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Summary of ActionsA regular meeting of the Board of Nursing was held January 24-25 2019, in Austin.The following is a summary of Board actions taken during this meeting.In the February 15, 2019, edition of theTexas Register:The Texas Board of Nursing (Board) proposed amendments to §213.33, relatingto Factors Considered for Imposition ofPenalties/Sanctions. The Texas Legislature adopted House Bill (HB) 2950 duringthe 85th Regular Legislative Session. HB2950 amended the Occupations Code§301.461 (Nursing Practice Act) to prohibit the Board from imposing upon anapplicant or licensee the costs of an administrative hearing at the State Officeof Administrative Hearings (SOAH). Theproposed amendments are necessary toconform to this statutory requirement.The proposed amendments also eliminate redundant language from the section and clarify the use of the Board'sDisciplinary Matrix. The earliest possibledate of adoption is March 17, 2019.In the February 22, 2019, edition of theTexas Register:The Board adopted amendments to§§221.2 - 221.5 and §§221.7 - 221.10.The Board simultaneously adoptedthe repeal of §221.4 and §221.11. Nochanges were made to §221.1, §221.6, or§§221.12 - 221.17. The amendments to§221.2, concerning APRN Titles and Abbreviations, and §221.4, concerning Licensureas an APRN, were adopted with changesto the proposed text as published in theOctober 12, 2018, issue of the Texas Register (43 TexReg 6753). The Board receivedthree written comments on the proposal. In response to the written commentson the published proposal, the Board hasmade changes to the title of the section,§221.2(b) and (c), and §221.4(a)(8)(B) and(10) as adopted. None of these changes,however, materially alter issues raised inthe proposal, introduce new subject matter, or affect persons other than those previously on notice. The adopted changesto §221.3(a) re-organize the definitionswithin the section for better overall organization and readability of the section. Thesection also includes changes for consistency with recommended provisions of theAPRN Consensus Model and the essentialsof masters/doctoral coursework. Adopted §221.3(e) - (g) clarify the educationalrequirements all APRNs must meet, in allfour roles, including the elements thatmust be included in each of the requiredcourses. The adopted changes to subsec-tions (h) - (j) clarify the review process forapplicants in multiple roles or populationfoci and the educational requirementsthat an individual must meet in order tobe licensed in more than one role andpopulation focus area. Proposed §221.5contains the standards that the Boardwill consider when determining whethera certification examination may be usedto satisfy a requirement for APRN licensure under the chapter. Section §221.7contains waiver provisions. This sectioncontains editorial changes and has beenre-organized for clarity. Adopted §221.8contains the requirements related toAPRN licensure renewal. The adoptedchanges re-organize the section for betterclarity. Adopted §221.9 contains requirements related to inactive status. Generally, the changes are editorial in nature.The majority of changes to §221.10 wereeditorial in nature. Adopted §221.10includes requirements related to a preceptor providing the supervised clinicalcomponent of a refresher course or extensive orientation. Amended §221.10also adopts by reference the Board's existing guidelines regarding APRN refresher course/extensive orientation requirements.Nursing Education Actions - January 2019 Board MeetingReviewed Reports on: New NursingEducation Programs and Currently Activeand Potential Proposals, Programs withSanctions, Communication Activitieswith Nursing Education Programs, 2018NCLEX-RN Examination Pass Rates, andan Analysis of Four Self-Study Reports Vocational Nursing Education Programs 2017 NCLEX-PN Examination Pass Rates.Western Technical College – BaccalaureateDegree Nursing (BSN) Education Programin El PasoApproved Change in Approval Statusfrom Conditional Approval to Full Approval:Approved Change in Approval Statusfrom Initial Approval to Full Approval:Vernon College – VN Education ProgramLamar State College – ADN EducationProgram in Port ArthurValley Grande Institute – VN EducationProgram in WeslacoApproved Report of Survey Visits:Texas State Technical College – ADN Education Program in HarlingenApproved Change in Approval Statusfrom Initial Approval to Initial Approvalwith Warning