FAQs Relating to Nursing Practice During Public Health EmergenciesSCOPES OF PRACTICE REMAIN UNCHANGEDIn a Public Health Emergency (PHE), such as a Natural Disaster or Pandemic, is there an expansion of the registered nurse (RN) or licensed vocational nurse (LVN) scope of practice? The RN and LVN scopes of practice remain unchanged during the PHE. Nurses follow the Nursing Practice Act (NPA) and Board Rules as well as any other laws, rules, or regulations affecting the nurse’s area of practice. The RN and LVN scopes of practice remain unchanged in a disaster. The Nursing Practice Act (NPA) describes a defined limit to nursing practice, as nursing practice “does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures” [NPA 301.002(2)&(5)]. The practice of nursing requires the acts/procedures being performed be within the scope of that particular nurses’ practice and that appropriate orders be in place for acts that go beyond the practice of nursing. The BON website contains guidance in the determination of what is within an individual nurse’s scope of practice. Board Staff recommend review of the following documents:
As noted in these resources, a nurse’s scope of practice is related to the nurse’s education, experience, knowledge, and physical and emotional ability. Additionally, an employer’s policies and procedures provide guidance to a nurse about their scope of practice within the practice setting. This would remain true during a PHE; however, the nurse would need to ensure that the disaster related policies and procedures to not expand the nurse’s scope of practice nor go against the standard of care for a patient during the given disaster.
Can a nurse do a medical screening exam in the ER during a PHE? In the definition of nursing, found in the Nursing Practice Act Section 301.002, medical diagnosis is excluded from the practice of nursing. If the purpose of a medical screening is to determine a medical diagnosis, this would be beyond the parameters of nursing practice. However, if the screening exam is not a means of medical diagnoses but is instead a form of triage to stabilize patients via a nursing assessment, that nursing assessment falls within the practice of nursing. It is important to remember a nurse is required to institute appropriate nursing interventions that might be required to stabilize a client’s condition and/or prevent complications [Board Rule 217.11 (1)(M)]. Additionally, a nurse is required to implement measures to prevent exposure to infectious or communicable conditions [Rule 217.11 (1)(O)]. One way to accomplish this standard is to identify incoming patients who might be infectious and provide them with a separate waiting area so as not to expose others to communicable conditions. These would both be examples of screening a patient via a nursing assessment. Keep in mind should a nurse be asked to complete a delegated medical act, in which a physician is delegating to a nurse, the nurse is expected to comply with the Standards of Nursing Practice just as if performing a nursing procedure. Position Statement 15.11, Delegated Medical Acts discusses physician delegation and the role of the nurse.
During a PHE – do I still need physician orders to provide medications to patients? The NPA describes a defined limit to nursing practice, as nursing practice “does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures” [NPA 301.002(2)&(5)]. In the course of routine operations, as well as PHEs, both LVNs and RNs must have a valid order for “the administration of a medication or treatment as ordered by a physician, podiatrist, or dentist” [NPA 301.002(2)(C)].Similarly, nurses may be utilizing delegation orders from a physician to provide aspects of care throughout normal day-to-day operations or during a disaster. Position Statement 15.5 Nurse with Responsibility for Initiating Physician Standing Orders outlines the differences between:
Board staff suggest review of this position statement as a resource for understanding the important elements of standing orders. Carrying out some physician’s orders may constitute the practice of nursing, but others may be considered delegated medical acts. Position Statement 15.11 Delegated Medical Acts is also a valuable resource for nurses. Delegated medical acts do not diminish the responsibility in any way of the nurse to adhere to the Board's Standards of Nursing Practice, Board Rule 217.11.
