PART 11. TEXAS BOARD OF NURSING

CHAPTER 221. ADVANCED PRACTICE NURSES

22 TAC §221.1, §221.3

INTRODUCTION. The Texas Board of Nursing (Board) proposes amendments to §221.1 (relating to Definitions) and §221.3 (relating to Education). The amendments are proposed under the Occupations Code §301.152(a) and (b) and §301.151 and are necessary to clarify existing language within the sections and to enhance consistency among Board rules related to advanced nursing practice. Specifically, the proposed amendments: (i) clarify that an applicant for advanced practice licensure must complete a qualifying program of study at the master's degree level or higher; (ii) replace references to the term "specialty" with references to the term "population focus area"; (iii) replace references to the term "advanced practice nurse" with references to the term "advanced practice registered nurse"; and (iv) replace references to the term "authorization" with references to the term "licensure".

The Advanced Practice Nursing Advisory Committee

The Advanced Practice Nursing Advisory Committee (Committee) met on February 17, 2010, to review and discuss the educational requirements of Chapter 221 (related to Advanced Practice Nurses). Members of the Committee expressed concern that the rule did not provide clear enough guidance regarding the completion of an advanced practice nursing program beyond a master's degree level. Members pointed out that the rule did not specifically address doctoral programs in nursing. Members felt that this omission could cause ambiguity or confusion regarding the manner in which the educational requirements of the rule could be satisfied. As a result, members recommended that the Board amend §221.1 and §221.3 to clarify that an applicant for advanced practice licensure could complete a doctoral program in nursing in order to satisfy the existing educational requirements of the rule.

The Committee also recommended replacing references to the term "specialty" in §221.1 and §221.3 with references to the term "population focus area" and replacing references to the term "advanced practice nurse" in §221.1 with references to the term "advanced practice registered nurse". These changes were recommended for consistency with the Advanced Practice Registered Nurse Model Act/Rules and Regulations and amendments previously made to Chapter 222 of this title (relating to Advanced Practice Registered Nurses with Prescriptive Authority). Finally, the Committee recommended replacing the term "authorization" in §221.3 with the term "licensure" for consistency with amendments previously made to §221.4 (relating to Advanced Practice Registered Nurse Licensure Requirements) and §221.6 of this chapter (relating to Interim Approval).

The Educational Requirements of §221.1 and §221.3

The Committee's recommended clarifications to §221.1 and §221.3 are consistent with the Board's historic interpretation and application of the educational requirements for advanced practice licensure. The Board has required an applicant for advanced practice licensure to complete an advanced practice program of study at the master's degree level since January 1, 2003. This has been the Board's minimum educational standard for advanced practice licensure since that time. Because the completion of an advanced practice program of study at a level higher than a master's degree level, such as at a doctorate level, necessarily meets and, even exceeds, the minimum educational requirements of §221.1 and §221.3, the Board has consistently permitted the completion of such programs to satisfy the educational requirements of Chapter 221 since 2003.

Although the Board itself has not received any questions from the public regarding the educational requirements of §221.1 and §221.3, the Board has determined that it is appropriate to propose amendments to these sections based upon the comments of the Committee, in order to clarify Board intent and meaning. The Board originally established the Committee to consider regulations that have an impact on advanced practice nursing and to provide comments and recommendations to the Board. As such, the Board considers the Committee's concerns and recommendations essential in monitoring the effectiveness of the Board's rules. The Board agrees with the Committee that the existing educational requirements in §221.1 and §221.3 could be clarified to address the completion of a post-master's certificate or doctoral degree program. As such, the Board is proposing amendments to §221.1(2) and §221.3(c)(4) and (d)(1) to clarify that the completion of a program of study at the master's degree or higher level (such as a post-master's certificate or doctoral degree program) may satisfy the educational requirements for advanced practice licensure. The Board has determined that clarifying the existing language of §221.1 and §221.3 will not alter the Board's historical interpretation or application of the educational requirements of these sections. Further, the proposed changes are designed to remove any ambiguity or confusion surrounding the application of the educational requirements of §221.1 and §221.3 and are not anticipated to result in a change in Board application or interpretation of these requirements in the future.

The Advanced Practice Registered Nurse Model Act/Rules and Regulations

The Advanced Practice Registered Nurse Model Act/Rules and Regulations (Regulations) were promulgated by the National Council of State Boards of Nursing (NCSBN) during its August, 2008, Delegate Assembly. NCSBN is comprised of 60 member boards and operates as the collective voice of nursing regulation in the United States and its territories. Collectively, NCSBN develops nursing examinations, monitors trends in nursing practice and education, promotes uniformity in the regulation of nursing, conducts research on nursing practice issues, provides opportunities for collaboration among its members and other nursing and health care organizations, and promulgates model rules and regulations. Because the Regulations were designed to promote a common understanding of the appropriate scope of practice for an APRN, the Board determined that it was important to amend its own rules to include a reference to the term "advanced practice registered nurse". As such, the Board amended Chapter 222 in the February 5, 2010, issue of the Texas Register (35 TexReg 866) to define the term "advanced practice registered nurse" and include its use throughout the chapter. The adopted definition of the term "advanced practice registered nurse" in Chapter 222 was designed to incorporate all of the substantive components of the term as set forth in the Regulations. The Regulations also included a definition of the term "population focus area". The Board amended Chapter 222 in the February 5, 2010, issue of the Texas Register (35 TexReg 866) to define the term "population focus area" and include its use throughout the chapter. The adopted definition of the term "population focus area" in Chapter 222 clarified the meaning of the term and was consistent with the definition of the term as set forth in the Regulations.