and Approval of SurveyVisit:Coastal Bend College – Vocational Nursing (VN) and Associate Degree Nursing(ADN) Education Programs in Beeville.National American University – BSN Education Program in AustinReceived Notifications of Voluntary Closure of Nursing Education Program:Wayland Baptist University – BSN Education Program in New BraunfelsBrightwood College – VN Education Programs in Corpus Christi and San AntonioApproved Change in Approval Statusfrom Initial/Full Approval with Warningto Full Approval:Joe G. Davis School of Vocational Nursing– VN Education Program in HuntsvilleApproved Proposals to Establish NewNursing Education Programs:Texas Southmost College – ADN Education Program in BrownsvilleClarendon College – ADN Education Program in Pampain Wichita FallsCarrington College – ADN EducationProgram in MesquiteApproved Change in Approval Statusfrom Initial Approval to Initial Approvalwith Warning:St. Philip’s College – ADN EducationProgram in San AntonioThe College of Health Care Professions –ADN Education Program in HoustonApproved Change in Approval Statusfrom Full Approval with Warning toConditional Approval:University of Texas of the Permian Basin–BSN Education Program in OdessaMcLennan College – ADN EducationProgram in Waco3

FAQ - Cosmetic Procedures for APRNsThe Board receives questions frequentlyabout whether cosmetic procedures arewithin 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 anall-purpose list of tasks that every nursecan or cannot perform, and it is up toeach individual nurse to use sound judgment when deciding whether or not toperform any particular procedure or act.The following resources, however, areintended to provide you guidance indetermining if cosmetic procedures arewithin your scope of practice.What is the APRN scope ofpractice in regards to cosmeticprocedures?An APRN is a registered nurse licensedby the Board to practice as an APRN onthe basis of completion of an advancededucational program. The term includesa nurse practitioner, nurse midwife,nurse anesthetist, and clinical nursespecialist [Tex. Occ. Code §301.152.(a)].The APRN scope of practice is addressedin Tex. Admin. Code §221.12, and mayinclude medical diagnosis and prescriptive authority when properly delegatedby a physician. The APRN scope of practice is based upon formal educationalpreparation, continued advanced practice experience and the accepted scopeof professional practice of the particularspecialty area. The Core Standards forAdvanced Practice found in Tex. Admin.Code §221.13 further clarify that APRNsmust function within the advancedrole and specialty appropriate to theireducational preparation [specificallyin Tex. Admin. Code §221.13(b)]. If theAPRN has had the formal educationto provide a specific service, thenthis is part of their scope of practice.The APRN must, however, have beeneducated not only in the provision ofthe service, but also in the response toand medical management of untowardevents/adverse reactions/complicationsexperienced as a result. You may findit helpful to review the Practice-APRNScope of Practice page on the BONwebsite. The APRN must also havethe appropriate physician delegationto engage in these medical aspects ofpatient care.Pertaining to cosmetic procedures, thescope of practice of the APRN will, inpart, be dependent on the educationalcomponent discussed above. When incorporating a new patient care activityor procedure into one’s individual scopeof practice, the Board expects the APRNto verify that the activity or procedure isconsistent with the professional scopeof practice for the licensed role andpopulation focus and permitted by lawsand regulations in effect at the time. Ifthe activity is not consistent with theprofessional scope of practice for thelicensed role and population focus, additional formal education and licensurefrom the BON in the second role and/or population focus are required. Position Statement 15.10, Continuing Education: Limitations for Expanding Scopeof Practice clarifies that expansion of anindividual nurse’s scope of practice haslicensure-related limitations. Informalcontinuing nursing education or on-thejob training CANNOT be substituted forformal education leading to the nextlevel of practice/licensure.If an APRN would like to perform medical aspects of care related to cosmeticprocedures s/he should first considerwhether the medical aspects of care related to cosmetic procedures relate tohis/her current licensed role and population