PART 11. TEXAS BOARD OF NURSING
CHAPTER 216. CONTINUING EDUCATION
The Texas Board of Nursing (Board) adopts the repeal of Chapter 216, §§216.1 - 216.11, concerning Continuing Education. The repeal is adopted without changes to the proposed text published in the May 15, 2009, issue of the Texas Register (34 TexReg 2864) and will not be re-published.
This repeal is necessary because the Board is simultaneously adopting a new chapter that promotes a comprehensive approach to continuing competency in nursing. Traditionally, nurses have primarily demonstrated continuing competency through the completion of continuing education courses. The requirements of the adopted new chapter, however, permit nurses to demonstrate continuing competency through other means. It is anticipated that this new approach to continuing competency will provide necessary flexibility to nurses while ensuring the ongoing delivery of safe nursing care in Texas. The adopted new chapter is also published in this edition of the Texas Register.
The adoption of the repeal will result in the promotion of a more comprehensive approach to continuing competency in nursing in Texas.
The Board did not receive any comments on the proposed repeal.
The repeal of §§216.1 - 216.11 is adopted pursuant to the Occupations Code §301.303 and §301.151. The Occupations Code §301.303(a) provides that the Board may recognize, prepare, or implement continuing competency programs for license holders under Chapter 301 and may require participation in continuing competency programs as a condition of renewal of a license. Further, §301.303(a) provides that the programs may allow a license holder to demonstrate competency through various methods, including completion of targeted continuing education programs and consideration of a license holder's professional portfolio, including certifications held by the license holder. Section 301.303(b) provides that the Board may not require participation in more than a total of 20 hours of continuing education in a two-year licensing period. Section 301.303(c) authorizes the Board by rule to establish a system for the approval of programs and providers of continuing education if the Board requires participation in continuing education programs as a condition of license renewal. Section 301.303(e) authorizes the Board to adopt rules as necessary to implement §301.303. Section 301.303(f) states that the Board may assess each program and provider under §301.303 a fee in an amount that is reasonable and necessary to defray the costs incurred in approving programs and providers. Section 301.303(g) provides that the Board by rule may establish guidelines for targeted continuing education required under Chapter 301. Further, §301.303(g) requires the rules adopted under §301.303(g) to address (i) the nurses who are required to complete the targeted continuing education program; (ii) the type of courses that satisfy the targeted continuing education requirement; (iii) the time in which a nurse is required to complete the targeted continuing education; (iv) the frequency with which a nurse is required to meet the targeted continuing education requirement; and (v) any other requirement considered necessary by the Board. The Occupations Code §301.151 authorizes the Board to adopt and enforce rules consistent with Chapter 301 and necessary to perform its duties and conduct proceedings before the Board; regulate the practice of professional nursing and vocational nursing; establish standards of professional conduct for license holders under Chapter 301; and determine whether an act constitutes the practice of professional nursing or vocational nursing.
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 July 27, 2009.
TRD-200903176
James W. Johnston
General Counsel
Texas Board of Nursing
Effective date: August 16, 2009
Proposal publication date: May 15, 2009
For further information, please call: (512) 305-6811
The Texas Board of Nursing (Board) adopts new Chapter 216, §§216.1 - 216.11, concerning Continuing Competency. New §§216.1 - 216.4, 216.6, and §216.8 are adopted with changes to the proposed text published in the May 15, 2009, issue of the Texas Register (34 TexReg 2865). New §§216.5, 216.7, and 216.9 - 216.11 are adopted without changes to the proposed text and will not be re-published.
The new sections are adopted under the Occupations Code §§301.152, 301.303, and 301.306, which authorize targeted continuing competency requirements for license holders, and are necessary to implement a comprehensive approach to continuing competency in nursing.
The Board is simultaneously adopting the repeal of existing §216.1 (relating to Definitions); §216.2 (relating to Purpose); §216.3 (relating to Requirements); §216.4 (relating to Criteria for Acceptable Continuing Education Activity); §216.5 (relating to Additional Criteria for Specific Continuing Education Programs); §216.6 (relating to Activities Which are not Acceptable as Continuing Education); §216.7 (relating to Responsibilities of Individual Licensee); §216.8 (relating to Relicensure Process); §216.9 (relating to Audit Process); §216.10 (relating to Appeals); and §216.11 (relating to Consequences of Non-Compliance). The adopted repeal of these sections is also published in this issue of the Texas Register. This adoption includes new sections to replace the repealed sections.
The Board formally proposed the new sections in the May 15, 2009, issue of the Texas Register (34 TexReg 2865). A public hearing on the rule proposal was held on July 9, 2009. In response to written comments on the published proposal and comments received during the public hearing, the Board has changed some of the proposed language in the text of the rule as adopted. The changes, however, do not materially alter issues raised in the proposal, introduce new subject matter, or affect persons other than those previously on notice.
The Board has made changes to §§216.1 - 216.4, 216.6, and 216.8 as adopted in response to comments that the proposed rules indirectly require a nurse to practice nursing in order to renew his or her license. Commenters state that Texas law does not impose a practice requirement on non-advanced practice nurses who renew a license, and the Board lacks authority to require a nurse to actively practice nursing in order to renew a license. Further, while the commenters generally agree that the proposed rules do not adequately address the effect of an "area of practice" requirement on nurses who do not actively practice nursing, the commenters propose different solutions to address the perceived problem. The Board continues to support the demonstration of continuing competency through the completion of continuing education in a nurse's area of practice. However, the Board agrees that there may be unanticipated or unintended consequences of the rule as proposed. This may be especially true with regard to nurses who are not actively practicing nursing or who work in non-traditional nursing occupations. As a result, changes have been made to §§216.1 - 216.4, 216.6, and 216.8 as adopted to provide necessary clarification, increase readability of the new sections, and eliminate the requirement that a nurse complete continuing education in his or her area of practice. The Board believes that the revisions to these sections as adopted address the commenter's' stated concerns.
The proposed requirement that nurses participate in continuing education courses that relate to their practice area has been eliminated from §216.2 as adopted, and a new sentence has been added to §216.2 that states: "The board encourages nurses to choose continuing education courses that relate to their work setting and area of practice or to attain, maintain, or renew an approved national nursing certification in their practice area, which benefits the public welfare." Although the Board is not requiring a nurse to complete continuing education in a specific area of practice in this rule adoption, the Board anticipates adopting such a requirement at some point in the future. As such, the Board is committed to encouraging nurses to choose to complete their continuing education in their specific areas of practice, even though they are not required to do so under the adopted rules. The proposed requirement that continuing education hours be obtained in the nurse's area of practice has also been eliminated from §216.3(a) and (e)(1) as adopted, and a new sentence has been added to §216.3(a) that states: "These hours shall be obtained by participation in programs approved by a credentialing agency recognized by the board." Further, the phrase "as defined in this chapter" has been added to §216.3(e)(1) for clarity, readability, and consistency with adopted §216.3(e)(2). The proposed requirement that continuing education programs must be in the nurse's area of practice has also been removed from §216.4 as adopted. The proposed statement that continuing education that is not in the nurse's area of practice will not meet the Board's continuing education requirements for licensure renewal has been removed from §216.6 as adopted. Also, the word "professional" has been changed to "nursing" in §216.6(3) as adopted to clarify Board intent that §216.6(3) applies to entry level competencies in both registered nursing practice and vocational nursing practice. The proposed requirements that a licensee must submit evidence of having completed 20 contact hours in his or her current or prior area of practice have been eliminated from §216.8(d)(1) and (e)(1) as adopted.
Finally, the proposed definition of area of practice has been changed in §216.1(4) as adopted. The revised definition defines area of practice as: "Any activity, assignment, or task in which the nurse utilized nursing knowledge, judgment, or skills during the licensure renewal cycle." Although the Board has eliminated the requirement that a nurse must obtain continuing education in his or her area of practice from the adopted rules, the Board is adopting §216.3(b) as proposed, without changes. Proposed §216.3(b) provides nurses the option of satisfying their continuing competency requirements by demonstrating the achievement, maintenance, or renewal of an approved national nursing certification in the nurse's area of practice. The revised definition of area of practice in §216.1(4) as adopted more closely aligns with the definition of professional nursing and vocational nursing found in the Occupations Code §301.002(2) and (5) and provides guidance to nurses in determining their specific area of practice for national nursing certification purposes.
The following paragraphs provide a brief summary and analysis of the reasons for the adopted rules, including a history of the methodologies and initiatives supporting a comprehensive approach to continuing competency in Texas. Staff began actively studying and analyzing national and local continuing competency initiatives in October, 2005, and routinely presented the data, observations, findings, and recommendations from these initiatives to the Board at the January, 2006; April, 2006; July, 2006; October, 2006; January, 2007; April, 2007; July, 2007; October, 2007; January, 2008; April, 2008; July, 2008; October, 2008; January, 2009; and April, 2009 Board meetings. At the April 2009, Board meeting, based upon a comprehensive study of the subject, Staff recommended, and the Board approved, adopting a comprehensive approach to continuing competency in Texas.
