Part 11.
BOARD OF NURSE EXAMINERS
Chapter 216.
CONTINUING EDUCATION
22 TAC §§216.1 - 216.3, 216.5
The Board of Nurse Examiners (Board) proposes amendments
to 22 Texas Administrative Code §§216.1 - 216.3 and §216.5,
concerning Continuing Education. Effective February 1, 2004, the Board of
Nurse Examiners and the Board of Vocational Nurse Examiners were merged into
one agency, the Board of Nurse Examiners. The Board of Vocational Nurse Examiners
ceased to exist as an agency. House Bill 1483, passed by the 78th Regular
Legislative Session, was the legislative action that implemented the consolidation.
These amendments implement House Bill 1483 and the make-up and function of
the new Board of Nurse Examiners. Concurrent with these proposed amendments
is the proposed repeal of Chapter 237 which addressed continuing education
for licensed vocational nurses only. Chapter 216 will subsequently be applicable
to all nurses. These amendments are for the purpose of preventing conflicting
rules and consolidating the rules applicable to all nurses under Part 11 (Board
of Nurse Examiners) of the Texas Administrative Code.
The Board gave a charge to the Nursing Practice Advisory Committee (NPAC)
at the October 2004 Board meeting, to review the existing Chapter 237, Vocational
Nursing Continuing Education (CE), and Chapter 216, RN Continuing Education
(CE), for the purpose of combining the rules. As a result of NPAC's recommendation,
the Board is proposing the repeal of the existing Chapter 237 (Vocational
Nursing Continuing Education) and the adoption of amendments to §§216.1
- 216.3 and §216.5 (Continuing Education) to bring all nurses under Texas
Occupations Code §301.303. This will consolidate the CE rules into one
chapter and will complete the consolidation of all the rules under one board.
The existing CE rules for Registered Nurses (RNs) (Chapter 216) and Licensed
Vocational Nurses (LVNs) (Chapter 237) are very similar. Twenty hours of continuing
education will still be required over a two year period and authorization
will continue for LVN associations through the existing Board that were previously
authorized in §237.1(4) and §237.15 by the Board of Vocational Nurse
Examiners to offer Type I CE.
Some differences, however, exist between the rules. These include: 1) Under
Chapter 237, LVNs were required to take Type I CEs for all 20 hours. Under §301.303
of the Nursing Practice Act and Chapter 216, however, at least 10 hours of
CEs must be Type 1 CE, but the remaining 10 hours can be Type II; 2) Chapter
237 has specific allowances for exemptions to the CE requirements which Chapter
216 does not explicitly provide. The practice of the Board, however, has been
to allow exemptions on a case-by-case basis, without specific exemptions being
delineated in the rule itself; 3) Chapter 237 allows LVNs to count CPR as
one CEU. Section 216.6 specifically prohibits CPR from qualifying as a CE,
because CPR is viewed as basic education preparation for all nurses. Due to
the additional flexibility of allowing Type II CE, this is not anticipated
to be an issue. Having equivalent requirements for both RNs and LVNs is seen
as being a priority.
Chapter 216's terminology is generic in referring to "license holders"
or "licensees," and only refers to Registered Nurses specifically in the Hepatitis
C continuing education requirement. (LVNs were not required to have this CE
course.) RNs and LVNs are specifically referred to in the Bioterrorism CE
requirement of this rule, because the statute imposing this requisite CE placed
the burden on the BNE to implement a Bioterrorism rule for all nurses. (The
Board is leaving in §216.3(4) addressing the Hepatitis C requirement
even though the time frame for compliance has expired. RNs will still be required
to show proof of CE from that time frame when audited, and may want to know
the origin of the requirement.)
During the NPAC review of the proposed rules, a question was posed concerning
the potential for the LVN associations to offer CE to RNs. To ensure that
any CE offered meets the definition of the rule "programs beyond the basic
preparation which are designed to promote and enrich knowledge...," the Board
determined that the rules needed clarification.
To promote clarification of the rules, revisions were made. In §216.1,
the definition of advanced practice nurse (APN) was changed to be consistent
with the definition in Chapter 221. In §216.2, the statute citation was
updated from the Revised Civil Statutes to the Occupations Code. Section 216.3(1)
includes an additional sentence to clarify that RNs must be a part of the
CE planning committee for target audiences that include RNs and for target
audiences that include both RNs and LVNs. Target audiences that are composed
of LVNs only would not need a RN on the planning committee. Section 216.3(3)(A)
was changed to include paragraph (5) addressing bioterrorism CE requirement
for APNs, and language was added to §216.5(3) to clarify that the requirements
are for one renewal period only. Section 216.5(4) was reorganized.
Katherine Thomas, Executive Director, has determined that for the first
five-year period the proposed amendments are in effect there will be no fiscal
implications for state or local government as a result of implementation.
Ms. Thomas has also determined that for each year of the first five years
the proposed amendments are in effect, the public benefit will be that the
proposed amendments will provide a unified set of continuing education requirements
for LVNs and RNs, more flexibility for LVNs by allowing Type II CE, and consistency
in applying the CE rules to all licensed nurses. The proposed amendments will
also prevent conflicting rules. There is no known effect on small businesses
and no anticipated cost to affected individuals as a result of the proposed
amendments.
Written comments on the proposal may be submitted to Katherine A. Thomas,
MN, RN, Executive Director, Board of Nurse Examiners, 333 Guadalupe, Suite
3-460, Austin, Texas 78701.
The amendments are proposed pursuant to the authority of Texas
Occupations Code §301.151 and §301.152 which authorizes the Board
of Nurse Examiners to adopt, enforce, and repeal rules consistent with its
legislative authority under the Nursing Practice Act.
The adoption of the proposed amendments will implement Texas Occupations
Code §§301.303 - 301.305.
§216.1.Definitions.
The following words and terms, when used in this chapter, shall have
the following meanings, unless the context clearly indicates otherwise:
(1)
(No change.)
(2)
Advanced Practice Nurse (APN)--
A registered nurse
approved by the board to practice as an advanced practice nurse based on completion
of an advanced educational program acceptable to the board. The term includes
a nurse practitioner, nurse-midwife, nurse anesthetist, and a clinical nurse
specialist.
[
(3) - (21)
(No change.)
§216.2.Purpose.
Continuing education in nursing includes programs beyond the basic
preparation which are designed to promote and enrich knowledge, improve skills
and develop attitudes for the enhancement of nursing practice, thus improving
health care to the public. Pursuant to authority set forth in Texas
Occupations Code §301.303,
[
§216.3.Requirements.
Twenty contact hours of continuing education within the two years immediately
preceding renewal of registration are required.
(1)
Type I. Ten contact hours shall be obtained by participation
in programs approved by a credentialing agency recognized by the board. The
program shall meet all criteria listed in §216.4 of this title (relating
to Criteria for Acceptable Continuing Education Activity). In addition, there
shall be a nurse on the planning committee and target audience shall include
nurses.
For RN or LVN/RN target groups, a RN shall be on the planning
committee to ensure that program objectives and content are commensurate with
recognized standards for RN continuing education courses.
The board
recognizes agencies/organizations to approve providers and/or programs for
Type I credit. A list of these agencies/organizations may be obtained from
the board's office.
(2)
(No change.)
(3)
Requirements for the Advanced Practice Nurse. The licensee
authorized by the Board as an advanced practice nurse (APN) is required to
obtain 20 contact hours of continuing education within the previous two years
of licensure.
(A)
The required hours are not in addition to the requirements
of paragraphs (1), (2), [
(B) - (D)
(No change.)
(4) - (5)
(No change.)
§216.5.Additional Criteria for Specific Continuing Education Programs.
In addition to those listed in §216.4 of this title (relating
to Criteria for Acceptable Continuing Education Activity), the following guidelines
shall apply to the selection and/or planning and implementation of specific
CE programs:
(1) - (2)
(No change.)
(3)
Self-directed study.
(A)
Program development and presentation.
(i) - (iii)
(No change.)
(iv)
Two hours of Type II credit per program topic
up
to five hours per renewal period
may be obtained through this means.
(B) - (C)
(No change.)
(D)
Authorship.
(i) - (iii)
(No change.)
(iv)
Five contact hours of Type II credit may be obtained through
this means
per renewal period
.
(4)
Out-of-state programs.
[
(A)
[
(B)
[
This agency hereby certifies that the proposal
has been reviewed by legal counsel and found to be within the agency's legal
authority to adopt.
Filed with the Office of
the Secretary of State on January 24, 2005.
TRD-200500331
Katherine Thomas
Executive Director
Board of Nurse Examiners
Earliest possible date of adoption: March 13, 2005
For further information, please call: (512) 305-6823
22 TAC §217.1, §217.4
The Board of Nurse Examiners (Board) proposes amendments
to 22 Texas Administrative Code §217.1 and §217.4, concerning Licensure,
Peer Assistance and Practice. Section 217.1 specifically addresses "Definitions"
and §217.4 is entitled "Requirements for Initial Licensure by Examination
for Nurses Who Graduate from Nursing Education Programs Outside of United
States' Jurisdiction." The proposed amendment to §217.1 will include
the definition of "credentialing evaluation services (CES)" in and delete
the definition of the Commission on Graduates of Foreign Nursing Schools (CGFNS).
