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.
Can I send my RN endorsement application and my APRN application in together?
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.
How can I obtain the APRN application?
If you wish to submit your application online, please click here.
How long will it take you to approve my application?
We make every attempt to review and respond as quickly as possible, but the process may take 10-15 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.
What can I do to speed up the approval process?
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.
What are the educational requirements for APRN licensure in Texas?
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.
How will I know if you have everything you need to process the 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.
Can I call you to check on the status of my application?
Please understand that it generally takes us 10-15 business 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.
I sent in my transcript and/or national certification with my RN endorsement application. Do I need to send another one with my APRN application?
Yes. Each application to our office requires its own set of documentation.
Can I send my APRN application and Prescriptive Authority application in together?
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.
What is interim approval?
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.
I just graduated from my APRN program. Can I work before I take the certification exam?
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.
I'm nationally certified as an APRN. Do I still need to apply for 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.
Can I call myself an APRN and/or use my advanced practice title if I have completed an APRN program and/or if I'm nationally certified?
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.
I'm licensed as an APRN in another state. Can I endorse into Texas as an APRN?
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.
What is the Nurse Licensure Compact?
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.
How does the Nurse Licensure Compact affect my ability to work as an APRN in Texas?
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.
What if I have eligibility issues (such as criminal history or disciplinary action in another state or on a different type of professional license)?
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.
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.
Once I am approved as an APRN, do I need to submit a new application to expand into a different role or population focus area of practice? Isn’t an APRN license good for practice in any area?
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.
Policy Regarding the Acceptance of APRN National Certification Examination Reviews Performed by NCSBN
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:
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 aprn@bon.texas.gov, 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.
Display of Designation
Texas nurses at all levels of licensure have a responsibility to appropriately display their designations while interacting with the public in a nursing role [NPA 301.351, Board Rule 217.10 & 221.2]. A Nurse’s designations may not include more than the following: .
licensure level; name, certifications; academic degrees; practice position; the name of the employing facility or agency, or other employer; and a picture of the nurse [Board Rule 217.10(b)].
APRNs must ensure compliance with Board Rule 221.2, which states that when providing care to patients, the APRN shall wear and provide clear identification that includes the current APRN designation and licensure title being utilized by the APRN. Advanced practice registered nurses are required to display both the “APRN” licensure designation, as well as the licensure title granted by the Board when providing care to patients. This means that, at a minimum, an APRN must list their credentials as: (Name), APRN, (licensure title). An individual’s licensure title should reflect the role and population focus for the APRN, and there are multiple ways to display this. Board Rule 221.2 identifies the four APRN roles as well as the population foci currently recognized by the Texas Board of Nursing for APRN licensure purposes. In the past, the Board recognized certain additional titles for APRN licensure. A list of these additional titles may be found in Board Rule 221.7. APRNs who were originally licensed with titles listed in Rule 221.7 are considered to be grandparented, and those APRNs must continue to use the title for which they were originally licensed.
When interacting with the public in a nursing role, the manner in which a nurse’s name appears, in reference to the use of first name and/or last name, is the nurse's preference in accordance with facility policy [Board Rule 217.10(b)(1)(A)]. The use of other designations, such as certification and education credentials (i.e., MSN, DNP, or PhD), is not required by Board rules. However, a nurse may choose to use certification and education credentials, so long as they are current, accurate, and not misleading as to their meaning. Texas RNs that hold national certification as advanced practice nurses but are not licensed as APRNs by the Texas Board of Nursing should not use the credential awarded by their national certification until they also obtain licensure as an APRN. Board Rule 221.2(d)(2) prohibits the use of any titles or other designations that imply a person is licensed as an APRN without possessing current licensure. Since many APRN certification credentials include the licensure title as part of the credential (e.g., CNM, FNP-BC), it would be misleading for nurses to use APRN certification credentials if they are not also licensed by the Board as APRNs.
RNs who are also licensed as APRNs are not prohibited from using the APRN designation when practicing in the RN role. That being said, Board staff generally recommend that APRNs who are practicing in the RN role only use the RN credential to avoid role confusion. Use of APRN credentials while practicing in the RN role may imply to patients and colleagues that the nurse is practicing in the APRN role when, in fact, he/she is practicing in the RN role. This may put the APRN in a position of being asked or expected to practice beyond the RN scope when he/she does not have appropriate physician delegation or privileges to do so. If an APRN chooses to use the APRN designation when practicing in the RN role, the APRN must take precautions to ensure patients, family members, and members of the public are not confused about the role in which he/she is practicing. Complaints regarding the misleading use of a designation will be reviewed by the Board.
For additional information on this topic reference the article titled “Display of Designations” on page 9 of the October 2021 Texas Board of Nursing Bulletin.
I am a nurse in Texas and recently graduated with a Doctor of Nursing Practice (DNP). Can I use the title "Dr" when I work with patients and other healthcare providers?
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.
of addressing a person with an earned doctoral degree as "doctor" began many centuries ago as did the tradition of addressing a physician as "doctor." The number of healthcare professionals with earned doctoral degrees may contribute to confusion for the public and for members of the healthcare team.
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 the 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.
Doctor of Nursing Practice Degree
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.
I am an APRN. Can I just complete the APRN refresher course in lieu of completing the RN refresher course?
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.
Does the BON consider the scope of practice for a clinical nurse specialist equivalent to the nurse practitioner scope of practice?
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.
What requirements need to be met for advanced practice registered nurses who want to first assist and be reimbursed for their services?
HB 1718, passed in the 79 th 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: .
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.
Is it within the advanced practice registered nurse's scope of practice to provide services such as ordering home health services or performing FAA medical examinations for pilots?
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.
May an Advanced Practice Registered Nurse (APRN) delegate tasks to other nurses or unlicensed assistive personnel using the same rules a physician uses?
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
The Board receives questions frequently about whether cosmetic procedures are within the scope of practice for an advanced practice registered nurse (APRN). Because each nurse has a different background, knowledge, and level of competence, the Board does not have an all-purpose list of tasks that every nurse can or cannot perform, and it is up to each individual nurse to use sound judgment when deciding whether or not to perform any particular procedure or act.
The following resources, however, are intended to provide you guidance in determining if cosmetic procedures are within your scope of practice.
What is the APRN scope of practice in regards to cosmetic procedures?
An advanced practice registered nurse is a registered nurse licensed by the Board to practice as an APRN on the basis of completion of an advanced educational program. The term includes a nurse practitioner, nurse midwife, nurse anesthetist, and clinical nurse specialist [Tex. Occ. Code §301.152.(a)]. The APRN scope of practice is addressed in Tex. Admin. Code §221.12, and may include medical diagnosis and prescriptive authority when properly delegated by a physician. The APRN scope of practice is based upon formal educational preparation, continued advanced practice experience and the accepted scope of professional practice of the particular specialty area. The Core Standards for Advanced Practice found in Tex. Admin. Code §221.13 further clarify that APRNs must function within the advanced role and specialty appropriate to their educational preparation [specifically in Tex. Admin. Code §221.13(b)]. If the APRN has had the formal education to provide a specific service, then this is part of their scope of practice. The APRN must, however, have been educated not only in the provision of the service, but also in the response to and medical management of untoward events/adverse reactions/complications experienced as a result. You may find it helpful to review the Practice-APRN Scope of Practice page on the BON website. The APRN must also have the appropriate physician delegation to engage in these medical aspects of patient care. .
Pertaining to cosmetic procedures, the scope of practice of the APRN will, in part, be dependent on the educational component discussed above. When incorporating a new patient care activity or procedure into one's individual scope of practice, the board expects the APRN 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. If the activity is not consistent with the professional scope of practice for the licensed role and population focus, additional formal education and licensure from the BON in the second role and/or population focus are required. Position Statement 15.10, 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.
