A nurse who wishes to be licensed to practice as an APRN in the state of Texas must be licensed as a Registered Nurse in Texas or have a current, valid RN license with multistate privilege...
from a state that is party to the Nurse Licensure Compact for RNs and LVNs/LPNs before any level of APRN licensure can be granted. If you need to apply for a Texas RN license, you will find endorsement applications on our website by clicking here. For more information about the Nurse Licensure Compact, see below.
Yes, however we will not grant any level of approval until you hold a current, valid RN license (temporary or full) or privilege to practice in the state of Texas.
If you wish to submit your application online, please click here. If you are not eligible to submit an application online or prefer not to use the online application, you may obtain a copy of...
the application by downloading it from the website (click here to download the application). If you are unable to download the application, you may request that an application be mailed to you by emailing the APRN office at firstname.lastname@example.org or by calling the APRN office at (512) 305-6843. Because applications are sent via bulk mail, it may take 1-3 weeks for you to receive the application by mail, depending on the United States' postal system. Generally, applications will be mailed within 5 business days from the date that the request for the application is received. We regret that we are unable to fax the application to you nor can we send it to you via overnight delivery services.
We make every attempt to review and respond as quickly as possible, but the process may take up to 30 business days based on the volume of applications received at any given time. Applications and supporting documentation are processed in the order in which they are received.
Review your application before you submit it; many times simple mistakes are made or questions are not answered and this may result in a delay in obtaining approval. In addition, please...
read the application instructions and Rule 221 (and 222 if you are applying for prescriptive authority) carefully to be certain you meet the requirements outlined in Board rules. If you submit your application online, please be certain to provide us with the supporting documentation as indicated in the completion packet that is part of the online application.
The educational requirements may be found in Board Rule 221.3. Although you may have been licensed/authorized as an APRN in another state, you must meet the educational requirements set by the Texas Board of Nursing in order to be licensed as an APRN in Texas. We recommend you review this rule very carefully before you submit your application.
Any requests for additional information will be written requests (e-mail if available) that will be mailed to your address of record. Due to the high volume of applications we receive, we generally will not call to alert you of mistakes or the need for new information.
Please understand that it generally takes us about 30 days to review and respond to new applications or new information that is sent to our office. If you call our office, we may not have had a chance to review your application. We make every attempt to review information as quickly as possible and to respond in writing (e-mail if available) with an approval or with a request for additional information.
Yes. Each application to our office requires its own set of documentation.
The application that is currently on the web site allows you to apply for both advanced practice licensure and prescriptive authority in a single application. Prescriptive authority is an optional authorization. If you are requesting only licensure as an advanced practice registered nurse, a $100 processing fee is required. If you are requesting both licensure and prescriptive authority, a $150 processing fee is required.
Interim approval allows an applicant to begin working as an Advanced Practice Registered Nurse during a period of time when the board is waiting for additional information. The APRN office...
may grant interim approval when it appears that the applicant will meet the requirements for full licensure as an APRN in Texas but additional information is needed. This type of approval is granted for a period not to exceed 120 days. Per Rule 221.6 (b)(3), extensions of the interim approval period may not be granted.
The Texas Board of Nursing no longer issues interim approval to new graduates who have not yet taken and passed their national certification examinations. You must submit evidence of current national certification (must show expiration date) before you will be eligible for interim approval or full advanced practice licensure.
Yes. National certification is one of the requirements for licensure as an APRN in Texas. However, you must meet all of the requirements that are outlined in Rules 221.3 and 221.4 in order to be licensed, practice, or hold yourself out as an APRN in Texas.
All advanced practice registered nurse titles are protected and may only be used by those nurses who meet the requirements for licensure as an APRN. You must apply for and receive an APRN...
license from the Texas Board of Nursing before you may claim to be an advanced practice registered nurse or hold yourself out as an advanced practice registered nurse in this state. You may not use a title or any other designation tending to imply that you are licensed as an advanced practice registered nurse without current licensure from the Texas Board of Nursing.
No, endorsement is not available for those who desire to be licensed as an APRN in Texas. Any person wishing to be licensed as an APRN in Texas must meet the requirements that are outlined in Rule 221, regardless of licensure in another state or prior work experience. APRN requirements vary from state to state. Therefore, please read Rule 221 carefully to determine that you are eligible for APRN licensure in Texas.
The Nurse Licensure Compact is an agreement between states that allows a nurse to obtain an RN license in the nurse's primary state of residence and allows the nurse to practice as an RN in any other Compact state without obtaining an RN license in that state....
