APRN Practice & Professional Advocacy in Texas

APRN Practice & Professional Advocacy in Texas
Lynda Woolbert, MSN, RN, CPNP-PC, FAANP APRN Consultant

Read notes in “normal” view
Overview APRN Consensus Model & LACE (Module I: Unit 1) APRN Practice in Texas, Scope of Practice & Licensure (Module I: Units 1 & 2) Prescriptive Authority (Module I: Unit 2) Texas Legislative & Regulatory Process (Module II) Advocating Effectively (Module II) Scope of Practice Review & BON Disciplinary Issues (Module I) CNAP & Texas Nurse PAC (Module II) Read notes in “normal” view

Why study APRN practice legislation & regulation now?
Must adhere to the law from the first day you practice as an APRN Evaluate & learn throughout clinical experiences Know resources to stay current Avoid being featured on 10 o’clock news as two NPs were for dispensing controlled substances to treat obesity. It is natural to wonder why you should study the laws and rules that govern APRN practice now when you are trying to acquire so many new clinical skills. APRN students must understand this content in order to apply the information from Day 1 when they begin practice. When you apply for your APRN license, you sign a statement that you read and understand the BON Rules. If you start now you can integrate that knowledge as you engage in your clinical courses. I hear from a lot of APRNs that have been out of school a year or two that they didn’t learn enough about these practice issues while in school. If you start observing APRN practices now during your clinical rotations, it will make it easier when you have to comply with the laws on your own. Like any other aspect of your practice, the laws that govern your practice (jurisprudence) change, and APRNs are legally obligated to stay up-to-date to comply with these laws. Knowing where to find jurisprudence information is essential. The most important reason to know the laws when you graduate is to avoid being featured on the 10 o’clock news (See Harwin Clinic video clip posted on BB Course Model I, Unit 1).

Consensus Model for APRN Regulation aligns Licensure, Accreditation, Certification and Education (LACE) The APRN Consensus Model called for aligning licensure, accreditation, certification and education to enhance public safety. The APRN Consensus Model is a required reading assignment and you will be test over this material. The APRN Consensus model is posted on the National Council of State Boards of Nursing (NCSBN) website. The purpose of the APRN consensus model is to ensure that all essential elements required for educating and licensing APRNs are in alignment so the public will have reasonable assurance that licensed APRNs meet established minimum standards for safe practice.

APRN Consensus Model: LACE
Accreditation Organizations Educational Programs Certification Organizations Boards of Nursing (BON is the state agency that licenses APRNs to protect the public.) It took a lot to begin the process to align all the essential elements in the process of educating and licensing APRNs. Accrediting organizations – Private organizations that determine if an organization or program meets certain standards. Just as the Joint Commission accredits hospitals, there are accrediting agencies for universities, programs of study within those universities (e.g., nursing) and certifying organizations. Certifying organizations – Private organizations that determine if individuals meet defined standards within a certain area of competence. Licensing boards - Governmental agencies empowered by the state’s legislative body to ensure public safety by regulating a profession, business or other activity. The steps in the process are: Accreditation – Appropriate accrediting organizations ensure that universities, APRN educational programs, and certifying bodies meet established standards. Even the accrediting bodies are accredited. Education– APRNs are educated in accredited master and doctoral programs that prepare the APRN with the basic knowledge and skills to practice safely at an entry-level in one of the designated APRN roles and population focus areas. Certification – APRNs take examinations that test entry-level knowledge essential for APRNs in the designated role and population focus area to practice. The certified APRN must then maintain certification and meet all the certifying organizations requirements for certification maintenance. The certifying body must be accredited and recognized by the state’s BON. Licensure – The state’s BON sets the minimum requirements for licensing the APRN in one or more of the APRN roles and population focus areas. The BON requires APRNs to graduate from an accredited master or doctoral level program that educates APRNs in the same role and population focus in which they will be licensed. The BON requires applicants for licensure to also be certified by a national certification organization the BON recognizes, and the certification must be in the same role and population focus area.

Consensus Model for APRN Regulation: Licensure
POPULATION FOCUS AREAS (FOCI) APRN ROLES Psychiatric Mental Health Adult Gerontology Acute or Primary Women’s Health (Gender Related) Women’s Health (Gender Related) Family (Lifespan) Pediatrics Acute or Primary Neonatal This is the portion of the Consensus Model for APRN Regulation that represents the licensure level of the APRN Regulatory Model. The four types or categories of APRNs are called APRN roles: CRNA, CNM, NP and CNS. The four APRN roles are further subdivided by their education within a specific population focus area. The population foci fall into six categories. A lot of APRNs ask what is the population focus for CRNAs and CNMs? All CRNAs and CNMs are educated to provide care across the lifespan. So it is the CNSs and NPs that must include their population focus area (family, adult-gerontology, neonatal, pediatrics, women’s health and psych-mental health) in their professional title. *Also note emergence of a new acronym for NPs. The model refers to certified nurse practitioners, CNPs. Texas does not yet use CNP in law or rules, but that could change when the BON adopts new rules in Chapter 221 in 2017 or early 2018. Nurse Anesthetist CRNA Nurse-Midwife CNM Nurse Practitioner CNP* Clinical Nurse Specialist CNS &

Licensing Titles CRNA CNM CNS NP AGCNS AGNP ACAGNP FCNS FNP NCNS NNP
PCNS PNP ACPNP PMHCNS PMHNP WHCNS WHNP How does the APRN licensing model translate into titles for specific roles and population foci? Since nurse anesthetists and nurse-midwives are educated across the lifespan, there are no population foci titles Clinical nurse specialists are educated across all settings so there are no acute care or primary care designations Nurse Practitioner population foci can be either acute care or primary care. Currently only adult-gerontology and pediatrics are educated and certified at the acute care and primary care levels

Scope of Practice (SOP)
Professional SOP – based on APRN education and certification SOP statements by professional organizations Personal SOP – based on personal competency State SOP – based on occupational licensing laws in the state Scope of Practice (SOP) is the most basic concept that APRNs must understand. There are 3 components that constitute each APRN’s SOP. Professional SOP - Because APRNs are educated, certified and licensed to treat a specific population of patients, their practices must stay within the boundaries of that APRN role and population focus area. The professional SOP is the broadest possible SOP for an APRN. Personal SOP - Most APRNs, however, are not competent in every possible aspect of the professional scope. Therefore an individual APRNs’ SOP is narrower, based on that individual APRN’s competencies. State SOP - The APRN Consensus Model recommends that every state allow APRNs to provide all services within their Professional and Personal Scopes of Practice (full practice authority). However, states, such as Texas, limit certain aspects of practice, such as requiring that physicians delegate authority for APRNs to prescribe medications.

Elements Determining Scope of Practice (SOP)
*Education *Certification Competency SOP is not determined by: Pre-NP specialization as an RN; or Setting While an employer may limit SOP, an employer can never expand SOP beyond that legally permitted. NONPF explains the difference between acute care and primary care is based on education and certification in a population, e.g., adult-gerontology acute care (AGAC), adult-gerontology primary care (AG), pediatric acute care (PAC), and pediatric primary care (P) (NONPF, 2012, p. 4). An additional element in determining SOP is personal competency to provide the care, treatment or service. SOP is not setting specific and there is overlap between the acute and primary care scopes of practice for any given population. The patient’s needs (e.g., whether stable or unstable) determine the type of NP prepared to treat the patient, not the setting in which the patient presents. Employers and physicians often do not understand SOP limitations. Sometimes the employer limits the NP regarding the treatment they may provide or impose additional physician supervision that would not be required by state law. While it is legal for employers to limit SOP, directions from an employer or physician is never an excuse to expand SOP beyond the NP’s education, certification and competency. If the task would be within the NP’s education and certification (legal scope of practice), then the employer and NP may work together so the NP becomes competent to provide the service. Source: NONPF. (2012). Statement on acute care and primary care certified nurse practitioner practice.

Scope of Practice References
BON Guidelines for Determining Scope of Practice with FAQs on Scope of Practice Professional organizations representing the APRN role and population focus. Examples AANP: scope and standards applicable to all NPs AACN: scope and standards applicable to acute care NPs NAPNAP: scope of practice for pediatric nursing from RN through primary care and acute care PNPs. The BON Guidelines for Determining Scope of Practice is a vitally important document that every APRN must know and understand. It is also important to be familiar with statements on scope and standards of practice established by professional organizations. While the BON is a state agency, the BON has authority to refer to standards developed by private professional organizations. An example is the BON’s Position Statement titled “The Role of the Nurse in Moderate Sedation.”

Review Certification and licensure: Know the difference.
What is the difference between certification organizations; professional organizations; and licensing boards? While most certifying organizations are an off shoot of professional organizations, accreditation standards require that certifying bodies are totally independent of any professional membership organization. For instance, the American Association of Nurse Practitioners (AANP) is a separate organization than the American Academy of Nurse Practitioners Certification Program (AANPCP). Professional organizations often set standards and outline the professional scope of practice for persons in the profession. Licensing boards, such as the Texas Board of Nursing, are governmental occupational licensing agencies that are part of each state’s executive branch government and are created by each state’s legislature to protect the public. The BON does NOT exist to help or promote nursing. Promoting nursing and helping nurses is the job of professional nursing organizations.

Statutory and Regulatory Basis of APRN Practice in Texas
This presentation primarily covers how APRNs are regulated on the state level. According to the U.S. Constitution, all powers not specifically granted the federal government are reserved by the states. One of those powers is occupational licensing and regulation. In our case, RNs and APRNs are regulated in Texas as part of Title III, Texas Occupations Code. That title of the Tex. Occ. Code governs health care professions.

Statutory – Laws passed by the state legislature (Nursing Practice Act) Regulatory – Rules passed by state agencies based on authority granted by the state legislature (BON Rules) The role of state governmental agencies or, in the case of the federal government, federal agencies is sandwiched between the legislative and executive branches of government. While state and federal agencies are part of the executive branch and ultimately answer to the governor or president, respectively, the authority under which the state or federal agency operates is granted through legislation enacted by the legislative branch.

What is the purpose of regulating health professionals?
Answer: Public Safety. Therefore the Texas Board of Nursing (BON) exists to protect the public. The BON does NOT exist to help or promote nursing. Promoting nursing and helping nurses is the job of professional nursing organizations.