The concept of implementing and evaluating continuing competency requirements in nursing is not new. In fact, nursing boards, commissions, and organizations have been developing continuing competency programs since the early 1990s. The Board began actively evaluating and testing models of continuing nursing competency after SB 617 (effective September 1, 1997) was enacted by the 75th Texas Legislature. SB 617 authorized the Board to conduct pilot programs to evaluate the continued competency of nurses in Texas. Pursuant to SB 617, the Board approved and funded six pilot studies, including: (i) evaluation of a mandatory competency evaluation program of an urban county hospital and the validity and reliability of a 360 degree performance appraisal system in an urban specialty hospital; (ii) delineation of competencies for nurses working in rural health care settings; (iii) the use of vignettes for targeted continuing education in psychiatric nursing; (iv) assessment of certification in ACLS and PALs as a valid indication of competence; (v) identification and assessment of competencies of nurses in long-term care; and (vi) development of reliable and validity information for assessing home health nurse competencies. Various recommendations resulted from these studies, including a recommendation from the Competency Advisory Committee that acceptable components of competency maintenance should not be limited solely to continuing education hours. The Board reported its findings and recommendations regarding continuing competency in a 2000 publication, Ensuring Professional Nursing Competency . Shortly thereafter, ongoing competency evaluation began receiving further national attention and review. For example, the National Council of State Boards of Nursing (NCSBN) formed a special task force to survey over 20,000 licensed vocational nurses and 20,000 registered nurses with at least one year of practice experience to determine competencies that were required in their work environments. The NCSBN also compiled state-by-state information about continued competency processes using the APPLE criteria (Administratively feasible, Publicly credible, Professionally acceptable, Legally defensible, and Economically feasible) for an analysis of best practices among states. Around the same time, the following groups in Texas began evaluating and testing competency models: The Alliance for Innovation in Nursing Education; North Texas Consortium School of Nursing; Texas Higher Education Coordinating Board Nursing Innovative Grant Program - Midwestern State University High Fidelity Clinical Simulation; and Texas Nurses Association Competency Task Force. In February, 2006, these groups formed the Texas Competency Consortium to share information and coordinate competency development in the state of Texas.
Board staff actively participated in the Texas Nurses Association Competency Task Force (Task Force) during this time period and routinely reported the activities and initiatives of the Task Force to the Board. The Task Force focused on two specific approaches to continuing competency: (i) whether competencies should be developed that are related to a nurse's specific role/practice in his or her work environment; or (ii) whether broad-based competencies for all nurses should be developed. The NCSBN also considered these approaches on a national level, opting to develop and test a core set of broad-based competencies for all nurses. Ultimately, this approach was also adopted by the Task Force. The Task Force spent five years evaluating and testing different approaches to continuing competency. In July 2008, the Task Force issued Continuing Competency: Movement Toward Assurance in Nursing, in which the Task Force outlined its recommendations for continuing competency requirements in Texas. Specifically, the Task Force recommended allowing nurses to meet their continuing competency requirements through either the completion of 20 hours of continuing education in their area of practice or through national certification in their area of practice.
The requirements of the adopted new chapter are patterned after the studies, findings, and recommendations of the aforementioned national and local groups. Traditionally, continuing competency has been demonstrated primarily through the completion of continuing education courses. However, based upon the recommendations of the Task Force and the Texas Competency Consortium and the studies conducted by the NCSBN over the last five to ten years, the Board is departing from this approach by authorizing nurses to utilize other methods of demonstrating continuing competency. Under the adopted new chapter, a nurse is authorized to demonstrate continuing competency through the achievement, maintenance, or renewal of an approved national nursing certification in the nurse's area of practice, as well as through the completion of continuing education courses. Recognizing this additional method of compliance provides nurses with the option of pursuing and maintaining a certification in a specific area of practice. The additional education and training associated with obtaining and maintaining such a certification serves the purpose of the adopted new chapter, which is to protect the public health, safety, and welfare by ensuring that nurses stay abreast of current industry practices, enhance their professional competence, learn about new technology and treatment regimens, and update their clinical skills. This additional method of compliance is also consistent with the Occupations Code §301.303(a), which authorizes the demonstration of competency through various methods, including consideration of a license holder's professional portfolio and certifications held by the license holder.
The adopted new chapter also provides nurses with the option of demonstrating continuing competency through the completion of continuing education courses. Although the adopted new chapter does not require a nurse to complete continuing education courses in a specific area of practice, the Board encourages nurses to choose continuing education courses that relate to their work setting and area of practice. The Board recognizes that there is benefit in continuing education activities that generally apply to all nursing practice. However, the Board believes that a nurse is able to provide a better quality of care in the area of practice in which he or she has received specified, targeted training and is most knowledgeable. As a result, the Board remains committed to emphasizing the benefit of completing continuing education courses in a specific area of practice even though the completion of such courses is not a requirement of this rule adoption.
The following paragraphs summarize the intended purpose of the adopted new sections.
Adopted new §216.1 is necessary to define the terms used in the new chapter. In particular, adopted new §216.1(4) defines the term area of practice, which more closely aligns with the definition of professional nursing and vocational nursing found in the Occupations Code §301.002(2) and (5) and provides guidance to nurses in determining their specific area of practice for national nursing certification purposes.
Adopted new §216.2 is necessary to define the purpose of the new chapter, which is to ensure that nurses maintain and enhance their professional competence through activities, courses, and programs that promote and enrich their knowledge and skills.
Adopted new §216.3(a) and (b) are necessary to implement the continuing competency requirements under the Occupations Code §301.303(a) and (b). The Occupations Code §301.303(a) authorizes the Board to recognize, prepare, and implement continuing competency programs for license holders under Chapter 301 and to require participation in continuing competency as a condition of renewal of a license. Section 301.303(b) states that the Board may not require participation in more than a total of 20 hours of continuing education in a two-year licensing period. Adopted new §216.3(a) and (b) prescribe the continuing competency requirements applicable to nurses for each two-year licensing period and authorize two acceptable methods of satisfying those requirements. Under adopted new §216.3(a) and (b), a nurse must either complete (i) 20 contact hours of continuing education within the two years immediately preceding renewal of registration; or (ii) achieve, maintain, or renew an approved national nursing certification in the nurse's area of practice. These adopted new requirements emphasize the adopted new chapter's comprehensive approach to continuing competency by authorizing a viable alternative to completing traditional continuing education courses.
Adopted new §216.3(c), (d), and (e) address specific continuing competency requirements applicable to advanced practice registered nurses; advanced practice registered nurses holding prescriptive authority; nurses working in emergency room settings; and volunteer retired registered nurses. These adopted new requirements are necessary to implement the Occupations Code §301.152(b) and (c) and §301.306. The Occupations Code §301.152(b) authorizes the Board to adopt rules to approve registered nurses as advanced practice nurses and advanced practice nurses with prescriptive authority. Further, §301.152(b) authorizes the Board to adopt rules to establish specialized training, including pharmacology, that a registered nurse must have to carry out a prescription drug order. Section 301.152(c) requires the rules adopted under §301.152(b) to require continuing education in clinical pharmacology and related pathology, in addition to any continuing education otherwise required under §301.303. Consistent with the requirements of §301.152(b) and (c), adopted new §216.3(c) specifies the continuing competency requirements for advanced practice registered nurses and advanced practice registered nurses holding prescriptive authority and the methods that may be utilized to achieve compliance. The adopted new continuing competency requirements for advanced practice registered nurses do not differ significantly from the adopted new continuing competency requirements for registered or vocational nurses. Adopted new §216.3(c) generally requires an advanced practice registered nurse to either obtain 20 contact hours of continuing education appropriate to the advanced specialty area and role recognized by the Board or to attain, maintain, or renew a national certification recognized by the Board. However, additional continuing competency requirements apply to an advanced practice registered nurse holding prescriptive authority. Adopted new §216.3(c)(3) requires an advanced practice registered nurse holding prescriptive authority to complete at least five contact hours of continuing education in pharmacotherapeutics, in addition to satisfying the continuing competency requirements in adopted new §216.3(c). This adopted new requirement is particularly important because advanced practice registered nurses holding prescriptive authority are authorized to prescribe medications for their patients. It is important for these nurses to stay abreast of any changes in medication and treatment regimens so they may continue to safely prescribe medications and treatments for their patients.
