Nursing Jurisprudence and Ethics in Texas Nursing CE Course

ealth. It also includes maintaining health or preventing illness, as well as administering medication or treatment. Other practices include the supervision or teaching of nursing; the administration, supervision, and evaluation of practices, policies, and procedures; and the development of the nursing care plan (TX BON, 2023).

Vocational nursing is a directed scope of nursing practice, which includes the performance of an act that requires specialized judgment and skill, the proper performance of which is based on the knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of vocational nursing. The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures (TX BON, 2023).

            The following are exclusions of the general provisions:

• nursing care for the sick provided by a friend
• nursing care provided during a disaster under the state emergency management plan
• nursing care where treatment is solely by prayer or spiritual means
• an act performed by a person under the delegated authority of a provider licensed by the Texas Medical Board
• an act performed by a person licensed by another state agency, except if that person also holds a Texas license
• the practice of nursing incidental to a program of study in a nursing education program for initial licensure
• the practice of nursing by a person licensed in another state for up to 72 hr (TX BON, 2023)

Subchapter B: Texas Board of Nursing

            The Texas BON is composed of 15 members appointed by the governor. The BON includes seven nurses, three nurse faculty members, and five members of the public. A nurse appointed to the board must have practiced nursing for at least 3 of the 5 years preceding the appointment date. Nurses are represented by two APRNs, two RNs (not licensed as APRNs or working as nurse faculty), and three LVNs who are not faculty members (§301.051). Members of the public must not work in health care or have a vested interest in the healthcare industry. They also cannot be registered as lobbyists (§ 301.053). Board members serve 6-year terms (§301.054). They must attend at least half of the scheduled meetings and are paid on a per-denim basis (§ 301.055, 301.056). Board members are offered a training program that covers laws, operations, programs, functions, rules, and budgets (§ 301.059; TX BON, 2023).

Subchapter C: Executive Director and Personnel

            The BON employs an executive director (ED) who may not be a BON member (§ 301.101). The ED keeps a record of meetings and a registry of each nurse registered. The BON also employs other individuals to conduct the board’s work. The salaries of these employees are set by the board (TX BON, 2023).

Subchapter D: General Powers and Duties of the Board

            The BON has general rulemaking authority and may adopt and enforce rules as outlined in Chapter 301. The BON determines whether acts constitute the practice of professional or vocational nursing (§ 301.151). The BON adopts rules regarding specialized training, such as for APRNs, nurse first assistants, and certain nurses assisting in surgery. The BON also licenses an RN as an APRN and outlines any specialized education or training required to prescribe or order medications (§ 301.152; TX BON, 2023).

            Other rules issued by the BON include those governing advertising and competitive bidding (§ 301.153), the delegation of certain medical acts (§ 301.154), and the consequences of a criminal conviction or deferred adjudication (§ 301.1545). The BON establishes fees (§ 301.155) to cover the costs of carrying out the duties outlined in the NPA and to publish a newsletter disseminating new information to license holders (TX BON, 2023).

            In section 301.157, Programs of Study and Approval, the BON recognizes three types of programs of study for initial RN licensure. These include a baccalaureate degree program, an associate degree program, and a diploma program. The BON approves two types of programs that prepare students for initial licensure as LVNs. These programs are conducted by hospital education units and within the structure of a school. The BON prescribes the minimum course of study and regulates matters such as the use of standardized examinations in nursing programs (TX BON, 2023).

            Disciplinary action may be posted on the BON website’s nurse licensure verification page (§ 301.1583). The BON may remove a disciplinary action from the verification page if the discipline is the only action taken against the nurse, was not related to the practice of nursing, or did not result in suspension or revocation of the license; the BON may also remove the action if the nurse has completed requirements related to the disciplinary action (TX BON, 2023).

            The BON assists in enforcing disciplinary action as outlined in Chapter 301, Section 301.161. The BON may issue a subpoena, compel a witness, administer an oath for testimony, and cause the prosecution of violators. The Texas Attorney General can provide legal assistance to the BON. The BON has the authority to initiate a criminal investigation into suspected nursing-related criminal acts. The BON may also assist federal, state, or local law enforcement agencies in investigating and prosecuting crimes related to nursing practice (TX BON, 2023).

            The BON (§ 301.1615) has the authority to request and receive criminal history record information (CHRI) from the Federal Bureau of Investigation or the Department of Public Safety. A criminal history obtained by the BON may be used only by the board and is privileged information. The BON may deny the application for a license or refuse to renew a license based on an applicant’s criminal history (TX BON, 2023).

