||Nurses Carrying out Orders from Physician Assistants
||Nurses may carry out physician orders relayed by a physician assistant (PA) when the PA is compliant with laws regulating the practice of the PA. The nurse is expected to clarify any order the nurse questions by communicating
with the PA or the physician.
||The Role of the Licensed Vocational Nurse in the Pronouncement of Death
|| LVNs must initiate CPR in the absence of a clear do-not-resuscitate (DNR) order. Laws regarding the pronouncement of death are not in the NPA or Board Rules. LVNs cannot pronounce death. The LVN may accept a physician’s order regarding post-mortem care, but cannot accept a verbal order to pronounce death.
||LVNs Engaging in Intravenous Therapy, Venipuncture, or PICC Lines
||The LVN must complete post-licensure training to engage in IV Therapy/Venipuncture (not typically included in LVN curriculum). Insertion of PICC lines is beyond the scope of practice for LVN.
||The Board supports educational mobility for nurse’s prepared at LVN, Diploma, ADN, and BSN levels without needless repetition of clinical experiences or time penalties. The Board also supports educational mobility for military personnel and veterans.
||Nurses with Responsibility for Initiating Physician Standing Orders
||Nurses may initiate physician’s standing medical orders or standing
delegation orders by selecting specific tasks or functions for patient management. The nurse is accountable to assure his/her actions are
in accordance with the NPA and Board Rules, including that the standing orders do not require the nurse to engage in independent medical judgment.
NOTE: RN’s who lack Advanced Practice licensure and LVNs
may not utilize “protocols” intended for use by APRN’s or PA’s (see
definitions of protocols from the Texas Medical Board in this position
||Board Rules Associated with Alleged Patient “Abandonment”
Differentiates employment vs. licensure issues; addresses relevant Board rules when a nurse engages in unprofessional conduct with regard to being unavailable to provide care to assigned patients (such as sleeping on the job).
Provides guidance for nurses in relation to emergency preparedness and workplace violence (including disasters, infectious disease outbreaks, or bioterrorism).
||The Role of LVNs & RNs in Management and/or Administration of Medications via Epidural or Intrathecal Catheter Routes
LVNs may provide nursing care to patients with epidural or
intrathecal catheters, but should not be responsible for catheter management, including administration of drugs via these routes.
Epidural & Intrathecal catheter management is within the RN’s scope of practice if the RN has current competency in both the knowledge
and skills required, with certain limitations recommended in the
obstetrical setting. Appropriate nursing policies and procedures must also be in place.
||Role of the Nurse in Moderate Sedation
LVNs cannot administer pharmacologic agents for the purpose of achieving moderate sedation to or monitor patients receiving moderate sedation.
The administration of drugs and monitoring of patients for moderate sedation may be within the RN’s scope of practice. If an RN elects to engage in administration of pharmacologic agents classified
as “anesthetic” agents to induce moderate sedation, the RN should either be skilled in, or have immediate availability of other practitioners skilled in advanced airway management along with appropriate equipment that might be necessary to rescue a patient from unintended deep sedation. The facility or physician’s office needs to have policies and procedures to guide the RN. See evidence-based practice standards of professional anesthesia association guidelines listed in the position statement.
||Performance of Laser Therapy by RN’s or LVNs
||A nurse must have the appropriate education, knowledge, and experience to engage in laser therapy. There are criteria to be followed by the nurse who accepts physician delegation in the use of non-ablative laser therapy and there are specific regulations related to laser hair removal (from the Texas Department of State Health Services).
||Continuing Education: Limitations for Expanding Scope of Practice
||Clarifies that expansion of an individual nurse’s scope of practice has licensure-related limitations. Informal continuing nursing education or on-the job
training cannot be substituted for formal education leading to the next level of practice/licensure.
||Delegated Medical Acts
||Specifies criteria which must be met for a nurse to carry out a
delegated medical act. This includes documentation of individual training and competency, procedures to be performed, physician order
to initiate, and appropriate medical and nursing back up.
||Use of American Psychiatric Association Diagnoses by LVN, RNs, or APRNs
||LVNs and RNs cannot determine medical diagnoses. Use of these
multi-disciplinary psychiatric diagnoses is permitted by advanced practice nurses designated as Clinical Nurse Specialists (CNS) or Nurse Practitioners (NP’s) whose population focus area is psych/mental health. Patient problems beyond the scope of training and education of the psychiatric mental health CNS/NP are to be referred to an appropriate psychiatric mental health or medical provider.
||Role of LVNs and RNs in School Health
||Discusses the role of the LVN and RN in school health. The Texas Education Code (TEC) defines a school nurse as a RN. The RN may delegate routine, repetitive tasks in the school setting in compliance with the BON’s Delegation Rules found in Chapters (§224 & §225). Also addresses the RN’s supervisory relationship to LVNs who provide nursing services in a school setting.
||Duty of a Nurse in any Practice Setting
||Establishes that a nurse has a responsibility and duty to a patient to provide and coordinate the delivery of safe, effective nursing care, through the NPA and Board Rules. This duty supersedes any facility policy or physician order.