If an APRN would like to perform medical aspects of care related to cosmetic procedures s/he should first consider whether the medical aspects of care related to cosmetic procedures relate to his/her current licensed role and population focus area. If it does NOT, then the APRN must obtain additional licensure in the appropriate licensed role and population focus area in order to provide medical aspects of care related to cosmetic procedures. If it is within their current licensed role and population focus area, then they should next consider whether they have the appropriate training, knowledge, skills, etc. to safely deliver the medical aspects of care related to the cosmetic procedure. Continuing education may be an adequate method to gain training, knowledge, and skills necessary to safely deliver the medical aspects of care related to cosmetic procedures within the APRN licensed role and population focus area.
An example of an APRN that would be practicing outside his/her licensed scope of practice in delivering medical aspects of care related to cosmetic procedures, is a Nurse Midwife delivering such care as cosmetic procedures are outside the Nurse Midwife’s licensed role. Another example is a Women’s Health Nurse Practitioner (WHNP) delivering such care to men as men are outside the WHNP’s population focus area. Additional formal education and APRN licensure authorizing practice in the pertinent role and population focus would be required in both instances. It is important to remember that the task or procedure must be consistent with both the licensed role and population focus area.
It is important to consider that an APRN who determines that performing medical aspects of cosmetic procedures is not within his/her scope of practice may determine that administration of a medication or performance of a non-invasive treatment is within the individual’s RN scope of practice using the Board’s Scope of Practice Decision-Making Model (DMM). For example, the WHNP described above may determine that administration of cosmetic injections ordered by an appropriately licensed provider is within his/her scope of practice as a registered nurse.
Remember that APRNs do not have full practice authority in the state of Texas. The provisions of medical aspects of care, including formulating diagnoses for the appropriate use of cosmetic injections and ordering the drugs themselves, requires delegation from a physician. It is not within the scope of APRN licensure to provide these services independent of a physician. The APRN may only accept physician delegation for those medical aspects of care and prescribing that are within the scope of the role and population focus area of APRN licensure.
It is important to remember that cosmetic procedures involving medications such as Botox or Restylane will require physician delegation as will the administration of local anesthetic blocks. Botox, for example, is considered a dangerous drug, so the prescriptive authority laws and regulations apply. The FDA has limited approved uses for these types of medications. Tex. Admin. Code §222.4(e) permits issuing prescriptions for non-FDA approved uses when the patient is enrolled in an IRB approved clinical research trial. This rule also describes the requirements that must be met when an APRN issues a prescription drug order for an off-label use of a medication. If the intent is to utilize Botox for a non-FDA approved use, one of these other criteria must be met. Additionally, the APRN must meet all other criteria for prescribing medications, including physician delegation and prescriptive authority agreement requirements as specified in Tex. Admin. Code §222.5.
To further assist nurses in determining whether a task/procedure/act is within his/her scope of practice, the Board has developed a step-by-step tool, the Scope of Practice Decision-Making Model (DMM). In preparation for any nurse (LVN, RN, or APRN) using the Scope of Practice Decision-Making Model (DMM), Board staff recommend review of several resources available on the Texas BON website to further guide you. These resources include:
Board staff also recommend review of the Texas Medical Board Rule 193.17, entitled Nonsurgical Medical Cosmetic Procedures, that addresses the rules related to physician delegation of nonsurgical medical cosmetic procedures. In addition, depending on the range of services you plan to provide, there may be specific licensure requirements including, but not limited to, Cosmetology Licensing. Having a nursing license authorizes you to practice nursing within your licensure level and scope of practice but not to do other things that require separate licensure/certification. You can find additional regulations related to cosmetologists/practicing cosmetology from the agency that regulates cosmetologists, the Texas Department of Licensing and Regulation. Additionally, there may be applicable guidance related to the practice setting; e.g., a private physician office might have specialty-specific guidelines from the American Board of Medical Specialties. Beyond following all applicable laws, rules and regulations regarding the acts/tasks and the setting, the nurse would need to practice consistently with the employer’s policies, assuming these policies promote patient safety (refer back to Position Statement 15.14 if necessary).
If a license is obtained via another agency or regulatory body to perform duties and tasks in another setting, for example a medical spa, the Board considers persons who hold nursing licensure accountable for acts within the practice of nursing even if these acts are performed ‘off duty’ or in another setting [Tex. Occ. Code §301.004(a)(5)]. One example of this may be performing a lower leg wax for a client who has diabetes and peripheral neuropathy; this client may not be able to feel if the wax is too hot and there may be associated burns and a poor outcome. In this example, you would be held responsible for applying your nursing knowledge and judgment with this particular client. There is also a Frequently Asked Question which relates to this discussion (Practice of Nursing). Position Statement 15.15 (Board’s Jurisdiction Over a Nurse’s Practice in Any Role and Use of the Nursing Title) reiterates that any licensed nurse in Texas is responsible to and accountable to adhere to both the NPA and Board Rules and Regulations when practicing nursing, which have the force of law [Tex. Admin. Code §217.11(1)(A)].
Food for Thought
It is important to remember that there is more to this topic than simply learning how to perform a particular procedure. Patient selection criteria, underlying physiology and/or pathophysiology, 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.
Are APRNs authorized to order or prescribe monoclonal antibody infusions for the treatment of COVID-19? Is this considered off-label use and prohibited by Board Rule?
Off label drug use is commonly considered to be the ordering or prescribing of a drug for an indication that differs from the indication for which the drug is approved by the US Food and Drug Administration (FDA). Off label use can also refer to the use of a drug in a different dosage or different form than was approved by the FDA or for a different patient population (Wittich, et al., 2012). Board Rules do not prohibit ordering and prescribing drugs off-label provided the decision to prescribe that drug is supported by evidence based research and is within the current standard of care for treatment of the disease or condition. Off-label prescribing by APRNs is specifically addressed in
With regard to the question about APRNs ordering or prescribing monoclonal antibodies for the treatment of COVID-19, it is necessary to consider that there are monoclonal antibody products that have emergency use authorization from the FDA. Information regarding these products may be further reviewed in this NIH and Infectious Diseases Society of America, it is reasonable to consider that this is the intended use of these monoclonal antibodies. Therefore, the use of monoclonal antibodies with emergency use authorization for the treatment of COVID-19 is not viewed in the same way as the off-label use of FDA approved drugs.
An APRN may order or prescribe monoclonal antibody treatments that have received emergency use authorization for COVID-19 patients when it is within the current standard of care to do so provided it is within the scope of the role and population focus for which the APRN has been licensed. The APRN must have the appropriate physician delegation [see Board Rule 221.13(d)] and prescriptive authority agreement (Board Rule 222.5) or facility-based protocol (Board Rule 222.6) in place prior to engaging in this practice.
It is important to recognize that the standard of care for the treatment of COVID-19 is changing rapidly as research and clinical trials continue to reveal new information about this virus, its variants, and its responses to pharmacological therapies and treatments. Thus, it is important to emphasize that each APRN has a duty to ensure that the drugs and treatments ordered or prescribed are within the current standard of care.
Wittich, C. M., Burkle, C. M., & Lanier, W. L. (2012). Ten common questions (and their answers) about off-label drug use. Mayo Clinic Proceedings, 87(10), 982–990. https://doi.org/10.1016/j.mayocp.2012.04.017
The advanced practice registered nurse’s (APRN’s) scope of practice is addressed in Board Rule 221.12. This rule states that the advanced practice registered nurse's scope of practice is based upon advanced practice nursing educational preparation, continued advanced practice experience and the accepted scope of professional practice of the particular specialty area. The Core Standards for Advanced Practice found in Board Rule 221.13 further clarify that advanced practice nurses must function within the advanced role and population focus area/specialty appropriate to their educational preparation.
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APRN programs for certain population foci provide education relating to provision of care to patients within a particular age range. The Board has never set a specific lower or upper age limit for APRNs licensed within neonatal, pediatric, or adult-gerontology population foci. The age limitations for such providers depends on the specific APRN education program they attended. For example, adult-gerontology nurse practitioner (AGNP) education generally includes formal preparation for the provision of care to adult patients, across the adult lifespan. It does not generally include content related to the care of children. However, it should be noted that most AGNP programs include content related to adolescents. It is possible that one AGNP program prepares nurse practitioners to see patients that are age 21 and older and another AGNP program prepares nurse practitioners to provide care to patients that are 13 and older. The lower end of the age range varies depending on the specific AGNP program attended. This information should be available from the program director of the program attended by the APRN.