The Occupations Code §301.306(a) requires a license holder who is employed to work in an emergency room setting to complete at least two hours of continuing education relating to forensic evidence collection. Further, §301.306(c) requires the Board to adopt rules to identify which license holders are required to comply with the requirements of §301.306(a) and to establish the content of the continuing education required under §301.306(a). Pursuant to §301.306, adopted new §216.3(d) clarifies that each nurse licensed in Texas and employed in an emergency room setting on or after September 1, 2006 shall complete a minimum of two hours of continuing education relating to forensic evidence collection. Adopted new §216.3(d) also defines the types of emergency room settings that are implicated by the adopted new requirements and specifies the information that must be addressed in continuing education courses focusing on forensic evidence collection. In addition to implementing the statutory requirements of the Occupations Code, adopted new §216.3(d) also helps ensure the preservation of valuable evidence. Persons who are the victims of crimes, such as sexual assault, assault, or abuse, often seek treatment in emergency rooms. In such situations, it may be necessary for an emergency room nurse to collect evidence of such crimes from the patient. While some institutions have a trained and certified Sexual Assault Nurse Examiner (SANE) on site to collect such evidence, not every institution will be able to provide a SANE nurse for evidence collection at certain times or locations. Adopted new §216.3(d) requires all nurses working in an emergency room setting to maintain competency in forensic evidence collection so that evidence may be appropriately preserved and collected from a patient at any time. This adopted new requirement furthers the public interest by ensuring the preservation of valuable evidence necessary for the prosecution of violent crimes.
Lastly, adopted new §216.3(e) addresses the continuing competency of retired nurses over the age of 65 who choose to volunteer their nursing services. The Board recognizes that these nurses are not compensated for providing volunteer nursing services and are generally not practicing nursing full time. However, these nurses are still providing patient care, and must comply with the requirements of the Nursing Practice Act. Further, because these nurses are providing patient care, it is important that they maintain their competency and clinical skills, stay abreast of current industry practices, and learn about new technology and treatment regimens. The Board recognizes that it may be inappropriate and financially burdensome to require a retired nurse who volunteers his or her nursing services on a part time basis to complete the same number of continuing education hours as a nurse who is not retired and practices nursing on a full time basis. As such, adopted new §216.3(e) requires a volunteer retired nurse to complete at least 10 contact hours of continuing education. In this way, adopted new §216.3(e) appropriately balances the need for retired volunteer nurses to demonstrate an acceptable level of continuing competency, while reducing the financial burden associated with completing continuing education courses.
Adopted new §216.4 and §216.5 address the criteria that a continuing education program must meet under the adopted new requirements. Adopted new §216.4 requires all continuing education programs to be approved by a credentialing agency, or an affiliated entity of such an agency, recognized by the Board. A credentialing agency must meet nationally, pre-determined criteria to approve programs and providers of continuing education in order to be recognized by the Board. Further, the Board recognizes that some nurses will choose to further their formal education and training and encourages those nurses to do so. As such, adopted new §216.5 permits certain, qualifying academic courses to satisfy all or a portion of a nurse's continuing competency requirements under the adopted new chapter. In order to qualify under adopted new §216.5, an academic course must either be included within the framework of a curriculum that leads to an academic degree in nursing or be relevant to nursing practice. Further, a nurse must be able to demonstrate that he or she completed the course with a grade of "C" or better or with a "Pass" on a "Pass/Fail" grading system. Adopted new §216.5 is intended to encourage nurses to further their nursing education through academic courses and to authorize the completion of these academic courses as an additional method of demonstrating continuing competency.
Adopted new §216.6 prohibits 10 categories of programs, activities, and courses from satisfying the adopted new continuing competency requirements. The Board recognizes that some continuing education programs, activities, and courses that are prohibited under adopted new §216.6 may provide nurses with helpful or valuable knowledge or may refresh a nurse's basic skills. While the Board recognizes that such knowledge is of value, the Board has determined that these programs, activities, and courses are not sufficient to advance or improve a nurse's knowledge or skill level or to develop a nurse's attitude for the enhancement of nursing practice. As such, while these programs, activities, and courses may provide helpful information, they cannot be used to satisfy the continuing competency requirements of the adopted new chapter.
Adopted new §216.7 is necessary to clarify a nurse's responsibility for satisfying the continuing competency requirements of the adopted new chapter. Adopted new §216.7 specifically requires each nurse to select, participate in, and maintain a record of qualifying continuing education programs, activities, and courses. Further, adopted new §216.7 prescribes the specific amount of time that a nurse must maintain a record of the completion of continuing education programs, activities, and courses. Not only do these adopted new requirements clearly delineate a nurse's compliance obligations under the adopted new chapter, but they also provide important information regarding compliance with adopted new §216.9. Adopted new §216.9 prescribes the audit process through which the Board will monitor a nurse's compliance with the adopted new continuing competency requirements. A nurse who is audited pursuant to adopted new §216.9 may be required to produce documentation to verify his or her continuing competency compliance for a specific period of licensure. If a nurse maintains records of the completion of continuing education programs, activities, and courses in compliance with adopted new §216.7, the nurse should also be able to provide the documentation necessary to prove his or her compliance during an audit conducted under adopted new §216.9.
Adopted new §216.8 clarifies the continuing competency requirements applicable to: licensees seeking renewal of their license; persons licensed by examination or endorsement; persons whose license is delinquent or inactive; and persons whose license has been revoked. These adopted new requirements provide important guidance to nurses regarding their responsibilities in meeting continuing competency requirements upon initial licensure and renewal and upon their license being returned to current or active status.
Adopted new §216.9 prescribes the process the Board will utilize in auditing and monitoring a nurse's compliance with the requirements of the adopted new chapter. The Board considers a nurse's compliance with the adopted new continuing competency requirements to be of utmost importance because a nurse's continuing competency directly affects the ongoing delivery of safe nursing care. Adopted new §216.9 implements an audit system, by which nurses will be randomly selected for a compliance audit 90 days prior to each renewal month. If a nurse is selected to be audited, the Board will review the nurse's continuing competency activities to determine compliance. To the extent that an audit reveals a nurse's non-compliance with any of the adopted new continuing competency requirements, it is anticipated that the Board will be able to take corrective action in a timely manner in order to prevent the nurse from providing potentially unsafe or incompetent care.
Adopted new §216.10 affords a nurse an opportunity to appeal a Board determination of continuing competency non-compliance. This adopted new section serves an important purpose. Under adopted new §216.9, the Board seeks to monitor and enforce compliance with its adopted new continuing competency requirements. However, the Board recognizes that incorrect compliance determinations may be made at times, due to human error. In such situations, it is important for a nurse to be afforded an opportunity to dispute the incorrect compliance determination. Adopted new §216.10 affords each nurse an opportunity to appeal a non-compliance determination and provide the Board with evidence of continuing competency compliance. The Board's goal in monitoring compliance with the adopted new continuing competency requirements is to identify non-compliant nurses so that corrective action may be taken as appropriate. However, corrective action is not necessary or appropriate in situations where a compliant nurse has been identified in error as non-compliant. Adopted new §216.10 seeks to minimize this risk by providing nurses the opportunity to challenge a determination of non-compliance and prove their compliance so that inappropriate corrective action may be timely avoided.
Finally, adopted new §216.11 clearly identifies the Board's expectations with regard to compliance with the adopted new continuing competency requirements. Adopted new §216.11 clearly states that a nurse's failure to comply with the continuing competency requirements will result in denial of renewal by the Board. Nurses are entrusted with the care of those most vulnerable by virtue of illness or injury. As such, their level of competence is of utmost importance in creating safe environments for patients. Because a nurse's continuing competency is such an integral part of providing safe nursing care to the public, the Board considers the denial of renewal one of the appropriate sanctions for non-compliance with the adopted new continuing competency requirements.