Consensus Model for APRN Regulation
Role & population determine licensure. BONs do not regulate specialization. POPULATION FOCUS AREAS (FOCI) APRN ROLES Psychiatric Mental Health Women’s Health (Gender Related) Women’s Health (Gender Related) Family or Individual (Lifespan) Adult Gerontology Neonatal Pediatrics The authors of the APRN Consensus Model, including the National Council of State Boards of Nursing (NCSBN), decided not to license and regulate beyond the population foci level. Therefore, specialties are not regulated by state nursing boards (BONs). There are certifying organizations that certify individuals at the specialty level, but certification exams that a state agency deems acceptable as a requirement for licensure are always at the entry level. Clinical Nurse Specialist CNS Nurse Practitioner (Acute or Primary) CNP* Nurse-Midwife CNM Nurse Anesthetist CRNA Neonatal

Advanced Practice Titles in Texas BON Rule 221.2
Nurse Anesthetists (CRNAs) Nurse-Midwives (CNMs) Nurse Practitioners (NPs) Clinical Nurse Specialists (CNSs) The four categories of APRNs in Texas follow the consensus model. Read the brief descriptions of each role on the National Council of State Boards of Nursing (NCSBN) website, and be able to apply that information to questions about each of the APRN roles. It is important to note that not all states include all four of these categories in advanced practice, and that some states use different terms to describe advanced practice. The Texas Legislature and BON changed the old term “Advanced Practice Nurse (APN)” to “Advanced Practice Registered Nurse (APRN)” and APRN is now a licensure title. However, there is conflict between the statute and BON Rules that is discussed in detail later in the presentation. It is interesting to note that the last advanced practice nursing role to develop was the nurse practitioner. The first was nurse anesthesia that has its roots in the Civil War when nurses first delivered anesthesia on the battle fields. Nurse-midwives came to the U.S. from England in the 1920s, and master’s programs educating clinical nurse specialists were developed in the 1950s. The first nurse practitioner program emerged in Colorado in It was a certificate program (not master degree) that trained RNs to be pediatric nurse practitioners. NCSBN. (2014). APRNs in the U.S.

BON Rules & Regulations for APRNs
§ 219 APRN Education § 221 APRN Licensure and Practice (expect revisions in ) § 222 Prescriptive Authority (new rules adopted November 15, 2013)

Population Foci Titles
Nurse Practitioners Acute Care Adult Acute Care Adult/Gero Acute Care Pediatric Adult Adult/Gerontology Family Gerontological Neonatal Pediatric Psychiatric/Mental Health Women’s Health Clinical Nurse Specialists Adult Health / MS Adult/Gerontology Community Health Nursing Critical Care Nursing Gerontological Nursing Pediatric Nursing Psychiatric/Mental Health Nursing. The BON is revising Chapter 221 to bring Texas fully into compliance with the APRN Consensus Model to the extent it is within the BON’s statutory authority to do so. One of the changes within their authority is to determine the titles of APRNs it will license. The adult and gerontological specialties will be eliminated in when new rules in Chapter 221 are adopted in late 2017 or early The adult/gerontology primary and acute care foci are being granted based on an October 2013 BON policy. Access the policy at

Advanced Practice Titles in Texas BON Rule 221.2
Current Rule - Advanced Practice Registered Nurse (APRN) is umbrella term and not a title to use after your name. NPA was amended in 2013, and BON issues APRN licenses. When BON revises rules in Chapter 221, BON will propose licensure and titling consistent with the Consensus Model.

BON Rules & Regulations for APRNs
§ 219 APRN Education § 221 APRN Licensure and Practice § 222 Prescriptive Authority REMEMBER… All BON Rules apply to APRN practice.

All BON Rules Apply to APRNs
Particularly Note: Chapter 217 § Standards of Nursing Practice § Unprofessional Conduct § Registered Nurses Performing Radiologic Procedures § RNs that First Assist at Surgery

First Assisting at Surgery
§ requires RNs that first assist: Complete a RNFA program (listed on CCI Website, CNOR certified; or APRN licensed - Limits RNFA scope to APRN Population Focus. If a job should ever include first assisting at surgery, you must meet the requirements in Section if you, or any other entity, is billing for your services as a first assistant. Please note that if you are not CNOR certified by the Competency & Credentialing Institute (CCI), and you are first assisting as an APRN, then you will be limited to first assisting on cases within your population focus area. All RNs and APRNs must complete an RNFA program in order to bill for first assisting services. It can be challenging for APRNs without previous surgery experience to find an RNFA program that will accept them. Unfortunately, Angelo State University no longer offers its RNFA Certificate Program that was specifically designed for APRNs with no previous OR experience.

ALL BON Rules Apply to APRNs
In addition to Chapter 217, Note: Chapters 216, 224, and 228 Chapter 216 – Continuing Competency Chapter 224 – Delegation to unlicensed personnel in acute care setting Chapter 228 – Pain Management Rules BON identifies as particularly relevant to APRNs are listed on the Advanced Practice Information webpage.

Other BON Resources Position Statements
Texas Board of Nursing Bulletin APRN Practice webpage In addition to listing specific rules that are particularly important for APRNs to understand, the BON’s advanced practice information webpage lists position statements that directly apply to APRNs. This is a webpage that you should bookmark.

BON Rules require RNs follow all state & federal rules that apply to their practices.
Examples: Texas Medical Board (TMB) Texas State Board of Pharmacy (TSBP) Texas Health & Human Services Commission – Medicaid & CHIP Federal Center for Medicare & Medicaid Services (CMS) Even though the BON regulates APRNs, other state & federal agencies have a role in determining APRN practice. * BON Rules make APRNs accountable for all state & federal statutes and rules that apply to their practices (BON Rule [1]). The following are examples. All the rules about the supervisory activities a physician must perform when delegating prescriptive authority are in the TMB Rules. The HHSC is the sole agency responsible for administering the Texas Medicaid program, so go to those rules to find the standards you must meet to be reimbursed by Medicaid. While the Medicaid program is administered individually by each state, the Medicare program is administered by the federal government. The agency responsible for Medicare is CMS, the Centers for Medicare & Medicaid Services (formerly HCFA), so go to CMS rules and website to learn about Medicare requirements, including documentation requirements for reimbursement.

APRN Licensure & Renewal

APRN Licensure in Texas BON Rule 221.4
2nd license in addition to RN license APRN license – AP###### Verify APRN license on BON website New application required for each role and/or population focus Requirements New graduate and national certification; or 400 hours practice and current national certification This is an overview of the Texas Board of Nursing’s requirements for APRN licensure While this is not the case in all states, Texas BON decided that APRN licensure should be a separate, second license and that all APRNs in Texas must also maintain their Texas RN license or an RN license from a state that is a party to the Interstate Nurse Licensure Compact. The APRN license number begins with AP standing for “advanced practice” and is followed by six numbers. The public may verify an APRN’s license, including the APRN’s role and population focus area/s on the BON website. If the APRN has prescriptive authority, that is also noted. Sometimes APRNs licensed in one role and/or population focus area decide they want to expand their practice and take a post-master’s program in a new role or population focus area. After graduation the APRN must go through the same process as any other new graduate in applying to the BON for authorization to practice is the new role or population focus area. The APRN must also apply for prescriptive authority in that role and population focus area. Requirements for initial licensure include practice and national certification components. If, at the time of initial APRN licensure or license renewal, the APRN graduated from the educational program less than 2 years ago, then the APRN is not required to have 400 hours of clinical practice. APRNs graduating 2 years before or more, are required to have completed at least 400 hours of clinical practice in the previous 2 years. In addition, the APRN must maintain certification. The APRN Consensus Model requires initial certification in the appropriate role and population focus area as a requirement for initial APRN licensure, and requires certification maintenance for license renewal. The Texas BON has the same certification requirement for licensure and renewal.

New Graduate APRN License (BON Rule 221
New Graduate APRN License (BON Rule 221.4) with Prescriptive Authority (BON Rule 222.2) Complete & submit licensure and Rx Authority applications (online preferred); Submit additional documents; Pass a certification exam recognized by the BON; and Notify BON Receive APRN License & verify Rx Authority Number online. This is an overview of the process for new APRN graduates to become licensed. When applying to a certification organization to take an exam, most will ask if you want the BON notified of test results. I recommend you grant permission because it can expedite the licensure process. However, as noted in Step 4, I also recommend you notify the BON of the results. Remember that passing the certification exam is only one step in the licensure process. You must receive notice from the BON that you are licensed or see the online verification. The APRN does not have to wait for the BON’s letter to start practicing if the BON posts the online verification first. The BON does not notify APRNs when prescriptive authority is granted. The APRN must verify this online.

Remember Until BON notification or verification on BON website of full APRN licensure, Do not use APRN skills except under direct supervision; and Do not use or claim an APRN title (including Graduate FNP, etc.) Direct supervision means there must be a physician or an APRN, whose scope of practice covers the same population, and the physician or APRN also sees the patient.

Remember Do not sign a prescription until:
Prescriptive authority number is verified on BON website, and Physician delegates prescriptive authority & signs Prescriptive Authority Agreement (PAA) or Facility-Based Protocols (as applicable to the type of practice). Prescriptive Authority Agreements and Facility-based Protocols are the documents through which physicians delegate prescriptive authority and other medical acts to APRNs or PAs in Texas. These documents, and the practice situations in which they are applicable, are discussed in more detail in the prescriptive authority section of the presentation.

