Texas Board of Nursing

  As a future Primary Mental Health Nurse Practitioner (PMHNP), it is essential to understand your state definition of a nurse practitioner along with the scope of practice, collaboration, and qualifications required by law. The purpose of this post is to summarize findings for the state of Texas and explain the different types of regulations that exist and the barriers that may have an impact when practicing independently as a PMHNP in the state of Texas.

Summary of the State of Texas

            The requirements to become certified and licensed as an Advanced Practice Registered Nurse (APRN) in the state of Texas, you must have a Registered Nurse (RN) license, a graduate degree in a Nurse Practitioner (NP) role, and national certification (American Association of Nurse Practitioners, 2020). Once these requirements have been met, an application can be submitted through the Texas Board of Nursing (TXBON) (Texas Board of Nursing, 2020). This APRN application can be submitted with prescriptive authority and can be completed online at www. Bon.tx.gov along with a 150.00 fee (Texas Board of Nursing, 2020). Once receiving this prescriptive authority, the Drug Enforcement Administration (DEA) is then contacted to obtain a DEA number so an APRN can prescribe, dispense, or administer schedule II-controlled substances. This DEA number for new APRNs can be completed online through the US Department of Justice on their website (Diversion Control Division, 2020). Texas is one of the 49 states that have a prescription monitoring program (PMP). The Texas State Board of Pharmacy manages this program, collecting and monitoring prescription data that any Texas pharmacy has dispensed for controlled substances of Schedule II, III, IV, V (Texas Prescription Monitoring Program, 2020).

            According to the scope of practice in Texas, Nurse Practitioners can provide a broad range of health services in a variety of settings if the NP is practicing within their practice specialty and role (Buppert, 2022). However, Texas also defines its scope of practice for an NP as limited, meaning that NP must practice under the supervision of a physician (Texas Board of Nursing, 2020). The NPS in Texas is authorized to work as independent healthcare professions in their graduate degree programs such as PMHNP if they are supervised by a physician within a 75-mile radius (Texas Board of Nursing, 2020).  

            The Texas state practice agreement reduces the ability for NPs to engage in at least one element of practice, such as NPs are currently not authorized to sign a Do Not Resuscitate Order (DNR) (American Association of Nurse Practitioners, 2020). This practice agreement in Texas requires an agreement with another health provider for the NP to provide any such patient care (American Association of Nurse Practitioners, 2020).  

Barriers that Could cause an Impact

            Due to Texas being regulated under the guidelines as limited, this may have an impact on APRNs, such as not being able to sign Do Not Resuscitate Orders (DNR) (Peterson, 2017). An example of this is a client wanting to become a DNR and a physician not signing off. Before this DNR is complete, the client requires CPR; even though the NP is aware of her client’s wishes, CPR must be initiated on her client sustaining the life due to this barrier of not signing the DNR herself. Another barrier would be an NP not writing a prescription that is needed due to the Schedule II Control Substance Prescriptive Authority (Peterson, 2017). There could be times when this would be needed, but due to it not being a selected setting or practice type, this may not be authorized, causing a complication or specific need for a patient.

Surprising

            When reading information this week for this assignment, I found it surprising that an APRN is authorized in the state of Texas to sign death certificates but unable to sign a DNR that could keep a client from death (American Association of Nurse Practitioners, 2020). I also found it surprising that a physician could be within a 75-mile radius for an APRN to practice within their scope (Texas Board of Nursing, 2020). I was under the impression that a physician needed to be in the existing facility when an NP was practicing.

            As future APRNs, we must know our state definition of a nurse practitioner and understand the scope of practice and the qualifications required by law. Understanding these regulations to practice within our states allows us to provide the safest environment for our clients and ourselves.

References

American Association of Nurse Practitioners. (2020). State practice environmenthttps://www.aanp.org/advocacy/state/state-practice-environment.

Buppert, C. (2022). Chapter 2 Nurse Practitioner Scope of Practice. In Nurse practitioner’s business practice and Legal Guide (Seventh, pp. 93–94). essay, Jones & Bartlett Learning.

Diversion Control Division. (2020). Application for Registration Under Controlled Substances Act of 1970. CSA registration tools: Login. Retrieved December 1, 2021, from https://apps.deadiversion.usdoj.gov/webforms2/spring/main?execution=e1s1.

Peterson, M. E. (2017). Barriers to practice and the impact on Health Care: A nurse practitioner focus. Journal of the Advanced Practitioner in Oncology, 8(1). https://doi.org/10.6004/jadpro.2017.8.1.6

Texas Board of Nursing. (2020). Texas Board of Nursing. Retrieved December 1, 2021, from https://www.bon.texas.gov/newaprn.asp.

Texas Prescription Monitoring Program. (2020). State Funding for PMP EHR Integration Ending. Texas Prescription Monitoring Program. Retrieved November 29, 2021, from https://txpmp.org/about.

unlike Massachusetts, Texas PMHNP can only practice under the supervision of physicians and these requirements means  NPs can collaborate with physicians and make diagnosis and prescribe medication to patients, hence NPs are prohibited by the law in Texas to practice beyond 75 miles radius of physician location. (Wofford, 2016). As a result of this legislature many patients in the urban,suburban, rural or countryside of the state are suffering or finding it difficult to receive adequate treatment simply because of a shortage of health practitioners that would have otherwise been available to open practice in many of these areas in the state that is experiencing shortage of medical personnel. The reason for not allowing NPs to practice on their own or being given Full Practice Authority is yet to be known because it is the same NPs that work effectively with the physicians when they are around that are not allowed to practice on their own or open a practice of their own. (Brassard & Smolenski, 2011). It simply does not make any sense especially with the increase in population in the state and yet refuse to change this ridiculous legislature that just makes it hard for many Texans to have access to quality service where they reside