focus area. If it does NOT, thenthe APRN must obtain additional licensure in the appropriate licensed role andpopulation focus area in order to provide medical aspects of care related tocosmetic procedures. If it is within theircurrent licensed role and population fo-cus area, then they should next considerwhether they have the appropriate training, knowledge, skills, etc. to safely deliver the medical aspects of care relatedto the cosmetic procedure. Continuingeducation may be an adequate methodto gain training, knowledge, and skillsnecessary to safely deliver the medicalaspects of care related to cosmetic procedures within the APRN licensed roleand population focus area.An example of an APRN that would bepracticing outside his/her licensed scopeof practice in delivering medical aspectsof care related to cosmetic procedures,is a Nurse Midwife delivering such careas cosmetic procedures are outside theNurse Midwife’s licensed role. Another example is a Women’s Health NursePractitioner (WHNP) delivering such careto men as men are outside the WHNP’spopulation focus area. Additional formal education and APRN licensure authorizing practice in the pertinent roleand population focus would be requiredin both instances. It is important to remember that the task or procedure mustbe consistent with both the licensed roleand population focus area.It is important to consider that an APRNwho determines that performing medical aspects of cosmetic procedures isnot within his/her scope of practice maydetermine that administration of a medication or performance of a non-invasivetreatment is within the individual’s RNscope of practice using the Board’s SixStep Decision-Making Model for Determining Scope of Practice. For example,the WHNP described above may determine that administration of cosmeticinjections ordered by an appropriatelylicensed provider is within his/her scopeof practice as a registered nurse.Remember that APRNs do not have fullpractice authority in the state of Texas.The provisions of medical aspects ofcare, including formulating diagnoses forthe appropriate use of cosmetic injeccontinued on next page4

Cosmetic Procedures - continued from previous pagetions and ordering the drugs themselves,requires delegation from a physician. It isnot within the scope of APRN licensureto provide these services independent ofa physician. The APRN may only acceptphysician delegation for those medicalaspects of care and prescribing that arewithin the scope of the role and population focus area of APRN licensure.It is important to remember that cosmetic procedures involving medicationssuch as Botox or Restylane will requirephysician 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 FDAhas limited approved uses for thesetypes of medications. Tex. Admin. Code§222.4(e) permits issuing prescriptionsfor non-FDA approved uses when thepatient is enrolled in an IRB approvedclinical research trial. This rule also describes the requirements that must bemet when an APRN issues a prescriptiondrug order for an off-label use of a medication. If the intent is to utilize Botox fora non-FDA approved use, one of theseother criteria must be met. Additionally,the APRN must meet all other criteria forprescribing medications, including physician delegation and prescriptive authority agreement requirements as specifiedin Tex. Admin. Code §222.5.To further assist nurses in determiningwhether a task/procedure/act is within his/her scope of practice, the Boardhas developed a step-by-step tool, theSix-Step Decision-Making Model for Determining Nursing Scope of Practice. Inpreparation for any nurse (LVN, RN, orAPRN) using the Six-Step Model, Boardstaff recommend review of several resources available on the Texas BON website to further guide you. These resources include:be directly applied to this situationand should be considered. All nursesmust:o (1)(A)- know and conform to theTexas Nursing Practice Act (NPA)and the board’s rules and regulations as well as all federal, state,or local laws, rules or regulationsaffecting the nurse’s current areaof nursing practice;(1)(B)- implement measures topromote a safe environment forclients and others;o(1)(C)- know the rationale forand the effects of medicationsand treatments and correctlyadminister the same;o(1)(G)- obtain instruction andsupervision as necessary whenimplementing nursing procedures or practices;o(1)(H)- make a reasonable effortto obtain orientation/training forcompetency when