Interim Approval (Not an option for new graduates and no interim approval is consistent with Consensus Model) BON Rule 221.6 Short term approval until all documents received and reviewed. Up to 120 days, no extensions Interim approval granted only 1 time per APRN role & population focus area No prescriptive authority The APRN Consensus Model does not allow any type of interim approval. The BON eliminated interim approval for new graduates unless they already passed the certification exam and, therefore, eligible for full APRN licensure. We anticipate Interim Approval will be eliminated when new Chapter 221 Rules are adopted, probably sometime in

Applicants for Texas APRN License Currently Licensed in Other States
Must have unencumbered Texas RN license or be a resident of a RN Licensure Compact state with a privilege to practice in other Compact states No interstate APRN Compact option - must complete the full application process for Licensure and Prescriptive Authority BON expected to eliminate option for Interim Approval in While the NCSBN adopted the revised APRN Compact model legislation and rules (a version consistent with the APRN Consensus Model) in May 2015, it will probably be several years before APRNs will be able to practice temporarily in another state without having APRN licensure or authorization in that state. Until three things happen APRNs must be licensed or authorized to practice in each state, before caring for any patients, even if those patients are being seen through telehealth rather than through a face-to-face visit. Texas adopts the new model legislation; Nine other states also adopt the model legislation; and the APRN compact administrators implement the APRN Compact. After the APRN Compact is implemented, APRNs will still have to apply for and receive prescriptive authority in each state because of the state-to-state variations in prescriptive authority. The APRN Consensus Model does not include interim approval. Therefore, when the BON revises the rules in Chapter 221 to be consistent with the consensus model, and adopts those changes, the BON will probably no longer grant any form of interim approval prior to full licensure to practice.

Maintaining APRN Licensure BON Rules 216.3 & 221.8
Renew APRN license in conjunction with RN license attesting requirements were met. Current national certification in the role & population focus area; 400 hours of current practice; 2 hours jurisprudence/ethics CE in past 6 years; 2 hours of CE in caring for older adults; and APRNs with Rx authority must have 5 hours of pharmacotherapeutics CE within the past 2 years . Those with Rx authority for controlled substances (CSs), need an additional 3 hours related to CSs. Know APRN licensure and licensure renewal requirements. Note that while the 2 CE hours for jurisprudence/ethics are only required every 6 years, the 5 CE hours for pharmacotherapuetics (for APRN who has prescriptive authority) and 3 hours on controlled substances (for any APRN who prescribes or orders CSs) must be completed every 2 years. Virtually all RNs must complete 2 hours of CE pertaining to older adults each 2-year licensure cycle. While this CE is required for “RNs whose practice includes the older adult or geriatric population to have CE in the care of older adults applies to almost all RNs” BON staff has stated in workshops that even nurses specializing in pediatrics should meet this requirement if they have any contact with older adults in the course of their practice (BON, 2013). BON. (2013). Education – Continuing nursing education & competency. Retrieved from

How to Sign Your Name (current rules)
“RN” identifies licensure Identify APRN role & population focus, e.g. FNP, ACNP, CNM, ACNS Multiple APRN role / population foci -- use the title that applies. Lynda Woolbert, RN, PNP Lynda Woolbert, MSN, RN, CPNP-PC

Likely Signature Requirements in 2018
RN or APRN could identify licensure. Identify APRN role & population focus, e.g. FNP, ACAGNP, AGNP Multiple APRN role / population foci -- use the title that applies. Lynda Woolbert, APRN, PNP Lynda Woolbert, MSN, APRN, CPNP-PC When the BON updates Chapter 221 in , it has two options for the way it requires APRNs to signify licensure. 1) It can allow the option of using either RN or APRN to signify licensure; or 2) The BON may require advanced practice registered nurses to use APRN to signify their licensure. Until the BON adopts a new titling rule, all APRNs identify their licensure as “RN”. In accordance with current statute but not BON rules

APRN Practice: Autonomous vs
APRN Practice: Autonomous vs. Delegated Elements of APRN Scope of Practice in Texas

Delegation Transferring authority from one person to another
Delegation always implies supervision Ordering a service to be provided by a licensed individual is NOT delegation. Physicians have broad delegatory authority. RNs and APRNs have limited delegatory authority based on BON Rules in Chapters 224 and 225. Delegation is a concept that is frequently misunderstood and frequently confused with assigning a task. Often physicians, and even nurses, think that when they write an order for a RN or LVN to administer a medication, they are delegating authority to administer the drug. That is incorrect. RNs and LVNs are licensed and it is part of their scope of practice to administer drugs ordered by physicians and other practitioners who have prescriptive authority. The physician or APRN does not supervise the RN or LVN who is giving the drug. Delegation applies to transferring authority from a person with independent authority to someone without independent authority. That concept does not apply to licensed individuals who are acting within the scope of their authority unless there is a law that says a specific task must be delegated.

APRN Practice: What is Autonomous?
Assessments Histories & physical exams Ordering diagnostic exams Interpreting diagnostic tests Recommending OTC Drugs Establishing treatment plans in the APRN’s scope of practice (excludes Rx & other functions specifically requiring physician delegation) Referrals, Consultation, Coordination of Care Autonomous means the APRN is performing the task under the APRN’s own licensure authority and scope of practice. No physician delegation is necessary. APRNs may perform histories and physical exams and order laboratory tests, radiologic exams and other diagnostic procedures. The BON sees those functions as nursing assessment on the advanced practice level, and therefore do not need to be delegated in protocols or a prescriptive authority agreement. The list on this slide is not an all inclusive. For instance, a CNM may care for the pregnant woman and attend the woman during delivery. All of that is in the CNM’s independent scope of practice. Autonomous acts for an RN (e.g., assessment, referrals, consultation and coordination of care) are always autonomous acts for APRNs. The term independent can also signify acts that are within the individual’s scope of practice, but many people confuse this with APRNs owning their practices. All health care providers rely on consultation and referral to adequately treat their patients. Therefore, no health care provider truly practices independently. Therefore, autonomous is the preferred term.

Texas APRN Practice: What is Delegated?
Based on definition of Professional Nursing in the NPA & no exclusion for APRNs Medical diagnosis; and Prescribing & ordering drugs, medical devices and durable medical equipment are delegated. Based on Provisions in Other Texas Laws Signing medical verifications for disabled parking placards Ordering Orthotics and Prosthetics Medicaid Rules can Limit Scope of Practice Physician delegation may be specifically required in some Texas laws or it may be based on scope of practice limitations in the Nursing Practice Act (NPA). The following is the definition of professional nursing in the NPA. (2) "Professional nursing" means the performance of an act that requires substantial specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of professional nursing. The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures [emphasis added]. Professional nursing involves: (A) the observation, assessment, intervention, evaluation, rehabilitation, care and counsel, or health teachings of a person who is ill, injured, infirm, or experiencing a change in normal health processes; (B) the maintenance of health or prevention of illness; (C) the administration of a medication or treatment as ordered by a physician, podiatrist, or dentist; (D) the supervision or teaching of nursing; (E) the administration, supervision, and evaluation of nursing practices, policies, and procedures; (F) the requesting, receiving, signing for, and distribution of prescription drug samples to patients at practices at which an advanced practice registered nurse is authorized to sign prescription drug orders as provided by Subchapter B, Chapter 157; (G) the performance of an act delegated by a physician under Section , , , or [emphasis added]; and (H) the development of the nursing care plan. Because the definition specifically denies medical diagnosis and ordering drugs and corrective measures and no exclusion exists in that definition or in a definition of advanced practice nursing, that means diagnosis and prescribing are physician delegated. That is further confirmed in the Medical Practice Act in Sections , granting the authority of physicians to delegate prescriptive authority. The Transportation Code, Section (f)(2), restricts verifying first applications for a temporary parking placard to physicians and those with delegated prescriptive authority. the Orthotics and Prosthetics Act (Section (14) and (18), Texas Occupations Code) states these services may be ordered by “a licensed physician, chiropractor, or podiatrist, or an advanced practice nurse or physician assistant acting under the delegation and supervision of a licensed physician as provided by Subchapter B, Chapter 157, and rules adopted by the Texas Medical Board…” The Texas Medicaid Program, operated under the rules of the Texas Health and Human Services Commission, also limits certain services that APRNs may order or provide for patients if the services are to reimbursed by the Texas Medicaid Program. From a practical standpoint, this may prevent the APRN from providing the services, or more commonly, just requires that the physician signs the form or order. The same thing happens in the Medicare Program and even private health insurance plans. These are examples of how payers can limit scope of practice beyond limitations that are imposed by statutes that directly govern APRN practice.

Medical Aspects of Care BON Rule 221.13 (d)
Medical Aspects of Care are acts that require physician delegation through a written document. Either a: Prescriptive Authority Agreement (PAA); or In facility-based practice, Protocols or other written authorizations (standing medical orders, standing delegation orders, or other order or protocol) BON Rule § states that medical aspects of care require mechanisms granting authority for the APRN to perform the care. Many people find the term “medical aspects of care” to be confusing. The term includes all of the functions listed on the slide that lists delegated acts. The mechanism granting authority to provided the aspects of care must be a PAA or, in a facility-based practice, a protocol or other written authorization. For instance, delegation of a medical diagnosis just requires a simple statement in the Facility-based Protocols or Prescriptive Authority Agreement (PAA) stating, “Mary Smith, FNP, may make a medical diagnosis within her scope of practice.” Developing a PAA authorizing ordering or prescribing drugs and medical devices includes minimum requirements that are discussed in the slides on prescriptive authority.

What are the physician’s liability implications for delegated acts?
Except when subject to other provisions in the law and/or mitigating circumstances, the professional delegating responsibility is liable. The Medical Practice Act (statute) and TMB Rule include a partial exemption for physicians delegating prescriptive authority. TMB Rule 193.5(b) states: “…delegating physicians remain responsible to the Board and to their patients for acts performed under the physician's delegated authority.” A section in the Medical Practice Act (§ , Texas Occupations Code) offers physicians some liability protection when they delegate prescriptive authority. It states: Sec PHYSICIAN LIABILITY FOR DELEGATED ACT. Unless the physician has reason to believe the physician assistant or advanced practice registered nurse lacked the competency to perform the act, a physician is not liable for an act of a physician assistant or advanced practice registered nurse solely because the physician signed a standing medical order, a standing delegation order, or another order or protocol, or entered into a prescriptive authority agreement, authorizing the physician assistant or advanced practice registered nurse to administer, provide, prescribe, or order a drug or device. While the Texas Medical Board (TMB) Rule §193.6(a) includes a very similar statement to the one above, subsection (b) of the rule undermines the partial exemption by stating: (b) Notwithstanding subsection (a) of this section, delegating physicians remain responsible to the Board and to their patients for acts performed under the physician's delegated authority. In summary, a physician who delegates prescriptive authority as some liability protection if the physician can show no direct involvement in the patient’s case and demonstrates supervision that meets all legal requirements. Liability is always based on the facts of a particular case, so APRNs should never assure physicians that they will not be liable if they delegate prescriptive authority.

