1. Anticipating the Future Maintaining Your License

2. Texas Occupations Code Governs many occupations Chapter 301 - Law that establishes & empowers Board of Nursing for the State of Texas Contains the Nurse Practice Act Contains law setting up rules and regulations for nursing practice in Texas – Defines the SCOPE of PRACTICE Texas Administrative Code –Provides more detail on how the requirements of the Occupations Code are to be carried out. –Appointment of members, meetings, proceedings, investigations, disciplinary actions, etc.

3. Texas Occupations Code Chapter 301: Nursing Practice Act Chapter 303: Nursing Peer Review Chapter 304: Nurse Licensure Compact Chapter 305: Advanced Practice Registered Nurse Licensure Compact

4. Texas Administrative Code TITLE 22TITLE 22 EXAMINING BOARDS PART 11PART 11 BOARD OF NURSING CHAPTER 211CHAPTER 211 GENERAL PROVISIONS RULE §211.1 Introduction (a)Name. Texas Board of Nursing Decision-making board appointed by the Governor (Texas Occupations Code). (b) Location. Austin, Texas (c) Legal Authority. Chapters 301, 303, 304. and 305 - Texas Occupations Code. (d) Composition. Persons appointed by the Governor with Senate approval.

5. Texas Administrative Code GENERAL PROVISIONS RULE §211.3 Organization and Structure ( (b) Terms of office for Board members. Six years in length with staggered terms. Members may be reappointed by the Governor. (c) Eligibility. Board member eligibility is governed by the Texas Occupations Code §§301.052 and 301.053. (d) Compensation. Per diem as provided by law for each day that the member engages in the business of the board Travel expenses Source Note: The provisions of this §211.3 adopted to be effective March 31, 2002, 27 TexReg 2236; amended to be effective May 17, 2004, 29 TexReg 4884

6. TEXAS OCCUPATIONS CODE AND STATUTES REGULATING THE PRACTICE OF NURSING AGENCY MISSION The mission of the Texas Board of Nursing (BON) is to protect and promote the welfare of the people of Texas by ensuring that each person holding a license as a nurse in the State of Texas is competent to practice safely. This mission, derived from the Nursing Practice Act, supersedes the interest of any individual, the nursing profession, or any special interest group.

7. Texas Administrative Code BOARD OF NURSING Purpose and Functions The board fulfills its mission through two principle areas of responsibility: (1) regulation of the practice of professional and vocational nursing (2) accreditation of schools of nursing.

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

9. Texas Administrative Code - Functions of BOARD OF NURSING The board shall perform the following functions as outlined in Texas Occupations Code chapters 301, 303, 304, & 305. (3) Receive complaints and investigate possible violations. (4) Discipline violators through appropriate legal action. (5) Provide a mechanism for public comment and by which the rules and regulations are modified when appropriate.

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

11. (10) Monitor the examination results of applicants for variances in the level of educational effectiveness. (11) Consultation and guidance to nurse schools for self-study, evaluation, and the development of effective education programs. (12) Provide advice to the faculty, staff of health care agencies utilizing nursing services, and practitioners of nursing to improve professional service. (13) Implement and manage all other programs and responsibilities as authorized and mandated by the Texas Legislature. Source Note: The provisions of this §211.2 adopted to be effective March 31, 2002, 27 TexReg 2236; amended to be effective May 17, 2004, 29 TexReg 4884

12. Standards of Nursing Practice in the state of Texas

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

14. Texas Administrative Code Chapter 217 Rule 217.11- Standards of Nursing Practice in the state of Texas cont. Obtain appropriate supervision, orientation, in-service info, & CE’s Accept responsibility for competence & growth Notify supervisor when leaving nursing assignment Maintain professional boundaries Comply with reporting requirements Provide care without discrimination & within own abilities and those of others you are supervising Implement measures to stabilize clients and prevent complications Implement measures to prevent exposure to infectious disease

15. Texas Administrative Code Chapter 217 Rule 217.11- Standards of Nursing Practice in the state of Texas cont. Clarify any order or treatment that may be inaccurate, non- efficacious or contraindicated by consulting the appropriate licensed practitioner and notifying the ordering practitioner when deciding not to administer the medication or treatment Collaborate with the client, care team, and when appropriate the client’s family to provide optimal care. Make appropriate referrals for continuity of care.

