Anticipating the Future
Maintaining Your License
By
Charlene Morris, RN, MSN
Texas Occupations Code
• Governs many occupations
• Chapter 301 - Law that establishes &
empowers
Board of Nursing for the State
of Texas
• Contains the Nurse Practice Act
• Contains law setting up rules and regulations for nursing
practice in Texas – Defines the SCOPE of PRACTICE
• Texas Administrative Code
– Provides more detail on how the requirements of the
Occupations Code are to be carried out.
– Appointment of members, meetings, proceedings,
investigations, disciplinary actions, etc.
Texas Occupations Code
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Chapter 301: Nursing Practice Act
Chapter 303: Nursing Peer Review
Chapter 304: Nurse Licensure Compact
Chapter 305: Advanced Practice
Registered Nurse Licensure Compact
TEXAS OCCUPATIONS CODE AND STATUTES REGULATING
THE PRACTICE OF NURSING
As Amended September, 2005
AGENCY MISSION
The mission of the Texas Board of Nursing (BON) is
to protect and promote the welfare of the people of
Texas by ensuring that each person holding a license
as a nurse in the State of Texas is competent to
practice safely.
This mission, derived from the Nursing Practice Act,
supersedes the interest of any individual, the
nursing profession, or any special interest group.
Protecting the People of Texas
Texas Administrative Code
BOARD OF NURSING
Purpose and Functions
Purpose.
The board fulfills its mission through two
principle areas of responsibility:
(1) regulation of the practice of professional
and vocational nursing
(2) accreditation of schools of nursing.
Texas Administrative Code - Functions of BOARD OF NURSING
The board shall perform the following functions as outlined in
Texas Occupations Code chapters 301, 303, 304, & 305.
(1) Establish standards and regulate the practice of
professional and vocational nursing.
(2) Interpret the Nursing Practice Act and Regulations
Relating to:
Nurse Education
Licensure and Practice to nurses
Employers
Public to ensure informed professionals,
allied health professionals, and consumers.
Texas Administrative Code - Functions of BOARD OF NURSING
The board shall perform the following functions as outlined in
Texas Occupations Code chapters 301, 303, 304, & 305.
(3) Receive complaints and investigate possible
violations.
(4) Discipline violators through appropriate legal
action.
(5) Provide a mechanism for public comment
and by which the rules and regulations are modified
when appropriate.
(6) Examine and license qualified applicants and
recognize qualified applicants for advanced practice
nursing as minimally competent.
(7) Grant licensure by endorsement and grant
recognition of advanced practice nurses from other
states.
(8) Recommend to legislature appropriate changes in
the Nursing Practice Act
(9) Establish standards for nursing education and
accredit or deny accreditation of schools.
(10) Monitor the examination results of applicants for variances
in the level of educational effectiveness.
(11) Consultation and guidance to nurse schools for self-study,
evaluation, and the development of effective education
programs.
(12) Provide advice to the faculty, staff of health care agencies
utilizing nursing services, and practitioners of nursing to improve
professional service.
(13) Implement and manage all other programs and
responsibilities as authorized and mandated by the Texas
Legislature.
Source Note: The provisions of this §211.2 adopted to be effective March 31, 2002, 27 TexReg 2236; amended to be effective May 17, 2004, 29 TexReg
4884
Standards of Nursing Practice
in the state of Texas
Texas Administrative Code
Chapter 217 Rule 217.11Standards of Nursing Practice in the state of Texas
• Know and conform to Nurse Practice Act &
Rules
• Promote safe environment
• Know rationale & effects of meds & treatments
Administer them safely, stabilize pts. and
question orders PRN
• Accurately document/report assessments and
response to care and pt. status as well as
contacts with other health care team members
• Respect patient’s right to privacy – confidentiality
• Provide education/counseling to client, family,
etc. & referrals
Texas Administrative Code
Chapter 217 Rule 217.11Standards of Nursing Practice in the state of Texas cont.
