Drawing the Line: Texas Nursing Law, Ethics and Professional Boundaries
About the Authors
Julie Mroczek, BSN, RN-BC, CLNC is a Certified Legal Nurse Consultant who has researched and developed legal medical personal injury and malpractice cases for attorneys for the last six years. She has worked as an in-patient charge nurse, clinical research coordinator doing research for pharmaceutical companies, and has served as the RN-case manager.
Ellen Rivers-Brown, RN, CEN, CLNC has more than two decades of experience in medical/surgical, long-term care, skilled nursing, discharge planning, infection control, endoscopy, and case management.
She is also a Certified Legal Nurse Consultant (CLNC). For the past several years, Ellen has assisted attorneys and other CLNC nurses with medical legal aspects of worker's compensation, criminal defense, and sexual assault cases. As a collaborator and strategist she offers professional opinions regarding the delivery of healthcare and the resulting outcomes. Ellen is a member of the National Alliance of Certified Legal Nurse Consultants, Emergency Nurses Association, and American Association of Critical Care Nurses.
Purpose and Goals
The purpose of this course is to educate the nurse regarding the statutes and administrative codes governing the regulation of nursing practice in Texas. In addition, ethical considerations that impact the safe practice of nursing is explored. Content will include Texas Nurse Practice Act, Board of Nursing rules including Standard of Care, position statements of the Board of Nursing, principles of ethics and professional boundaries. The goal is that nurses will be safe practitioners respecting legal and ethical points of practice.
- Describe the importance of the Nurse Practice Act found in the Texas Occupational Code.
- Explain the mission statement of the Texas Board of Nursing.
- Apply selected standards of nursing practice written by the Board of Nursing in the Texas administrative code title 22, part 11, Chapter 217.
- Describe professional boundaries and ways to maintain healthy nurse-patient relationships.
- Outline how the (ANA) code of nurses, guides the ethical behavior of the professional nurse.
- Identify how the diversion of controlled substances affects the nurse's clinical practice and resulting damage to patients, employers, and coworkers.
Without a doubt, the United States is in a state of flux, constantly evolving, tearing itself down and remaking itself in its own image. With the advent of newer and faster technology, the internet at our fingertips and in our pockets, events from the other side of the world are sent to our emails as they occur. Information that at one time took days, weeks, or even months to circumnavigate the globe now appears before our eyes within seconds. But while the digital age has brought the world to us, it has also sequestered us from one another, reducing us to mere consumers of information, with each person engrossed in the electronic device of his or her choice. That which was designed to bring us closer together has effectively placed in quarantine; a quarantine that reaches into our homes, our cars and into our workplaces. Technology enables doctors to see patients in an ER hundreds of miles away via telemedicine, guiding the practice of the local staff members to save a life that otherwise may have been lost or severely impaired after an inadequately treated stroke. Monitoring equipment for critically ill and injured patients is more accurate and highly sensitive for today's highly advanced healthcare environment. Be that as it may, cloud technology cannot look into a patient's eyes, and a smartphone is incapable of considering a patients' home life, or their economic or familial situation. Technology, as useful and as efficient as it may be, has no capacity for empathy, compassion, or instinct. Google cannot and must not replace the human touch in the arena of healthcare.
While the touch screens and the sheer volume of data that can be communicated are alluring, those things cannot replace the compassion and empathy of a nurse, who must practice her profession not only with her skills, but with her heart. Nurses are a central part of healthcare. Making up the largest segment of healthcare professionals, nurses cannot be replaced by any technologically advanced piece of equipment. The caring touch from the nurse of a patient dying alone in an intensive care unit demonstrates the compassion that simply cannot be replicated by technology. Software, no matter how written cannot compare to the empathy, instinct, or even the compassion capable of being generated by the human mind. Nurses are the safeguard between the patient and a set of algorithms that can only respond to the input of data. The critical thinking of a seasoned nurse when caring for a patient with complex medical and surgical histories cannot be replaced. Nurses are and will continue to be the core of healthcare. Primary care providers and attending physicians rely on the eyes, ears, and observations of nurses to make decisions about the medical management of their patients. The degree of confidence and trust that ideally accompanies the role of the nurse is something that we as nurses don't truly comprehend.
