According to the January 2016 news bulletin published by the Texas Board of Nursing (BON), Texas is launching the Choosing Wisely campaign, a program developed by the national Physicians Alliance through the American Board of Internal Medicine Foundation. This program aims to integrate recommendations from industry partners to improve the use of evidence-based healthcare. The core of the program depends on effective communication between practitioners, patients, and patients’ families. Because of this, MSN-educated nurse administrators, clinical nurse leaders, educators, informaticists and advanced practice registered nurses (APRN) were among those selected to pilot the program.
Graduate-educated and nationally certified as nurse-midwives, nurse practitioners, clinical nurse specialists and nurse anesthetists, APRNs fulfill a multitude of specialized roles within Texas’s health care system, where they are allowed to practice independently and have the authority to prescribe medications.
The BON reports that in 2015, the state was home to 20,394 licensed and practicing APRNs. Nurse Practitioners made up the majority (15,482 nurses), followed by 4,240 certified nurse anesthetists, 1,348 clinical nurse specialists, and 457 certified nurse-midwives.
The US Department of Labor (DOL) projects that Texas will experience a staggering increase in demand for APRNs in all roles during its ten-year projection period through 2022. The percentage increase in the number of jobs for each APRN role reported as projected by the US DOL:
- Nurse Practitioners – 41%
- Certified Nurse Midwives – 30%
Certified Registered Nurse Anesthetists – 30%
As of 2016, about 3.9 million of the 27 million residents in Texas are 65 years or older. As residents age, rates of diseases like cancer and Alzheimer’s Disease rise, placing a larger strain on the state’s health care system, and increasing the need for master’s-educated, highly trained advanced practice registered nurses.
Licensing Requirements for the Advance Practice Registered Nurse Roles Recognized in Texas
To become a state licensed APRN through the Texas Board of Nursing, an RN must meet three requirements:
- Have an active RN Texas license or an RN multi-state license from a state that participates in the Nurse Licensure Compact for RNs
- Complete a post-basic advanced degree program in an advanced nursing role recognized by the Board (a Master of Science in Nursing (MSN) or higher)
- Obtain national certification in the role and specialty from a Board-approved national accrediting agency
Texas recognizes four APRN roles with associated population focus areas:
- Clinical Nurse Specialist (CNS)
- Adult Health/Medical-Surgical Nursing
- Community Health Nursing
- Critical Care Nursing
- Gerontological Nursing
- Pediatric Nursing
- Psychiatric/Mental Health Nursing
- Nurse Practitioner (NP)
- Acute Care Adult
- Acute Care Pediatric
- Psychiatric/Mental Health
- Women’s Health
- Certified Nurse Anesthetist (CNA)
- Certified Nurse-midwife (CNM)
After completing their MSN, an RN must pass a certification test in their role and population focus. The test must be offered by a Board-approved national certifying agency. All agencies approved by the National Council on State Boards of Nursing (NCSBN) are considered Board-approved, because the credentialing requirements the NCSBN uses to evaluate credentialing tests is equivalent to Board requirements. However, the Board retains the right to rescind their approval, so an RN should verify Board approval before taking a national exam. The following is not an exhaustive list of all Board-accepted national certification agencies, but includes the most common utilized agencies.
Certified Nurse Anesthetist
- Acute Care Nurse Practitioner (ACNP)
- Acute Care Adult/Gerontology Nurse Practitioner (A/GACNP)
- Acute Care Pediatric Nurse Practitioner (ACPNP)
- Adult Nurse Practitioner (ANP)
- Adult/Gerontology Nurse Practitioner (A/GNP)
- Family Nurse Practitioner (FNP)
- Gerontological Nurse Practitioner (GNP)
- American Nurses Credentialing Center’s GNP
- American Academy of Nurse Practitioners Certification Program’s GNP
- Neonatal Nurse Practitioner (NNP)
- Pediatric Nurse Practitioner (PNP)
- Psychiatric/Mental Health Nurse Practitioner (PMHNP)
- Women’s Health Nurse Practitioner (WHNP)
Clinical Nurse Specialist
- Adult Health Nursing
- Adult/Gerontology Nursing
- Gerontological Nursing
- Neonatal Nursing
- Pediatric Nursing
- Psychiatric/Mental Health Nursing (take exam relevant to education)
Earning a Master of Science in Nursing (MSN) in Texas
The first step to becoming an APRN is to acquire a Master of Science in Nursing (MSN). An MSN combines comprehensive foundational knowledge, advanced specialty coursework based on the RN’s focus area, and clinical education to provide an RN with the skills and experience they need to become a certified APRN.