Subchapter E: Public Interest Information and Complaint Procedures

            The BON will provide the public with a description of its functions and instructions for filing complaints (§ 301.201). Procedures are established for submitting complaints, including by mail or telephone (§ 301.202). The BON maintains a system for the prompt and efficient handling of complaints and provides information regarding complaint investigation and resolution procedures (§ 301.203). The BON must ensure that complaints receive appropriate consideration before dismissal; if a complaint is dismissed, the complainant must receive a letter explaining the action taken (§ 301.204). The BON also establishes complaint-processing schedules, notifies parties of projected time requirements, and reports dismissed complaints at public Board meetings (§ 301.204). Members of the public are afforded a reasonable opportunity to appear before the BON and speak on matters under its jurisdiction (§ 301.205; TX BON, 2023).

            The BON also establishes complaint-processing schedules, notifies parties of projected time requirements, and reports dismissed complaints at public Board meetings (§ 301.204). Members of the public are afforded a reasonable opportunity to appear before the Board and speak on matters under its jurisdiction (§ 301.205; TX BON, 2023).

Subchapter F: License Requirements

            A license is required to practice professional or vocational nursing in Texas. Unless a license is held, a person cannot use the title of “Registered Nurse,” “Professional Nurse,” “Licensed Vocational Nurse,” “Vocational Nurse,” “Licensed Practical Nurse,” “Practical Nurse,” “Graduate Nurse,” or any abbreviation of these titles (§ 301.251). To obtain licensure, an applicant must submit to the BON a set of fingerprints and a completed form to obtain a criminal history record. The BON may deny a license applicant for failing to comply with this requirement (§ 301.2511). Each applicant must submit to the BON an application and evidence that the applicant has a good professional character, successful completion of a program of professional or vocational nursing, and evidence of passing the jurisprudence examination provided by the BON. The jurisprudence exam covers licensing requirements, rules, regulations, and other laws related to the nursing profession in Texas (§ 301.252; TX BON, 2023).

            An applicant must take the examination prescribed by the BON—currently, the National Council for Licensure Examination [NCLEX] is used in Texas—as long as the applicant meets the qualifications and pays the required fees (§ 301.253). A national testing service or the BON must administer the examination. The exam is designed to determine the applicant’s competence and ability to practice professional or vocational nursing. The BON determines what constitutes a passing score on the examination, but the requirements will not exceed those required by most states. The BON will notify the examinee of the exam results (§ 301.254). If the applicant fails the exam, the BON will establish conditions for the applicant to retake the exam. For an applicant who fails twice or more, the BON may require the applicant to take additional educational requirements or deny the applicant the opportunity to retake the exam (§ 301.255). Pending the exam results, the BON may issue a permit to practice professional nursing under the direct supervision of an RN or vocational nursing under the direct supervision of an RN or LVN. The permit expires upon issuance of a permanent license or 6 months after issuance. Applicants who have previously failed the exam cannot obtain a temporary permit (§ 301.258; TX BON, 2023).

            An applicant licensed as an RN or LVN in another state may qualify for a temporary license to practice in Texas by submitting an endorsement fee, a completed sworn application, evidence that they possess the qualifications for licensing in Texas, and proof of initial license by examination. The applicant must have no history of license suspension, surrender, restriction, cancellation, or revocation by another state (§ 301.260; TX BON, 2023).

            Nurses not actively engaged in professional or vocational nursing may have their license placed on inactive status by the BON (§ 301.261). This status is applied after the licensee submits a written request to the BON. A person with an inactive license may reactivate it by requesting that the BON remove the inactive status, paying a fee, and meeting requirements set by the TX BON (2023).

Subchapter G: License Renewal

            A person may renew an unexpired license by paying a renewal fee to the BON before the expiration date and in compliance with any other renewal requirements. Texas has a 2-year licensure period. A person with an expired license for 90 days or less may renew that license by paying an additional late fee. For licenses that have expired for more than 90 days but less than 1 year, renewal requires payment of the renewal fee and a late fee equal to twice the original late fee. Practicing professional or vocational nursing after the expiration date is illegal and may result in the license being revoked or suspended (§ 301.301). If the nurse has an expired Texas license but has been practicing nursing in another state for the 2 years preceding the application, they may renew their expired Texas license by paying an initial license fee and a renewal fee (§ 301.302; TX BON, 2023).

            The BON requires continuing competency as a condition of license renewal (§ 301.303). In general, most nurses must complete 20 hr of continuing education over a 2-year licensure period or maintain national nursing certification in their area of practice. APRNs and certain other licensees may be subject to additional continuing education requirements (TX BON, 2023). The current targeted recommendations and continuing education program requirements for Texas licensees are listed in Table 1.

