The Texas Board of Nursing (BON) safeguards the health and prosperity of Texans by making sure all licensed nurses possess the skills to provide secure and skillful care. Rooted in the Nursing Practice Act, this commitment takes precedence over personal interests, the nursing profession, and any specific interest groups. Following the NPA, rules, and guidance for Graduate Vocational Nurses (GVNs), Graduate Nurses (GNs), and newly licensed Licensed Vocational Nurses (LVNs) and Registered Nurses (RNs) ensures patient safety and supports the development of Texas’s future nurses.
Temporary Authorization for Graduate Nurses
According to Rule 217.3, graduates from accredited nursing programs in the U.S. applying for initial licensure in Texas can get permission to work as a GN or GVN while awaiting exam results. This permission isn’t renewable and ends when the candidate passes or fails the NCLEX-PN® or NCLEX-RN® test or 75 days after the temporary authorization’s effective date [217.3(2)].
Candidates from nursing programs outside the United States seeking Texas licensure by examination don’t qualify for temporary authorization [Rule 217.4]. Candidates who have failed the NCLEX-PN® or NCLEX-RN® are also ineligible. Based on a Board determination under NPA Section 301.257 and Rule 213.30, a graduate may be deemed ineligible for temporary permission to practice.
Checking Permission to Practice
Starting January 1, 2006, eligible licensure candidates (GVN or GN) get a temporary “permission to practice” on the Board’s website, www.bon.texas.gov. Employers must confirm a candidate’s current permission online or by calling the Board at (512) 305-7400. Paper permits are no longer issued.
Expired or Invalid Permission
Graduates can’t work as GVNs or GNs after failing the NCLEX-RN® or NCLEX-PN®, even if their permission hasn’t expired. Employers must check test results, monitor license issuance via phone (512/305-7400), or use online verification. Nurse managers and new graduates might face disciplinary action if the graduate continues practicing after failing the exam.
The Board won’t grant permission until all application steps are complete, making the graduate eligible for the NCLEX-PN® or NCLEX-RN® exam. Graduates should schedule the exam quickly because their Authorization To Test (ATT) is active for 75 days. If a license isn’t obtained before the permission expires, the GVN or GN must stop practicing as a graduate nurse. Temporary permission extensions aren’t granted if the licensing exam isn’t scheduled.
License Verification
Per Texas Occupations Code §301.254, NCLEX-PN® or NCLEX-RN® results are mailed within 30 days. Candidates can get “quick results” from NCS Pearson within 48 hours, but these are unofficial and require verification from NCS Pearson/VUE to the Board. Employers/candidates can verify licensure online or by phone (512/305-7400) using the candidate’s social security number. These systems only confirm license issuance and don’t report exam failures. A GVN or GN’s absence from the registry only means a license hasn’t been issued as of the inquiry date, not necessarily that they failed the exam. Call the Board office for results no sooner than 21 days after testing.
Nursing Law Essentials
All licensure candidates and new nurses in Texas must know and follow the Nursing Practice Act (NPA) and Board Rules and Regulations. Start with the definitions of professional and vocational nursing in the NPA §301.002(2) and (5), and §301.353 regarding vocational nurse supervision. Key rules include Rule 217.11, Standards of Nursing Practice, and Rule 217.12, Unprofessional Conduct. Find the NPA and Rules on the Board’s website at www.bon.state.tx.us, or purchase hard copies.
Licensed nurses must stay informed about the latest NPA and Rules, available on the website and in the Texas Board of Nursing Bulletin, mailed to current licensees in the U.S. Archived Bulletins are also online.
Integrating New Nurses Into Practice
The graduate nurse (GVN or GN) and the newly licensed nurse transition from student to professional. As novices, they are inexperienced and not fully integrated into their professional role. The Board stresses the importance of new nurses seeking direction, supervision, consultation, and collaboration from experienced nurses.