Although APRNs may have experience working with a particular subset of patients as a registered nurse, experiences gained as a registered nurse are not considered equivalent to nor may they be accepted in lieu of formal educational preparation in a specific advanced practice role and population focus area/specialty. If an APRN wishes to provide advanced practice nursing care to patients outside their population foci of education and licensure they would need to complete additional formal education and obtain licensure as an APRN within the desired APRN role and/or population focus. Otherwise, an APRN may only participate in the care of such a patient, to the extent they are capable, within the scope of an RN.
Additional resources and information relating to this topic can be found on the APRN Practice information page and the APRN Scope of Practice information page on the Board’s website. Board staff also recommend review of position statements, curriculum guidance, and other publications from national nursing organizations.
For additional information on this topic reference the article titled “Display of Designations” on page 9 of the October 2021 Texas Board of Nursing Bulletin.
In Texas, APRNs may pronounce death in accordance with Chapter 671 of the Texas Health and Safety Code (THSC). Authority in the form of delegation from a physician does not provide authorization for an APRN to pronounce death in a manner not otherwise permitted by this chapter. APRNs cannot pronounce death if artificial means of life support preclude the pronouncement. They may otherwise pronounce death in accordance with written policy, jointly developed and approved by the medical staff or medical consultant and the nursing staff, of the appropriate licensed health care facility, institution, or entity providing services to the patient. If an APRN does not have authority to pronounce death, the APRN must notify a person legally authorized to pronounce the death.
Following the pronouncement of death, APRNs may complete the medical certification for a death certificate or fetal death certificate in accordance with Chapter 193 of the Texas Health and Safety Code (THSC). As a result of the 87th legislative session House Bill (HB) 4048 was signed by the Governor on 6/15/2021, and took effect immediately. Previously, state law only permitted APRNs to complete the medical certification for a death certificate or fetal death certificate if a patient was receiving palliative care, or had a written certification of a terminal illness and elected to receive hospice care and was receiving hospice services from a qualified hospice provider. HB 4048 amended Chapter 193 of the THSC to permit APRNs to compete the medical certification, if not otherwise prohibited by laws and rules applicable to the practice setting or the circumstances of the death, if the death occurred while under their care in connection with the treatment of the condition or disease process that contributed to the death.
Completing a medical certification for a death certificate or fetal death certificate is an example of a medical aspect of care. Texas APRNs may not provide any medical aspects of care independently; there must be a collaborative relationship and practice agreement with a physician. When providing medical aspects of care Board Rule 221.13 requires APRNs to utilize written mechanisms which provide authority for that care. Delegation of authority to complete the medical certification for a death certificate or fetal death certificate should be included in the written mechanism used by an APRN. For additional information on death records contact the Texas Department of State Health Services.
Yes, so long as the H&P is limited to a comprehensive health history and comprehensive physical assessment (single or multi system). Pursuant to 22 Tex. Admin. Code §221.3(f), in order to be licensed in Texas, an APRN must demonstrate completion of an advanced health assessment course that includes assessment of all human systems, advanced assessment techniques, concepts, and approaches. As such, an APRN meeting this requirement is qualified to collect a patient’s health history and perform a comprehensive assessment. However, the completion of an advanced assessment course alone does not qualify an APRN to formulate medical diagnoses and determine medical plans of care that are not within the role and population focus area for which the APRN was educated and is licensed.
All APRNs are educationally prepared to provide a scope of services in at least one role and to at least one population focus area, as defined by nationally recognized role and population-focused competencies. Advanced assessment, along with advanced pathophysiology and advanced pharmacotherapeutics, are foundation courses that support the additional didactic and clinical content completed in the APRN role and population focus core courses. It is the APRN’s education in the specific role and population focus core courses that provides the APRN with the knowledge, skills, and competence to synthesize the patient’s history and assessment findings with the knowledge of the underlying physiology/pathophysiology and pharmacotherapeutics specific to the role and population focus to make clinical diagnoses and determine appropriate plans of care for the medical management of the patient.
If an APRN is obtaining a patient history and completing a physical examination with the intent to formulate a diagnosis and determine medical management by ordering drugs and devices or performing procedures, they may only do so for patients that are within the scope of the role and population focus for which they have been licensed by the Board. For example, completion of the APRN core courses would not prepare an adult/gerontology nurse practitioner to provide advanced practice nursing care for a seven-year-old child. Likewise, it would not prepare a nurse anesthetist to provide routine management of hypertension for a patient seeking care for this condition in a clinic setting. In both examples, the APRN is in a position of diagnosing and managing diseases and conditions that are beyond the scope of his/her role and population focus core education, even if the APRN has the foundational knowledge to complete a patient history and perform an assessment for these patients. In these situations, although not required, it would be prudent for the individual who is educationally prepared and licensed to diagnose and medically manage the patients’ conditions to also perform the H&P.
An APRN should also be aware that although reimbursement regulations do not fall under the purview of the Board, a diagnosis must accompany the H&P in order to bill for this service. If an APRN renders a diagnosis or determines a medical plan of care for a patient or for a disease or condition that is not within the scope of his/her educational preparation and licensure, the APRN is exceeding his/her scope of practice. If an APRN wishes to expand his/her scope of practice, s/he must complete additional formal education and obtain licensure in the additional role and/or population focus from the Board [see 22 Tex. Admin. Code §221.4(a)(10) and (c)(8)]. On the job training or continuing education courses are not sufficient to expand one’s scope of practice to a different APRN role or population focus area (see also Board Position Statement 15.10).
APRNs function under their own licenses and assume responsibility and accountability for quality, safe care in accordance with all applicable laws, rules, and regulations [22 Tex. Admin. Code §217.11(1)(A)]. As a member of a patient’s healthcare team, an APRN should consider how determinations are made regarding a patient’s care and the APRN’s role in this process. When performing and documenting an H&P, an APRN should consider how this information will be utilized and by whom.
The medical condition and mental state of a person proposed for guardianship must be considered by the courts in a guardianship proceeding. Historically, only a licensed physician was eligible to complete a physician’s certificate of evaluation for the individual who was proposed for guardianship.
Effective September 1, 2023, APRNs are now authorized to examine a person to determine whether that person is incapacitated for the purpose of guardianship proceedings. The Texas Estates Code permits judges to consider a letter or certificate of evaluation from an APRN as part of a guardianship proceeding. As noted in Section 1101.1011 of the Estates Code, physician delegation is required for an APRN to provide this service. Additionally, the Estates Code requires that both the APRN and their delegating physician sign the letter or certificate regarding a proposed ward’s incapacity that is based on an examination by the APRN. The letter or certificate of evaluation must include all elements required by Texas law. APRNs who choose to provide this service should review Chapters 1101, 1102, and 1202 of the Estates Code to be certain the information they provide complies with these requirements.
Is current CPR certification a licensure requirement for nurses?
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 and stabilize a client condition [(217.11(1)(M)]. Nurses have a responsibility to maintain continuing competence in nursing practice through educational opportunities that promote individual professional growth (Board Rule 217.11(1)(G)(H)(R).
Do all nurses have an obligation to initiate CPR for a client? Does the Texas Board of Nursing have rules that establish a nurse's duty to initiate CPR?
Yes. All nurses have an obligation or duty to initiate CPR for clients who require resuscitative measures [217.11(1)(M)]. 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.
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 [Board Rule 217.11(1)(B)]. 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.”
What is the role of the licensed vocational nurse (LVN), registered nurse (RN), and advanced practice registered nurse (APRN) in initiating CPR in a witnessed arrest?
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.
Does the BON have a position statement that addresses the RN's role in the management of an unwitnessed cardiac or respiratory arrest in a long-term care facility?
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.
Are nurses expected to perform CPR on clients with obvious clinical signs of irreversible death?
Board Rule 217.11(1)(A) requires all nurses to know and conform to the Texas Nursing Practice Act and Board rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurses’ current area of nursing practice.
Additionally, nurses should know and follow their facility, agency or employer’s policies. 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).
