22 TAC §221.2, §221.7
The Board of Nurse Examiners (Board) adopts amendments without
changes to 22 TAC §221.2 and §221.7, addressing Advanced Practice
Nurses. The proposed amendments to the rule were published in the February
11, 2005, issue of the
Texas Register
(30
TexReg 635). 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.
At the July 2004 meeting, the Board voted to propose amendments to Rules
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 and also held a public hearing
following this publication. 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 they believe this issue has implications for advanced practice
beyond the State of Texas.
On December 16, 2004, the American Nurses Association 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, staff
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 sub-specialty
focused model for advanced educational preparation and subsequent examination.
In addition to broad-based educational preparation, examination must also
test for entry-level competence at the advanced practice level across that
same broad base.
In order to progress from the current specialty and sub-specialty focused
model for education and examination to the model that appeared to have the
most support from the profession, there must be a step-wise approach. The
Board currently recognizes 19 nurse practitioner and 22 clinical nurse specialist
specialty and sub-specialty 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 Advanced Practice Nursing Advisory Committee's recommendation for revisions
to Rules 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 sub-specialization would
then be considered value-added after legal recognition for authorization to
practice at the advanced practice level is granted.
The Board reconsidered this issue at its January 2005 meeting. Because
of requirements imposed by the Texas Register and because the proposed amendments
were published in August 2004, it was not possible to grant TNA the six month
moratorium for further discussion of this issue without taking action on the
proposed amendments. A meeting, however, had been convened at the national
level to discuss this issue as suggested by TNA. As a result, the Board voted
to take action that allowed for the moratorium requested by TNA by withdrawing
the amendments to the rules as proposed in July 2004, responding to the comments
received, and re-proposing new amendments to Rules 221.2 and 221.7.
The new proposed language did not change the titles previously proposed
for continued recognition. It did, however, contain other substantive changes
as recommended by the comments received in response to the original proposed
language, including a list of the titles that may be recognized via an exemption.
Two comments were received regarding the proposed rule: TNA (Jim Willman)
and one individual. One individual supported the proposed changes, stating
they would support moving toward a system of education and authorization/licensure
that is consistent across educational programs and jurisdictions. The other
comment was submitted by James Willmann on behalf of TNA. Mr. Willmann's letter
states that, although TNA would prefer the Board delay action until national
consensus is reached, TNA does not oppose proceeding with adoption of the
rule at this time. The comments and the Board's responses received are as
follows:
Comment: One individual supports moving toward a system of education that
allows for consistency across educational programs as well as authorization/licensure
that is consistent across jurisdictions.
Response: The Board agrees that the revisions to Rules 221.2 and 221.7
are a step toward consistency in regulation. The Board currently recognizes
a number of advanced practice titles for which individuals cannot obtain authorization
to practice in most other jurisdictions.
Comment: The Texas Nurses Association (TNA) recommends rewriting proposed
subsection 221.7(e)(1) such that the exemption to utilize certain titles is
not discretionary with the board.
Response: The Board disagrees that the subsection should be rewritten.
The issuance of any advanced practice authorization is discretionary in that
the applicant must demonstrate compliance with all eligibility requirements.
Amending the language as TNA suggests could subject the Board to challenge
if an application from an individual requesting an exemption is denied or
approval is delayed because it appears the individual does not meet other
eligibility requirements.
Comment: TNA suggests that it may be beyond the authority of the BNE to
limit an advanced practice nurse's practice to the State of Texas before Texas
adopts a multi-state compact for advanced practice nurses. TNA also questions
whether this language is applied only to advanced practice nurses recognized
on the basis of an exemption.
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. For example, provisions for waiver of the master's requirement
for certain certificate-prepared women's health nurse practitioners and nurse-midwives
already exist in current Rule 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.
The language in the proposed rule is similar in format to the language that
is in current Rule 221.7(d).
The adopted 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 adoption of the
amendments will not affect any existing statute.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on April 25, 2005.
TRD-200501678
Katherine Thomas
Executive Director
Board of Nurse Examiners
Effective date: May 15, 2005
Proposal publication date: February 11, 2005
For further information, please call: (512) 305-6823