Frequently Asked Questions - Nursing Practice

Workplace and Employment — General Information

What is the BON Proposed Nursing Work Hours Position Statement?

At the October 2006 Texas Board of Nursing (Board or BON) meeting, the Board charged the Nursing Practice Advisory Committee (NPAC) to develop a position statement on nursing work hours and the impact of fatigue on patient safety.  

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Mandatory Overtime

Can an employer require a nurse to work longer than scheduled, or to work overtime?

The duty of every nurse is to provide safe patient care, and this duty supersedes any employment related requirements. Once a nurse assumes duty of a patient, the nurse has a regulatory responsibility to provide safe patient care in accordance with all applicable laws, rules and regulations.  

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Consecutive Shifts/Work Hours

How many consecutive hours or shifts can a nurse work?

The Texas Board of Nursing (Board or BON) licenses and regulates nurses in the State; the Board does not have purview over facility operations or most facility policies or procedures. As such, the Board does not have any jurisdiction over employment related matters including: work hours, scheduling, staffing, or extended work hours. The Board does, however, have applicable laws and rules that pertain to this topic as it relates to a nurse’s duty to patients. Board Rule 217.11 Standards of Nursing Practice, outlines the minimum standards for safe nursing practice at all levels of licensure, including the requirement that all nurses must implement measures to promote a safe environment for clients and others [§217.11(1)(B)] and accept only those nursing assignments that take into consideration client safety and that are commensurate with the nurse’s educational preparation, experience, knowledge, and physical and emotional ability [§217.11(1)(T)].  

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Staffing Ratios

Is there a law regarding how many patients (nurse: patient ratio) a nurse can be assigned to care for in Texas?

The Texas Board of Nursing (Board or BON) has no authority over staffing ratios, a workplace/employment matter; however, the Board does have applicable regulations that relate to a nurse’s duty to patients. The Texas  (NPA) and  are written broadly so they can be applied by all nurses (LVNs, RNs, & APRNs) in any practice setting. Board Rule 217.11, Standards of Nursing Practice, provides the minimum standards nurses must meet in accepting any assignment, including situations involving inadequate staffing, specifically:  

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Floating to Unfamiliar Practice Settings

Nurses in my facility are often required to float from their home unit to other care units where they do not have clinical competence and/or clinical experience. What is the duty of the nurse when it comes to floating to different clinical units (i.e., adult, pediatric, ER, etc.)? Can a nurse invoke safe harbor? If so, how do nurses invoke safe harbor?

The Nursing Practice Act (NPA) and Board Rules are written broadly to apply to nursing practice in any setting.  Although the Board of Nursing (Board or BON) has no authority over workplace matters, such as floating or staffing ratios, nurse staffing was addressed in SB 476 during the 81st Texas Legislative Session in 2009.  As a result of the bill, new chapters (Chapters 257 and 258) were added to the Texas Health and Safety Code concerning “Nurse Staffing” and “Mandatory Overtime for Nurses Prohibited” respectively.

The changes created by SB 476 are applicable to you if you work in a hospital and, among other things, require hospitals to have a nurse staffing committee, policy, and plan to ensure that an adequate number and skill mix of nurses are available to meet the level of patient care needed.  Further, the staffing plan must include a method for adjusting the staffing plan for each patient care unit to provide staffing flexibility to meet patient needs and a contingency plan when patient care needs unexpectedly exceed direct patient care staff resources. Floating ...  

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When Does a Nurse's Duty to a Patient Begin and End?

Employment versus Licensure

There is no routine answer to the question, “When does the nurse’s duty to a patient begin?” A nurse's duty is not defined by any single event such as clocking in, or taking report. From a Board of Nursing standpoint, the focus is on the relationship and responsibility of the nurse to the patient(s), not to the nurse's employer or employment.  

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A Nurse's Duty Not Limited to Assignment:

All nurses, regardless of practice setting, position, title or role, are required to adhere to the NPA and other statutes, as well as the Board Rules. Two of the main rules that relate to nursing practice are Texas Administrative Code, Rule §217.11 Standards of Nursing Practice, and Texas Administrative Code, Rule §217.12 Unprofessional Conduct.  

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Decision Making for Determining Nursing Scope of Practice

Where can I find a list of tasks that LVNs and/or RNs can or cannot do in the State of Texas?

The Texas Nursing Practice Act (NPA) and Texas Board of Nursing (Board or BON) Rules are written broadly so they can apply to nursing practice in any setting. As such, the BON does not provide an all-purpose list of tasks that every nurse can perform, nor does the Board provide step-by-step procedures regarding how certain tasks are to be carried out by a nurse.  

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Nurses Have a Duty to Report Confidential Health Information

Do nurses have a duty to report confidential health information to administrators, law enforcement of to a patient's family?

Nurses have a duty to report patient information, including mental health information, to members of law enforcement, a patient's family, and others when a patient is a serious danger to themselves or others.  

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Nurse Admitted As Patient Under the Influence

I currently work in an ICU. I had an opportunity to care for a patient/nurse (who was a nurse at another facility) who overdosed. She was transferred, when stable, to a treatment center by court order. I was told we cannot report her to the board due to HIPAA. My question is, "How do we plan to handle this type of incident in the future?" "Will there be any specific changes made to address problems like this in the future?" I understand with the renewal of our license we must answer the question of treatment for use of "alcohol or any other drug." But if there is no report of her being in the hospital for treatment, due to HIPAA, it's possible that she may not answer the question truthfully. Can you please help with these questions. I appreciate your time.

Whether a nurse is admitted for an overdose of a substance, or admitted secondary to some type of accident related to being under the influence of any mind-altering substance, the answer would remain the same.  

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CPR - A Nurse's Duty to Initiate

Is current CPR certification a licensure requirement for nurses?

No. The Texas Board of Nursing (Board or BON) does not require cardiopulmonary resuscitation (CPR) certification for licensure renewal; however, employers may have specific requirements regarding current CPR certification as a condition of employment. 

Nurses are encouraged to use their professional judgment when deciding whether to maintain current CPR certification. This decision should take into consideration whether they are employed in patient care settings in which CPR may be necessary to resuscitate and stabilize a patient’s condition [Board Rule 217.11(1)(M)]. Texas nurses have a responsibility to maintain continued competency in nursing practice. This is achieved through educational opportunities that promote individual professional growth [Board Rule 217.11(1)(G), (1)(H), & (1)(R)]. 

In general, the Texas Nursing Practice Act and Board rules and regulations establish a nurse’s duty to initiate CPR by requiring a nurse to provide safe and effective care for clients [Board Rule 217.11(1)(B)]. These rules and regulations apply to every nurse, regardless of expertise, specialty, or practice setting, BON licensure laws and rules do not specifically require a nurse to have a current CPR card in order to perform CPR or utilize other life-saving interventions for a client. Instead, the minimum standards of nursing practice addressed in Board Rule 217.11 (1)(B)&(M) require a nurse to “implement measures to promote a safe environment for clients and others” as well as “institute appropriate nursing interventions that might be required to stabilize a client’s condition and/or prevent complications.”

What is the role of the licensed vocational nurse (LVN), registered nurse (RN), and advanced practice registered nurse (APRN) in initiating CPR in a witnessed arrest? 

Texas Health and Safety Code Chapter 671 requires the facility, institution, or entity to have a written policy that is jointly developed and approved by the medical staff or medical consultant and the nursing staff. This policy must specify the circumstances under which an RN can make a pronouncement of death.

An RN and/or an APRN can pronounce death when a patient is not receiving artificial means of life support and has a properly documented do-not-resuscitate/out of hospital do-not-resuscitate physician’s order, provided that the employer has policies and procedures in place to acknowledge the RN and/or APRN’s authority to pronounce death.  However, an RN may not complete the medical certification of a death certificate under any circumstances. On the other hand, an APRN may complete the medical certification for a death certificate, if permitted by the laws and rules applicable to the practice setting or the circumstances of the death, provided that the death occurred while under their care and was related to   the treatment of the condition or disease process that contributed to the death. Please see Texas Administrative Code Chapter 193 for additional information.

Once you receive confirmation from the BON that you have passed your NCLEX-PN (or NCLEX-RN) licensure exam, you will be entitled to hold yourself out as a Licensed Vocational Nurse (LVN) or Licensed Registered Nurse (RN) as applicable, with all of the privileges and responsibilities that go along with each license.  The Board strongly discourages newly licensed nurses from accepting employment in any independent living environment setting until the new nurse achieves twelve (12) to eighteen (18) months of nursing experience in an acute health care setting (such as a hospital).

The Board believes that the newly licensed nurse (LVN or RN) needs adequate time to apply newly learned nursing knowledge and clinical skills, as well as time to develop clinical judgment and decision-making skills.  In addition, the Board believes that this process occurs most effectively in a structured health care environment where resources and supervision are immediately available to the new nurse. Once licensed, you are required to “know and comply with” the  (NPA) and Board Rules, as the content of each has the force of law with regard to nursing practice in Texas. The NPA and rules may be viewed in their entirety using the hyperlinks above.  

Board Rule 217.11 Standards of Nursing Practice is the heart of nursing practice and applies to all nurses. Specifically, Board Rule 217.11(1)(B) requires nurses to always maintain client safety and Board Rule217.11(1)(T) requires nurses to accept only those assignments that are commensurate with the nurse’s education, licensure, experience, and abilities.  If a newly-licensed nurse decides to work in home health, and is subsequently reported to the Board for possible violations of the Board Rules, the nurse would likely be asked to explain their rationale for accepting employment in a home health setting, particularly when the Board clearly cautions new nurses against working in this environment.

Revised 2023

The practice of nursing involves the nurse’s use of specialized knowledge, skills, and abilities acquired from nursing education to perform a task, an activity, or to complete an assignment or job, regardless of whether or not compensation is received. Whether a nurse is in a paid or volunteer role, the nurse must know and comply with the Nursing Practice Act, Board Rules and Regulations, and any laws, rules, or regulations applicable to the nurse's area of practice [Board Rule 217.11(1)(A)]. A nurse is responsible to maintain professional boundaries and confidentiality in relation to the nursing care being provided [Board Rule 217.11(1)(J)&(E)].

Nurses use their specialized nursing knowledge, skills and abilities for example, when a nurse is in the role of a nurse researcher performing health related research in support of improved practice and patient outcomes. Other examples of non-traditional nursing roles include health education, utilization review, health information technology, policy and rule writing, consulting, and writing for nursing publications such as journal articles, books or continuing nursing education programs. 

If a nurse uses their knowledge, skills and abilities acquired from a nursing program, then the nurse is said to be practicing nursing and should be licensed as a nurse, regardless of whether or not the employment position uses the title of nurse or requires a nursing license. The Board does not have regulatory purview over employment practices and most policies and procedures.

There is not a requirement for a specific number of hours of nursing practice within a licensure cycle for the LVN or the RN to maintain active licensure status. Area of practice is defined as "any activity, assignment, or task in which the nurse utilized nursing knowledge, judgment, or skills during the licensing period" and may provide additional guidance in answering this licensure application question.

Please be aware that advanced practice registered nurse is required to have a minimum of 400 hours of current practice within the preceding two years of practice that must meet the requirements of the Board’s rules in Chapter 221, related to Advanced Practice Registered Nurses.  Current practice for APRNs is defined in Board Rule 221.1(7). There is nothing that requires direct patient care hours, only that the APRN fulfills 400 hours in their APRN role and population focus area of licensure.

References:

• Nursing Practice Act, Section 301.002 (2) & (5). Nursing Practice Act
• Texas Board of Nursing Rule 217.11 (1) (A) & (1) (E) & (1) (J). Standards of Nursing Practice
• Texas Board of Nursing Rule 216.1 (4). Continuing Competency
• Texas Board of Nursing Rule 221.8. Advanced Practice Nurses
• Texas Board of Nursing Rule 221.1 Definitions

Reviewed 2023

1. It is recommended that a newly licensed nurse not practice in independent settings, such as group homes, assisted living facilities, hospice and home or school health, where access to a clinical supervisor is limited, for a period of 12-18 months post-licensure. This allows the newly licensed nurse sufficient practice experience in more structured settings and the opportunity to assimilate knowledge learned in school consistently into practice.
2. The Board believes it is essential for newly licensed nurses to seek and receive direction, supervision, consultation and collaboration from experienced nurses during the transition into nursing practice. In any practice setting where newly licensed LVNs and RNs are employed, experienced nurses should be willing to supervise and mentor novice nurses.
   1. Direct supervision should be continued for a period of six (6) months or, if agreed upon by the newly licensed nurse and the supervising nurse, a lesser period of time when appropriate. Competence to practice without direct supervision should be mutually determined by the newly licensed nurse and the supervising nurse.  This competency should be both demonstrated and supported by documentation. 
   2. Once the above-mentioned period of direct supervision has been completed, the newly licensed LVN must be sure to have the appropriate continued supervision as required by their level of licensure. Keep in mind that, regardless of the number of years of experience, the LVN has a directed scope of practice and must have a registered nurse, advanced practice registered nurse, physician, physician’s assistant, dentist or podiatrist as a supervisor of their clinical nursing practice [NPA Sections 301.002(5) and 301.353; Board Rule 217.11(2)].