Healthcare is not a static profession. No matter one's position on the recent changes in healthcare laws, one cannot deny that the practice of medicine on all levels is now, and will continue to be subject to the winds of change. Nurses, even more so than physicians must be ready to adapt, not just to the escalating advancements of technology, but to changes in legislation and the ground-level implementation of the latter and the former.
However, nurses must not only adapt to the shifting sands of technology and policy; they must do so while retaining that delicate balance of professionalism and compassion that will ensure effective treatment of their patients while maximizing their time at work. Nurses must be able to stop the swing of the pendulum between meeting administrative demands, and delivering the necessary care. They must be able to do both things, do them well, and do them consistently.
The Nurse Practice Act and Administrative Codes
The professionalism and autonomy to follow a set of standing orders and protocols put into place by healthcare facilities comes with the expectation of competency in nursing. Texas, and other states have a Statute (called the Nurse Practice Act). The NPA defines the BON's responsibility for regulating nursing education, licensure, and practice. This law is created by the state legislature.
In Texas it is located in the Texas Occupations Code (TOC) Chapter 301.303.304 and 305. In addition, the Texas Administrative Code, Title 22, Part 11 contains the rules that are determined by the Board of Nursing. This contains more specific information on licensure, peer assistance, and the minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. The Board of Nursing is given the authority to determine the rules by the Texas Occupations Code Chapter 301. Each state has its own board of nursing which is a regulatory agency to ensure safe nursing practices are followed. In their mission statement the Texas Board of Nursing states "The mission of the Texas Board of Nursing (BON) is to protect and promote the welfare of the people of Texas by ensuring that each person holding a license as a nurse in the State of Texas is competent to practice safely. The board fulfills its mission through the regulation of the practice of nursing and the approval of nursing education programs. This mission supersedes the interest of any individual, the nursing profession, or any special interest group."
The following chart, Figure 1, contains Legal Considerations as written in the NPA and Texas Administrative Code (TOC) Title 22, Examining Boards Part 11, Texas Board of Nursing.
Texas Administrative Code Title 22, Part 11, chapter 217.11 Standards of Nursing Practice
Nurses are subject to the Board of Nursing (BON) which was formulated to "establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted." All nurses, RN, LVN and Advanced Practice RN are required: know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; know, recognize, and maintain professional boundaries of the nurse-client relationship".
Chapter 301 of the Texas Occupations Code (TOC)
The Texas (BON) outlines specific rules and regulations which nurses must follow to legally and ethically practice their profession. The Texas Nurse Practice Act (NPA) may be found under Chapter 301 of the Texas Occupations Code (TOC). Within it the NPA "creates the BON and defines its responsibility for regulating nursing education, licensure and practice." Texas licensed nurses are expected to know and remain in compliance with chapters 301, 303, 304 and 305 of TOC and BON rules. Nurses are also required to notify the BON with 10 days of any changes regarding name or address to avoid a potential lapse in licensure.