NURSING WORKFORCE ISSUES DURING APUBLIC HEALTH EMERGENCY: During a disaster, can I be required to work overtime? During times of disaster, there is an unexpected increased need for health care personnel. An emergency, disaster, or unforeseen event constitutes an exception to the prohibition of mandatory overtime and is detailed in the Health and Safety Code-Licensing of Health Facilities: Chapter 258 Mandatory Overtime for Nurses Prohibited. Board rule 217.11(1)(A) requires nurses to know and conform to the Texas Nursing Practice Act and the Board’s rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse’s current area of nursing practice. Is it patient abandonment if I call in sick during a PHE? A nurse may have to choose between the duty to provide safe patient care and protecting the nurse's own life during an emergency, including but not limited to natural disasters or other PHEs. These situations are challenging for all nurses and their employers, therefore the Board recommends policies and procedures be developed, and periodically reviewed to provide clear guidance and direction to nurses in order for patients to receive safe and effective care. All nurses, regardless of practice setting or position title/role, are required to adhere to the NPA and Board Rules. There is no routine answer to the question, "When does the nurse's duty to a patient begin?" The nurse's duty is not defined by any single event such as clocking in or taking report. From a BON standpoint, the focus, related to disciplinary sanctions, is on the relationship and responsibility of the nurse to the patient, not to the employer or employment setting. Position Statement 15.6 Board Rules Associated with Alleged Patient ”Abandonment” provides additional guidance on this topic. The Board believes nurses should be vigilant and exercise sound professional judgment when accepting assignments that may be requested by employers who need nurses to fill vacant shifts for licensed nursing staff, or other staffing-related situations. Clear communication between staff and supervisors is essential to arrive at solutions that best focus on patient care needs without compromising either patient safety or a nurse’s license. What do I do if my employer requires me to stay for a double shift during a disaster and I am already physically exhausted? I am concerned I cannot give proper care and attention to my patients due to fatigue. A nurse must consider Board Rule 217.11, Standards of Nursing Practice Sections (1)(B) & (1)(T), that state a nurse must accept only those assignments that take into consideration client safety and that are commensurate with the nurse’s educational preparation, experience, knowledge and physical and emotional ability. If a nurse feels they are being asked to accept an assignment that would potentially cause the nurse to violate their duty to a patient, the nurse may be able to invoke “safe harbor,” depending on whether or not the nurse’s employer meets requirements that would make it mandatory for the employer to have a nursing peer review plan in place. This is established in the NPA, Chapter 303, Peer Review, and in Board Rule 217.20, Safe Harbor Nursing Peer Review and Whistleblower Protections. Safe Harbor has two effects related to the nurse’s license:
A nurse may orally invoke safe harbor due to immediate patient care needs by notifying the nurse's supervisor of the request. The supervisor must then document all the requirements specified in Board Rule 217.20(d)(3) the Safe Harbor Quick Request. A detailed written account of the safe harbor request that meets the requirements of the Comprehensive Written Request for Safe Harbor Nursing Peer Review must be completed before leaving the work setting at the end of the work period [Board Rule 217.20(d)(4)]. We cannot get enough staff and I feel my patient load is unsafe. If I invoke Safe Harbor, can I just refuse the assignment? Patients are better off with the nurse than without the nurse in the vast majority of cases, and this is especially true in disasters. However, Board Rule 217.20(g) clarifies that a nurse may accept the assignment when safe harbor has been invoked and is pending peer review determination unless the requested assignment or conduct is one that:
During aPHE, staffing is typically a challenge. This can cause staffing ratios to be well beyond that number of patients that a nurse would normally provide care to under routine circumstances. This could potentially cause the nurse to feel as though their duty to their patients and the Board rules could be violated. Therefore, when a nurse believes the nurse staffing levels are unsafe and there is no other patient safety issue, this would be an instance in which a nurse would accept the assignment and engage in the conduct pending nursing peer review’s determination. If the only patient safety issue is the nurse to patient ratio, then the assignment in question is not a criminal act, one that constitutes unprofessional conduct, nor is it one that is beyond a nurse’s knowledge, skills, or ability to meet the minimum standards of nursing practice. For more information on these and other topics, use the search field at the top right corner of the page. Should you have further questions or are in need of clarification, please feel free to contact the Board.
Reviewed 2023
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