16. Texas Administrative Code Chapter 217 Rule 217.11- Standards of Nursing Practice in the state of Texas cont. Make appropriate/safe assignments based on ability and client’s needs Accept only those assignments that you can do safely. Supervise those for whom they are responsible. Ensure verification of current licensure or compact privilege when administratively responsible

17. Texas Administrative Code Chapter 217 Rule 217.11- Standards of Nursing Practice in the state of Texas – just for RN’s. Use systematic approach to provide individualized, goal directed nursing care based on nursing process. Delegate tasks to unlicensed personnel in compliance with Chapter 224 (acute care settings) and Chapter 225 (independent living environments) with stable and predictable conditions. Contact BON http://www.bon.state.tx.us/contact

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

19. Applying for your License See the http://www.ncsbn.org/ andhttp://www.ncsbn.org/ www.pearsonvue.com/nclex web siteswww.pearsonvue.com/nclex See check list at end of application –BON Application finger prints & photo BNE application with fee –Registration for NCLEX-RN Exam NCLEX-RN Examination application form pay fee forNCLEX Registration –Affidavit of Graduation from Nursing Program

20. NCLEX Test Plan **Please access the linked PDF document for current detailed information NCLEX test and guidelines for success on NCLEX **This site is importantlinked PDF document During the administration of the NCLEX-RN examination candidates will be required to respond to items in a variety of formats. These formats may include, but are not limited to: multiple choice, multiple response, fill-in-the-blank calculation, drag and drop, and/or hot spots. All item types may include multimedia, such as charts, tables, graphics, sound and video. For more information, please visit the NCSBN Web site at www.ncsbn.org to review Information about Alternate Item Formats. www.ncsbn.org

21. Type of Testing CAT – Computer Adaptive Testing Identifies 95% chance of safe practice –Various types of questions Pictures, fill in the blank, multiple answer, etc. –Don’t make wild guesses to finish items –Each test is different Computer selects items for candidate’s skill level Level of question based on answer to previous question Different questions each time applicant tests –Contains some items that are not graded –Instructions, sample items, and breaks are included in testing time period allowed www.pearsonvue.com/nclexwww.pearsonvue.com/nclex *for more information

22. NCLEX-RN Success Web sites HESI exam as predictor – danger < 850 Review course or review books Level 4 exam scores predictor of specific areas

23. Test Taking Tips Study & practice (1 question per 60 to 70 seconds) Plan –Austin testing sites * ck link for available locations* ck link for available locations –Pearson Professional Centers-Austin, TX –Schedule carefully –Sleep, eat, take precautions to promote calm Strengthen testing strategies –Read carefully (1 to 2 min./item) –Think through but don’t read into question –Remember entry level for LVN and/or CNA or UAP –Text book not the patient you saw in clinical –Use your breaks to rest

24. What to Expect/Prepare Arrive 30 minutes early, if you are more than 30 min. late for testing, you will need to be rescheduled and pay fee again Come alone no children/family/friends waiting or calling No hats, scarves, coats, calculators, pencils, etc. permitted in testing area Bring –Authorization to Test (ATT) form – needed to schedule testing session – Name same as on ID –Valid non-expired Photo ID with your signature Finger print, Palm print, photo, & signature will be taken on admission to test and after breaks May take up to 6 hours to complete test - raise hand don’t get up –First optional break after 2 hrs. – palm vein imaging before and after breaks –Second is 90 minutes after test resumes Must use computer calculator 75 to 265 questions – 15 unscored Number of questions does not predict Pass/Fail –75 high pass or fail as computer determines trends Must answer each item to continue the test after (ENTER), can’t go back

25. What to Expect/Prepare Official results come from BON- up to 14 days after BON receives scores –Pay a small fee to get preliminary results in 24 hours. Retest every 45/90 days for 4 years in Texas Sec. 301.255 Re-examination. (Texas Occupations Code- BON may require additional educational requirements or deny retesting if test is failed 2 or more times.)