Legal Implications of Practice
Increasingly, nurses are called upon to perform above and beyond the expectations once placed on their predecessors. Baby boomer aged nurses who will be entering retirement will place more stressors on the remaining nursing workforce. Moreover, they are being called to do so in healthcare situations in which the number of those people seeking care will continue to increase; particularly in emergency room, ICU, home health and convalescent settings due to population growth, increased life expectancy and an aging society. Nursing shortages add to the stressors placed upon nurses. During the 2012-2013 enrollment period 79,659 qualified applicants for BSN and graduate nursing programs were turned away citing insufficient faculty, clinical sites, classroom space, clinical preceptors, and budget constraints. (AACN)
The increased demand for care, the changes in healthcare laws and insurance coverage; and the rapid evolution of technology in the arenas of healthcare and information will undoubtedly create new stressors for nurses. Not only will nurses in the 21st Century have to meet these challenges and adapt to them, they must do so while maintaining the level of care that the public has come to expect from the professionals in the hospitals and other healthcare settings. These stressors may cause nurses to respond in a reactive manner, rather than a proactive manner to the various duties and situations that arise during a shift or home visit. Because of the nature of their work, nurses must safeguard themselves against that possibility. Nurses are no less immune to those things that complicate one's life. However, unlike other many occupations, nurses must be able to set aside those complications while at work to give their full time, attention and effort to patient care. Failure to do so can result in improper patient care and personal or corporate liability.
TOC Chapter 303. Nursing Peer Review
An employer of 10 or more nurses, at least 5 of whom are RNs must create a nursing peer review. The peer review committee may be contracted from another facility or establishment. The committee is required to give the nurse being review minimum due process which includes notice and a hearing, if desired. The committee members must be comprised of at least 75% RNs or LVNs, two thirds of which must be RNs and voting members must be RNs. At least one RN must be familiar with the area of nursing practice in which the incident in question occurred.
TOC Chapter 304. Nurse Licensure
Nursing Compact is to facilitate the states' responsibilities to protect public health and safety, increase the cooperation of member states regarding licensing and regulation of licensed nurses and to promote compliance with governance of nursing practice in all areas of regulation. Nurses licensed in a member state may not hold a license in another member state. When a nurse changes residence from one member state to another member state and applies for licensure in the new residence state, the license in the former state is forfeited. However, if the nurse holds a license in a nonmember state, the nonmember state is unaffected.
Ethical Considerations for the Nurse
In a 2013 Gallup poll survey nurses were at the top of the list of trusted professions; trumping teachers, police officers and judges consistently for almost a decade. (Gallop) Nurses have proven that they have earned the trust of the American public because of their ethical standards and honesty. Nurses are held to high standards by nursing schools, their respective state boards of nursing and their peers in their personal and professional lives. Nurses are expected to maintain professionalism on and off the job and will gain the respect of their community when honesty and ethical values are preserved.
In nursing theory classes students are given detailed instruction of the ethics and values of the profession into which they are entering. Nursing excellence relies of those ethical standards which define the right and wrong behavior of each individual. Minimum ethical standards and behaviors that are taught early and consistently upheld throughout nursing education and will continue throughout the career of each nurse.
Defining the ethics to which all nurses nationwide are expected to adhere are professional organizations including the American Nurses Association (ANA). In their position statement regarding Risk and Responsibility of Providing Patient Care, the ANA adopted the following: "Nurses are challenged to thoughtfully analyze the balance of professional responsibility and risk, including moral obligation and options, in particular situations in order to preserve the ethical mandates of the profession. Nursing creates a relationship of trust between nurse and patient, with special duties for the nurse, including the responsibility to care for patients. The nurse has a moral obligation or duty to patients and is not at liberty to abandon patients in need of nursing care."
In their Policy Statement- ANA Code for Nurses: "(Code for Nurses) explicates the goals, values and ethical precepts that direct the profession of nursing. The ANA believes the Code for Nurses is nonnegotiable and that each nurse has an obligation to uphold and adhere to the code of ethics."