Many RNs opt for an online MSN program. Some online programs have self-paced coursework to allow an RN to obtain their MSN without disrupting their current job. Online programs eliminate the need to travel to a school or to relocate, and often programs work with the student to find local options to complete required clinical hours. Many programs offer a blend of both online and in-class curriculum options.
While most with an MSN finish certification as an APRN and take up a career in clinical settings, many individuals use their MSN to enter non-clinical fields, such as research, health administration, nurse education, or informatics.
The Commission on Collegiate Nursing Education (CCNE) and the Accreditation Commission for Education in Nursing (ACEN) are the certification agencies for the NP and CNS programs at the graduate level. CNA programs are accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA). CNM programs are accredited by the American College of Nurse-Midwives (ACNM).
- Texas has over 25 in-state CCNE accredited MSN programs
- The ACEN has accredited five in-state MSN programs
- Texas has two programs accredited by COA
- Texas has one ACNM-accredited MSN program
Texas Board Requirements for Accredited MSN Programs that Prepare Advanced Practice Registered Nurses
MSN and other graduate programs for advanced practice registered nurse license candidates in Texas must meet several Board requirements:
- Must be Board-approved or accredited by a national accrediting body recognized by the Board
- Programs outside Texas must be accredited by a Board-approved national accrediting body or by the appropriate licensing body of that state (state requirements must meet or exceed Texas Board requirements)
- Program must be at least one year in length
- Must include a formal preceptorship
- If studying more than one role and/or specialty, applicant must demonstrate they meet the curriculum requirements for each role and/or specialty
- Coursework for those studying in the NP or CNS roles must include separate, dedicated courses in
- Pharmacotherapeutics, including content in pharmacokinetics, pharmacodynamics, pharmacology of current/common medications, and disease treatment though drug therapy
- Advanced assessment, including content in data acquisition, diagnoses of health status, and formulating clinical management plans
- Pathophysiology and/or psychopathology (psychopathology accepted only or APRN in the psychiatric/mental health focus area) with a system-focused pathology approach, including content in normal physiology vs. pathological phenomena analysis across a life span
- Coursework in clinical major courses in selected specialty area including both formal didactic content and clinical experiences
- Demonstrated theoretical and clinical role preparation, including both formal didactic content and clinical experiences
- Documented practicum, preceptorship, or internship in a health care setting to obtain clinical experiences complementary with clinical major coursework
- Must be planed and monitored by designed faculty member or qualified preceptor
- Documented/evidence of a completed minimum of 500 separate, non-duplicated clinical hours for each advanced role and specialty
- Those studying in the role of Clinical Nurse Specialist (CNS) must also complete at least nine semester credit hours or the equivalent in a specific clinical major
- Clinical major courses must include didactic content and clinical experiences in a specific clinical practice or specialty area
- The American Association of Colleges of Nursing recommends a minimum of 1,000 hours of direct clinical practice during the graduate program, however this is not a requirement for graduation
Selecting the Right Program Based on Current Education
Graduate nursing students would select their program based on their current education level:
- RNs with a Bachelor of Science in Nursing (BSN): RNs with a BSN should enter a traditional MSN program, called a BSN-to-MSN program. This is the most common track for professionals seeking APRN licensure. These programs generally require two years for completion.
- Non-nursing professionals with a bachelor’s degree in an area other than nursing: Individuals at this level of education must enter a direct-entry or entry-level program. These programs allow a student to obtain RN licensure and an MSN in one accelerated program.
- RNs with an Associate Degree in Nursing (ADN): An RN must also complete a BSN to enter an MSN program. RN-to-MSN programs allow an RN to obtain their BSN and their MSN in one accelerated program. RN-to-MSN programs typically take three years to complete.
