Consensus Model - Coalition for Nurses in Advanced Practice

Consensus Model - Coalition for Nurses in Advanced Practice

APRN Practice & Professional Advocacy in Texas Lynda Woolbert, MS, RN, CPNP-PC, FAANP APRN Consultant & CNAP CEO 1 Overview APRN Consensus Model & LACE (Module I: Unit 1) APRN Practice in Texas, Scope of Practice & Licensure (Module I: Units 1 & 2)

Prescriptive Authority (Module I: Unit 2) Texas Legislative & Regulatory Process (Module II) Advocating Effectively (Module II) Scope of Practice Review & BON Disciplinary Issues (Module I) CNAP & Texas Nurse PAC (Module II) Notes in normal view contain further explanation & information you may need to know for testing. 2 Why study APRN practice legislation &

regulation now? Must adhere to the law from the first day you practice as an APRN Evaluate & learn throughout clinical experiences Know resources to stay current Avoid being featured on 10 oclock news as two NPs were for dispensing controlled substances to treat obesity. (Harwin Weight Loss Clinic News Clip) 3 Consensus Model for APRN Regulation aligns Licensure, Accreditation,

Certification and Education (LACE) 4 APRN Consensus Model: LACE Accreditation Organizations Educational Programs Certification Organizations Boards of Nursing (BON is the state agency that licenses APRNs to protect the public.) 5

Consensus Model for APRN Regulation: Licensure 6 POPULATION FOCUS AREAS (Population Foci) Family (Lifespan) Adult Gerontology Neonatal Acute or Primary

Nurse Anesthetist CRNA NurseMidwife CNM 4 APRN ROLES Pediatrics Acute or Primary

Womens Health (Gender Related) Clinical Nurse Specialist CNS & Psychiatric Mental Health

Nurse Practitioner CNP* 6 Licensing Titles CRNA CNM CNS NP



Scope of Practice (SOP) Professional SOP based on: APRN education; Certification; and SOP statements by professional organizations. Personal (Individual) SOP based on personal competency. State SOP based on occupational licensing laws in the state. 8 Elements Determining Scope of Practice (SOP)

*Education *Certification Competency SOP is not determined by: Pre-NP specialization as an RN; or Setting. While an employer may limit SOP, an employer can never expand SOP beyond that legally permitted. Source: NONPF. (2012). Statement on acute care and primary care certified nurse practitioner practice. 9 Scope of Practice References

BON Guidelines for Determining Scope of Practice with FAQs on Scope of Practice Professional organizations representing the APRN role and population focus. Examples AANP: scope and standards applicable to all NPs AACN: scope and standards applicable to acute care NPs NAPNAP: scope of practice for pediatric nursing from RN through primary care and acute care PNPs. 10 Review What is the difference between certification organizations;

professional organizations; and licensing boards? Know the purpose of each, how they differ from each other, and the interests they represent. 11 Statutory and Regulatory Basis of APRN Practice in Texas 12 Statutory Laws passed by the state legislature (Nursing Practice Act)

Regulatory Rules passed by state agencies based on authority granted by the state legislature (BON Rules) 13 ? What is the states purpose in regulating health professionals? 14

Consensus Model for APRN Regulation Role & population determine licensure. BONs do not regulate specialization. POPULATION FOCUS AREAS (FOCI) Family or Individual (Lifespan) Adult Gerontology Neonatal

Pediatrics Womens Health Psychiatric (Gender Related) Mental Health APRN ROLES Nurse

Anesthetist CRNA NurseMidwife CNM Clinical Nurse Specialist CNS Nurse Practitioner (Acute or Primary)

CNP* 15 Advanced Practice Titles in Texas BON Rule 221.2 Nurse Anesthetists (CRNAs) Nurse-Midwives (CNMs) Nurse Practitioners (NPs) Clinical Nurse Specialists (CNSs) NCSBN. (2014). APRNs in the U.S. 16 BON Rules & Regulations for APRNs