Does the Texas Board of Nursing have purview over the pronouncement of death?
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.
Is there a difference between the decision to initiate CPR and the decision to pronounce death?
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.
For additional information on APRN scope of practice and pronouncement of death please reference the Board’s FAQ.
Can an RN or an APRN pronounce death?
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 (Texas Administrative Code, Title 22, Part 9, Chapter 193.18).
The Texas Health and Safety Code chapter 671 requires that in order for an RN 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. An RN may not sign a death certificate under any circumstances.
Can LVNs pronounce death or accept an order to pronounce death in Texas?
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). TMB Rule 193.18 requires LVNs to inform physicians of the following minimum findings:
It is imperative that LVNs document their focused assessment findings, nursing interventions, and communication with physician and physician’s orders.
What additional references are available should be considered when establishing policies and procedures for nursing staff in my facility?
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
Do nurses have a duty to report confidential health information to administrators, law enforcement of to a patient's family?
In January 2013, the U.S. Department of Health and Human Services - Office for Civil Rights issued clarification regarding the Health Insurance Portability and Accountability Act (HIPAA) titled, Message to Our Nation's Health Care Providers. The message can be found at http://www.hhs.gov/ocr/office/lettertonationhcp.pdf.
Nurses have a duty to report patient information, including mental health information, to members of law enforcement, a patient's family and others when a patient is a serious danger to himself or others. The confidentiality rule also known as the Health Insurance Portability and Accountability Act (HIPAA) does not prevent nurses, when acting in "good faith", from reporting necessary information about a patient to those who may be able to prevent or lessen a danger to a patient or the public. The confidentiality rule is balanced to protect a patient's health information while allowing information to be disclosed that could protect both the public and a patient from harm.
The Texas Board of Nursing has developed standards of nursing practice that apply to nurses' duty to report confidential health information and require licensed vocational nurses, registered nurses, and advanced practice registered nurses to: understand and follow the laws applicable to their area of practice; provide a safe environment for a patient and others; and respect a patient's right to confidentiality and disclose information to the proper authorities when necessary to protect a patient and the public from harm. To learn more about the standards of nursing practice, see Rule 217.11, Standards of Nursing Practice.
Nurse anesthetists who choose to hold themselves out as nurse anesthesiologist or use the term nurse anesthesiologist in their advertising should remain mindful that false, deceptive, and misleading statements and information are not protected commercial free speech and may violate state law and/or regulation. Licensees should pay special attention to representations that imply false claims or that create unjustified expectations or confusion regarding an individual’s credentials, education, experience, expertise, or lawful scope of practice.
The Texas Nursing Practice Act [Texas Occupations Code, §301.152(a)] defines an APRN as follows:
(a) … “advanced practice registered nurse” means a registered nurse licensed by the [B]oard to practice as an advanced practice registered nurse on the basis of completion of an advanced educational program. The term includes a nurse practitioner, nurse midwife, nurse anesthetist, and clinical nurse specialist. The term is synonymous with “advanced nurse practitioner” and “advanced practice nurse.”
The Nursing Practice Act limits the title to “nurse anesthetist”, and the Board is not statutorily authorized to expand the title beyond that specified in statute.
The Board will investigate complaints regarding nurse anesthetists utilizing the term nurse anesthesiologist as their title or in their advertising materials to determine if such use conforms to state statute, the Board’s rules, the Texas Medical Board rules and regulations, and to ensure that such use is not false, deceptive, or inherently misleading
Rule 222.4(b): Minimum Standards for Signing Prescriptions.
Rule 222.8: Authority to Order and Prescribe Controlled Substances
Does the physician’s name need to be included on the prescription?
Yes, the physician’s name, address and telephone number are required to be included on the prescription drug order. If the prescription is for a controlled substance, the physician’s DEA number is also required to be included on the prescription. The requirements for what needs to be included on a prescription drug order are specified in Section 157.056 of the Texas Occupations Code and may only be amended by the Texas legislature.
Is there still a ratio for the number of APRNs or PAs to whom a physician may delegate prescriptive authority?
The answer to the question depends on the practice setting. In facility-based hospital practices and in practices that serve medically underserved populations, there are no limitations to the number of APRNs or PAs to whom a physician may delegate prescriptive authority. However, a physician may delegate prescriptive authority via facility-based protocol at no more than one licensed hospital or no more than two long term care facilities. In all other practice settings, one physician may delegate to no more than seven full time equivalent APRNs and PAs (1:7 FTEs).
Is there a waiver if a physician wants to delegate prescriptive authority to more than seven full time equivalent APRNs and PAs?
No, waivers for the delegation ratio may not be granted. A physician may only delegate prescriptive authority to more than seven full time equivalent APRNs and PAs in facility based hospital practices and in practices that serve medically underserved populations. In all other settings and practice scenarios, the 1:7 FTE ratios applies.
How many delegating physicians may one APRN have?
There is no limit to the number of physicians who may delegate prescriptive authority to one APRN provided all requirements for such delegation are met.
What is a dangerous drug? Are these legend drugs?
Texas is one of just a few states that use the term “dangerous drugs.” The Dangerous Drug Act defines a dangerous drug as a device or drug that is unsafe for self-medication and that is not included in Schedules I through V or Penalty Groups 1 through 4 of Chapter 481, Health and Safety Code (Texas Controlled Substances Act). The term includes a device or drug that bears, or is required to bear, the legend: “Caution: federal law prohibits dispensing without prescription” or “Rx only” or another legend that complies with federal law. Many other states use the term “legend drug.” Examples of “dangerous drugs” or “legend drugs” include antibiotics, antihypertensive drugs, or any non-scheduled drug requiring a prescription.
Is prescriptive authority required to order durable medical equipment (DME)?
Yes, it is necessary to have prescriptive authority to order these devices. APRNs may order or prescribe this equipment provided all requirements for delegation of prescriptive authority are met.
Am I required to submit my prescriptive authority agreement or facilty-based protocol to the Board when I sign a new one?
No, you are not required to submit either of these documents to the Texas Board of Nursing unless you are requested to do so.
Do I have to produce my prescriptive authority agreement or facility-based protocol if a licensing board asks to see it?
Yes. You are required to provide a copy of the prescriptive authority agreement to the Texas Board of Nursing, the Texas Medical Board, or the Texas Physician Assistant Board when requested. It must be provided within three business days of the date on which it was requested. Although Texas law does not specifically note that.
facility-based protocols must also be submitted within this time frame, each licensing board has the authority to request this information. Failure to provide the requested information could result in disciplinary action against the professional license.
Am I required to notify the Board when my delegating physican changes or if I add additional physicians?
This information is not provided to the Texas Board of Nursing. However, if you have a new physician who is delegating prescriptive authority, you and the physician must.
register the delegation with the Texas Medical Board. There is a portion of the registration that you must complete and then the physician must go in and complete his/her portion of the registration and certify the delegation. Please note that Texas Board of Nursing staff does not have access to this system and cannot assist you with this process.
If you are practicing under an agreed order or the Texas Board of Nursing has imposed limitations on your prescriptive authority, you will not be eligible to register your prescriptive delegation online. A paper registration form must be completed and submitted to the Texas Medical Board for review and approval.
What is the difference between medication orders and prescriptions?
A medication order is an order for administration of a drug or device to a patient in a hospital for administration while the patient is in the hospital or for emergency use on the.
patient’s release from the hospital, as defined by §551.003, Occupations Code and §481.002, Health and Safety Code. A prescription is an order to dispense a drug or device to a patient for self-administration as defined by §551.003, Occupations Code.
How many miles from my delegating physician can my practice site be?
The law is silent regarding the practice location of the physician and its proximity to the practice site of the APRN. That said.
it is important to consider that the physician must be able to complete chart reviews and the APRN and physician must conduct monthly meetings as required by Texas law. The physician should also be accessible to the APRN to provide required delegation and consultation as necessary. If the physician is not accessible for a period of time, an alternate physician should be designated.
Does my delegating physician have to be licensed in Texas?