The Compact status is only extended to those nurses who meet requirements for licensure in their home state that is a member of the Nurse Licensure Compact. Proof of a nurses's primary state of residence may be required. Documentation to verify this information may include, but is not limited to, a driver's license with a home address, voter registration card displaying a home address, and/or federal income tax return declaring the primary state of residence. A nurse who permanently moves from one Compact state to another must obtain an RN license in the new home state. For more information on the Nursing Licensure Compact, click here: https://www.ncsbn.org/nlc.htm. For a list of current Compact states, please click here: https://www.ncsbn.org/Implementation_dates_list.pdf.
Please note that at this time, Texas has not implemented the APRN compact. Therefore, in order to practice in Texas, you must have a privilege to practice on your RN license from your home state that is party to the Nurse Licensure Compact. If your primary state of residence is not party to the Nurse Licensure Compact, you must obtain a Texas RN license.
If you have a current, valid Compact RN license, you are not required to obtain a Texas RN license before applying for APRN licensure in Texas.
You are required to declare certain information as described in the questions on the application and provide a written explanation of the incident(s) you are declaring. Once all necessary documentation is received, we will forward this information to our enforcement department for review....
This may take up to three months to complete if an eligibility
determination is required. Additional fees may also be required. If additional fees are needed, you will be notified in
writing. No approvals will be granted until clearance is received from the enforcement department. If you have
eligibility issues to declare, you will not be able to submit your application online. You may download an application by
clicking here or by e-mailing your request for
application materials to email@example.com.
Please note: Providing false information on your application is a violation of board rule and the Texas Penal Code. Additional information is available in the board's disciplinary sanction policy on lying and falsification.
In answer to your second question, no. APRN licensure is granted for the purpose of authorizing a nurse to practice in a particular role and population focus area (such as family nurse practitioner or nurse-midwife). The license is based on your formal education in a specific advanced practice...
role and population focus area. You cannot legally expand your
scope of practice from one area of licensure to another without meeting the educational and licensure requirements set by
the board (see above). This means you must submit a separate application and fee for each APRN role
and population focus area in which you are seeking licensure.
This is also the case for prescriptive authority. Although you have prescriptive authority in one role and population focus area, you must apply for and meet the requirements for prescriptive authority in each APRN category in which you wish to be licensed to practice.
Rule 221.4(b) requires that applicants for advanced practice registered nurse licensure obtain national certification in their advanced role and population focus if they completed their advanced educational program on or after January 1, 1996...
The Texas Board of Nursing (Board) recognizes specific certification examinations for specific roles and population focus areas. The Board has an obligation to the public it serves and to its licensees to verify that each certification examination tests for entry level competence in the particular advanced practice role and population focus area. Therefore, the Board must have a process in place whereby each examination is reviewed for initial recognition and on a recurring basis in order to be certain the certification process continues to meet the criteria set forth by the Board in the “Criteria for Evaluation of National Certification Examinations for Recognition from the Texas Board of Nursing,” adopted in October 2003.
The National Council of State Boards of Nursing (NCSBN) also has a review process in place for advanced practice certification examinations. The NCSBN’s examination review criteria have been reviewed and determined to be substantially equivalent to the evaluation criteria adopted by the Board. Therefore, it shall be the policy of the Board to recognize certification examinations that have previously been reviewed and approved by the NCSBN in lieu of completing a separate evaluation. This shall include both review of new examinations as well as recurrent reviews of existing examinations.
The Board reserves the right to complete its own review of any certification examination at any time. Factors that may trigger a review include but are not limited to the following:
- Unusually high or low pass rate
- New examinations that have not yet and/or will not be reviewed by NCSBN
- Substantive concern from the community of interest related to the quality of the examination content or the certification process
Should the NCSBN review an examination as a result of any of the aforementioned factors, the Board may elect to accept the NCSBN’s review in lieu of completing its own evaluation.
Adopted July 21, 2005
Which certifications are recognized by the Texas Board of Nursing?
The certification examinations that are recognized for each role and population focus area of licensure may be found here....
Why are APRNs required to be nationally certified?
There is no licensure examination for APRNs. Therefore, national certification examinations serve to assess the nurse’s knowledge of the APRN core and role competencies across the population focus area for which the nurse was educated and is seeking licensure (Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education, 2008). This is one mechanism by which boards of nursing can provide assurance to the public that the APRN demonstrated the minimum level of competency for entry into practice in the APRN role and population focus area prior to issuing an APRN license.
I completed my APRN education prior to January 1, 1996. Do I have to be nationally certified?