219 APRN Education 221 APRN Licensure and Practice (expect revisions in 2017-2018) 222 Prescriptive Authority (new rules adopted November 15, 2013) laws_and_rules_rules_and_regulations.asp 17 Population Foci Titles Nurse Practitioners

BON Rule 221.2 & BON Policy Acute Care Adult Clinical Nurse Specialists

Acute Care Adult/Gero Adult Health / MS Acute Care Pediatric Adult/Gerontology Adult Adult/Gerontology Community Health Nursing Family Critical Care Nursing Gerontological Gerontological Nursing Neonatal Pediatric Nursing Pediatric

Psychiatric/Mental Health Psychiatric/Mental Health Womens Health Nursing Advanced Practice Titles in Texas BON Rule 221.2 Current Rule - Advanced Practice Registered Nurse (APRN) is umbrella term and not a title to use after your name. NPA was amended in 2013, and BON issues APRN licenses. When BON revises rules in Chapter 221, BON will propose licensure and titling

consistent with the Consensus Model. 19 BON Rules & Regulations for APRNs 219 APRN Education 221 APRN Licensure and Practice 222 Prescriptive Authority REMEMBER All BON Rules apply to APRN practice. 20

All BON Rules Apply to APRNs Particularly Note: Chapter 217 217.11 Standards of Nursing Practice 217.12 Unprofessional Conduct 217.14 Registered Nurses Performing Radiologic Procedures 217.18 RNs that First Assist at Surgery 21 First Assisting at Surgery 217.18 requires RNs that first assist: Complete a RNFA program (listed on CCI Website, CNOR certified; or APRN licensed - Limits RNFA scope to APRN Population Focus. 22 ALL BON Rules Apply to APRNs In addition to Chapter 217, Note: Chapters 216, 224, and 228 Chapter 216 Continuing Competency Chapter 224 Delegation to unlicensed personnel

in acute care setting Chapter 228 Pain Management Rules BON identifies as particularly relevant to APRNs are listed on the Advanced Practice Information webpage. 23 Other BON Resources Position Statements Texas Board of Nursing Bulletin APRN Practice webpage 24

BON Rules require RNs follow all state & federal rules that apply to their practices. Examples: Texas Medical Board (TMB) Texas State Board of Pharmacy (TSBP) Texas Health & Human Services Commission (HHSC) Federal - Center for Medicare & Medicaid Services (CMS) 25 APRN Licensure & Renewal BON Rules Chapter 221

26 APRN Licensure in Texas BON Rule 221.4 2nd license in addition to RN license APRN license AP###### Verify APRN license on BON website New application required for each role

and/or population focus Requirements New graduate and national certification; or 400 hours practice and current national certification 27 New Graduate APRN License (BON Rule 221.4) with Prescriptive Authority (BON Rule 222.2) 1. Complete & submit licensure and Rx Authority applications (online preferred); 2. Submit additional documents; 3. Pass a certification exam recognized by the

BON; and 4. Notify BON 5. Receive APRN License & verify Rx Authority Number online. 28 Remember Until BON notification or verification on BON website of full APRN licensure, Do not use APRN skills except under direct supervision; and Do not use or claim an APRN title (including Graduate FNP, etc.)

29 Remember Do not sign a prescription until: Prescriptive authority number is verified on BON website, and Physician delegates prescriptive authority & signs Prescriptive Authority Agreement (PAA) or Facility-Based Protocols (as applicable to the type of practice). 30 Interim Approval

(Not an option for new graduates and no interim approval is consistent with Consensus Model) BON Rule 221.6 Short term approval until all documents received and reviewed. Up to 120 days, no extensions Interim approval granted only 1 time per APRN role & population focus area No prescriptive authority 31 Applicants for Texas APRN License Currently Licensed in Other States Must have unencumbered Texas RN license or be a resident of a RN Licensure Compact state with

a privilege to practice in other Compact states No interstate APRN Compact option - must complete the full application process for Licensure and Prescriptive Authority BON expected to eliminate option for Interim Approval in 2017-2018. 32 Maintaining APRN Licensure BON Rules 216.3 & 221.8 Renew APRN license in conjunction with RN license attesting requirements were met.