Yes. Section 301.002(2)(G) of the Texas Occupations Code permits APRNs to accept delegation from physicians who are licensed by the Texas Medical Board. It does not include delegation from physicians who are not licensed in Texas. Therefore, your delegating physician must be licensed to practice medicine in Texas by the Texas Medical Board.
Does my delegating physician have to practice in the same specialty area as my area of practice to delegate prescriptive authority?
Texas law does not require that your delegating physician practice in the same specialty. However, you may wish to consider what would happen if your patient’s condition changes such that it is no longer within your scope of practice to manage the patient. If your delegating physician has a different specialty area, you will need to have a plan in place for transfer of the patient to an appropriate provider to manage that patient’s care. The plan must take into consideration patient safety and the need to expedite transfer of care in emergency situations.
I already have prescriptive authority in one APRN role and population focus area. Do I need to apply for prescriptive authority again if I become licensed in a second APRN role and/or population focus area?
Yes. Just like APRN licensure, prescriptive authority is specific to each role and/or population focus area. Having prescriptive authority in one role and population focus area does not authorize you to expand your area of prescribing to an additional role and/or population focus area without authority to do so from the Texas Board of Nursing.
I already have my APRN license, but I forgot to apply for prescriptive authority when I applied for licensure. Is it possible to add prescriptive authority now?
Yes, you may add prescriptive authority for the role and population focus area of licensure. Please refer to the APRN application FAQs for more information about how to complete this process.
May a nurse practitioner who is educated to practice in a primary care population focus area (e.g., FNP or PNP) practice in a hospital?
The Nursing Practice Act and Board rules are written broadly to apply to all nurses, including advanced practice registered nurses (APRNs), across all practice settings. Neither are prescriptive to specific tasks or services APRNs may perform or provide. Likewise, they do not address specific practice settings for specific categories of APRNs. Scope of practice is not specific to a practice setting; rather, it is determined by the patient’s condition and patient care needs at the time services are provided. Board Rules 221.12 and 221.13 clarify that education is the foundation for determining APRN scope of practice.
When making scope of practice determinations, it is important to consider the patient's condition and patient care needs. Primary care educated APRNs may provide care in the acute care setting for patients with similar patient care needs and diseases and conditions to those they diagnose and manage in the outpatient setting. For example, a family nurse practitioner may be part of a group practice in a specialty such as orthopedics or palliative care and required to round in an inpatient setting in collaboration with the delegating physician. There is nothing in the Nursing Practice Act or Board Rules that prohibits this practice provided management of the patient’s condition is within the scope of the APRN’s educational preparation.
Although the Board grants APRN licensure titles that are consistent with the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, & Education, it is important to remember that there are APRNs who have been grand-parented under Board Rules. For example, an individual who is licensed as an adult nurse practitioner rather than an adult/gerontology nurse practitioner is still permitted to provide care to geriatric patients based on education in adult health. When reading the Consensus Model, it is important to bear in mind that it contemplates licensure and education based on an APRN role and a population focus. Nothing in the Consensus Model requires scope of practice be specific to a practice setting.
Is an APRN able to prescribe medications for off label use?
Off label drug use is commonly considered to be the ordering or prescribing of a drug for an indication that differs from the indication for which the drug is approved by the US Food and Drug Administration (FDA). Off label use can also refer to the use of a drug in a different dosage or different form than was approved by the FDA or for a different patient population (Wittich, et al., 2012). Board Rules do not prohibit ordering and prescribing drugs off-label provided the decision to prescribe that drug is supported by evidence-based research and is within the current standard of care for treatment of the disease or condition. Off-label prescribing by APRNs is specifically addressed in
(f) APRNs may order or prescribe only those medications that are FDA approved unless done through protocol registration in a United States Institutional Review Board or Expanded Access authorized clinical trial. "Off label" use, or prescription of FDA-approved medications for uses other than that indicated by the FDA, is permitted when such practices are:
(1) within the current standard of care for treatment of the disease or condition; and
(2) supported by evidence-based research.
Board Rule 222.4(f) has been in effect since February 14, 2010. The rule was first proposed on November 27, 2009. The proposal of the rule was considered at the July 30, 2009, and September 23, 2009, meetings of the Advanced Practice Nursing Advisory Committee, one of the Board’s standing advisory committees comprised of various types of APRNs representing various APRN stakeholder groups. Following publication in the Texas Register for a 30-day comment period, the Board did not receive any public comments on the rule.
The rule was adopted among an increased number of inquiries regarding the prescription of medications for "off label" use, as well as prescriptions for medications that had not been approved by the FDA.
The Texas Medical Board also addressed this issue at that time, in a rule located at 22 Texas Administrative Code §190.8(1)(K). The Medical Board rule prohibits the prescription or administration of a drug in a manner that is not approved by the FDA for use in human beings or does not meet standards for "off-label" use, unless an exemption has otherwise been obtained from the FDA. Chapter 200 of the same title contains additional Texas Medical Board rules related to complementary and alternative medicine. Staff is aware that physicians may commonly prescribe drugs for “off-label” uses other than that specified by the FDA or supported by evidence based research, but the delegation for similar “off-label” prescribing authority to an APRN has been limited by Board Rule 222.4(f) since 2009. The delegated authority within the prescriptive authority agreement of the APRN may further restrict the decision of an APRN to consider any "off label" prescription. The minimum standards that must be met in a prescriptive authority agreement are set forth in Board Rule 222.5.
Evidence-Based Research and Evidence-Based Practice
Sackett, et al. (1996) define evidence-based medicine as the “conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external evidence from systematic research.” Sigma Theta Tau (2005) defines evidence-based nursing as the “integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families and communities.” While these definitions recognize the importance of individual expertise and patients’ values and preferences, it is important to recognize that the need for evidence- based research to provide support for clinical decision making is common to both definitions. However, the existence of research in and of itself is not sufficient to inform practice. The overall purpose of research is to generate new knowledge, whereas evidence-based practice translates evidence to clinical decision making and practice. Fineout-Overholt, et al. (2005) emphasize that clinicians must engage in a critical appraisal of those research studies to ensure the results are valid, reliable, and relevant to the care of the patient. It is necessary for the APRN to consider how the research supports or does not support the intended practice before incorporating it into patient care. A sample of existing resources to assist with appraising evidence are provided below.
Keeping in mind that the scope of practice for an APRN includes both the provision of nursing aspects of patient care and medical aspects of patient care in compliance with Texas law, it is incumbent upon APRNs to actively review and evaluate both nursing and medical evidence based research related to their area(s) of practice. Evidence-based research from other disciplines may also be applicable based on the nature of the practice.
Board Rule 222.4(f) applies to all medications prescribed by APRNs for “off label” use. It is important to recognize that the standard of care for the treatment of diseases and conditions can change rapidly as research and clinical trials continue to reveal new information about disease processes and their responses to pharmacological therapies and treatments. Thus, it is important to emphasize that each APRN has a duty to ensure that the drugs and treatments ordered or prescribed are within the current standard of care.
Evidence-Based Practice Resources
Ohio State University College of Nursing Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare:
https://fuld.nursing.osu.edu/
JBI - Joanna Briggs Institute at the University of Adelaide:
http://joannabriggs.org/
References
Fineout-Overholt, E., Melnyk, B. M., & Schultz, A. (2005). Transforming health care from the inside out: advancing evidence-based practice in the 21st century. Journal of Professional Nursing: Official Journal of the American Association of Colleges of Nursing, 21(6), 335–344. https://doi.org/10.1016/j.profnurs.2005.10.005
Sackett, D. L. Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn’t. BMJ: British Medical Journal, 312(7023), 71-72.
https://doi.org/10.1136/bmj.312.7023.71.
Do I need to have a protocol in addition to a prescriptive authority agreement?
APRNs are required to have delegated authority to provide medical aspects of patient care. Historically, this delegation has occurred through a protocol or other written authorization. Rather than have two documents, this delegation can now be included in a prescriptive authority agreement if both parties agree to do so.
Can prescriptive authority meetings be held more frequently than monthly?