3. It is recommended that a newly licensed nurse not hold a position as a charge nurse or nurse manager for a period of six (6) months, unless a lesser time period is mutually agreed upon by the newly licensed nurse and the supervising nurse based upon the evaluation of competency of the newly licensed LVN or RN. The intent is to ensure that the newly licensed nurse has an opportunity to assimilate into their new role and environment prior to taking on the additional responsibility of supervising others (such as taking on the role of a director or assistant director of nursing). Allowing a newly licensed nurse time to become competent in their practice is vital before taking on additional responsibilities.
4. Newly licensed nurses are permitted to perform any function that falls within the scope of nursing practice for which they are licensed.  The newly licensed nurse should take into consideration the patient’s safety, as well as their own educational preparation, experience, knowledge, and physical and emotional ability before accepting an assignment [Board Rule 217.11(1)(T)]. Additionally, newly licensed nurses should obtain instruction, supervision, orientation and training to demonstrate competency when implementing nursing procedures or practices, when encountering new equipment and technology or unfamiliar care situations, or taking on new roles. [Board Rule 217.11(1)(G), (1)(H), &(1)(R)].

Additional BON resources for newly licensed nurses:

• Rules and Guidelines Governing the Graduate Vocational and Registered Nurse Candidates or Newly Licensed Vocational or Registered Nurse
• Position Statement 15.27, The Licensed Vocational Nurse Scope of Practice
• Position Statement 15.28, The Registered Nurse Scope of Practice

The National Council of State Boards of Nursing (NCSBN) also has a resource for newly licensed nurses which can be found at https://www.ncsbn.org/transition-to-practice.htm.

Revised 2023

LVNs provide valuable and essential nursing care in different types of health care settings. When LVNs work in settings, such as hospitals, long-term care facilities, rehabilitation centers, or skilled nursing facilities, RNs are likely to serve as the LVN's supervisor. LVNs also work in private physician or dentist offices, where physicians, dentists, or podiatrists function as the LVN's supervisor. It is important to make the distinction between clinical and non-clinical supervisory functions. Because LVNs may practice in these various healthcare settings, the term “clinical supervisor” is used to describe the different licensed healthcare providers that are authorized in the NPA to supervise and direct the LVN's practice, e.g., registered nurse, advanced practice registered nurse, physician, physician assistant, podiatrist, or dentist. These types of clinical supervisors oversee the nursing practice of an LVN by monitoring the health status of patients and then directing the LVN's actions to ensure the delivery of safe and effective nursing care. A non-clinical supervisor can carry out supervisory functions of non-nursing issues, e.g., attendance, time cards, or approving vacation time; but, when it comes to supervising a LVN’s nursing practice, neither an LVN, unlicensed supervisor, nor a non-clinical person can carry out those functions.

Because the Texas Board of Nursing (BON) does not define initial assessment, it does not determine whether an LVN may complete an initial assessment. All nurses are required to know and conform to not only the Nursing Practice Act and Board rules, but all federal, state and local laws affecting the nurses’ area of practice [Board Rule 217.11(1)(A)]. As such, Board staff recommends contacting the agency that regulates the specific type of practice setting the nurse works in to determine if other laws and regulations apply to the completion of an initial assessment. For example, acute care facilities such as hospitals, are licensed by the Texas Health and Human Services Facility Licensing Group. Nursing homes, long term care facilities, and home health are also regulated by Texas Health and Human Services Commission. If regulations from these other entities require that an RN perform the initial patient/client assessment, then the LVN cannot perform the initial assessment for the RN.

RNs conduct comprehensive health assessments. As defined by the BON, a comprehensive assessment is "an extensive data collection (initial and on-going) for individuals, families, groups and communities addressing anticipated changes in client conditions as well as emergent changes in a client's health status; recognizing alterations to previous conditions; synthesizing the biological, psychological, spiritual and social aspects of the client's condition; and using this broad and complete analysis to make independent decisions and nursing diagnoses; plan nursing interventions, evaluate need for different interventions, and the need to communicate and consult with other health team members (Board Rule 217.11(3)(A)(i) and Position Statement 15.28 The RN Scope of Practice.)

Licensed vocational nurses may only conduct focused health assessments. A focused assessment is an appraisal of an individual client's status and situation at hand [what is occurring at that moment], contributing to the comprehensive assessment by the RN, supporting on-going data collection, and deciding who needs to be informed of the information and when to inform (Board Rule 217.11(2)(A)(i) and the Position Statement 15.27 LVN Scope of Practice.)

In situations requiring comprehensive assessments by an RN, the LVN cannot begin by performing a focused assessment and have the RN follow up with an assessment of only those parameters not assessed by the LVN. A comprehensive assessment is a different level of assessment requiring that the RN use his/her own independent nursing judgment. Board Rule 217.11(1)(T) clarifies that a nurse is responsible for accepting assignments based on the nurse’s individual educational preparation, experience, knowledge, skills and abilities. Likewise, when a nurse makes assignments to another person(s), the nurse must consider the educational preparation, experience, knowledge, and skills of the person(s) receiving the assignment [Board Rule 217.11(1)(S)].

Revised  2021

The difference between LVN and RN scope of practice is based on differences in educational preparation of nurses licensed at each level as defined in the Differentiated Essential Competencies of Graduates of Texas Nursing Programs (DECs). The DECs may be viewed in its entirety or downloaded from “Education”, then “Documents” on the BON website at https://www.bon.texas.gov/education_documents.

Board staff recommends review of Board Rule 217.11, Standards of Nursing Practice, as well as Position Statement 15.27, The Licensed Vocational Nurse Scope of Practice.

Revised 2021

Though the BON does not regulate employers, and the NPA and Board rules are not prescriptive to specific practice settings, the Board believes triage, telephonic nursing, and/or being on-call to handle urgent/emergent issues are all beyond the scope of practice for LVNs. Of concern to the Board are situations where the LVN would be required to independently engage in assessment (either telephonically or face-to-face) for purposes of triaging a patient.

The Board's concerns are based on the fact that LVNs are not educationally prepared to perform triage assessments, either telephonically or in the role of the health care professional initially assessing a patient face-to-face to determine treatment priorities in any setting.  The  (DECs) provide a set of outcomes expected of nursing education programs to ensure that newly licensed nurses enter practice with a knowledge base and a set of skills, including decision-making abilities, for safe practice. This document states in part that LVN nursing programs in Texas prepare entry-level LVN graduates to care for “patients with predictable health care needs within structured health care settings through a supervised, directed scope of practice.” In either telephone or face-to-face triage, the LVN is likely to be dealing with a situation where the patient's condition is not predictable. Further, LVNs are educated in focused assessment skills using the senses of sight, smell, touch, and hearing; and, triage requires comprehensive assessment skills (which are taught at the RN level of education).

In alignment with the educational preparation for vocational nursing, Board Rule 217.11, Standards of Nursing Practice, establishes that LVNs “collect data and perform focused nursing assessments, assisting in the determination of predictable health care needs of patients” [§217.11(2)(A)(i)]. NPA Section 301.353 and Board Rule 217.11(2) further establish that LVNs have a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician assistant, physician, podiatrist, or dentist.

Placing an LVN in a position to perform duties requiring comprehensive (versus "focused") assessments of patients who are potentially experiencing unpredictable changes in health status, as well as in a position to make independent nursing judgments (such as would be required for either telephone or on-site initial triage), may place the LVN in a position that violates the BON's Standards of Nursing Practice found in Board Rule 217.11.

Position Statement 15.10 (Continuing Education: Limitations for Expanding Scope of Practice) clarifies that an individual nurse’s scope of practice has licensure-related limitations.  While LVNs may expand their practice to a certain degree with post-licensure Continuing Nursing Education, this does not permit LVNs to expand their practice to the extent that additional formal education and another level of licensure is required (such as performance of comprehensive assessments). This relates to Board Rule 217.11(1)(B), which holds each nurse accountable to maintain patient safety. This standard supersedes any doctor's order or facility policy; thus, a nurse cannot avoid their "duty" to maintain patient safety by placing responsibility for nursing actions on another party. Position Statement 15.14 (Duty of a Nurse in Any Practice Setting) further clarifies a nurse's duty, regardless of the level of nursing licensure held.

It remains the opinion of the Board (consistent with the opinion of the former Board of Vocational Nurse Examiners) that on-site triage and/or telephone triage by an "on-call" LVN that requires the LVN to perform a comprehensive assessment and make independent treatment decisions on the basis of information supplied by the patient is beyond the scope of practice for an LVN. Triage is not taught in one-year vocational nurse education programs. The LVN has not received education in the complex details of comprehensive assessment as provided in a professional registered nurse education program that would include the knowledge base necessary for on-site and telephone .

The Board believes that the performance of a MSE is not within the scope of practice for an LVN, regardless of years of experience or post-licensure Continuing Nursing Education at the LVN level. The Board believes that RN educational preparation and licensure constitutes the minimum acceptable level of competence necessary to serve as the qualified medical personnel to conduct a MSE. Even still, the RN must undergo training and be properly authorized within the setting to conduct the MSE, according to EMTALA provisions and requirements [§217.11(1)(A)]. As defined in Board Rule 217.11(2)(A), the scope of practice for an LVN is limited to data collection and the performance of focused assessments of individual patients. Even if a physician wishes to delegate the assessment of medical conditions and/or treatments to an LVN, the LVN is accountable to only accept those assignments within his or her scope of practice as outlined in the NPA and in Board Rule 217.11, Standards of Nursing Practice. Position Statement 15.11 (Delegated Medical Acts) contains additional information on physician delegation to nurses.

While the NPA and Board Rules prevent an LVN from practicing nursing in a completely independent manner (that is, without appropriate direction and supervision by an RN, APRN, physician, PA, podiatrist, or dentist), the required proximity of the licensed supervisor to the LVN and/or the LVN’s practice setting is not specified. The proximity to the LVN’s practice setting and the type of licensure of the LVN’s supervisor should be determined on a case-by-case basis with input from the LVN and his/her licensed supervisor. However, an appropriately licensed supervisor must be accessible to the LVN at least telephonically or by similar means at all times.

There are many factors to consider when determining the appropriate proximity of the licensed supervisor, including, but not limited to:

• the type of practice setting;
• the stability of the patient’s condition;
• the complexity of tasks being performed by the LVN;
• the LVN’s experience and knowledge; and
• any laws and/or regulations that apply to the specific practice setting or situation at hand.

To illustrate, compare an LVN who performs routine nursing tasks with an LVN who performs a delegated medical act (such as, Botox® administration). These are very different situations, and a determination of who (RN or physician, for example) is appropriate to supervise the LVN as well as the necessary proximity of the licensed supervisor will vary in these situations. Other regulations outside of the Board’s purview, for example, those related to reimbursement, may also be a factor in the latter situation [Board Rule 217.11 (1)(A)].

As a reminder, whether a task is a nursing act or a delegated medical act, each nurse (LVN or RN) is individually responsible for providing a safe environment and is accountable for the tasks he/she chooses to perform [Board Rule 217.11 (1)(B) & (1)(T)]. Position Statement 15.14, Duty of a Nurse in Any Practice Setting, further illustrates a nurse’s duty to his/her patients.

Revised 2021

There is a Frequently Asked Question on the BON website that helps individuals determine what the Practice of Nursing entails.  When it comes to evaluating and supervising the practice of nursing, neither an LVN, unlicensed supervisor, nor a non-clinical person can carry out those functions, as this would be the practice of professional nursing and require RN licensure.

