Texas Nurse Practice Act

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Texas Nurse Practice Act
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– it is considered nursing law and applies to all licensed nurses regardless of educational level – This Occupations Code defines nursing practice and gives the BON the authority to make rules which are then implemented and interpreted in the Texas Nurse Practice Act
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Legislature
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only the Legislature can change the NPA but the BON can make rule changes as needed to help in the application of the NPA due to evolving practice and settings.
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Board of Nursing Mission/ Primary Purpose
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To regulate the practice of nursing which ensures the protection and promotion of the welfare of the people of Texas by ensuring that everyone with a nursing license is competent and can practice safely
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Board of Nursing Responsibilities
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– Regulation of the practice of both professsional (PN) and vocational nursing (VN) – Licensure and Practice for nurses, employers and the public to ensure that HC professionals and consumers are informed — examine and license qualified applicants of GVN, GN, & APN — License by endorsement qualified applicants
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Board of Nursing Functions
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– establish standards of nursing practice and regulate the practice of PN and VN – receive complaints and investigate violations of the NPA – Discipline violators through appropriate legal actions – Provide a mechanism for public comment about rules and regulations
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BON Functions
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– Recommend to the legislature changes to the NPA to remain current with public needs – Establish standards for nursing education and accredit or deny accreditation to schools of nursing — recommendations — commendations
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BON Functions
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– Monitor NCLEX results to determine effectiveness of school programs (reason for Exit Exam) – Provide advice and counsel to faculty of educational programs to continually improve – Implement and manage all other programs and responsibilities authorized and mandated by legislature
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Role of the Legislature
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– NPA can only be changed by the Texas Legislature which convenes every 2 years for 140 days or in special sessions called by the Governor – Legislature gives the BON general rule-making authority which allows them to develop more details – Lobbying by interested parties is done by professional organizations
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Sunset Review
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– Process by which Texas Legislature determines if state agencies should continue to exist or be “sunset” (Discontinued) – sunset review occur every 12 years – BON underwent Sunset review during the 2007 legislative session
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Licensure
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– Is necessary to practice or offer to practice as a RN or VN – Acceptable titles: RN, GN, or Professional Nurse, LVN, GVN, Vocational nurse (LPN) – Only these titles may use the term “Nurse” – Exceptions are authorized by the state or federal govt. or under the delegation of a RN (nurse aide) — CNA — Doctor’s offices?
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Licensure
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– Licenses must be renewed every 2 years based on birth month and year. – Includes requirements for continuing education – Failure to renew on time and continue to work will result in disciplinary actions which may include revoking your license
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Name Badges
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– Name according to nurse’s preference – Must include type of license (RN, LVN) – May include: degrees, certifications, position, picture, employer
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Nurse Imposters
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Some people with either a revoked license or a little knowledge will hire into a doctor’s office or home health agency with the promise of a license to come. – These people will be arrested and prosecuted for being a nurse imposter. Your picture will show up in the BON Nursing Quarterly
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Definition of “Professional Nursing”
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– Performance/act that requires substantial specialized judgment and skill – Includes: the observation, holistic assessment, intervention, evaluation, rehabilitation, care/counsel, or health teachings of a person is ill, injured, infirm, or experiencing a health change – Maintenance of health/prevention of illness – Administration of medication – Supervision of teaching of nursing – The requesting/receiving/signing for/ and distribution of prescription drug – performance of act delegated by physicians – development of a nursing care plan
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Basics of Nursing Practice
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– you must keep the Board informed of your current address at all times. Do this by sending written notice, clearly marked “change of address” to the Board’s office any time you move. – failure to do so can result in a lapse of your license and potential disciplinary action
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Standards of Nursing Practice – Rule 217-11
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– Standards of Practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure – Failure to adhere standards may result in action against the nurse’s license even if no harm occurred to patient – the hospital administrators, the Chief Nursing Officer and Nurse Managers all have duty to uphold all recognized standards.
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Standards of Nursing Practice
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– “Professional nursing: performance of an act which requires substantial specialized judgment and skill…based on the knowledge and application of the principles of bio, physical, and social science” – Vocational nursing: “means a directed scope of practice” – This means a LVN must always be under the supervision of a licensed practitioner such as RN, physician, podiatrist. – This supervision does not necessarily mean on-site but may be by phone, but must be easily reached.