Scope of Practice and State Laws Governing Advanced Practice Registered Nursing in Texas
An APRN retains their RN scope of practice, and expands their scope based on their certified role and population focus/specialty. The Board determines an APRN’s scope of practice based on their educational preparation, continued advance practice experience, and the accepted scope of professional practice of the role and specialty area. Accepted scope of professional practice is largely determined by the professional organizations or agencies associated with their specialty and role.
The BON specifies practices that are within all APRN scopes of practice:
- APRN acts independently and/or collaboratively with a health team to observe, assess, diagnose, intervene, evaluate, rehabilitate, care and counsel, and provide health teaching of ill, injured, and infirm patients, as well as those experiencing changes from their normal health processes.
- Utilize mechanisms to authorize their medical practices, including protocols and written authorizations
- Protocols and written authorizations should be developed collaboratively between APRN and appropriate physician
In addition, the Board provides a set of guidelines to further determine individual scope of practice. The BON recognizes that APRNs may face unique challenges and situations which place strains on their scope of practice. To allow APRNs to respond to the specific setting they work in, but still remain within their scope of practice, the Board provides a set of guidelines and questions to develop scope of practice at the individual level.
The Board advocates for an APRN to make sure the practice in question falls within their specified guidelines:
- Within professional scope of practice
- Consistent with statutory or regulatory laws
- Consistent with APRN’s education in their role and specialty
- Consistent with the scope of APRN’s title and does not crossover into a role or specialty requiring separate education and accreditation
- Consistent with BON Standards of Nursing Practice (Board Rule 217.11)
- Aligns with evidence-based, reasonable, and prudent practices
- APRN must be willing to accept accountability and liability for the practice and outcomes
- APRNs should not provide medical care or prescribe medications to patients with whom they have a close, personal relationship with (such as a spouse or immediate family).
Certified Nurse Anesthetists – The American Association of Nurse Anesthetists (AANA) provides the CNA scope of practice
Nurse Practitioner – The American Association of Nurse Practitioners provides a broad scope of practice for NPs
Clinical Nurse Specialist – The American Association of Critical Care Nurses outlines CNS scope of practice
Certified Nurse-Midwife – The American College of Nurse-Midwives defines scope of practice for Certified Nurse-Midwives
Independent Practice and Collaborative Agreement
APRN practice in Texas is not completely independent. APRNs in each role function under a written agreement that specifies the scope of practice, as well as what acts are permitted with or without the supervision of a MD, DO, DSS, or podiatrist.
All APRNs in Texas are required to have a written agreement, called delegated authority, to provide medical care to patients. Delegated authority may be a protocol or written agreement, agreed upon and signed by both the APRN and the physician, and reviewed and signed annually.
The Texas Board of Nursing grants prescriptive authority to individuals with full APRN status, or a provisional APRN authorization. When an individual applies for a state APRN license, they have the option to apply for prescriptive authority at the same time, with an additional fee. An APRN can also apply for prescriptive authority after receiving their state license. Regardless of when an APRN applies for prescriptive authority, they must obtain a delegated authority agreement (aka prescriptive authority agreement) from a collaborating physician. All BON rules and regulations related to prescriptive authority can be found here.
An APRN is required to have prescriptive authority if they work in a clinic, center, or other medical practice associated with a hospital or long-term care facility that is not physically located in the associated facility.
To receive prescriptive authority, the APRN must meet several requirements:
- Hold a current, permanent Texas RN license, or a multi-state RN license while also residing in Texas
- Hold a full, active APRN state license, OR a provisional APRN authorization (graduate APRN)
- As a graduate APRN, one can hold prescriptive authority for up to one year from their graduation/APRN program completion date, while they are waiting to take a certification exam
- Establish delegated authority from a physician in addition to Board-approved prescriptive authority
- Delegated authority can be a separate written authorization or be included with the prescriptive authority agreement if both APRN and physician agree to do so
- Prescriptive authority agreements also require periodic face-to-face meetings with the APRN and collaborating physician to discuss issues related to patient treatment, care, and treatment plans.