encounteringnew equipment and technologyor unfamiliar care situations;o(1)(M)- institute appropriatenursing interventions that mightbe required to stabilize a client’scondition and/or prevent complications;o(1)(O)- implement measures toprevent exposure to infectiouspathogens and communicableconditions;o(1)(R)- be responsible for one’sown continuing competence innursing practice and individualprofessional growth; ando Tex. Admin. Code§217.11 (Standards of NursingPractice) outlines the minimumstandards of nursing care at alllicensure levels (LVN, RN, APRN).Specific subsections of this rule cano (1)(T)- accept only those nursing assignments that take intoconsideration client safety andthat are commensurate with thenurse’s educational preparation,experience, knowledge, andphysical and emotional ability.Position Statement 15.9 (Performance of Laser Therapy by RNs orLVNs) Position Statement 15.23 (The Useof Complementary Modalities bythe LVN or RN) Position Statement15.11 (Delegated Medical Acts) specifically addresses the nurse’srole with delegated medical acts.Board staff recommend cautionwhen performing a delegatedmedical act, as delegatedmedical acts do not diminish theresponsibility of the nurse in anyway to adhere to the Board'sStandards of Nursing Practice,Board Rule 217.11. Nurses function under their own licenses andassume responsibility and accountability for quality, safe care inaccordance with all applicable laws/rules/regulations; nurses do notpractice under a physician’s license. Position Statement 15.14 (Dutyof a Nurse in any Practice Setting)- discusses a landmark court casewhich demonstrates how everynurse has a duty to promotepatient safety and that duty to apatient supersedes any physicianorder or facility policy. Position Statement15.10 (Continuing Education:Limitations for Expanding Scope ofPractice) - clarifies that expansionof an individual nurse’s scope ofpractice has licensure-relatedlimitations and that informalcontinuing nursing education oron-the job training cannot besubstituted for formal educationleading to the next level ofpractice/licensure or authorization.Board staff also recommend review ofthe Texas Medical Board Rule 193.17, entitled Nonsurgical Medical Cosmetic Procedures, that addresses the rules relatedto physician delegation of nonsurgicalmedical cosmetic procedures. In addition, depending on the range of servicesyou plan to provide, there may be specific licensure requirements including, butnot limited to, Cosmetology Licensing.Having a nursing license authorizes youcontinued on next page5

Guidelines for PrescribersIn 2017, the United States Department of Health and Human Servicesdeclared the opioid crisis to be a public health emergency. Efforts tocombat the misuse and abuse of opioids and other prescription drugscontinue at both the state and national levels. Texas has implementedprograms such as the prescription monitoring program to assist prescribers of controlled substances with monitoring patient prescriptionhistory in an effort to avoid duplicative prescriptions. Other laws, suchas those that will require prescribers to check the prescription monitoring program before prescribing opioids, barbiturates, benzodiazepines, or carisoprodol, are scheduled to go into effect on September 1, 2019.State and federal agencies have also developed guidelines to assist health care providers who care for patients who may be taking these drugs for chronic conditions. The Texas Board of Nursing’s Guidelines forResponsible Prescribing of Controlled Substances were published in the October 2018 issue of the TexasBoard of Nursing Bulletin and are available on the Board’s website at www.bon.texas.gov/practice guidelines.asp#RG Prescribe. Another helpful resource is the Center for Disease Control’s (CDC’s) Guideline forPrescribing Opioids for Chronic Pain. Permission was obtained from the CDC to share a fact sheet based onthis national guideline to assist prescribers and nurses who care for patients receiving opioid therapy (Seepages 7-8). Additional information is available at l.Cosmetic Procedures - cont. from prev. pageto practice nursing within your licensure level and scope of practice butnot to do other things that requireseparate licensure/certification. Youcan find additional regulations related to cosmetologists/practicingcosmetology from the agency thatregulates cosmetologists, the TexasDepartment of Licensing and Regulation. Additionally, there may beapplicable