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Standards of Practice
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– you must know the laws, regulations, standards of TX NPA: Patient’s Bill of Rights, Code of Ethics, Abuse laws, etc. – ignorance is not a defense – following institutional policies is not a defense – You must be able to identify how the LVN and RN Scope of Practice are alike and how they differ.
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Standards of Nursing Practice
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– Implement measures to insure a safe environment — this may come partly from institutional policies — but nurses have a direct duty to the patient and following policies is not enough – Know purpose and side effects of every medication and treatment the patient receives. — duty is to the patient so do not blindly follow orders or policies – Accurately and thoroughly document aspects of care
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Standards of Nursing Practice
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– Provide for privacy and confidentiality – Promote and provide education and counseling – Be responsible for your orientation, supervision, and training — this includes safe and correct handling of all equipment. – Provide care without discrimination — Examples: homeless – Clarify orders — duty to question incomplete or questionable orders: name, dose, route, frequency – Implement appropriate infection control policies — hand washing; sterile fields – Collaboration with other HC Providers – Coordination of Care – Consultation/referrals- nurses should be familiar with community resources
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Duty to Report
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– Nurses have a duty to patients based on: — the patients vulnerability — the nurse’s position of power – Every nurse either RN or LVN has a duty to report any of the following: — Violations of the NPA or a BON rule which results or contributes to the death or serious injury of a client
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Duty to Report
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– Suspicions of a nurse who may be impaired due to drugs or alcohol – Commissions of abuse, neglect, fraud, exploitation of any patient – Violations of professional boundaries — Remember: financial, sexual, emotional, physical, etc. – Actions which indicate the nurse lacks the judgment, or consciousness that continuing practice may result in harm to a client – Any peer review committee results except for minor incidents
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Others with a Duty to Report
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– Nursing schools: legally and ethically obligated to report students who break any of these standards – employers – professional organizations which expels or takes disciplinary action against a nurse – State agencies such as Dept of Health and Human Services, Child Protective services, etc. – Liability insurer – Prosecuting attorney
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Standards Specific to R.N.s
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Nursing process: R.N.s utilize a systematic holistic approach to care for patients. Only a RN can do the initial assessment of every patient.
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Nursing Process Differences: LVN
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– collecting data and focused assessments – participate in planning care – development & modification of the plan – implement the plan under the scope of practice – assist in evaluation of response to nursing
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Nursing Process Differences: RN
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– Systematic approach to individualized, goal-oriented care – obtain a comprehensive assessment – develop nursing diagnoses – develop a plan of care based on assessments and diagnoses – implement the plan – evaluate the responses
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Delegations by R.N.s
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– authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs tasks – RNs delegate to unlicensed persons – UP= unlicensed personnel – Delegation may only be done by a RN – LVN may only assign tasks because they must be under the supervision of a RN
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Delegation
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1. The RN must make an assessment of nursing needs before delegating tasks 2. The nursing task must be one that a reasonable and prudent RN would find within the scope of nursing to delegate. The most fundamental criteria for delegation is the professional judgment of the RN. 3. The nursing task must be one that can be safely delegated 4. The nursing task must not require professional nursing judgment 5. The unlicensed person must be adequately identified. 6. The RN must have either instructed the unlicensed person or verified competency to perform nursing task 7. The RN shall supervise the performance of delegated task 8. If the delegation occurs over time the RN shall evaluate the delegation of task on a regular basis.