• Obtain appropriate supervision, orientation, inservice info, & CE’s
• Accept responsibility for competence & growth
• Notify supervisor when leaving nursing
assignment
• Maintain professional boundaries
• Comply with reporting requirements
• Provide care without discrimination & within own
abilities and those of others you are supervising
• Implement measures to stabilize clients and
prevent complications
• Implement measures to prevent exposure to
infectious disease
Texas Administrative Code
Chapter 217 Rule 217.11Standards of Nursing Practice in the state of Texas cont.
• Clarify any order or treatment that may be
inaccurate, non-efficacious or
contraindicated by consulting the
appropriate licensed practitioner and
notifying the ordering practitioner when
deciding not to administer the medication
or treatment
• Collaborate with the client, care team, and
when appropriate the client’s family to
provide optimal care.
• Make appropriate referrals for continuity of
care.
Texas Administrative Code
Chapter 217 Rule 217.11Standards of Nursing Practice in the state of Texas cont.
• Make appropriate/safe assignments based
on ability and client’s needs
• Accept only those assignments that you
can do safely.
• Supervise those for whom they are
responsible.
• Ensure verification of current licensure or
compact privilege when administratively
responsible
Texas Administrative Code
Chapter 217 Rule 217.11Standards of Nursing Practice in the state of Texas –
just for RN’s.
• Use systematic approach to provide
individualized, goal directed nursing care
based on nursing process.
• Delegate tasks to unlicensed personnel in
compliance with Chapter 224 (acute care
settings) and Chapter 225 (independent
living environments) with stable and
predictable conditions.
Contacting the Texas Board of
Nursing
Location of Board’s office:
333 Guadalupe, 3-460
Austin, Texas 78701
Telephone:
512/305-7400
Web page:
http://www.bon.state.tx.us/contact/
Contact Person: Katherine Thomas, MN, RN, Executive Director
Texas Licensure
Assuring Competence
• NCLEX-RN – assures knowledge base &
decision-making ability
• Graduation from accredited school –
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Psychomotor/technical skill safety
Legal/ethical knowledge & values
Interpersonal skills
Decision-making skills
• Basis for school’s evaluation criteria from BON
Rules & Regulations
– “Standards of Nursing Practice in Texas”
– “Unprofessional Conduct”
Applying for your License
• See the http://www.ncsbn.org/ and
www.pearsonvue.com/nclex web sites
• See check list at end of application
– BON Application
• 2 FBI finger print cards
• $139.00 fee BNE application
• 2x2 passport photo, signature, date taken
– Registration for NCLEX-RN Exam
• NCLEX-RN Examination application form
• $200 NCLEX Registration
– Affidavit of Graduation from Nursing Program
NCLEX Test Plan
4 categories of client needs
• Safe & effective care environment
– Management of care – 13-19%
• Providing and directing care enhancing care and protection of client
– Safety and infection control – 8-14%
• Protection from environmental hazards
• Health Promotion & Maintenance – 6-12%
• Growth and development, prevention, early detection, health promotion
• Psychosocial Integrity – 6-12%
• Care supporting emotional, mental, and social wellbeing in stressful events
• Physiologic Integrity
– Basic care and comfort – 6-12%
• Activities of daily living
– Pharmacological & parenteral therapies – 13-19%
• Care related to medication and blood/blood product administration
– Reduction of risk potential – 13-19%
• Decreasing risk of complications of illness or treatments
– Physiological adaptation – 11-17%
• Care for clients with acute. Chronic, and life threatening illnesses
Test Plan cont.
Processes integrated into the previous categories
• Nursing Process
• Caring
– Nurse and patient interaction
– Collaborative environment
• Communication & documentation
• Teaching/Learning
• Life span in various settings
Some questions will apply knowledge from 2
different categories
Type of Testing
• CAT – Computer Adaptive Testing
• Identifies 95% chance of safe practice
– Various types of questions
• Pictures, fill in the blank, multiple answer, etc.