A non-RN supervisor can carry out supervisory functions of non-nursing issues, e.g., attendance, timecards, or approving vacation time. In general, for non-clinical issues or questions related to general employment matters, those may be directed to the non-clinical supervisor in their work environment, unless there is another law, rule, or regulation that applies to the setting that prevents those issues from being addressed by the non-clinical supervisor [Board Rule 217.11(1)(A)].

A medical screening exam is necessary to determine whether or not an emergency medical condition, not nursing condition, exists. EMTALA requires assessment of a patient for the existence of an emergency medical condition before the patient can be transferred or released from the emergency department. An emergency medical condition is defined under federal law, 42CFR §489.24 and may be readily viewed in its entirety at the U.S. Government Publishing Office Electronic Code of Federal Regulations. An understanding of what EMTALA is and what is meant by performance of a medical screening exam is essential to nurses practicing in facilities affected by this federal regulation.

An RN may be able to perform a medical screening exam if he/she possesses adequate knowledge and skills and there are adequate support systems and standing orders from a physician in place to delegate this medical aspect of care; however, the RN should always have telephonic access to a physician who is also capable of physically responding to do a hands-on evaluation if needed or requested by the RN. RNs who do not also hold advanced practice registered nurse licensure cannot independently engage in medical diagnosis or the prescription of therapeutic or corrective measures, as this is beyond the scope of practice for an RN.

The Texas Board of Nursing (BON or Board) does not have purview over specific employment policies, procedures, or site-based requirements. Therefore, in addition to being permitted by an employing facility, the RN must also be competent to carry out the assigned task in a manner that complies with the Texas Nursing Practice Act (NPA) and Board Rules. Likewise, there may be additional laws, rules, or regulations applicable to the nurse’s practice setting that may impact his/her practice.

There is broad, general guidance for registered nurses accessible on BON website in Practice then Scope – Registered Nurse Scope of Practice. This includes  Board Rule 217.11, Standards of Nursing Practice; the Board's Scope of Practice Decision-Making Model (DMM), and Position Statement 15.14, Duty of a Nurse in any Practice Setting. The referenced position statement establishes that a nurse has a responsibility and duty to a patient to provide and coordinate the delivery of safe, effective nursing care, through compliance with the NPA and Board Rules and demonstrates the importance for nurses to intervene or advocate on behalf of their patients. This “duty to patients” supersedes any facility policy or physician order. The Scope of Practice Decision-Making Model (DMM) guides nurses in deciding if a task is within the nurse's scope of practice. The steps combine BON references and resources with additional references and resources (policies and procedures from the employment setting and nursing and healthcare research and literature) and use reflective questions to guide a nurse's practice decisions. At any point, if a nurse reaches a Stop Sign, he/she should consider the activity or intervention in question beyond (or outside) his/her scope of practice. Each nurse is accountable for the assignments the he/she accepts [Board Rule 217.11 (1)(T)]. Position Statement 15.11, Delegated Medical Acts, contains additional information on physician delegation to nurses.

Off label use indicates that the medication is being used in a way not specified in the U. S.  Federal Drug Administration’s (FDA’s) approved packaging label, or insert. All prescription drugs marketed in the U.S. have an FDA-approved label. The label provides detailed instructions regarding approved uses and doses which are based on the results of clinical studies that have been submitted by the drug maker to the FDA. Off label use of a medication may be supported by research and literature that addresses the necessary knowledge, required safeguards and risks associated with the off label use of the medication.

In the Scope of Practice Decision-Making Model , question one includes references to documents and information on the BON website, including statutes, rules, and position statements. While there is nothing specific in the Nursing Practice Act or Board Rules and Regulations that allows or prohibits the administration of medications for off-label use, there are laws and rules that licensed vocational nurses (LVNs) and registered nurses (RNs) should consider in this scope of practice decision. For example, the LVN cares for patients whose healthcare needs are predictable. When considering the administration of a medication, the predictability of the patient, the patient's response and the nurse's skill set required to address the needs of the patient, must be considered. If any of these cannot be addressed by the LVN, then it would be beyond the scope of practice of the LVN to administer off-label medications.  Position Statement 15.25, Administration of Medication & Treatments by LVNs, addresses medication administration; however, if the route of the medication administration is intravenous (IV), then Position Statement 15.3, LVNs Engaging in Intravenous Therapy, Venipuncture, or PICC Lines, must also be considered.

One of the main rules applicable to a nurse's practice is Board Rule 217.11, Standards of Nursing Practice. When a nurse is considering performing a task, such as the off-label administration of medications, several standards in section one of this rule, will apply to all LVNs and RNs. Patient safety must be considered in every assignment a nurse accepts [(Board Rule 271.11(1)(B)]. A nurse must know about the medication, why it is being used, what effects can be expected, and how to administer the medication correctly in order to administer it safely [(Board Rule 271.11(1)(C)]. Some medications may require an assessment, vital signs, and a pain description and pain level provided by the patient. Certain medications require the presence of equipment or monitoring during and following the medication administration due to the potential or known effects of the medication. Some medications require the nurse administering the medication to have specific skills and current competencies to include emergency interventions should adverse outcomes occur. Last, but not least, medication administration is not complete without accurate documentation [(Board Rule 217.11(1)(D)].

There are several Position Statements that apply to the off-label administration of a medication. Position Statement 15.14, Duty of a Nurse in Any Practice Setting, utilizes a landmark court case to illustrate the responsibility a nurse has to advocate for the patient, thus emphasizing the nurse's critical role in patient safety. Some medication administration is initiated through physician standing orders as addressed in Position Statement 15.5, Nurses with Responsibility for Initiating Physician Standing Orders. Occasionally, a physician delegated act includes medication administration; see Position Statement 15.11, Delegated Medical Acts. There are two position statements that specifically address either the RN or LVN scope of practice in broad terms. These are Position Statements 15.27, The Licensed Vocational Nurse Scope of Practice and 15.28, The Registered Nurse Scope of Practice.

Question two of the Scope of Practice Decision-Making Model directs nurses to look for a valid order authorizing the activity or intervention.

Question three asks if the activity or intervention is consistent with current policies and procedures in the employing organization or facility. Facility policy may identify specific levels of licensure for the administration of certain medications, or specific areas or units within the facility where the administration of medications may occur. There may be specific requirements related to current competencies of the personnel who will be administering medications, and for monitoring the patient after the administration of medications. There may be a policy distinction between label uses and off-label uses of medications. When a nurse identifies the safety issues involved in administering any off-label medication correctly, looking for an employer's policy outlining the safety measures required for the safe administration of the medication may assist a nurse in determining if off-label administration of medications will be safe in a specific setting.

Nurses are required to administer medications correctly, using evidence to support or refute giving a medication. Question four of the Scope of Practice Decision-Making Model requires the performance of the activity or intervention to be consistent with current evidence-based practice findings and/or guidelines or scope of practice/position statements from national nursing organizations and does not negate the requirement for nurses to administer medications correctly.

If there is literature to support the safe off-label administration of a medication, a nurse should consider questions five, six, and seven of the Scope of Practice Decision-Making Model . Question five asks if the nurse has the current competencies to perform the activity or intervention safely & effectively, in accordance with the accepted nursing “standard of care”. If a medication is being given via the IV route, having current skills to assess and intervene are important. If a pump is being used to administer the IV medication, then being familiar with the pump is essential.

Question six asks for the nurse to consider whether a reasonable and prudent nurse would administer the off-label medication in a similar circumstance. Finally, question seven is a personal reflective question and asks the nurse to accept accountability for the provision of safe care and the outcome of the care rendered.

Question eight is specifically for LVNs and asks if there will be adequate supervision available. This is a reminder that the LVN has a directed scope of practice under the supervision of a registered nurse, advance practice registered nurse, physician, physician assistant, dentist, or podiatrist [(Board Rule 217.11(2)]. For additional assistance in answering this question, Board Staff recommend review of the Frequently Asked Question (FAQ): LVNs “Supervision of Practice”.

Both the mission of the Board and the nurse's duty to the patient align in favor of patient safety. Therefore, a nurse is obligated to make the safest decision for the patient and using the Scope of Practice Decision-Making Model for determining scope of practice is one tool to help nurses with the decision of whether to accept or refuse an assignment related to the off-label administration of medications.

Revised 2021

References:

Texas Department of State Health Services Schedules of Controlled Substances
Texas Board of Nursing (2012). Nurses on guard-best practice in patient safety: Off-label administration ok ketamine for pain management by a nurse. Texas Board of Nursing Bulletin, 43(4), 5-6.
Ketalar Label from FDA website
Tex. Admin. Code § 217.11
Tex. Admin. Code § 217.20
Tex. Occ. Code, Sec.301.002 (5)
Tex. Occ. Code, Sec. 301.352
Tex. Occ. Code, Sec. 301.353

When registration with the Board is required, RNs must complete the BON application for registration form and submit it to the Board. There is no cost for registering. The RN who is registered with the Board must notify the BON within 30 days of any changes that render the information provided on the application incorrect, such as, changes in the identity of the practitioner or director of radiologic services under whose instruction or direction the radiological procedures are performed [Board Rule 217.14 (c)].

Board Rule 217.14 (d) requires an RN who performs radiologic procedures to complete a training program that adequately prepares the nurse to provide safe and effective nursing care in that role. The Board does not prescribe a specific course that must be completed. Depending on the specific procedures to be performed, the training content, method, and length may vary. Board Rule 217.14 also references other laws outside of the BON's jurisdiction, e.g., the Medical Radiologic Technologist Certification Act (Texas Occupations Code Ch. 601), any applicable rules of the Texas Medical Board, and others. These laws and regulations also require an RN to demonstrate competency in performing radiologic procedures. Each RN is responsible for maintaining a record demonstrating completion of an appropriate training program that has adequately prepared the RN to perform the radiologic procedures. This record must be maintained for a minimum of three consecutive renewal periods, or 6 years, for auditing purposes.

Some radiologic procedures may be considered delegated medical acts. BON staff recommend caution when performing a task as a delegated medical act. The Board's Position Statement 15.11, Delegated Medical Acts, provides more detail on this subject. Delegated medical acts do not diminish the responsibility of the nurse in any way to adhere to the Board's Standards of Nursing Practice, found in Board Rule 217.11. Included in Board Rule 217.11 are standards requiring a nurse to know and comply with the Nursing Practice Act (NPA) and Board's Rules and Regulations as well as all federal, state, or local laws to maintain client safety [§217.11(1)(A) & (1)(B)]. Further, nurses must accept only those assignments that are within the nurse's knowledge, skills, and abilities; seek instruction as necessary when implementing new procedures/practices; and maintain competency when performing tasks in any practice setting [§217.11(1)(G), (1)(R), & (1)(T)].

For general information on nurses practicing in the area of radiology, BON staff recommend contacting the Occupational Safety and Health Administration and professional nursing organizations, such as, the Radiological Society of North America (http://www.rsna.org) or the Association for Radiologic and Imaging Nursing (http://arinursing.org). Other nursing organizations related to a nurse's specialty practice setting may provide further guidance. Additionally, national patient safety organizations may provide resources and procedure guidelines for evidence-based practice. Examples include:

• Agency for Healthcare Research and Quality
• National Quality Measures Clearinghouse
• Institute for Safe Medication Practices
• Health and Medicine Division (formerly Institute of Medicine)

Although the GN or GVN may not practice in an independent setting (such as home care) until licensed, the BON has no requirements for co-signatures.. In fact, BON staff highly discourage a nurse from co-signing anything that nurse did not directly witness or immediately verify personally. Co-signature implies that the signer agrees in total and was either witness to, or went immediately behind the GN/GVN to assess and verify the findings of the GN/GVN. 

Co-signatures may be necessary when documenting certain nursing tasks, such as witnessing the wastage of a unit-dosed amount of a narcotic. Such requirements are beyond the jurisdiction of the BON. Contacting the appropriate licensing authority such as the Health & Human Services or the Texas Department of State Health Services, or an applicable credentialing organization (such as The Joint Commission) for any regulations specific to the practice setting is recommended. Please note that co-signature does not provide legitimacy to the actions of a GN/GVN that exceeded their scope of practice at the time the services were provided

Revised 2023

The question of an RN co-signing after an LVN most often arises in situations when an attempt is made to expand the LVN’s scope of practice by holding the RN responsible for expanded tasks performed by the LVN. The RN co-signing for something that is beyond the LVN’s scope of practice does not legitimize the LVN’s actions. A nurse never functions “under the license” of another nurse. For example, if a patient requires a comprehensive assessment performed by an RN, the comprehensive assessment (or a portion thereof) may not be assigned to an LVN. If such an assignment is  given to an LVN, the LVN is responsible for notifying the nurse who made the assignment that it is beyond the LVN’s scope of practice to perform the assigned task [Board Rule 217.11(1)(S) & (T)]. Each nurse has a duty to maintain client safety [Board Rule 217.11(1)(B)] that includes communication with appropriate personnel [Board Rule217.11(1)(P)]. Position Statement 15.14, Duty of a Nurse in Any Setting, further explains a nurse’s duty to a client.