When performing medical aspects of care, is the APRN practicing medicine or nursing?
All health care professionals have overlapping scopes of practice. Professional practice acts recognize this by including a provision exempting other health professionals. When a nurse performs “medical acts,” the nurse is practicing NURSING. It is not uncommon for APRNs, usually NPs, to say they practice medicine because they perform some of the same functions and procedures as physicians. Making this type of claim is wrong and it is dangerous to the integrity of APRN practice. If we claim to be practicing medicine, we cannot legitimately avoid being regulated by the Texas Medical Board where we would forever be subject to physician supervision like physician assistants (PAs). All health care professionals having over-lapping scopes of practice. For example, when a CRNA provides anesthesia, the CRNA is practicing nursing. When a physician is providing anesthesia, the physician is practicing medicine. The fact that one is practicing nursing and the other is practicing medicine does not make one more or less competent than the other. Can you think of other examples of over-lapping scopes of practice among professionals?

Overlapping Scopes of Practice
NP · PA · MD · DO Pharmacists Therapists Dentists Optometrists Radiology Techs, etc…. This list includes examples of health care providers that have overlapping scopes of practice to varying extents, but this list is not exclusive. All health professionals have scopes of practice that overlap in some way. All health professionals have SOPs that overlap in some way.

Facts about Physician Assistants (PAs)
Regulated by the Physician Assistant Board Licensing Statute is in Medical Practice Act (Subtitle B, Chapter 204, Texas Occupations Code). PA rules are in Chapter 185 of the TMB Rules. Education is similar to 3rd year medical school. Scope of practice is based on supervising physician. All aspects of PA practice are delegated by the supervising physician. In Texas, PA & APRN prescriptive authority are identical. The Physician Assistant (PA) Board is one of three health care professional boards that operate as part of the Texas Medical Board (TMB). Both the PAs and acupuncturists have their own boards and staff in charge of licensing their professions, but they are part of the TMB, and the rules for those professions are in the TMB Rules. If you wish to learn more about the ways in which NPs and PAs roles in hospitals overlap, refer to the applicable section in Chapter 6 of A Guide for APRN Practice in Texas, 5th ed. The following research article is also informative. Kartha, A., Restuccia, J. D., Burgess, J. F., Jr., Benzer, J., Glasgow, J., Hockenberrry, Kaboli, P. J. (2014). Nurse practitioner and physician assistant scope of practice in 118 acute care hospitals. Journal of Hospital Medicine,9, doi: /jhm.2231

Terminology Referring to APRNs & PAs
Best to call professionals by their names, e.g., Nurse Practitioner Physician Assistant When a collective term is used: Avoid mid-level provider or practitioner Exception: DEA and DPS Better: Advanced Practice Providers (APP) or advanced practice practitioners. APRNs and PAs provide treatment that must meet the same standards as treatment provided by a physician. To call APRNs and PAs mid-level providers implies that their services are inferior to that provided by a physician. APRNs and PAs should not support this type of terminology by using it themselves. They should also take every opportunity to discourage its use by others. There are existing laws that use that term, or a variation. The federal Drug Enforcement Agency and, consequently, the Texas Department of Public Safety, use the term midlevel practitioner in the rules for obtaining federal and state controlled substances registration numbers. (It should be noted that starting on September 1, 2016, the DPS will no longer issue Controlled Substances Registrations, and the Texas State Pharmacy Board (TSBP) will assume regulation for all aspects of prescribing controlled substances previously regulated by DPS.) If a collective term for APRNs and PAs is used, advanced practice providers or advanced practice practitioners (APPs) is preferred. Most of the larger hospitals that employ both APRNs and PAs are using APP as the collective term.

Prescriptive Authority in Texas
Nursing Statutes: Sections & , NPA BON Rules: Chapter 222 Medical Statutes: Sec – , MPA TMB Rules: – and Applicable Definitions in TMB Rule 193.2 All of the information about prescriptive authority is contained in Board of Nursing Rule 222 and in Texas Medical Board Rules (certain definitions applying to prescriptive authority delegation), and – Chapter 193 contains rules on a physician’s general authority to delegate and delegation to pharmacists. It is important for APRNs to know which sections are specific to a physician’s authority to delegate prescriptive authority to APRNs. It is not uncommon for employers, and sometimes even attorney’s, to misapply the general delegation regulations by assuming the same restriction and physician supervision is required for APRNs. Therefore, APRNs must explain which regulations apply to their practices and which do not.

Definitions Prescribing vs. Ordering
Prescription filled at outpatient pharmacy Must have prescriptive authority to sign a Rx Includes orders written in long-term care facilities Ordering Medications dispensed from inpatient pharmacy for administration Must be consistent with facility policy and “Protocol, PAA or other written authorization” As of November 1, 2013, when S.B. 406 went into effect, the law specifies that physicians must delegate both ordering and prescribing drugs and medical devices. However, there is still a difference between the two and APRNs should understand the legal distinction (Tex. Occ. Code §§ [24. “Medication order”] and [37. “Prescription drug order”]).

Definitions Two Broad Drug Categories in Law
Dangerous Drugs - Drugs & medical devices that require a prescription, excluding controlled substances. Controlled Substances (with limitations) – Drugs deemed to have abuse potential and subject to additional regulation. Controlled substances are divided into 5 schedules. Drugs and medical devices are subject to both federal and state laws. In Texas, the term, dangerous drug, is defined in the Dangerous Drug Act (Chapter 483, Texas Health & Safety Code) and Controlled Substance is defined in the Texas Controlled Substances Act (Chapter 481, Texas Health & Safety Code).

Controlled Substances (CSs)
Schedules are based on abuse potential & medical use. I - highest abuse with no medical use II - high abuse with recognized medical use III - moderate abuse potential IV - moderate to low abuse potential V - some abuse potential Schedules III-V subject to less regulation than Schedules I and II. Because drugs in Schedule I do not have a recognized medical use, they are not prescribed by practitioners. The only exception in a few states is marijuana. Schedule I drugs encompass illegal street drugs and possession is only permitted for research and by law enforcement.

A Universal Limitation on APRN Prescriptive Authority
Scope of Practice In any state, prescriptions are limited to the scope of practice authorized by state law and the state’s board of nursing. There is one limitation on prescriptive authority that doesn’t just apply to Texas. Even in states with independent prescriptive authority, where practice is consistent with the APRN Consensus Model, APRNs can only prescribe within their scopes of practice (i.e., appropriate to the APRN’s role and population focus area). An adult-gerontology nurse practitioner cannot prescribe for an infant or child. If your education didn’t include prescribing certain types of drugs, you cannot prescribe them for your patients. The fact that APRNs always practice within the limits of their education and experience, makes them very safe health care providers, and it is absolutely vital for the public safety and our profession that every advanced practice registered nurse understands the limits of their professional and personal scopes of competence.

Limitations on APRN Rx Authority in Texas
Delegated & Supervised No Schedule II Controlled Substances in most practices If you think in terms of how prescriptive authority is limited for APRNs, it boils down to 2 major components. * It is delegated. In other words just because the BON grants you a prescriptive authority number, it does not mean that you may start prescribing for patients. That authority must be delegated to you by a physician. * Before November 1, 2013, a physician could only delegate prescriptive authority to APRNs and PAs practicing in a qualifying site, and the APRN or PA could only write prescriptions when practicing in that particular site. Physician supervision requirements varied based upon the type of practice site. S.B. 406 eliminated that major restriction and simplified physician supervision. * Limitations on prescribing controlled substances remain. However, for the first time in Texas APRNs and PAs treating hospice patients or in certain hospital facility-based practices will be permitted prescribe or order Schedule II Controlled Substances.

MD may delegate ordering & prescribing:
Dangerous Drugs – Any category Controlled Substances (CS)- Limitations Schedules III – V 90-day Rx (or refills equal 90-day supply) Prior authorization required for: Refills beyond 90-days Any CS for Children Under 2 yrs. Schedule II to APRNs treating: patients in hospital ER (APRN must be facility-based) Inpatients (APRN must be facility-based); or Hospice patients Physicians have been able to delegate prescriptive authority to APRNs and PAs in medically underserved areas since But that authority was limited to dangerous drugs only, meaning that APRNs and PAs could not prescribe any controlled substances. If you needed a controlled substance for your patient, you either had to find a physician to sign the prescription or call the doctor and get permission to call the prescription to the pharmacy as the physician’s designated agent. However, in the 2003 legislative session, medical organizations finally agreed to allow physicians to delegate prescriptive authority for controlled substances, with certain limitations. Physicians can delegate Schedules III – V and that includes most of the drugs for moderate pain or severe cough, as well as the benzodiazepines to treat anxiety. The maximum duration of a prescription was increased from 30-days prescription with no refills to 90 days in If a refill is required beyond the initial 90 day supply, you must consult with the physician, and the consultation must be noted in the chart. So if a PMHNP, for instance, is seeing a patient and needs to prescribe a benzodiazepine on a continuing basis, it is probably going to be best to have the physician sign that prescription so refills can be put on the prescription. *Also note that APRNs are not allowed to prescribe controlled substances for any child under 2 years without consultation. *Most APRNs and PAs are still limited to prescribing only Schedules III-V. However, in 2013, SB 406 began permitting facility-based APRNs and PAs treating ER patients or inpatients admitted for a stay of 24 hours or more to prescribe or order Schedule II drugs, if delegated by the physician. However, pharmacists are only allowed to fill a Schedule II prescription signed by an ARPN or PA in that hospital’s outpatient pharmacy (BON. [2015]. FAQs – APRN: Prescriptive authority FAQs related to SB 406). The only non-facility based APRNs permitted to prescribe or order Schedule II drugs (e.g., morphine, Demerol, or most stimulant drugs to treat ADHD) are those treating hospice patients.