Current national certification in the role & population focus area; 400 hours of current practice; 2 hours jurisprudence/ethics CE in past 6 years; 2 hours of CE in caring for older adults; and APRNs with Rx authority must have 5 hours of pharmacotherapeutics CE within the past 2 years . Those with Rx authority for controlled substances (CSs), need an additional 3 hours related to CSs. 33 How to Sign Your Name (current rules) RN identifies licensure Identify APRN role & population focus, e.g. FNP, ACNP, CNM, ACNS

Multiple APRN role / population foci -- use the title that applies. Lynda Woolbert, RN, PNP Lynda Woolbert, MS, RN, CPNP-PC, FAANP 34 Likely Signature Requirements in 2018 RN or APRN could identify licensure. Identify APRN role & population focus, e.g. FNP, ACAGNP, AGNP Multiple APRN role / population foci -- use the title that applies. Lynda Woolbert, APRN, PNP Lynda Woolbert, MS, APRN, CPNP-PC

In accordance with current statute but not BON rules 35 APRN Practice: Autonomous vs. Delegated Elements of APRN Scope of Practice in Texas 36 Delegation Transferring authority from one person to another Delegation always implies supervision

Ordering a service to be provided by a licensed individual is NOT delegation. Physicians have broad delegatory authority. RNs and APRNs have limited delegatory authority based on BON Rules in Chapters 224 and 225. 37 APRN Practice: What is Autonomous? Assessments Histories & physical exams Ordering diagnostic exams

Interpreting diagnostic tests Recommending OTC Drugs Establishing treatment plans in the APRNs scope of practice (excludes Rx & other functions specifically requiring physician delegation) Referrals, Consultation, Coordination of Care 38 Texas APRN Practice: What is Delegated? Based on definition of Professional Nursing in the NPA & no exclusion for APRNs.

Medical diagnosis; and Prescribing & ordering drugs, medical devices and durable medical equipment are delegated. Based on Provisions in Other Texas Laws Signing medical verifications for disabled parking placards Ordering Orthotics and Prosthetics Medicaid Rules can Limit Scope of Practice 39 Medical Aspects of Care

BON Rule 221.13 (d) Medical Aspects of Care are acts that require physician delegation through a written document. Either a: Prescriptive Authority Agreement (PAA); or In facility-based practice, Protocols or other written authorizations (standing medical orders, standing delegation orders, or other order or protocol) 40 What What are are the the physicians

physicians liability liability implications implications for for delegated delegated acts? acts? Except when subject to other provisions in the law and/or mitigating circumstances, the delegating professional is liable.

The Medical Practice Act (statute) and TMB Rule 193.5 include a partial exemption for physicians delegating prescriptive authority. TMB Rule 193.5(b) states: delegating physicians remain responsible to the Board and to their patients for acts performed under the physician's delegated authority. 41 When When performing performing medical medical aspects aspects of of

care, care, isis the the APRN APRN practicing practicing medicine medicine or or nursing? nursing? All health care professionals have overlapping scopes of practice. Professional practice acts recognize this by including a provision exempting other health professionals. When a nurse performs medical acts, the nurse is

practicing NURSING. 42 Overlapping Overlapping Scopes Scopes of of Practice Practice NP PA MD DO Pharmacists Therapists Dentists Optometrists Radiology Techs, etc.

All health professionals have SOPs that overlap in some way. 43 Facts Facts about about Physician Physician Assistants Assistants (PAs) (PAs) Regulated by the Physician Assistant Board Licensing Statute is in Medical Practice Act (Subtitle B, Chapter 204, Texas Occupations Code).