guidance related to thepractice setting; e.g., a private physician office might have specialty-specific guidelines from the AmericanBoard of Medical Specialties. Beyond following all applicable laws,rules, and regulations regarding theacts/tasks and the setting, the nursewould need to practice consistentlywith the employer’s policies, assuming these policies promote patientsafety (refer back to Position Statement 15.14 if necessary).If a license is obtained via anotheragency or regulatory body to perform duties and tasks in anothersetting, for example a medical spa, theBoard considers persons who hold nursinglicensure accountable for acts within thepractice of nursing even if these acts areperformed ‘off duty’ or in another setting[Tex. Occ. Code §301.004(a)(5)]. One example of this may be performing a lowerleg wax for a client who has diabetes andperipheral neuropathy; this client may notbe able to feel if the wax is too hot andthere may be associated burns and a pooroutcome. In this example, you would beheld responsible for applying your nursingknowledge and judgment with this particular client. There is also a Frequently AskedQuestion which relates to this discussion(Practice of Nursing). Position Statement15.15 (Board’s Jurisdiction Over a Nurse’sPractice in Any Role and Use of the Nursing Title) reiterates that any licensed nursein Texas is responsible to and accountableto adhere to both the NPA and Board Rulesand Regulations when practicing nursing,which have the force of law [Tex. Admin.Code §217.11(1)(A)].6Food for ThoughtIt is important to remember thatthere is more to this topic than simply learning how to perform a particular procedure. Patient selectioncriteria, underlying physiology and/or pathophysiology, as well as indications for and contraindications tothe procedure are among the manyconcepts that are fundamental tolearning a new procedure. You mustalso learn to respond to and manage(as appropriate) untoward events/adversereactions/complicationsthat may occur as a result of theprocedure. In many cases, on-thejob training will not include this typeof content. If you are ever requiredto defend your practice for any reason (whether to the BON or any other entity), you will likely be requiredto provide evidence of education/training and documentation of competence related to the specific service you provided.

CDC RECOMMENDATIONSDETERMINING WHEN TO INITIATE OR CONTINUE OPIOIDS FOR CHRONIC PAIN123OPIOIDS ARE NOT FIRST-LINE THERAPYNonpharmacologic therapy and nonopioid pharmacologic therapyare preferred for chronic pain. Clinicians should consider opioidtherapy only if expected benefits for both pain and function areanticipated to outweigh risks to the patient. If opioids are used, theyshould be combined with nonpharmacologic therapy and nonopioidpharmacologic therapy, as appropriate.Nonpharmacologic therapies andnonopioid medications include: Nonopioid medications such asacetaminophen, ibuprofen, or certainmedications that are also used fordepression or seizuresESTABLISH GOALS FOR PAIN AND FUNCTION Physical treatments (eg, exercisetherapy, weight loss) Behavioral treatment (eg, CBT) Interventional treatments(eg, injections)Before starting opioid therapy for chronic pain, clinicians shouldestablish treatment goals with all patients, including realistic goalsfor pain and function, and should consider how opioid therapywill be discontinued if benefits do not outweigh risks. Cliniciansshould continue opioid therapy only if there is clinically meaningfulimprovement in pain and function that outweighs risks to patient safety.DISCUSS RISKS AND BENEFITSBefore starting and periodically during opioid therapy, clinicians should discuss with patients known risks andrealistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.OPIOID SELECTION, DOSAGE, DURATION, FOLLOW-UP, AND DISCONTINUATION456USE IMMEDIATE-RELEASE OPIOIDS WHEN STARTINGWhen starting opioid therapy for chronic pain, clinicians shouldprescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids.USE THE LOWEST EFFECTIVE DOSEWhen opioids are started, clinicians should prescribe the lowesteffective dosage. Clini

Kathy Leader-Horn, LVN representing LVN Practice Granbury Melissa D. Schat, LVN representing LVN Practice Granbury Francis Stokes, BA representing Consumers . sure of Nursing Education Program: Brightwood College – VN Education Pro-grams in Corpus Christi and San Antonio Joe G. Davis School of Vocational NursingFile Size: 2MB