Rx Authority Delegation
MD or DO Witten delegation document: Protocol if facility-based; or Prescriptive Authority Agreement (PAA). Physicians register APRNs & PAs to whom they delegate Rx authority through a PAA. Physician & APRN must keep records until 2 years from the date the PAA is terminated. FAQs may be accessed at either the BON or TMB websites. Resources: CNAP’s Sample Prescriptive Authority Agreement CNAP’s Sample Facility-Based Protocols A Guide for APRN Practice in Texas FAQs on TMB and BON Websites

Prescribing Controlled Substances (CSs) DPS and DEA Registrations
Must have delegated prescriptive authority for CSs. Before 9/1/16, request permit application from Texas Department of Public Safety (DPS) Physician must register delegation for CSs with TMB Physician must sign DPS CSs registration application Apply for DEA# online Report DEA # to DPS until 9/1/16; then TSBP. This slide lists the requirements the APRN must meet before signing a prescription for a controlled substance. The address registered with the DPS and DEA is the practitioner’s primary practice location. The only practitioners required to register multiple locations are those in charge of the CSs. In 2015, the Texas Legislature passed SB 195. It eliminate the requirement for practitioners prescribing controlled substances to register with the State of Texas (i.e., eliminates the DPS #). It transfers authority for the Prescription Drug Monitoring Program (CS prescription tracking) to the Texas State Board of Pharmacy (TSBP). TSBP proposed new rules on prescribing controlled substances in the December 18, 2015 issue of the Texas Register. These rules will be effective on September 1, 2016, and will reside in a new Chapter 315 (22 TAC §§315.1 – ).

Rx Authority Review An APRN from a nurse licensure compact state is going to practice in Texas for four months. What licenses must the APRN have before prescribing dangerous drugs in Texas? (Check all that apply) a) Texas APRN license b) Texas APRN prescriptive authority number c) Texas DPS Controlled Substances registration d) Texas RN license Synthesizing the information learned about licensing APRNs and the information just presented about prescribing, how would you answer this multiple answer question? Answer: A and B The APRN does not need a DPS or DEA controlled substances registrations because the APRN is only prescribing dangerous drugs. The APRN does not need a Texas RN license because the requirement for an RN license is fulfilled by having a license in an interstate nurse licensure compact state.

Texas Prescriptive Authority Law
Special Practice Designations exempt practices from certain restrictions Do not submit site changes to BNE or the Texas Medical Board (TMB) While site-based prescriptive authority was eliminated in 2013, in order to avoid having some aspects of supervision more restrictive in certain settings than it was prior to implementation of SB 406 (Acts of the 83rd Texas Legislature), some practice designations were retained.

Prescriptive Authority
Two Types of Practice Designations Practice serving a medically underserved population Facility-based practice or site These are practice designations that permit the delegating physician certain exemptions or variations that do not apply to any other physicians delegating prescriptive authority to APRNs or PAs.

Medically Underserved
Medically Underserved Population (MUP) Definition Federally designated HPSA, RHC, FQHC Public health or family planning clinic under contract with HHSC or DSHS Designated by DSHS (Health Professions Resource Center) Titles V, X, XVIII, XIX, XXI Federal funding or state-funded County, state or federal correctional facility Any practice designation as a site serving a MUP prior to March 1, 2013. Students must be able to recognize practices that qualify as a MUP. HPSA – Health Professional Shortage Area RHC – Rural Health Clinic FQHC – Federal Qualified Health Center HHSC – Texas Health & Human Services Commission DSHS – Texas Department of Health Services Title V funding – Maternal and Child Health Title X funding – Family Planning Title XVIII – Medicare Title XIX – Medicaid Title XXI – Children’s Health Insurance Program (CHIP)

Medically Underserved
PAA requirements same as other sites Advantage - No physician to APRN/PA ratio Physician limited to delegating at no more than 3 MUP practices = 150 hrs./wk.

Facility-Based Sites Licensed Hospital Long-term Care Facility
Only delegated by certain physicians Limited to 1 hospital (under facility- based hospital provisions) Long-term Care Facility Only delegated by medical director Limited to 2 facilities Find the definition and rules on facility-based practices in BON Rule and TMB Rule Only certain physicians may delegate prescriptive authority through the facility-based provisions. In a hospital the physicians who may delegate under the facility-based provisions include the following: medical director or chief of medical staff of the facility in which the physician assistant or advanced practice registered nurse practices, the chair of the facility's credentialing committee, a department chair of a facility department in which the physician assistant or advanced practice registered nurse practices, or a physician who consents to the request of the medical director or chief of medical staff to delegate prescriptive authority in the facility. Remember: Because of fewer restrictions, authorities usually recommend delegating prescriptive authority and other medical acts through Protocols in facility-based practices, rather than a PAA.

Facility-Based Sites: Advantages
Licensed Hospital No delegation ratio May use protocols or PAA Long-term Care Facility 1 physician to 7 APRN/PA ratio (no advantage) Physicians delegating under facility-based provisions may delegate to 7 additional APRNs/PAs through a PAA. The advantages of delegating prescriptive authority under the facility-based provisions are noted in bold print. While physicians are limited to delegating under the facility-based provisions in only one hospital or two long-term care facilities, the law allows these physicians to also delegate prescriptive authority under the Prescriptive Authority Agreement provisions to additional APRNs and/or PAs in other facilities or practices.

Protocols BON Rule (d) Preferred written delegation document in facility-based practices Protocol should promote the exercise of professional judgment commensurate with: APRN’s education and experience; and Complexity of patient’s condition. Advantage – No specific QAI requirements that are specified in the PAA. “A protocol or other written authorization” is the primary mechanism for delegating medical aspects of care in facility-based practices. It is important to understand that protocols do not have to be detailed descriptions of treatment. The definition of protocol in both the Nursing and Medical Board Rules state that they are to be written in such a fashion as to promote the exercise of professional judgment. A protocol briefly describes the relationship between the physician and APRN, the medical acts being delegated, and the QA process. CNAP’s Sample Facility-Based Protocol is available at The definition of Protocols is in TMB Rule (18) Protocols--Written authorization delegating authority to initiate medical aspects of patient care, including delegation of the act of prescribing or ordering a drug or device at a facility-based practice. The term protocols is separate and distinct from prescriptive authority agreements as defined under the Act and this chapter. However, prescriptive authority agreements may reference or include the terms of a protocol(s). The protocols must be agreed upon and signed by the physician, the physician assistant and/or advanced practice registered nurse, reviewed and signed at least annually, maintained on site, and must contain a list of the types or categories of dangerous drugs and controlled substances available for prescription, limitations on the number of dosage units and refills permitted, and instructions to be given the patient for follow-up monitoring or contain a list of the types or categories of dangerous drugs and controlled substances that may not be prescribed. Protocols shall be defined to promote the exercise of professional judgment by the advanced practice registered nurse and physician assistant commensurate with their education and experience. The protocols used by a reasonable and prudent physician exercising sound medical judgment need not describe the exact steps that an advanced practice registered nurse or a physician assistant must take with respect to each specific condition, disease, or symptom. The reasons physicians in facility-based practices should delegate prescriptive authority and other medical acts through Facility-based Protocols and not a Prescriptive Authority Agreement (PAA) is the avoid the chart review and monthly face-to-face meetings that a physician must perform under the quality assurance and improvement (QAI) provision that are required in a PAA. That does not mean there should not be any QAI procedures, but the physicians, APRNs and PAs in a facility-based practice may select quality assurance approaches that suit the practice.

Prescriptive Authority Agreement (PAA)
Written document through which a physician delegates the authority to order and prescribe drugs and/or devices in all practices except facility-based. Remains an option for facility-based. Definition of prescriptive authority agreement in TMB Rule 193.2 (17) Prescriptive authority agreement--An agreement entered into by a physician and an advanced practice registered nurse or physician assistant through which the physician delegates to the advanced practice registered nurse or physician assistant the act of prescribing or ordering a drug or device. Prescriptive authority agreements are required for the delegation of the act of prescribing or ordering a drug or device in all practice settings, with the exception of a facility-based practice, pursuant to § of the Act. Definition of prescriptive authority agreement in BON Rule (a) The prescriptive authority agreement is a mechanism by which an APRN is delegated the authority to order or prescribe drugs or devices by a physician.

Requirements for Parties to the PAA
Physicians are limited to delegating Rx authority to no more than 7 APRNs and/or PAs (FTEs) All parties must disclose: Prior disciplinary action by the licensing board before executing the PAA. Investigation by the licensing board while a party to the PAA. All parties must cooperate with TMB and BON staff during an inspection or audit relating to the PAA and its implementation. In calculating the number of APRNs and PAs, the TMB defines a full time equivalent (FTE) as 50 hours/week. Therefore, the actual number of APRNs and/or PAs to whom one physician may delegate prescriptive authority may exceed seven if some are working part time. The information in this slide comes from BON Rule and TMB Rule See slide 102 for more information about the BON’s investigation and disciplinary process.

PAA Requirements In writing, signed and dated by all parties
Name, address & professional license # of parties Nature of the practice, locations, or settings Categories of drugs that may or may not be prescribed Plans for: Consultation & referral Addressing patient emergencies Communicating & sharing information related to treatment Quality assurance and improvement (QAI) that includes chart review, meetings, & documenting implementation of QAI BON Rule and TMB Rule Know the PAA requirements and compare those requirements with those included in the TMB definition of “protocols” (Slide 61).

QAI Plan Requirements Chart review - Number determined jointly
Purpose/content of QAI monthly meetings share information about patient care & treatment, changes in treatment plans and issues relating to referrals QAI monthly in-person meetings Location, day and time determined jointly Face-to-face 1 year for APRNs who prescribed for 5 of past 7 yrs Face-to-face for 3 years for APRNs with less experience Thereafter, meet quarterly in-person & monthly in between by electronic means. Document implementation method & compliance The quality assurance and improvement (QAI) plan requirements are the most complex aspect of the prescriptive authority law. BON Rule and TMB Rule contain specific information about the QAI meetings and determining the length of time APRNs must meet face-to-face monthly. (d) The periodic face to face meetings described by subsection (c)(9)(B) of this section must: (1) include: (A) the sharing of information relating to patient treatment and care, needed changes in patient care plans, and issues relating to referrals; and (B) discussion of patient care improvement; and (2) be documented and occur: (A) except as provided by subparagraph (B) of this paragraph: (i) at least monthly until the third anniversary of the date the agreement is executed; and (ii) at least quarterly after the third anniversary of the date the agreement is executed, with monthly meetings held between the quarterly meetings by means of a remote electronic communications system, including video conferencing technology or the internet; or (B) if during the seven years preceding the date the agreement is executed, the APRN for at least five years was in a practice that included the exercise of prescriptive authority with required physician supervision: (i) at least monthly until the first anniversary of the date the agreement is executed; and (ii) at least quarterly after the first anniversary of the date the agreement is executed, with monthly meetings held between the quarterly meetings by means of a remote electronic communications system, including video conferencing technology or the internet.