Rule 217.3(a)(3), Temporary Authorization to Practice, requires graduates authorized to practice as a GVN or GN to work under a licensed nurse’s direct supervision. Vocational nursing graduates need supervision from a LVN or RN; registered professional nursing graduates need supervision from a RN. “Direct supervision” means the licensed nurse is physically present and readily available for consultation. In multi-unit facilities, the supervising nurse must work on the same unit as the new graduate.
GVNs or GNs aren’t “licensed” and shouldn’t be in supervisory or independent roles like home health. They must pass the NCLEX-PN® or NCLEX-RN® before considering charge nurse/nurse manager positions or independent practice.
The Board advises employers to provide continued direct supervision for six months post-licensure, or less if mutually agreed upon. Competence should be mutually determined by the new graduate and supervisor with documentation.
New graduates can perform functions within their nursing practice scope for which they’ve been educated and shown minimal competency. Holding a charge nurse or nurse manager position within the first six months is discouraged unless mutually agreed upon based on competency evaluation. Practicing in independent settings like home health within 12-18 months post-licensure isn’t advised to allow sufficient experience in structured settings. Employers should ensure experienced nurses are available to supervise and mentor new graduates.
Experienced Nurses Transitioning
Nurses in Texas may pause their practice or change their main area for many reasons. The Texas Board of Nursing is concerned about how this affects competence, as it may impact the nurse’s ability to provide safe and effective care as required by the Nursing Practice Act (NPA) and Board Rules. Nurses re-entering the workforce after four or more years may lack current knowledge of new drugs, therapies, and technologies. Nurses transitioning to a different practice setting may also lack the needed knowledge. A 1994 Board and Lamar University study found that nurses in these categories were at higher risk for practice errors leading to Board discipline. Therefore, appropriate orientation, direction, supervision, consultation, and collaboration from nurses with current skills and knowledge are crucial during the transition.
Rule 217.11, Standards of Nursing Practice, requires that charge and staff nurses consider client safety, education, knowledge, skills, and abilities when making assignments.
Relevant standards in Rule 217.11 include:
- (1)(B): Promoting a safe environment.
- (1)(G): Obtaining instruction and supervision when needed.
- (1)(H): Seeking orientation/training for new equipment and unfamiliar situations.
- (1)(T): Accepting assignments that consider client safety and align with education, experience, knowledge, and abilities.
Nurse Guidance
Returning nurses or those changing practice areas should consider:
- Continuing direct supervision as mutually determined, considering competence. Direct supervision means an experienced nurse (minimum 2 years) is readily available to coordinate, direct, and observe.
- Performing functions within their scope of practice for which they’ve been educated and demonstrated competency.
- Avoiding charge nurse or similar roles for at least six months, unless mutually agreed upon based on documented competency.
- Experienced staff nurses should supervise, collaborate with, and mentor nurses returning to work or changing practice areas.
Employer Guidance
To help nurses transition, employers should:
- Establish policies for incorporating transitioning nurses into roles and staffing.
- Develop preceptors for direct supervision and mentoring.
- Assign a consistent preceptor for ongoing evaluation, aligned with Board Rule 217.11 and national standards. Orientation should be individualized.
- Evaluate each nurse regularly (up to six months per §217.3) to determine competency.
These guidelines exclude Clinical Nurse Specialists, Nurse Practitioners, Nurse Anesthetists, and Nurse Midwives who have completed formal education with a clinical practicum when entering advanced practice.
These guidelines aid employers and nurses in safely integrating into licensed vocational or professional nursing roles and functions.
Determining APRN Scope of Practice
The Texas Board of Nursing acknowledges that advanced nursing practice is dynamic and evolves through experience, knowledge, evidence-based practice, technology, and healthcare changes. APRNs may need to practice in new settings, perform new procedures, and develop new skills. Common questions include, “Can an APRN treat this condition?” or “Is this procedure within the APRN scope?”.
Scope of practice involves the activities a provider performs in patient care, reflecting the patients they can care for, procedures they can perform, and ability to seek reimbursement.