The delegated prescriptive authority agreement must include several features:
- Be in writing, signed, and dated by all parties to the agreement
- State name, address, and all professional license numbers of all parties to the agreement
- Define the nature of the practice, the practice locations, and the practice settings
- Define the types of categories or drugs and devices that may be ordered and prescribed
- The agreement can state the authorized drugs/devices OR state the unauthorized/excluded drugs/devices, but it doesn’t require both
- Include a general plan for
- Consultations and referrals
- Addressing patient emergencies
- State the process of communication and information sharing between the APRN and collaborating physician
- Name alternate physician supervision, if applicable
- Designate a temporary supervising physician
- Describe a prescriptive authority quality assurance and improvement plan with specified methods for documentation of plan implantation
Restrictions to Prescriptive Authority – An APRN may prescribe Schedule II drugs in only two different situations:
- Hospital facility-based practice
- APRN must follow policies approved by hospital’s medical staff
- Can be prescribed as part of care for a patient who has been admitted to the hospital for 24 hours or greater or is receiving care in the emergency department of that facility (free-standing emergency care departments do not qualify)
- As part of a care plan for a patient with a written certification of a terminal illness
- Patient must have elected to receive hospice care and is receiving the care from a qualified hospice provider
In all cases, prescription must be filled at the hospital/facility pharmacy.
APRNs can prescribe Schedule III-V Controlled Substances (“dangerous drugs”) with four restrictions:
- Prescription duration, including refills, cannot exceed 90 days
- APRN must meet with their delegating physician to continue treatment with the same controlled substance past the 90 days
- Treatment of a child under two years of age requires a consultation with the delegating physician
- All consultations with the delegating physician must be included in the patient’s medical record
Implementation of the APRN Consensus Model in Texas
The APRN Consensus Model, presented in 2008, seeks to define APRN status, licensing requirements, and scope of practice in a uniform way across all states and jurisdictions nationwide. The NCSB provides information on the implementation status for each state, based on a 28 point scoring system. As of 2014, Texas scores in the 14-20 (50-71%) range, meaning APRNs are not yet designated as independent practitioners.
Texas complies with the Consensus Model in the categories of APRN titles, roles, license, education, and certification. However, it does not comply with the Model in the categories of practice and prescribing autonomy. All four APRN roles in Texas require written collaborative agreements for both independent practice and independent prescribing authority.
Continuing Education Requirements for APRNs in Texas
All nurses are required to satisfy continuing nursing education (CNE) requirements every two years, coinciding with the renewal of their license.
The BON requires APRNs to meet foundational requirements, with some conditional requirements:
- Must complete 20 contact hours of CNE through Board-approved CNE programs
- OR must obtain, maintain, or renew APRN national certification from a Board-approved national accrediting agency
- All APRNs must complete at least two contact hours in nursing jurisprudence and nursing ethics every third licensure renewal cycle
- APRNs with a geriatric care specialty must complete at least two contact hours in older adult or geriatric care every licensure renewal cycle
- APRNs with prescriptive authority must also complete an additional five contact hours in Pharmacotherapeutics
- If prescribing controlled substances, APRNs must complete an additional three contact hours of continued education related to prescribing controlled substances (a total of 28 contact hours for APRNs with prescriptive authority who prescribe controlled substances)
An APRN can meet their CNE requirements by taking programs from a Board-approved credentialing agency or through other sources shown here:
- American Association of Nurse Practitioners
- American Association of Critical-Care Nurses
- American Association of Nurse Anesthetists
- American College of Nurse Midwives
- American Nurses Credentialing Center
- Emergency Nurses Association
- National Association for Practical Nurse Education and Service
- National Association of Pediatric Nurse Practitioners
- National Federation of Licensed Practical Nurses
- Other State Boards of Nursing
- Category I Continuing Medical Education
- Colleges and Universities in the United States of America
All programs approved by these credentialing agencies are considered Board-approved. The BON also offers webinars, workshops, and online CNE courses to help nurses meet their CNE requirements.
An APRN can also meet their CNE requirements by obtaining, maintaining, or renewing their certification from Board-approved national credentialing agencies.
Exceptions to using certification to meet CNE requirements:
- Certification does not fulfill the two contact hours of nursing jurisprudence and nursing ethics requirement
- Certification related to older adult/geriatric care fulfills the CNE requirement for two contact hours for APRNs in a geriatric care specialty.