Prescription Form patient's name and address; name, strength, and quantity of the dangerous drug or controlled substance; directions to the patient regarding taking the drug and the dosage; intended use of the drug, if appropriate; name, address, and telephone number of the delegating physician; continued BON Rule 222.4(b) includes the components that must be included on a prescription that is signed by an APRN. This list is identical to that in the Texas State Board of Pharmacy Rules. #4. Sometimes it is inappropriate to include the intended use of the drug to protect patient confidentially.

Prescription Form – cont’d
APRN’s prescriptive authority # address & telephone # of site; date of issuance; number of refills permitted; and If a controlled substance: DEA # for APRN & MD/DO DEA # for APRN Including all these items can be an issue for some employers and especially some electronic prescription programs. It is vital to explain that the law requires all these components to be included. In addition, the APRN’s signature must meet the BON’s signature requirements. TSBP stands for Texas State Board of Pharmacy. TSBP Rule (b)(7)(A) can be difficult to locate because this rule is lengthy and requires multiple pages. Copy this URL in your browser You can find this citation on page 2 of the rule. BON Rule 222.4(b) & TSBP Rule (b)(7)(A)

? Would a NP be able to prescribe dangerous drugs or medical devises without DPS and DEA registrations? Answer: Yes. Prescribing dangerous drugs does not require DPS and/or DEA registration(s). Please note that starting September 1, 2016, Texas will not require state controlled substances registration. On and after that date, only a DEA number is required.

Prescribing Standards: Writing a Prescription
Avoid abbreviations on The Joint Commission’s “Do Not Use” list Refer to Stewart & DeNisco The Joint Commission’s Do Not Use list is also available online,

Prescribing Standards: Generic Substitution
Requires written and faxed prescriptions designate “brand medically necessary” or “brand necessary” in the prescriber’s handwriting. Rules allow electronic prescriptions designated on the prescription. TSBP Rule 309.3

Prescribing Standards: BON
FDA approved Off label use permitted only if: Part of a research protocol approved by IRB or Expanded Access authorized clinical trial Within the current standard of care and supported by evidence-based research Patient-practitioner relationship must exist Do not prescribe for self, friends or family May treat STDs for partners of established patient after examining the patient Students must be able to apply these prescribing standards and any applicable BON position statements to patient situations.

Prescribing Controlled Substances
Schedule III-V Controlled Substances may be prescribed on a standard prescription form. CSs may be prescribed electronically Essential Resources if prescribing CSs BON Prescribing Controlled Substances Rule, 22 TAC §222.8 Pain Management Rules – BON Chapter 228 & TMB Chapter 170 DPS (Before September 1, 2016) TSBP – Resources on Abuse & Misuse (including TMB links) The TMB Pain Management Rules are included because they include more specific information and guidelines than the BON Rules. While only the BON rules govern APRN practice, the TMB Rules establish a certain standard and APRNs should abide by those standards. If questions arise that are not addressed in the BON rules, refer to the other resources listed on the slide. The BON expects an APRN who prescribes CSs to know this information.

“Official Prescription Form”
Term for the form required when prescribing Schedule II Controlled Substances (triplicate) Schedule II Controlled Substances may be prescribed electronically DPS requires that the delegating physician sign the APRN’s application for DPS controlled substances registration. (This will not be a requirement after 8/31/16.)

What APRNs Must Know about Rx Authority
Apply for a prescriptive authority number when applying for license to practice as an APRN. Separate Prescriptive Authority required for each APRN role & population-focus area May not write prescriptions until a physician 1) delegates authority, 2) signs PAA or Protocol Register delegation on TMB website within 30 days. May not prescribe controlled substances until have DPS # (CSR) (until 9/1/16) and DEA #. May not prescribe for yourself, friends or family. In review, these are the vital points to remember about prescriptive authority in Texas. When you graduate you will apply for your prescriptive authority number when you apply for license to practice. Prescriptive authority authorization is specific to each role and population focus area. If you receive additional education and the BON authorizes you to practice in an additional APRN role and/or population focus, you must also apply for prescriptive authority for that new APRN role. The BON does not issue an additional Rx number, but the APRN verification on the BON website shows if the APRN is authorized to prescribe in each role and population focus area. Just because you have a prescriptive authority number, doesn’t mean you can start writing prescriptions. APRNs must have a signed PAA or Protocol. APRNs may not prescribe controlled substances until they have both a DPS Controlled Substances permit and a DEA#. The DPS # is also referred to as the Controlled Substances Registration (CRS) and is the state registration required before you can receive the federal DEA#. As noted on previous slides, Texas will not require a state CSR after 8/31/16). Even though prescriptive authority is no longer site-based, APRNs should not prescribe for friends and family. Never write a prescription for yourself.

? What Texas state agencies regulate the information included on a prescription form when the APRN signs a prescription for a controlled substance? (Check all that apply.) a) Board of Nursing (BON) b) Department of Public Safety (DPS) c) Texas Medical Board (TMB) d) Texas State Board of Pharmacy (TSBP) Answer : A, B and D (After 9/1/16, the correct answer will no longer include B – Department of Public Safety.) The Texas Medical Board is not correct. While the TMB designates the requirements for physicians signing and delegating prescriptive authority, the TMB does not regulate APRNs who are prescribing medication. The TSBP Rules include the information that must be on a prescription form.

Advocacy and the Texas Legislative Process

Barriers to Practice Federal Level State Level
Some Medicare reimbursement policies APRN not allowed to order home health in Medicare & Medicaid State Level Definition of Professional Nursing in the NPA Physician delegation Limitations on controlled substances Provisions in the Insurance Code Some Medicaid reimbursement policies

Texas Legislative Basics
Begins with Interim Charges. Stakeholders take part in hearings. Session starts the 2nd Tuesday in January. Bills are filed by legislators until 60th day. Companion bills – Same bill filed in House & Senate The same bill number must pass House & Senate The Regular Session lasts 140 days Governor may call a 30-day Special Session for specific purpose/s (The Call) The Texas Legislature meets in regular session once every other year. Most people think that the session does not begin until the second Tuesday in January of each odd-numbered year. While that is when the session opens, preparation for the session begins over a year earlier when the Lt. Governor issues interim charges to the Senate committees and the Speaker of the House issues interim charges to the House committees. These interim charge signal the issues that are hot topics and are likely to result in major legislation filed the following session. If stakeholders are not involved in the hearings about the interim charges that affect their practices, then they fail to have input as the legislation is drafted. Bills may be pre-filed before the session begins. While the exact date varies each session, pre-filing usually begins the second week in November of even-numbered years and billing filing continues until the 60th day of the legislative session. Because the same bill with the same bill number must pass both the House and Senate, senators and representatives who are promoting similar legislation often coordinate their efforts and file the same bill in the House and Senate. These are known as companion bills as a strategy to expedite the process and increase the chances the bill will pass.

Texas Legislative Session Cycle
2016 Interim Charges issued fall 2015 – 1/16 Elections – 3/1, 5/24, 11/1 Interim Reports – 11/1 – 12/1 Begin Pre-filing bills 85th Legislature 2017 85th Session Begins 1/10 Bill filing deadline 3/11 Session Ends 5/29 Special Session Governor calls Special Purpose – “The Call” 30-day 2018 This is a flow chart of the same Texas legislative process discussed on the previous slide, but includes specific dates for the 2016(84th) Legislative Session elections and the 85th Texas Legislature Regular Session.

Legislative Process: Bill to Statute
Bill Introduced & Referred to Committee Committee Hearing → Committee Report Floor Vote → Engrossed Received in 2nd Chamber & Referred Committee Hearing → Committee Report Floor Vote → Enrolled Sent to Governor → Signed Statute (Law) Bills are drafted to amend, add or strike specific sections of current statutes. Many bills that are filed never receive a committee hearing. Committee chairs are powerful because they control the agenda (what bills are considered at any given committee hearing) and control what bills are considered for a vote. Most bills die in committee, either because they are never receive a vote even if they are considered in a hearing. Bills that a committee passes are usually amended or substituted during the committee process. While a bill in Texas must relate to the subject of the caption and the original content of the bill, often the provisions in a bill change dramatically as it goes through the legislative process, so stakeholders must read the bill carefully at each stage of the process. The version of the bill as it is passed from committee is called the “Committee Report”. Bills that are sent to the full House or Senate often die at this point because they are never put on the House or Senate Calendar. In the House, the Calendars Committee has controlled of what bills are listed on the House Calendar for consideration. In the Senate, the Lt. Governor in his role as President of the Senate controls the bill that are considered by the Senate. If a bill passes the chamber in which it originated, that version of the bill is called the Engrossed version. Then the bill is sent to the second chamber where it is referred to a committee. The bill goes through a similar process in the second chamber as it did in the first, and it can be amended or substituted at every step in the process. When companion bills have been filed, if the companion bill has already been considered by the committee, the committee will not vote on the bill until its companion that already passed the first chamber is referred to the committee. When this happens, the bill is put on the agenda but the committee does not have to hold a second hearing on the same content. The committee can simply consider the companion bill that already passed the first chamber instead of its companion bill. That is the reason companion bills can move faster than bills filed only in the House or only in the Senate. When a bill passes the second chamber, it is called the Enrolled version. If the engrossed and enrolled versions are different. The two chambers must concur with the final version of the bill or it will be referred to a conference committee to resolve the differences. Bills can die in conference committee too. If both the House and Senate pass the conference committee report, then the bill is enrolled and sent to the Governor. The Governor may sign the bill, allow the bill to become law without signing it, or may veto the bill. If the bill is not vetoed within 20 days of the end of the legislative session, it becomes law and the changes are incorporated into the Texas statutes.

Legislation to Regulation

Legislation Regulation
State agency proposes & adopts rules Agency takes action within statutory authority against regulated persons / entities that violate rules. Texas Legislature passes a bill. Governor signs into law. Statute directs state agency to implement. Changes in statutes usually direct specific state agencies to implement the changes in the law. At that point, the state agency assumes responsibility to develop and adopt rules to implement the law. This is called the regulatory process. State agencies are limited to adopting rules that are within the statutory authority granted by the legislature. Rules and regulations usually include much more detail than the provisions in the statute.

