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Nursing Issues

The fact that nursing is a dynamic profession in an environment of constant change is no news to nurses. This section is intended to provide you with some information and news about your practice.

Nurse Staffing APRN
Care Coordination Designation for the Doctorally Prepared Nurse
Staffing Toolkit Immunization Information
Workplace Violence Geriatrics

 Gereatric Issues


In 2009, the Health and Safety Code was amended by SB 476, adding Chapters 257 and 258, to provide structure and guidelines for safe nurse staffing and mandatory overtime. The law represents the culmination of a collaborative effort to bring nurses and hospitals together to better serve Texas patients.

FACT: The 2009 law gives nurses even more influence in staffing decisions.
Direct care nurses throughout Texas have an even stronger voice in setting appropriate nurse-to-patient staffing levels at their hospitals.

  • The law enhances existing nurse staffing regulations and strengthens the voice of Texas nurses
  • on staffing matters in several ways.
  • It adds a legal requirement for hospital governing boards to adopt a nurse staffing policy that considers staffing guidelines set forth by professional nursing organizations.
  • The role and status of the nurse staffing committee is elevated to a standing committee that reports directly to the hospital board.
  • The nurse staffing committee is to be comprised of at least 60% registered nurses who provide direct patient care at least 50% of the time and that are selected by their nurse peers who also provide direct patient care at least 50% of the time.
  • The nurse staffing committee is responsible for identifying the nurse-sensitive outcome measures to be used in evaluating the staffing plan.
  • The committee will evaluate and report on the staffing plan’s effectiveness at least semiannually to the hospital board.
  • Hospitals are required to report annually certain data about their nurse staffing plan to the Texas Department of State Health Services (TDSHS).

FACT: Direct care nurses know best what their patients need.
Patient outcomes are linked directly to appropriate staffing, so it makes good sense for nurses to have the opportunity to influence staffing.

  • Nurse staffing committees allow nurses to influence appropriate staffing levels at each hospital in Texas based on the unique needs of each patient, the specific expertise and experience of nurses on each shift, and the particular characteristics of each hospital.

FACT: The law also prohibits mandatory overtime.

  • The Law includes a prohibition on mandatory overtime in hospitals except in emergency circumstances, such as a natural disaster.

FACT: Collaboration works.
Texas has led the Nation in addressing nurse staffing in hospitals, thanks to a collaborative approach that brings nurses and other stakeholders together to best serve patients.

  • Texas has been at the forefront of nurse staffing in hospitals.
  • For more than 100 years, TNA has advanced the nursing profession and improved nurses’ practice environments and patient care by working collaboratively with other stakeholders to effect real, positive change.
  • Members of the TNA are Texas registered nurses who advocate for patients, nurses and the nursing profession, and quality care for all Texans. TNA hosts the Nursing Legislative Agenda Coalition (NLAC). Representing more than 20 nursing organizations in Texas, the NLAC identifies significant nursing and health care related issues that the Texas Legislature should address. Since NLAC represents all practice settings and segments of nursing, it serves as the body that builds a unified position on the issues important to nurses and their patients.

Click on the links below to view the law:



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Nurse Staffing Committee Charter Helpful Formulas
Unit Based Staffing Committee Survey How Nursing Hours are Budgeted
Nursing Organization Staffing Standards
Inpatient Workforce Planning and Staffing & Scheduling Assessment Chart
Standards for Nursing-Sensitive Care: An Initial Performance Measure Set

Sample Worksheets and Examples

Example of Budget FTE
Indicator Tracking Tool
Telemetry Matrix Valley Medical Center Staffing Plan
Budget Case Application Worksheets


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Nursing options on a Safe Harbor Peer Review Request Safe Harbor Peer Review Comprehensive Request Form
Safe Harbor Peer Review Quick Request Form Medical Reasonableness of Physician Order Form
Rules Governing Peer Review
The Quick Request Form is an abbreviated form to allow a nurse to quickly jot down the key information necessary to invoke Safe Harbor in writing as required by Rule 217.20 at the time the nurse is asked to accept what he/she believes to be an unsafe assignment. Use of the form is not required, but is provided to make safe harbor an easier process for the nurse.
The Comprehensive Request for Safe Harbor Form is a sample form that may be used to document the more in-depth information that the nurse must commit to writing before leaving the work setting at the end of the work period. The nurse may still supply supporting documents at a later time, however the details of the events surrounding the request must be recorded prior to the nurse leaving the premises. The comprehensive form also includes a fill-in-the-blank format that the peer review committee and CNO or nurse administrator can utilize to document the safe harbor peer review process. Again, this form is not mandatory, but is offered a guide to the process. An entity required to have a peer review plan must have policies and procedures that encompass other aspects both within and beyond the statutes and rules of peer review. In other words, it is not sufficient to use the BON Safe Harbor forms in place of official policies and procedures on nursing peer review.
The third form is for those occasions when the reason for the nurse’s need to invoke Safe Harbor is related to the actions or orders of a physician. In this case, the nurse may not need to use either the Quick or the Comprehensive request forms, since it will be an individual physician who will make a determination, rather than a nursing peer review committee. In other words, to question the medical reasonableness of a physicians order, a nurse will likely only need to use this third form by itself.
A facility or other entity establishing a nursing peer review plan may establish it’s own’ forms and procedures that comply with the peer review statutes and rule 217.20 Safe Harbor Peer Review.

