What Are the General Rules Concerning the Supervision and Practice of CRNAs

The Texas Board of Nursing (BON) requires that all advanced practice registered nurses (APRNs) be licensed in one or more of several different roles and/or population focus areas. The Nursing Practice Act and BON rules govern APRNs’ practice, and violating those rules can lead to disciplinary action. If you are facing disciplinary proceedings before the BON as an APRN, you should not hesitate to contact a nursing license defense lawyer for advice and counsel.

Understanding the Role of APRNs

22 Tex. Admin. Code §221.1(3) defines an APRN as a registered nurse approved by the BON to practice as an advanced practice nurse based on completing a board-approved advanced educational program. APRNs include nurse practitioners, nurse midwives, nurse anesthetists, and clinical nurse specialists. These healthcare professionals can act independently or collaborate with others in all healthcare settings. 

Scope of Practice of APRNs

22 Tex. Admin. Code §221.12 defines the scope of practice for APRNs. Although APRNs provide a broad range of healthcare services in various settings, they are limited to performing those functions within their BON-authorized professional and individual scopes of practice for their role and population areas. Their functions also must comply with the Nursing Practices Act, BON rules, and applicable state and federal laws. 

BON considers multiple factors in determining whether a certain action falls within an APRN’s individual and/or professional scope of practice under 22 Tex. Admin. Code §221.12(c). These factors include the following:

  • Whether the APRN received training regarding the particular action in their advanced educational program;
  • Whether the action falls within generally accepted standards of care appropriate for the APRN’s role and population focus area, as determined by a professional specialty organization;
  • Whether the APRN has demonstrable clinical competence and/or experience in acting in the role of an APRN, obtained through supervision and/or training by a qualified practitioner;
  • Whether the APRN has been credentialed by a health care facility’s credentialing body and/or holds a privilege to perform the action at a health care facility;
  • Whether the APRN has completed additional training for the specific action being performed. Additional training means education obtained by the APRN post-APRN licensure in their role and population focus area that is adequate for the action being performed by the APRN.
    • To determine whether the additional training obtained by an APRN is adequate for the action being performed by the APRN, the following factors will be considered:
      • the type of instruction provided, such as online instruction, in-person instruction, didactic instruction, or clinical instruction;
      • the learning objectives, content, materials, and methods for evaluating participation contained in the training curriculum;
      • the length and/or quantity of the training;
      • the qualifications of the person/entity providing the training;
      • whether the training has been certified or recognized by a professional specialty organization for the APRN’s role and population focus area;
      • whether the training is consistent with evidence-based practice;
      • whether the training is sponsored by an educational institution, such as a formal fellowship or precepted experience; and
      • whether an entity provides the training in conjunction with the use of the entity’s product, drug, or medical apparatus/equipment.
    • All training must include a method of objective, verifiable participant competency following completion of the training.

Furthermore, APRNs may not act outside their authorized scope of practice. Doing so may subject the APRN to disciplinary action. 

Protocols and Authorization for APRNs to Provide Medical Care

22 Tex. Admin. Code §221.13 requires that APRNs use mechanisms that provide authority for that care, such as protocols or other written authorizations. However, this section does not require authorization for APRNs to provide nursing care. The APRN maintains all professional accountability for advanced practice nursing care.

Protocols or other written authorizations should promote the exercise of professional judgment by the APRN based on education and experience. The level of detail in these protocols and authorizations may vary according to various factors, including the complexity of the situation, the advanced specialty area of practice, education, and experience. Furthermore, protocols must be:

  • Jointly developed by the APRN and appropriate physician(s);
  • Signed by both the APRN and the physician(s);
  • Reviewed and re-signed at least annually;
  • Maintained in the practice setting of the APRN; and
  • Made available to verify the authority to provide medical aspects of care. 

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Special Rules Relating to the Provision of Anesthesia Services by Nurse Anesthetists 

One role that APRNs may take on after completing a board-approved advanced educational program is that of a nurse anesthetist. Special rules apply to anesthesia services by nurse anesthetists that differ according to the practice setting.

22 Tex. Admin. Code §221.15 governs anesthesia services by nurse anesthetists in licensed hospitals or ambulatory surgery centers. In these settings, the APRN may select, obtain, and administer drugs, including determining the appropriate dosages, techniques, and medical devices for their administration according to a physician’s order for anesthesia or an anesthesia-related service. However, the physician is not required to make the order drug, dosage, or administration-technique specific. The APRN may also order anesthesia-related medications during perianesthesia periods to prepare for or recover from anesthesia. 

On the other hand, 22 Tex. Admin. Code §221.16 governs the provision of anesthesia services by nurse anesthetists in outpatient settings and outlines the minimum acceptable standards for providing these services in outpatient settings. Therefore, the standards outlined in this section do not apply to some outpatient settings, such as the outpatient facilities of licensed hospitals, licensed ambulatory surgery centers, and governmental facilities. 

APRNs working in facilities subject to this section must take on the following responsibilities:

  • Comply with standards and guidelines of the American Association of Nurse Anesthetists (AANA) and other relevant national standards;
  • Comply with all building, fire, and safety codes;
  • Select, obtain, and administer drugs according to a physician’s order delegating this responsibility to an APRN.

The APRN providing anesthesia services in this setting must also comply with various other standards of care outlined in this section. They also must register biennially with the BON, submit proof of current competency in advanced life support, and pay a registration fee. 

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We Are Here to Defend You Throughout Your Disciplinary Proceedings

Facing an investigation and potential disciplinary proceedings before the BON can be a difficult and stressful experience. Disciplinary proceedings can have an adverse effect on your nursing license. We can help you resolve your disciplinary investigation in the most positive manner possible. Get legal assistance from an experienced Texas nursing license defense attorney today. Contact Bertolino LLP at (512) 515-9518 or visit us online.

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