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Five Rights of Delegation
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1. The right task 2. The right person to whom the delegation is made 3. The right circumstance (stable patient) 4. The right direction/communication with R.N 5. Right supervision of the task
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Supervision after Delegation
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– Degree of supervision is determined by the RN – Need to consider many factors such as: — stability of patient — training and experience of UP — nature of task being delegated — proximity and availability of the RN to the UP
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Tasks Most Often Delegated
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– Non-invasive and non-sterile treatments – collecting, reporting, and documenting of data: V/S, pulse ox, height/ weight, I&O blood test and urine test for sugar environmental situations (cleanliness of patient & room) client/ family comments related to patient care turning & positioning & ambulation transportation of client in facility personal hygiene, elimination, vaginal irrigations, enemas feeding socialization activities ADLs (note: UP can assist with self-medication, this is defined as an ADL Reinforcement of health teaching given by RN. Be careful about this
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Nursing Tasks Prohibited from Delegation
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– initial assessment & physical, psychological, & social assessment – formulation/ evaluation of the nursing care plan – specific tasks within the care plan that require nursing judgment – the responsibility for health teaching to client & family – administration of meds – including IV fluids except as permitted to the title of Medication Aide (long-term care facilities/home health)
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Tasks Which usually Should Not be Delegated
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– sterile procedures (wound care) – non-sterile procedures (dressing changes) – invasive procedures such as putting tubes into a cavity, instilling or inserting substances into an indwelling tubes (IVs, foley catheters, NG tubes) – care of broken skin except for first aid
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Delegation to Nursing Students
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nursing students performing tasks as part of educational program (clinical only) are exempted from the application of delegation rules however, when performing nursing tasks outside of educational program (for money or volunteer) they are in fact functioning as unlicensed persons
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Discretionary Delegation
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– This is the rule which applies to all unlicensed nursing students who are working in a health care facility or company — nurse extern, PCA, etc. – Rn must be directly responsible for the patient – Facility must have a protocol or policy which addresses: — the complexity of the task — how the UP demonstrates competency — a method and frequency for revaluation of the competency — a method to determine who should be allowed to do the task
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Assignment-Making
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– Assignment-making is from one licensed nurse to another licensed nurse – Assigning: Administratively directing a person to perform a task that they have the legal authority to perform – RNs assign tasks to LVNs – BON regulates both making and accepting assignments in that the nurse should only make and accept assignments in coordination with their educational preparation, experience and knowledge and are capable of doing based on the nurse’s physical and emotional health.
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LVNs and Assignments
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LVNs operate under authority of their own license and delegation is not required for them to perform tasks falling within scope of their practice. Delegation is related only to unlicensed personnel
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New Graduates: Temporary Authorization to Practice
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– Must be under direct supervision of appropriate nurse who must be on the same “unit” and readily available for 6 months – New RN should not charge for at least 1 year – New grads should not practice in unsupervised settings such as home health for at least 12-18 months
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Continuing Education Requirements
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Every licensed nurse must complete 20 hours of continuing education related to their practice area every 2 years. – the education must be approved by the TNA Continuing Education committee or and approved person/facility – 60 minutes equals one CE credit – The BON may require specific topics to be studied according to national concerns or related to a specific clinical area: Bioterrorism, forensic nursing – There are rules regarding what is accepted as continuing education because it must be patient centered. – can not be about new equipment at the facility – very long detailed process for approval – Process is done through Texas Nurses Association who approves providers and programs.
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Nursing Ethics
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Ethical conduct = Good Professional Character Unprofesssional Conduct: – criminal behaviors – professsional boundaries – intemperate use of alcohol mental illness
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Ethical conduct
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– ethical conduct is necessary because of the relationship of the nurse to vulnerable populations – BON requires Good Professional Conduct which is determined by consistent behaviors in personal, academic, and occupational history
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Ethical Conduct
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– Expected behaviors include but are not limited to honesty, accountability, trustworthiness, reliability, and integrity – And the nurse should be able to: — distinguish right from wrong — think and act rationally — keep promises and honor obligations — be accountable for his or her own behaviors — practice autonomously — recognize and honor interpersonal boundaries — promptly and fully relate facts, circumstances, events, errors, etc. which might effect health and well-being of patients/clients
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Unprofessional Conduct
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– the unprofessional conduct rules are intended to protect the public from unethical and illegal conduct – the rules are different from 217.11 because these rules place emphasis on blameworthy behavior rather than a nurse failing to comply with standard
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Unsafe Practice
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– Failure to comply with accepted standards (infection control principles) – Improper record management (documentation or storage of data) – improper assignment making or delegation – Improper acceptance of assignment
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Unprofessional Conduct
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– Failure to comply with any license restrictions – Practicing with the inability to practice safely due to physical, mental, etc. issues – Endangering patients (actual injury does not have to be established) – Inappropriate leaving assignments (patient abandonment). Once you accepted an assignment you must stay. However, in cases of extreme emergency you must notify the supervisor and give him time to find a replacement
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Unprofessional Conduct