Determining scope includes:
- Advanced practice education
- Legal implications (NPA and Board Rules)
- Scope statements from national organizations
Professional and individual scopes exist. Professional scopes come from organizations, while individual scopes depend on knowledge, skills, and competencies. Each APRN must practice within their individual scope.
Professional Scope
National organizations define scope of practice for each role, addressing function, population, and setting. These documents provide the broadest parameters.
Individual Scope
Formal education forms the basis for individual scope, evolving over time. Clinical experience, continuing education, coursework, and healthcare developments all impact scope. However, expanding scope has limits without further education. APRNs can’t change their titles or designations through experience alone; additional education and legal requirements are needed.
Questions to clarify if a new activity can be added:
- Is it consistent with professional scope?
- Is it consistent with laws?
- Is it consistent with education?
- Is it consistent with recognized title, or does it require additional education and recognition?
- Is it consistent with Board Rule 217.11?
- Is it consistent with evidence-based care?
- Is it consistent with reasonable practice?
- Are you willing to accept accountability?
Adding New Procedures
When adding procedures, APRNs should document education and competency. Suggestions include:
- Identify benefit, considering demand, standards, and APRN interest.
- Ensure statutes don’t constrain the activity.
- Identify professional standards supporting the activity.
- Establish learning goals and methods.
- Demonstrate competent performance.
- Maintain records of competency.
Individual scopes vary, but the Board holds APRNs accountable for knowing and practicing within their professional and individual scope.
Responsible Prescribing of Controlled Substances
All APRNs must comply with Board Rule 222 regarding APRNs with prescriptive authority, and those in pain management must follow Board Rule 228. Understanding the challenges of prescribing opioids, benzodiazepines, barbiturates, and carisoprodol (Soma) and complying with Board rules, the Texas State Board of Pharmacy, and the DEA is vital. The Texas Medical Board also offers guidance on pain management. These guidelines align with Texas Health and Safety Code, §481.0762(a).
These drugs have addictive potential and are prevalent in disciplinary cases. Non-therapeutic prescribing has public health implications, including rising emergency department visits for overdoses. The opioid epidemic is linked to infectious diseases like hepatitis C and HIV, which are receiving attention in Texas and nationally.
Texas Health and Safety Code, §481.0762 requires agencies licensing prescribers of controlled substances to develop prescribing guidelines. While general prescribing principles apply, additional considerations are needed.
Texas has a prescription monitoring program (PMP) for controlled substances. APRNs must check the Texas PMP before prescribing any controlled substance. The PMP is on the Texas State Board of Pharmacy’s website at www.pharmacy.texas.gov/PMP/. Effective September 1, 2019, APRNs prescribing opioids, benzodiazepines, barbiturates, or carisoprodol (Soma) must access and review the Texas PMP per Texas Health and Safety Code, §481.0764(a).
Treating pain requires considering the patient’s overall health, including physical function, psychological, social, and work-related factors. Treatment plans must be evidence-based and within the standard of care. APRNs must treat the condition, not just symptoms.
Consultation and referral are essential for patients experiencing pain, addressing both physical and psychological components. Patients with substance use disorder histories need consultation and referral to addiction specialists. Those with co-existing psychological/psychiatric disorders need referral to experts in those areas. APRNs must know their limits and refer appropriately.
APRNs must be aware of FDA warnings, such as the black box warning on respiratory depression, sleep apnea, and death when combining opioids with benzodiazepines or other central nervous system depressants, including alcohol. They must consider these risks and prescribe judiciously.
Comply with Board Rule 222.8 when prescribing any controlled substance. For instance, testosterone is a Schedule III drug. All requirements of Board Rule 222.8 must be met, including reviewing the PMP.
National guidelines for safe prescribing include:
- Texas Board of Nursing Rules 222 and 228: http://www.bon.texas.gov/laws_and_rules_rules_and_regulations_current.asp
- Texas Medical Board Rules 170 and 195: http://www.tmb.state.tx.us/page/board-rules