Adopted new §216.1 defines the terms to be used in the adopted new chapter. Adopted new §216.2 states that the purpose of continuing competency is to ensure that nurses stay abreast of current industry practices, enhance their professional competence, learn about new technology and treatment regimens, and update their clinical skills. Further, adopted new §216.2 makes clear that 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. Additionally, adopted new §216.2 recognizes that nursing certification is another method of demonstrating continuing competence. Adopted new §216.2 also states that, pursuant to authority set forth in the Occupations Code §301.303, the Board requires participation in continuing competency activities for license renewal. Further, the procedures set forth in the adopted new chapter provide guidance to fulfilling the continuing competency requirement. Finally, although not required to do so, nurses are encouraged to participate in continuing education courses that relate to their work setting or area of practice or to attain, maintain, or renew an approved national nursing certification in their practice area, which benefits the public welfare. Adopted new §216.3(a) and (b) require a nurse to either (i) complete 20 contact hours of continuing education within the two years immediately preceding renewal of registration or (ii) demonstrate the achievement, maintenance, or renewal of an approved national nursing certification in the nurse's area of practice. Adopted new §216.3(a) further requires the 20 contact hours of continuing education to be obtained by participation in programs approved by a credentialing agency recognized by the board. Further, adopted new §216.3(a) states that a list of the credentialing agencies/organizations may be obtained from the Board's office or web site. Adopted new §216.3(b) states that a list of approved national nursing certification criteria may also be obtained from the Board's office or web site. Adopted new §216.3(c) states that a licensee authorized by the Board as an advanced practice registered nurse (APRN) is required to obtain 20 contact hours of continuing education or attain, maintain or renew the national certification recognized by the Board as meeting the certification requirement for the advanced practice registered nurse's role and population focus area of licensure within the previous two years of licensure. Further, adopted new §216.3(c) provides that national certification will only meet the requirement for licensure renewal. Additionally, adopted new §216.3(c)(1) states that the required hours are not in addition to the requirements of §216.3(a) or (b). Adopted new §216.3(c)(2) provides that the 20 contact hours of continuing education must be appropriate to the advanced specialty area and role recognized by the Board. Adopted new §216.3(c)(3) provides that the APRN who holds prescriptive authority must complete, in addition to the required continuing competency requirements in §216.3(c), at least five contact hours of continuing education in pharmacotherapeutics. Adopted new §216.3(c)(4) states that Category I Continuing Medical Education (CME) contact hours will meet requirements as described in the adopted new chapter. Adopted new §216.3(d)(1) requires each nurse licensed in Texas and employed in an emergency room setting on or after September 1, 2006 to complete a minimum of two hours of continuing education relating to forensic evidence collection, as required by the Occupations Code §301.306 and adopted new §216.3(d) by (i) September 1, 2008 for nurses to whom this requirement applies who are employed in an emergency room setting on or before September 1, 2006; or (ii) within two years of the initial date of employment in an emergency room setting. This requirement may be met through completion of approved continuing education activities, as set forth in §216.4 (relating to Criteria for Acceptable Continuing Education Activity). Further, adopted new §216.3(d)(2) provides that this requirement applies to nurses who work in an emergency room setting that is: (i) the nurse's home unit; (ii) an ER unit to which the nurse "floats" or schedules shifts; or (iii) a nurse employed under contractual, temporary, per diem, agency, traveling, or other employment relationship whose duties include working in an emergency room. Additionally, adopted new §216.3(d)(3) states that a licensed nurse in Texas who would otherwise be exempt from continuing education requirements during the nurse's initial licensure or first renewal periods under §216.8(b) or (c) (relating to Relicensure Process) shall comply with the requirements of §216.3. This is a one time requirement for each nurse employed in an emergency room setting. In compliance with §216.7(b) (relating to Responsibilities of Individual Licensee), each licensee is responsible for maintaining records of continuing education attendance. Validation of course completion in Forensic Evidence Collection should be retained by the nurse indefinitely, even if a nurse changes employment. Further, adopted new §216.3(d)(4) provides that the minimum two hours of continuing education requirement shall include information relevant to forensic evidence collection and age or population-specific nursing interventions that may be required by other laws and/or are necessary in order to assure evidence collection that meets requirements under the Government Code §420.031 regarding use of a service-approved evidence collection kit and protocol. The content may also include, but is not limited to: documentation, history-taking skills, use of sexual assault kit, survivor symptoms, and emotional and psychological support interventions for victims. Lastly, adopted new §216.3(d)(5) provides that the required hours under adopted new §216.3(d) are included in the continuing education requirements for nurses. Adopted new §216.3(e)(1) provides that a nurse who is 65 years old or older and who holds or is seeking to hold a valid volunteer retired nurse authorization in compliance with the Occupations Code §112.051 and §217.9(d) (relating to Inactive Status) must have completed at least 10 hours of continuing education during the previous biennium, unless the nurse also holds valid recognition as an advanced practice registered nurse or is a Volunteer Retired Registered Nurse with advanced practice authorization in a given role and specialty in the State of Texas. Further, adopted new §216.3(e)(2) provides that a nurse who is 65 years old or older and who holds or is seeking to hold a valid volunteer retired nurse authorization in compliance with the Occupations Code §112.051 and §217.9(d) must have completed at least 20 hours of continuing education as defined in the adopted new chapter if authorized by the Board in a specific advanced practice role and specialty. The 20 hours of continuing education must meet the same criteria as advanced practice registered nurse continuing education defined under §216.3(c). An advance practice registered nurse authorized as a volunteer retired registered nurse with advance practice registered nurse authorization may not hold prescriptive authority. This does not preclude a registered nurse from placing his/her advance practice registered nurse authorization on inactive status and applying for authorization only as a volunteer retired registered nurse. Finally, adopted new §216.3(e)(3) provides that a nurse who is 65 years old or older and who holds or is seeking to hold a valid volunteer retired nurse authorization in compliance with the Occupations Code §112.051 and §217.9(d) is exempt from fulfilling targeted continuing education requirements except as required for volunteer retired advanced practice registered nurses. Adopted new §216.4 states that continuing education programs must be approved by a credentialing agency or an affiliated entity of one of these agencies. Proof of successful completion shall contain the name of the provider; the program title, date, and location; number of contact hours; provider number; and credentialing agency. Adopted new §216.5 states that in addition to those programs reviewed by a Board-approved entity, a licensee may attend an academic course that meets certain criteria. First, the course shall be within the framework of a curriculum that leads to an academic degree in nursing or any academic course relevant to nursing practice. Second, participants, upon audit by the Board, shall be able to present an official transcript indicating completion of the course with a grade of "C" or better, or a "Pass" on a Pass/Fail grading system. Adopted new §216.6 enumerates the following list of activities that do not meet continuing education requirements for licensure renewal: Basic Life Support or cardiopulmonary resuscitation courses; in-service programs; nursing refresher courses; orientation programs; courses which focus upon self-improvement, changes in attitude, self-therapy, self-awareness, weight loss, and yoga; economic courses for financial gain, e.g., investments, retirement, preparing resumes, and techniques for job interview; courses which focus on personal appearance in nursing; liberal art courses in music, art, philosophy, and others when unrelated to patient/client care; and courses designed for lay people; self-directed study. Adopted new §216.7(a) provides that it shall be the licensee's responsibility to select and participate in continuing competency activities that will meet the criteria listed in the adopted new chapter. Adopted new §216.7(b) provides that the licensee shall be responsible for maintaining a record of continuing education activities. These records shall document attendance as evidenced by original certificates of attendance, contact hour certificates, academic transcripts, or grade slips and copies of these shall be submitted to the Board upon audit. Adopted new §216.7(c) provides that these records shall be maintained by the licensee for a minimum of two consecutive renewal periods or four years. Adopted new §216.8(a) provides that, upon renewal of the license, the licensee shall sign a statement attesting that the continuing education or approved national nursing certification requirements have been met. The contact hours must have been completed in the biennium immediately preceding the license renewal. Continuing education contact hours from a previous renewal period will not be accepted. Additional contact hours earned may not be used for subsequent renewal periods. Adopted new §216.8(b) states that a candidate licensed by examination shall be exempt from the continuing education or approved national nursing certification requirement for issuance of the initial license and for the immediate renewal period following licensure. Adopted new §216.8(c) states that an applicant licensed by endorsement shall be exempt from the continuing education or approved national nursing certification requirement for the issuance of the initial Texas license and for the immediate renewal period following initial Texas licensure. Adopted new §216.8(d)(1) provides that a license that has been delinquent for less than four years may be renewed by the licensee showing evidence of having completed 20 contact hours of acceptable continuing education or an approved national nursing certification within two years immediately preceding the application for relicensure and by meeting all other Board requirements. A licensee shall be exempt from the continuing education requirement for the immediate renewal period following renewal of the delinquent license. Further, adopted new §216.8(d)(2) provides a license that has been delinquent for four or more years may be renewed upon completion of requirements listed in §217.6 (relating to Failure to Renew License). Adopted new §216.8(e)(1) provides that a license that has been inactive for less than four years may be reactivated by the licensee submitting verification of having completed at least 20 contact hours of continuing education or a current approved national nursing certification in their current or prior area of practice within the past two years immediately prior to application for reactivation. Adopted new §216.8(e)(2) provides that a license that has been inactive for four or more years may be reactivated upon completion of requirements in §217.9. Adopted new §216.8(f) states that a licensee whose license has been revoked and subsequently applies for reinstatement must show evidence that the continuing competency requirement and other Board requirements have been met prior to reinstatement of the license by the Board. Adopted new §216.9(1) provides that the Board shall select a random sample of licensees 90 days prior to each renewal month. Audit forms shall be sent to selected licensees to substantiate compliance with the continuing competency requirements. Within 30 days following notification of audit, these selected licensees shall submit an audit form and documentation as specified in adopted §216.4 and §216.5 and any additional documentation the Board deems necessary to verify compliance with continuing education requirements for the period of licensure being audited or a copy of the current approved national nursing certification and any additional documentation the Board deems necessary to verify compliance with continuing competency requirements for the period of licensure being audited. Further, adopted new §216.9(2) provides that failure to notify the Board of a current mailing address will not absolve the licensee from audit requirements. Additionally, adopted new §216.9(3) provides that an audit shall be automatic for a licensee who has been found noncompliant in an immediately preceding audit. Finally, adopted new §216.9(4) states that failure to complete the audit satisfactorily or falsification of records shall constitute unprofessional conduct and provide grounds for disciplinary action. Adopted new §216.10 states that any individual who wishes to appeal a determination of non-compliance with continuing competency requirements must submit a letter of appeal within 20 days of notification of the audit results. The Board or its designee shall conduct a review in which the appellant may appear in person to present reasons why the audit decision should be set aside or modified. Further, the decision of the Board after the appeal shall be considered final and binding. Finally, adopted new §216.11 provides that failure to comply with the Board's continuing competency requirements will result in the denial of renewal.