The answer to your question depends on whether the program you completed was accredited by a national nursing education accreditation organization recognized by the Texas Board of Nursing (Board) at the time you completed the APRN program. Please note that the accreditation must have covered the specific APRN program or track you completed. Also, please be aware that the entity that accredits the program now may not have accredited the program at the time you completed it. If your program met this accreditation requirement, you are not required to maintain national certification as a requirement to maintain APRN licensure in Texas. However, if your program was not accredited by a national nursing education accreditation organization recognized by the Board at the time you completed it, you must maintain your national certification in order to maintain APRN licensure in Texas.
I was licensed as an APRN in another state where national certification was not required. Do I need to get certified to endorse my APRN license to Texas?
Yes. Texas bases all APRN licensure decisions on whether the education and certification requirements as specified in Board Rule have been met. It is not possible for staff to grant an exemption to the national certification requirement, and the Board has never granted such an exemption. National standards for APRN licensure require licensure decisions that are based on formal education and national certification in the APRN role and population focus area, and the Board’s rules are consistent with this standard. Board staff consider all applications for licensure based on the standards contained in Board Rule.
Does my national certification allow me to practice before I get my Texas APRN license since it is a national document?
No. National certification organizations do not grant authority to practice in any jurisdiction, including Texas. You must have a Texas APRN license in order to practice as an APRN in Texas.
The national certifying organization says I can use my APRN certification credential now that I have passed my test. Is this correct?
APRN titles are protected titles in the state of Texas. Board Rule 221.2(c)(2) prohibits the use of any titles that imply the bearer is an APRN if the individual is not licensed by the Board as an APRN in the state of Texas. Certification credentials for APRNs include the use of various APRN titles. It could be confusing to patients and to the public who may not readily understand the differences between APRN licensure and certification. You may use your national certification credential when you are licensed by the Texas Board of Nursing as an APRN if you choose to do so. Board Rule 221.11 requires only that you use your RN credential and the APRN licensure title that is specified on your APRN license (e.g., RN, FNP or RN, CNS-PMH). Use of certification credentials is optional.
If I am licensed in more than one APRN role and/or population focus area, do I have to be certified in each of the additional roles and/or population focus areas?
Yes. APRN licensure is specific to each role and population focus area. Therefore, in order to obtain or maintain licensure in each role and population focus, you must maintain national certification in each.
The Board recognizes more than one national certification examination for my APRN role and population focus area. Does the Board have a preference for which exam I should take?
No. The Board has never had a preference for one certification organization over another. All certification organizations that offer APRN exams required for licensure purposes are held to the same quality standard. Neither the Board nor its staff can advise you which exam you should take. We recommend that you review information regarding the certification process and determine which exam would be best for you. Questions regarding the process should be directed to the certifying organization.
I have a question about the certification process or renewal of my certification. Can the Board help me with those questions?
No. Board staff cannot speak as experts on requirements that are not within the Board’s jurisdiction. Questions about certification requirements and certification renewal requirements must be directed to the appropriate certification organization. Certification requirements are not determined by the Board, and only the certification organization has the authority to advise on its requirements.
I was certified, but my certification accidentally lapsed. Can I still practice since my APRN license is current?
If your certification has lapsed, you are not eligible to practice as an APRN in Texas until your certification or recertification status is current (Rule 221.8). The Texas Board of Nursing is not notified by the certifying bodies when national certifications lapse or expire, so it is incumbent upon you as an APRN to recognize when your national certification has lapsed or expired and cease practice in the APRN role and population focus area. You may continue to practice as a registered nurse until your national certification or recertification has been returned to current status.
Is the Texas Board of Nursing automatically notified when I pass my certification examination or if my certification status changes?
Generally, the answer to this question is no. Some certifying organizations provide notice to boards of nursing when a certificate holder’s status changes; however, this is not the case for all certifying organizations. If your certification status changes for any reason, you should submit a copy of the status change document you received from the certification organization to the Texas Board of Nursing. You may submit a copy via email to firstname.lastname@example.org, by fax to 512-305-8101—Attention: APRN Office, or by postal mail to Texas Board of Nursing, Attention APRN Office, 333 Guadalupe, Ste 3-460, Austin, TX, 78701.
The certification organization will not let me sit for the examination because they said I completed my program too long ago. Can the Board require them to let me sit for the certification examination?
No. The national certification organizations have authority to determine the requirements to sit for national certification. The Board has no authority to require these organizations to amend or waive their published eligibility requirements. You must comply with the certification requirements set by the organization.
If I am not eligible to obtain national certification, is there something I can do in lieu of the certification requirement so I can obtain my Texas APRN license?