As discussed above, each licensed nurse is responsible for accepting assignments that are within the educational preparation, experience, knowledge, and physical and emotional ability of the individual nurse [Board Rule 217.11(1)(T)]. Both LVNs and RNs are required to document the nursing care they render; each is held accountable for doing it accurately and completely [Board Rule 217.11(1)(D)]. This is part of a nurse’s duty to a client.

Revised 2023

The Board does not draft legislation or introduce new bills in the Texas Legislature, nor can the Board or Board staff support or oppose proposed bills during a legislative session. Board Members and Board staff are prohibited from lobbying the legislature regarding any bill that may go before the Texas Legislature and amend the Nursing Practice Act or other statutes, in or outside the authority of the BON, that otherwise impacts nurses.

The Nursing Practice Act (NPA) (Ch. 301), Nursing Peer Review (Ch. 303), and the Nurse Licensure Compact (Ch. 304), are all part of the Texas Statutes in the Texas Occupations Code. The Board Rules are part of the Texas Administrative Code (TAC). The Board fulfills its mission of protecting the public by carrying out the applicable statutes in the Occupations Code, and by establishing rules which are published in the Administrative Code.

In Texas government, policy making duties are divided between the legislature and the governor. The legislature writes the laws and appropriates the funds for state agency operations. The Governor, the State's Chief Executive Officer, has a major voice in setting the legislative agenda and vetoing bills. However, the legislature and the Governor delegate to state agency boards, like the Board of Nursing, the tasks of carrying out the laws applicable to the profession the agency is responsible for regulating.

The Board meets regularly to execute its responsibilities for administering the law governing nursing practice and education. The Board employs professional and support staff to carry out the provisions of the law along with the rules and regulations established by the Board. The Board pursues its mission by upholding minimum standards for nursing pre-licensure educational programs, licensing qualified individuals as nurses, educating licensed nurses regarding current nursing regulations and any changes in the law, investigating alleged violations, and imposing appropriate discipline on the licenses of those found to be in violation of the NPA or Board rules.

Unlike the Board of Nursing, a professional nursing association is a private organization whose members must pay dues to receive the benefits of membership. One of the primary functions of a nursing association is to represent its members in legislative, political, and practice matters. It provides a central voice and avenue for advocacy for its nurse membership.

A nursing association can lobby the legislature and Governor for the interests of its members and the profession of nursing. A nursing association provides a united voice that can speak out on the issues important to a specific area of nursing practice and/or to the nursing profession as a whole. In addition, a nursing association provides leadership in other areas such as improving working conditions and benefits for nurses. A nursing association also may lead the way in developing public health policies.

Summary:

The Board and nursing associations have separate but equally important roles. Nursing associations represent the interests of nurses with a main focus on advancing the nursing profession; while, the Board’s mission centers around public protection, and the Board protects the people of Texas by ensuring that nurses know and conform to minimum standards of safe nursing practice and upholding minimum standards for nursing educational programs. The Board accomplishes this by developing and revising rules that are based on the Texas Statutes in the Texas Occupations Code, as well as and through additional resources, such as position statements, interpretive guidelines, and frequently asked questions, which are available on the BON’s website.

Revised 2021

Credentials by Law

Known as the Healing Art Identification Act, Texas Occupations Code (TOC), Chapter 104.001 addresses the use of the term “doctor”. According to TOC Chapter 104.004 a nurse is required to include the degree that gives rise to the use of the title doctor as a credential and indicate the profession being practiced. The Nursing Practice Act (NPA) and Board Rules mandate that a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN) display a clearly legible insignia specifying name and licensure level (NPA Section 301.351 & Board Rule 217.10). The Advanced Practice Registered Nurse (APRN) is identified both as a RN and uses the appropriate advanced practice title authorized by the Board of Nursing (BON) when providing advanced practice care to patients (Based on requirements in the referenced Texas laws, doctorally prepared nurses could not simply identify themselves as Dr. _____. The nurse must include the academic credential such as PhD (Doctor of Philosophy), DNS (Doctor of Nursing Science), DNP (Doctor of Nursing Practice), or any other doctoral degree. Nurses must also include licensure level with appropriate APRN title, if applicable.

Communication

Communication takes many forms. Some verbal communications occur in person and have associated visual cues such as a name badge. Other verbal communications may occur by telephone, presenting unique challenges in assuring the parties are correctly identified. The information exchanged should include the name and licensure level of the parties involved. Written communications are required to include the name, licensure level, and the appropriate advanced practice title, if applicable, and may include academic degrees and certifications. The academic credential cannot replace the licensure credential. Inadequate identification of a nurse can be confusing to the public. Failure to comply with laws, rules, and regulations can result in disciplinary action. When using a doctoral credential, nurses are obligated to use the term in compliance with the law by identifying the “degree that gives rise to the use of the title” (TOC, Section 104.004).

Additional resources and references related to identification and advanced practice titles include:

• Texas Board of Nursing Bulletin – When the Profession is Nursing and the Title is Dr……, July 2011, p.4;
• Texas Board of Nursing Bulletin – Use of Advanced Practice Titles, July 2008, p.8; and
• RN Update – RN Identification is Essential in Today’s Health Care Environment, January 1999, p.1.

To access these archived issues on the Board’s website at www.bon.texas.gov  click on About then Newsletters.

References

Board Rule 221.2
Nursing Practice Act (NPA), TOC, Section 301.351 and Board Rule 217.10
Texas Occupations Code (TOC), Section 104.001
Texas Occupations Code, Section 104.004

Revised  2023

Vocational nursing involves:

1. collecting data and performing focused nursing assessments of the health status of an individual;
2. participating in the planning of the nursing care needs of an individual;
3. participating in the development and modification of the nursing care plan;
4. participating in health teaching and counseling to promote, attain, and maintain the optimum health level of an individual;
5. assisting in the evaluation of an individual’s response to a nursing intervention and the identification of an individual’s needs; and
6. engaging in other acts that require education and training, as prescribed by board rules and policies, commensurate with the nurse’s experience, continuing education, and demonstrated competency [Tex. Occ. Code §§301.002(5)].

Additionally, Vocational nursing must be performed under the supervision of a registered nurse, advanced practice registered nurse, physician assistant, physician, dentist, or podiatrist [Tex. Occ. Code §301.353].

Regardless of the setting or practice area, the NPA and Board Rules and Regulations prevent LVNs from practicing in a completely independent manner. Vocational nursing requires the acts/procedures being performed be within the scope of the LVN’s practice and appropriate orders be in place. While the NPA and Board rules do not specifically address cosmetic procedures, when a medication has been appropriately ordered for a specific client by a provider who has authorization to order such treatments, each nurse would need to individually determine whether or not that specific act is within his/her scope of practice. Each LVN would need to individually apply the Board’s Scope of Practice Decision-Making Model (DMM) , a step-by-step tool designed to assist LVNs in determining whether a task or procedure is within his/her scope of practice. Note that two LVNs could both utilize the Scope of Practice Decision-Making Model (DMM) and come to differing answers of whether or not the same given task is within their respective scopes of practice because each nurse has his/her own individual knowledge, experience, training, etc.

Below are some examples of what you should consider when evaluating whether a cosmetic procedure is within your scope of practice:

1. Whether you have the necessary educational preparation and knowledge to perform the task safely.
1. Was the procedure taught to you as a part of your formal educational curriculum in a school of vocational nursing?
2. Do you know what complications and/or untoward effects may result from the task or procedure?
3. Does the task or procedure require a higher level of licensure or a different level of authorization?
2. Whether you have the competency and skill to safely perform the task or procedure.
1. Have you obtained additional training or continuing education specific to the cosmetic procedure?
1. Keep in mind that continuing education and on-the-job training may expand competency at the current level of licensure but CANNOT qualify a LVN to perform the same level of care as an RN or APRN.
2. In the event of complications and/or untoward effects, are you able to respond appropriately?
3. Whether there is an appropriate order from a provider authorized to prescribe such treatments
1. For administration of drugs, such as Botox, does the order contain all pertinent information, such as dose, strength, route, etc.?
2. Do you have a standing delegation order, if applicable?
4. Whether there is appropriate nursing and medical supervision available.
1. Is the supervising RN on-site?
2. Is the ordering provider on-site?

An LVN should not perform a cosmetic procedure if the LVN lacks the necessary educational preparation, knowledge, competency, or skill to safely perform the procedure; lacks an order for the procedure; or lacks appropriate supervision.

To further assist you in determining whether a cosmetic procedure is within your scope of practice, Board Staff recommend review of several resources available on the Texas BON website. These resources include:

• Tex. Admin. Code §217.11 (Standards of Nursing Practice) outlines the minimum standards of nursing care at all licensure levels (LVN, RN, APRN). Specific subsections of this rule can be directly applied to this situation and should be considered. All nurses must:
• (1)(A)- know and conform to the Texas NPA 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;
• (1)(B)- implement measures to promote a safe environment for clients and others;
• (1)(C)- know the rationale for and the effects of medications and treatments and correctly administer the same;
• (1)(G)- obtain instruction and supervision as necessary when implementing nursing procedures or practices;
• (1)(H)- make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations;
• (1)(M)- institute appropriate nursing interventions that might be required to stabilize a client’s condition and/or prevent complications;
• (1)(O)- implement measures to prevent exposure to infectious pathogens and communicable conditions;
• (1)(R)- be responsible for one’s own continuing competence in nursing practice and individual professional growth; and
• (1)(T)- accept only those nursing assignments that take into consideration client safety and that are commensurate with the nurse’s educational preparation, experience, knowledge, and physical and emotional ability.
• Position Statement 15.9 (Performance of Laser Therapy by RNs or LVNs)
• Position Statement 15.23 (The Use of Complementary Modalities by the LVN or RN)
• Position Statement 15.11 (Delegated Medical Acts) - specifically addresses the nurse’s role with delegated medical acts. Board staff recommend caution when performing a delegated medical act, as delegated medical acts do not diminish the responsibility of the nurse in any way to adhere to the Board's Standards of Nursing Practice, Tex. Admin. Code §217.11. Nurses function under their own licenses and assume responsibility and accountability for quality, safe care in accordance with all applicable laws/rules/regulations; nurses do not practice under a physician’s license.
• Position Statement 15.14 (Duty of a Nurse in any Practice Setting) - discusses a landmark court case which demonstrates how every nurse has a duty to promote patient safety and that duty to a patient supersedes any physician order or facility policy.
• Position Statement 15.10 (Continuing Education: Limitations for Expanding Scope of Practice) - clarifies that expansion of an individual nurse’s scope of practice has licensure-related limitations and that informal continuing nursing education or on-the job training cannot be substituted for formal education leading to the next level of practice/licensure or authorization.

Board Staff also recommend review of the Texas Medical Board Rule 193.17, entitled Nonsurgical Medical Cosmetic Procedures, that addresses the rules related to physician delegation of nonsurgical medical cosmetic procedures. In addition, depending on the range of services you plan to provide, there may be specific licensure requirements including, but not limited to, Cosmetology Licensing. Having a nursing license authorizes you to practice nursing within your licensure level and scope of practice but not to do other things that require separate licensure/certification. You can find additional regulations related to cosmetologists/practicing cosmetology from the agency that regulates cosmetologists, the Texas Department of Licensing and Regulation. Additionally, there may be applicable guidance related to the practice setting; e.g., a private physician office might have specialty-specific guidelines from the American Board of Medical Specialties. Beyond following all applicable laws, rules and regulations regarding the acts/tasks and the setting, the nurse would need to practice consistently with the employer’s policies, assuming these policies promote patient safety (refer back to Position Statement 15.14 if necessary).