Section 217.4 will broaden the acceptable verification organizations and availability
of organizations that can provide credential evaluation services (CES) of
foreign-educated nurses. As a result, the time period in obtaining the necessary
information requested from the credentialing organizations would be shorter
time periods and provide equal and some enhanced services. By requiring credentials
from these organization, the CGFNS certification program requirement would
become unnecessary and, therefore, eliminated.
The State of Florida issued a Request for Proposal (RFP) for organizations
to provide credentialing services for foreign-educated nurses wanting to be
licensed in Florida. In response to the RFP, two organizations submitted their
proposals to the Florida board and assured that they could render the necessary
services within an equal or shorter time period. The BNE Staff reviewed the
credential evaluation service requirements of the Florida RFP and determined
that its minimum requirements met our credentialing needs for foreign graduates.
The Texas Board has historically used only the Commission on Graduates of
Foreign Nursing Schools (CGFNS), but the waiting period for the credentialing
services has taken longer over time. In order to provide equal service and
quicker time periods for processing, the Staff requests that this Board approve
the addition of these two organizations (the two organizations that responded
to the Florida RFP) for the provision of credentialing service for nurses
educated outside U.S. jurisdictions--Educational Records Evaluation Service
(ERES) and the International Education Research Foundation (IERF). For foreign
candidates needing H1 visa credentialing, only CGFNS is recognized to provide
this service which means some candidates might have to have two sets of credentials
completed if they do not initially utilize CGFNS.
Katherine Thomas, executive director, has determined that for the first
five-year period the proposed amendments are in effect there will be no fiscal
implications for state or local government as a result of implementation.
Katherine Thomas, executive director, has determined that for each year
of the first five years the proposed amendments are in effect the public benefit
will allow foreign nursing graduates to have equal service, quicker processing
of credentials, and will eliminate the certification program requirement.
There is no known effect on small businesses and the anticipated cost to affected
individuals as a result of this proposed amendment would be for foreign candidates
needing H1 visa credentialing if they do not use CGFNS originally, because
only CGFNS is recognized to provide this service which means some candidates
might have to have two sets of credentials completed.
Written comments on the proposal may be submitted to Katherine A. Thomas,
MN, RN, Executive Director, Board of Nurse Examiners, 333 Guadalupe, Suite
3-460, Austin, Texas 78701.
The amendments are proposed pursuant to the authority of Texas
Occupations Code §301.151 and §301.152 which authorizes the Board
of Nurse Examiners to adopt, enforce, and repeal rules consistent with its
legislative authority under the Nursing Practice Act.
The proposed amendments will not affect any existing statute.
§217.1.Definitions.
The following words and terms, when used in this chapter, shall have
the following meanings, unless the context clearly indicates otherwise:
(1) - (6)
(No change.)
(7)
Credential Evaluation Services (CES)
[
(8) - (50)
(No change.)
§217.4.Requirements for Initial Licensure by Examination for Nurses Who Graduate from Nursing Education Programs Outside of United States' Jurisdiction.
(a)
Nurse applicants for initial licensure applying under this
section.
(1)
A licensed vocational nurse applicant must:
(A)
(No change.)
(B)
have successfully completed an approved program for educating
vocational/practical (second level general nurses) nurses or curriculum content
comparable to the Texas curriculum requirements for graduates of approved
vocational nursing education programs
by providing a Credential Evaluation
Service Full Education Course-by-Course Report from the Commission on Graduates
of Foreign Nursing Schools (CGFNS), Educational Records Evaluation Service
(ERES), or the International Education Research Foundation (IERF);
[
(C)
have
achieved an approved score on an English proficiency
test acceptable to the Board
[
(2)
A registered nurse applicant must provide a [
(A) - (C)
(No change.)
(D)
is currently registered/licensed as a first-level general
nurse;
and
(E)
has achieved an approved score on an English proficiency
test acceptable to the Board.
[
[
(3) - (5)
(No change.)
(b) - (e)
(No change.)
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State on January 26, 2005.
TRD-200500368
Katherine Thomas
Executive Director
Board of Nurse Examiners
Earliest possible date of adoption: March 13, 2005
For further information, please call: (512) 305-6823
22 TAC §220.2
The Board of Nurse Examiners (Board) proposes amendments
to 22 Texas Administrative Code §220.2 (Issuance of a License by a Compact
Party State), concerning Nurse Licensure Compact. Texas joined the Nurse Licensure
Compact on January 1, 2000. This compact allows nurses licensed in Texas to
practice in member states without having to apply for each member states'
individual license. This proposed amendment will adopt the standard passed
by the Nurse Licensure Compact Administrators (NLCA) requiring all nurse applicants
for initial licensure in a compact home state to have passed the NCLEX or
its predecessor examination in order to obtain a multistate privilege.
Once the compact is enacted in a state, each compact state designates a
Nurse Licensure Compact Administrator to facilitate the exchange of information
between the states relating to compact nurse licensure and regulation. On
January 10, 2000, the NLCA was organized to protect the public's health and
safety by promoting compliance with the laws governing the practice of nursing
in each party state through the mutual recognition of party state licenses.
(The Executive Director is the Texas compact administrator.) The Nurse Licensure
Compact grants authority to the Compact Administrators to develop uniform
rules to facilitate and coordinate implementation of the Compact. On Sunday,
December 5, 2004, the NLCA passed the requirement that all applicants for
initial licensure for a compact privilege must make a passing score on the
relevant NCLEX exam. This rule will not affect licensure in Texas as Texas
already requires the NCLEX for all licensure. It is for the purpose of having
consistent compact rules in compact states. Compact states that do not require
NCLEX for licensure, however, will only be able to grant a single state license
to a nurse who has not taken the NCLEX or its predecessor exam, and that particular
nurse will not be granted a multistate privilege to practice in other compact
states.
Katherine Thomas, executive director, has determined that for the first
five-year period the proposed amendment is adopted there will be no fiscal
implications for state or local government as a result of implementation.
Katherine Thomas, executive director, has determined that for each year
of the first five years the proposed amendment is adopted the public benefit
will be that the proposed amendment will provide consistent standards in all
compact states and a benchmark determination of nursing competency for purposes
of the Compact. There is no known effect on small businesses and the anticipated
cost to affected individuals as a result of this proposed amendment would
be the cost of taking the NCLEX which is required of all nurses practicing
in Texas.
Written comments on the proposal may be submitted to Katherine A. Thomas,
MN, RN, Executive Director, Board of Nurse Examiners, 333 Guadalupe, Suite
3-460, Austin, Texas 78701.
This proposed amendment is pursuant to the authority of Texas
Occupations Code §§301.151, 301.152 and 304.003 which authorizes
the Board of Nurse Examiners to adopt, enforce, and repeal rules consistent
with its legislative authority under the Nursing Practice Act. The adoption
of the proposed amendments will further implement Texas Occupations Code Chapter
304.
§220.2.Issuance of a License by a Compact Party State.
(a)
As of July 1, 2005, no applicant for initial
licensure will be issued a license granting a multistate privilege to practice
unless the applicant first obtains a passing score on the applicable NCLEX
examination or its predecessor examinations used for licensure.
(b)
[
(1)
a driver's license with a home address;
(2)
voter registration card displaying a home address; or
(3)
federal income tax return declaring the primary state of
residence.
(c)
[
(d)
[
(e)
[
(f)
[
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State on January 25, 2005.
TRD-200500348
Katherine Thomas
Executive Director
Board of Nurse Examiners
Earliest possible date of adoption: March 13, 2005
For further information, please call: (512) 305-6823
22 TAC §221.2, §221.7
The Board of Nurse Examiners (Board) proposes amendments
to 22 TAC §221.2 and §221.7, addressing Advanced Practice Nurses.
Section 301.152 of the Nursing Practice Act states that advanced practice
nurses are granted authorization to practice and utilize titles based upon
their educational preparation. Advanced practice nurses who are authorized
by the board in either the nurse practitioner or clinical nurse specialist
role are also recognized in a particular specialty area appropriate to their
educational preparation and must limit their advanced nursing practice to
the role and specialty for which they have been educated. For example, an
advanced practice nurse who is educated and authorized to practice as a pediatric
nurse practitioner is not authorized to provide advanced practice nursing
care to adults.
Concerns have increased regarding the increasing number of subspecialty
areas in which nurses are seeking advanced practice authorization. Within
the last two years alone, the board has received inquiries and requests for
authorization to practice as an advanced practice nurse in subspecialty areas
such as diabetes management, ophthalmology, forensic nursing, and palliative
care. This issue has also raised concern at the national level. For some years,
the Advanced Practice Registered Nurse (APRN) task force of the National
Council of State Boards of Nursing (NCSBN) has had concerns regarding the
proliferation of nurse practitioner and clinical nurse specialist subspecialty
preparation. Educational preparation in a subspecialty area results in an
individual with a very narrow scope of practice who may not be prepared to
recognize a broad range of diseases and conditions commonly seen. From a regulatory
perspective, there is concern that narrow specialty preparation does not provide
a broad enough foundation for safe practice, including the identification
and treatment of other presenting symptoms/problems and appropriate referral.