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Timeline for review What results when NO IBPR is initiated
How an Incident is Handled when IBPR is initiated Rules Governing Peer Review
What Constitutes Reportable Conduct (document of information below)


Conduct Normally Not Required to Be Reported to the Board (Minor Incidents)

An incident should be evaluated to determine if:

  1. the incident is primarily the result of factors beyond the nurse's control and addressing those factors is more likely to prevent the incident from reoccurring; or
  2. the incident was a medication error caused primarily by factors beyond the nurse's control rather than failure of the nurse to exercise proper clinical judgment.
  3. If either of these conditions listed above are present, a presumption should exist that the nurse's conduct does not indicate the nurse's continued practice poses a risk of harm to a patient or another person and does not need to be reported to the board.

How to Document a Minor Incident

A minor incident should be documented as follows:
  1. A report must be prepared and maintained for a minimum of 12 months that contains a complete description of the incident, patient record number, witnesses, nurse involved and the action taken to correct or remedy the problem.
  2. If a medication error is attributable or assigned to the nurse as a minor incident, the record of that incident should indicate why the error is being attributed or assigned to the nurse.

Conduct Required to be Reported

A nurse must be reported to the board or to a nursing peer review committee for the following conduct:
  1. An error that contributed to a patient's death or serious harm.
  2. Criminal Conduct defined in Texas Occupations Code §301.4535.
  3. A serious violation of the board's Unprofessional Conduct rule §217.12 of this title (relating to Unprofessional Conduct) involving intentional or unethical conduct including but not limited to fraud, theft, patient abuse or patient exploitation.
  4. A practice-related violation involving impairment or suspected impairment by reason of chemical dependency, intemperate use, misuse or abuse of drugs or alcohol, mental illness, or diminished mental capacity required to be reported in accordance with §301.410(b) of the Nursing Practice Act and §217.19(g) of this title (relating to Incident Based Nursing Peer Review and Whistle Blower Protections).
  5. If a nursing peer review committee determines that a nurse engaged in the conduct listed above the committee must report the nurse to the board. For errors involving the death or serious injury of a patient, if a nursing peer review committee makes a determination that a nurse has not engaged in conduct subject to reporting to the board, the committee must maintain documentation of the rationale for their belief that the nurse's conduct failed to meet each of the factors in above. 

Evaluation of Multiple Incidents

  1. Evaluation of Conduct: In evaluating whether multiple incidents constitute grounds for reporting it is the responsibility of the nurse manager or supervisor or peer review committee to determine if the minor incidents indicate a pattern of practice that demonstrates the nurse's continued practice poses a risk and should be reported.
  2. Evaluation of Multiple Incidents: In practice settings with nursing peer review, the nurse must be reported to peer review if a nurse commits five minor incidents within a 12-month period. In practice settings with no nursing peer review, the nurse who commits five minor incidents within a 12 month period must be reported to the Board.

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Workplace Violence/Bullying

Bullying can be described as unwelcome behaviors displayed by one colleague toward another. Sometimes the behavior is easily recognized, such as when one nurse criticizes another in front of a patient. Other times, it may be less obvious, such as when a nurse is excluded from unit activities.  The most important step in fighting horizontal violence or bullying is recognizing these behaviors and not accepting them as part of the daily work environment:

  • Being accused of errors made by someone else
  • Nonverbal intimidation, including being stared at or glared at
  • Being belittled
  • Having thoughts or feelings ignored
  • Being excluded from activities or conversations
  • Being gossiped about or being the topic of rumors
  • Being yelled at or screamed at in front of others
  • Being humiliated in front of others
  • Being assigned undesirable work
  • Being sabotaged
  • Having resources or information withheld, thereby impeding job performance
  • Being physically threatened
The steps to dealing with these behaviors are:
  • Recognize the behaviors
  • Prepare to confront the individual and make it known the behavior will not be tolerated and will be dealt with each time it occurs
  • If confronting the individual does not work, then report the behaviors to the manager
  • Be very aware of the policies in your facility to address workplace abuse
  • Workplace bullying/violence  can negatively affect the delivery of health care services, can have financial and organizational effects on the employer, may affect the efficiency, accuracy, safety and outcomes of care and may hinder recruitment and retention of nurses. With support from TNA, the Texas Department of State Health Services (DSHS) established a rule requiring hospitals to: adopt, implement and enforce a written policy for identifying and addressing instances of alleged verbal or physical abuse or harassment of hospital employees or contracted personnel by other hospital employees or contracted personnel or by a health care provider who has clinical privileges at the hospital. (Chapter 133, Section 133.45).
  • Know your hospital's policy and procedure for abusive behavior.
Next step:
  • Schedule a meeting with the physician and your Director, in accordance with any Hospital Policy you have, to address the behavior and issue a “no tolerance” statement about unprofessional conduct.   Follow the conflict resolution/grievance chain of command, policy and procedure.
  • If it is a physician, inquire about the Medical Staff By-Laws and any behavioral provisions that might be outlined within those By-Laws. Follow any steps for reporting contained in the By-Laws.
  • If the behavior is not corrected after the two steps above, report to Human Resources jointly with your Director. Outline the hostile work environment that has been created by the staff/physician behavior. Outline the steps taken thus far to address it that have been unsuccessful.
  • Ensure your institution has a policy and procedure for workplace violence in compliance with the Rule above. If not, work collaboratively with your Director and HR to draft one.
  • After reporting to HR, Administrative staff will need to deal with staff/physician.