Yes as agreed to by the parties to the prescriptive authority agreement. The requirements for monthly meetings are the minimum requirements specified in Texas law. You may meet more frequently than required by law. You may not meet less frequently than what is required by law. An APRN should meet the requirements of the prescriptive authority agreement which may have more frequent meetings required.
Must monthly meetings be face to face?
Monthly meetings are not required to be face to face. You may meet with your delegating physician via internet technology, teleconference or via other mechanisms that permit you and the delegating physician to have a meaningful dialogue on the required elements of the monthly meeting. Monthly meetings must be documented and include: the sharing of information relating to patient treatment and care, needed changes in patient care plans, and issues relating to referrals; and discussion of patient care improvement. It is important to remember that meetings conducted via technology must take into consideration the need to keep protected health information confidential.
How must the chart reviews and monthly meetings be documented?
As for how chart reviews are documented, that is up to the APRN and delegating physician. We generally see physicians documenting in the medical record when they review charts; however, a list of charts reviewed is also acceptable. Regarding monthly meeting documentation, Board rules do not specifically outline what this documentation must include; however, it would be reasonable to ensure that monthly meeting documentation accurately reflects that the required elements were discussed.
What constitutes a license that is in good standing for purposes of entering a prescriptive authority agreement?
An APRN may enter into a prescriptive authority agreement unless his/her license is revoked, suspended, delinquent, inactive, has been voluntarily surrendered, or is subject to a disciplinary order that specifically prohibits entering into a prescriptive authority agreement. If the Texas Board of Nursing limits an APRN’s authority to order or prescribe drugs or devices, the licensee may enter into a prescriptive authority agreement and order or prescribe drugs and devices only to the extent permitted by the board order.
Do I have to disclose information regarding investigations and discipline? If so, to whom must this information be disclosed?
Yes. Prior to signing a prescriptive authority agreement, you must disclose to the other party/parties to the prescriptive authority agreement if you have been disciplined in the past. This includes disciplinary action taken by licensing boards in other states. Once you are a party to a prescriptive authority agreement, you are required to immediately notify the other party/parties to the agreement if you receive notice that you are the subject of an investigation.
What needs to be included in a prescriptive authority agreement?
Prescriptive authority agreements must be in writing and include the following elements: .
Does the BON have a standardized template for the prescriptive authority agreement?
No, there are no standardized templates. Due to variations in individual practice settings, patient populations, knowledge and experience of individual providers, and a number of other factors, the format and content of prescriptive authority agreements can vary widely. For this reason, it is not possible to create a template for use by all categories of APRNs. APRNs should be certain to review Board Rule 222.5 and ensure that their prescriptive authority agreements include all elements noted in this rule in order to be in compliance.
How many charts must be reviewed?
Texas law requires that the delegating physician review medical records. The law does not provide a specific number or percentage of charts that must be reviewed. Rather, the law provides that the number of charts to be reviewed is determined by the parties.
to the prescriptive authority agreement. The number may vary from one practice setting to another. Factors such as the length of time the APRN has been in practice, the length of time the physician and APRN have practiced together, whether the parties to the prescriptive authority agreement practice together in the same practice setting, and the complexity of patient care needs should be given consideration when making this determination. That said, there has been no change in the law that requires that a physician must provide adequate supervision of delegates.
How often are quality assurance meetings required?
The meetings must occur at least monthly.
Can we skip doing monthly meetings if the physician and APRN practice together at the same location?
No. You must have monthly meetings as part of your quality assurance and improvement plan.
What if an alternate physician is involved in delegation of prescriptive authority on a temporary basis?
The prescriptive authority agreement designates who may serve as an alternate physician if alternate physician supervision will be utilized. If an alternate physician(s) will participate in the quality assurance and improvement meetings with the APRN, this information must be included in the prescriptive authority agreement.
If I work in a clinic owned by the hospital, is this considered a facility-based practice?
No. Free standing clinics, centers or other medical practices that are owned or operated by or associated with a hospital or long term care facility that are not considered facility based practices. Prescriptive authority agreements are required in these settings.
Is a prescriptive authority agreement required in a hospital or long term care facility-based practice?
Although it is possible to use a prescriptive authority agreement in a hospital or long term care facility-based practice, it is not required. You may practice under facility-based protocols in these settings. APRNs must exercise prescriptive authority under one of these delegation mechanisms.
At how many facilities can one physician delegate prescriptive authority through protocols?
A physician may delegate prescriptive authority via facility-based protocol at no more than one licensed hospital or no more than two long term care facilities.
Who may delegate prescriptive authority in a hospital facility-based practice?
In a hospital facility-based practice, the delegating physician may be the medical director, the chief of medical staff, the chair of the credentialing committee, a department chair, or a physician who consents to the request of the medical director or chief of the medical staff to delegate.
Who may delegate prescriptive authority in a long term care facility based practice?
In a long term care facility based practice, delegation is by the medical director.
Is a nurse anesthetist required to have prescriptive authority and register that delegation with the Texas Medical Board?
Section 157.058 of the Texas Occupations Code clarifies that CRNAs are required to have physician delegation to order drugs and devices for the purpose of.
providing anesthesia or anesthesia-related services, The CRNA may provide these services in accordance with facility policy or medical staff bylaws pursuant to a physician’s order for anesthesia or anesthesia-related services. CRNAs are not required to have prescriptive authority from the Texas Board of Nursing nor are they required to be registered with the Texas Medical Board. The delegation is limited to the hospital or ambulatory surgery center in which the CRNA is credentialed to practice.
In outpatient anesthesia settings, the drugs administered and devices applied by a CRNA who provides anesthesia or anesthesia-related services are supplied by the practice setting. Therefore, they are ordered for use in that setting by the surgeon. Just as in the hospital or ambulatory surgery center, the CRNA selects and administers drugs and applies devices pursuant to an order to administer anesthesia or an anesthesia-related service in this setting. Because the surgeon has supplied the drugs and devices for the purpose of providing anesthesia or anesthesia-related services, the CRNA is not required to have prescriptive authority for this purpose. All parties are required to follow the laws and regulations for ordering, storing, wasting and tracking the use of medications and devices in these settings.
If CRNAs are practicing in settings in which they are writing prescriptions, such as a CRNA who may be working with a pain management specialist, the CRNA must have prescriptive authority and all requirements for delegation of prescriptive authority must be met. This includes requirements for a prescriptive authority agreement or facility-based protocol as appropriate and registration of physician delegation on the Texas Medical Board’s website. If controlled substances will be prescribed, the CRNA must also have the required controlled substance registrations (DEA and DPS). CRNAs with prescriptive authority may only order or prescribe drugs and devices for the purpose of provision of anesthesia or an anesthesia-related service.
Links to Outpatient Anesthesia Rules:
Who can prescribe Schedule II drugs under physician delegation?
APRNs may prescribe schedule II drugs in the following situations: .
Can schedule II authority be delegated in a free standing emergency department that is affiliated with a hospital?
No. A free standing emergency department is not located within the hospital anddoes not qualify as an eligible site for delegation of schedule II authority. The physician may only delegate authority to prescribe controlled substances in schedules III through V in this setting. Authority to prescribe dangerous drugs, nonprescription drugs and devices may be delegated in any setting.
How often is physician consultation required when prescribing controlled substances?
APRNs must consult with the delegating physician for refills of a prescription for controlled substances after the initial 90-day supply and every 90 days thereafter as long as the patient continues to receive a prescription for controlled substances. Consultation is also required when prescribing controlled substances for children under the age of two years. In both cases, the consultation must be documented in the patient’s medical record.
May an APRN prescribe Schedule II prescriptions to the patient as part of the hospital’s discharge process?
The law does not allow Schedule II prescriptions to be written by APRNs with the intent that the prescription be filled outside of the hospital facility-based practice setting. In order for such a prescription to be lawful, it must be filled at the hospital’s facility-based pharmacy. .
APRNs who issue Schedule II prescriptions upon discharge must educate patients regarding the requirement to have the prescription filled at the facility-based pharmacy in order to avoid disruption of care. If a Schedule II prescription is to be filled anywhere outside the hospital facility-based setting, the prescription must be completed by a licensed physician.