When jobs are not available in the narrow specialty area in which these
applicants seek authorization to practice, advanced practice nurses prepared
in these areas may seek to broaden their scope of practice without completing
additional education. This places boards of nursing who recognize or license
nurse practitioners and clinical nurse specialists in subspecialty areas in
a position where they are faced with the challenge of limiting scopes of practice
to the subspecialty area only. The Board has already seen disciplinary cases
in which the advanced practice nurse prepared in a broader specialty area
was found to be practicing outside his/her scope (e.g., clinical nurse specialist
in psychiatric/mental health nursing practicing in thoracic oncology, adult
nurse practitioner providing advanced practice nursing care to pediatric patients).
Due to this concern, the Board at its April 2003 meeting charged the Advanced
Practice Nursing Advisory Committee (APNAC) with reviewing APN titles currently
recognized by the Board and recommending whether such titles should continue
to be recognized in the future. The committee completed that charge and recommended
that the titles recognized by the Board be limited to specialty areas that
include broad-based educational preparation and to areas for which there is
a national certification examination specifically targeted for both the role
and the specialty that already exists or is about to be released. The committee
completed a survey of member boards to determine whether other jurisdictions
recognized some of the titles it proposes to eliminate. An overwhelming majority
of the boards who responded (34 state boards) do not recognize the titles
being requested for elimination.
The board adopted the committee's recommendation to propose an amendment
to §221.2, relating to Authorization and Restriction to Use of Advanced
Practice Titles. The proposed amendment continues to include those titles
that the committee recommended the Board continue to recognize. The APNAC
also requested that the Board consider the proposal of an amendment to §221.7,
relating to Petitions for Waiver. The latter would create a time-limited exception
for those individuals who might currently be enrolled in an advanced educational
program of study that prepares them to function in a role and specialty that
is currently recognized by the Board but not included in the recommendation
for continued recognition. This exception would permit these individuals to
be authorized to practice as advanced practice nurses in these specialty areas
and would limit their practice to the geographical boundaries of the State
of Texas. At the July 2004 meeting, the Board voted to propose amendments
to §221.2 and §221.7, relating to advanced practice titles. The
rule was published in the
Texas Register
on
August 13, 2004.
The board office received many written comments on these proposed amendments.
The comments received from state and national organizations were compiled,
summarized and responses drafted. Many other comments were received from individuals
who expressed concern regarding one particular practice-related issue.
Additional comments were received during a public hearing held on October
20, 2004. During that public hearing, staff presented additional information
that outlined the historical perspective and rationale for the proposed rules.
Comments were then received from sixteen individuals and representatives of
various organizations. Three individuals representing themselves and a representative
of the Staff of the Utah Board of Nursing spoke in support of the proposed
amendments. Four individuals and eight organizational representatives spoke
against adoption of the proposed amendments. Comments not in support of the
proposed amendments reiterated comments already received during the written
comment period. During the public hearing, the Texas Nurses Association (TNA)
requested a six month moratorium on action related to this rule amendment
to allow time for the issue related to titles to be addressed at the national
level because it believes this issue has implications for advanced practice
beyond the State of Texas.
On December 16, 2004, the American Nurses Association (ANA) hosted a meeting
of national advanced practice registered nurse stakeholder organizations to
discuss this issue at the request of TNA. Dr. Rounds and Ms. Thomas attended
this meeting on behalf of the Board. The model for regulation of advanced
practice nurses that appeared to have the greatest support from the profession
was to license the advanced practice nurse in the broad roles as either a
nurse-midwife, nurse anesthetist, nurse practitioner, or clinical nurse specialist
without regard to specialty preparation. In order to do so, however, the Board
believes that regulation must be able to assure the public that individuals
licensed with each of these titles are educated broadly across patient populations
and practice settings rather than the current specialty and subspecialty focused
model for advanced educational preparation and subsequent examination. In
addition to broad-based educational preparation, examination must also test
for entry-level competency at the advanced practice level across that same
broad base.
In order to progress from the current specialty and subspecialty focused
model for education and examination to the model that appeared to have the
most support from the profession, a step-wise approach must exist. The Board
currently recognizes 19 nurse practitioner and 22 clinical nurse specialist
specialty and subspecialty titles. It would be virtually impossible to proceed
from this current model of regulation to that proposed by the profession in
a relatively short period of time particularly when the Board continuously
receives requests to recognize additional titles not currently recognized.
The APNAC's recommendation for revisions to §221.2 and §221.7 that
were presented for the Board's consideration in July 2004 is a logical step
from the current model to that discussed at the meeting hosted by ANA on December
16. The proposed amendments presume that less specialization and broader preparation
are essential for licensure at the advanced practice level. Specialization
and subspecialization would then be considered value-added after Board recognition
for authorization to practice at the advanced practice level is granted. The
Board would like to acknowledge and respond in the following paragraphs to
the comments received in response to the initially proposed amendments to
the rules.
The Board received written comments from the following interested groups
or associations: Texas Nurses Association (TNA) (Willmann), Coalition for
Nurses in Advanced Practice (CNAP) (Woolbert), American Nurses Association
/American Nurses Credentialing Center (ANA/ANCC) (Carson-Smith), National
Association of Clinical Nurse Specialists (NACNS) (Clark), Texas Clinical
Nurse Specialists (TxCNS) (unsigned), American Association of Colleges of
Nursing (AACN) (Bartels), University of Texas at Austin (UT) (Clark/John/Coward/Shine),
American Board of Nursing Specialties (ABNS) (Niebuhr), Wound Ostomy Continence
Nursing Certification Board (WOCNCB) (Walden/Wright), Lance Armstrong Foundation
(LAF) (Miller), Association of Community Cancer Centers (ACCC) (Baker), American
Cancer Society - Texas Division (ACS) (Hornaday/Redrow), American Society
of Clinical Oncology (ASCO) (Johnson), Oncology Nursing Society (ONS) (Stanley/Ponto),
University of Texas at Arlington (UTA) (Perley), Hospice and Palliative Nurses
Association (HPNA) (Dahlin), National Board for Certification of Hospice and
Palliative Nurses (NBCHPN) (Martinez), Texas & New Mexico Hospice Organization
(TNMHO) (Farrow), American Academy of Hospice and Palliative Medicine (AAHPM)
(Cleary), and 67 individuals.
In addition, the Board held a public hearing on October 20, 2004. Testimony
was received from five individuals and eleven representatives of organizations.
The following organizations were represented: NACNS and TxCNS (Clark), TNA
(Wieck), ANA (Bickford), ANCC (MacDonald), Utah Board of Nursing/Nurse Licensure
Compact Administrators/National Council of State Boards of Nursing APRN Task
Force (UTBON/NLCA/NCSBNAPRNTF) (Poe), Texas and New Mexico Hospice Association
(TNMHO) (Farrow), ONS (Lundgren), Adams (UT at Arlington), American Holistic
Nurses Association (AHNA) (Erickson), UTHSC at Houston (McNeill), and ONCC
(Williams). Comments were received both in support and in opposition of the
rule.
Comment: The grandparenting provision as proposed in the preamble should
be in rule with language authorizing APNs to use current authorizations approved
by the board though not included in subdivisions (a)(3) and (4). CNAP
Response: The Board agrees with this suggestion and will add the grandparenting
provision to §221.2(b) as proposed.
Comment: Restraint of trade issues due to negative effect on schools of
nursing that have invested in planning solid, broad-based programs that allow
CNS specialization in a variety of fields. Rules imply that the Board is more
capable of curriculum development than are doctorally-prepared faculty who
are also CNSs or NPs. NACNS
Response: The Board disagrees with this comment. Schools of nursing and
nursing programs are not faced with the challenges associated with licensing
advance practice nurses, whether that grant of authority is for practice within
a narrow or broad spectrum. The Board does not control or mandate specialty
nursing curriculum developed by the schools. By the same token, the minimum
educational requirements the Board seeks to establish for licensure in advance
practice nursing can not be controlled or mandated by nursing programs or
schools of nursing. Nursing schools remain free to develop educational programs
that address specialty areas of their choice. While the Board recognizes that
its rules may influence the development of nursing programs, the Board believes
that it must uphold the public trust legislatively mandated to it and attempt
to define the proper recognition for advanced practice nurses. The Board believes
it has done so reasonably by taking into account the potential impacts on
the future of nursing programs.
The Board believes that subspecialty practice is valuable and may continue
under this proposed rule; however, the Board also believes that the role of
regulation is to approve advanced practice nurses for entry into advanced
practice and that it is both impractical and not in the public's best interest
to provide legal authorization in continually narrowing areas of subspecialty.
Under this proposed rule, schools of nursing do not need to eliminate subspecialty
content from their curricula. The Board requires a minimum of 500 clinical
hours in the broad-based specialty areas it proposes to continue to recognize.
Because subspecialty practice would not require recognition from the board,
programs could offer intensive subspecialty courses as electives for students
within the broad-based program. For example, an adult nurse practitioner student
whose program includes 750 hours of clinical experiences could complete experiences
beyond the 500 hour minimum in adult health in such areas as diabetes management
or palliative care. This gives the individual a broad foundation for entry
into advanced practice but also provides additional expertise in a specific
subspecialty area. Schools might also offer this content as post-master's
options for individuals who are already advanced practice nurses. Although
schools may argue that APNs are unwilling to do this, staff receives a number
of APN applications each year from individuals who completed post-master's
study.