– Don’t make wild guesses to finish items
– Each test is different
• Computer selects items for candidate’s skill level
• Level of question based on answer to previous question
• Different questions each time applicant tests
– Contains some items that are not graded
– Instructions, sample items, and breaks are included in
testing time period allowed
www.pearsonvue.com/nclex
NCLEX-RN Success
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Web sites
HESI exam as predictor – danger < 850
Review course or review books
Level 4 exam scores predictor of specific
areas
Test Taking Tips
• Study & practice (1 question per 60 to 70 seconds)
• Plan
– Austin testing sites
– Pearson Professional Centers-Austin, TX
301 Congress Avenue Suite 565
Austin,Texas78701
512-469-0276
– Schedule carefully
– Sleep, eat, take precautions to promote calm
• Strengthen testing strategies
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Read carefully (1 to 2 min./item)
Think through but don’t read into question
Remember entry level for LVN and/or CNA or UAP
Text book not the patient you saw in clinical
Use your breaks to rest
www.pearsonvue.com/nclex
What to Expect/Prepare
• Arrive 30 minutes early, if you are more
than 30 min. late for testing, you will need
to be rescheduled and pay fee again
• Come alone no children/family/friends
waiting or calling
• No hats, scarves, coats, calculators,
pencils, etc. permitted in testing area
• Bring
– Authorization to Test (ATT) form – needed to schedule testing session –
Name same as on ID
– Valid non-expired Photo ID with your signature
– Finger print, photo, & signature will be taken
on admission to test and after breaks
What to Expect/Prepare
• May take up to 6 hours to complete
test - raise hand don’t get up
– First optional break after 2 hrs. – fingerprinting before and after
breaks
– Second is 90 minutes after test resumes
• Must use computer calculator
• 75 to 265 questions – 15 unscored
• Number of questions does not predict
Pass/Fail
– 75 high pass or fail as computer determines trends
• Must answer each item to continue
the test after (ENTER), can’t go back
What to Expect/Prepare
• Official results come from BON- up to
14 days after BON receives scores
– Pay a small fee to get preliminary results in 24 hours.
• Retest every 45/90 days for 4 years in
Texas
• Sec. 301.255 Re-examination. (Texas
Occupations Code- BON may require
additional educational requirements
or deny retesting if test is failed 2 or
more times.)
Jurisprudence Exam
• Students applying for licensure after
9/1/08 or having to retake the NCLEX-RN
• You must take the exam and pass it once
to become an RN.
• Cost of exam will be part of application
and will be taken on your computer from
the BON website.
• You may take it as many times as you
need to for a passing score – q 7 days.
Exam cont.
• You will know if you passed upon
completion – 75% is a passing score.
• It will be open book from the NPA and it
will be timed – 2 hours.
• 50 Questions and will be knowledge and
application. (Will not ask for specific
section numbers of Nurse Practice Act but
will test for understanding)
Test Blueprint
• 5 subject areas with weight
• A. Nursing Licensure & Regulation in
Texas –15%
• B. Nursing Ethics –20%
• C. Nursing Practice - 30%
• D. Nursing Peer Review- 15%
• E. Disciplinary Action – 20%
Topic areas to guide review of content are
available on the BON website.
Test Review

BON has developed an online Test
Review/Prep Workshop which costs about
$25 and takes about 2 hours to complete.
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This course is accessed on the BON
website after applying and obtaining a pin
number from the BON.
Guidelines for New Graduates &
New RN’s
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What are the requirements that must be
met to obtain a GN Verification Letter?
Once granted, what are the limitations of
practice placed on a GN using this
privilege?
Compare these limitations to those that
the BON recommends for newly licensed
RN’s.
Guidelines for New Graduate’s
Employment
• GN verification letter issued after:
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Completion of application for licensure
Criminal checks complete
Affidavit of graduation
Received your Authorization to Test
Registered with Pearson
NCLEX testing date set
• No outstanding eligibility issues
• 75 day period specified on GN Verification letter or
results of first NCLEX attempt
• If first NCLEX is failed MUST stop GN practice
• Must know and follow Nurse Practice Act – Rules and
Regulations
Graduate Nurse Requirements
• Temporary Authorization to Practice
• Must work under direct supervision of RN
– RN physically available
– RN at same site
• May not be in charge or supervising
• May not function in an independent setting
• May perform any function that falls within
the scope of practice for which they have
educational preparation and demonstrated
minimal competency
BON Rule 217.3
Recommendations After Licensure
These are for your protection
• Direct supervision for 6 months or less if
agreed upon by new graduate and supervising
RN
– Competence agreed upon by both
– Successful completion of orientation requirements
• Newly licensed should not be in charge for 6
months unless agreed upon by grad & RN
Newly Licensed Nurse
• Guideline:
– Amount of supervision and charge positions
should be mutually agreed upon
– 12-18 months experience in a structured
setting before practicing in independent living
environment
Continuing Competency
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Identify how competency is maintained
and validated.