In accordance with Section 157.054(a-1) of the Medical Practice Act, a hospital facility-based practice setting does not include free standing clinics—including clinics located on hospital grounds, but not physically attached to the hospital’s main structure—community health centers, or other medical practices associated with or owned and operated by the hospital.
Are there any settings other than a hospital facilty-based practice at which an APRN may prescribe Schedule II drugs?
Physicians may delegate authority to APRNs to prescribe Schedule II controlled substances as part of the plan of care for the treatment of a patient who has executed a written certification of terminal illness and has elected to receive hospice care from a qualified hospice provider. The prescriptions for Schedule II drugs issued by the APRN in this situation must be for the purpose of hospice care only. There are no other outpatient settings at which APRNs may prescribe Schedule II controlled substances.
I applied for my DEA registration but I do not have it yet. Can the Board help me with that process?
No, the Board cannot assist you with the DEA process. However, you may wish to verify that you and your delegating physician have registered delegation of prescriptive authority with the Texas Medical Board. The DEA verifies delegation of prescriptive authority has been authorized using the Texas Medical Board’s website. If you and the physician have not registered delegation of prescriptive authority, the DEA will not issue your registration until you do so.
I have a DEA registration in another state. May I use that in Texas?
We would recommend that you contact the DEA directly to learn what is required to transfer your registration for use in Texas.
How do I register for prescription drug monitoring program?
We would recommend that you contact the DEA directly to learn what is required to transfer your registration for use in Texas.
Am I required to check the prescription monitoring program when I write prescriptions for controlled substances?
Effective March 1, 2020, all APRNs who prescribe opiates, benzodiazepines, barbiturates, or carisoprodol are required to check the prescription monitoring program before prescribing any of these drugs unless the patient has been diagnosed with cancer or sickle cell disease or is receiving hospice care (Texas Health and Safety Code, §§ 481.0764 and 481.0765). The prescriber must clearly note in the prescription record that the patient has been diagnosed with cancer or sickle cell disease or is receiving hospice care.
Are APRNs exempt from checking the prescription monitoring program for the required drugs when receiving in a hospital or ambulatory surgical center visit?
The answer to the question depends on whether the APRN is issuing a medication order or a prescription drug order. Texas law defines a medication order as an order for administration of a drug [Texas Occupations Code, §551.003(24)]. APRNs are not required to check the prescription monitoring program before writing a medication order for opiates, benzodiazepines, barbiturates, or carisoprodol that will be administered to a patient while the patient is receiving care in the hospital or in an ambulatory surgery center. However, if the APRN issues a prescription drug order to be filled upon discharge from the hospital or ambulatory surgery center, the APRN is responsible for reviewing and documenting the review of the prescription monitoring program and the rationale for prescribing the drug as required by Board Rule 228.2(d). Prescription drug orders are defined as orders to a pharmacist for a drug or device to be dispensed [Texas Occupations Code §551.003(37)].
May APRNs allow other qualified individuals to check the prescription monitoring program on their behalf as the Texas Medical Board rule permits for physicians?
Texas Health and Safety Code §481.076 addresses the requirements for checking the PMP. §481.076(a)(5)(B) states that individuals who are authorized to check the prescription monitoring program include:
a practitioner who:
(i) is a physician, dentist, veterinarian, podiatrist, optometrist, or advanced practice nurse or is a physician assistant described by Section 481.002 (39)(D) or an employee or other agent of a practitioner acting at the direction of a practitioner; and
(ii) is inquiring about a recent Schedule II, III, IV, or V prescription history of a particular patient of the practitioner;
Therefore, the APRN may designate an appropriately licensed individual to access the prescription monitoring program on his/her behalf. However, the APRN remains responsible for reviewing the information contained in the prescription monitoring program, documenting that the review occurred, and documenting the rationale for prescribing the controlled substance as required by Board Rule 228.2(d).
May an APRN issue prescriptions for patients care services provided via telemedicine in Texas?
Yes, provided the prescription is issued for a legitimate medical purpose by an APRN who issues the prescription for a legitimate medical purpose as part of a patient-practitioner relationship as set forth in Texas Occupations Code, §111.005. If an APRN who is licensed to practice in another state plans to provide telemedicine services to a patient located in Texas, the APRN must hold an active Texas APRN license and an active Texas RN license or RN nursing license with multistate privilege from a state that is party to the Nurse Licensure Compact. The APRN must meet all requirements for physician delegation of authority to provide medical aspects of patient care and have a valid prescriptive authority agreement. The APRN must conform to the Texas Nursing Practice Act, Board rules, and all other federal and state laws when providing services in this manner.
What is the standard of care when providing telemedicine services and issuing prescriptions?
The standard of care is the same standard that would apply to the assessment, diagnosis and issuance of the prescription in an in-person setting. The APRN is required to meet the standard of care and demonstrate professional practice standards and judgment consistent with all current laws and rules when providing telemedicine and telehealth services.
May an APRN prescribe controlled substances for pain management via telemedicine?
Treatment of acute pain with scheduled drugs via telemedicine services is permitted unless otherwise prohibited under federal and state law. APRNs must be aware that acute pain is time limited and refers to the normal, predicted, physiological response to a stimulus, such as trauma, disease, and operative procedures. The APRN must be authorized to prescribe the controlled substance via a valid prescriptive authority agreement with a delegating physician and current DEA registration. APRNs are not permitted to prescribe controlled substances for chronic pain via telemedicine services unless federal or state law expressly permits this practice. Chronic pain is a state in which pain persists beyond the usual course of an acute disease process or healing of an injury and may be associated with a chronic pathological process that causes continuous or intermittent pain over a period of months or years.
Frequently Asked Questions on new APRN license numbers
What will my new license number look like?
The new license number is alpha-numeric. It will be AP followed by 6 digits (example: AP999999).
How can I find out what my APRN license number is?
To find out your license number, click on “Verify license.” In order to be provided your APRN license number, you must look up your license using either your Texas RN license number or your date of birth and last four digits of your social security number.
Will the Board notify all appropriate parties of my new number, or is that my responsibility?
The Board has notified a large number of key stakeholders regarding the change in procedure, but will not notify each individual stakeholder or distribute a list of numbers detailing what a particular APRN’s new license number is. It is up to the APRN to notify all appropriate parties of his/her new Texas APRN license number.
Which license number will I need to provide to other parties (e.g. credentialing, 3rd party payers, Texas Medical Board website)?
The Board of Nursing advises you to check with these entities directly. The Board of Nursing notified a large number of key stakeholders regarding this upcoming change to APRN licensure. However, the Board of Nursing cannot speak to the requirements of other jurisdictions or agencies. Click here to see the stakeholder notification letter.
Can (I, my employer, credentialer, 3rd party payer, etc…) look up my APRN number online by using my Texas RN number?
Yes. Nurse licensure can be verified online 24 hours a day, 7 days a week and can be searched by first and last name, license number, or date of birth and last four digits of social security number. Your APRN license number will be provided through our online verification system if your license is searched using either your Texas RN license number or date of birth and last four digits of your social security number. Your license number will not appear online if your license is searched using only your name.
Will I get a new number for each APRN title I hold?
No. Only one APRN license number will be issued and each title will be tied to that number.
Will I receive a new wall certificate?
One APRN wall certificate will be mailed as a courtesy with your next APRN renewal, provided that your license is renewed between April 2014 and April 2016. For those wanting a copy before or after these dates, please visit our website and print the online verification for your records. Remember, you must search by either the license number or Date of Birth and last four digits of social security number to be get the most specific information on licensure.
When will I receive a new wall certificate?
An APRN wall certificate will be mailed to you the next time you renew your APRN license provided the renewal occurs between April 2014 and April 2016.
Is this number required to be on a prescription?
The required prescription information does not currently require your RN or APRN number. It requires your Prescriptive Authority Number as well as other information. A list of this information can be found under What Needs to be on a Prescription?
Do I still have to maintain and renew my RN license?
Yes. You must maintain your RN license in order to have an APRN license.