No. Requiring national certification in the advanced practice role and population focus area is a national standard for APRN licensure. The Texas Board of Nursing has required national certification as a requirement for APRN licensure since January 1996.
I obtained a specialty certification related to the specialty area in which I currently practice. May I maintain the specialty certification in lieu of the certification in the role and population focus area since my practice is in the specialty area?
No. You must maintain your national certification in the advanced practice role and population focus area of licensure in order to maintain your Texas APRN license. Specialty certifications demonstrate expertise in a particular area of your practice and may be utilized for the purpose of demonstrating knowledge related to a specific health care need (e.g., oncology, orthopedics, or diabetes education). The national certification that you are required to obtain and maintain for APRN licensure purposes is based on your formal education in an APRN role and population focus area. Specialty certification does not demonstrate the breadth of your education and expertise in the full scope of your role and population focus area and is therefore not accepted for APRN licensure purposes.
If I attain national certification in an additional role and/or population focus area, will this allow me to automatically expand my scope of APRN practice since I already have an APRN license?
No. The Board does not issue a generic APRN license; rather, the APRN license is specific to an advanced practice role and population focus area. National certification in an additional role and/or population focus does not automatically expand your APRN scope of practice in Texas. To expand your scope to the additional role and/or population focus area, you must meet the educational and licensure requirements to do so and apply for expanded licensure through the Texas Board of Nursing.
I completed my APRN program in 1992 and am not required by the Texas Board of Nursing (Board) to maintain national certification to maintain my license. However, my employer says I have to be nationally certified. Can my employer require this if the Board does not?
Yes. The Board determines requirements for licensure only; the Board does not set requirements for employment settings. Employers may set requirements for employment that are more restrictive than those set by the Board for licensure purposes. Therefore, if your employer requires you to hold national certification to practice in that setting, you must meet this requirement as a condition of your employment.
I am trying to get credentialed as a Medicare provider. They refuse to credential me because I am not nationally certified. Can the Board help me?
When it comes to credentialing as a Medicare provider, federal law determines the requirements for credentialing. If federal law requires national certification as a requirement for credentialing, then you must be nationally certified to be credentialed. Although you may be licensed, third party entities, including the Center for Medicare and Medicaid Services may set their own requirements for providers who wish to be credentialed for reimbursement. The Texas Board of Nursing has no jurisdiction over these requirements nor can it require any other entity to credential you.
Will my national certification meet the requirements for continuing education?
Attaining, maintaining or renewing national certification will meet the requirement for 20 contact hours of continuing education for APRNs in accordance with Rule 216.3(c). National certification cannot be used to meet the continuing education requirements for prescriptive authority nor can it serve to meet certain specific continuing education requirements such as the requirement for two contact hours of continuing education targeted for nursing jurisprudence and nursing ethics.
I am a family nurse practitioner who obtained national certification as an emergency nurse practitioner. How can I add this to my license?The Board cannot grant an Emergency Nurse Practitioner licensure title to FNPs who obtain certification as ENPs. We understand that some national certifying organizations are now offering this as a specialty certification credential. It is acceptable to list this title on CVs or resumes, employment applications, and so forth for individuals who have been granted this credential. However, there is not a mechanism to add this certification to one's APRN licensure. Under Texas law, the Board issues APRN licensure titles based on the role and population focus area in which the APRN was educated and that is the title the APRN is required to use. The APRN is required to maintain the national certification that is congruent with his/her formal APRN education for licensure purposes. In this regard, the Board's Rule is consistent with the Consensus Model.
One of the hallmarks of nursing is the approach to lifelong learning. As nurses earn advanced degrees, the number of nurses earning doctoral degrees is increasing. The longstanding tradition...
Known as the Healing Art Identification Act, Texas Occupations Code, Chapter 104 addresses the use of the term doctor. All nurses must know and comply with the Nursing Practice Act and Board’s Rules as well as all federal, state, and local laws [Board Rule §217.11(1)(A)]. To comply with this law, a nurse is required to include the degree that allows him/her to use to title Dr. ___ as a credential and indicate the profession being practiced. The Advanced Practice Registered Nurse (APRN) must be identified both as an RN as well as use the appropriate advanced practice title that has been authorized by the Board of Nursing.
The Nursing Practice Act and Board’s Rules do not prohibit the use of ‘Dr. ____’; however, based on requirements in the Texas laws, doctorally prepared nurses cannot simply identify themselves as Dr. _____. The nurse must include the academic credentials and licensure level with appropriate APRN title. Board staff recommends review of “When the Profession is Nursing and the Title is Doctor….” available in the July, 2011 BON Quarterly Newsletter, page 4.