Table 1

Texas Nursing Continuing Education Requirements

Recommended Licensee	Type of Continuing Education	Requirement
All license holders	Continuing nursing education in the nurse’s area of practice (§ 301.303)	20 contact hours every 2 years
APRN treating tick-borne illnesses	Related to tick-borne illnesses (§ 301.304)	2 contact hours every licensing period (recommended)
All license holders	Nursing jurisprudence and nursing ethics (§ 301.305)	2 contact hours every third 2-year license period (required)
License holders employed in the emergency room setting	Forensic evidence collection (§ 301.306)	2 contact hours within 2 years of initial employment in the ER setting (required once)
License holders treating older adults	Older adult or geriatric care (§ 301.307)	2 contact hours every 2 years or maintenance of certification in the area of practice (required)
License holders providing direct patient care	Human trafficking prevention course (§ 301.308)	Every 2 years, the course must be approved by the executive commissioner of Health and Human Services (required)
APRN with prescriptive authority	Pharmacotherapeutics (§ 216.3)	5 additional contact hours in pharmacotherapeutics every licensing period (required)
APRN with prescriptive authority agreement authorizing opioids	Safe and effective pain management (related to the prescribing of opioids and other controlled substances; § 216.3)	2 contact hours annually, for a total of 4 contact hours every licensing period (required)
LVN/RN volunteer retired (VR) Nurse	Continued nursing education in the area of practice (§ 216.3)	10 contact hours within 2 years before the application for renewal of VR status
APRN VR Nurse	Continued nursing education in the area of practice (§ 216.3)	20 contact hours within 2 years before the application for renewal of VR status

(TX BON, 2019, 2023, 2024)

Subchapter H: Practice by License Holder

            When practicing nursing for the public, nurses are expected to wear a legible insignia identifying their nursing designation. The badge may include only the RN/LVN designation, the nurse’s name, certifications, degrees, position, employer, a picture, or additional board-authorized information (§ 301.351). A nurse cannot be suspended, terminated, disciplined, or discriminated against for refusing to engage in an act or omission of patient care that would constitute grounds for reporting or a violation of the NPA (§ 301.352). Nurses may not be penalized for refusing to work mandatory overtime, as this does not constitute patient abandonment or neglect (§ 301.356). The practice of vocational nursing must be performed under the supervision of an RN, a healthcare provider (HCP), an HCP assistant, a podiatrist, or a dentist (§ 301.353; TX BON, 2023).

Subchapter I: Reporting Violations and Patient Care Concerns

            A report is made in good faith if the nurse making the report believes (a) it is required or authorized and (b) there is a reasonable legal basis for that belief (§ 301.4011). A nurse must report another nurse if there is reasonable cause to suspect that the other nurse has engaged in conduct subject to reporting, is a student unable to perform services of the nursing profession, or is impaired by chemical dependency. The report must be written and signed (§ 301.402). A nurse may report a practitioner, agency, or facility if there is reasonable cause to believe they have exposed a patient to a substantial risk of harm (§ 301.4025). The BON also states that it is the duty of peer review committees (§ 301.403), nursing education programs (§ 301.404), employers (§ 301.405), professional associations (§ 301.406), state agencies (§ 301.407), and liability insurers (§ 301.408) to report a licensed nurse or nursing student for conduct subject to review, termination, or suspension, chemical misuse, or failure to provide nursing care. Prosecuting attorneys should forward to the BON a court record of any convictions of a felony or misdemeanor involving moral turpitude, violation of narcotic or controlled substance laws, Medicare or Medicaid fraud or abuse, or a finding that the nurse is mentally ill or incompetent. The nurse will receive notice of what was reported to the board and be allowed to submit a written rebuttal (§ 301.409). If the BON determines it is necessary, an investigation will occur. The BON will decide whether the licensee’s continued nursing practice poses a risk of harm. If the BON chooses not to investigate, it will maintain a record of the report. These reports may be investigated if there are two or more similar reports within 5 years (§ 301.4105, 301.416; TX BON, 2023).

Subchapters J-L: Prohibited Practices, Disciplinary Actions, and Penalties

            A person is subject to license refusal or disciplinary action for the following reasons:

• a violation of this chapter, a rule or regulation not inconsistent with this chapter, or an order issued under this chapter
• fraud or deceit in procuring or attempting to procure a license to practice professional nursing or vocational nursing
• a conviction for, or placement on deferred adjudication community supervision or deferred disposition for, a felony or for a misdemeanor involving moral turpitude
• conduct that results in the revocation of probation imposed because of conviction for a felony or a misdemeanor involving moral turpitude
• use of a nursing license, diploma, permit, or school transcript that has been fraudulently purchased, issued, counterfeited, or materially altered
• impersonating or acting as a proxy for another person in the licensing examination required under section 301.253 or 301.255
• directly or indirectly aiding or abetting an unlicensed person in connection with the unauthorized practice of nursing
• revocation, suspension, or denial of, or any other action relating to, the person’s license or privilege to practice nursing in another jurisdiction or under federal law
• intemperate use of alcohol or drugs that the board determines endangers or could endanger a patient
• unprofessional conduct in the practice of nursing that is likely to deceive, defraud, or injure a patient or the public
• adjudication of mental incompetency
• a lack of fitness to practice because of a psychological or physical health condition that could result in injury to a patient or the public
• failure to care adequately for a patient or to conform to the minimum standards of acceptable nursing practice in a manner that, in the board’s opinion, exposes a patient or another person unnecessarily to risk of harm
• abandonment or endangering an older adult or patient with a disability (§ 301.451, 301.452, 301.253, 301.255; TX BON, 2023)