||Board's Jurisdiction over a Nurse's Practice in Any Role and Use of the Nursing Title
||If a RN or LVN functions in role of lower than current level of licensure, or in another area with an overlapping scope of practice, the nurse is still held to the level of education and competency of the nurse's highest licensure. Also restricts use of the titles LVN or RN or any designation implying nursing licensure by non-nurses
(NPA Section 301.351 and NPA Section 301.004(a) (5)and Rule 217.10).
||Development of Nursing Education Programs
||Judicious development of new nursing programs is urged as adding programs alone will not address the growing nursing shortage. Key considerations are delineated.
||Texas Board of Nursing/ Board of Pharmacy Joint Position Statement, Medication Errors
||Stresses the need to look at “systems” and not just “individual competency” in determining root causes of medication errors and implementing strategies to effectively reduce errors, thus better protecting the public.
||Nurses Carrying Out Orders from Advanced Practice Registered Nurses
||Nurses may carry out orders issued by APRN’s as long as the orders are within the APRN’s scope of practice in their role and population focus. The nurse is expected to question orders they believe are nonefficacious or contraindicated by consulting with the APRN or the physician.
||Nurses Carrying Out Orders from Pharmacists for Drug Therapy Management
||There are rules that permit pharmacists to write orders for Drug Therapy Management (DTM) while working under physician delegation. A nurse may carry out these orders provided the orders originate from a written protocol authorized by a physician. The nurse is responsible and accountable for his/her actions as with any physician order.
||Registered Nurses In the Management of an Unwitnessed Arrest in a Resident in a Long Term Care Facility
||Guidance is provided concerning the appropriateness of initiating cardiopulmonary resuscitation (CPR) when the RN encounters an unwitnessed resident arrest without a do not resuscitate (DNR) order in the long term care setting only. Presumptive and conclusive signs of death are delineated, to assist the RN in making a decision that CPR would be futile. Documentation, RN obligation to the patient, care planning/advanced directives, and RN pronouncement of death are also discussed.
||In 2005, the Nursing Practice Act (NPA) expanded to include LVNs. This allowed LVNs to be included in the safe harbor provisions eliminating the need for Position Statement 15.21, Application of Safe Harbor Peer Review to LVNs.
||APRNs Providing Medical Aspects of Care for Individuals with whom there is a Close Personal Relationship
||The BON is concerned that when APRNs provide medical aspects of care for individuals with whom they have a close personal relationship the APRNs risk allowing their personal feelings to cloud their professional judgment. Thus APRNs should not provide medical treatment or prescribe medications for individuals with whom they have a close personal relationship.
||The Use of Complementary Modalities by the LVN or RN
||Regardless of practice setting, nurses who incorporate complementary modalities into their practice are accountable and responsible for adherence to the NPA and BON Rules and Regulations. Specific regulations of particular relevance are identified in the position statement, including a reference to the BON’s Six-Step Decision-Making Model for Determining Nursing Scope of Practice. Also, a list of criteria is included in order for nurses to show accountability for the care they provide. Lastly, nurses are accountable to hold proper credentials (e.g., license, certification, registration) to safely engage in specific practices, where applicable.
||Nurses Engaging In Reinsertion of Permanently Placed Feeding Tubes
||LVNs & RNs should receive post-licensure training and demonstrate competency in reinsertion of a displaced permanently placed feeding tube prior to engaging in this activity. Verification of correct placement is essential to prevent life-threatening complications. Reinsertion by a nurse is not recommended prior to 8-12 weeks post-initial
insertion; specific physician orders must be obtained regarding reinsertion by a nurse.
||Administration of Medication & Treatments by LVNs
||LVNs are educationally prepared to administer medications and treatments as ordered by a physician, podiatrist, dentist or any practitioner legally authorized to prescribe the ordered medication. LVNs may administer medications and treatments ordered by physician assistants (PS 15.1) and advanced practice registered nurses
(PS 15.18). Also see NPA 301.002(5), the definition of vocational nursing.
||Guideline 3.8.6.a Simulation in Pre-Licensure Nursing Education has replaced Position Statement 15.26, Simulation in Prelicensure Nursing Education.
||The Licensed Vocational Nurse Scope of Practice
||The LVN scope of practice is a directed scope of practice and requires appropriate supervision. The LVN is responsible for providing safe, compassionate, and focused nursing care to assigned patients with predictable health care needs.
||The Registered Nurse Scope of Practice
||The RN takes responsibility and accepts accountability for practicing
within the legal scope of practice and is prepared to work in all health care settings, and may engage in independent nursing practice without supervision by another health care provider. The RN is responsible for providing safe, compassionate, and comprehensive nursing care to patients and their families with complex healthcare needs.
||Professional Boundaries including Use of Social Media by Nurses
||The purpose of this Position Statement is to provide guidance to nurses regarding expectations related to professional boundaries, inclusive of social media, and to provide nurses with guidance to prevent boundary violations.