Within the last year, there has been a great deal of discussion at the national level about the doctor of nursing practice degree. This degree is promoted by professional organizations such as the American Association of Colleges of Nursing (AACN)....
The Texas Board of Nursing has not discussed this issue and does not have a position on the issue at this time. Additionally, although the board would never discourage nurses from furthering their education, nothing in current rules requires that advanced practice registered nurses be educated at the doctoral level to obtain licensure in an advanced practice role and population focus.
No. You must complete the RN refresher course in its entirety before your RN license may be reinstated. You must have a current RN license in order to complete an APRN refresher course/extensive orientation.
The physician I work with wants me to perform a specific procedure as part of the services I provide in my practice setting. I did not learn how to do this procedure in my advanced practice program, but the physician is willing to teach me. Is it ok if the physician shows me how to perform the procedure?
The Standards of Nursing Practice in Rule 217.11 require nurses to accept only those assignments that take into consideration patient safety and that are commensurate with their own educational preparation, experience, knowledge, and physical and emotional ability [(1)(T)]....
However, all nurses frequently find themselves in the position of needing to learn new procedures. Nurses at all levels of licensure are obligated to make a reasonable effort to obtain orientation/training for competency when encountering new equipment, technology, or unfamiliar patient care situations [Rule 217.11(1)(H)]. The BON also holds all nurses, including advanced practice registered nurses, accountable for their own continuing competence in nursing practice and individual professional growth [Rule 217.11(1)(R)]. The most appropriate mechanism for learning the new procedure and documenting competence will depend on the nature of the procedure. It is imperative that you and the physician work together to find an existing educational activity or develop a program that will prepare you appropriately to perform the procedure and provide the concomitant advanced practice nursing care to the patient.
It is important to remember that there is more to this issue than simply learning how to perform a particular procedure. Patient selection criteria, underlying physiology and/or pathophysiology (depending on the nature of the procedure) as well as indications for and contraindications to the procedure are among the many concepts that are fundamental to learning a new procedure. You must also learn to respond to and manage (as appropriate) untoward events/adverse reactions/complications that may occur as a result of the procedure. In many cases, on-the-job training will not include this type of content. If you are ever required to defend your practice for any reason (whether to the BON or any other entity), you will likely be required to provide evidence of education/training and documentation of competence related to the specific service you provided. As an advanced practice registered nurse, you retain professional accountability for any advanced practice registered nursing services you provide [Rule 221.13(e)].
I am licensed to practice in a particular population focus area. I want to expand my scope of practice to include a second population focus area. (Examples of this situation include but are not limited to: adult health expanding to include pediatrics, family practice expanding to include care of patients with complex psychiatric pathologies, and primary care expanding to include acute/critical care). Can I do this by completing continuing nursing education activities specific to the population focus and working with another advanced practice registered nurse licensed in that population focus or a physician?
There are finite limits to expanding one's scope of practice without completing additional formal education and obtaining the requisite licensure to practice in the additional role and/or...
population focus from the BON. When incorporating a new patient care activity or procedure into one's individual scope of practice, the board expects the advanced practice registered nurse to verify that the activity or procedure is consistent with the professional scope of practice for the licensed role and population focus and permitted by laws and regulations in effect at the time. For example, a women's health nurse practitioner or nurse-midwife who wishes to incorporate performance of colposcopies in his/her practice may do so without obtaining an additional licensure to practice from the BON because this activity is consistent with the professional scope of practice for those roles.
If the activity is not consistent with the professional scope of practice for the licensed role and population focus, additional formal education and authorization from the BON in the second role and/or population focus is required. For example, an advanced practice registered nurse who is licensed to practice in gerontological nursing wishes to provide advanced practice nursing care to all adult patients. In order to do so, he/she must complete education that will prepare him/her in an advanced practice role and population focus that encompasses advanced practice registered nursing care of adults of all ages. Rule 221.4(c) requires that this additional education meet the curricular requirements outlined in Rule 221.3, relating to advanced practice registered nursing education. After completing the additional formal education, you must obtain national certification in the additional role and population focus as well as licensure to practice in the particular role and population focus from the BON before you begin practicing in the additional population focus or role.
An advanced practice registered nurse has recently joined my practice. I have requested that this advanced practice registered nurse provide certain services that he/she says are not within his/her scope of practice. As a registered nurse, his/her scope of practice encompasses nursing care of patients across the lifespan in all settings—from critical care to home health and everything in between. Why isn't his/her advanced practice scope of practice the same? As a physician, I can see any patient.