A person may also be denied admission to the licensing examination for the behaviors listed above. The BON may require a nurse or applicant to undergo a physical or psychological evaluation only if the BON has probable cause to believe they have a physical or mental impairment or chemical dependency that would affect patient care. The BON will also temporarily suspend a nurse’s license if the nurse tests positive for alcohol or a prohibited drug, refuses to comply with a BON drug or alcohol test, or fails to participate in the peer assistance program, or if the program issues a letter of dismissal (§ 301.4521; TX BON, 2023).

The BON’s decision to suspend or restrict a license is made by a simple majority vote, based on the evidence presented (§ 301.455). A proceeding is initiated by a written complaint. A preliminary investigation will be conducted. If probable cause is found, the BON will file formal charges against the nurse. The BON will determine whether a continuing and imminent threat to public welfare exists if the nurse continues to practice. The nurse must appear in person or by counsel at a formal hearing (§ 301.457). If the BON determines that cause for disciplinary action exists, one or more of the following will be imposed (§ 301.453):

• denial of an application for a license or renewal
• written warning
• public reprimand
• limitation or restriction of license
• suspension of license
• revocation of license
• monetary fine or administrative penalty (TX BON, 2023)

If the BON decides on disciplinary action, including warnings and reprimands, it will send a copy of the final order to the nurse and the nurse’s last known employer. If the BON suspends or revokes a license, or the nurse surrenders their license, the BON may impose conditions for reinstatement that must be met before a new license is issued. For administrative penalties, the person can pay the penalty or file a petition for judicial review to appeal the decision. If the court rules that the penalty is not sustained, it will order that the penalty is not owed. Administrative penalties accrue interest. If a person is found in violation of the NPA, they may be liable for a civil or criminal penalty, depending on the violation (§ 301.453; TX BON, 2023).

Subchapter M: Anesthesia in the Outpatient Setting

            The BON establishes minimum standards for anesthesia services. These rules are designed to protect the public’s health, safety, and welfare. They do not apply to local anesthesia or peripheral nerve blocks; to a licensed hospital; to a licensed ambulatory surgical center; to a clinic on Native North American land; to a state- or local-government-owned facility; or to an outpatient setting accredited by other accrediting bodies (§ 301.603). Any certified registered nurse anesthetist providing anesthesia services in an outpatient setting must comply with the rules adopted by the BON (§ 301.605). The nurse anesthetist must also register biennially and pay a fee (§ 301.604). The BON may conduct inspections to enforce these rules (§ 301.606; TX BON, 2023).

Subchapter N: Corrective Action Proceeding and Deferred Action

            Corrective action may include a fine, remedial education, or a combination of both, imposed on the licensee. It is not considered a disciplinary action and is subject to disclosure like a complaint (§ 301.652). Deferred action is an action against a licensee that is postponed to a later date (§ 301.651). The BON may defer the final action if the licensed individual complies with specified conditions imposed by the BON. The BON may also dismiss the complaint if the licensee successfully meets those conditions (§ 301.655; TX BON, 2023).

Chapter 303: Nursing Peer Review

            The Nursing Peer Review Committee (NPRC) is established under the authority of a governing body to conduct peer reviews of nurse employees. The governing body may be a nurse association, an agency, a nursing home, a health care facility, or a similar entity. A peer review evaluates nursing services, a nurse’s qualifications, the quality of patient care, or the merits of complaints (§ 303.001). The committee will provide the nurse under review with due process, including notice and an opportunity for a hearing, and then make recommendations regarding complaints (§ 303.002). An NPRC must have nurses as three-fourths of its members. An NPRC that reviews VNs must include VNs as members. An NPRC that conducts peer reviews of RNs must have RNs as two-thirds of its members (§ 303.003). Peer review proceedings are confidential, and all communications are privileged. The NPRC will evaluate a nurse’s conduct and determine the extent to which a deficiency in care resulted from deficiencies in the nurse’s judgment, knowledge, training, or skill. A nurse who requests a peer review in good faith cannot be disciplined or retaliated against (§ 303.006, 303.009, 303.011; TX BON, 2023).