PA rules are in Chapter 185 of the TMB Rules. Education is similar to 3rd year medical school. Scope of practice is based on supervising physician. All aspects of PA practice are delegated by the supervising physician. In Texas, PA & APRN prescriptive authority are identical. 44 Collective Collective Terms Terms for for APRNs APRNs & & PAs

PAs Best to call professionals by their names, e.g., Nurse Practitioner Physician Assistant When a collective term is used: Avoid mid-level provider or practitioner Exception: DEA Better: Advanced Practice Providers (APP) or advanced practice practitioners. 45 Prescriptive

Prescriptive Authority Authority in in Texas Texas Nursing Statute (NPA): 301.152 & 301.168 BON Rules: Chapter 222 Medical Statute (MPA): 157. 051 157. 060 TMB Rules: 193.5 193.14 and Applicable Definitions in TMB Rule 193.2 46 Definitions Prescribing vs. Ordering

Prescribing Prescription filled at outpatient pharmacy Must have prescriptive authority to sign a Rx Includes orders written in long-term care facilities Ordering Medications dispensed from inpatient pharmacy for administration Must be consistent with facility policy and Protocol, PAA or other written authorization 47 Definitions

Two Broad Drug Categories in Texas Law Dangerous Drugs - Drugs & medical devices that require a prescription, excluding controlled substances. Controlled Substances (with limitations) Drugs deemed to have abuse potential and subject to additional regulation. Controlled substances are divided into 5 schedules. 48 Controlled Substances (CSs)

Schedules are based on abuse potential & medical use. I - highest abuse with no medical use II - high abuse with recognized medical use III - moderate abuse potential IV - moderate to low abuse potential V - some abuse potential Schedules III-V are subject to less regulation than Schedules I and II. 49

A Universal Limitation on APRN Prescriptive Authority Scope of Practice In any state, prescriptions are limited to the scope of practice authorized by state law and the states board of nursing. 50 Limitations on APRN Rx Authority in Texas Delegated & Supervised

No Schedule II Controlled Substances in most practices 51 Rx Authority Delegation MD or DO licensed in Texas Witten delegation document: Protocol if facility-based; or Prescriptive Authority Agreement (PAA). Physicians register APRNs & PAs to whom they delegate Rx authority through a PAA. Physician & APRN must keep records until 2 years

from the date the PAA is terminated. Resources: CNAPs Sample Prescriptive Authority Agreement CNAPs Sample Facility-Based Protocols A Guide for APRN Practice in Texas FAQs on TMB and BON Websites 52 MD may delegate ordering & prescribing: Dangerous Drugs Any category Controlled Substances (CS)- Limitations Schedules III V 90-day Rx (or refills equal 90-day supply)

Prior authorization required for: Refills beyond 90-days Any CS for Children Under 2 yrs. Schedule II to APRNs treating: patients in hospital ER (APRN must be facility-based) Inpatients (APRN must be facility-based); or Hospice patients 53 Rx Authority Review An APRN from a nurse licensure compact state is going to practice in Texas for four months. What licenses must the APRN have before prescribing

dangerous drugs in Texas? (Check all that apply) a) Texas RN license b) Texas APRN license c) Texas APRN prescriptive authority number d) DEA Controlled Substances Registration 54 Texas Prescriptive Authority Law Special Practice Designations exempt from certain restrictions Do not submit site changes to BNE or the Texas Medical Board (TMB) 55

Prescriptive Authority Two Types of Practice Designations Practice serving a medically underserved population Facility-based practice or site 56 Medically Underserved Medically Underserved Population (MUP) Definition Federally designated HPSA, RHC, FQHC Public health or family planning clinic under contract with HHSC or DSHS

Designated by DSHS (Health Professions Resource Center) http:// Titles V, X, XVIII, XIX, XXI Federal funding or state-funded County, state or federal correctional facility Any practice designation as a site serving a MUP prior to March 1, 2013. 57 Medically Underserved PAA requirements same as other sites Advantage - No physician to APRN/PA ratio Physician limited to delegating at no more than 3 MUP practices = 150 hrs./wk.