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– Unlawful practice: violating board order, violating duty to report – improper supervision by faculty (failure to supervise students) – lack of responsible oversight by CHIEF NURSING OFFICER – Failure to pay student loans/child support – Falsifying records entering assessment data or vital signs not actually taken. However, late entries on things actually done is legal – Failure to cooperate with any BON investigation – Causing patient any harm – Patient neglect or abuse – Violating professional boundaries such as financial or sexual misconduct
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Examples of Misconduct
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– violent or threatening behavior toward patients, families or in the workplace – misappropriation of funds, payments, or materials – giving false information false employment information – dismissal from peer assistance (for noncompliance related to drugs/alcohol) – crossing professional boundaries – improper solicitation or referral – some things will automatically be reported to the judicial or referral
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Misconduct that will automatically be reported to the judicial system
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– diverting narcotics – drug related misconduct: — improper record keeping, improper medication wastage, positive drug screen, falsifying prescriptions
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Professional Boundaries
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Definition: – the appropriate limits which should be established by the nurse/client relationship due to the nurse’s power and the patient’s vulnerability. – Remain within Professional Boundaries at all times — Know, recognize and maintain professional boundaries…
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Professional Boundaries
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– Nurses must refrain from inappropriate involvement in the client’s personal relationships and or the obtainment of the nurse’s personal gain at the client’s expense – always promotes the client’s dignity, independence, and best interests and avoids involvement in client’s personal life. – Boundaries include any exploitation of client or client’s family related to: — physical needs (withholding care) — emotional needs — sexual misconduct even if consensual — financial areas – Maintaining boundaries is always the nurse’s responsibility
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Criminal Behaviors
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Four Major Areas of Disciplinary and Eligibility Sanctions – Fraud, theft, and deception – lying and falsification – sexual misconduct – substance abuse or misuse, including intemperate use Any conviction of a felony or misdemeanor involving moral turpitude
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Felonies and Deferred Adjudications
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– These are conclusive considered evidence of guilt – Related to Texas Occupations Code 53 – Subject to discipline including license revocation – There is also a process if nurse has been subject to discipline in another state
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Intemperate Use and Mental Illness
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– substance abuse or addiction diagnosis or treatment within last 5 years – evidence of intemperate use of alcohol of recreational drugs – social media – mental illness diagnosis or treatment within last 5 years — schizophrenia, bi-polar, paranoid personality disorder, antisocial personality or borderline personality
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Texas Peer Assistance Program for Nursing
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– This is a TNA program provides assistance for nurses with substance abuse or have certain mental illness to with treatment for their individual problems and allows them to safely transition back to safe nursing practice – when enrolled in the TPAPN program nurses must submit to both random and for cause drug testing – They are assigned a peer counselor based on individual’s problem such as another recovering substance abuser – You have a duty to report nurses with a substance abuse problem. If you see them actually doing drugs at work; call the house supervisor immediately . Let administration handle this. – If you are working in a substance abuse clinic or psychiatric facility, you may not report any licensed person you may see.
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Nursing Peer Review Law
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Chapter 303 – SB 993 enacted in 2007 – placed a greater emphasis on nursing peer review’s role in identifying external/ or system inadequacies that may have contributed to a deficiency in care.
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Incident Peer Review
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based nursing peer review which evaluates an incident or a nurse’s practice to ascertain the nurse’s accountability
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Safe Harbor nursing Peer Review
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Peer review requested by a nurse to determine if the nurse has been asked to engage in conduct that would violate his/her practice – This is frequently associated with staffing issues such as a floating to another unit or with a lack of nurses for the number of patients to safely provide nursing care
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Peer Review
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The evaluation of nursing services, qualifications of the nurse, quality of patient care rendered by the nurse, and the merits of a complaint about the nurse. Peer review process is one of fact finding, analysis, and study of events by nurses in a collegial atmosphere for problem solving. Must follow the rules of the NPA and the NPR
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Incident Peer Review
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Patient’s Protection from unsafe or unprofessional nursing care or system problem Purpose: evaluate the nurses’s accountability by: — Incident: to identifying external factors and system inadequacies that may have contributed to the problem — define minimum due process — provide guidance to any one who uses the services of nurses in the development and application of a incident-based peer-review plan – Assure nurses have knowledge of the incident-based peer-review plan – Provide guidance for the incident-based peer-review committee in its fact finding mission
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Nursing Peer Review Committee
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Shall be developed if the employer regularly employs 10 or more LVN’s or RN’s of whom at least 5 are RNs – If the employee is an RN, the committee should of at least 2/3 of committee – If the employee is a LVN, the committee may consists of only LVN and RN members – Must include at least 1 person from the nursing practice area
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Peer Review Law
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A facility conducting peer review must have written policies/procedures regarding: – Level of participation – Confidentiality – Handling of cases – Reporting of nurses to BON
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Mandatory Reporting for IPR
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Duties of who should report: all nurses, employers, peer review committees, nursing schools, certifying organizations, liability carriers, state agencies, and prosecuting attorneys have stipulations for reporting – Minor Incidents (5 minor in a calendar year only if no one was harmed before being reported) – Other incidents which must be reported
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Minor Incidents Definition
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conduct by a nurse that may be a violation of the Nursing Practice Act or a Board rule but does not indicate the Nurse’s continued practice poses a risk of harm to a patient or another person.