Chapters 221 and 222 contain the Board's advanced practice nursing requirements. The Board has determined that the terms used throughout these two chapters should be as consistent as possible, as such consistency promotes a better understanding of the Board's rules. The Board agrees with the Committee's recommendations that §221.1 and §221.3 should include the same terminology as Chapter 222, especially where the two chapters address similar issues. As a result, the Board is proposing amendments to §221.1(2) to: (i) replace references to the term "speciality" with references to the term "population focus area"; and (ii) to replace references to the term "advanced practice nurse" with references to the term "advanced practice registered nurse". Further, the Board is proposing amendments to §221.3(c) to replace references to the term "specialty" with references to the term "population focus area". These terms appear throughout Chapter 222. The proposed amendments are designed to provide necessary consistency between the two chapters.

Remaining Amendments

Finally, the Board is proposing amendments to §221.3(c) and (d) for consistency with changes previously made to §221.4 and §221.6 of this chapter in the November 14, 2008, issue of the Texas Register (33 TexReg 9237). At its October 2007 meeting, the Board charged the Committee with reviewing issues related to advanced practice nursing in preparation for implementation of the Advanced Practice Registered Nurse Compact (Compact), which is authorized under the Occupations Code Chapter 305. Specifically, the Board directed the Committee to examine and determine whether the Board's approval process for advanced practice registered nurses should be referred to as a "licensure" process. At the time of the Board's charge, the Board did not refer to its approval process for advanced practice registered nurses as a "licensure" process. Instead, the Board granted individuals "authorization" to practice as advanced practice registered nurses. Based upon the Committee's recommendations, the Board ultimately determined that it would begin to refer to its approval process for advanced practice registered nurses as a "licensure" process. This decision was consistent with at least 50% of other member boards of NCSBN who already referred to their approval processes for nurse anesthetists, nurse midwives, and nurse practitioners (advanced practice registered nurses) as a licensure process. Nearly 40% of these boards also issued licenses to clinical nurse specialists (advanced practice registered nurses). Further, the Board's determination did not alter any substantive aspect of the Board's existing approval process at that time. The amendments to §221.4 and §221.6 that were adopted by the Board in November, 2008, included a change in terminology from "authorization" to "licensure" to reflect the Board's decision. In an effort to further ensure consistency between Chapters 221 and 222, the Board is now proposing amendments to §221.3(c) and (d) to replace references to the term "authorization" with references to the term "licensure".

Section-by-Section Overview.

Proposed amended §221.1(2) defines an advanced educational program as a post-basic advanced practice nurse program at the certificate, master's degree, or higher level. Further, proposed amended §221.1(2) states that, beginning January 1, 2003, a minimum of a master's degree in the advanced practice role and population focus area will be required for recognition as an Advanced Practice Registered Nurse.

Proposed amended §221.1(5) updates the definition of the Texas Board of Nursing.

Proposed amended §221.3(c) states that applicants for licensure to practice in an advanced practice role and population focus area recognized by the Board must submit verification of completion of all requirements of an advanced educational program that meets the following criteria:

(A) Advanced educational programs in the State of Texas shall be approved by the Board or accredited by a national accrediting body recognized by the Board.

(B) Programs in states other than Texas shall be accredited by a national accrediting body recognized by the Board or by the appropriate licensing body in that state. A state licensing body's accreditation process must meet or exceed the requirements of accrediting bodies specified in Board policy.

(C) Programs of study shall be at least one academic year in length and shall include a formal preceptorship.

(D) Beginning January 1, 2003, the program of study shall be at the master's degree or higher level.

(E) Applicants prepared in more than one advanced practice role and/or specialty shall demonstrate that all curricular requirements set forth in §221.3(c) have been met for each role and/or specialty.

Proposed amended §221.3(d) states that applicants for licensure as clinical nurse specialists must submit verification of the following requirements in addition to those specified in §221.3(c): completion of a master's degree or higher level in the discipline of nursing and completion of a minimum of nine semester credit hours or the equivalent in a specific clinical major. Further, clinical major courses must include didactic content and offer clinical experiences in a specific clinical specialty/practice area.

FISCAL NOTE. Katherine Thomas, Executive Director, has determined that for each year of the first five years the proposed amendments will be in effect, there will be no fiscal impact to state or local governments as a result of the enforcement or administration of the proposal. There will be no anticipated effect on local employment or the local economy as a result of the proposal.

