LEVELS OF NURSING PRACTICE IN TEXAS

Licensed Vocational Nursing

[This section is abridged from: Board Position Statements 15.23. The Use of Complementary Modalities by the LVN or RN; 15.27. The Licensed Vocational Nurse Scope of Practice; TAC Title 22, Part 11, §217.11. Standards of Nursing Practice; TOC Ch. 301.002. Definitions; and TOC Ch. 301.353. Supervision of Vocational Nurse.]

The Texas NPA and the Board’s Rules and Regulations define the legal scope of practice for the licensed vocational nurse (LVN). The LVN, with a focus on patient safety, is required to function within the parameters of the legal scope of practice and in accordance with the federal, state, and local laws, rules, regulations, and policies, procedures, and guidelines of the employing healthcare institution or practice setting. The LVN is responsible for providing safe, compassionate, and focused nursing care to assigned patients with predictable healthcare needs.

LVN SCOPE OF PRACTICE

The LVN uses a systematic problem-solving process in the care of multiple patients with predictable healthcare needs to provide individualized, goal-directed nursing care. LVNs may contribute to the plan of care by collaborating with interdisciplinary team members, the patient, and the patient’s family. LVN scope of practice does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures.

The practice of vocational nursing is a directed scope of nursing practice and requires appropriate supervision of a registered nurse, advanced practice registered nurse, physician, physician assistant, dentist, or podiatrist. The LVN may not practice in a completely independent manner, but direct and on-site supervision of the LVN may not be required in all settings or patient care situations.

Determining the degree of proximity of an appropriate clinical supervisor, whether the supervisor is available by phone or actually physically present, should be made by the LVN and the LVN’s clinical supervisor. An appropriate clinical supervisor may need to be physically available to assist the LVN.

The setting in which the LVN provides nursing care should have well-defined policies, procedures, and guidelines and be one in which assistance and support are available from an appropriate clinical supervisor.

NURSING PROCESS FOR THE LICENSED VOCATIONAL NURSE

Assessment

The LVN assists in determining the physical and mental health status, needs, and preferences of culturally, ethnically, and socially diverse patients and their families. The LVN collects data and information, recognizes changes in conditions, and reports this to the RN supervisor or another appropriate clinical supervisor. The LVN cannot perform independent assessments.

The LVN’s role in the nursing process is to appraise the patient’s status or the situation at hand. Also known as a focused assessment, this appraisal may be considered a component of a more comprehensive assessment performed by an RN or another appropriate clinical supervisor. The LVN reports the information that is collected either verbally or in writing. Written documentation must be accurate and complete.

Nursing Diagnosis / Problem Identification / Planning

The second step in the nursing process is nursing diagnosis or the identification of patient problems. The role of the LVN is to report data to assist in the identification of problems and the formulation of goals/outcomes in patient-centered plans of care.

The third step in the nursing process is planning nursing care needs. The LVN participates by reporting data and other information to the appropriate clinical supervisor, such as the RN. The LVN participates in the development and revision of the nursing care plan, but the RN has the responsibility for plan development as well as the overall responsibility to coordinate nursing care for patients.

Implementation

Implementing the plan of care is the fourth step in the nursing process. The LVN is responsible for providing safe, compassionate, and focused nursing care to assigned patients within legal, ethical, and regulatory parameters.

Delegating tasks to unlicensed assistive personnel (UAPs) is beyond the scope of practice for LVNs; however, LVNs may make appropriate assignments to other LVNs and UAPs according to Rule 217.11(2).

The RN is generally responsible and accountable for supervising not only the LVN’s practice but the UAP’s performance of tasks as well. For example, the RN may have trained, verified competency, and delegated tasks to a UAP, and the LVN may then proceed to assign those same tasks that need to be accomplished for that day to a UAP.

In addition, LVNs can participate in implementing established teaching plans for patients and their families with common health problems and well-defined health learning needs.

Evaluation

A critical and final step in the nursing process is evaluation. The LVN participates in the evaluation process by identifying and reporting any alterations in patient responses to therapeutic interventions in comparison to expected outcomes. The LVN may contribute to the evaluation phase by suggesting any necessary modifications to the plan of care and making appropriate referrals.

IV THERAPY

[This section is taken from TX BON Position Statement 15.3. LVNs Engaging in Intravenous Therapy, Venipuncture, or PICC Lines.]

Basic competency in management of intravenous lines/intravenous therapy is not a given for any specific LVN licensee. Instruction and skill evaluation relating to LVNs performing insertion of peripheral IV catheters and/or administering IV fluids and medications as prescribed by an authorized practitioner may allow an LVN to expand their scope of practice to include intravenous therapy.

It is the opinion of the Board that the LVN shall not engage in IV therapy 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 LVN’s practice relative to IV therapy must also comply with any other regulations that may exist under the jurisdiction of other regulatory agencies or entities.

Professional Nursing

[This section is taken from TX BON Position Statement 15.28. The Registered Nurse Scope of Practice; TAC Title 22, Part 11, §217.11. Standards of Nursing Practice; and TOC, Ch. 301.002. Definitions.]