Chapter 304: Nurse License Compact

            Nurses with multistate licenses can practice in other states that are part of the Nurse Licensure Compact. Each state will recognize a multistate license to practice registered or practical nursing issued by a home state under the multistate licensure privilege and allow the nurse to practice as an RN or a VN, as specified on the license. A nurse practicing in a state under the multistate license must comply with the state practice act of the state where the patient receives treatment when service is provided (Article III). The home state will be contacted if the party state takes action against the nurse. The Texas BON will take action against a nurse using the same procedures as for nurses practicing in Texas (Article V). If a nurse moves their primary residence to another party state, the nurse must apply for licensure in the new home state, and the multistate license issued by the old state will be deactivated (Article IV; TX BON, 2023). Starting in 2024, after relocating to another compact state, nurses have 60 days to apply for a new license in the new primary state or residence (TX BON, n.d.-c).

Texas Board of Nursing Administrative Code

            The Texas BON Administration Code governs nursing practice, education, licensure, safety, reporting, and pain management. We will now highlight the chapters discussing nursing practice, ethics, and disciplinary action (TX BON, 2024).

Section 217.11: Standards of Practice

            The Texas BON has standards of practice that establish a minimum acceptable level of nursing. Failure to meet these standards can result in action taken against the licensee, even if no patient injury occurred. The standards that apply to all nurses, as listed in Section 217.11, include:

• know and conform to the Texas NPA and the BON’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
• implement measures to promote a safe environment for patients and others
• know the rationale for and the effects of medications and treatments and correctly administer the same
• accurately and completely report and document:
• the patient’s status, including signs and symptoms
• nursing care rendered
• HCP, dentist, or podiatrist orders
• administration of medications and treatments
• patient response(s)
• contacts with other health care team members concerning significant events regarding the patient’s status
• respect the patient’s right to privacy by protecting confidential information unless required or allowed by law to disclose the information
• promote and participate in education and counseling to a patient(s) and, where applicable, the family/significant other(s) based on health needs
• obtain instruction and supervision as necessary when implementing nursing procedures or practices
• make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations
• notify the appropriate supervisor when leaving a nursing assignment
• know, recognize, and maintain professional boundaries of the nurse-patient relationship
• comply with mandatory reporting requirements of the Texas Occupations Code Section 301 (NPA), Subchapter I, which include reporting a nurse:
• who violates the NPA or a board rule and consequently contributes to the death or serious injury of a patient
• whose conduct causes a person to suspect that the nurse’s practice is impaired by chemical dependency or drug or alcohol misuse
• whose actions constitute abuse, exploitation, fraud, or a violation of professional boundaries
• whose actions indicate that the nurse lacks knowledge, skill, judgment, or conscientiousness to such an extent that the nurse’s continued practice 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
• except for minor incidents, peer review, or peer assistance if no practice violation has occurred, as stated in the NPA and board rules
• provide, without discrimination, nursing services regardless of the age, disability, economic status, gender, national origin, race, religion, health problems, or sexual orientation of the patient served
• institute appropriate nursing interventions that might be required to stabilize a patient’s condition and/or prevent complications
• clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, nonefficacious, 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
• implement measures to prevent exposure to infectious pathogens and communicable conditions
• collaborate with the patient, members of the health care team, and, when appropriate, the patient’s significant other(s) in the interest of the patient’s health care
• consult with, utilize, and make referrals to appropriate community agencies and health care resources to provide continuity of care
• be responsible for one’s continuing competence in nursing practice and individual professional growth
• make assignments to others that take into consideration patient 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
• accept only those nursing assignments that take into consideration patient safety and that are commensurate with the nurse’s educational preparation, experience, knowledge, and physical and emotional ability
• supervise nursing care provided by others for whom the nurse is professionally responsible
• ensure the verification of current Texas licensure or other compact state licensure privileges and credentials of personnel for whom the nurse is administratively responsible when acting as a nurse administrator (TX BON, 2024)

Standards Specific to LVNs

            The LVN practice is a directed scope of nursing practice under the supervision of an RN, APRN, HCP assistant, HCP, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of the performance of an activity. The LVN shall assist in determining patients’ predictable health care needs within health care settings and perform the standards applicable to vocational nurses. As listed in Section 217.11, an LVN:

• shall utilize a systematic approach to provide individualized, goal-directed nursing care by:
• collecting data and performing focused nursing assessments
• participating in the planning of nursing care needs for patients
• participating in the development and modification of the comprehensive nursing care plan for assigned patients
• implementing appropriate aspects of care within the LVN’s scope of practice
• assisting in the evaluation of the patient’s responses to nursing interventions and the identification of the patient’s needs
• shall assign specific tasks, activities, and functions to unlicensed personnel commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made and shall maintain appropriate supervision of unlicensed personnel
• may perform other acts that require education and training as prescribed by board rules and policies, commensurate with the LVN’s experience, continuing education, and demonstrated LVN competencies (TX BON, 2024)

Standards Specific to RNs

            The RN shall assist in determining patients’ health care needs and perform the standards applicable to RNs. As listed in Section 217.11, an RN shall:

• utilize a systematic approach to provide individualized, goal-directed nursing care by:
• performing comprehensive nursing assessments regarding the health status of the patient
• making nursing diagnoses that serve as the basis for the strategy of care
• developing a plan of care based on the assessment and nursing diagnosis
• implementing nursing care
• evaluating the patient’s responses to nursing interventions
• delegate tasks to unlicensed personnel in compliance with Section 224 of this title, relating to patients with acute conditions or in acute care environments, and Section 225 of this title, relating to independent living environments for patients with stable and predictable conditions (TX BON, 2024)

Standards Specific to RNs with Advanced Practice Authorization 

            Standards for a specific role and specialty of an advanced practice nurse supersede RN standards if a conflict arises. In addition to paragraphs 1 and 3 of this subsection, an RN who holds authorization to practice as an APRN shall perform the standards as listed in Section 217.11:

• practice in an advanced nursing practice role and specialty in accordance with the authorization granted by the board
• prescribe medications following the prescriptive authority granted under the board with standards set by the NPA and in compliance with state and federal laws and regulations relating to the prescription of dangerous drugs and controlled substances (TX BON, 2024)

Section 217.12: Unprofessional Conduct

            Nursing has been voted the most trusted profession in the United States for the past 24 years (American Nurses Association [ANA], 2026). Nurses have a code of ethics that guides the members of the profession. The nursing code of ethics was established by the ANA and state boards of nursing (ANA, 2025).

            Nurses should be aware of these four common foundational ethical principles used in nursing ethics. These principles are as follows:

• autonomy—recognizing each individual’s right to self-determination and decision-making
• beneficence—acting for the good and welfare of others with attributes such as kindness and charity, also defined as actions guided by compassion
• justice—having an element of fairness in all medical and nursing decisions and care
• nonmaleficence—doing no harm by selecting interventions that will cause the least harm to the patient (Potter et al., 2026)

            There are ten main provisions in the ANA’s nursing code of ethics. This code of ethics includes an interpretive statement that provides more specific guidance for a nurse’s practice. These provisions of the nursing code of ethics are as follows (ANA, 2025):

1. The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.
2. The nurse’s primary commitment is to the recipient(s) of nursing care, whether an individual, family, group, community, or population.
3. The nurse establishes a trusting relationship and advocates for the rights, health, and safety of the recipient(s) of care.
4. Nurses have authority over nursing practice and are responsible and accountable for their practice consistent with their obligations to promote health, prevent illness, and provide optimal care.
5. The nurse has moral duties to self as a person of inherent dignity and worth, including an expectation of a safe place to work that fosters flourishing, authenticity of self at work, and self-respect through integrity and professional competence.
6. Nurses, through individual and collective effort, establish, maintain, and improve the ethical environment of the work setting that affects nursing care and the well-being of nurses.
7. Nurses advance the profession through multiple approaches to knowledge development, professional standards, and the generation of policies for nursing, health, and social concerns.
8. Nurses and their professional organizations work to enact and resource practices, policies, and legislation to promote social justice, eliminate health inequities, and facilitate human flourishing.
9. The nursing profession, collectively through its professional organization, must articulate nursing values, maintain the profession’s integrity, and integrate principles of social justice into nursing and health policy.
10. Nursing, through organizations and associations, participates in the global nursing and health community to promote human and environmental health, well-being, and flourishing.

            Safe and ethical nursing practice requires knowledge of the laws governing nursing and the avoidance of unprofessional conduct. The following rules, found in Section 217.12, are used by the Texas Secretary of State to identify behaviors in nursing practice that are likely to deceive, defraud, or injure patients or the public.