58 Facility-Based Sites Licensed Hospital Only delegated by certain physicians Limited to 1 hospital (under facilitybased hospital provisions) Long-term Care Facility Only delegated by medical director Limited to 2 facilities 59 Facility-Based Sites: Advantages

Licensed Hospital No delegation ratio May use protocols or PAA Long-term Care Facility 1 physician to 7 APRN/PA ratio (no advantage) May use protocols or PAA Physicians delegating under facility-based provisions may delegate to 7 additional APRNs/PAs through a PAA. 60

Protocols BON Rule 221.13 (d) Preferred written delegation document in facility-based practices Protocol should promote the exercise of professional judgment commensurate with: APRNs education and experience; and Complexity of patients condition. Advantage No specific QAI requirements that are specified in the PAA. 61

Prescriptive Authority Agreement (PAA) Written document through which a physician delegates the authority to order and prescribe drugs and/or devices in all practices except facility-based. Remains an option for facility-based. 62 Requirements for Parties to the PAA Physicians are limited to delegating Rx authority to no more than 7 APRNs and/or PAs (FTEs) All parties must disclose: Prior disciplinary action by the licensing board before executing the PAA.

Investigation by the licensing board while a party to the PAA. All parties must cooperate with TMB and BON staff during an inspection or audit relating to the PAA and its implementation. 63 PAA Requirements In writing, signed and dated by all parties Name, address & professional license # of parties Nature of the practice, locations, or settings Categories of drugs that may or may not be prescribed Plans for:

Consultation & referral Addressing patient emergencies Communicating & sharing information related to treatment Quality assurance and improvement (QAI) that includes chart review, meetings, & documenting implementation of QAI 64 QAI Plan Requirements Chart review - Number determined jointly

Purpose/content of QAI monthly meetings share information about patient care & treatment, changes in treatment plans and issues relating to referrals QAI monthly in-person meetings Location, day and time determined jointly Face-to-face 1 year for APRNs who prescribed for 5 of past 7 yrs Face-to-face for 3 years for APRNs with less experience Thereafter, meet quarterly in-person & monthly in between by electronic means.

Document implementation method & compliance 65 ? Would a NP be able to prescribe dangerous drugs or medical devises without a DEA registration? 66 Prescribing Standards 67

Prescribing Standards: Writing a Prescription Avoid abbreviations on The Joint Commissions Do Not Use list Refer to Stewart & DeNisco or The Joint Commission facts_about_do_not_use_list/ 68 Prescription Form 1.

2. 3. 4. 5. patient's name and address; name, strength, and quantity of the dangerous drug or controlled substance; directions to the patient regarding taking the drug and the dosage; intended use of the drug, if appropriate; name, address, and telephone number of the delegating physician; continued

69 Prescription Form contd 6. APRNs prescriptive authority # 7. address & telephone # of site; 8. date of issuance; 9. number of refills permitted; and 10. If a controlled substance: DEA # for APRN & MD/DO DEA # for APRN BON Rule 222.4(b) & TSBP Rule 291.34 (b)(7)(A) 70

Prescribing Standards: Generic Substitution Requires written and faxed prescriptions designate brand medically necessary or brand necessary in the prescribers handwriting. Rules allow electronic prescriptions if brand necessary is designated on the prescription. TSBP Rule 309.3 71 BON 222.4 Prescribing Standards Off label use permitted only if: Part of a research protocol approved by IRB or

Expanded Access authorized clinical trial Within the current standard of care and supported by evidence-based research Patient-practitioner relationship must exist Do not prescribe for self, friends or family May treat STDs for partners of established patient after examining the patient 72 Prescribing Controlled Substances (CSs) Follow limitations and requirements for prescribing controlled substances limitations specified in BON Rule 222.8

1.Schedules 3-5 only if do not meet requirements in #4 2.90-day Rx (or refills equal 90-day supply) 3.Prior authorization required for: Refills beyond 90-days Any CS for Children Under 2 yrs. 4.Schedule 2 to APRNs treating: Patients in hospital ER (APRN must be facility-based) Inpatients (APRN must be facility-based); or Hospice patients 5. Obtain a DEA # before prescribing any CS. 73

Prescribing Standards: Controlled Substances Schedule 3 - 5 Controlled Substances (CSs) may be: prescribed on a standard prescription form; prescribed electronically; called to the pharmacy by a practitioner or designated agent; and refilled up to 5 times within 6 months of Rx issuance. Essential Resources if prescribing CSs

BON Prescribing Controlled Substances Rule, 22 TAC 222.8 Pain Management Rules BON Chapter 228 & TMB Chapter 170 TSBP CS Rules Chapter 315 TSBP Resources on Abuse & Misuse (including TMB links) DEA Practitioners Manual 74 DEA Controlled Substances (CSs) Registration 1. Must have delegated prescriptive authority for CSs.