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Criteria for Evaluating Minor Incidents
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Did the nurse ignore a substantial risk of significant physical, emotion, or financial harm? Does the nurse lack a conscientious approach to accountability for his or her practice? Does the nurse lack the knowledge and competencies to make clinical judgments and can not be remedied?
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Conduct Required to be Reported
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An error that contributed to a patient’s death or serious harm regardless of other factors For errors involving the death or serious injury of a patient, if a nursing peer review committee makes a determination that a nurse has not engaged in conduct subject to reporting to the board, the committee must maintain documentation of the rationale for their belief that the nurse’s conduct failed to meet each of the factors in paragraph (1)(A) – (D) of this subsection
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Minimum Due Process Rules
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Is guaranteed and includes that: – The facility have a written plan for peer review – The nurse or the representative meet or exceed the level of participation in the process set out by the rule – Is based on confidentiality and safeguards to prevent impressible disclosures including a written agreement to abide by the rules. – Handling of cases which are about nurses with a substance abuse problem or suspected substance abuse, mental illness, or diminished mental capacity are referred to Peer Assistance. – Reporting to BON according to statues. – Effective date of changes to the policy – There are no guarantee of privacy for the nurse under review. Information may be shared in the Quarterly Bulletin or with legal authorities.
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Peer Review Process
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– Provide written notice to nurse in person or certified mail that his/her practice is being evaluated. – Written notice must state that peer review committee will be in 21-45 calendar days from date of notice. – Written notice must include written copy of peer review plan – The letter should also include: description of incident including the date, time, location, and persons involved; name, address, and phone number of a contact person – Provide the nurse or his or her attorney the opportunity to review documents at least 15 calendar days before the meeting.
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Peer Review Process
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– Provide the nurse with the opportunity to submit a written statement about the incident. – Call and question witnesses and be present when testimony is being given – Be provided a list of witnesses, written testimony, and evidence 48 hours before meeting – the ability to make an open statement — ask the committee questions and respond to questions – Make a closing statement – Provide the nurse with copies of the witness list at least 48 hours before proceeding – Nurse must be given opportunity to make opening statement to committee, ask questions of committee, make a closing statement after all evidence presented.