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Care Coordination

Care Coordinators: Chart ANA Position Statement Care Coord
Nurses in the Role of Care Coordinators


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APRN consensus model brief BON APRN Scope of Practice information
Myths Regarding Advanced Registered Nurse Practitioner:
  • APRN’s risk patient safety: Fact-No data shows any difference in patient outcomes based on states with full autonomy.
  • APRN’s are trying to be doctors: Fact-APRN’s can manage up to 80-90% primary care within their own scope of practice.
  • Abuse of drugs will increase: Fact-There is no data to substantiate this.
  • APRN’s will not go to underserved areas: Fact-Even in the city APRN’s care for medically underserved patients more than physicians.
  • Our current system works fine: Fact-APRN’s face practice challenges related to a restrictive regulatory model, especially in rural areas, where physicians won’t go, leaving many Texans without healthcare access.
Barriers and Opportunities:
  • The United States has the opportunity to transform its health care system, and nurses can and should play a fundamental role in this transformation:
  • APRN’s should be able practice to full extent of their education and training.
  • Nurse should achieve higher levels of education and training.
  • Nurses should be full partners with physicians and other healthcare professionals.
  • Prepare and enable nurses to lead change to advance health.
   *The Future of Nursing, Leading Changes, Advancing Health, Consensus Report, RWJF at IOM, October 2010

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Designation for the Doctorally Prepared Nurse

The Texas Board of Nursing is the state agency with the legal authority to regulate nursing licensure and practice in the state of Texas. Questions have been raised regarding use of the title “doctor” by nurses who have been educated at the doctoral degree level.  Board staff offers the following information regarding use of doctoral credentials by licensed nurses.
Chapter 104 of the Texas Occupations Code addresses Healing Art Practitioners.  This particular chapter is not a part of the Nursing Practice Act.  However, a section of this chapter is applicable to nurses who hold doctoral education credentials.  Section 104.004 addresses use of the term “doctor” by individuals who are not physicians, dentists, podiatrists, optometrists or chiropractors as follows:
In using the title "doctor" as a trade or professional asset or on any manner of professional identification, including a sign, pamphlet, stationery, or letterhead, or as a part of a signature, a person other than a person described by Section 104.003 shall designate the authority under which the title is used or the college or honorary degree that gives rise to the use of the title.
Acts 1999, 76th Leg., ch. 388, Sec. 1, eff. Sept. 1, 1999.
Board staff advises nurses who wish to use the term “doctor” in connection with their practice to be certain to identify the appropriate doctoral credential, whether it is DNP, DNS, PhD, or another doctoral degree.  Because it can be confusing or misleading, when providing patient care or otherwise interacting with the public or other healthcare providers, nurses must provide a very clear explanation that they are not physicians; rather, they are nurses who have earned doctoral degrees. 
Section 301.351 of the Nursing Practice Act (Texas Occupations Code) requires all nurses to clearly identify themselves to the public with the appropriate licensure credential [licensed vocational nurse (LVN) or registered nurse (RN)].  Registered nurses who also hold licensure as an advanced practice registered nurse must also clearly identify themselves using the advanced practice title granted by the Board (22 Texas Administrative Code, § 221.11).  It is important for all nurses to remember that failure to appropriately identify oneself and use appropriate licensure credentials when interacting with the public is a violation of the Nursing Practice Act and Board Rules, and nurses could be subject to disciplinary action in such situations. 
For additional information regarding the use of doctoral degree credentials by nurses in the state of Texas, we would recommend nurses review a July 2011 article in the Texas Board of Nursing Bulletin.  To locate this article, please click on the link below and go to the article on page four (“When the Profession is Nursing and the Title is Doctor. . .”: July 2011 issue 
Advanced practice registered nurses may also find it helpful to review the following article from on page eight of the BON newsletter regarding the “Use of Advanced Practice Titles”. July 2008 issue

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Immunization Information

Resolution for Mandatory Influenza Vaccination for Health care Workers

Vaccine-Preventable Diseases
During the 82nd session, the Texas Legislature, legislators passed Senate Bill 7, which contained a provision requiring that all hospitals implement a policy specifying which vaccines they will require for health care workers who provide direct patient care. Policies must be in place by September 1, 2012.


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Nursing Practice



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