How are CE’s approved?
What type of learning experiences can
be counted as CE credit toward license
renewal? What learning experiences are
not acceptable?
Describe required record keeping related
to CE’s.
Continuing Competency (Sec.
301.303 – Occupations Code
• Completion of targeted cont. ed. Programs
• Professional portfolio including
certifications
• May not require more than 20 hours CE
per 2 year period
• Specific State Requirements
– Hepatitis C between June 2002 – June 2004
– Bioterrorism Response was a one time
requirement
– Forensic Evidence Collection – 2 hrs. for ER
nurses by Sept. 1, 2008
Texas Administrative Code (216.1) - 2005
• All CE’s – To count toward licensure renewal, a program must have
been approved by one of the credentialing agencies recognized by
the Board. The credentialing agencies have met nationallypredetermined criteria to approve programs and providers of CE.
– RN planner
– Approved by accepted credentialing agency
– Class or individualized home study/programmed instruction
• A 3hr. academic nursing course (part of a degree plan taken for
credit with grade C or better or a pass of pass/fail) counts for 15
hours
• ACLS, ATLS, and PALS, or national certification in a non-advanced
nursing practice specialty (i.e. CCRN, RNFA, CWOCN, etc.) may be
counted for CE credit
• In-services, CPR, Refresher courses do not count.
• Keep records for 4 years
• One CE hour = 60 minutes not 50 as in the past
License Renewal
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Describe the license renewal process for new
RN’s and experienced RN’s. What criteria
must be met for standard renewal?
What are the requirements for reactivation
when the license was in an official inactive
status for more than 4 years?
What are the requirements for licensure for
retired RN’s who volunteer their service at a
community agency?
Texas Administrative Code (216.1) - 2005
• License Renewal every 2 years - $65
– End of Birth month and odd or even years based on
birth year
– Receive post card reminder 30 days prior
(90 days if CE audit required)
– Renew on line at BON web site & credit/debit card if
meet all criteria
• No bars: delinquent student loans/child support, legal issues,
Psych illness, drugs, and lack of required CE’s
• Application implies legal signature/testimony of meeting
criteria and makes nurse legally responsible for accuracy.
• First renewal
• Continuing education required – not need 20 hours
– ER Forensic Evidence Collection 2 hours
• Six to 29 months after first issued depending on nurses date
of birth.
Nursing Licensure Compact
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States participating in a Licensure Compact
accept similar requirements for licensure. What
is a nurse’s Home State and how does that
relate to licensure?
When a nurse practices in a party state whose
laws and scope of practice guide the care
provided by the nurse?
Can the nurse simultaneously hold a home
state license in more than one party state?
Under what circumstance can the nurse hold a
license in more than one state at the same
time?
Nursing Licensure Compact
• Chapter 304
• Rule 220
Nurse Licensure Compact
• States agreeing to recognize each others
nursing licenses
• Texas among the first to adopt this plan - 2000
• Premise:
– Only defines the requirements to hold a license
• Similar licensure requirements in most states
– Each state defines its own scope of practice
– States share information related to problems
• Warnings
• Suspensions
• Licenses that have been revoked
• Imposters
Map indicates states that have enacted the RN and LPN/VN Nurse
Licensure Compact (NLC).