PUBLIC BENEFIT/COST NOTE. Ms. Thomas has also determined that for each year of the first five years the proposed amendments will be in effect, the anticipated public benefit will be the adoption of clear and consistent requirements, which should result in more efficient regulation. There are no anticipated economic costs to persons who are required to comply with the proposal. None of the proposed amendments substantively alter the existing requirements of §221.1 or §221.3 or impose new or additional requirements or restrictions upon individuals required to comply with the proposal. Rather, the proposed amendments clarify the existing educational requirements for advanced nursing practice. The Board does not anticipate altering its historical interpretation or application of these educational requirements nor does it anticipate that an individual's method of compliance with these requirements will be altered due to the proposed amendments. Further, the proposed amendments update terminology used throughout §221.1 and §221.3 for consistency with terminology contained in Chapter 222. However, the proposed amendments do not substantively affect the requirements of the sections nor do they impose any new or additional requirements or restrictions upon individuals required to comply with the proposal. Additionally, the Board does not anticipate that an individual's method of compliance with the requirements of §221.1 and §221.3 will be altered due to the proposed amendments.

ECONOMIC IMPACT STATEMENT AND REGULATORY FLEXIBILITY ANALYSIS FOR SMALL AND MICRO BUSINESSES. As required by the Government Code §2006.002(c) and (f), the Board has determined that the proposed amendments will not have an adverse economic effect on any small or micro business because there are no anticipated economic costs to any person who is required to comply with the proposal.

TAKINGS IMPACT ASSESSMENT. The Board has determined that no private real property interests are affected by this proposal and that this proposal does not restrict or limit an owner's right to property that would otherwise exist in the absence of government action and, therefore, does not constitute a taking or require a takings impact assessment under the Government Code §2007.043.

REQUEST FOR PUBLIC COMMENT. To be considered, written comments on the proposal or any request for a public hearing must be submitted no later than 5:00 p.m. on June 6, 2010, to James W. Johnston, General Counsel, Texas Board of Nursing, 333 Guadalupe, Suite 3-460, Austin, Texas 78701, or by e-mail to dusty.johnston@bon.state.tx.us, or faxed to (512) 305-8101. An additional copy of the comments on the proposal or any request for a public hearing must be simultaneously submitted to Jolene Zych, Advanced Practice Nursing Consultant, Texas Board of Nursing, 333 Guadalupe, Suite 3-460, Austin, Texas 78701, or by e-mail to jolene.zych@bon.state.tx.us, or faxed to (512) 305-8101. If a hearing is held, written and oral comments presented at the hearing will be considered.

STATUTORY AUTHORITY. The amendments are proposed under the Occupations Code §301.152(a) and (b) and §301.151. Section 301.152(a) defines the term "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 also synonymous with "advanced nurse practitioner." Section 301.152(b) authorizes the Board to adopt rule to establish: (i) any specialized education or training, including pharmacology, that a registered nurse must have to carry out a prescription drug order under the Occupations Code §157.052 and a system for assigning an identification number to a registered nurse who provides the Board with evidence of completing the specialized education and training requirement under §301.152(b)(1)(A); (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 under the Occupations Code Chapter 157. 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 Chapter 301; and (iv) determine whether an act constitutes the practice of professional nursing or vocational nursing.

CROSS REFERENCE TO STATUTE. The following statutes are affected by this proposal: Rule §221.1 and §221.3, Statute §301.152(a) and (b) and §301.151.

§221.1.Definitions.

The following words and terms, when used in this chapter, shall have the following meanings unless the context clearly indicates otherwise:

(1) (No change.)

(2) Advanced educational program--A post-basic advanced practice nurse program at the certificate, [or] master's degree, or higher level. Beginning January 1, 2003, a minimum of a master's degree in the advanced practice role and population focus area [specialty] will be required for recognition as an Advanced Practice Registered Nurse.

(3) - (4) (No change.)

(5) Board--The Texas Board of Nursing [Board of Nurse Examiners for the State of Texas].

(6) - (15) (No change.)

§221.3.Education.

(a) - (b) (No change.)

(c) Applicants for licensure [authorization ] to practice in an advanced practice role and population focus area [specialty] recognized by the Board must submit verification of completion of all requirements of an advanced educational program that meets the following criteria:

(1) - (3) (No change.)

(4) Beginning January 1, 2003, the program of study shall be at the master's [graduate] degree or higher level.

(5) (No change.)

(d) Applicants for licensure [authorization ] as clinical nurse specialists must submit verification of the following requirements in addition to those specified in subsection (c) of this section:

(1) completion of a master's degree or higher level in the discipline of nursing, and

(2) (No change.)

(e) - (f) (No change.)

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State on April 26, 2010.

TRD-201002027

Jena Abel

Assistant General Counsel

Texas Board of Nursing

Earliest possible date of adoption: June 6, 2010

For further information, please call: (512) 305-6822