Advocacy Basics What is the difference between legislation and regulation? Does the Texas Legislature meet in Regular Session every year? Does your congressman work in Austin or in Washington, D.C.? How do you address your state legislators? How do you find your legislators’ names? Who represents you in Austin & D.C.? First we start with some basic knowledge that APRNs need in order to be effective advocates. Legislation – Bills filed by members of the legislative branch that, if passed, amend statutes. Regulation – Rules passed by a state or federal agency under the authority granted through statute. A state agency is part of the executive branch under the governor and a federal agency in part of the executive branch under the U.S. President. The Texas Legislature meets in regular session for 140 days every other year The session begins on the second Tuesday in January of each odd year (e.g. 2013, 2015, etc.). A congressman works in Washington, D.C. A U.S. Representative may also be referred to as a congressman and may be addressed as Congressman ___ or Representative ____. Never refer to, call or address a state legislator as Congressman. Proper forms of address. The proper form of address for all political dignitaries when addressing an envelop is “The Honorable _____.” Proper forms of address when speaking with a member of the Texas House of Representatives would be “Representative ____”. It is also appropriate to use “Mr. ____” or “Ms._____”. Open a letter with “Dear Representative _____”. If the representative chairs a committee, it is also appropriate to open the letter with “Dear Chairman” or an alternate for a female chair is “Dear Madame Chair”. Always address senators as “Senator ____” . If the senator chairs a committee, it would be appropriate to address the senator as “Chairman” or, if a woman, “Dear Madame Chair”. The link to find your legislators’ names can be accessed through the Texas Legislature Online (TLO) home page, U.S. Senators’ (both the same for the entire state) names are at the top. Currently Texas has 36 congressional districts. Your U.S. Representative (congressman or congresswoman) with contact information will be listed first. Your state senator is next, and then your state representative. Occasionally the computer program cannot match your home address to an exact house or senate district. If you find more than one district listed, you will find your district numbers listed on your voter registration card or you can call the country clerk’s office for that information.

Following Bills through Legislative Process
How to Find and Read a Bill Finding a Bill How a Bill Becomes Law How to Find and Read a Bill is a simple one-page document that is required reading in Module II. If you are following a bill through the legislative process, you can track the bill through the Texas Legislature Online (TLO) website. It is highly recommended that students become familiar with this website since it is a portal to almost all aspects of Texas law and the Texas Legislature. If you wish to know more details about the legislative process the Texas Legislative Council (TLC) is the best resource. The article linked to CNAP’s website also includes instructions to identify your Congressional and Texas State legislators.

APRN Legislative Priorities
Remove unnecessary restrictions that prevent & delay care. Contract directly with insurance providers and serve as primary care providers whether the delegating physician is in-network or not. Authorize physicians to delegate prescribing Schedule II medications (especially to psychiatric APRNs and APRNs providing palliative care). Handouts: 2015 Legislative Summary The overall goal of APRNs’ advocacy efforts are to “Remove unnecessary restrictions that prevent and delay care.” Two examples are listed. Neither of these legislative goals were met in 2015, so they may still be on the agenda for There is a wrap-up of the 2015 legislative session on TNA’s website. The 2015 Legislative Session was frustrating for APRNs, but we will continue to pursue our goals. APRN groups start meeting in fall 2015 to begin developing their goals for 2017. There are handouts on various issues that are important to APRNs on TNP’s websites. These handouts could be updated and used for visits with legislators. When CNAP’s new website is fully developed, you will find additional information about making legislative visits on CNAP’s webpage.

Visits with Legislators
Lobbying is education – Identify purpose & 3 goals Flow of the visit Getting to know you – finding commonalities Listen before telling. Find out what the legislator /staff knows about your issue/s. for info on representatives for into on senators Give the information the legislator needs. End on time with your request. Follow-up with a letter to the legislator & staff.

Visiting/Writing Legislators
Research the issue & ask for help as needed. APRN state & national organizations and Policy Institutes: & Address the right issue to the right legislator Limit to 1 page Use enclosures as necessary Use correct forms of address “The Honorable Donald Doorman” to address the envelop “Dear Representative Doorman:” to open the letter Include your card / your contact information. Tailor your message to the legislator you are writing. The Texas Public Policy Foundation ( is an example of a well-respected conservative think tank in Texas. The Center for Public Policy Priorities ( is an example of a well-respected liberal think tank. Both are reliable sources of information, but the reports and articles, reflect the point of view of the organization. If you are communicating with a conservative legislator, he/she is more likely to be impressed with information or a supportive position issued by the The Texas Public Policy Foundation (TPPF). On the other hand, a legislator from the Democratic Party is more likely to be impressed by supportive information from the Center for Public Policy Priorities (CPPP). Make sure you are contacting the correct legislator to address your issue. If you have concerns about operation of the local county hospital district, the issue should be brought to your county commissioner. If you want to change a provision that affects the Texas Medicaid program or changes the Texas Nursing Practice Act, those are state-level issues are need to be addressed with your state senator and representative. If you want a change in Medicare law, then that is a federal issue then that is a congressional issue and you need to contact your U.S. senators and your U.S. Representative. Busy legislators and staff do not have time to read long communications. Make every word count and make the subject of your communication clear in the first sentence. Your goals should always be to limit the length of your letter to one page. It is very important to use correct forms of address. You may call a Texas Representative “Representative” or Mr. or Ms. A Texas Senator is always referred to as “Senator.” If the representative or senator you are addressing is a committee chair, they may be called Mr. Chairman or Madame Chair. For more information. It is very frustrating for staff if you do not include your contact information. Staff needs to know how to contact you in case there is a follow-up question. Always include your voting address so the legislator will know you are a constituent. Constituents’ opinions are always important to politicians. Communications from non-constituents are usually disregarded. A good resource about communicating with state officials is available at

Writing Legislators by Email
Be sure the will be read by asking if is a preferred form of communication. Write it like a letter - Include a salutation & closing Edit very carefully Remember how easily s are forwarded Never put anything in an you would not want the public to read. can be efficient and many staff members rely on . However, that is not always the case for the legislators. s should be as carefully drafted as a letter. The quality of the writing reflects on your professionalism. The tone of any communication with staff and legislators must always be polite and positive, even when you disagree on an issue.

Relationships with Legislators
Be a regular At least contacts a year Meet with legislators in home district Always be polite, even when you disagree Visit when you need no favors Write notes – Handwritten notes are good Congratulatory Items or articles of interest Volunteer and donate Attend fundraisers

Responding to Action Alerts
Read the entire alert carefully. Clarify if needed. Verify the alert is from a reputable source. Respond if appropriate in time frame requested. Read & Follow directions/guidelines exactly. Put your response in your own words. Edit carefully. Close the loop. Let requestor know you responded. Responding through an organization’s automated response system Professional organizations that are advocating for APRNs often alert members and others on their lists that they need constituents to contact their legislators. If the request or information is coming from an unknown source, be very careful and research the information before responding. If it is from a reliable source, read the entire alert very carefully. Most of these alerts are time sensitive, often requiring immediate action or action within a defined time frame. Often the organization will draft a sample letter or . However, your communication will be much more effective if you put the information in your own words, even when responding through the organization’s automated communication system.

Becoming an Effective Advocate
Join and attend professional meetings Get informed & organized Register or Join to receive professional org.’s updates Organize so everyone plays to their strengths Recruit colleagues Do what you can, when you can Join your statewide professional organizations TNA, TNP, and CNAP. Contribute to Texas Nurse PAC Form relationships with your legislators & staff. There are many ways to get involved. The slide suggests a few. Everyone has times in their lives when they can be more engaged than others. However, it is important that every professional stays up to date and contributes financially or with their active involvement, or both. Start by attending professional meetings, and learning about the issues. Find more about TNA advocacy at Find more about TNP at The local NP organization in Houston is Houston Area NPs. Find more about the organization at The North Harris County Montgomery Advanced Practice Nurse Society (NHMAPNS) is usually more convenient for those living or working in north of Houston. Find information about this local organization at For those interested in pediatrics, check out the Houston Area Chapter of the National Association of Pediatric Nurse Practitioners (HAC-NAPNAP) at a The Texas RN/APRN PAC became the Texas Nurse PAC in Learn about the primary PAC for Nurses under the Advocacy tab. Be aware that advocacy information and notices on Websites becomes outdated very quickly. Do not act on any information that doesn’t appear to be current.

Location: Bullock Museum in Austin Register at bit.ly/APRNday
APRN Legislative Day Monday, February 22, 2016 Location: Bullock Museum in Austin Register at bit.ly/APRNday By February 15th Example of activities where NP students can learn more about their roles as advocates. $50 Registration fee

Reasons the BON Disciplines APRNs Scope of Practice Review What To Do If a Complaint is Filed BON Disciplinary Options Disciplinary action by the Board of Nursing is something that no RN wants to contemplate. However, knowing what led to other APRNs to be disciplined, and understanding the disciplinary process is very important to avoiding potential pitfalls in practice.

Administrative Violations of the NPA
Fails to: Obtain APRN Licensure Renew APRN Licensure Renew RN License Maintain National Certification Attain or maintain records of CE Sign name properly identifying APRN role & population Solicit / inform patients ethically or in accordance with HIPPA About 10 years ago, CNAP reviewed all disciplinary actions involving APRNs for the previous 10 years. It is not surprising that the most common issues cited in disciplinary order had to do with process and paperwork-type violations of the Nursing Practice Act (NPA).

APRNs Practice Violations
Fail to: Maintain or annually sign /date Rx authority written documentation Document Assess or monitor Maintain a safe environment for patient Refer to a physician or others Prescribe and/or administer drug appropriately The second most common disciplinary actions are related to substance abuse. Third most common were practice errors of the type listed on the slide.