If a license is obtained via another agency or regulatory body to perform duties and tasks in another setting, for example a medical spa, the Board considers persons who hold nursing licensure accountable for acts within the practice of nursing even if these acts are performed ‘off duty’ or in another setting [Tex. Occ. Code §301.004(a)(5)]. One example of this may be performing a lower leg wax for a client who has diabetes and peripheral neuropathy; this client may not be able to feel if the wax is too hot and there may be associated burns and a poor outcome. In this example, you would be held responsible for applying your nursing knowledge and judgment with this particular client. There is also a Frequently Asked Question which relates to this discussion (Practice of Nursing). Position Statement 15.15 (Board’s Jurisdiction Over a Nurse’s Practice in Any Role and Use of the Nursing Title) reiterates that any licensed nurse in Texas is responsible to and accountable to adhere to both the NPA and Board Rules and Regulations when practicing nursing, which have the force of law [Tex. Admin. Code §217.11(1)(A)].

Food for Thought

It is important to remember that there is more to this topic than simply learning how to perform a particular procedure. Patient selection criteria, underlying physiology and/or pathophysiology, as well as indications for and contraindications to the procedure are among the many concepts that are fundamental to learning a new procedure. You must also learn to respond to and manage (as appropriate) untoward events/adverse reactions/complications that may occur as a result of the procedure. In many cases, on-the-job training will not include this type of content. If you are ever required to defend your practice for any reason (whether to the BON or any other entity), you will likely be required to provide evidence of education/training and documentation of competence related to the specific service you provided.

Professional nursing involves:

1. the observation, assessment, intervention, evaluation, rehabilitation, care and counsel, or health teachings of a person who is ill, injured, infirm, or experiencing a change in normal health processes;
2. the maintenance of health or prevention of illness;
3. the administration of a medication or treatment as ordered by a physician, podiatrist, or dentist;
4. the supervision or teaching of nursing;
5. the administration, supervision, and evaluation of nursing practices, policies, and procedures;
6. the requesting, receiving, signing for, and distribution of prescription drug samples to patients at practices at which an advanced practice registered nurse is authorized to sign prescription drug orders as provided by Subchapter B, Chapter 157;
7. the performance of an act delegated by a physician under Tex. Occ. Code §§157.0512, 157.054, 157.058, or 157.059; and
8. the development of the nursing care plan [Tex. Occ. Code §301.002(2)].

Professional nursing requires the tasks/procedures/acts being performed be within the scope of the RN’s practice and appropriate orders be in place. While the NPA and Board rules do not specifically address cosmetic procedures, when appropriately ordered for a specific client by a provider who is authorized to prescribe such treatments, each RN would need to individually determine whether or not that specific act is within his/her scope of practice. Each RN would need to individually apply the Board’s Scope of Practice Decision-Making Model (DMM)  a step-by-step tool designed to assist a nurse in determining whether a task/procedure/act is within his/her scope of practice. Note that two RNs could both utilize the Scope of Practice Decision-Making Model (DMM) and come to differing answers of whether or not the same given task/procedure/act is within their respective scopes of practice because each nurse has his/her own individual knowledge, experience, training, etc.

Below are some examples of what you should consider when evaluating whether a cosmetic procedure is within your scope of practice:

1. Whether you have the necessary educational preparation and knowledge to perform the task safely.
1. Was the procedure taught to you as a part of your formal educational curriculum in a school of professional nursing?
2. Do you know what complications and/or untoward effects may result from the task or procedure?
3. Does the task or procedure require a higher level of licensure or a different level of authorization?
2. Whether you have the competency and skill to safely perform the task or procedure.
1. Have you obtained additional training or continuing education specific to the cosmetic procedure?
1. Keep in mind that continuing education and on-the-job training may expand competency at the current level of licensure but CANNOT qualify a RN to perform the same level of care as an APRN.
2. In the event of complications and/or untoward effects, are you able to respond appropriately?
3. Whether there is an appropriate order from a provider authorized to prescribe such treatments.
1. For administration of drugs, such as Botox, does the order contain all pertinent information, such as dose, strength, route, etc.?
2. Do you have a standing delegation order, if applicable?
4. Whether there is appropriate medical supervision available.
1. Is the ordering provider on-site?

An RN should not perform a cosmetic procedure if the RN lacks the necessary educational preparation, knowledge, competency or skill to safely perform the procedure; lacks an order for the procedure; or lacks appropriate supervision.

To further assist you in evaluating whether a cosmetic procedure is within your scope of practice, Board Staff recommend review of several resources available on the Texas BON website. These resources include:

• Tex. Admin. Code §217.11 (Standards of Nursing Practice) outlines the minimum standards of nursing care at all licensure levels (LVN, RN, APRN). Specific subsections of this rule can be directly applied to this situation and should be considered. All nurses must:
• (1)(A)- know and conform to the Texas NPA 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;
• (1)(B)- implement measures to promote a safe environment for clients and others;
• (1)(C)- know the rationale for and the effects of medications and treatments and correctly administer the same;
• (1)(G)- obtain instruction and supervision as necessary when implementing nursing procedures or practices;
• (1)(H)- make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations;
• (1)(M)- institute appropriate nursing interventions that might be required to stabilize a client’s condition and/or prevent complications;
• (1)(O)- implement measures to prevent exposure to infectious pathogens and communicable conditions;
• (1)(R)- be responsible for one’s own continuing competence in nursing practice and individual professional growth; and
• (1)(T)- accept only those nursing assignments that take into consideration client safety and that are commensurate with the nurse’s educational preparation, experience, knowledge, and physical and emotional ability.
• Position Statement 15.9 (Performance of Laser Therapy by RNs or LVNs)
• Position Statement 15.23 (The Use of Complementary Modalities by the LVN or RN)
• Position Statement 15.11 (Delegated Medical Acts) - specifically addresses the nurse’s role with delegated medical acts. Board staff recommend caution when performing a delegated medical act, as delegated medical acts do not diminish the responsibility of the nurse in any way to adhere to the Board's Standards of Nursing Practice, Tex. Admin. Code §217.11. Nurses function under their own licenses and assume responsibility and accountability for quality, safe care in accordance with all applicable laws/rules/regulations; nurses do not practice under a physician’s license.
• Position Statement 15.14 (Duty of a Nurse in any Practice Setting) - discusses a landmark court case which demonstrates how every nurse has a duty to promote patient safety and that duty to a patient supersedes any physician order or facility policy.
• Position Statement 15.10 (Continuing Education: Limitations for Expanding Scope of Practice) - clarifies that expansion of an individual nurse’s scope of practice has licensure-related limitations and that informal continuing nursing education or on-the job training cannot be substituted for formal education leading to the next level of practice/licensure or authorization.

Board Staff also recommend review of the Texas Medical Board Rule 193.17, entitled Nonsurgical Medical Cosmetic Procedures, that addresses the rules related to physician delegation of nonsurgical medical cosmetic procedures. In addition, depending on the range of services you plan to provide, there may be specific licensure requirements including, but not limited to, Cosmetology Licensing. Having a nursing license authorizes you to practice nursing within your licensure level and scope of practice but not to do other things that require separate licensure/certification. You can find additional regulations related to cosmetologists/practicing cosmetology from the agency that regulates cosmetologists, the Texas Department of Licensing and Regulation. Additionally, there may be applicable guidance related to the practice setting; e.g., a private physician office might have specialty-specific guidelines from the American Board of Medical Specialties. Beyond following all applicable laws, rules and regulations regarding the acts/tasks and the setting, the nurse would need to practice consistently with the employer’s policies, assuming these policies promote patient safety (refer back to Position Statement 15.14 if necessary).

If a license is obtained via another agency or regulatory body to perform duties and tasks in another setting, for example a medical spa, the Board considers persons who hold nursing licensure accountable for acts within the practice of nursing even if these acts are performed ‘off duty’ or in another setting [Tex. Occ. Code §301.004(a)(5)]. One example of this may be performing a lower leg wax for a client who has diabetes and peripheral neuropathy; this client may not be able to feel if the wax is too hot and there may be associated burns and a poor outcome. In this example, you would be held responsible for applying your nursing knowledge and judgment with this particular client. There is also a Frequently Asked Question which relates to this discussion (Practice of Nursing). Position Statement 15.15 (Board’s Jurisdiction Over a Nurse’s Practice in Any Role and Use of the Nursing Title) reiterates that any licensed nurse in Texas is responsible to and accountable to adhere to both the NPA and Board Rules and Regulations when practicing nursing, which have the force of law [Tex. Admin. Code §217.11(1)(A)].

Food for Thought

It is important to remember that there is more to this topic than simply learning how to perform a particular procedure. Patient selection criteria, underlying physiology and/or pathophysiology, as well as indications for and contraindications to the procedure are among the many concepts that are fundamental to learning a new procedure. You must also learn to respond to and manage (as appropriate) untoward events/adverse reactions/complications that may occur as a result of the procedure. In many cases, on-the-job training will not include this type of content. If you are ever required to defend your practice for any reason (whether to the BON or any other entity), you will likely be required to provide evidence of education/training and documentation of competence related to the specific service you provided.

• (1)(A)- know and conform to the Texas NPA 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.   For example, the Texas State Board of Pharmacy (TSBP) may have more information on the specific requirements for the mixing of additives in an IV bag or may have other regulations that apply to the practice setting. Additionally, the rules from the Texas Medical Board (TMB) that define standing delegation orders are found in Title 22 of the Texas Administrative Code, Chapter 193 (see Position Statement 15.5 below) should be followed. Lastly, there may be employer policies designed to promote patient safety or other applicable laws, rules and regulations regarding the acts/tasks, or the setting the nurse might need to know and conform.    
• (1)(B)- implement measures to promote a safe environment for clients and others,
•  (1)(C)- know the rationale for and the effects of medications and treatments and shall correctly administer the same,
• Medication administration involves more than the use of appropriate technique. Nurses should have knowledge about the medications they administer and understand, in general, the rationale for a medications administration. Although a nurse may not receive a detailed description of a provider’s specific rationale for a medication order, nurses should recognize the appropriate use of a medication for a patient through their nursing assessment. The package insert accompanying a drug when it is dispensed, also available online, is a good resource for nurses on the FDA approved indications and usage for a drug. This information may also be found in available drug guides. Such resources also contain other information related to appropriate medication administration and patient monitoring. The Board’s FAQ titled Off Label Use of Medications reminds nurses that the focus of nursing care is on patients, and that the standard of care for appropriate medication administration is evidenced based. Off label use of a medication may be supported by research and literature that addresses the necessary knowledge, required safeguards and risks associated with the off label use of the medication. Nurses have a duty to their patients to ensure they administer medications in accordance with evidence based practice.
• (1)(D)- accurately and completely report and document: the client’s status, including signs and symptoms; nursing care rendered; physician, dentist or podiatrist orders; administration of medications and treatments; client response(s); and contacts with other health care team members concerning significant events regarding client’s status,
•  In some instances, there may be applicable standing orders, created by a physician, in place to guide nursing interventions related to initiating IV hydration and/or vitamin therapy.  Since nurses cannot medically diagnose or prescribe therapeutic or corrective measures, an order would be necessary.  Facility policy, procedures, and accreditation standards may provide guidance in relation to the implementation of standing orders specific to IV hydration and/or vitamin therapy.
• (1)(G)- obtain instruction and supervision as necessary when implementing nursing procedures or practices
• (1)(H)- make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations,
• (1)(N)- clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer a medication or treatment,
• (1)(P)- collaborate with the client, members of the health care team, and when appropriate, the client’s significant other(s) in the interest of the client’s health care,
• (1)(Q) Consult with, utilize, and make referrals to appropriate community agencies and health care resources to provide continuity of care,
• (1)(R)- be responsible for one’s own continuing competence in nursing practice and individual professional growth,
•  (1)(S) – make assignments to others that take into consideration client safety and that are commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made
• (1)(T)- accept only those nursing assignments that take into consideration client safety and that are commensurate with the nurse’s educational preparation, experience, knowledge, and physical and emotional ability.
• Nurses considering this practice setting would need to critically assess if the proposed assignment would require the nurse to function beyond their scope of practice.  It is important to consider that even if all criteria for initiating physician standing delegation orders are met, nurses are still required to accept only those nursing assignments that take into consideration patient safety as the nurse’s duty to keeping patient’s safe supersedes any physician order or employer policy.