26. Jurisprudence Exam You must take the exam and pass it once to become an RN.You must take the exam and pass it once to become an RN. Cost of exam will be part of application fee and will be taken on your computer from the BON website.Cost of exam will be part of application fee and will be taken on your computer from the BON website. You may take it as many times as you need to for a passing score – q 7 days.You may take it as many times as you need to for a passing score – q 7 days. You will know if you passed upon completion – 75% is a passing score.You will know if you passed upon completion – 75% is a passing score. It will be open book from the NPA and it will be timed – 2 hours.It will be open book from the NPA and it will be timed – 2 hours. 50 Questions and will be knowledge and application. (Will not ask for specific section numbers of Nurse Practice Act but will test for understanding) 50 Questions and will be knowledge and application. (Will not ask for specific section numbers of Nurse Practice Act but will test for understanding)

27. Test Blueprint-Jurisprudence 5 subject areas with weight5 subject areas with weight –A. Nursing Licensure & Regulation in Texas –15% –B. Nursing Ethics –20% –C. Nursing Practice - 30% –D. Nursing Peer Review- 15% –E. Disciplinary Action – 20% Topic areas to guide review of content are available on the BON website.Topic areas to guide review of content are available on the BON website. BON has developed an online Test Review/Prep Workshop which costs about $25 and takes about 2 hours to complete. BON has developed an online Test Review/Prep Workshop which costs about $25 and takes about 2 hours to complete. · This course is accessed on the BON website after applying and obtaining a pin number from the BO· This course is accessed on the BON website after applying and obtaining a pin number from the BO

28. Guidelines for New Graduates/New RN’s What are the requirements that must be met to obtain a GN Verification Letter? Once granted, what are the limitations of practice placed on a GN using this privilege? Compare these limitations to those that the BON recommends for newly licensed RN’s.

29. Guidelines for New Graduate’s Employment GN verification letter issued after: –Completion of application for licensure –Criminal checks complete –Affidavit of graduation –Received your Authorization to Test –Registered with Pearson –NCLEX testing date set No outstanding eligibility issues 75 day period specified on GN Verification letter or results of first NCLEX attempt If first NCLEX is failed MUST stop GN practice Must know and follow Nurse Practice Act – Rules and Regulations

30. Graduate Nurse Requirements Temporary Authorization to Practice Must work under direct supervision of RN –RN physically available –RN at same site May not be in charge or supervising May not function in an independent setting May perform any function that falls within the scope of practice for which they have educational preparation and demonstrated minimal competency –Amount of supervision and charge positions should be mutually agreed upon –12-18 months experience in a structured setting before practicing in independent living environment –BON Rule 217.3 Recommendations After LicensureBON Rule 217.3

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

32. Continuing Competency (Sec. 301.303 – Occupations Code Completion of targeted cont. ed. Programs Professional portfolio including certifications May not require more than 20 hours CE per 2 year period Specific State Requirements- Please access CE Requirements BONPlease access CE Requirements BON –Hepatitis –Bioterrorism –Forensic Evidence Collection All CE’s – To count toward licensure renewal, a program must have been approved by one of the credentialing agencies recognized by the Board. The credentialing agencies have met nationally-predetermined criteria to approve programs and providers of CE. –RN planner –Approved by accepted credentialing agency –Class or individualized home study/programmed instruction A 3hr. academic nursing course (part of a degree plan taken for credit with grade C or better or a pass of pass/fail) counts for 15 hours ACLS, ATLS, and PALS, or national certification in a non-advanced nursing practice specialty (i.e. CCRN, RNFA, CWOCN, etc.) may be counted for CE credit In-services, CPR, Refresher courses do not count. Keep records for 4 years One CE hour = 60 minutes not 50 as in the past

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

34. Texas Administrative Code (216.1) - 2005 License Renewal every 2 years –End of Birth month and odd or even years based on birth year –Receive post card reminder 30 days prior (90 days if CE audit required) –Renew on line at BON web site & credit/debit card if meet all criteria No bars: delinquent student loans/child support, legal issues, Psych illness, drugs, and lack of required CE’s Application implies legal signature/testimony of meeting criteria and makes nurse legally responsible for accuracy. First renewal -access BON linkaccess BON link Continuing education required – not need 20 hours Six to 29 months after first issued depending on nurses date of birth.

35. Nursing Licensure Compact *access this site Nursing Licensure Compact *access this site Chapter 304 Rule 220 States participating in a Licensure Compact accept similar requirements for licensure. What is a nurse’s Home State and how does that relate to licensure? When a nurse practices in a party state whose laws and scope of practice guide the care provided by the nurse? Can the nurse simultaneously hold a home state license in more than one party state? Under what circumstance can the nurse hold a license in more than one state at the sam e time?