• unsafe practice—actions or conduct including, but not limited to:
• carelessly failing, repeatedly failing, or exhibiting an inability to perform vocational, registered, or advanced practice nursing in conformity with the standards of a minimum acceptable level of nursing practice set out in §217.11 of this chapter
• failing to conform to generally accepted nursing standards in applicable practice settings
• improper management of patient records
• delegating or assigning nursing functions or a prescribed health function when the delegation or assignment could reasonably be expected to result in unsafe or ineffective patient care
• accepting the assignment of nursing functions or a prescribed health function when the acceptance of the assignment could be reasonably expected to result in unsafe or ineffective patient care
• failing to supervise the performance of tasks by any individual working under the nurse’s delegation or assignment
• failure of a clinical nursing instructor to supervise or to ensure adequate supervision of student experiences
• failure of a chief administrative nurse to follow standards and guidelines required by federal or state law or regulation or by facility policy in providing oversight of the nursing organization and nursing services for which the nurse is administratively responsible
• failure to practice within a modified scope of practice or with the required accommodations, as specified by the board, in granting an encumbered license or any stipulated agreement with the board
• conduct that may endanger a patient’s life, health, or safety
• inability to practice safely—a demonstration of actual or potential inability to practice nursing with reasonable skill and safety to patients because of illness, use of alcohol, drugs, chemicals, or any other mood-altering substances, or as a result of any mental or physical condition
• misconduct—actions or conduct that include, but are not limited to, the following:
• falsifying reports, patient documentation, agency records, or other documents
• failing to cooperate with a lawful investigation conducted by the board
• causing or permitting physical, emotional, or verbal abuse or injury or neglect to the patient or the public, or failing to report the same to the employer, appropriate legal authority, and/or licensing board
• violating professional boundaries of the nurse/patient relationship, including but not limited to physical, sexual, emotional, or financial exploitation of the patient or the patient’s significant other(s)
• engaging in sexual conduct with a patient, touching a patient in a sexual manner, requesting or offering sexual favors, or demonstrating language or behavior suggestive of the same
• threatening or violent behavior in the workplace
• misappropriating, in connection with the practice of nursing, anything of value or benefit, including, but not limited to, any property—real or personal—of the patient, employer, or any other person or entity, or failing to take precautions to prevent such misappropriation
• providing information that was false, deceptive, or misleading in connection with the practice of nursing
• failing to answer specific questions or providing false or misleading answers in a licensure or employment matter that could reasonably affect the decision to license, employ, certify, or otherwise utilize a nurse
• offering, giving, soliciting, or receiving or agreeing to receive, directly or indirectly, any fee or other consideration to or from a third party for the referral of a patient in connection with the performance of professional services
• failure to pay child support payments as required by the Texas Family Code
• drug diversion—the diversion or attempts to divert drugs or controlled substances
• dismissal from a board-approved peer assistance program for noncompliance and referral by that program to the board
• other drug-related actions or conduct that include, but are not limited to, the following:
• use of any controlled substance or any drug, prescribed or unprescribed, or device or alcoholic beverages while on duty or on call, and to the extent that such use may impair the nurse’s ability to conduct safely to the public the practice authorized by the nurse’s license
• falsification of or making incorrect, inconsistent, or unintelligible entries in any agency, patient, or other record pertaining to drugs or controlled substances
• failing to follow the policy and procedure in place for the wastage of medications at the facility where the nurse was employed or working at the time of the incident(s)
• a positive drug screen for which there is no lawful prescription
• obtaining or attempting to obtain or deliver medication(s) through means of misrepresentation, fraud, forgery, deception, and/or subterfuge
• unlawful practice-actions or conduct that include, but are not limited to, the following:
• knowingly aiding, assisting, advising, or allowing an unlicensed person to engage in the unlawful practice of vocational, registered, or advanced practice nursing
• violating an order of the board; carelessly or repetitively violating a state or federal law relating to the practice of vocational, registered, or advanced practice nursing; or violating a state or federal narcotics or controlled substance law
• aiding, assisting, advising, or allowing a nurse under board order to violate the conditions set forth in the order
• failing to report violations of the Nursing Practice Act and/or the board’s rules and regulations
• leaving a nursing assignment, including a supervisory assignment, without notifying the appropriate personnel (TX BON, 2024)

            Beginning in 2026, Senate Bill 912 required the TX BON to establish a continuing education tracking system to verify nurses’ compliance with continuing competency requirements, resulting in amendments to the BON’s Continuing Competency Rules (Chapter 216; TX BON, n.d.-a, 2024).

Board of Nursing Position Statements

            The BON uses position statements to provide expert guidance on issues that affect its members. These position statements provide nurses with relevant information on nursing practice but are not legally enforceable. The Texas BON reviews and updates its position statements annually to ensure clinical accuracy. Twenty-nine position statements guide the nurse’s role, carrying out orders, and ensuring patient protection during care. For example, this module will highlight position statement 15.29 on professional boundaries, including the use of social media by nurses (TX BON, 2026).

Texas BON Position Statement on Professional Boundaries

This position statement aims to provide guidance on professional boundaries and to help nurses prevent violations of them. This section also addresses social media. The Texas BON expects all nurses to know, recognize, and maintain professional boundaries with their patients. Professional boundaries are defined as “appropriate limits which should be established by the nurse in the nurse/patient relationship due to the nurse’s power and the patient’s vulnerability” (TX BON, 15.29 para. 1, 2026).

Professional boundaries promote the patient’s dignity and self-determination while preventing inappropriate involvement in patient relationships. They also prohibit the nurse from gaining at the patient’s expense. Professional boundaries can be viewed as the space between the nurse’s power and the patient’s vulnerability. Nurses hold a professional position and have access to sensitive personal information. An imbalance of power arises from the difference between the personal information the nurse knows about the patient and what the patient knows about the nurse. Nurses must respect this power imbalance and ensure a patient-centered relationship (National Council of State Boards of Nursing, n.d.; TX BON, 2026).