Board staff also recommend review of the following resources that may be of further assistance:

• “IV Hydration: What Texas Nurses Need to Know” (Texas Board of Nursing Bulletin - July 2020, page 8) is an article about IV Hydration/vitamin therapy and may also be helpful in answering your questions as it directly relates to your inquiry.
• Board Position Statement 15.5 discusses nurses with the responsibility for initiating physician standing orders. Acts/procedures being performed must be within the scope of that particular nurse's level of licensure, and appropriate orders must be in place for acts that go beyond the practice of nursing.  This position statement outlines the differences between:
• Standing delegation orders -written instructions, orders, or procedures that provide the authority for a plan to be implemented for patients presenting prior to being examined or evaluated by a physician; however, are intended to be used based on pre-determined criteria, cannot authorize the person carrying out the standing orders to exercise independent medical judgement, and can only be authorized by a physician.
• Standing medical orders - written instructions, orders or procedures prepared by a physician or approved by the medical staff of an institution for patient that have been evaluated or examined by a physician, and
• Protocols- narrowly defined by TMB and applicable only to Advanced Practice Registered Nurses (APRNs) and Physician Assistants (PAs).
• Board 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.  Nurses function under their own licenses and assume responsibility and accountability for quality, safe care in accordance with all applicable laws/rules/regulations.  Nurses do not practice under the protections of a physician’s license.  Each nurse is ultimately individually responsible for the assignments he/she accepts. Physician delegation does not provide authority for a nurse at any level of licensure to exceed the scope of practice for which he/she has been licensed and is not considered to be mitigating.
• Board Position Statement 15.23- The Use of Complementary Modalities by the LVN or RN- discusses considerations in the use of complimentary modalities (e.g. vitamin therapy) and may be helpful in further assisting with your inquiry.
• Position Statement 15.14, Duty of a Nurse in Any Practice Setting discusses a landmark court case which demonstrates that regardless of receiving orders from the appropriately licensed practitioner, the nurse's duty to keep patients safe cannot be superseded by physician orders, facility policies, or administrative directives.
• Each nurse must individually determine his/her scope of practice; and, the Board provides a resource for doing so, The Board’s Scope of Practice Decision-Making Model (DMM).  Board staff are rarely able to provide a simple “yes” or “no” answer to questions asked by/for nurses because every situation is different and there are many variables to consider.  The DMM a step-by-step tool all nurses practicing in Texas can use to determine if any given task/procedure is within their individual scope of practice.  The DMM is designed to be used in sequence, beginning at the top with question number one.  In the model, nurses are asked reflective questions, and depending on how they answer, they are directed to continue through the model or stop.  When using this model, the nurse must consider, among other steps: I if the IV therapy nursing services are consistent with current nursing evidence-based practice guidelines.  As with all nursing practice, evidence-based practice is the foundation for practice decisions.  The nurse would need to determine if performing the activity or intervention is consistent with current evidence‐based practice findings and/or guidelines or scope of practice/position statements from national nursing organizations. To do so, the nurse would need to perform a literature search and/or contact national nursing organizations/associations and/or accreditation/certification organizations for guidance as to the standard of care in a particular care delivery setting or specialty area.  In this practice setting, examples of sources of prevailing nursing standards of care, may include those published by the National Infusion Center Association (NICA) Minimum Standards for In-Office Infusions or the Infusion Nurse’s Society (INS) recommendations.  At any point, if the nurses reach a Stop Sign, he/she should consider the activity or intervention in question beyond (or outside) his/her scope of practice.

Please note that Board staff can only speak to the requirements for nursing practice in the State of Texas.  The Board does not have rules regarding business ownership, so we cannot advise you on this.  We would recommend you seek your own legal counsel for assistance with these matters. If you do not have legal counsel, the State Bar of Texas (not affiliated with the Texas Board of Nursing) has a Lawyer Referral and Information Service that may also be able to assist you. . 

References

Texas Board of Nursing. (2019). Nursing practice act. Retrieved from: https://www.bon.texas.gov/laws_and_rules_nursing_practice_act.asp

Texas Board of Nursing. (2019). Scope of practice decision-making model. Retrieved from: https://www.bon.texas.gov/pdfs/publication_pdfs/Scope%20of%20Practice%20Decision-Making%20Model%20-%20DMM.pdf

Texas Board of Nursing. (2019). Standards of nursing practice. Retrieved from: https://www.bon.texas.gov/rr_current/217-11.asp

Texas Medical Board. (2019). Texas administrative code §193. Retrieved from: https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=9&ch=193&rl=1

Added September 2021

The initiation of IV therapy is a learned skill practiced by many Texas nurses, and as always  nurses licensed to practice nursing in Texas must adhere to the Nursing Practice Act (NPA) and Board Rules, as well as other regulations pertinent to their practice setting. Additionally, there are necessary considerations for the safe performance of this skill outside of a traditional facility setting such as a mobile unit or wellness clinic. When reflecting on scope of practice there are several unique considerations for the LVN. Vocational nursing scope of practice is defined in the NPA section 301.002(5) as a directed scope of practice. The practice of vocational nursing must  be performed under the supervision of a registered nurse (RN), advanced practice registered nurse (APRN), physician, physician assistant (PA), podiatrist, or dentist [NPA Section 301.353 & Board Rule 217.11 (2)]. These licensed supervisors are responsible for directing, guiding, and influencing the outcome of an LVN’s performance of an activity [Board Rule 217.11 (2)]. Each LVN, regardless of practice setting, has a responsibility to ensure they have appropriate supervision for any assignment they accept. 

Under the direction and supervision of an appropriately licensed supervisor, Texas LVNs provide nursing care to patients with healthcare needs that are predictable in nature. The term “predictable” describes health conditions that behave or occur in an expected way. A predictable health condition does not mean that the patient is always stable. Instead, predictable health conditions follow an expected range or pattern that allows the LVN, with their clinical supervisor, to anticipate and appropriately plan for the needs of patients. When complications arise or events occur that are outside the predicted range, the LVN must be able to recognize this change in condition and notify their clinical supervisor. This can be contrasted with the RN who may independently plan and implement nursing care while caring for patients with complex healthcare needs.

RNs conduct comprehensive assessments. As defined by the BON, a comprehensive assessment is "an extensive data collection (initial and on-going) for individuals, families, groups and communities addressing anticipated changes in client conditions as well as emergent changes in a client's health status; recognizing alterations to previous conditions; synthesizing the biological, psychological, spiritual and social aspects of the client's condition; and using this broad and complete analysis to make independent decisions and nursing diagnoses; plan nursing interventions, evaluate the need for different interventions, and the need to communicate and consult with other health team members. Licensed vocational nurses may conduct focused assessments. A focused assessment is an appraisal of an individual client's status and situation at hand [what is occurring at that moment], contributing to the comprehensive assessment, supporting on-going data collection, and deciding who needs to be informed of the information and when to inform. Essentially, each LVN will need to determine whether the performance of a particular assignment is based upon a focused assessment, performed under the direction and supervision of an appropriately licensed supervisor, or if it involves a comprehensive assessment, which requires the advanced knowledge and skill of the Registered Nurse. 

Another significant consideration for LVN scope of practice is whether an LVN has received training to perform the IV therapy. The basic educational curriculum for LVNs does not mandate teaching of principles and techniques for insertion of peripheral IV catheters, or the administration of fluids and medications via the IV route. Therefore, it cannot be presumed that all LVN licensees possess basic competency in the management of IV therapy. It is the opinion of the Board that LVNs shall not engage in IV therapy related to either peripheral or central venous catheters, including venipuncture, administration of IV fluids, and/or administration of IV push medications, until successful completion of a validation course that instructs the LVN in the knowledge and skills applicable to the LVN’s IV therapy practice. 

The BON does not define or set qualifications for an “IV Validation Course” or for "LVN IV certification." The LVN who chooses to engage in IV therapy must first have been instructed in the principles of IV therapy congruent with prevailing nursing practice standards. Prior to performing aspects of care associated with IV therapy every LVN must reflect on their training and current competence to determine if they have the requisite knowledge, skills, and ability to perform the necessary services safely. For additional information on this topic review the Board's Position Statement 15.3 titled LVNs Engaging in Intravenous Therapy, Venipuncture, or Peripherally Inserted Central Catheter (PICC) Lines.

The NPA and Board rules do not specifically address the provision of IV hydration therapy and/or vitamin therapy. However, there are applicable sections as they related to LVN scope of practice. 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 to be within the scope of that nurse’s practice and that appropriate orders be in place for acts that go beyond the practice of nursing. According to the NPA, nurses 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). When appropriately ordered for a specific client by a provider who is authorized to prescribe such treatments, each LVN would need to determine whether that specific act is within their scope of practice (see Scope of Practice Decision-Making Model below). 

An IV therapy order may come from a provider who has examined the patient or may be established in other settings where a physician utilizes standing delegation orders. If a nurse intends to provide these services under a physician standing delegation order, he/she should review the rules from the Texas Medical Board (TMB) that define standing delegation orders, found in Title 22 of the Texas Administrative Code, Chapter 193, and Board Position Statement 15.5 Nurses with Responsibility for Initiating Physician Standing Orders. Nurses function under their own licenses and assume responsibility and accountability for the care they provide, as nurses do not practice under a physician’s license.  

Even if all criteria for initiating physician standing delegation orders are met, nurses are required to act in the best interest of their patients, and this duty supersedes any physician order or employer policy. In all practice settings, nurses must clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious, or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment [Board Rule 217.11(1)(N)]. 
 

In response to a valid order, the performance of IV hydration in a non-traditional setting, such as a mobile unit or wellness clinic, should be consistent with applicable regulations, prevailing standards of care, and current national nursing guidelines specific to IV therapy. In the best interest of patients and to ensure sound decision-making and quality nursing care, nurses should stay informed about current evidence-based practice standards or guidelines applicable to their area of practice. Evidence-based practice guidelines and/or nation­al nursing organizations can help nurses determine the best practices and standards in a particular area of nursing practice. Also, national nursing organizations may specify which qualifications or certifica­tions are necessary for a nurse to perform a particular role, activity, or procedure. The Board expects that all nurses practice in accordance with the current standard of care, best practices, and evidence-based practice findings/guidelines relevant to their practice setting and services provided. The Food and Drug Administration (FDA) “has become increasingly aware of drug products compounded at medical offices and clinics that were prepared under insanitary conditions. The FDA has also become aware of business models, such as intravenous hydration clinics, medical spas, and mobile IV infusion services, that are compounding drugs that may not meet the conditions of section 503A of the FD&C Act or comply with state regulations. Contaminated, or otherwise poor quality compounded drug products can lead to serious patient illnesses, including death.”

Board Rule 217.11 Standards of Nursing Practice outlines the minimum standards of nursing practice applicable to all levels of licensure (LVN, RN, and APRN).  Board staff recommend review of the rule in its entirety, but some specific standards are highlighted below.
 
 All nurses must:

• (1)(A)- know and conform to the Texas NPA 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.   For example, the Texas State Board of Pharmacy (TSBP) may have more information on the specific requirements for the mixing of additives in an IV bag or may have other regulations that apply to the practice setting. Additionally, the rules from the Texas Medical Board (TMB) that define standing delegation orders are found in Title 22 of the Texas Administrative Code, Chapter 193 (see Position Statement 15.5 below) should be followed. Lastly, there may be employer policies designed to promote patient safety or other applicable laws, rules and regulations regarding the acts/tasks for the setting the nurse might need to know and conform.    
• (1)(B)- implement measures to promote a safe environment for clients and others,
•  (1)(C)- know the rationale for and the effects of medications and treatments and shall correctly administer the same,
  • Medication administration involves more than the use of appropriate technique. Nurses should have knowledge about the medications they administer and understand, in general, the rationale for a medication’s administration. Although a nurse may not receive a detailed description of a provider’s specific rationale for a medication order, nurses should recognize the appropriate use of a medication for a patient through their nursing assessment. The package insert accompanying a drug when it is dispensed, also available online, is a good resource for nurses on the FDA approved indications and usage for a drug. This information may also be found in drug guides. Such resources also contain other information related to appropriate medication administration and patient monitoring. The Board’s FAQ titled Off Label Use of Medications reminds nurses that the focus of nursing care is on patients, and that the standard of care for appropriate medication administration is evidenced based. Off label use of a medication may be supported by research and literature that addresses the necessary knowledge, required safeguards and risks associated with the off-label use of the medication. Nurses have a duty to their patients to ensure they administer medications in accordance with evidence-based practice.
• (1)(D)- accurately and completely report and document: the client’s status, including signs and symptoms; nursing care rendered; physician, dentist, or podiatrist orders; administration of medications and treatments; client response(s); and contacts with other health care team members concerning significant events regarding client’s status,
  •  In some instances, there may be applicable standing orders, created by a physician, in place to guide nursing interventions related to initiating IV hydration and/or vitamin therapy.  Since nurses cannot medically diagnose or prescribe therapeutic or corrective measures, a valid order would be necessary.  Facility policy, procedures, and accreditation standards may provide guidance in relation to the implementation of standing orders specific to IV hydration and/or vitamin therapy.
• (1)(G)- obtain instruction and supervision as necessary when implementing nursing procedures or practices
• (1)(H)- make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations,
• (1)(N)- clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer a medication or treatment,
• (1)(P)- collaborate with the client, members of the health care team, and when appropriate, the client’s significant other in the interest of the client’s health care,
• (1)(Q) Consult with, utilize, and make referrals to appropriate community agencies and health care resources to provide continuity of care,
• (1)(R)- be responsible for one’s own continuing competence in nursing practice and individual professional growth,
•  (1)(S) – make assignments to others that take into consideration client safety and that are commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made
• (1)(T)- accept only those nursing assignments that take into consideration client safety and that are commensurate with the nurse’s educational preparation, experience, knowledge, and physical and emotional ability.
  • Nurses considering this practice setting would need to critically assess if the proposed assignment would require the nurse to function beyond their scope of practice.  It is important to consider that even if all criteria for initiating physician standing delegation orders are met, nurses are still required to accept only those nursing assignments that take into consideration patient safety as the nurse’s duty to keeping patients safe supersedes any physician order or employer policy.