Taking ethical issues to another level is identifying the professional boundaries between nurse and patient. There is an unspoken, and sometimes spoken, relationship between nurse and patient that must be identified by the nurse. Nurses are in a position of trust when caring for a patient's physical and emotional well-being whether in a medical setting or not. Nurses are expected to be the professional in the nurse-patient relationship and crossing the line to become the needier contributor in the relationship places the patient in a more vulnerable position. A healthy nurse-patient relationship is patient-centered and focused on the needs of the patient. Hildegard E. Peplau, a prominent nurse theorist, identified four phases of the therapeutic nurse-patient relationship: orientation, identification, exploitation and resolution phases. (Black, 2013)
Sec. 301.351 (TOC) Designations
Sec. 301.352 (TOC) Protection for Refusal to Engage in Certain Conduct
Sec. 301.402. (TOC) Mandatory Report by Nurse
Peplau's Phases of Healthy Nurse-Patient Relationship
- The Orientation phase is directed by the nurse and involves engaging the client in treatment, providing explanations and information, and answering questions. (Black, 2013) During this phase the nurse and patient have the opportunity to get to know each other, become familiar with the situation and develop trust. The use of therapeutic communication is important for the nurse as she gathers necessary information from the patient. It is important at this time for the nurse to be worthy of the trust she is gaining by being consistent and doing what she says she will do. "I will be back in 10 minutes with your pain medication.' If for some reason the nurse is unable to keep her word it is important to be honest with the patient in order to maintain that trust.
- The Identification phase begins when the client works interdependently with the nurse, expresses feelings, and begins to feel stronger. (Black, 2013) The nurse and patient develop a stronger relationship and have a sense of trust and mutual respect. It is also very important for the nurse to become familiar with the patient's needs and history prior to entering into this phase and be aware of her own biases or personal judgments prior to introducing herself to the patient. She must be able to separate personal biases from her professional practice.
- During the Exploitation phase the client makes full use of the services offered. (Black, 2013). The nurse provides services the facility or organization offers and the patient is the consumer of the services. Whether the services are medical, psychiatric, home care, correctional, etc. the nurse is the provider of the services offered by the organization. At this time, the patient is vulnerable and dependent upon the nurse for his or her care.
- Finally, in the Resolution phase the client no longer needs professional services and gives up dependent behavior. (Black, 2013) The goals and care plans have been achieved and the relationship ends. At this time, the nurse must maintain professionalism as separation may sometimes be difficult for the patient, especially if the relationship has been over an extended period of time.
Boundaries of Nurse-Patient Relationship
Nurses must pay close attention to the feelings and behaviors that may arise when caring for patients. They must examine themselves continuously to ensure the actions and interactions remain patient-focused. If the relationship no longer focuses on the patient's needs it may become one of serving the nurse's needs. The change may come very overtly but most often is subtle and a nurse's primary or secondary gain may become the focus.
The National Council of State Boards of Nursing (NCSBN) is an independent, not-for-profit organization through which the Boards of Nursing act and counsel together in matters of common interest and concern affecting public health, safety, and welfare including the development of nursing licensure examination. See their chart in Figure 4 (www.ncsbn.org).
Warning Signs in Crossing Professional Boundaries (NCSBN)
Speaking poorly about coworkers or the facility in which the nurse is employed is sympathy seeking behavior. The act of complaining about the workplace is placing the needs of the nurse ahead of the patient's. It also creates a reversal of roles in which the patient is now the caregiver who is listening to the complaints of the nurse, and may be offering sympathy and empathy. The line between caregiver and patient has not just been blurred at this point, or even crossed; it has arguably been twisted. By focusing on patient-centered care and avoiding crossing the line into the needs of the nurse, patients will receive the therapeutic relationship they need during the interaction. Along those same lines, a nurse who is seeking validation, a compassionate ear, or a shoulder upon which to cry has placed her needs above those of her patient. In doing so, she has in effect made herself the focus of her practice and made the needs of her patient and the art of medicine subordinate to her own needs. Not only should a nurse be conscious of this potential hazard, but hospitals and healthcare agencies should be mindful of this as well. These organizations would be well advised to make provisions against such an eventuality by providing appropriate staffing solutions, making counseling available to employees, and by providing timely, professional debriefing, or debriefings for nurses following traumatic incidents. Appropriate outlets for dealing with personal and professional issues, augmented by comprehensive training and effective leadership may prevent an unwanted scenario from unfolding. Nurses can also play an active role in preventing the development of an inappropriate relationship by being aware of the issues that are present in their own lives and seeking a proper resolution to them, rather than "self-medicating" through improper interaction with their patients.