The RN scope of practice is extremely broad without limitation as to setting or patient population because the education the nurse completed to prepare him/her to practice as an RN was broad. His/Her RN education provided him/her with didactic (classroom) and clinical learning...
experiences that provided him/her with the knowledge, skills, and competence to provide nursing care to patients regardless of age, diagnosis or practice setting. Therefore, RN licensure is not limited based on practice setting or specific patient population.
Similarly, physicians complete broad education that encompasses the provision of medical care to patients across the lifespan, regardless of diagnosis or practice setting. Physicians do not specialize or sub-specialize in medical school; rather, they do so after completing their initial medical education.
In order to be licensed as an advanced practice registered nurse, this individual completed additional educational preparation to expand his/her scope of practice beyond that of the RN. His/Her advanced practice registered nursing education, however, focused on expanding his/her nursing scope of practice in a particular advanced practice role and population focus (e.g. anesthesia, women's health, gerontology). Although he/she may have gained experience in a particular area in the RN role, experiences gained as an RN are not equivalent to and cannot replace formal education in the particular advanced practice role and population focus.
The BON has been regulating advanced practice registered nurses since 1980. It has always viewed the clinical nurse specialist and nurse practitioner roles as separate and distinct roles. The Board acknowledges that there may be some overlap in the scopes of practice of these two categories of advanced practice registered nurses. The amount of overlap will vary based on the individual's advanced practice educational preparation.
HB 1718, passed in the 79th Regular Legislative Session (2005), amended the Nursing Practice Act to include Section 301.353. This section defines a nurse first assist as an individual who:...
- Is licensed to practice as an RN,
- Has completed a nurse first assistant educational program approved or recognized by an organization recognized by the board, and
- Is either (1) certified in perioperative nursing (CNOR) OR (2) recognized by the board as an advanced practice registered nurse and qualified by education, training or experience to perform the tasks involved in perioperative nursing.
Therefore, if you are recognized by the board as an advanced practice registered nurse and qualified by education, training or experience to perform the tasks involved in perioperative nursing, you will only need to complete a nurse first assistant educational program. The nurse first assistant educational programs recognized by the Texas Board of Nursing are the nurse first assistant educational programs that are included on the Competency and Credentialing Institute's (CCI's) list of acceptable RNFA programs. You may access that list of programs on-line at the following URL: CCI Competency & Credentialing Institute, Steps to Become a CRNFA, http://cc-institute.org/crnfa/certification/steps/programs.aspx.
Please note: Advanced practice registered nurses who are recognized by the BON as nursemidwives may complete the American College of Nurse-Midwives' (ACNM's) process for incorporating first assistant responsibilities for obstetrical and/or gynecological procedures into their scopes of practice in lieu of a course accepted by CCI.
Although many categories of advanced practice registered nurses may have been educated to provide these and many other patient care services, other laws and regulations [such as...
federal laws, other state laws (e.g., Texas Health and Safety Code), or JCAHO requirements] significantly impact an advanced practice registered nurse's ability to provide a specific service. Although the BON may state that the performance of a particular procedure or provision of a specific patient care activity is within an advanced practice registered nurse's professional scope of practice, the advanced practice registered nurse may not perform the procedure or provide the particular service if other laws and regulations prohibit this.
The Standards of Nursing Practice in Rule 217.11 remind nurses at all levels of licensure that they are obligated to know and conform to the Nursing Practice Act and BON rules in addition to all federal, state and local laws, rules or regulations affecting their current area of nursing practice [(1)(A)]. BON staff cannot speak as experts on other agencies' laws and regulations. Therefore, it is important for advanced practice registered nurses to investigate whether other laws or regulations prohibit the performance of a procedure or patient care activity before they perform it.
My office practice employs two advanced practice registered nurses who are approved in different population foci. I understand that there is overlap in their scopes of practice. [An example of such a situation is an OB/GYN setting in which both a family nurse practitioner (FNP) and a women's health nurse practitioner (WHNP) practice]. Does this mean both advanced practice registered nurses have the same scope of practice in this setting?
BON Rule 221.12 defines the advanced practice registered nurse's scope of practice. It is important to understand that scope of practice for the advanced practice registered nurse is founded first and foremost upon his/her advanced educational preparation....
The patient population, individual advanced educational program content and competencies attained in the advanced practice registered nursing educational program always serve as the foundation for advanced practice registered nursing practice. Rule 221.13(b), relating to the core standards for advanced practice, further states that advanced practice registered nurses must practice within the role and population focus appropriate to their educational preparation.