The Board does not agree that the proposed rule implies that the Board
is more capable of curriculum development than doctorally-prepared faculty.
The Board function is to license advance practice nurses when it can verify
that it is in the public's interest to do so. The Board has been asked to
recognize advance practice nurses in nursing specialties developed by nursing
programs for which no jobs exist, for which graduates may not be able to be
recognized in Texas or elsewhere, and for which the advanced practice nurse
is at significant risk to exceed his/her scope of practice. Recently, for
example, a graduate of a clinical nurse specialist in neonatal nursing program
contacted the board office requesting information regarding how she was expected
to maintain her APN authorization if she was unable to find employment to
complete the current practice hours. She was living in a major metropolitan
area in Texas and was unable to locate employment in her role and specialty.
She stated that she had never been advised that there is little regulatory
recognition of the CNS role in her specialty area of neonatal nursing throughout
the country nor that she might anticipate difficulty in locating employment
as a CNS in neonatal nursing. She was considering accepting a position as
a neonatal nurse practitioner at the time she contacted the board office,
a position that would have required her to exceed her recognized scope of
practice. The proposed rules would avoid these potentially dangerous predicaments.
The Board wishes only to verify that APN curriculum contains sufficient content
such that each individual who holds a specific title meets the same minimum
level of competence for entry into advanced practice and that he/she is sufficiently
educated to recognize a broad range of diseases and conditions common to patients
in a specialty area.
Comment: Certification organizations will also be negatively affected economically.
NACNS
Response: The Board disagrees the proposed rule must be modified based
on this comment. Even assuming there may be an economic impact on certification
organizations (although the Board has not seen any evidence of this), the
Board's mission is public safety, and the Board should not be controlled by
the economic interest of certification organizations. The Board would point
out that each of the specialties listed in the proposed rule has a corresponding
national certification examination that will continue to be required as a
condition for authorization to practice as an advanced practice nurse. The
Board also believes that once an advanced practice nurse is licensed by the
Board, a national certification could allow APNs to demonstrate additional
expertise in a subspecialty area such as oncology, diabetes management, or
palliative care. APNs could take these additional examinations and utilize
the certification credentials without the need for additional authorization
from the board. Board staff is aware of APNs who have obtained national certification
(in addition to that required for authorization to practice) despite that
certification not being recognized by the Board. For example, staff have talked
with family nurse practitioners who have obtained additional certification
in diabetes management and clinical nurse specialists in medical-surgical
nursing who have obtained national certification in oncology. Additionally,
a gerontological nurse practitioner who has obtained certification in palliative
care provided testimony during the public hearing. Thus, it is possible that
certification bodies will see an increase in the numbers of individuals sitting
for these examinations.
Comment: Concerns about eliminating recognition for many CNS specialties
because many CNSs educated out of state will not be able to identify themselves
as CNSs in this state, therefore discouraging them from moving to this state
in time of a nursing shortage. CNAP, one individual.
Response: The Board disagrees. The new rules are designed to eliminate
the misconception by nurses educated as CNSs, as well as the public, that
the Board must recognize all CNS specialties and subspecialties. Even before
this proposed rule, the Board did not recognize all purported or promoted
CNS specialties. The CNS specialty titles that the Board proposes to continue
to recognize are based on a broad educational foundation for entry into practice
at the advanced level. The titles have a confirmed history of quality education,
competency, and broad applicability. They do not focus on a specific disease
entity but rather on the total health care needs of individuals within the
specialty area. Although the patients served by CNSs may have a primary medical
diagnosis such as cancer, these patients also have or will develop co-morbidities.
A CNS prepared in a narrow subspecialty area (such as a disease entity) is
not necessarily prepared to provide advanced nursing care to the total patient.
Thus, the CNS may be prepared to provide advanced practice nursing care for
needs related to a cancer diagnosis, but may not be prepared to also provide
advanced practice nursing care for the same patient's hypertension, diabetes,
and asthma. No consistent educational standards exist for such subspecialty
areas nor is there consistency in educational preparation among graduates
of such programs. For example, staff has reviewed educational preparation
for two graduates of two different CNS programs in oncology nursing. The first
applicant's advanced educational program included some broader content that
addressed the care of some co-morbidities commonly seen in oncology patients.
The second applicant's program did not include this content, focusing almost
entirely on the cancer diagnosis. Even the pathophysiology course included
in the second applicant's curriculum focused entirely on the pathophysiology
of cancer. Based on such differences in educational preparation, these two
individuals would have somewhat different scopes of practice. Without guidance
provided by the proposed rule, the Board is faced with a choice of whether
to grant both individuals the same title CNS in oncology nursing and the public,
employers, third party payers, et. al. presume that because they have the
same title, they have the same scope of practice.
Significant differences in educational preparation within a specific subspecialty
could potentially create difficulty for the Board in evaluating scope of practice
for enforcement purposes. When advanced practice nurses are reported to the
board for issues related to practicing beyond their scope, the burden of proof
rests with the board. In the aforementioned scenario, it would be impossible
for the board to determine whether these individuals have equivalent scopes
of practice based on title alone.
While it is true that some historically recognized titles will be grandfathered,
but no longer licensed in the future, it is also important to note that these
titles do not have a corresponding national certification examination targeted
for individuals educated specifically in the APN role and specialty area.
When reviewing other types of professional licensure, it is noted that entry
into practice includes requirements for both educational preparation and examination
to assure the public the professional demonstrates minimum competence for
safe entry into practice. Although CNSs are registered nurses (RNs) and have
passed that licensure examination, the CNS role requires mastery of knowledge,
skills and abilities that are beyond the RN scope of practice. Requiring an
advanced practice nurse to pass a reliable, valid, psychometrically sound
and legally defensible national certification examination provides an objective
mechanism to assure the public that the individual possesses the knowledge
and abilities required for competent practice in the advanced role and specialty
that will be recognized by the board.
Comment: CNSs who do not include medical management in the scope of their
role, recommend the option of being authorized to use the title, "clinical
nurse specialist." CNAP
Response: The Board does not agree that this recommendation can be considered
under current rules or under the proposed rule. There is significant variation
in CNS education, not only within the state of Texas, but also within an institution.
Staff is aware of one institution that offers a CNS track that includes medical
diagnosis and management content. Another CNS track within the same academic
institution does not offer this option. Within the State of Texas, very traditional
CNS programs currently exist that offer no medical management content, some
that include medical management content, and others that offer the medical
management content as an option. Likewise, graduates of CNS programs outside
the State of Texas reflect similar variations in educational preparation.
At this point, it would appear to be confusing to the public for the Board
to create two categories of individuals recognized in the CNS role those who
include medical management in the scope of their role and those who do not.
However, the variations of CNS education and scope of practice deserves further
study by the Board.
Comment: Section 221.7 regarding waiver mechanism for students currently
enrolled in APN programs that specialize in areas outside of those listed
in the rule creates a degree of uncertainty for these students and recommend
delayed implementation date for new graduates seeking provisional authorization
and APNs from other states seeking interim authorization. Therefore, no waiver
process. "Waiver" should be "exemption." CNAP, TNA (recommends 1/1/2008 implementation
date)
Response: The Board agrees there may be some confusion and anxiety for
students and new graduates of programs. In an effort to relieve this potential
uncertainty for students, the Board agrees to change the term "waiver" to
"exemption." Further, the Board agrees to extend the period during which applicants
may be granted an exemption using titles outside of those listed in proposed §221.2
to January 1, 2010, to allow for a longer period of time for students enrolled
in programs as well as advanced practice nurses from other states.
Comment: If the Board decides to proceed with the waiver, explicit language
should be added 1) grandparenting in APNs recognized prior to 1/1/2004 with
non-sec. 221.2 titles, and 2) addressing their authority, or lack of authority,
to practice outside the geographical boundaries of Texas. Also, what non-sec.
221.2 titles will be recognized prior to 1/1/ 2005 under the waiver should
be explicitly stated in rules. TNA
Response: As stated previously, the Board agrees to include grandparenting
language related to those APNs approved prior to the effective date of the
rule. The Board also agrees to explicitly list titles that may be recognized
under the exemption in proposed amendments to §221.7(e). The Board does
not see significant value in including language in the proposed rule about
the authority of grandparented APNs outside the state's geographical boundaries.
It is suggested that this might be more appropriately addressed later if Texas
elects to enter the APRN Compact.
Comment: Restrictions of titles should occur as an overall strategy for
boards of nursing to recognize only the four basic APN types: Nurse Practitioner
(NP), Clinical Nurse Specialist (CNS), Certified Registered Nurse Anesthetist
(CRNA), and Certified Nurse Midwife (CNM). APN specialties would be through
private certifying bodies. TNA
Response: The Board does not agree that this is possible at this point
in time given the historical evolution of advanced practice licensure and
the number of NP and CNS titles recognized by the Board. It should be noted
that the new rule would likely encourage a step to uniformity in advanced
practice titles and recognition that may be an example nationally. Staff believes
this comment suggests modeling advance practice nursing similar to medical
licensure with post licensure specialty certification and is a logical long-term
step in advanced practice nursing regulation. The Board will monitor closely
the national debate regarding APN practice. The Board wishes to be at the
forefront should there be mutual agreement between the education, certification,
and regulation communities at a national level in this area. The Board believes
that a national and uniform policy regarding advance practice will be in the
public's interest. However, the Board believes that before basic recognition
is accomplished as suggested by the commenter, all stake holders would need
to agree on a single broad-based curriculum and testing for NPs and CNSs,
similar to those utilized by CRNAs and CNMs. Once the NP or CNS completed
the educational preparation and initial examination, the NP or CNS could then
specialize through additional education and certification awarded by private
certifying bodies in the same manner that RNs are educated and then obtain
additional education and/or certification in a specialty area.