Area of Practice Requirements
Comment: An individual commenter states that she does not consider it to be a good "best practice" policy to require any practicing RN to limit continuing education hours to only their "field of practice". Further, the commenter states that some fields of nursing do not see regular continuing education opportunities and to limit what areas an RN can seek their hours in is going to make completion of the hours very difficult to obtain.
A commenter representing an organization states that the organization supports and applauds the Board's efforts to ensure competency in nursing practice and does not want anything to demean the nursing practice. However, the commenter is concerned that those nurses who do not have a clinical practice or an area of practice may lose their license as a result of the proposed rules. The commenter states that Texas law does not impose a practice requirement on non-advanced practice nurses who renew a license. Further, the commenter states that the proposed rules would indirectly require licensed nurses to engage in the practice of nursing by requiring all nurses who renew their licenses to have a practice area. The commenter states that there are many nurses in Texas who renew their licenses every two years and do not practice nursing. The commenter gives examples of nurses who do not practice nursing, such as nurse attorneys who do not represent nurses or have health care-related legal practices, the Board's own nurse investigators, and the Board's Executive Director. The commenter states that the Nursing Practice Act does not require a registered or licensed vocational nurse to maintain a nursing practice in order to maintain professional nursing licensure. Further, the commenter states that a nurse may submit a written request to the Board to request to be placed on inactive status. The commenter also argues that the Board cannot place a nurse on inactive status absent such a request, pursuant to the Occupations Code §301.261. The commenter states that although the Nursing Practice Act does not require continuing education as a condition of licensure or for renewal of a license, the Board has the discretion to require continuing education as a condition of licensure and as a condition for renewal of a license. However, the commenter states that the Board may not exercise this discretion in a way that deprives a nurse of the right to maintain an active license by indirectly requiring a nurse to be engaged in the practice of nursing. Further, the commenter states that the Board does not have the authority to condition a nurse's licensure on ambiguous continuing education requirements that could be interpreted to require the nurse to practice nursing.
Further, the commenter states that an indirect result of the proposed rule would make a dramatic change in nursing practice in Texas. The commenter also states that as long as there has been a Nursing Practice Act, a nurse has been able to renew his or her license without having an area of practice.
The commenter also states that the Board should be concerned about the indirect impact of the proposed rule on the shortage of nurses. In the Board's strategic plan published for 2009-2013, the Board largely focused on the shortage of nurses. The commenter points out that an entire section of that plan focused on how to retain nurses in practice. The commenter further states that, if a nurse were to have to lose his or license to take time off to have a family, to take time out for a hiatus, or if the nurse didn't have an area of practice to do continuing education in, that would be a barrier to nurses coming back to nursing practice and exacerbate the nursing shortage we have.
The commenter further states that she has reviewed the documents supporting the rules, including the Texas Nurses Association (TNA) Task Force Report, and has come to the conclusion that the Board didn't really intend for nurses to lose their licenses. The commenter bases this conclusion on the fact that the reports primarily focused on patient safety issues and clinical settings and that there was nothing in the reports regarding nurses who did not have practice areas. The commenter states that although the Board contends that the new requirements will not impose such a practice requirement on all nurses, that contention is not evident from the proposed rule as written. The commenter states that both the TNA paper and the preamble to the proposed rule indicate that general application of continuing education is an appropriate mechanism for demonstrating competency, but the Board has come to the conclusion as a result of its studies that it might be better if a nurse did continuing education in the nurse's specific area of practice if the nurse had one.
The commenter states that her organization's proposed solution would further the goal of patient safety and would be consistent with the rule's preamble and the TNA report. The commenter states that the Board can further its goals of competency in the practice of nursing without indirectly requiring a nurse to be actively engaged in the practice of nursing. The commenter suggests that the Board require a nurse to complete continuing education in his or her area of clinical practice if they have one and require nurses who do not have one to complete 20 approved contact hours every two years.
The commenter believes that the proposed alternative allowing certification by a national organization will be helpful to many nurses. The commenter also states that the members of her organization do not object to a nurse having to do continuing education for the renewal of a license, and that if a nurse who did not have a practice area decided to reenter nursing practice, they would not object to having to do a major refresher course because it would be required in order for that nurse to be competent. Further, the commenter states that her organization would be very supportive of stronger rules with regard to refresher courses for nurses re-entering practice in clinical settings.
A commenter representing another organization states that the organization supports the Board's decision to permit nurses to demonstrate competency through means other than continuing education. The commenter states that the proposed rules permit a nurse to demonstrate continued competency through continuing education in the nurse's area of practice; national certification in the nurse's area of practice; or completion of an academic course in the nurse's area of practice. The commenter's organization supports this model because implementing it should be the Board's and nursing's goal. The commenter states that her organization has studied this issue for over five years and has compiled a short and long version. Her organization believes nursing has taken, like other health professions, a very long time in addressing competency. For that reason, her organization encourages the Board to move forward with the rule it proposed, but she states that her organization is quick to say it does not have all the answers with regard to area of practice and would recommend that the Board put into place all aspects of the proposed rules, but delete that section to see if, after a short period of time of study (3-6 months), her organization and others can come up with answers to questions that nurses are just beginning to ask. The commenter states that this is a very complex issue and she believes an agreement can be reached, but at this point in time, there are more questions arising than can be answered.
The commenter states that, while the concept of "area of practice" is one that nurses intuitively understand, it is a concept that is difficult to define with the precision needed for this rule. The commenter states that if area of practice is defined too broadly, it becomes diluted as being a measure of true competency and fails to achieve the desired objective that continuing education enhance a nurse's competency in the specific knowledge and skills needed by the nurse in the nurse's area of practice. However, the commenter states that if it is defined too narrowly, there will be many outliers in the nursing profession that don't fit into the mainstream and it precludes the use of general continuing education, such as jurisprudence from being used to fulfill the continuing education requirement.
The commenter states that, before area of practice can be satisfactorily defined, nursing needs to try to reach consensus on some questions, such as:
Should a nurse be permitted to use continuing education (e.g., jurisprudence) applicable to all areas of practice to satisfy the continuing education component of the new model? If so, to satisfy the entire continuing education requirement or only some of it? If only some, how much?
If a nurse primarily practices in one area of practice but infrequently practices in several others, can the nurse take continuing education in any of these areas? Should the nurse have to take at least some continuing education in the nurse's primary area of practice?
What if the nurse does not engage in any nursing during the license renewal period, e.g., takes three years off to raise a family?
Does it make any difference in the type of continuing education a nurse should take if he or she is involved in direct patient care?
The commenter states that her organization does not believe the continuing education component of the new model can be satisfactorily addressed until more thought is devoted to these questions and some consensus is achieved. The commenter notes that TNA's Competency Task Force did not work through all of the implications of these questions.
The commenter also suggests coming up with a broad base. The commenter suggests utilizing the four modalities outlined in TNA's original paper on the subject. As an example, the commenter states that a nurse in clinical practice could select from the first and second domain, while other areas could utilize domains three and four.
The commenter's organization recommends that the continuing education component in the proposed rules be modified to delete the requirement that the continuing education be in the nurse's area of practice. However, the commenter's organization also recommends that the Board announce that its intent is to add such a requirement in the near future and immediately appoint a work group to begin working out the details of how some of the previously identified questions should be answered and how area of practice should be defined.
The commenter's organization believes that any questions that may arise about area of practice as applied to national certification problems do not present the same level of difficulty and supports retaining the requirement that national certification be in the nurse's area of practice.
Finally, the commenter states that if the Board decides to proceed with immediately requiring that continuing education be in the nurse' area of practice, her organization believes that the rules need to incorporate some type of transition to the new requirement. One possibility would be to provide that nurses gets credit for any continuing education taken prior to the rules' effective date or some other time certain.