Although both programs included content related to a particular specialty or sub-specialty, the depth of the content included in each program varies significantly. As in the example of OB/GYN specialty content for the FNP and WHNP, the FNP educational program provided some content related to OB/GYN. It did not, however, include OB/GYN specialty content to the same depth that the WHNP's program did. Therefore, although there will be overlap in the scope of the services each advanced practice registered nurse provides in this setting, there may be procedures or patient care activities that are within the WHNP's scope of practice that are not within the FNP's scope of practice in this particular setting. Each advanced practice registered nurse is responsible for practicing within the role and population focus licensed by the board and appropriate to his/her educational preparation. Additionally, each advanced practice registered nurse is responsible for recognizing when he/she is in danger of exceeding his/her personal and professional scope of practice.
No. Advanced practice registered nurses are regulated solely by the Texas Board of Nursing. As RNs, advanced practice registered nurses may only delegate tasks to unlicensed staff or...
assistive personnel utilizing the applicable RN Delegation Rules 224 or 225 as appropriate and in compliance with Rule 217.11(3)(B). Advanced practice registered nurses are not authorized to exceed the delegation criteria in Rules 224 and 225.
With regard to other nurses, it is important to note that an advanced practice registered nurse may make an assignment to another nurse that takes into account his/her scope of practice and level of licensure [Rule 217.11(1)(S)]. An advanced practice registered nurse may not assign tasks to RNs or LVNs that exceed the RN or LVN scope of practice, even if the advanced practice registered nurse agrees to co-sign the RN's or LVN's documentation. An advanced practice registered nurse's co-signature for something that is beyond the RN's or LVN's scope of practice does not legitimize the RN's or LVN's actions. A nurse never functions "under the license" of another nurse nor does a nurse "delegate" to another licensed nurse. For more information see Texas Board of Nursing Laws & Rules
No. The Texas Board of Nursing (Board or BON) does not require CPR for licensure renewal; however, employers may have specific requirements for maintaining current CPR status as a condition of employment. Nurses should use their professional judgment when deciding to maintain...
current CPR certification, taking into consideration whether they are employed in patient care settings in which CPR may be necessary to resuscitate a client. Nurses have a responsibility to maintain continuing competence in nursing practice and individual professional growth; therefore, many nurses as well as their employers consider current CPR certification as a means for demonstrating continuing competency and a measure for promoting professional standards.
Yes. All nurses have an obligation or duty to initiate CPR for clients who require resuscitative measures. The decision to initiate CPR can ";preserve life, restore health, relieve suffering, limit disability, and respect the individual's decisions, rights, and privacy." In all healthcare settings, nurses must initiate CPR immediately in the absence of a client’s do-not-resuscitate/out of hospital do-not-resuscitate order. A...
do-not-resuscitate/out of hospital do-not-resuscitate order is a medical order that must be given by a physician and in the absence thereof; it is generally outside the standard of nursing practice to determine that CPR will not be initiated. The initiation of CPR does not require a physician’s order in the absence of do-not-resuscitate/out of hospital do-not-resuscitate order. While the Board does not have purview over certain facility, agency, or employment policies, these policies should be written clearly and easily implemented to support a client’s wishes.
In general, the Texas Nursing Practice Act and Board Rules and Regulations establish a nurse’s duty to initiate CPR and require every nurse, regardless of expertise, specialty, or practice setting to provide safe and effective care for clients. Licensure laws and rules do not specifically require a nurse to have a current CPR card in order to perform CPR or utilize other life-saving interventions for a client. Instead, the minimum standards of nursing practice addressed in Board Rule 217.11 require a nurse to “implement measures to promote a safe environment for clients and others” as well as “institute appropriate nursing interventions that might be required to stabilize a client’s condition and/or prevent complications.”
In the absence of a do-not-resuscitate/out of hospital do-not-resuscitate order from a physician, all nurses should initiate CPR immediately in a witnessed arrest, regardless of healthcare setting. CPR should continue and the physician should be notified of the client’s change in condition to include current life-saving interventions being provided to the client.
Yes, Position Statement 15.20, Registered Nurses in the Management of an Unwitnessed Arrest in a Resident in a Long-Term Care Facility. The purpose of this position statement is to provide...
recommendations and guidance to clarify issues for compassionate end-of-life care for residents residing in long-term care facilities only. This position statement is specific to long-term care facilities and is not to be construed as applicable to other healthcare settings in which nurses are employed.