Comment: Regulations are not rationally related to a legitimate state purpose,
exceed the authority of the Board, and are tantamount to economic regulation
of practice. ANA/ANCC
Response: The Board disagrees with this statement. Section 301.152 of the
Texas Occupations Code (Nursing Practice Act) grants the BNE authority to
adopt rules that include but are not limited to the minimum requirements for
authorization to practice as an advanced practice nurse in the State of Texas.
This section states as follows: Sec. 301.152. Rules Regarding Specialized
Training.
(a) In this section, "advanced practice nurse" means a registered nurse
approved by the Board to practice as an advanced practice 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.'
(b) The Board shall adopt rules to:
(1) establish:
(a) any specialized education or training, including pharmacology, that
a registered nurse must have to carry out a prescription drug order under
Section 157.052; and
(b) a system for assigning an identification number to a registered nurse
who provides the Board with evidence of completing the specialized education
and training requirement under Subdivision (1)(A);
(2) approve a registered nurse as an advanced practice nurse; and
(3) initially approve and biennially renew an advanced practice nurse's
authority to carry out or sign a prescription drug order under Chapter 157.
Furthermore, authorization to practice as an advanced practice nurse in
any role and specialty from the Board of Nurse Examiners must serve the purpose
of providing the public with assurance that certain minimum criteria have
been met and all individuals who are authorized to use a specific title have
the same core knowledge, skills, and abilities, regardless of where they completed
their educational preparation. Those titles included in the list for continued
recognition are believed to meet this criterion. Those not included in that
list generally do not (as indicated in the aforementioned example regarding
two CNSs in oncology nursing).
In limiting the advanced practice titles to those included in the proposed
rule, the Board seeks to further assure the public that advanced practice
nurses possess the knowledge, skills and abilities necessary to meet the complex
health care needs of their patients. The very complexity of the health care
needs of the advanced practice nurse's patient populations demands that the
APN have a broad underlying educational foundation for practice, regardless
of whether the APN chooses to limit his/her practice to a subspecialty area.
Nurse anesthetists, for example, do not limit their educational preparation
to only anesthesia for cardiac cases or obstetric populations; rather, they
complete broad educational preparation as the foundation for a practice that
may be limited to patient populations with a common thread such as cardiac
disease or pregnancy.
It is important to understand that the scope of practice of advanced practice
nurses has evolved and increased significantly in terms of the complexity
of services provided services that exceed the scope of practice of the registered
nurse. As such, the potential for harm to the public is significantly greater
and a requirement for broader-based educational preparation for entry into
advanced practice is warranted.
It should also be noted that advanced practice nurses prepared in narrower
specialties may have significant difficulty finding employment, and the Board
does not wish to perpetrate these difficulties. When these individuals are
unable to find employment within their specialty, they may accept employment
as advanced practice nurses in specialty areas that are outside their authorized
scope of practice. With a broader based educational foundation, the advanced
practice nurse would have the ability to transition into subspecialty areas
without being in violation of the rules related to scope of practice.
There is significant variation in the regulation of advanced practice nurses
from one state to another and advanced practice nurses with subspecialty preparation
may have difficulty obtaining authorization in other states. Staff surveyed
other boards of nursing to inquire whether those states also recognized individuals
with some of the titles the Board proposes to no longer recognize. Of the
thirty four (34) jurisdictions that responded, only five recognize CNSs or
NPs in oncology, only four recognize CNSs in maternal-child health nursing,
and only two recognize palliative care nurse practitioners.
In summary, the Board believes that the proposed rules are rationally related
to a legitimate state purpose and do not exceed the authority of the Board
in any way.
Comment: To determine the best approach to regulation, the Board should
discuss the value given to the RN license when evaluating APN expertise, instead
of writing rules as if APN practice is a second level of independent licensure.
ANA/ANCC
Response: The Board disagrees with this comment. As stated above, authorization
to practice as an advanced practice nurse in any role and specialty from the
Board of Nurse Examiners must serve the purpose of providing the public with
assurance that certain minimum criteria have been met and all individuals
who are authorized to use a specific title have the same core knowledge, skills,
abilities, and educational preparation, regardless of where they completed
their educational preparation. Those titles included in the list for continued
recognition generally meet this criterion. Those not included in that list
generally do not (as indicated in the aforementioned example regarding two
CNSs in oncology nursing).
In limiting the advanced practice titles to those included in the proposed
rule, the Board seeks to further assure the public that advanced practice
nurses possess the knowledge, skills and abilities necessary to meet their
patients' complex health care needs. The very complexity of the health care
needs of the advanced practice nurse's patient populations demands that the
APN have a broad underlying educational foundation for practice, regardless
of whether the APN chooses to limit his/her practice to a subspecialty population.
Nurse anesthetists, for example, do not limit their educational preparation
to only anesthesia for cardiac cases or obstetric populations; rather, they
complete broad educational preparation as the foundation for a practice that
may be limited to patient populations with a common thread such as cardiac
disease or pregnancy.
The Board recognizes that the advanced practice nurse's scope is built
upon education and licensure as a registered nurse. However, an advanced practice
nurse's scope of practice significantly exceeds that of the registered nurse
and is not authorized unless sanctioned by the Board based on the minimum
criteria for recognition. For example, the advanced practice nurse's scope
may include medical diagnosis and management of patients, but the RN's scope
does not include these activities. It is also important to understand that
the scope of practice of advanced practice nurses has evolved and increased
significantly in terms of the complexity of services provided services that
exceed the scope of practice of the registered nurse. As such, the potential
for harm to the public is significantly greater and a requirement for broader-based
educational preparation for entry into advanced practice is warranted. Although
advanced practice nurses work collaboratively with physicians, they are engaged
in activities that include but are not limited to making medical diagnoses
and ordering appropriate pharmacologic and non-pharmacologic management. The
knowledge, skills, and abilities required to provide advanced practice nursing
care build upon but significantly exceed those acquired through entry-level
nursing education programs that prepare individuals as registered nurses.
Comment: No potential harm to the public is mentioned as justification
for rules, but regulatory ease. ANA/ANCC, NACNS, TNMHO
Response: The Board disagrees with the comment for reasons previously stated.
Further, the comment ignores the need to prevent regulatory practices that
could lead to harm to the public before those practices occur.
Comment: Rule never adequately defines "subspecialty" limitation, and its
application of the term falls outside of the profession's definition and comprehension
of specialty. ANA/ANCC
Response: The Board disagrees. It has utilized the term "subspecialty"
in the preamble to the proposed rule to explain the basis for limitation of
titles in the rule. The term is not in the rule itself and does not need to
be defined.
Comment: Based on ANA's criteria for determining specialty practice, oncology,
geriatric nursing and diabetes education should be specialties. ANA/ANCC
Response: The Board disagrees with the comment and would note that the
ANA is a professional organization that exists for the purpose of serving
the interests of the nursing profession. While ANA/ANCC's interests often
directly support the Board's mission, the ANA/ANCC are responsible to their
members (nurses) rather than the public and address specific issues that best
serve their members' needs. They have determined their own criteria for determination
of specialty practice to serve the needs of their members. As such, the ANA's
purpose for defining specialty practice differs from that of the Board.
The Board's mission is to protect and promote the public welfare and that
mission supercedes any special interest groups, including professional organizations.
The Board's rule is designed to better address the public's interests by limiting
the number of specialties and subspecialties now seeking recognition as advanced
practice nurses and assuring that individuals authorized to practice as advanced
practice nurses have broad enough educational preparation to care for the
whole patient. The narrow focus of the educational preparation in such subspecialties
as oncology and diabetes and the risk for public harm as a result of such
narrow preparation has already been addressed above.
Comment: Education programs have many filters and safeguards to assure
competency, i.e., broad-based curricula, 500 hours minimum (AACN Master's
Essentials and NACNS Statement on the Clinical Nurse Specialist Practice and
Education, 2d ed. (2004)). NACNS
Response: The Board disagrees. Although some programs may meet these criteria,
the Board has already provided examples of education programs that do not
have broad-based curricula. The Board can also provide examples of advanced
educational programs that do not include a minimum of 500 clinical hours in
the advanced educational program (2003 graduate of a CNS program) as well
as numerous examples of applicants who recently completed programs that do
not meet the standards outlined in the
AACN's Essentials
of Master's Education
, despite the fact that these standards have existed
for more than eight years.