If the expiration date on my compact RN license from another state does not coincide with my Texas APRN License #, what will my expiration date be for my Texas APRN license?
The APRN license will still be issued in accordance with the rules and regulations stating that the license expiration date is based on birth month and year (biennium).
Can I renew my APRN License online?
At this time, only Texas RNs who are also licensed APRNs can renew their APRN license online in conjunction with their RN renewal. Please be aware that certain eligibility issues may prohibit online renewal. A paper renewal application is still required for APRNs using a compact RN license from another state or those wishing to renew their Texas RN only (thereby placing the APRN license on inactive status).
Why are APRN’s being issued license numbers?
It has been the goal of the Texas Board of Nursing to comply as closely as possible with the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education. Senate Bill 406, passed during the 83rd Regular Legislative session, has given the Texas Board of Nursing clear authority to issue an APRN license. Like LVNs and RNs, APRNs now have the term “license” used when talking about their authorization to practice in the state of Texas.
What is the benefit of issuing an APRN License number?
Advanced practice nursing has evolved as a result of the complexity of services provided and the level of knowledge, skills, and competence required by individuals who are authorized to provide such care. The services provided by APRNs exceed the scope of practice of registered nurses. Therefore, the potential for harm to the public is significantly greater for APRNs than for RNs, and a higher level of accountability for the APRN is necessary. Typically, licensure is considered the preferred method of regulation when the regulated activities are complex, requiring specialized knowledge, skills, and decision-making. Licensure in any profession is required when the potential for greater risk of harm to the public exists and the professional must be held to the highest level of accountability. Issuance of a license number provides a better mechanism to track APRNs and will make it easier for employers, credentialing organizations, third party payers and others who need to quickly and easily identify an APRN as a licensed provider.
Will there be separates fee to renew my APRN License # and my RN #?
The fee structure has not changed. APRNs with a Texas RN license already pay combined fees to renew both the RN and APRN license at the same time.
Statement: Hydrocodone Containing Products and Tramadol
The Texas Board of Nursing, Texas Medical Board and Texas State Board of Pharmacy advise their respective licensees that the United States Drug Enforcement Administration (DEA) published a final rule reclassifying hydrocodone combination products (HCPs) as Schedule II controlled substances. The reclassification becomes effective on October 6, 2014. HCPs include products such as Lortab®, Vicodin®, and Norco®.
All providers who order, dispense, or prescribe HCPs in the state of Texas must comply with requirements for prescribing Schedule II medications as set forth in state and federal law beginning on October 6, 2014. Advanced practice registered nurses and physician assistants may only prescribe hydrocodone combination products when providing care to hospice patients or practicing in hospital facility based practices as provided for in Chapter 157.0511(b-1) of the Texas Occupations Code and if registered with DEA and DPS to prescribe Schedule II controlled substances.
It is important for all prescribers, pharmacists, and pharmacy staff to be aware that prescriptions written for HCPs on or after October 6, 2014, must be written on a DPS official prescription form and no refills may be authorized. Any prescriptions for HCPs that are dispensed before October 6, 2014, that have additional refills authorized may be dispensed in accordance with state and federal law. The allowance to dispense these refills expires on April 8, 2015.
The Boards of Nursing, Medicine and Pharmacy also remind their respective licensees that the DEA classified tramadol as a Schedule IV controlled substance. This change became effective on August 18, 2014. All prescribers and pharmacy personnel must comply with requirements for ordering, prescribing and handling Schedule IV medications as set forth in state and federal law.
May a CRNA hand off care of an anesthetized patient to an Anesthesia Assistant (AA)?
A CRNA has a duty and responsibility to ensure the safety of a patient when handing off patient care because his/her practice is regulated by the Texas Board of Nursing. This duty is derived from the Nursing Practice Act and Texas Board of Nursing Rules. A physician’s order for a CRNA to turn over the care of an anesthetized patient to an AA does not relieve the CRNA of his/her duty to the patient.
Prior to patient hand-off, the CRNA must ensure that the AA has obtained the appropriate delegation from an anesthesiologist to take over that patient’s care. Delegation to the AA by the anesthesiologist is regulated by the Texas Medical Board and the application of Texas Occupations Code, §157.001. Because this is within the purview of the Texas Medical Board regulations, they have developed an FAQ related to delegation to an AA by an anesthesiologist. The CRNA is not considered to be delegating authority to provide anesthesia or an anesthesia-related service to an AA during patient hand-off. The CRNA is required by the Board of Nursing to ensure that a patient hand-off is safe. To do this, the CRNA must know that the AA has the appropriate authority and is competent to take over patient care.
If the hand-off is unsafe or puts a patient at risk, the CRNA will be held responsible by the Board of Nursing for unsafe practice. This is distinguished from an AA, whose authority to care for the patient originates through anesthesiologist delegation. It is important for CRNAs to keep in mind that they retain professional accountability for the advanced practice nursing care they provide [22 Tex. Admin. Code, §221.13(e)]. CRNAs are not accountable for care provided by AAs under the delegated authority of an anesthesiologist if the hand-off was safe at the time the CRNA turned over care of the patient to the AA.
Are face to face meetings still required between an APRN and his/her delegating physician?
It depends on when the prescriptive authority agreement was executed. House Bill 278, passed in the 86th Legislative Session (2019), removed the face to face meeting requirement for APRNs. The new law requires that meetings between the APRN and physician take place at least once a month in a manner determined by the physician and APRN and only applies to prescriptive authority agreements entered into on/after the bill’s effective date of September 1, 2019. This means that APRNs who enter into a prescriptive authority agreement on/after September 1, 2019 must have monthly meetings for the duration of the prescriptive authority agreement, and the meetings may take place via other means, such as via telecommunication. If an APRN chooses not to sign a new agreement, the law in effect on the date the agreement was entered into applies, and the face to face in person meetings are required. APRNs who provide care in Texas may wish to sign a new prescriptive authority agreement beginning September 1, 2019 in order to take advantage of the changes to Texas law.
Can an APRN work as an RN?
All APRNs are first licensed as RNs, and they are required to maintain RN licensure in order to maintain advanced practice licensure. An APRN is not prohibited from accepting an assignment that is within the scope of practice of a RN [Board Rule 221.12(2) (http://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=11&ch=221&rl=12) ]. When the APRN is working in the RN role, scope of practice is limited to that of the RN. RNs who are also APRNs may not cross over into APRN scope and engage in activites such as medical diagnosis and ordering or prescribing when practicing in the RN role.
It is also important to note that a RN who holds current licensure as an APRN will be held to the highest level of his/her education and competency. To explain further, there may be a situation in which a nurse is caring for a patient in the RN role and due to his/her knowledge and skills related to medical diagnosis and management, he/she recognizes signs and symptoms of a health condition that is not readily recognizable to a RN who is not an APRN. In this situation, although the RN is not eligible to medically diagnose and manage this particular patient because it is outside the RN's scope of practice at the time, he/she should still recognize the condition (based on his/her advanced practice education) and take appropriate nursing action, such as notifying an appropriate provider. The Board's Position Statement 15.15 Boards's Jurisdiction Over a Nurse's Practice in Any Role and Use of the Nursing Title (https://www.bon.texas.gov/practice_bon_position_statements_content.asp#15.15) provides further explanation.
Additionally, based on preference and facility policy, the dually licensed nurse would need to determine how he or she will identify him or herself when interacting with the public. When practicing in the RN role, RNs must clearly identify themselves as registered nurses in accordance with Board Rule 217.10 (https://www.bon.texas.gov/rr_current/217-10.asp) . RNs who are also licensed as APRNs are not prohibited from using the APRN designation when practicing in the RN role. However, use of APRN credentials while practicing in the RN role may imply to colleagues that the APRN is practicing in the APRN role when, in fact, he/she is practicing in the RN role. This may put the APRN in a position of being asked or expected to practice beyond the RN scope when he/she does not have appropriate physician delegation to do so. The nurse and employer may want to reflect on these concepts and plan ahead to avoid role confusion.
For more information on these and other topics, use the search field at the top right corner of the page. Should you have further questions or are in need of clarification, please feel free to contact the Board.