Mistakes Resulting in Serious Outcomes
APRN Practicing as RN without proper orientation Practicing as APRN in primary care does not maintain high tech RN skills. Practicing when fatigued / over 12 hours or too many days in a row. (See the Texas BON Bulletin, April 2015.) This slide emphasizes two potential pitfalls. Sometimes employers assume that APRNs are going to be highly qualified to work as RNs in any area. If an APRN has been caring for primary care patients, they soon lose competence in providing nursing care for seriously ill patients. The most common pitfall is working when fatigued. Research shows that working more than 60 hours a week results in poorer performance and judgment. Working without adequate sleep can has many of the same results as consuming alcohol. The professionals feels they are more competent than they really are.

Mistakes Resulting in Serious Outcomes
Violating APRN Scope of Practice most common cause for: disciplinary action R/T practice error bad outcomes I am glad to report that practice errors that resulted in serious harm were very rare, averaging about 2.5 occurrences per year. The most common reason for bad outcomes seemed to be related to not staying within the bounds of the APRN’s scope of practice.

May APRNs provide any service or perform any procedure delegated by a physician?
NO Must fall within formal APRN education: Population of patients Type of services Physicians are allowed to delegate anything to anyone they think is competent, except when specifically restricted by law. Physicians, however, often fail to understand that APRNs and other RNs may not be able to accept that delegation if it is outside the nurse’s scope of practice or competence. APRNs must always be very aware of SOP limitations and know how to talk with physicians about these issues. If the limitation is one of competence in performing a procedure or caring for a specialty population that falls within the APRN’s population focus area, then the APRN may explain the process necessary to become competent. See the BON Webpages, and

Scope of Practice Review
Is a primary care educated NP permitted to practice in a specialty? YES The APRN Consensus Model and the Texas BON do not regulate APRNs at the specialty level. The Texas BON does hold the APRN responsible for being competent to treat the population of patients.

Scope of Practice Review
Is a primary care educated NP permitted to practice in a hospital? YES, But limited to the level of care included in APRN educational program. APRNs educated in primary care treat patients needing preventive, chronic and acute (but not critical) care. APRNs educated in acute care provide treatment for patients needing chronic, acute and critical care. There is considerable overlap and the setting where the treatment takes place never determines the APRN’s scope of practice. There are obvious limits to the level of care that a primary care educated NP should treat. Primary care NPs should never be responsible for the overall medical management of patients in unstable condition. They could, however, consult on certain aspects of treatment.

What to do if a Complaint is Filed
Notice means BON opened an investigation. You have 20 days to respond. Use the time wisely. Identity of complainant is confidential. Fail to respond, the case moves forward without your side of the story. Consult an attorney and colleagues. If you have prescriptive authority through a PAA, notify delegating physician and other parties. If you receive notice the Board of Nursing opened an investigation, the investigative unit already reviewed the complaint and determined the BON has jurisdiction over the matter, and you possibly violated the Nursing Practice Act. You have 20 days from the date the certified letter was sent for the BON to receive your response. Acting deliberately and wisely in the next 20 days can make a huge difference in the outcome of the investigation. You will immediately feel scared and defensive. You may even feel unfairly treated since the law requires keeping the name of the person who filed the complaint (complainant) confidential. However, you will be given the facts of the case presented in the complaint, and it is vital that you respond knowledgably in responding to those facts. The law does not require you to respond. However, failure to do so means you lost your best opportunity to: 1) demonstrate that you are a conscientious and knowledgeable nurse who takes appropriate and timely action; and 2) offer your side of the facts. If your response demonstrates you acted appropriately and did not violate the NPA and the BON investigators find your facts are correct, the case is dropped at that point. While the complainant’s name is withheld, you may be able to identify the patient based on the facts presented. If you can, review the chart to refresh your memory. If you can, make a copy of the pertinent portions of the chart or take notes. However, it is wise to do so in front of one or more witnesses who can verify you did not alter the chart in the process. If you think you or other made errors, be factual in identifying and disclosing errors, and explain the action you took upon discovering the error. Consulting an administrative law attorney who is experienced in dealing with the BON is probably a good idea. However, if the attorney you consult recommend you respond to the BON with a blanket denial, this attorney is probably not the right person. Doing a blanket denial ensures the board’s investigation will continue. You need an attorney, or at the very least a knowledgeable and unbiased colleague who can review the response you draft. You want to be sure that you put your best case forward and you present the fact in the most unbiased fashion possible. Level-headed colleagues can help add perspective and allow you to vent anger, frustration and fear. Remember, if you are a party to a Prescriptive Authority Agreement (PAA), the law requires you to disclose the fact that you are under investigation by the BON to your delegating physician and other persons who are parties to the PAA. To find more information, refer to resources on the Board of Nursing Website. However, the BON is obligated to notify you of your rights and the disciplinary process. The BON never offers advise and information about the informal settlement process is difficult to find. The best and most comprehensive resource is Woolbert, L. F. (2013). Chapter 8: BON disciplinary process, TPAPN and peer review. In Woolbert, L. F. & Ziegler, B. A Guide for APRN Practice in Texas (4th ed.). In the 5th edition, this information is in Chapter 9. Resources: BON Website & A Guide for APRN Practice in Texas, Chapter 9.

BON Disciplinary Process: Chapter 213 Disciplinary Options
The BON may issue a Board Order taking any of the following actions against the RN/APRN license: Warning (can be deferred) Reprimand Restrict Suspend Revoke These levels of disciplinary action are presented in order of severity, with a warning being the least severe sanction and revoking the APRN’s RN and/or APRN license/s the most sever action.

BON Disciplinary Options SB 1415 (2009) & SB 1058 (2013)
“Corrective Action” BON finds nurse committed a minor violation of the Nursing Practice Act or BON Rule. A non-disciplinary, administrative action. May count as a disciplinary action in future sanctions Not reported to National Data Bank Not disclosed to public The Texas Legislature granted the BON authority to take corrective action for certain types of “administrative” violations in This is not classified as disciplinary action and therefore the BON is not required to report the action to the National Practitioner Databank or make any other public disclosure. If future violations occur, then a record of the original infraction remain in BON records and could be an aggravating factor in determining future discipline.

Corrective Action Determined by BON Executive Director
First offense for: Delinquent license less than 6 months Noncompliance with CE Inaccurate answers R/T criminal history, etc. Fails to report new name or address to BON Fails to assure credentials for personnel Does not maintain peer review plan Fine is $500 The BON has the option of taking “corrective action” at the discretion of the BON Executive Director. This usually involves a fine and often the BON requires the nurse to take a jurisprudence course. This slide shows the original list of offenses that qualified for corrective action. The program seems to be very effective and efficient with very few nurses committing subsequent offenses. The BON has expanded the list of offenses that qualify for corrective action. Rules & adopted on

BON Disciplinary Options
Deferred Disciplinary Action Cases are eligible if a warning or lesser discipline proposed (not a license reprimand, suspension or revocation). If nurse completes requirements, BON removes public record of the infraction after 5 years. May count as a disciplinary action in future sanctions Reported to National Data Bank but modified five years after completing. While the BON is required to report all disciplinary action to the National Practitioner Data Bank, they are adding a modifier to the report if there are no subsequent complaints against the RN for five years. The BON has also found this program to be successful and is developing other programs to help nurses return to safe practice without leaving permanent black marks that follow them throughout their careers.

More about the Coalition for Nurses in Advanced Practice (CNAP), Texas Nurses Association, & Texas Nurse PAC It is important to understand the role various organizations play in advocating for APRNs in Texas. Three of these organizations in Texas are CNAP, TNA and the Texas RN/APRN PAC. These are two distinctly different types of organizations created for different purposes, but both are important in advocacy for APRNs.

CNAP Mission Educate APRNs and stakeholders about the legal aspects of APRN practice; Educate APRNs about advocating for their practices; and Promote regulations that allow APRNs to reach their full potential to improve the health and well-being of all Texans.

CNAP APRN Group Members
Texas NAPNAP Tx CNS Texas PAPNs Tx ANNP CTCNM GCAPNA Consortium of Texas Certified Nurse-Midwives Texas Clinical Nurse Specialists Greater Texas, Houston Area & South Texas Chapters of the National Association of Pediatric NPs Psychiatric Advanced Practice Nurses : Austin Houston San Antonio Gulf Coast Gerontological APN Association CNAP is composed of APRN local, regional and smaller statewide organizations that represent various types of APRNs and specialties. Texas Association of Neonatal Nurse Practitioners

TNA is taking a lead role in coordinating the APRN legislative agenda through its Advanced Practice Nursing Advisory Committee, the Texas Team and the APRN Alliance.

Texas Nurse PAC

PAC – Political Action Committee
PACs contribute money to support political candidates Incorporated organizations may not make political contributions Incorporated organizations, whether structure as for profit or non-profit corporations may not contribute to political campaigns. Most professional organizations such as the Texas Nurses Association, Texas Nurse Practitioners, Texas Clinical Nurse Specialists and Texas Association of Nurse Anesthetists are categorized as 501(c)(6) non-profit corporations.

Texas Nurse PAC Administered by TNA, CNAP and TANA
Texas RN PAC became RN/APRN PAC in 1995 Administered by TNA, CNAP and TANA Became the Texas Nurse PAC in 2015 Contributes to candidates for state office

PACs must be separate from prof. organizations, e.g., TNA, TNP & CNAP
When I give $$ to the Texas RN/APRN PAC, am I giving to a professional group that hires lobbyists? NO PACs must be separate from prof. organizations, e.g., TNA, TNP & CNAP

Spread the word and recruit 4 colleagues to do the same
Do Your Fair Share Contribute $30 /mo. for professional organizations $15 /month to Texas Nurse PAC ( Total = 1 hour of your salary / month) It will take at least 1,000 APRNs all doing their fair share. That includes giving one hour of your salary a month: $30 a month to professional organizations that advocate for APRNs and $15 a month to the Texas Nurse PAC. APRNs need to educate their legislators about their practices and why full practice authority for APRNs is good for Texas. It takes time to develop a good relationship with your legislators, and it takes 7 visits during each 2-year legislative cycle to develop name ID with your legislators. Finally, recruit your colleges to also do their fair share. The more APRNs we have pulling together with this effort, the easier it will be for all of us. Visit your legislators 7 times Spread the word and recruit 4 colleagues to do the same

Thanks for Joining CNAP
Questions? Contact Lynda Woolbert (979) (512) APRN practice & advocacy resource cnaptexas.com

APRN Practice & Professional Advocacy in Texas

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