Last Updated: [July 2008]
Compact Definitions
• Party States
– States who have adopted the compact
• Primary state of residence –(Home state)
– Where you permanently reside or your declared fixed
permanent & principal home for legal purposes
• Remote state
– Where you practice using multistate privilege
– Must be a party state
Compact Requirements
• Nurse must:
– Maintain home state license
– Adhere to practice laws of state in which the
patient is located at time of care
– Use multi state privilege only in party states
– Hold a home state license in only one party
state at a time
• If permanent home address changes to another
party state, relinquishes license of previous state
• Applies for & meets requirements for licensure in
new Home state (30 day grace period for
processing new license)
Practicing in a Different State
1. How is a nurse’s licensure impacted when
he/she changes their permanent address from
one state to another? Differentiate between
movement from one party state to another as
opposed to movement from a party state to a
non-party (remote) state?
2. Can a nurse hold permanent residence on a
party state and work in a remote state?
3. What are the requirements and limitations of a
nurse licensed in a remote state when they
wish to obtain a license to practice in Texas?
Practicing in a Non-Party State
• Must obtain a license from the non-party
state
• May hold both a home state license and a
license from the non-party state
• If you live in a non-party state
– Must obtain a non-resident Texas license to
practice in Texas
– Lose multistate licensure privilege in other
party states
Impact of Licensure Compact
• States share information
– Nurses licensed
– Disciplinary action
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Protects public health and safety
More mobile workforce for employers
Allows nurses to be more mobile
Provides for new forms of practice
– Online practice
– Telephone practice
Peer Review
Incident-Based Peer Review
Rule 217.19
And
Safe Harbor Peer Review Rule 217.20
Determine Scope of Practice
• The Six Step Decision Making Model
found in the back of Nursing Practice Act,
Nursing Peer Review, Nurse Licensure
Compact
Rule 217.11 and 217.12
• Rule 217.11 Standards of Practice
• and 217.12 Unprofessional Conduct
– Provide baseline for safe and effective care
– Establish minimal acceptable level
– Identifies unprofessional behaviors
Unprofessional Conduct &
Peer Review
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Discus unprofessional conduct.
Describe the types of agencies that must
have a Peer Review Committee.
Describe an incident based peer review
process.
Are the findings always reported to the
BON? What must be reported? How is it
reported?
Incident-Based Nursing Peer Review
• Evaluation of
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Nursing services
Qualifications of a nurse
Quality of care provided
The merits of a complaint about a nurse
Recommendations about a complaint
• Nurse under review given written notice to
attend with info about complaint
• Fact finding process, analysis studying events
that occurred - due process as right to question
witnesses and confidentiality
• Climate of collegial problem solving
• Not a legal proceeding but can have lawyer/peer
• If fault is found nurse is subject to Reporting
Requirements
Peer Review – RN’s & LVN’s
• Employers of 10 or more licensed nurses
must have a Peer Review Committee
– Putting a patient or other person at risk of
unnecessary harm
– Failure to adequately care for a patient
– Unprofessional conduct (217.12)
– Failure to conform to minimum standards of
practice (217.11)
– Impairment or likely impairment of the nurse’s
practice due to chemical dependency
The Nurse’s Duty to Report
• Licensed care giver, agency, or facility
– Exposing a patient to substantial risk of harm due to
lack of minimum standard of nursing care
• Another nurse
– Impairment, lack of minimum standard of care,
unprofessional conduct, or unnecessary exposure of
pt. to risk for harm
• Nursing student
– Chemical impairment
– Ability to perform professional service within
reasonable expectations
Reporting
(for Peer Review or BON)
• Must be in writing and signed
• Must include name of nurse or student and
information required by the Board
• May take the report to the employer or
school
Action Peer Review Committee/BON
• Problem reported to employer
• Proceedings are confidential
• If committee finds cause they must report
to BON
– Identity
– Problem
– Corrective action taken
– Recommendation for BNE action
Minor Incidents - Rule 217.16
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Describe a minor incident.
When and how are they reported and to
whom?
What are the consequences of frequent
minor incidents?
What types of incidents are considered
major?