Board staff also recommend review of the following resources that may be of further assistance:

• Board Position Statement 15.3 - LVNs Engaging in Intravenous Therapy, Venipuncture, or Peripherally Inserted Central Catheter (PICC) Lines
• “IV Hydration: What Texas Nurses Need to Know” (Texas Board of Nursing Bulletin - July 2020, page 8) is an article about IV Hydration/vitamin therapy and may also be helpful in answering your questions as it directly relates to your inquiry.
• Board Position Statement 15.5 discusses nurses with the responsibility for initiating physician standing orders. Acts/procedures being performed must be within the scope of that particular nurse's level of licensure, and appropriate orders must be in place for acts that go beyond the practice of nursing.  This position statement outlines the differences between:
  • Standing delegation orders -written instructions, orders, or procedures that provide the authority for a plan to be implemented for patients presenting prior to being examined or evaluated by a physician; however, are intended to be used based on pre-determined criteria, cannot authorize the person carrying out the standing orders to exercise independent medical judgement, and can only be authorized by a physician.
  • Standing medical orders - written instructions, orders or procedures prepared by a physician or approved by the medical staff of an institution for patients that have been evaluated or examined by a physician, and
  • Protocols- narrowly defined by TMB and applicable only to Advanced Practice Registered Nurses (APRNs) and Physician Assistants (PAs).
• Board 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.  Nurses function under their own licenses and assume responsibility and accountability for quality, safe care in accordance with all applicable laws/rules/regulations.  Nurses do not practice under the protections of a physician’s license.  Each nurse is ultimately individually responsible for the assignments he/she accepts. Physician delegation does not provide authority for a nurse at any level of licensure to exceed the scope of practice for which he/she has been licensed and is not considered to be mitigating.
• Board Position Statement 15.23- The Use of Complementary Modalities by the LVN or RN- discusses considerations in the use of complimentary modalities (e.g. vitamin therapy) and may be helpful in further assisting with your inquiry.
• Position Statement 15.14, Duty of a Nurse in Any Practice Setting discusses a landmark court case which demonstrates that regardless of receiving orders from the appropriately licensed practitioner, the nurse's duty to keep patients safe cannot be superseded by physician orders, facility policies, or administrative directives.
• Each nurse must individually determine their scope of practice; and, the Board provides a resource for doing so, The Board’s Scope of Practice Decision-Making Model (DMM).  Board staff are rarely able to provide a simple “yes” or “no” answer to questions asked by/for nurses because every situation is different and there are many variables to consider.  The DMM is a step-by-step tool all nurses practicing in Texas can use to determine if any given task/procedure is within their individual scope of practice.  The DMM is designed to be used in sequence, beginning at the top with question number one.  In the model, nurses are asked reflective questions, and depending on how they answer, they are directed to continue through the model or stop.  When using this model, the nurse must consider if the IV therapy nursing services are consistent with current nursing evidence-based practice guidelines.  As with all nursing practice, evidence-based practice is the foundation for practice decisions.  The nurse would need to determine if performing the activity or intervention is consistent with current evidence‐based practice findings and/or guidelines or scope of practice/position statements from national nursing organizations. To do so, the nurse would need to perform a literature search and/or contact national nursing organizations/associations and/or accreditation/certification organizations for guidance as to the standard of care in a particular care delivery setting or specialty area.  In this practice setting, examples of sources of prevailing nursing standards of care, may include those published by the National Infusion Center Association (NICA) Minimum Standards for In-Office Infusions or the Infusion Nurse’s Society (INS) recommendations.  At any point, if the nurses reach a Stop Sign, he/she should consider the activity or intervention in question beyond (or outside) their scope of practice.

Please note that Board staff can only speak to the requirements for nursing practice in the State of Texas.  The Board does not have rules regarding business ownership, so we cannot advise you on this.  We would recommend you seek your own legal counsel for assistance with these matters. If you do not have legal counsel, the State Bar of Texas (not affiliated with the Texas Board of Nursing) has a Lawyer Referral and Information Service that may also be able to assist you.

References

Texas Board of Nursing. (2019). Nursing practice act. Retrieved from: https://www.bon.texas.gov/laws_and_rules_nursing_practice_act.asp

Texas Board of Nursing. (2019). Scope of practice decision-making model. Retrieved from: https://www.bon.texas.gov/pdfs/publication_pdfs/Scope%20of%20Practice%20Decision-Making%20Model%20-%20DMM.pdf

Texas Board of Nursing. (2019). Standards of nursing practice. Retrieved from: https://www.bon.texas.gov/rr_current/217-11.asp
 
 Texas Medical Board. (2019). Texas administrative code §193. Retrieved from: https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=9&ch=193&rl=1

U.S. Food & Drug Administration (2021). FDA highlights concerns with compounding of drug products by medical offices and clinics under insanitary conditions.  Retrieved from: https://www.fda.gov/drugs/human-drug-compounding/fda-highlights-concerns-compounding-drug-products-medical-offices-and-clinics-under-insanitary 

U.S. Food & Drug Administration (2018). Section 503A of the Federal Food, Drug, and Cosmetic Act.  Retrieved from: https://www.fda.gov/drugs/human-drug-compounding/section-503a-federal-food-drug-and-cosmetic-act

Added December 2022

In Texas, there are specific laws and rules related to medical cannabis. One such law is the Texas Compassionate Use Act (Senate Bill 339), enacted in the 2015 legislative session. This legislation resulted in laws and rules related to low-THC cannabis, regulated by the Texas Department of Public Safety (DPS). On the Texas DPS webpage for the Compassionate Use Program, you will find information on the laws and FAQs. For a prescription to be legal in Texas it would have to, at a minimum, meet the requirements of the laws and rules provided by the Texas DPS, as this is the entity that regulates the legal use of such substances.

Additionally, Board Rule 217.11 (Standards of Nursing Practice) outlines the minimum standards of nursing care at all levels of licensure and for all practice settings. Board staff recommend review of the rule in its entirety but some specific standards relevant to this question are:

• (1)(A) 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;
• As mentioned above, the Texas Compassionate Use Act would need to be followed for a nurse to be in compliance with all laws, rules and regulations.
• Additionally, there may be facility policies and procedures that address over-the -counter and prescription medication use by staff in the nurse’s specific practice setting. The agency/organization that regulates and/or accredits the setting may have applicable regulations as well. 

• (1)(C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same;
  • Evidence-based practice standards and guidelines related to administering medical cannabis, including low-THC products, help ensure the product is properly administered, has an appropriate rationale, and outlines the known effects on a specific patient population. Professional organizations or other health care specialty organizations may offer more specific guidance related to evidence-based practice or the standard of care for the nurse’s specific patient population or practice setting.
• (1)(N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment
  • If a nurse is questioning an order for a medication or treatment, including low-THC cannabis, it is the nurse’s responsibility to address their concerns and clarify that order with the appropriate licensed practitioner and notify the ordering practitioner if the nurse refuses to administer the medication or treatment.

In contrast to the Standards of Nursing Practice that all nurses must uphold, Board Rule 217.12 (Unprofessional Conduct) outlines actions that nurses should avoid.  It is important to note that the Board considers it to be unprofessional conduct to fail to conform to generally accepted nursing standards in applicable practice settings and accept an assignment that could result in unsafe/ineffective care [Board Rule 217.12(1)(B)&(E)].  The Board also considers careless or repetitive conduct that may endanger a patient's life, health, or safety regardless of whether there has been an actual injury as unprofessional conduct [Board Rule 217.12(4)].  It is important to take both the Standards and the Unprofessional Conduct rules hand in hand when determining licensure responsibilities in the State of Texas.

Additionally, Board Rule 217.11 (Standards of Nursing Practice) outlines the minimum standards of nursing care at all levels of licensure and all practice settings. Board staff recommend review of the rule in its entirety but some specific standards relevant to this question are:

• (1)(A) 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;
• Nurses should refer to the Texas Health and Safety Code Chapter 443 and the Consumable Hemp Program to ensure they are in compliance with all laws, rules and regulations related to CBD.
• Additionally, there may be facility policies and procedures that address over the counter and prescription medication use by staff in the nurse’s specific practice setting. The agency/organization that regulates and/or accredits the setting may have applicable regulations as well. 

• (1)(C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same;
  • Evidence-based practice standards and guidelines related to administering medical cannabis, including CBD products, help ensure the product is properly administered, has an appropriate rationale, and outlines the known effects on a specific patient population. Professional organizations or other health care specialty organizations may offer more specific guidance related to evidence-based practice or the standard of care for the nurse’s specific patient population or practice setting.

• (1)(N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment.
• If a nurse is questioning an order for any product, including CBD, it is the nurse’s responsibility to address their concerns and clarify that order with the appropriate licensed practitioner and notify the ordering practitioner if the nurse refuses to administer the medication or treatment.

In contrast to the Standards of Nursing Practice that all nurses must uphold, Board Rule 217.12 (Unprofessional Conduct) outlines actions that nurses should avoid.  It is important to note that the Board considers it to be unprofessional conduct to fail to conform to generally accepted nursing standards in applicable practice settings and accept an assignment that could result in unsafe/ineffective care [Board Rule 217.12(1)(B)&(E)].  The Board also considers careless or repetitive conduct that may endanger a patient's life, health, or safety regardless of whether there has been an actual injury as unprofessional conduct [Board Rule 217.12(4)].  It is important to take both the Standards and the Unprofessional Conduct rules hand in hand when determining licensure responsibilities in the State of Texas.

For Low-THC products:

The Texas Compassionate Use Act (Senate Bill 339) was enacted in the 2015 legislative session. This legislation resulted in laws and rules related to low-THC cannabis, which are regulated by the Texas Department of Public Safety (DPS). On the Texas DPS webpage for the Compassionate Use Program, you will find information on the laws and FAQs. For a prescription to be legal in Texas it would have to meet the requirements of the laws and rules provided by the Texas DPS, as this is the entity that regulates the legal use of such substances.

For CBD products:

The Texas Department of State Health Services (DSHS) has oversight over distribution and sale of CBD in Texas. You may find more information on the DSHS webpage, Consumable Hemp Program. Texas Health and Safety Code Chapter 443 allows distribution and retail sale of consumable hemp products in Texas, such as CBD, as long as it meets the specifications listed in Chapter 443, the Consumable Hemp Program, and any other regulations promulgated by the State of Texas.

For Low-THC and CBD products:

Concerning the use of any medication, prescribed or otherwise, Board Staff recommend review of Board Rule 213.29(f)(1). This rule discusses a nurse’s Fitness to Practice, though this specific section communicates the Board’s review of a nurse as it relates to eligibility and disciplinary actions. The Board recognizes that individuals may have a variety of medical conditions that require medical treatment and/or a medication regime that includes prescription drugs.

Although authorized by law and medically necessary, prescription drugs may affect an individual's fitness to practice. A nurse must be able to function safely while under the effects of prescription drugs. An individual who abuses their prescription drugs or who has been unable to stabilize the synergistic effect of their medications may not possess current fitness to practice. Further, some prescription medications may cause side effects that affect an individual's fitness to practice, even when taken properly. In some cases, an individual's physical condition may prevent the individual from practicing nursing safely.