Agency Response: The Board is committed to protecting and promoting the welfare of the people of Texas by ensuring that each person holding a license as a nurse in the State of Texas is competent to practice safely. The Board believes that enacting rules that promote competency in a nurse's area of practice is one way to support this mission. While the Board continues to support the demonstration of continuing competency in a nurse's specific area of practice, the Board agrees that there may be unanticipated or unintended consequences of the rule as proposed, specifically regarding those nurses working in nontraditional nursing occupations or those nurses who are not actively practicing nursing. The Board recognizes the complexities that have been raised by various commenters and that are associated with requiring a nurse to obtain continuing education in his or her area of practice. While the Board agrees that the rules as proposed do not adequately address the particular complexities associated with an "area of practice" competency requirement, the Board feels that an "area of practice" component should be incorporated into the continuing competency requirements at some point in the future. The Board considers the completion of appropriate continuing education to be an essential method in demonstrating a nurse's ability to safely practice nursing. However, in response to comments received, the Board has modified the rules as proposed to eliminate the requirement that a nurse must obtain continuing education in his or her area of practice. Further, because the Board continues to believe that there is value in requiring nurses to obtain continuing education in their specific area of practice, the Board has assigned a working group to study the issue in depth, paying particular attention to those nurses who work in non-traditional nursing occupations and those nurses who do not actively practice nursing. The Board has further charged the work group with making recommendations to the Board regarding the enactment of a rule that would incorporate an "area of practice" component for all individuals seeking to renew a nursing license. The Board will consider any recommendations made by the working group in a separate rule proposal.
The Board agrees that any questions that may arise regarding a nurse's "area of practice" in regards to national certification will not present the same types of difficulties or complexities and, therefore, adopts the requirement that national certification be in a nurse's area of practice, as proposed.
NAMES OF THOSE COMMENTING FOR AND AGAINST THE PROPOSAL.
For: None.
Against: One individual.
For, with changes: The Texas Nurses Association; The American Association of Nurse Attorneys, Texas Chapter.
Neither for nor against, with changes: None.
The new rules are adopted under the Occupations Code §§301.152, 301.303, 301.306, and 301.151. The Occupations Code §301.152(a) defines advanced practice nurse as 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. Section 301.152(b) authorizes the Board to adopt rules to: (i) establish any specialized education or training, including pharmacology, that a registered nurse must have to carry out a prescription drug order and a system for assigning an identification number to a registered nurse who provides the Board with evidence of completing the required specialized education and training requirement; (ii) approve a registered nurse as an advanced practice nurse; and (iii) initially approve and biennially renew an advanced practice nurse's authority to carry out or sign a prescription drug order. Section 301.152(c) requires the rules adopted under §301.152(b) to (i) require completion of pharmacology and related pathology education for initial approval; (ii) require continuing education in clinical pharmacology and related pathology in addition to any continuing education otherwise required under §301.303; and (iii) provide for the issuance of a prescription authorization number to an advanced practice nurse approved under §301.152. Section 301.152(d) provides that the signature of an advanced practice nurse attesting to the provision of a legally authorized service by the advanced practice nurse satisfies any documentation requirement for that service established by a state agency. Section 301.303(a) authorizes the Board to recognize, prepare, or implement continuing competency programs for license holders under Chapter 301 and to require participation in continuing competency programs as a condition of renewal of a license. The programs may allow a license holder to demonstrate competency through various methods, including completion of targeted continuing education programs and consideration of a license holder's professional portfolio, including certifications held by the license holder. Section 301.303(b) provides that the Board may not require participation in more than a total of 20 hours of continuing education in a two-year licensing period. Section 301.303(c) authorizes the Board by rule to establish a system for the approval of programs and providers of continuing education if the Board requires participation in continuing education programs as a condition of license renewal. Section 301.303(e) authorizes the Board to adopt other rules as necessary to implement §301.303. Section 301.303(f) states that the Board may assess each program and provider under this section a fee in an amount that is reasonable and necessary to defray the costs incurred in approving programs and providers. Section 301.303(g) authorizes the Board by rule to establish guidelines for targeted continuing education required under Chapter 301. The rules adopted under §301.303(g) must address: (i) the nurses who are required to complete the targeted continuing education program; (ii) the type of courses that satisfy the targeted continuing education requirement; (iii) the time in which a nurse is required to complete the targeted continuing education; (iv) the frequency with which a nurse is required to meet the targeted continuing education requirement; and (v) any other requirement considered necessary by the Board. Section 301.306(a) provides that, as part of continuing education requirements under §301.303, a license holder who is employed to work in an emergency room setting and who is required under Board rules to comply with §301.303 shall complete at least two hours of continuing education relating to forensic evidence collection not later than September 1, 2008 or the second anniversary of the initial issuance of a license under this chapter to the license holder. Section 301.303(b) states that the continuing education required under §301.303(a) must be part of a program approved under §301.303(c). Section 301.303(c) authorizes the Board to adopt rules to identify the license holders who are required to complete continuing education under §301.303(a) and to establish the content of that continuing education. Further, the Board may adopt other rules to implement §301.303, including rules under Section 301.303(c) for the approval of education programs and providers. Section 301.151 authorizes the Board to adopt and enforce rules consistent with Chapter 301 and necessary to: (i) perform its duties and conduct proceedings before the Board; (ii) regulate the practice of professional nursing and vocational nursing; (iii) establish standards of professional conduct for license holders under this chapter; and (iv) determine whether an act constitutes the practice of professional nursing or vocational nursing.
§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) Academic course--A specific set of learning experiences offered in an accredited school, college or university. Academic credit will convert on the following basis: One academic quarter hour = 10 contact hours; one academic semester hour = 15 contact hours.
(2) Advanced Practice Registered Nurse (APRN)--A nurse anesthetist, nurse practitioner, nurse midwife, or clinical nurse specialist approved by the board to practice as an advanced practice registered nurse based on completion of an advanced educational program acceptable to the board.
(3) Approved--Recognized as having met established standards and predetermined criteria of the:
(A) credentialing agencies recognized by the board (applies to providers and programs); and
(B) certifying bodies accredited by a national certification accreditation body recognized by the board.
(4) Area of Practice--Any activity, assignment, or task in which the nurse utilized nursing knowledge, judgment, or skills during the licensure renewal cycle.
(5) Audit--A random sample of licensees taken to verify satisfactory completion of the board's requirements for continuing competency during a biennial license renewal period.
(6) Authorship--Development and publication of a manuscript related to nursing and health care.
(7) Certification--Nursing certification from an approved certifying body accredited by a national accreditation body recognized by the board.
(8) Classroom instruction--Workshops, seminars, institutes, conferences or short term courses which the individual attends which may be acceptable for continuing education credit.
(9) Clinical learning experiences--Faculty-planned and guided learning experiences designed to assist students to meet the course objectives and to apply nursing knowledge and skills in the direct care of patients/clients. This includes laboratories, acute care facilities, extended care facilities, and other community resources.
(10) Competency--The application of knowledge and the interpersonal decision making, and psychomotor skills expected for the nurse's practice role, within the context of public health, safety, and welfare.
(11) Contact hour--Sixty consecutive minutes of participation in a learning activity.
(12) Continuing Education (CE)--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.
(13) Continuing education program--An organized educational activity, e.g, self paced (online), classroom, approved through an external review process based on a predetermined set of criteria. The review is conducted by an organization(s) recognized by the board to approve programs and providers.
(14) Credentialing agency--An organization recognized by the board as having met nationally predetermined criteria to approve programs and providers of CE.
(15) Prescriptive Authority--Authorization granted to an advanced practice registered nurse who meets the requirements to carry out or sign a prescription drug order.
(16) Program number--A unique number assigned to a program upon approval which shall identify it regardless of the number of times it is presented.
(17) Provider--An individual, partnership, organization, agency or institution approved by an organization recognized by the board which offers continuing education programs.
(18) Provider number--A unique number assigned to the provider upon approval by the credentialing agency or organization.
§216.2.Purpose.
The purpose of continuing competency is to ensure that nurses stay abreast of current industry practices, enhance their professional competence, learn about new technology and treatment regimens, and update their clinical skills. 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. Nursing certification is another method of demonstrating continuing competence. Pursuant to authority set forth in the Occupations Code §301.303, the board requires participation in continuing competency activities for license renewal. The procedures set forth in these rules provide guidance to fulfilling the continuing competency requirement. The board encourages nurses to choose continuing education courses that relate to their work setting and area of practice or to attain, maintain, or renew an approved national nursing certification in their practice area, which benefits the public welfare.
§216.3.Requirements.
(a) A nurse must meet either the requirements of this subsection or subsection (b) of this section. A nurse may choose to complete 20 contact hours of continuing education within the two years immediately preceding renewal of registration. These hours shall be obtained by participation in programs approved by a credentialing agency recognized by the board. A list of these agencies/organizations may be obtained from the board's office or web site.
(b) A nurse must meet either the requirements of this subsection or subsection (a) of this section. A nurse may choose to demonstrate the achievement, maintenance, or renewal of an approved national nursing certification in the nurse's area of practice. A list of approved national nursing certification criteria may be obtained from the board's office or web site.
(c) Requirements for the Advanced Practice Registered Nurse. The licensee authorized by the board as an advanced practice registered nurse (APRN) is required to obtain 20 contact hours of continuing education or attain, maintain or renew the national certification recognized by the board as meeting the certification requirement for the advanced practice registered nurse's role and population focus area of licensure within the previous two years of licensure. National certification as discussed in this section will only meet the requirement for licensure renewal.