Although accrediting bodies survey advanced educational programs, they
survey graduate programs as a whole. Historically, they have not reviewed
each individual advanced practice nursing track within a graduate program
to verify that graduates complete essential content for entry into practice
at the advanced practice level. Although the accrediting bodies have recognized
this omission and their standards and survey criteria have recently changed
to focus on APN programs more specifically, program review occurs only every
eight to ten years. It should also be noted that advanced educational programs
that are not accredited by a national nursing education accrediting body continue
to exist. Graduates of these programs have been permitted to obtain national
certification despite no external review of the program.
Comment: More harm to the public from using a generalist exam for advanced
specialization knowledge. NACNS
Response: The Board disagrees with this comment for reasons stated above.
Comment: The Board has chosen to define specialization and subspecialization
without collaborating with state and national leaders in CNS specialty organizations
in a national forum. NACNS, one individual
Response: The Board disagrees. The discussions utilizing the terms "specialization"
and "subspecialization" have been helpful in outlining the issues surrounding
advanced practice nurse licensure and the Board's proposed rules to limit
title recognition. However, the Board has not included definitions of specialization
or subspecialization within the proposed rules because it is not necessary.
Additionally, the Board would disagree that it has failed to collaborate with
state and national leaders in CNS specialty organizations. One of the NACNS's
directors is a member of the APN Advisory Committee that discussed these proposed
revisions for more than a year in open meetings and that were presented for
Board review in substantial similar form as proposed. A former NACNS director
is also a member of that advisory committee. The current president-elect of
the NACNS attended one of the advisory committee meetings. The proposed rule
was recommended for Board adoption as a consensus of the committee that included
these members.
The APN advisory committee meetings were open meetings, and notice of the
meetings as well as the agendas are routinely published in the
Texas Register
. Notification that the committee discussed issues related
to APN titles was also published routinely in the Board's quarterly newsletter.
Other than one meeting attended by the president-elect, no other representatives
of CNS organizations contacted Board staff regarding the committee's work
or a desire to address the committee.
It should also be noted that these individuals have been invited to participate
in an ongoing dialogue with the regulatory community through the National
Council of State Boards of Nursing's APRN Task Force. After much discussion
with these organizations over a period of several years, the Task Force has
issued a position statement outlining its recommendations for regulation of
advanced practice nurses. The Board and APNAC members have reviewed this statement,
and considered that statement in the development of the proposed rule. In
this manner, the Board has obtained input from representatives of national
professional organizations.
Comment: NACNS and ANCC are working on a CNS core certification exam that
will be administered by ANCC and will be psychometrically sound and legally
defensible. The Board should support development of such solutions instead
of creating more barriers to CNS practice. NACNS
Response: The Board disagrees that it is creating barriers to practice.
When the exam is released, the Board will consider the new examination and
review it based on the criteria for review of national certification examinations
adopted by the Board in October 2003. Based on the results of that review,
the Board may choose to consider recognizing this examination if it sufficiently
meets the criteria established by the Board. Certification examinations are
used by regulatory authorities as an objective demonstration of competence
for practice in a profession. Thus, it is regulation that must determine whether
a specific examination is acceptable for this purpose and whether it can defend
the requirement for completion of a specific certification process rather
than the certifying body or the profession.
Comment: The Board should delay action on this rule until national concensus
is reached about the nature of specialization, subspecialization, regulation,
and credentialing among all stakeholders. TxCNS, TNA, AACN
Response: The Board disagrees. If the public interest is served by these
proposed rules, the Board believes there is no justification to delay action.
The issues identified in the comments have been discussed at the national
level for ten years, and a recommendation for regulation has been clearly
stated by many regulators and their representatives at the National Council
of State Boards of Nursing. It appears to the Board that consensus among the
commenter's identified "stakeholders" is not likely to occur in the near future.
Some jurisdictions already limit the titles recognized. Credentialing and
education have continued to develop new subspecialty educational programs
and examinations without regard for the concerns put forth by Boards of Nursing
or in pursuit of national consensus. Rather than working toward national uniformity
or consensus, there appears to be continuing request for approval of educational
programs for more and more specialized scopes of practice and newly created
certification examinations to match them.
Comment: Potential economic harm to individuals who are unable to practice
their trade as a specialist and harm to clients due to denial of highly qualified
specialist care. TxCNS, AACN
Response: The Board disagrees. It believes that this is not likely to cause
economic harm to advanced practice nurses or their patients. This proposed
rule does not prevent an advanced practice nurse from obtaining certification
from private organizations nor does it limit where a nurse chooses to practice.
In fact, the Board believes that the result of these rules will be more economic
opportunity for APNs. Advanced practice nurses with broader educational preparation
are more marketable in that they can provide for the health care needs of
the whole patient rather than just a single disease entity. This ultimately
decreases costs to the patient as well in that the patient is then less likely
to have to spend a great deal of time and money seeing multiple health care
providers for their health care needs. Further, the Board's proposed rules
do not limit the assumption of subspecialty knowledge, skills, and abilities
that can be desirable and marketable once licensed as a APN.
Comment: Proposed rules will freeze NP and CNS titles and indirectly specialty
roles at an arbitrary point in time and may interfere with the natural evolution
of APN specialty roles. TNA
Response: The Board disagrees. The Board is not opposed to consideration
of additional titles in the future should additional broad-based specialties
emerge. The rule is open for review and possible revision at least every four
years as required by the Texas Government Code or more often as deemed necessary
by the Board.
Comment: If titles are limited to some finite list of specialty titles,
what titles should be on the list may need further discussion. TNA
Response: The Board disagrees. The proposed list of titles has been discussed
for more than a year in open meetings by the APN advisory committee at the
Board's direction. Over the course of that year, a number of individuals have
attended those meetings and provided input to the committee, including but
not limited to an APN educator, APNs in practice, the president-elect of the
NACNS, and an applicant for authorization to practice as an advanced practice
nurse who had a vested interest in the committee's recommendation. This issue
has been discussed nationally with the Board's involvement and input for an
even longer period of time.
The Board believes that the proliferation of ever narrowing specialties
gives reason to limit titles at this time. The addition of multiple new narrow
specialty titles only continues to authorize individuals to practice who are
not prepared broadly enough and creates an increasingly heavy administrative
burden on the agency.
Comment: Use of "may" in §221.2(a) should be changed to "shall be."
TNA
Response: The Board agrees with this comment and will make the suggested
change.
Comment: Recommends deletion of the geographical limitation on APNs with
non-sec. 221.2 titles because beyond Board's rule-making authority until Texas
adopts multistate compact. TNA
Response: The Board disagrees that it does not have the authority to state
that any advanced practice nurse's authorization to practice is limited to
the State of Texas. Board staff has received numerous calls from individuals
who believed that the Nurse Licensure Compact for RNs included advanced practice
designations. Provisions for waiver of the master's requirement for certain
certificate-prepared women's health nurse practitioners and nurse-midwives
already exist in current §221.7(d). These provisions have been in the
rule since 2001, and there has been no discussion that such a limitation was
beyond the Board's rule making authority since the adoption of that language.
Comment: By limiting the specialties which would have title protection,
the public's access to knowledgeable and experienced APNs is being hindered.
ABNS, ONCC, AHNCC, ONS
Response: The Board disagrees with this comment. The Board is not rescinding
any current advanced practice nurse's authorization to practice nor does the
rule prevent nurses from becoming certified by private organizations. The
Board has also agreed to clarify its grandparenting provision. The Board intends
to utilize the rule to provide better assurance to the public that APNs who
hold a Board authorization are prepared to provide for a patient's specific
health care need as well as a broad range of co-morbidities that may be contributing
to the patient's overall health status. The Board is concerned that APNs who
are prepared in narrow specialty areas are not prepared to recognize and appropriately
manage or refer other co-morbid conditions the patient may have.
Comment: ABNS challenges the Board to justify the cost to Texas consumers
in its call for a specialty nursing certification board to demonstrate compliance
with criteria identified in Texas that are the same as those already deemed
acceptable by NCSBN at the national level. ABNS
Response: The Board is uncertain of the meaning of this comment. The Board
has adopted examination review criteria for those examinations it accepts.
The Board is aware that NCSBN has a review process in place, but the Board
has not determined that it will accept the NCSBN review in lieu of completing
its own review. In addition, the Board must have a mechanism to review national
certification examinations when they are new examinations not previously recognized
by the Board and to review examinations about which the Board receives substantive
complaints. National certifying bodies want boards of nursing to utilize their
certification processes for regulatory purposes. In order to do that, however,
boards of nursing must have criteria for acceptable examination processes
and a mechanism in place in order to assure the public that the examination
is actually testing what it is intended to test, especially when substantive
complaints about the examination are received.
Comment: ABNS urges the Board to accept APN specialty certification examinations
accredited by ABNS and authorize practice and title protection to those practicing
in accredited specialties. ABNS
Response: The Board does not accept this recommendation. The Board does
not agree that authorization to practice as an advanced practice nurse can
be dictated by any certification examination accredited by ABNS. Professional
organizations, such as ABNS, are responsible to their members certifying organizations.