2. Apply for DEA# online - Form 224 3. Include address of the primary practice where you will be prescribing CSs. 4. Business activity. APRNs mark MLP Nurse Practitioner. 5. Ensure the CSs schedules you mark are consistent with those delegated in Protocols or PAA and with Texas law. Schedules 2 and 3 are subdivided into Narcotic and Non-narcotic drugs. 2N and 3N signify the non-narcotic drugs in Schedules 2&3. 75 Official Prescription Form

Term for the form required when prescribing Schedule II Controlled Substances (CSs). (Also called triplicate) Schedule II CSs may be prescribed electronically. Practitioners signing the form must have DEA registration that includes Schedule II narcotic &/or nonnarcotic drugs. Delegating physician must sign the APRNs order form for official prescription forms. If a physician terminates Schedule II Rx authority, the APRN must return unused forms to the TSBP. Prescriptions for Schedule II drugs may not be refilled. 76 Official Prescription Forms

Schedule II Prescriptions must be: Written for no more than a 30-day supply; Filled within 21 days; Printed in ink or typewritten; and Dated for the day they are signed by the practitioner. Prescriptions may never be: Postdated, or Pre-signed by a physician or other practitioner.

77 Official Prescription Forms Schedule II Prescriptions may be: Prepared by a designated individual for signature by the practitioner. Multiple prescriptions: May be issued for up to a 90- day supply Other than the first prescription, must indicate the earliest date on which a pharmacy may fill each prescription. 78 What APRNs Must Know about Rx Authority

1. Apply for a prescriptive authority number when applying for license to practice as an APRN. 2. Separate Prescriptive Authority required for each APRN role & population-focus area 3. May not write prescriptions until a physician 1) delegates authority, 2) signs PAA or Protocol 4. Register delegation on TMB website within 30 days. 5. May not prescribe controlled substances until have DEA #. 6. May not prescribe for yourself, friends or family. 79 ? What Texas state agencies regulate the information included on a prescription form

when the APRN signs a prescription for a controlled substance? (Check all that apply.) a) Board of Nursing (BON) b) Department of Public Safety (DPS) c) Texas Medical Board (TMB) d) Texas State Board of Pharmacy (TSBP) 80 Advocacy and the Texas Legislative Process 81 Barriers to Practice

Federal Level Some Medicare reimbursement policies APRNs not allowed to order home health in Medicare & Medicaid State Level Definition of Professional Nursing in the NPA Physician delegation Limitations on controlled substances Provisions in the Insurance Code Some Medicaid reimbursement policies

82 Texas Legislative Basics Begins with Interim Charges. Stakeholders take part in hearings.

Session starts the 2nd Tuesday in January. Bills are filed by legislators until 60th day. Companion bills Same bill filed in House & Senate The same bill number must pass House & Senate The Regular Session lasts 140 days Governor may call a 30-day Special Session for specific purpose/s (The Call) 83 Texas Legislative Session Cycle 2018 Legislative Process: Bill to Statute

Bill Introduced & Referred to Committee Committee Hearing Committee Report Floor Vote Engrossed Received in 2nd Chamber & Referred Committee Hearing Committee Report Floor Vote Enrolled

Sent to Governor Signed Statute (Law) 85 Legislation to Regulation 86 Legislation Texas Legislature passes a bill. Governor signs into law. Statute directs

state agency to implement. Regulation State agency proposes & adopts rules Agency takes action within statutory authority against regulated persons / entities that violate rules. 87

Advocacy Basics What is the difference between legislation and regulation? Does the Texas Legislature meet in Regular Session every year? Does your congressman work in Austin or in Washington, D.C.? How do you address your state legislators? How do you find your legislators names? Who represents you in Austin & D.C.? 88