(1) The required hours are not in addition to the requirements of subsection (a) or (b) of this section.
(2) The 20 contact hours of continuing education must be appropriate to the advanced specialty area and role recognized by the board.
(3) The APRN who holds prescriptive authority must complete, in addition to the requirements of this subsection, at least five additional contact hours of continuing education in pharmacotherapeutics.
(4) Category I Continuing Medical Education (CME) contact hours will meet requirements as described in this chapter.
(d) Forensic Evidence Collection.
(1) Each nurse licensed in Texas and employed in an emergency room (ER) setting on or after September 1, 2006 shall complete a minimum of two hours of continuing education relating to forensic evidence collection, as required by the Occupations Code §301.306 and this subsection:
(A) by September 1, 2008 for nurses to whom this requirement applies who are employed in an ER setting on or before September 1, 2006; or
(B) within two years of the initial date of employment in an ER setting. This requirement may be met through completion of approved continuing education activities, as set forth in §216.4 of this chapter (relating to Criteria for Acceptable Continuing Education Activity).
(2) This requirement shall apply to nurses who work in an ER setting that is:
(A) the nurse's home unit;
(B) an ER unit to which the nurse "floats" or schedules shifts; or
(C) a nurse employed under contractual, temporary, per diem, agency, traveling, or other employment relationship whose duties include working in an ER.
(3) A licensed nurse in Texas who would otherwise be exempt from CE requirements during the nurse's initial licensure or first renewal periods under §216.8(b) or (c) of this chapter (relating to Relicensure Process) shall comply with the requirements of this section. This is a one-time requirement for each nurse employed in an ER setting. In compliance with §216.7(b) of this chapter (relating to Responsibilities of Individual Licensee), each licensee is responsible for maintaining records of CE attendance. Validation of course completion in Forensic Evidence Collection should be retained by the nurse indefinitely, even if a nurse changes employment.
(4) The minimum 2 hours of continuing education requirement shall include information relevant to forensic evidence collection and age or population-specific nursing interventions that may be required by other laws and/or are necessary in order to assure evidence collection that meets requirements under the Government Code §420.031 regarding use of a service-approved evidence collection kit and protocol. Content may also include but is not limited to documentation, history-taking skills, use of sexual assault kit, survivor symptoms, and emotional and psychological support interventions for victims.
(5) The required hours under this subsection are included in the continuing education requirements for nurses.
(e) A nurse who is 65 years old or older and who holds or is seeking to hold a valid volunteer retired (VR) nurse authorization in compliance with the Occupations Code §112.051 and §217.9(d) of this title (relating to Inactive Status):
(1) Must have completed at least 10 hours of continuing education as defined in this chapter during the previous biennium, unless the nurse also holds valid recognition as an advanced practice registered nurse or is a Volunteer Retired Registered Nurse (VR-RN) with advanced practice authorization in a given role and specialty in the State of Texas.
(2) Must have completed at least 20 hours of CE as defined in this chapter if authorized by the board in a specific advanced practice role and specialty. The 20 hours of CE must meet the same criteria as APRN CE defined under subsection (c) of this section. An APRN authorized as a VR-RN with APRN authorization may not hold prescriptive authority. This does not preclude a registered nurse from placing his/her APRN authorization on inactive status and applying for authorization only as a VR-RN.
(3) Is exempt from fulfilling targeted CE requirements except as required for volunteer retired advanced practice registered nurses.
§216.4.Criteria for Acceptable Continuing Education Activity.
Continuing Education programs must be approved by a credentialing agency or an affiliated entity of one of these agencies. Proof of successful completion shall contain the name of the provider; the program title, date, and location; number of contact hours; provider number; and credentialing agency.
§216.6.Activities Which are not Acceptable as Continuing Education.
The following activities do not meet continuing education requirements for licensure renewal.
(1) Basic Life Support (BLS) or cardiopulmonary resuscitation (CPR) courses.
(2) In service programs. Programs sponsored by the employing agency to provide specific information about the work setting and orientation or other programs which address the institution's philosophy, policies and procedures; on-the-job training; basic CPR; and equipment demonstration are not acceptable for CE credit.
(3) Nursing refresher courses. Programs designed to update knowledge or current nursing theory and clinical practice, which consist of a didactic and clinical component to ensure entry level competencies into nursing practice are not accepted for CE credit.
(4) Orientation programs. A program designed to introduce employees to the philosophy, goals, policies, procedures, role expectations and physical facilities of a specific work place are not acceptable for CE credit.
(5) Courses which focus upon self-improvement, changes in attitude, self therapy, self-awareness, weight loss, and yoga.
(6) Economic courses for financial gain, e.g., investments, retirement, preparing resumes, and techniques for job interview.
(7) Courses which focus on personal appearance in nursing.
(8) Liberal art courses in music, art, philosophy, and others when unrelated to patient/client care.
(9) Courses designed for lay people.
(10) Self-directed study--An educational activity wherein the learner takes the initiative and the responsibility for assessing, planning, implementing and evaluating the activity including, but not limited to:
(A) academic courses that are audited, or that are healthcare-related courses but not part of a nursing degree program, or that are prerequisite courses such as mathematics, physiology, biology, government, or other similar courses are not acceptable;
(B) authorship; and
(C) program development and presentation.
§216.8.Relicensure Process.
(a) Renewal of license.
(1) Upon renewal of the license, the licensee shall sign a statement attesting that the CE or approved national nursing certification requirements have been met.
(2) The contact hours must have been completed in the biennium immediately preceding the license renewal. CE contact hours from a previous renewal period will not be accepted. Additional contact hours earned may not be used for subsequent renewal periods.
(b) Persons licensed by examination. A candidate licensed by examination shall be exempt from the CE or approved national nursing certification requirement for issuance of the initial license and for the immediate renewal period following licensure.
(c) Persons licensed by endorsement. An applicant licensed by endorsement shall be exempt from the CE or approved national nursing certification requirement for the issuance of the initial Texas license and for the immediate renewal period following initial Texas licensure.
(d) Delinquent license.
(1) A license that has been delinquent for less than four years may be renewed by the licensee showing evidence of having completed 20 contact hours of acceptable continuing education or an approved national nursing certification within two years immediately preceding the application for relicensure and by meeting all other board requirements. A licensee shall be exempt from the continuing education requirement for the immediate renewal period following renewal of the delinquent license.
(2) A license that has been delinquent for four or more years may be renewed upon completion of requirements listed in §217.6 of this title (relating to Failure to Renew License).
(e) Reactivation of a license.
(1) A license that has been inactive for less than four years may be reactivated by the licensee submitting verification of having completed at least 20 contact hours of continuing education or a current approved national nursing certification in their current or prior area of practice within the past two years immediately prior to application for reactivation.
(2) A license that has been inactive for four or more years may be reactivated upon completion of requirements in §217.9 of this title (relating to Inactive Status).
(f) Reinstatement of a license. A licensee whose license has been revoked and subsequently applies for reinstatement must show evidence that the continuing competency requirement and other board requirements have been met prior to reinstatement of the license by the board.
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 July 27, 2009.
TRD-200903177
James W. Johnston
General Counsel
Texas Board of Nursing
Effective date: August 16, 2009
Proposal publication date: May 15, 2009
For further information, please call: (512) 305-6811
CHAPTER 681. PROFESSIONAL COUNSELORS
The Texas State Board of Examiners of Professional Counselors (board) adopts amendments to §§681.45, 681.49, 681.72, 681.91, and 681.93, concerning the licensing and regulation of professional counselors without changes to the proposed text as published in the June 5, 2009, issue of the Texas Register (34 TexReg 3491), and the sections will not be republished.
The amendments are adopted to ensure that the rules are updated to reflect current legal, policy, and operational considerations; to improve draftsmanship; and to make the rules more accessible, understandable, and usable. The amendments are also necessary to clarify supervision requirements and duties of supervisors; to make the term of supervisor approval begin and end on the same date as license renewal; and to provide penalties for continuing to act as a supervisor after approval has expired.
Government Code, §2001.039, requires that each state agency review and consider for re-adoption each rule adopted by that agency pursuant to the Government Code, Chapter 2001 (Administrative Procedure Act). Sections 681.45, 681.49, 681.72, 681.91, and 681.93 have been reviewed and the board has determined that the reasons for adopting the sections continue to exist in that rules concerning the licensing and regulation of professional counselors are still needed.
SECTION-BY-SECTION SUMMARY
Section 681.45(e) is added to require the licensee to report any arrests, convictions, or disciplinary actions within 30 days to the board.
Section 681.49(i) is amended to allow a licensed professional counselor who carries the supervisor status to use the designation "LPC-S."
Section 681.72(d) is amended to require a current copy of the supervisor's license to be attached to the supervisory agreement form.