36. Nurse Licensure Compact States agreeing to recognize each others nursing licenses Texas among the first to adopt this plan - 2000 Premise: –Only defines the requirements to hold a license Similar licensure requirements in most states –Each state defines its own scope of practice –States share information related to problems Warnings Suspensions Licenses that have been revoked Imposters

37. States that have enacted the RN and LPN/VN Nurse Licensure Compact *access here for more information access here for more information Access here for current compact states 2013 Party States States who have adopted the compact Primary state of residence –(Home state) Where you permanently reside or your declared fixed permanent & principal home for legal purposes Remote state Where you practice using multistate privilege Must be a party state

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

39. Practicing in a Different State-answer questions 1.How is a nurse’s licensure impacted when he/she changes their permanent address from one state to another? Differentiate between movement from one party state to another as opposed to movement from a party state to a non-party (remote) state? 2.Can a nurse hold permanent residence on a party state and work in a remote state? 3.What are the requirements and limitations of a nurse licensed in a remote state when they wish to obtain a license to practice in Texas?

40. Practicing in a Non-Party State Must obtain a license from the non-party state May hold both a home state license and a license from the non-party state If you live in a non-party state –Must obtain a non-resident Texas license to practice in Texas Lose multistate licensure privilege in other party states Impact Compact Licensure States share information –Nurses licensed –Disciplinary action Protects public health and safety More mobile workforce for employers Allows nurses to be more mobile Provides for new forms of practice –Online practice –Telephone practice

41. Peer ReviewPeer Review *access here for information Incident-Based Peer Review Rule 217.19 And Safe Harbor Peer Review Rule 217.20

42. Determine Scope of PracticeDetermine Scope of Practice *access The Six Step Decision Making Model found in the back of Nursing Practice Act, Nursing Peer Review, Nurse Licensure Compact Rule 217.11 Standards of Practice and 217.12 Unprofessional Conduct –Provide baseline for safe and effective care –Establish minimal acceptable level –Identifies unprofessional behavior s

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

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

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

46. The Nurse’s Duty to Report Licensed care giver, agency, or facility – Exposing a patient to substantial risk of harm due to lack of minimum standard of nursing care Another nurse –Impairment, lack of minimum standard of care, unprofessional conduct, or unnecessary exposure of pt. to risk for harm Nursing student –Chemical impairment –Ability to perform professional service within reasonable expectations Must be in writing and signed Must include name of nurse or student and information required by the Board May take the report to the employer or school

47. Action Peer Review Committee/BON Problem reported to employer Proceedings are confidential If committee finds cause they must report to BON –Identity –Problem –Corrective action taken –Recommendation for BNE action

48. Minor Incidents - Rule 217.16 Describe a minor incident. When and how are they reported and to whom? What are the consequences of frequent minor incidents? What types of incidents are considered major? Continued practice doesn’t pose risk of harm to client(s) –Potential risk of harm is very low; Incident is singular –Nurse’s approach to practice is conscientious and accountable –Has knowledge and skill for safe practice 5 minor incidents in any consecutive 12 month period must be reported to Peer Review Committee –If no Peer Review Committee is available must report to BON

49. 217.12 Unprofessional Conduct Purpose: –Protect the public from Incompetent & careless Unethical Illegal conduct of nurses –Applies to any licensed nurse Required by law Identifies, assists, and monitors professional colleagues so they can work Experiencing mental health, alcohol or drug problems Problems impair or may impair job performance or safe care Peer Assistance Rule 217.13

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

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

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

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

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

55. Differentiated Practice Structured nursing roles based on: –Education –Experience –Competence Education based – different prep = different roles Assessment based – all facets, competency focused 20+ years of studies –Roles and compensation level delineated according to education level not widely used Basis of competency models –ANA’s standards of care with levels of practice –Novice to expert (RN 1 to RN 4) –Can be based on job description and evaluation

56. Regulatory Agencies BON Certification- government standards Accreditation - non-government standards –Medicare/Medicaid – federal standards –Accreditation – non - government JCAHO - hospitals CHAP – Community Health Accreditation Program Advisory Secretary of Health, Congress – National Advisory Council on Nurse Education and Practice –Workforce diversity –Cultural competency –Nursing shortage JCAHO – Nursing Advisory Council

57. Texas Nurses Association Mission: Promote excellence through leadership, advocacy, and innovation Advocate for nursing in the legislature Continuing education Updates on legal issues and legislation Interpretation of legal & BON changes www.texasnurses.org Advocates for Nursing Profession Defines ethical standards of practice for Profession –General RN –Specialty areas Provides avenue for nursing to be involved in national level of decision making AJN

58. The End