Following Bills through Legislative Process How to Find and Read a Bill Finding a Bill Legislative Process Citizen Handbook & other publications 89 APRN Legislative Priorities in 2015 Remove unnecessary restrictions that prevent & delay care. Contract directly with insurance providers and serve as primary care providers whether the delegating physician is in-network or not. Authorize physicians to delegate prescribing Schedule II medications

(especially to psychiatric APRNs and APRNs providing palliative care). Handouts: 2015 Legislative Summary page=SessionUpdates#ID 90 APRN Legislative Priority in 2017 Full Practice Authority But unlikely to pursue expansion of prescribing Schedule 2 medications 91

Visits with Legislators Lobbying is education Identify purpose & 3 goals Flow of the visit Getting to know you finding commonalities Listen before telling. Find out what the legislator /staff knows about your issue/s. for info on representatives for into on senators Give the information the legislator needs. End on time with your request. Follow-up with a letter to the legislator & staff.

92 Visiting/Writing Legislators Research the issue & ask for help as needed. APRN state & national organizations and Policy Institutes: & Address the right issue to the right legislator Limit to 1 page Use enclosures as necessary Use correct forms of address

The Honorable Donald Doorman to address the envelop Dear Representative Doorman: to open the letter Include your card / your contact information. 93 Writing Legislators by Email Be sure the email will be read by asking if email is a preferred form of communication. Write it like a letter - Include a salutation & closing Edit very carefully Remember how easily emails are forwarded Never put anything in an email you would not

want the public to read. 94 Relationships with Legislators Be a regular At least 3 - 4 contacts a year Meet with legislators in home district Always be polite, even when you disagree Visit when you need no favors Write notes Handwritten notes are good Congratulatory

Items or articles of interest Volunteer and donate Attend fundraisers 95

Responding to Action Alerts Read the entire alert carefully. Clarify if needed. Verify the alert is from a reputable source. Respond if appropriate in time frame requested. Read & Follow directions/guidelines exactly. Put your response in your own words. Edit carefully. Close the loop. Let requestor know you responded. Responding through an organizations automated response system 96

Becoming an Effective Advocate Join and attend professional meetings Get informed & organized Register or Join to receive professional org.s updates Organize so everyone plays to their strengths Recruit colleagues Do what you can, when you can Join your statewide professional organizations

TNA, TNP, and CNAP. Contribute to Texas Nurse PAC Form relationships with your legislators & staff. 97 NP Week at the Capitol Sponsored by TNP November 6 12, 2016 APRN Legislative Day Sponsored by APRN Alliance February 2017 98

Reasons the BON Disciplines APRNs Scope of Practice Review What To Do If a Complaint is Filed BON Disciplinary Options 99 Administrative Violations of the NPA Fails to: Obtain APRN Licensure Renew APRN Licensure Renew RN License Maintain National Certification

Attain or maintain records of CE Sign name properly identifying APRN role & population Solicit / inform patients ethically or in accordance with HIPPA 100 APRNs Practice Violations Fail to: Maintain or annually sign /date Rx authority written documentation Document Assess or monitor Maintain a safe environment for patient Refer to a physician or others

Prescribe and/or administer drug appropriately 101 Mistakes Resulting in Serious Outcomes APRN Practicing as RN without proper orientation Practicing as APRN in primary care does not maintain high tech RN skills. Practicing when fatigued / over 12 hours or too many days in a row. (See the Texas BON Bulletin, April 2015.) 102

Mistakes Resulting in Serious Outcomes Violating APRN Scope of Practice most common cause for: disciplinary action R/T practice error; and bad outcomes 103 May APRNs provide any service or perform any procedure delegated by a physician? NO

Must fall within formal APRN education: Population of patients Type of services 104 Scope of Practice Review Is a primary care educated NP permitted to practice in a specialty? YES 105

Scope of Practice Review Is a primary care educated NP permitted to practice in a hospital? YES, But limited to the level of care included in APRN educational program. 106