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Peer Review Process
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– Committee must conclude its review in 14 calendar days – Committee must provide written notice to nurse – Nurse has opportunity to provide written rebuttal statement within 10 calendar days of the written notice of results from committee – Peer review is not a legal proceeding – However nurse has a right to have an attorney present – If either party uses an attorney they must notify the other party 7 days before the hearing and equal representation is allowed
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Peer Review Process
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If peer review committee finds that a nurse has engaged in reportable conduct to board the committee’s report must include a description of action taken against nurse and if committee recommends disciplinary action to be taken against the nurse to the BON in writing Report does not have to be filed if the committee determines that the reported conduct was a minor incident or the person has already been reported to BON
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Peer Review Process
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A nurse may report a nurse for peer review and it will satisfy requirement to report a BON The findings of the committee can not be overturned, changed, or dismissed by Adminstration
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Exclusions to Minimum Due Process
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– After a report has already been made to the BON – Practice is suspected of impaired by chemical dependency, drug or alcohol abuse, substance abuse/misuse, “intemperate use,” mental illness, or diminished mental status – Anything requiring direct reporting to the BON – A nurse may report to the employer or other entity anything that puts the patients at risk for being harmed as a result of not meeting minimal standards. – The reporting nurse may not be disciplined, suspended, terminated, or discriminated against for reporting. – An Incident Peer Review process is a lengthy process occurring over weeks to ensure gathering information and preparation of a defense
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Safe Harbor Nursing Peer Review
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At the time the nurse is requested to engage in the conduct believed to be in violation of the nurse’s practice he/she must notify the supervisor making the assignment that the nurse is invoking “safe harbor in good faith” “Good faith” – a reasonable factual or legal basis for the request. Must be invoked before the nurse accepts the assignment or conduct or if the assignment changes At the same time the nurse must submit a written request for safe harbor utilizing the Safe Harbor form provided on the BON web site
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Safe Harbor Process: Making a Request
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– Must be writing and include: Nurse’s name & signature, date & time of request, location of assignment or requesting conduct. – A brief description of why the nurse is requesting safe harbor: May use a quick response form for this info or write by hand as long as it includes all necessary information. – A comprehensive Written Request for safe harbor must be completed at the end of the work period. – It provides more details such as nurse’s responsibilities , resources available, extenuating or contributing factors impacting the situation. Detailed description of how the assignment or conduct violated the NPA with the standards listed as unprofessional conduct rules – Any other documentation – Nurse’s name, title, and signature along with supervision or person making the request relationship to the nurse
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Safe Harbor Process: Making a Request
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– The requesting nurse is responsible for maintaining all records – Nurse & Supervisor should collaborate to develop an alternative plan and document in writing and maintain it in the peer review records. – Then due process is invoked which is similar to Incident-Peer Review except time lines are much shorter
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Safe Harbor Due Process
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– a policy is required – Minimum requirements the same as IPR — need a minimum of 10 nurses with 2/3 RN and 1 from practice area — The review must be completed in 14 days and the nurse must be notified within 48 hours of decision regardless – The findings are not binding if CNO believes in good faith that the findings are incorrect – Employer may decide to discipline nurse for not engaging in requested conduct
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Disciplinary Action R/T Licensing
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– Nurse must renew the license every 2 years based on the year of birth – Can not practice if license has been revoked – Easy to renew online – If caught practicing with an expired license, the license will be permanently revoked – Areas of concern: — criminal background — mental illness — diminished capacity — chemical dependency
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Disciplinary Action R/T Licensing
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– DUIs, DWIs, and PI must be reported to the board and are not considered minor trafic violations because they may affect the nurse’s judgment. – Criminal actions are not limited to convictions but also include deffered adjudications – Every case must be investigated and an eligibility determination made on a case-by-case basis
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Rationales for Disciplinary Action
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– The nurse must exhibit good professional character, current sobriety, and fitness to practice because their clients involved, clients, their families, and significant others in many different settings – Nurses are in autonomous roles and are working with vulnerable populations – Nurse also has access to all kinds of personal information – Chemical dependency, mental illness or diminished mental capacity can alter the nurse’s ability for discernment of issues and timely responses to problems – Based on the BON’s mission it must investigate the possibility of factors which might make a nurse unsafe — Eligibility Issues — Declaratory Orders
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Disciplinary Process
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– May result from a peer review decision or straight reporting to the BON – Complaints must be made in writing – A written notice is sent to the nurse – Any notice to the nurse is considered effective even if the nurse does not get it because evidently they did file a change of address which is also a violation – Board conducts an investigation which is based on priorities like dangers to the patient – The nurse has 20 days to respond – The nurse may have an attorney for representation of use just self – Board tries to resolve the issue informally but if this does not work a date for a formal hearing is set – If the nurse fails to respond, the board can issue a default judgment against the nurse which the nurse has admitted to alleged charge and therefore the license may be revoked for 1 year
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Disciplinary Process
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– Formal hearings are like a trial and are conducted by lawyers – Board determines fines and penalties – Licenses may be suspended, remediated, or revoked – If a license is revoked it can not be reinstated for 1 year – Nurses experiencing problems with chemical dependency or mental illness may be referred to peer assistance in lieu of continuation of the disciplinary process – Board must consider system problems that may have contributed to deficiency in care
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Disciplinary Process
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March 2007 – set how board will determine “present fitness to practice” when a criminal history is involved evaluation by psychologist/psychiatrist or polygraph. The evaluation is voluntary and nurse can refuse. The board determines fines or penalties to license and to nurse.

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