Additionally, Board Rule 217.11 (Standards of Nursing Practice) outlines the minimum standards of nursing care at all levels of licensure. Board staff recommend review of the rule in its entirety but some specific standards relevant to this question are:

• (1)(A) 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;
• As mentioned above, the laws and rules related to the Texas Compassionate Use Act and Consumable Hemp Program would need to be followed in order for a nurse to be in compliance with all laws, rules and regulations.
• (1)(B) Implement measures to promote a safe environment for clients and others;
• Nurses must promote a safe environment for patients by ensuring they are capable of providing safe care.
• (1)(T) Accept only those nursing assignments that take into consideration client safety and that are commensurate with the nurse’s educational preparation, experience, knowledge, and physical and emotional abilities.
• Nurses would need to make sure that they are physically and emotionally able to accept assignments when taking medications, either over the counter or prescription.

In contrast to the Standards of Nursing Practice that all nurses must uphold, Board Rule 217.12 (Unprofessional Conduct) outlines actions that nurses should avoid.  It is important to note that the Board considers it to be unprofessional conduct to fail to conform to generally accepted nursing standards in applicable practice settings and accept an assignment that could result in unsafe/ineffective care [Board Rule 217.12(1)(B)&(E)].  The Board also considers careless or repetitive conduct that may endanger a patient's life, health or safety regardless of whether there has been an actual injury as unprofessional conduct [Board Rule 217.12(4)].  It is important to take both the Standards and the Unprofessional Conduct rules hand in hand when determining licensure responsibilities in the State of Texas.

It may also be helpful to review what the Board considers to be conduct subject to reporting.  The definition of conduct subject to reporting can be found in NPA Section 301.401 and is included below; however, you are encouraged to review this section in its entirety.  Conduct subject to reporting means conduct by a nurse that:

• Violates this chapter or a board rule and contributed to the death or serious injury of a patient;
• Causes a person to suspect that the nurse’s practice is impaired by chemical dependency or drug or alcohol abuse; or
• Constitutes abuse, exploitation, fraud, or violation of professional boundaries; or
• Indicates that the nurse lacks knowledge, skill, judgement, or conscientiousness to such an extent that the nurse’s continued practice of nursing could reasonably be expected to pose a risk of harm to a patient or another person, regardless of whether the conduct consists of a single incident or a pattern of behavior.

Resources

• Cannabis and the Law. Cannabidiol (CBD) & Industrial Hemp. Texas State Law Library. Updated May 25, 2023. https://guides.sll.texas.gov/cannabis/cbd
• Compassionate Use Program
• Consumable Hemp Program

Texas Health and Safety Code, Chapter 443, Manufacture, Distribution, and Sale of Consumable Hemp Products

Unlike manufactured drugs that have gone through the FDA evaluation and approval process, compounded drugs are not FDA-approved, and are therefore generally intended to meet the needs of a specific patient pursuant to a medical order from a practitioner.  Further, compounded drugs are typically prepared by a pharmacy or by a practitioner or practitioner’s agent in a medical setting for administration to a patient being treated on-site. Poor drug compounding practices can result in serious quality problems for the preparation, such as contamination, which can raise the risk of infection, and medication errors, such as the creation of a compounded drug that contains an inaccurate amount of active ingredients. Ultimately, poor compounding practices can lead to serious patient injury and death¹. Nurses that engage in drug compounding need to ensure a safe environment for their patients and obtain the requisite knowledge and training necessary to create compounded drugs safely and competently.

Reviewing Board Rule 217.11, Standards of Nursing Practice, is an important initial step for any practice decision. This rule establishes the minimum acceptable level of nursing practice for all nurses in every practice setting. Board Rule 217.11(1) outlines the minimum standards of nursing practice applicable to all levels of licensure (LVN, RN, and APRN). It is recommended to review of the rule in its entirety, but some specific standards relevant to this subject include:

(A) 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;

• Nurses may create compounded drugs consistent with their individual scope of practice for immediate use on-site. Nurses cannot distribute compounded drugs for use off-site. The Texas State Board of Pharmacy (TSBP) is the state agency responsible for establishing regulations for pharmacy practice and the licensing/registration of Texas pharmacists, pharmacy technicians, and pharmacies. For more information on the laws and rules that apply to the practice of pharmacy, including the regulations that apply to pharmacies engaging in sterile or non-sterile compounding, it is recommended to contact TSBP directly.

(B) Implement measures to promote a safe environment for clients and others;

• The process of drug compounding can be influenced by a multitude of intrinsic and extrinsic factors to the nurse including training, human and material resources, equipment and supplies, and facility infrastructure. If such factors are of poor quality, then the likelihood of compounded drugs being contaminated or ineffective increases thus exposing patients to significant risk of adverse events. Identifying safety concerns and advocating for patients is critical to ensuring patient safety.

(C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same;

• Nurses should have knowledge about the medications they administer and understand, in general, the rationale for administration. Compounded drugs are not approved by the FDA and their use is considered to be off-label. The drugs are being used in a way not specified in the FDA-approved labeling for the product. All prescription drugs marketed in the U.S. have an FDA-approved label, which provides detailed information on approved uses and doses, important considerations prior to administration and patient monitoring, and when applicable, specific instructions on how to prepare the product for parenteral administration (e.g., the diluent, resultant strength, and storage time).  Accordingly, if the instructions given in the approved labeling or other supplemental documents provided by the product’s manufacturer are not followed, then the preparation may be categorized as an unapproved compounded drug.    

Nurses are often the final professional to evaluate the appropriate use of a drug prior to administration. The off-label use of drugs may be supported by research and literature that addresses the necessary knowledge, required safeguards, and potential risks associated with the off-label use of the medication. If a nurse has concerns about the safety of an order and/or their ability to prepare and administer the medication correctly, the nurse has a responsibility to think critically and take action that reflects the best interest of their patients.

(G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices;

• Nurses may locate relevant policies and procedures at their place of practice for guidance on appropriate practices and procedures related to drug compounding. It may be prudent to speak with other nurses or professionals with expertise in drug compounding, such as a pharmacist. If a policy or procedure does not exist, or is not current, it may be appropriate to consider developing or updating a policy or procedure to offer guidance to nurses. If a nurse is not comfortable performing an act independently, it may be necessary that they obtain supervision to reduce the risk of error.

(H) Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations;

• Prior to drug compounding, nurses should perform a self-evaluation to ensure that they have the appropriate education and training to perform the act, and currently possess the depth and breadth of knowledge necessary to do so safely and competently. Improperly prepared, or otherwise poor quality, compounded drug products can lead to serious patient harm. The Board expects that nurses practice in accordance with the current standard of care, best practices, and evidence-based practice findings/guidelines relevant to their practice area. The United States Pharmacopeia (USP) develops standards for preparing compounded drugs to help reduce risk for contamination, infection, or incorrect dosing. In particular, USP General Chapter <797> (Pharmaceutical Compounding – Sterile Preparations) covers all facets of sterile compounding and is aimed at protecting patients. Nurses should know and conform to the national standards outlined by the USP relevant to their practice of drug compounding. Continuing education options, such as those that offer accredited certificate-based education and training in practical sterile compounding, e.g. Critical Point, can assist nurses in understanding chapters of the USP related to drug compounding.

(N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment;

• Patients under the care of a nurse are, by their very nature, vulnerable. Nurses have a duty to act in the best interest of their patients, and this dutysupersedes any physician order or employer policy. Although a nurse may not receive a detailed description of a provider’s specific rationale for an order, nurses should recognize the appropriate use of a medication for a patient through their nursing assessment. If concern for the safety of a compounded drug order exists, nurses must communicate with the ordering provider. A nurse never functions under the license of another professional, like a physician. Nurses function under their own licenses and assume responsibility and accountability for the provision of safe care.

(O) Implement measures to prevent exposure to infectious pathogens and communicable conditions;

• Compounded drugs prepared, packaged, or held under insanitary conditions place patients at risk of harm. The FDA has become increasingly aware of drug products compounded at medical offices and clinics that were prepared under insanitary conditions. Examples of insanitary conditions include but are not limited to: poor aseptic practices, using dirty equipment, and improper facility design to maintain appropriate levels of cleanliness. The use of contaminated drug products intended to be sterile has led to serious patient illnesses, hospitalization, and death².

(T) Accept only those nursing assignments that take into consideration client safety and that are commensurate with the nurse's educational preparation, experience, knowledge, and physical and emotional ability;

• Prior to creating compounded drugs, nurses need to critically assess their scope of practice. The Board’s Scope of Practice Decision-Making Model (DMM) can assist nurses in making sound scope of practice determinations. Nurses should be confident in the decisions they make and be prepared to accept accountability for the provision of safe care and the outcome of the care rendered.

Drug compounding is a practice nurses encounter in a variety of settings. The Board frequently receives inquiries about drug compounding from nurses practicing in settings that market wellness promotion services, such as intravenous (IV) hydration, also sometimes referred to as “IV vita­min therapy” or “hydration therapy”. The FDA has become aware of sterile compounding activities, including adding vitamins to IV infusion bags, being performed by business entities such as IV hydration clinics, medical spas, and mobile IV infusion companies. While such activities may suggest that the compounds being prepared will be used immediately or within a short period of time following preparation, it is unknown if drug products in these practices are being prepared, packaged, and held under sanitary conditions. Regardless, the quality standards found in the USP General Chapter <797> are intended to serve as scientifically based guidelines for any setting where sterile compounding is performed, including medical office settings or other non-pharmacy settings (e.g., ambulatory clinics, acute care settings, etc.) where a patient may receive parenteral therapy.  Again, nurses should adhere to such standards where applicable, especially those applicable to immediate-use sterile compounding (e.g., aseptic technique, vial coring, microbiology beyond-use-dating, non-microbial contamination prevention, glass ampule safety considerations, proper flush syringe use, etc.).

The Board’s article titled “IV Hydration: What Texas Nurses Need to Know”  is an additional resource for information on concerns for patient safety in IV hydration settings (Texas Board of Nursing Bulletin - July 2020, page 8). Nurses have a duty to ensure patient safety by complying with drug compounding standards. Nurses have a duty to deter other sources of risk, such as false and unsupported health claims, by clarifying orders or treatment regimens that the nurse has reason to believe are inaccurate, non-efficacious, or contraindicated. In 2018, the Federal Trade Commission (FTC) filed charges against a marketer and seller of IV therapy products in Texas for making false and unsupported health claims. In this case, the marketer and seller advertised IV therapy products to treat serious diseases such as cancer, multiple sclerosis, diabetes, and congestive heart failure. The final FTC order prohibits the company from making such claims, unless they can be supported by competent and reliable scientific evidence³. Nursing practice is evidence based and the duty of a nurse is first and foremost to their patients, not the employer or other persons [Position Statement 15.14 Duty of a Nurse in Any Practice Setting].  

It is incumbent upon every nurse to seek appropriate information, support, and resources to inform their practice decisions. Drug compounding is a process requiring attention to detail and unique knowledge, training, and skill to perform. It is critical that any manipulation of medications, particularly those required to be sterile, occurs in accordance with conditions and practices designed to prevent contamination and other quality concerns. Patients can be significantly harmed when drugs are compounded in a way in which quality or sterility cannot be assured¹. Likewise, patients can be significantly harmed if medication is not administered correctly. For additional information on this practice area it is recommended to review the Board’s FAQ addressing IV Hydration for RNs and LVNs. For more information about the USP, visit https://www.usp.org.

References

¹U.S. Food and Drug Administration. (2021, October 25). FDA highlights concerns with

compounding of drug products by medical offices and clinics under insanitary conditions. U.S. Food and Drug Administration. https://www.fda.gov/drugs/human-drug-compounding/fda-highlights-concerns-compounding-drug-products-medical-offices-and-clinics-under-insanitary?utm_medium=email&utm_source=govdelivery

²U.S. Food and Drug Administration. (2022, June 29). Compounding and the FDA: Questions &

Answers. https://www.fda.gov/drugs/human-drug-compounding/compounding-and-fda-questions-and-answers

³Federal Trade Commission. (2018, September 20). FTC brings first-ever action targeting “iv

cocktail” therapy marketer. Retrieved from: https://www.ftc.gov/news-events/news/press-releases/2018/09/ftc-brings-first-ever-action-targeting-iv-cocktail

-therapy-marketer