas BON establish a standard of care to protect the public while guiding healthcare professionals regarding their respective duties and scope of practice at each level of nursing. Nurses formulating patient care plans should collaborate with the entire healthcare team to deliver optimal care for each individual. Although other healthcare providers may contribute to treatment plans, nurses hold a central role in coordinating all aspects of a patient's care. As a result, they often serve as the primary point of contact for both team members and patients.

Nurses are responsible for communicating with the patient's healthcare team and others involved in their care. Each communication should be documented in the patient record or nursing care plan to keep the entire healthcare team informed and work toward achieving the best possible outcome. As RNs are responsible for coordinating and implementing patient care plans, effective communication with the entire healthcare team is vital to their nursing practice. Nurses must also advocate for their patients, ensuring their autonomy is respected in all aspects of their care. When a patient's condition exceeds a nurse's level of expertise, they should seek consultation from other experienced nurses or other healthcare providers to prioritize patient safety. Ethical standards establish expectations among healthcare professionals and guide the public in what they can expect.