They do not have a primary responsibility to protect the public. To automatically
defer to a private accrediting program as the appropriate regulatory review
would be an improper delegation of agency authority in violation of the constitutional
non-delegation doctrine. Further, there does not appear to be the appropriate
safeguards in place to warrant such a delegation or deference. The ABNS reviews
and accredits national certification examinations for nurses at all levels,
including nurses who are not APNs. Additionally, ABNS accredits examinations
that are targeted for many subspecialty practices and exams that do not meet
the criteria outlined in the Board's previously approved examination review
criteria. For example, the national certification examination for palliative
care may be taken by individuals who completed a specific program that prepared
them in palliative care or by APNs who completed other types of programs but
have worked a limited number of hours in palliative care. Accepting this certification
exam would ignore the education requirement that must also be met.
Authorization to practice as an advanced practice nurse in any role and
specialty from the Board of Nurse Examiners must serve the purpose of providing
the public with assurance that certain minimum criteria have been met and
all individuals who are authorized to use a specific title have the same core
knowledge, skills, abilities, and educational preparation, regardless of where
they completed their educational preparation. The proposed amendment continues
to recognize those titles that generally meet this criterion. Those not included
in that list generally do not (as indicated in the aforementioned example
regarding two CNSs in oncology nursing). ABNS accreditation cannot assure
the Board that certifying bodies continue to enforce or require the same standard.
Comment: TNA urges a six month moratorium on changes to the rule as well
as a six month moratorium on recognition of new titles by the Board to allow
for participatory discussion of this issue by stakeholders at the national
level. TNA, UT at Arlington
Response: The Board has agreed to the six month moratorium. The original
proposed rule has been withdrawn. New rule amendments are proposed that include
substantive and non-substantive changes as recommended in some of the comments
received. This will allow for further discussion of this issue for a six month
time period.
Comment: Advanced practice nurses for whom no national certification examination
exists should not be recognized by the Board. Examination provides for an
objective measure of competence that cannot be guaranteed based on graduation
from a program. UTBON/NLCA/NCSBNAPRNTF, Individual comment
Response: The Board agrees. Psychometrically sound examinations that meet
criteria specified by the Board provide for an objective measure of entry
level competency in an advanced practice role and specialty that is legally
defensible. Although alternatives to examination may seem attractive to the
profession, there are no alternatives that provide the opportunity to measure
entry-level competency in a manner that is equally as objective as examination.
Furthermore, such alternatives are not likely to survive legal challenge should
such challenge arise.
Comment: The increasing number of titles causes confusion for the public,
legislators, and regulators. Individual comment
Response: The Board agrees with this comment. Staff can provide numerous
examples of inquiries regarding advanced practice titles and individual scope
of practice from the public, other health care providers, other regulatory
entities, and offices of public officials. The additional use of certification
and education credentials causes concern for individuals who are not clear
what each means.
In situations in which two advanced practice nurses bearing the same title
have different scopes of practice based on differences in educational preparation
(such as the aforementioned examples of the two CNSs in oncology nursing),
the public, employers, and other health care providers become confused and
frustrated when trying to determine the services that each individual may
provide. In such situations, decisions regarding such issues as credentialing
are then left to an employer who may be unskilled in reading and interpreting
transcripts and course descriptions or who is not knowledgeable regarding
advanced practice nursing curricula. Additionally, the Board is concerned
that advanced practice nurses with narrower scopes of practice are increasingly
placed in positions where they are pressured to accept assignments for which
they lack appropriate educational preparation and that are beyond their scopes
of practice. This is of particular concern in situations in which two advanced
practice nurses have the same title but differing scopes of practice based
on differences in educational preparation.
Comment: Graduate nursing programs would have increased flexibility in
their ability to develop subspecialty tracks provided there is a core platform
for education in a broad specialty. Individual comment
Response: The Board agrees. The majority of the advanced practice programs
in the State of Texas have in excess of 700 clinical hours. Both national
standards and current Board rules only require a minimum of 500 hours be completed
in the specialty area. Thus, a program could offer a broad-based specialty
with at least 500 hours of clinical experience (such as adult health) as the
foundation of the program with electives that include didactic and clinical
content in subspecialty areas (such as palliative care). In doing so, the
graduate completes broad-based education to care for the total health care
needs of the patient but also gains additional expertise in a subspecialty
of interest. Another such example might be to complete a program in pediatrics
as the broad foundation with subspecialty electives in oncology. Such programs
would allow the advanced practice nurse to have a foundation with which to
care for patients, to recognize a broad range of diseases and conditions,
and to care for the whole patient. In addition, they would have educational
preparation in a specific subspecialty giving them additional expertise in
providing care to patients with those specific health care needs. It is possible
that advanced educational programs would then have greater flexibility to
explore the development of additional specialty electives for value-added
educational experiences.
Comment: Limiting the number or titles recognized by the Board is the first
step to a broader model of advanced practice nursing recognition and regulation.
UTBON/NLCA/NCSBNAPRNTF
Response: The Board agrees the proposed rule may provide an initial step
in moving from the 22 CNS and 19 NP titles it currently recognizes to broader
recognition of just the NP and CNS titles. Based on discussions during a national
meeting hosted by the ANA on December 16, 2004, it appears that broader based
legal recognition of just the NP and CNS titles holds the most support from
the profession. The Board would likely support this model of regulation if
it is demonstrated to be in the public interest.
Comment: The proposed rule will assure greater mobility for advanced practice
nurses moving from one state to another because many jurisdictions do not
recognize subspecialty titles. UTBON/NLCA/NCSBNAPRNTF, Individual comment
Response: The Board agrees with this comment. Board staff has had contact
with individuals who were eligible for recognition in Texas with a subspecialty
title but were not eligible to be recognized in other jurisdictions. APNs
frequently do not appreciate the significant variation in regulation of advanced
practice nurses from one jurisdiction to another. The proposed rule limits
legal recognition of APN titles to those most recognized in other jurisdictions.
For example, when staff queried other boards of nursing regarding the APN
titles they recognized, only five responded that they recognize clinical nurse
specialists in oncology nursing. Only two jurisdictions indicated that they
recognized palliative care nurse practitioners. With a broad-based foundation
in their advanced educational programs, these same APNs could possibly qualify
as clinical nurse specialists or nurse practitioners in a broad specialty
area with additional expertise in their respective subspecialty areas of oncology
or palliative care.
It is also important to consider that APNs who are recognized in narrow
subspecialties can and do experience difficulty finding employment even when
staying within Texas (for example, the aforementioned CNS in neonatal nursing).
Staff is repeatedly asked if the Board grants exemptions from the practice
requirement for maintenance of APN recognition when the individual APN cannot
find employment in his/her area of recognition. Likewise, the Board has taken
disciplinary action in cases in which the APN accepted employment outside
his/her specialty area or beyond his/her authorized scope of practice.
Comment: Advanced practice nurses who do not have a broad foundation before
specializing (much like physicians do) risk failing to accurately diagnose
and respond to co-morbid diseases and conditions. Individual comments
Response: The Board agrees with these comments. The Board does not wish
to deprive the public of expert advanced practice nursing care in subspecialty
areas; however, the Board recognizes that APNs must have a solid, broad-based
foundation upon which to build their expertise in more narrow subspecialty
areas in order to recognize a wide variety of co-morbidities that may be experienced
by patients under their care. Additionally, advanced practice nurses that
do not have a broad foundation upon which to build subspecialty expertise
may fail to make appropriate referrals for patients to obtain needed health
care services. The Board believes that the proposed rule seeks to continue
to recognize those advanced practice roles and specialties that provide consistent
education across a broad specialty area (such as family practice or adult
health). The individual may then build upon this foundation with subspecialty
expertise in order to better provide for the health care needs of the patient
as a whole rather than providing for health care needs related to a particular
subspecialty only.
In conclusion, the
Texas Register
requires
that the Board take action on a proposed rule (either adoption or withdrawal)
within six months of rule publication. Therefore, because the initially proposed
amendments were published in August 2004, it was not possible to grant TNA's
request for the six month moratorium for further discussion of this issue
without taking action on the proposed amendments. In order to allow for the
moratorium requested by TNA, the Board agrees to withdraw the amendments to
the rules as proposed on August 13, 2004, in the
Texas Register
and respond to comments received. The initially proposed
rule amendments were withdrawn effective January 27, 2005. In response to
those comments, the Board has integrated some of the requested changes and
re-proposed the rules using the language in the current proposed rule amendments.
The proposed amended rule language does not change the titles previously proposed
for continued recognition. It does, however, contain other substantive changes
as recommended by the comments received.
Katherine Thomas, executive director, has determined that for the first
five-year period the proposed amendments are in effect, fiscal implications
may exist for state or local government because some of the government funded
nursing education programs with advanced educational programs with subspecialty
tracks may see a drop in enrollment. Advanced practice nursing students may
not seek to enroll in those tracks due to the inability to obtain initial
authorization to practice.
Katherine Thomas, executive director, has determined that for each year
of the first five years the proposed amendments are in effect, the public
benefit will be more consistency nationally in APN titles and that limiting
the number of titles recognized by the Board provides assurance to the public
that advanced practice nurses who are authorized to practice in Texas have
completed broad-based educational preparation for entry into practice at the
advanced level. They are prepared to recognize a wide range of diseases and
conditions most commonly seen in their patient populations. Additionally,
each of the advanced roles and specialties recommended for continued recognition
have a national certification examination that is specifically targeted for
the role and the specialty area that exists or is in development to be released
later this year (acute care pediatric nurse practitioner). The time-limited
exception provides a mechanism for those individuals whose titles have not
been included in the list of recommended titles. Thus, programs and their
students are given fair notice (three calendar years) of the change. Finally,
the individual advanced practice nurse will benefit in that he/she could subspecialize
without having to seek and maintain additional authorizations with the board.