Section 681.91(e) is amended to change the length of time a temporary license is issued.
Section 681.91(f) describes what happens if the required supervised experience hours needed for licensure are not met within the time period of a temporary license.
Section 681.93(c) is amended to change the supervisor renewal from one year to two years.
Section 681.93(f) is amended to allow for the board to decide if supervisory hours can count if the supervisor's status has been denied, revoked, or suspended.
Section 681.93(k) is added to require the supervisor to refund all monies paid by the intern if the supervisor status expires during the supervision and is not renewed.
Section 681.93(l) is added to allow for disciplinary action to be taken against the supervisor for allowing the supervisor status to expire.
COMMENTS
The board received two comments regarding the proposed rules during the comment period. Both commenters agreed with the proposed changes, and therefore, no action is necessary.
SUBCHAPTER C. CODE OF ETHICS
STATUTORY AUTHORITY
The amendments are authorized by Occupations Code, §503.203, which authorizes the board to adopt rules necessary for the performance of the board's duties. The review of the rules implements Government Code, §2001.039.
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 August 3, 2009.
TRD-200903311
Glynda Corley
Chair
Texas State Board of Examiners of Professional Counselors
Effective date: September 1, 2009
Proposal publication date: June 5, 2009
For further information, please call: (512) 458-7111 x6972
STATUTORY AUTHORITY
The amendment is authorized by Occupations Code, §503.203, which authorizes the board to adopt rules necessary for the performance of the board's duties. The review of the rules implements Government Code, §2001.039.
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 August 3, 2009.
TRD-200903312
Glynda Corley
Chair
Texas State Board of Examiners of Professional Counselors
Effective date: September 1, 2009
Proposal publication date: June 5, 2009
For further information, please call: (512) 458-7111 x6972
STATUTORY AUTHORITY
The amendments are authorized by Occupations Code, §503.203, which authorizes the board to adopt rules necessary for the performance of the board's duties. The review of the rules implements Government Code, §2001.039.
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 August 3, 2009.
TRD-200903313
Glynda Corley
Chair
Texas State Board of Examiners of Professional Counselors
Effective date: September 1, 2009
Proposal publication date: June 5, 2009
For further information, please call: (512) 458-7111 x6972
CHAPTER 711. DIETITIANS
The Texas State Board of Examiners of Dietitians (board) adopts the repeal of §§711.1 - 711.22 and new §§711.1 - 711.22, concerning the licensing and regulation of dietitians without changes to the proposed text as published in the February 27, 2009, issue of the Texas Register (34 TexReg 1374).
BACKGROUND AND PURPOSE
Government Code, §2001.039 requires that each state agency review and consider for readoption each rule adopted by that agency pursuant to the Government Code, Chapter 2001 (Administrative Procedure Act). Sections 711.1 - 711.22 have been reviewed and the board has determined that the reasons for adopting the sections continue to exist in that rules concerning the licensure and regulation of dietitians still needed; however, the rules are repealed and adopted as new rules as described in this preamble. The adopted repeals and new sections are the result of the comprehensive rule review undertaken by the board and the board's staff.
SECTION-BY-SECTION SUMMARY
In addition to the changes specifically outlined, the rules have been revised and reorganized as new rules to ensure appropriate section, subsection, and paragraph organization and captioning; to ensure clarity; to improve spelling, grammar, and punctuation; to improve agency-wide consistency between programs, as appropriate; to ensure that the rules reflect current legal, policy, and operational considerations; to ensure accuracy of legal citations; to delete repetitive, obsolete, or unnecessary language; to improve draftsmanship; and to make the rules more accessible, understandable, and usable, to the extent possible.
The following changes are adopted relating to the repeal and readoption of §711.1 (Definitions). The definition of "formal hearing" was deleted as not necessary.
The following changes are adopted relating to the repeal and readoption of §711.2 (The Board's Operation) and §711.3 (Fees). Section 711.2 was reorganized for ease of use and the subsection that formerly related to licensing fees was moved to a separate section, the new §711.3 (Fees).
The following changes are adopted relating to the repeal of §711.3 and was adopted as new §711.4 (The Profession of Dietetics and Code of Ethics). The section was renamed. New provisions were added at §711.4(c)(1)(P) that require a license holder to report child abuse or neglect and abuse or neglect of the elderly or disabled, in accordance with existing laws.
The following changes are adopted relating to the repeal of §711.8 and renumbered as new §711.9 (Determination of Eligibility for Licensure). The provision requiring that the board ratify applications approved by staff was deleted as obsolete and unnecessary.
The following changes are adopted relating to the repeal of §711.17 and new §711.16 (Continuing Education Requirements). The board adopts requiring the Texas jurisprudence examination as an ongoing condition of license renewal and allows license holders one hour of continuing education credit for its completion. The rules formerly provided that the jurisprudence exam would be required only for licenses renewed between January 1, 2007, and December 31, 2008. Additionally, the board adopts deletion of the provision allowing a license holder who is not in active practice and is more than 60 years of age to be exempt from continuing education requirements. The board finds that the public interest is best served by requiring licensed dietitians to maintain licenses in active status and regularly complete continuing education and the Texas jurisprudence examination.
The following changes are adopted relating to the repeal of §711.16 (Inactive Status). The board adopts deletion of the provisions relating to inactive status as unnecessary. The statute does not require that inactive status be an option for licensees and few licensees avail themselves of the option. The board finds that the public interest is best served by requiring licensed dietitians to maintain licenses in active status and regularly complete continuing education and the Texas jurisprudence examination.
PUBLIC COMMENT
The board has prepared the following responses to comments received regarding the proposed rules. The commenters were individuals who were not against the rules in their entirety; however, the commenters suggested recommendations for changes, which are addressed in the summary of comments.
Comment: Concerning the rules in general, one commenter stated that the board needs to do a better job of communicating rule changes to its licensees.
Response: While the board appreciates that it can always do a better job of communicating information to its licensees, the board would disagree with the commenter in this instance that appropriate communication of the board's rule changes was made. First, the board placed the rule proposal on the board's website. The board believes that it is each licensee's responsibility to periodically review the website for information governing the profession of dietetics. Secondly, the board legally complied with the requirements of the Administrative Procedure Act by publishing its proposed rules in the Texas Register for a thirty-day comment period. Third, a representative of the Texas Dietetics Association attends each board meeting and was fully aware of the proposed rules being published. No change was made as a result of this comment.
Comment: Concerning §711.16(i)(1), a commenter commented that the board's jurisprudence examination should not have to be taken every two years.
Response: The board disagrees with the commenter as the board believes that its role in regulating dietitians involves ensuring Texas consumers that its licensees are well-versed in the practice of dietetics, and that by taking the jurisprudence examination every two years, the consuming public in Texas will be protected. Additionally, the commenter commented about the perceived high cost of taking the jurisprudence examination. While the board remains concerned about fees and costs for its licensees, the cost of the jurisprudence examination, which is $40, is established by the contracted examination company and the board does not find the cost to be excessive. No change was made as a result of this comment.
Comment: Concerning §711.16(f)(7), a commenter suggested that the board's continuing education requirements should mirror that of the American Dietetic Association, particularly as it relates to the allowance of "self-study" credit hours.
Response: The board was created by the Texas Legislature to regulate Texas dietitians and was given the authority to determine the number, type, and content of continuing education courses that would be required of said licensees. The board is not bound by the decisions made by the American Dietetic Association as they relate to self-study hours involving continuing education credit hours. No change was made as a result of this comment.
STATUTORY AUTHORITY
The repeals are authorized by Texas Occupations Code, §701.151(2), which requires the board to adopt a code of ethics; by Texas Occupations Code, §701.152, which authorizes the board to adopt rules consistent with the chapter; by Texas Occupations Code, §701.1535(a), which requires the board to adopt rules on consequences of criminal conviction; and by Texas Occupations Code, §701.154(a), which requires the board to set fees by rule. Review of the rules implements Government Code, §2001.039.
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 July 30, 2009.
TRD-200903225
Janet Hall
Chair
Texas State Board of Examiners of Dietitians
Effective date: August 19, 2009
Proposal publication date: February 27, 2009
For further information, please call: (512) 458-7111 x6972
The new rules are authorized by Texas Occupations Code, §701.151(2), which requires the board to adopt a code of ethics; by Texas Occupations Code, §701.152, which authorizes the board to adopt rules consistent with the chapter; by Texas Occupations Code, §701.1535(a), which requires the board to adopt rules on consequences of criminal conviction; and by Texas Occupations Code, §701.154(a), which requires the board to set fees by rule. Review of the rules implements Government Code, §2001.039.
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 July 30, 2009.
TRD-200903226
Janet Hall
Chair
Texas State Board of Examiners of Dietitians
Effective date: August 19, 2009
Proposal publication date: February 27, 2009
For further information, please call: (512) 458-7111 x6972