            Patients rely on nurses to have adequate knowledge and to advocate for their health care. The nurse must protect the patient and recognize that both over- and underinvolvement can harm the patient. The nurse is responsible for understanding the appropriate boundaries for each patient, as each patient is different. Care should be adjusted to each patient’s needs (TX BON, 2026).

            A violation of professional boundaries is included in the BON statute for conduct subject to reporting. A professional boundary violation is also considered unprofessional conduct, as defined by the TAC. Professional boundary violations include physical, sexual, emotional, and financial violations (TX BON, 2024, 2026).

            Nurses have access to personal information and play a significant role in transmitting and interpreting it. As technology and social media expand, rapid information exchange can pose risks to patients and nurses. The BON recognizes that social media can be a valuable tool in health care but that inappropriate use can have multiple consequences. Online postings can harm patients if they disclose protected health information. Social media postings may also reflect negatively on individual nurses, the nursing profession, or employers. The BON has articulated the following position on the use of social media (TX BON, 2026):

• Nurses have an ethical and legal obligation to always maintain patient privacy and confidentiality. When using social media, nurses do not identify patients by name or post or publish information that may lead to patient identification. Limiting access to postings through privacy settings is not sufficient to ensure privacy. Nurses must promptly report any identified breach of confidentiality or privacy.
• Nurses maintain professional boundaries in the use of electronic media. The nurse must establish, communicate, and enforce professional boundaries with patients online. Nurses do not refer to patients disparagingly, even if the patient is not identified, or transmit information that may be reasonably anticipated to violate patient rights to confidentiality or privacy or otherwise degrade or embarrass the patient.
• Nurses must provide nursing services without discrimination and not make threatening, harassing, profane, obscene, sexually explicit, racially derogatory, homophobic, or other offensive comments.
• Nurses must be aware of and comply with all laws and rules, including employer policies regarding using electronic devices, such as employer-owned computers, cameras, and personal devices in the workplace. In addition, nurses must ensure appropriate and therapeutic use of all patient-related electronic media—including patient-related images, photos, or videos—per applicable laws, rules, and institutional policies and procedures.

References

American Nurses Association. (2025). Provisions. https://codeofethics.ana.org/provisions

American Nurses Association. (2026, January 12). Nurses ranked most trusted profession for 24th consecutive year. [Press release]. https://www.nursingworld.org/news/news-releases/2026-news-releases/nurses-ranked-most-trusted-professionals-for-24th-consecutive-year/

Bayuo, J., Wong, A. K. C., & Wong, F. K. Y. (2025). Legal precedents and nursing: Implications of four key court findings for the future of nursing jurisprudence in the United States. Nursing Outlook, 73(3), Article 102427. https://doi.org/10.1016/j.outlook.2025.102427

National Council of State Boards of Nursing. (n.d.). Professional boundaries. Retrieved July 27, 2026, from https://www.ncsbn.org/nursing-regulation/practice/professional-boundaries.page

Potter, P. A., Perry, A. G., Stockert, P. A., Hall, A., & Ostendorf, W. R. (2026). Fundamentals of nursing (12th ed.). Elsevier.

Texas Board of Nursing. (n.d.-a). Current CNE tracking information. Retrieved July 24, 2026, from https://www.bon.texas.gov/CNE_Tracking_Information.asp.html

Texas Board of Nursing. (n.d.-b). History—Texas board of nursing. Retrieved July 24, 2026, from https://www.bon.texas.gov/history.asp.html

Texas Board of Nursing. (n.d.-c). Licensure—Endorsement information. Retrieved July 27, 2026, from https://www.bon.texas.gov/licensure_endorsement.asp.html

Texas Board of Nursing. (n.d.-d). Mission and values. Retrieved July 24, 2026, from https://www.bon.texas.gov/about_mission_and_values.asp.html

Texas Board of Nursing. (2019). Education—Continuing competency requirements. Retrieved July 25, 2026, from https://www.bon.texas.gov/education_continuing_education.asp.html#Z

Texas Board of Nursing. (2023). Nursing practice act, nursing peer review, & nurse licensure compact: Texas occupations code as amended September 2023. https://www.bon.texas.gov/pdfs/law_rules_pdfs/nursing_practice_act_pdfs/NPA2023.pdf

Texas Board of Nursing. (2024). Rules and regulations relating to nurse education, licensure and practice. https://www.bon.texas.gov/pdfs/law_rules_pdfs/rules_regulations_pdfs/December%202024%20Rules%20and%20Regulations.pdf

Texas Board of Nursing. (2026). Texas Board of Nursing board position statements. https://www.bon.texas.gov/pdfs/practice_dept_pdfs/position_statements_pdfs/BON%20Position%20Statements%202026.pdf

           

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