An extreme example of healthcare workers crossing a professional boundary is sexual misconduct with a patient. Even flirtatious and off-color jokes are an abuse of the nurse's position of trust with the patient. The National Council of State Boards of Nursing states in regards to sexual misconduct: "Boundary violations are extremely complex. Most are ambiguous and difficult to evaluate. Boundary violations may or may not lead to sexual misconduct. In some cases, extreme sexual misconduct, such as assault or rape, may be habitual behavior, while at other times it is a crime of opportunity. Regardless of the motive, extreme sexual misconduct is not only a boundary violation, it is criminal behavior."(NCSBN)
Nurses must also be aware of and recognize any behavior coming from the patient that may cross the line of a therapeutic nurse-patient relationship. Similar to the situation described above, the risk here is that the roles are reversed again, but in this case patient has the potential to become the person who controls the relationship which will compromise the ability of the nurse to give effective care. Any untoward communication or advances from a patient must be redirected to support a healthy nurse-patient relationship. The nurse must be cognizant that he or she may be confronted by such behavior and quickly reestablish the boundaries with the patient. If the nurse is unable to bring the communication or behavior back in line with a professional stance, the nurse should report the situation to supervisors for consultation and reassignment, if possible.
Nurse-Patient Relationship & Use of Social Media
When the nurse-patient relationship ends the patient may want to continue the relationship on a social basis. The sharing of personal information or connecting via social media is a boundary violation of the therapeutic nurse-patient relationship. The nurse should kindly decline a request for phone numbers or offers for the interaction to continue outside the healthcare setting, this includes connection via social media.
In their position statement regarding the use of social media the Texas Board of Nursing states: "The use of social media can be of tremendous benefit to nurses and patients alike. However, nurses must be aware of the potential consequences of disclosing patient-related information via social media. Nurses must always maintain professional standards, boundaries, and compliance with state and federal laws as stated in Board Rule 217.11(A). All nurses have an obligation to protect their patient's privacy and confidentiality [as required by Board Rule 217.11(E)] which extends to all environments, including the social media environment." (https://www.bon.texas.gov/practice_bon_position_statements.asp). In the age of technology, social media is in our lives to stay. The use of it must be weighed and used very cautiously. Patient confidentiality and privacy must be at the forefront of healthcare providers' minds when discussing any healthcare issue over social media. The use of patient identifiers, the obvious name and possibly type of case can be an identifier but there can be other identifiers that in other situations would not. For instance, a person of Middle Eastern descent in a predominantly Caucasian community would easily identify a patient or a patient with an unusual diagnosis or characteristics may be easily identified and HIPAA rules may be violated.
In addition to social media, texting patient information among caregivers is also unacceptable according to The Joint Commission (2012). The receiver is unable to make certain a nondescript patient identifier (room or medical record number) are for the patient being discussed, the communication cannot be placed into the medical record and anything sent via text message has the potential to be inadvertently sent to an errant number or intercepted by an unauthorized person potentially causing a breech in patient confidentiality.
Controlled Substances in the Workplace
With highly technological advancement in all forms propelling our society, stressful nursing units, higher expectations of nurse-patient ratios and changing healthcare environments comes increased stressors on the individual healthcare worker. Those stressors may entice a nurse to take advantage of the controlled narcotics around them. A healthcare worker who succumbs to the use of narcotics illegally creates perilous situations to others around them as well as their employer and especially to the patients who trust their nurse is going to take good care of them in an ethical and professional manner.