       Several physician professional organizations in the U.S., such as the American Medical Association, function under the assumption that since physicians undergo a more rigorous and more prolonged medical training, NPs are less capable of offering quality care in the same degree and manner as physicians. Such perspectives might impede the relationships between NPs and physicians, which can hinder the provision of quality care. On numerous occasions, healthcare professionals and physicians often lack knowledge concerning NP’s scope of practice. The problem in Massachusetts is more likely to occur given that NPs have currently received the mandate to operate independently. Although NPs and physicians have similar work goals, a lack of collaboration still exists. Secondly, some institutions follow the traditional medical hierarchal model that acts as a barrier to providing care. The model is less likely to suffice in the future due to the growing aging population and NP shortages. Thus, a lack of knowledge about the role of NPs hinders their ability to deliver care.

References

Brassard, A., & Reinhard, S. C. (2017). AARP initiatives. Health Policy and Advanced Practice Nursinghttps://doi.org/10.1891/9780826169457.0009  

E. Peterson, MS, APRN, AOCNP, M. (2017). Barriers to practice and the impact on Health Care: A nurse practitioner focus. Journal of the Advanced Practitioner in Oncology8(1). https://doi.org/10.6004/jadpro.2017.8.1.6  

Fitzgerald, M. A. (2017). Nurse practitioner certification examination and practice preparation. F.A. Davis Company.  

I agree that the state’s definition of a nurse practitioner and the scope of practice, collaboration, and credentials required by law are critical considerations for any aspiring Primary Mental Health Nurse Practitioner (PMHNP). I’m glad to learn more about registered nurses in the state of Texas who want to practice as APRNs, where they need to hold a Master of Science degree in Nursing and national certification (Oyeleye, 2019). Nurse Practitioners in Texas are being allowed to work in a wide variety of settings, as long as they stay within the bounds of their practice specialty and role gives them some form of autonomy and also increases opportunities for them. The fact that APRNs may find themselves unable to sign documents in Texas because of the state’s strict regulation is a bit different from  Maryland which is my state. An NP being not in a position to write a prescription due to the Schedule II Control Substance Prescriptive Authority is quite another obstacle (Thomas et al., 2020).

References

Oyeleye, O. A. (2019). The nursing licensure compact and its disciplinary provisions: What nurses should know. OJIN: The Online Journal of Issues in Nursing24(2).

Thomas, M. B., McDermott, E., Green, D., & Benbow, D. (2020). Evaluation of nursing practice-breakdown: a resource for peer review. Journal of Nursing Regulation11(1), 42-47.

 I am considering relocating from Massachusetts to a warm climate area once I obtain my APRN license and Texas was on the relocation list. Prior reading your post, I was unaware that Texas APRN did not have full authority to practice independently. I was also surprised at the supervision proximate guidelines for PMHNPs, however it appears to give more autonomy in practice. With the limitations in Texas, do you plan on practicing there?

Another interesting fact you mentioned was the limitations surrounding Do Not Resuscitate (DNR) orders. This limitation seems very unfortunate and can add to the patients and families emotional distress as it can causes significant delays in locating an physician or a sign off physician, especially when the supervision physician is a not on site or in rural areas where the next closest physician is a great distance away and/or the next closest physical is hesitant or reluctant to sign the DNR without knowing or have seen the patient.

Thank you for your discussion post regarding the scope of practice for APRNs in the state of Texas. I found your discussion of the do not resuscitate (DNR) orders and advance directives very interesting. On average, approximately one out of three adults has some type of advance directive or DNR (Yadev et al., 2017).  

I think the patient population in our country would benefit from more end-of-life health care planning. Of course, no one wants to die or think about their death, but making plans while they are cognizant in contact with their care team and family is a much better option.

I think a side benefit of an advance directive is that it can help patients make positive health choices because they’ve already planned for the end stages of life. I honestly had never considered this topic; however, since we are going state-specific, I found that Virginia allows APRNs to sign a DNR without restriction provided there is a “Bona Fide” ongoing provider-patient relationship (Virginia Department of Health, 2017).

I could see where this issue would be a solid candidate for reform, especially if you are a nurse practitioner specializing in geriatrics. Health care outcomes can be improved with geriatric nurse practitioners When a continuum of care is integrated between patients, providers, and families (Buerhaus et al.,2021).

References.

Buerhaus, P. I., Chang, Y., DesRoches, C., Guzikowski, S., Norman, L., & Donelan, K. (2021). Registered nurses and nurse practitioners’ roles and clinical activities in practices caring for older adults. Nursing Outlook69(3), 380–388. https://doi.org/10.1016/j.outlook.2020.11.011

Virginia Department of Health. (2017). Durable Do Not Resuscitate (DDNR) FACT SHEET. Retrieved December 4, 2021, from https://www.vdh.virginia.gov/content/uploads/sites/23/2017/12/AuthorizedDurableDNRForm-2017.pdf.

Yadav, K. N., Gabler, N. B., Cooney, E., Kent, S., Kim, J., Herbst, N., Mante, A., Halpern, S. D., & Courtright, K. R. (2017). Approximately one in three US adults completes any advance directive for end-of-life care. Health Affairs36(7), 1244–1251. https://doi.org/10.1377/hlthaff.2017.0175

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