Employers of advanced practice nurses would also benefit in that they would
not have to wait for board approval or certification in subspecialty areas.
The effect on small businesses may be that some of the advanced educational
programs who offer subspecialty tracks may see a drop in enrollment because
individuals will not seek to enroll in those courses due to the inability
to obtain initial authorization to practice. The board, however, is not recommending
that existing courses disappear, but that the programs continue to offer these
courses as electives or as post-master's options for those who wish to complete
additional subspecialty courses. The anticipated cost to affected individuals
as a result of these proposed amendments are that advanced practice nurses
who are authorized in those specialties not on the list may be concerned that
they are not eligible for continued authorization to practice and, therefore,
not able to find suitable employment. Grandparenting will allow continued
recognition for those who have already been approved in those advanced roles
and specialty areas.
Written comments on the proposal may be submitted to Katherine A. Thomas,
MN, RN, Executive Director, Board of Nurse Examiners, 333 Guadalupe, Suite
3-460, Austin, Texas, 78701.
The proposed amendments are pursuant to the authority of Texas
Occupations Code §301.151 and §301.152 which authorizes the Board
of Nurse Examiners to adopt, enforce, and repeal rules consistent with its
legislative authority under the Nursing Practice Act.
The proposed amendments will affect the implementation of Texas Occupations
Code §301.152.
§221.2.Authorization and Restrictions to Use of Advanced Practice Titles.
(a)
Effective January 1, 2006, a registered nurse
[
(1)
nurse anesthetist
;
[
(2)
nurse-midwife
;
[
(3)
nurse practitioner
in the following specialties:
[
(A)
Acute Care Adult;
(B)
Acute Care Pediatric;
(C)
Adult;
(D)
Family;
(E)
Gerontological;
(F)
Neonatal;
(G)
Pediatric;
(H)
Psychiatric/Mental Health;
(I)
Women's Health; and/or
(4)
clinical nurse specialist
in the following specialties:
[
(A)
Adult Health/Medical-Surgical
Nursing;
(B)
Community Health Nursing;
(C)
Critical Care Nursing;
(D)
Gerontological Nursing;
(E)
Pediatric Nursing; and
(F)
Psychiatric/ Mental Health
Nursing.
(b)
A registered nurse
[
(c)
Unless authorized as an advanced practice nurse by the
board as provided for by §§
221.4 - 221.8
[
(1) - (2)
(No change.)
(d)
(No change.)
§221.7.Petitions for Waiver and Exemptions .
(a) - (d)
(No change.)
(e)
Exemptions granting authorization
to utilize titles not authorized by §221.2 of this chapter may be granted
to qualified applicants who complete their advanced educational programs prior
to January 1, 2010. Applicants must meet all other requirements as stated
in §221.4 of this chapter.
(1)
The following specialty titles may be considered
for exemption if the individual is not qualified for authorization to utilize
a title authorized by §221.2 of this chapter:
(A)
Acute Care Clinical Nurse Specialist;
(B)
Critical Care Nurse Practitioner;
(C)
Cardiovascular Clinical Nurse Specialist;
(D)
Emergency Nurse Practitioner or Clinical Nurse
Specialist;
(E)
Family Clinical Nurse Specialist;
(F)
Home Health Clinical Nurse Specialist;
(G)
Maternal (Parent)-Child Health Clinical Nurse
Specialist (with or without subspecialization);
(H)
Neonatal Clinical Nurse Specialist;
(I)
Oncology Nurse Practitioner or Clinical Nurse
Specialist;
(J)
Pediatric Critical Care Nurse Practitioner;
(K)
Perinatal Nurse Practitioner or Clinical Nurse
Specialist;
(L)
School Nurse Practitioner; and
(M)
Women's Health Clinical Nurse Specialist.
(2)
Those individuals authorized on the basis of
this exemption shall be limited to providing advanced practice nursing care
within the geographical boundaries of the State of Texas. This shall not prevent
the individual from utilizing Nurse Licensure Compact privileges to function
as a registered nurse.
(3)
The applicant must submit all required documentation
necessary to demonstrate that all requirements for authorization to practice
have been met.
(4)
The applicant must submit a written request
for exemption to §221.2 of this chapter and indicate the desired title.
(5)
Interim, provisional, or full authorization
may be granted to qualified applicants.
(6)
Advanced practice nurses authorized to practice
on the basis of this exemption shall use the advanced practice title specified
on the authorization to practice document provided by the board.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of
the Secretary of State on January 27, 2005.
TRD-200500377
Katherine Thomas
Executive Director
Board of Nurse Examiners
Earliest possible date of adoption: March 13, 2005
For further information, please call: (512) 305-6823
Chapter 237.
CONTINUING EDUCATION
Subchapter A. DEFINITIONS
A professional nurse, currently licensed in the State
of Texas, who is prepared for advanced nursing practice by virtue of knowledge
and skills obtained in an advanced educational program of study acceptable
to the board and meets requirements of Rule 221 and/or Rule 222.
]
Civil Statutes, Article 4518, §7,
] the board is establishing rules requiring participation in continuing
education activities for license renewal. The procedures set forth in these
rules provide a variety of means for licensees to comply with this requirement.
The board assumes licensed nurses will maintain the high standards of the
profession in selecting quality educational programs to fulfill the continuing
education requirement. The board also assumes that providers will plan and
implement quality educational programs which meet the criteria of the board.
and
] (4)
, and (5)
of this section.
(A)
]
A continuing education program attended or
undertaken in a jurisdiction outside of Texas may be accepted:
(i)
] for Type I credit if all criteria
are met and if it is approved by one of the board's recognized credentialing
agencies/organizations; and
(ii)
] for Type II credit if it meets
the criteria listed in §216.4 of this title and §216.5 of this section
concerning criteria for acceptable continuing education activity and additional
criteria for specific continuing education programs.
Chapter 217.
LICENSURE, PEER ASSISTANCE AND PRACTICE
Commission on Graduates of Foreign Nursing Schools (CGFNS) Certificate
]--Documentation
that verifies the educational credentials
and licensure
[
and/or CGFNS examination results
] of graduates of foreign nursing schools.
as evidenced by a transcript in English or one translated by an official translation
service;
] and
passed an examination of English
proficiency with a board-approved score
].
Commission
on Graduates of Foreign Nursing Schools (CGFNS) certificate, or a CGFNS
]
Credential Evaluation Service Full Education Course-by-Course Report
from the Commission on Graduates of Foreign Nursing Schools (CGFNS), Educational
Records Evaluation Service (ERES), or the International Education Research
Foundation (IERF)
and an English proficiency test acceptable to the
Board, or the equivalent which verifies that the applicant:
demonstrated proficiency in the
English language; and
]
(F)
passed the CGFNS Qualifying
Exam, if submitting a CGFNS certificate.]
Chapter 220.
NURSE LICENSURE COMPACT
(a)
] A nurse applying for a license
in a home party state shall produce evidence of the nurse's primary state
of residence. Such evidence shall include a declaration signed by the licensee.
Further evidence that may be requested may include but are not limited to:
(b)
] A nurse changing primary state
of residence, from one party state to another party state, may continue to
practice under the former home state license and multistate licensure privilege
during the processing of the nurse's licensure application in the new home
state for a period not to exceed thirty days.
(c)
] The licensure application in
the new home state of a nurse under pending investigation by the former home
state shall be held in abeyance and the thirty day period stated in subsection
(c)
[
(b)
] of this section shall be stayed until resolution
of the pending investigation.
(d)
] The former home state license
shall no longer be valid upon the issuance of a new home state license.
(e)
] If a decision is made by the
new home state denying licensure, the new home state shall notify the former
home state within ten business days and the former home state may take action
in accordance with that state's laws and rules.
Chapter 221.
ADVANCED PRACTICE NURSES
Registered nurses
] holding
him or herself
[
themselves
] out to be
an
advanced practice
nurse shall be authorized
to practice and hold a title in
[
nurses may include, but not be
limited to,
] the following categories [
of advanced practice nurses
]:
,
]
,
]
,
]
.
]
Registered nurses
]
who
holds
[
hold
] current authorization to practice as
an
advanced practice
nurse
[
nurses
] issued by
the board
in any of the categories indicated in the previous subsection
shall
[
may
] use
that
[
the
] title
when functioning in the advanced practice role. A registered nurse who was
granted authorization to practice in an advanced role and specialty not indicated
in the previous subsection prior to January 1, 2006, may continue to use the
advanced practice title approved by the Board provided all requirements for
maintenance of advanced practice authorization are met.
[
specified
on that authorization.
] "Advanced practice nurse" shall not be used
as a title.
221.5-8
] of this chapter (relating to
Full Authorization;
Provisional
Authorization; Interim Approval; Petitions for Waiver; and Maintaining Active
Authorization as an Advanced Practice Nurse), a registered nurse shall not:
Part 12.
BOARD OF VOCATIONAL NURSE EXAMINERS