A registered nurse (RN) is any person licensed in Texas to practice professional nursing. The practice of professional nursing means the performance of an act that requires substantial specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of professional nursing.

Unless licensed as an advanced practice registered nurse, the RN scope of practice does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures.

NURSING PROCESS FOR THE REGISTERED NURSE

Assessment

The comprehensive assessment is the first step and lays the foundation for the nursing process. Nursing judgment is based on the assessment process. The RN uses clinical reasoning and knowledge, evidence-based outcomes, and research as the basis for decision-making and comprehensive care.

Based upon the comprehensive assessment, the RN determines the physical and mental health status, needs, and preferences of culturally, ethnically, and socially diverse patients and their families using evidence-based health data and a synthesis of knowledge.

Nursing Diagnosis / Problem Identification / Planning

The second step in the nursing process is nursing diagnosis and problem identification. The role of the RN is to synthesize comprehensive assessment data to identify problems, formulate goals/outcomes, and develop plans of care for patients, families, populations, and communities using information from evidence-based practice and published research in collaboration with these groups and the interdisciplinary healthcare team.

The third step in the nursing process is planning. The RN synthesizes the data collected during the comprehensive assessment to identify problems, make nursing diagnoses, and formulate goals, teaching plans, and desired outcomes. A nursing plan of care for patients is developed by the RN, who has the overall responsibility to coordinate nursing care for patients.

Implementation

Implementing the plan of care is the fourth step in the nursing process. The RN may begin, deliver, assign, or delegate certain interventions within the plan of care for patients within legal, ethical, and regulatory parameters and in consideration of health restoration, disease prevention, wellness, and promotion of healthy lifestyles.

The RN’s duty to patient safety when making assignments to other nurses or when delegating tasks to unlicensed staff is to consider the education, training, skill, competence, and physical and emotional abilities of those to whom the assignments or delegation is made. The RN is responsible for reasonable and prudent decisions regarding assignments and delegation.

The RN may determine when it is appropriate to delegate tasks to unlicensed personnel and maintains accountability for how the unlicensed personnel perform the tasks (see also “Delegation to Unlicensed Personnel” below). The RN is responsible for supervising the unlicensed personnel when tasks are delegated.

Evaluation and Reassessment

A critical and final step in the nursing process is evaluation. The RN evaluates and reports patient outcomes and responses to therapeutic interventions in comparison to benchmarks from evidence-based practice and research findings. Revisions to the plan of care may be made as needed as well as plans for follow-up care and appropriate referrals.

Specialty Certification

[This section is taken from TOC Ch. 301.152 and Ch. 301.354; TAC Title 22, Part 11, §217.18. Assisting at Surgery, §219.2. Definitions, §221.12. Scope of Practice, and §221.13. Core Standards for Advanced Practice.]

ADVANCED REGISTERED NURSE PRACTITIONER

An advanced registered nurse practitioner (ARNP) is a registered nurse licensed by the Texas Board of Nursing to practice as an advanced practice registered nurse on the basis of completion of an advanced educational program. The term includes a nurse practitioner, nurse midwife, nurse anesthetist, and clinical nurse specialist.

The advanced practice nurse provides a broad range of health services, the scope of which shall be based upon educational preparation, continued advanced practice experience, and the accepted scope of professional practice of the particular specialty area.

Scope of Practice

The scope of practice of particular specialty areas shall be defined by national professional specialty organizations or advanced practice nursing organizations recognized by the Texas Board of Nursing. The advanced practice nurse may perform only those functions that are within that scope of practice and that are consistent with the Nursing Practice Act, Board rules, and other laws and regulations of the state of Texas.

The advanced practice nurse’s scope of practice shall be in addition to the scope of practice permitted a registered nurse and does not prohibit the advanced practice nurse from practicing in those areas deemed to be within the scope of practice of a registered nurse. The advanced practice nurse acts independently and/or in collaboration with the healthcare team.

Protocols

When providing medical aspects of care, advanced practice nurses shall utilize mechanisms that provide authority for that care. Protocols or other written authorization shall promote the exercise of professional judgment by the advanced practice nurse commensurate with their education and experience. The degree of detail within protocols / policies / practice guidelines / clinical practice privileges may vary in relation to the complexity of the situations covered by such protocols, the advanced specialty area of practice, the advanced educational preparation of the individual, and the experience level of the individual advanced practice nurse.

Protocols or other written authorization:

• Should be jointly developed by the advanced practice nurse and the appropriate physician(s)
• Shall be signed by both the advanced practice nurse and the physician(s)
• Shall be reviewed and re-signed at least annually
• Shall be maintained in the practice setting of the advanced practice nurse
• Shall be made available as necessary to verify authority to provide medical aspects of care

REGISTERED NURSE FIRST ASSISTANT

Nurse first assistant means a registered nurse who has passed a nurse first assistant educational program approved or recognized by an organization recognized by the Board and is either:

• Certified in perioperative nursing by an organization recognized by the Board, or
• Recognized by the Board as an advanced practice nurse and qualified by education, training, or experience to perform the tasks involved in perioperative nursing