After assessment of the resident is completed and appropriate interventions are implemented, documentation of the circumstances and the assessment of the resident in the medical record are required. The rules of the BON establish legal documentation standards.
Nurses should know and follow their facility, agency or employer’s policies in advance of establishing a nurse-patient relationship....
The American Heart Association recommends that all clients receive CPR immediately unless attempts at CPR would be futile; such as when clients exhibit obvious clinical signs of irreversible death. Obvious clinical signs of irreversible death include decapitation (separation of head from body), decomposition (putrefactive process; decay), dependent lividity (Dark blue staining of the dependent surface of a cadaver, resulting from blood pooling and congestion), transection, or rigor mortis (body stiffness that occurs within two to four hours after death and may take 12 hours to fully develop).
No. The Board of Nursing does not have purview over physician practice, employer policies, or the laws regulating the pronouncement of death in Texas. Additional information on Texas regulations regarding pronouncement of death may be found in the Texas Health and Safety Code Chapter 671 and Texas Administrative Code Chapter 193 (22 TAC, §193.9).
Yes. The decision to initiate CPR for all nurses should be a spontaneous clinical decision and nursing intervention for a client in cardiac or respiratory arrest. Delay in initiating CPR can be critical to the outcome of CPR. CPR should not be delayed to review the client’s medical record or chart to determine the client’s wishes or search physician orders for...
do-not-resuscitate/out of hospital do-not-resuscitate documentation. Employers and nurses should take a proactive approach to ensure that healthcare setting policies are in place to ascertain a physician’s order for resuscitative status upon admission and to update the plan of care to anticipate the immediate need to access a client’s current resuscitation status physician’s order so that CPR is initiated appropriately and without delay.
Texas Statutes and Rules and Regulations outside of the nursing licensure laws and rules govern who can pronounce death, and only those legally authorized to pronounce death may do so (i.e., physician, justice of the peace). Texas regulations regarding pronouncement of death may be found in Texas Health and Safety Code Chapter 671 and Texas Administrative Code Chapter 193 (22 TAC, §193.9).
During the 72nd Texas Legislative session (January, 1991 to May, 1991), Senate Bill 823 passed which permitted RNs legal authority to assess a client and make a determination of death, unless the pronouncement is clearly prohibited under the Health and Safety Code (such as when an inquest is required). The passing of this bill is addressed in Health & Safety Code §671.001-.002. The law requires that in order for a nurse to pronounce death, the facility, institution, or entity must have a written policy which is jointly developed and approved by the medical staff or medical consultant and the nursing staff, specifying under what circumstances an RN can make a pronouncement of death.
An RN and/or an APRN can pronounce death when a client has executed a properly documented do-not-resuscitate/out of hospital do-not-resuscitate physician orders and when the employer has policies and procedures in place to acknowledge that the RN and/or APRN may pronounce death. Neither an RN nor an APRN may sign the death certificate under any circumstances.
No. The Board of Nursing Position Statement 15.2 addresses the Role of The Licensed Vocational Nurse in the Pronouncement of Death. LVNs have a directed scope of practice under the supervision of RNs, APRNs, PAs, Physicians, Dentists, and Podiatrists....
LVNs conduct focused assessments that include making nursing observations and recognizing significant changes in a client’s condition. These observations and changes in condition are reported to the physician. LVNs may not accept an order to pronounce death; however, after LVNs communicate their findings which include presumptive and/or obvious clinical signs of irreversible death to the physician and in accordance with facility policy, the LVN may accept a reasonable physician’s order regarding the care of the client (i.e., notification of family and funeral home and postmortem care). It is imperative that LVNs document their focused assessment findings, nursing interventions, and communication with physician and physician’s orders.
In addition to the current American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, the Board website (www.bon.texas.gov) may provide assistance and serve as a resource in developing policies and procedures to further support safe practice...
with regard to CPR. The Board recommends employers consider the following references when establishing policies and procedures in the healthcare setting.
- Board Rule 217.11, Standards of Nursing Practice
- Position Statement 15.27, LVN Scope of Practice
- Position Statement 15.28, RN Scope of Practice
- Position Statement 15.14, Duty of a Nurse in Any Practice Setting
- Position Statement 15.2, The Role of the Licensed Vocational Nurse in the Pronouncement of Death
- Position Statement 15.20 Registered Nurses in the Management of an Unwitnessed Arrest in a Resident in a Long Term Care Facility
- Frequently Asked Question, RN Pronouncement of Death
- Texas Administrative Code Chapter 193 (22 TAC, §193.9)
- Texas Health and Safety Code Chapter 671