What to do if a Complaint is Filed Notice means BON opened an investigation. You have 20 days to respond. Use the time wisely. Identity of complainant is confidential. Fail to respond, the case moves forward without your side of the story. Consult an attorney and colleagues. If you have prescriptive authority through a PAA, notify delegating physician and other parties. Resources: BON Website & A Guide for APRN Practice in Texas, Chapter 9.107 BON Disciplinary Process: Chapter 213 Disciplinary Options

The BON may issue a Board Order taking any of the following actions against the RN/APRN license: Warning (can be deferred) Reprimand Restrict Suspend Revoke 108 BON Disciplinary Options SB 1415 (2009) & SB 1058 (2013) Corrective Action BON finds nurse committed a minor violation of

the Nursing Practice Act or BON Rule. A non-disciplinary, administrative action. May count as a disciplinary action in future sanctions Not reported to National Data Bank Not disclosed to public 109 Corrective Action Determined by BON Executive Director First offense for:

Delinquent license less than 6 months Noncompliance with CE Inaccurate answers R/T criminal history, etc. Fails to report new name or address to BON Fails to assure credentials for personnel Does not maintain peer review plan Fine is $500 Rules 211.7 & 213.32 adopted on 11-6-09 110 BON Disciplinary Options Deferred Disciplinary Action

Cases are eligible if a warning or lesser discipline proposed (not a license reprimand, suspension or revocation). If nurse completes requirements, BON removes public record of the infraction after 5 years. May count as a disciplinary action in future sanctions Reported to National Data Bank but modified five years after completing. 111 More about the Coalition for Nurses in Advanced Practice (CNAP),

Texas Nurses Association, & Texas Nurse PAC 112 CNAP Mission 1. Educate APRNs and stakeholders about the legal aspects of APRN practice; 2. Educate APRNs about advocating for their practices; and 3. Promote regulations that allow APRNs to reach their full potential to improve the health and well-being of all Texans. 113

CNAP APRN Group Members CTCNM Consortium of Texas Certified NurseMidwives Tx Tx Texas Texas

ANNP CNS NAPNAP PAPNs Texas Clinical Nurse Specialists

Greater Texas, Houston Area & South Texas Chapters of the National Association of Pediatric NPs Psychiatric Advanced

Practice Nurses : Austin San Antonio Texas Association of Neonatal Nurse Practitioners VANPs Victoria Area

Nurse Practitioners TNA is taking a lead role in coordinating the APRN legislative agenda through its Advanced Practice Nursing Advisory Committee, the Texas Team and the APRN Alliance. Texas Nurse Practitioners (TNP) takes the lead in advocating for legislative change for NPs. TNP is also part of the APRN Alliance.

115 Texas Nurse PAC 116 PAC Political Action Committee 117 PACs contribute money to support political candidates Incorporated organizations may not make political contributions Texas Nurse PAC

118 Texas RN PAC became RN/APRN PAC in 1995 Administered by TNA, CNAP and TANA Became the Texas Nurse PAC in 2015 Contributes to candidates for state office When I give $$ to the Texas RN/APRN PAC, am I giving to a professional group that hires lobbyists? NO

PACs must be separate from prof. organizations, e.g., TNA, TNP & CNAP 119 Do Your Fair Share Contribute $30 /mo. for professional organizations $15 /month to Texas Nurse PAC ( Total = 1 hour of your salary / month) Visit your legislators 7 times Spread the word and recruit

4 colleagues to do the same120 Thanks for Joining CNAP y c a c o v Contact ad & e Lynda Woolbert e rc om

c i u .c t [email protected] c so s a a r e x (979) 345-5974 p r te N p

(512) 750-3747 R a cn AP Questions? 121

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    A forgalomirányítási bejegyzéseknél a betű a következő routert, a szám az út hosszát jelöli (pl. B,2 azt jelenti, hogy a D cél B-n keresztül 2 távolságra van). * Nézzük hogyan reagál az algoritmusunk a topológia változására (B-D link használhatatlanná válik).