Minor Incidents
Rule 217.16
• Continued practice doesn’t pose risk of harm to
client(s)
– Potential risk of harm is very low
– Incident is singular
– Nurse’s approach to practice is conscientious and
accountable
– Has knowledge and skill for safe practice
• 5 minor incidents in any consecutive 12 month
period must be reported to Peer Review
Committee
– If no Peer Review Committee is available must report
to BON
Conduct Assistance
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What is unprofessional conduct? Provide
examples of this type of problem.
What types of problems fall under
217.13? What types of assistance is
available to nurses who have these types
of problems?
What can happen to their license if they
can not comply with professional conduct
or restrictions of supervision?
217.12 Unprofessional Conduct
• Purpose:
– Protect the public from
• Incompetent & careless
• Unethical
• Illegal conduct of nurses
– Applies to any licensed nurse
Peer Assistance Rule 217.13
• Required by law
• Identifies, assists, and monitors
professional colleagues so they can work
– Experiencing mental health, alcohol or drug
problems
– Problems impair or may impair job
performance or safe care
Safe Harbor Peer Review
Safe Harbor Peer Review
• Protects nurses asked to engage in conduct
which they believe violates duty to patient
• “Duty to Patient” – means conduct including
administrative decisions directly affecting a
nurse’s ability to comply with that duty required
by:
– Standards of practice: “Best Practices” originate
from Evidence Based Research
– Professional conduct adopted by the Board in Section
303.005 (a)
• Required by facilities employing/contracting at
least 10 nurses
Safe Harbor Peer Review/Protection
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Describe how Safe Harbor Peer Review differs
from Incident Based Peer Review.
What is duty to patient? How is the nurse who
invokes Safe Harbor protected? When Safe
Harbor is invoked, how is the nurse’s
accountability for safe patient care impacted?
How does a nurse invoke Safe Harbor?
Describe the Safe Harbor Peer review
process.
Safe Harbor Peer Review Protection
• Nurse may not be disciplined or discriminated
against for making the request
• May engage in requested conduct pending the
peer review
• Is not subject to the reporting requirement just
presented
• May not be disciplined by BON for engaging in
conduct while review is pending
Requesting Safe Harbor
• Must be done in good faith
• Must notify supervisor making the assignment
that he/she is invoking safe harbor
• Use form on BON web site
– Or include all info. on required form
• If used to question a medical order
– Medical staff/director will make a determination
• Nurse invoking Safe Harbor will get a copy of
Peer Review Committee’s determination and the
administrator’s review
Entry into Practice Issues
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1965 ANA paper recommended BSN
50 + years of debate
Same licensing exam
2000 ANA reaffirmed it’s recommendation
Public Health Nursing usually requires
BSN
• Specialist positions may require MSN
• Certification
Differentiated Practice
• Structured nursing roles based on:
– Education
– Experience
– Competence
• Education based – different prep = different roles
• Assessment based – all facets, competency
focused
Differentiated Practice Models
• 20+ years of studies
– Roles and compensation level delineated
according to education level not widely used
• Basis of competency models
– ANA’s standards of care with levels of
practice
– Novice to expert (RN 1 to RN 4)
– Can be based on job description and
evaluation
Regulatory Agencies
• BON
• Certification- government standards
• Accreditation - non-government standards
– Medicare/Medicaid – federal standards
– Accreditation – non - government
• JCAHO - hospitals
• CHAP – Community Health Accreditation Program
Advisory Groups
• Secretary of Health, Congress – National
Advisory Council on Nurse Education and
Practice
– Workforce diversity
– Cultural competency
– Nursing shortage
• JCAHO – Nursing Advisory Council
Examples of Texas Legislation
• Nursing shortage
• Hepatitis C & Bioterrorism continuing
education requirements
Texas Nurses Association
• Mission: Promote excellence through
leadership, advocacy, and innovation
• Advocate for nursing in the legislature
• Continuing education
• Updates on legal issues and legislation
• Interpretation of legal & BON changes
• www.texasnurses.org
American Nurses Association
• Advocates for Nursing Profession
• Defines ethical standards of practice for
Profession
– General RN
– Specialty areas
• Provides avenue for nursing to be involved in
national level of decision making
• AJN
The End