A nurse working under the influence of controlled substances has the potential of placing patients at risk for injury or coworkers at risk for litigation and direct or indirect harm. The potential for making mistakes in calculations of medications for a patient can cause serious harm and possible irreparable injury or death. There may also be the collateral damage from working closely with other healthcare workers, possibly becoming party to the injury unwittingly. There may be increased costs to the facility when a patient is consuming more medications than expected as a result of a healthcare worker diverting the medications. The theft of drugs by a healthcare worker is punishable under several counts of controlled substance abuse, theft from the employer, among others.
Medication diversion is taken very seriously by the healthcare licensing agencies and employers alike. The opportunity for nurses to divert drugs from patients to an unintended recipient or themselves is, in some cases a daily occurrence. In the article Diversion of Drugs Within Health Care Facilities, a Multiple-Victim Crime: Patterns of Diversion, Scope, Consequences, Detection, and Prevention, the author states "Addiction is sometimes viewed as a victimless crime. When the addiction is supported by drug diversion within the health care facility workplace environment, it becomes, in most situations, a multiple-victim crime in which patients, health care workers, and employers can be harmed directly or indirectly." (NCBI) In a surgical or endoscopy setting, if the drugs used for sedation are not given to the patient but instead pocketed by the nurse for her own use, the patient may be inadequately sedated for the procedure. The experience of the patient may be devastating both physically and psychologically. The subsequent damage to the facility's reputation could seriously affect the volume of patients as the community members choose other options for their healthcare needs thus resulting in loss of revenue for the facility. The potential for a lawsuit from the patient is a possibility resulting in monetary damages to the facility, the nurse and the nurse's coworkers.
The Texas BON says this in regards to drug dependency: The Board believes it has a responsibility to both the public and the nurse when information about a nurse's substance use disorder comes to the Board's attention. The responsibility to the public is for swift action to remove a nurse from performing duties involving direct patient care until the nurse is deemed safe to return to those duties. The Board's responsibility towards the nurse is to recognize that person's past service in the provision of patient care and give that person an opportunity to seek treatment at an approved treatment facility for the substance use disorder and then return to providing patient care when able to submit verifiable, documented proof that he/she has a year of sobriety and is in stable recovery.
Since Florence Nightingale began the profession, nurses have been faced with various stressors. The fluctuating state of healthcare in the U.S., the increasing number of patients, particularly the Baby Boomer Generation, along with the concerns that affect every working American are bound to induce stress in even the most seasoned and cool-headed nurses. Add to that resistant strains of super viruses in the United States, increased emphases on isolation, decontamination and the need for more personal protective equipment, and today's nurses will find themselves navigating waters that would never have been charted in Nightingale's day.
Black, Beth. (2013). Communication and Collaboration In Nursing. In Professional nursing: Concepts & Challenges (7th ed., pp. 170-172). Saunders/Elsevier.
Diversion of Drugs Within Health Care Facilities, a Multiple-Victim Crime: Patterns of Diversion, Scope, Consequences, Detection, and Prevention. (2012, July) Retrieved from
Eligibility and Disciplinary Sanctions for Nurses with Substance Abuse, Misuse, Substance Dependency, or other Substance Use Disorder. (2008, January 18) from
Honesty/Ethics in Professions. (December 8, 2013 ) Retrieved from
National Council of State Boards of Nursing (NCSBN). (2014). Nurse practice act, rules, and regulations. Retrieved from
Nursing Shortage.Retrieved April 24, 2014 from
Professional Boundaries. Retrieved September 14, 2014 from
Professional Standards. Retrieved September 21, 2014 from
Texas Board of Nursing Position Statements. Retrieved October 8, 2014 from
Texas Board of Nursing (TXBON). (2014). Texas Board of Nursing position statements. Retrieved from
Texas Occupations Code and Texas Administrative Code title 22, , part 11, Chapter 217.11 Retrieved October 28, 2014 from
Texas Secretary of State. Welcome to the Texas administrative code. Retrieved October 23, 2014 from