2.6 The Board's Scope of Practice Decision-Making Model (DMM)
Key Takeaways
- The DMM was developed by Board staff as a tool to help individual nurses make scope-of-practice determinations; it contains eight questions and must be used in sequence beginning with question one.
- If the nurse works through the model without reaching a stop sign, the model guides the nurse to proceed; reaching a stop sign at any point means the act should be considered outside that nurse's scope.
- Scope under the DMM is individual, not categorical — two RNs on the same unit can reach different answers because education, competence, orders, resources, and supervision differ.
- APRNs use a separate APRN DMM built on nine questions, which adds role-and-population-focus consistency and a written delegation mechanism with a physician for relevant medical aspects of care.
The Board's Scope of Practice Decision-Making Model (DMM)
Why this is on the NJE: The Resource List names Scope of Practice Decision Making Model (DMM) as a distinct Nursing Practice topic, with the model itself as the cited resource. The BON also publishes a DMM poster and a dedicated FAQ, Decision Making for Determining Nursing Scope of Practice. It appears on the Board's LVN, RN, and APRN scope pages alike, which is a strong signal of how central the Board considers it.
What the DMM Is — and Is Not
The BON's own description is precise: the DMM is a tool to assist individual nurses with scope of practice determinations, developed by Board staff. It is:
- Sequential. The model contains eight questions and is intended to be used in order, beginning at the top with question one.
- Reflective. The nurse answers each question honestly about their own situation; the answers direct the nurse either to continue or to stop.
- Gated by stop signs. If the nurse progresses through the model without reaching a stop sign, the model guides the nurse to proceed with the activity, task, procedure, role, or intervention under consideration. If the nurse reaches a stop sign at any point, the nurse should consider that activity to be beyond — outside — their scope of practice.
What the DMM is not: it is not a list of permitted tasks. The BON deliberately declines to publish a task list, because, as the Board puts it, every situation is different and there are many variables to consider. Two RNs with the same licence can run the same act through the model and reach opposite answers.
The Logic of the Eight Questions
The eight questions move from the most general legal constraint down to the most individual, and they are ordered that way for a reason: there is no point evaluating your personal competence to perform an act that state law forbids outright.
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| SCOPE OF PRACTICE DECISION-MAKING MODEL -- THE SEQUENCE |
| |
| DEFINE THE ACT FIRST |
| State precisely what activity, task, procedure or intervention |
| is under consideration. A vague question gets a vague answer. |
| | |
| v |
| LAYER 1 -- IS IT LEGAL AT ALL? |
| Is the act prohibited by the NPA, Board rules, or any other |
| federal, state, or local law affecting the practice setting? |
| Is it consistent with the definition of nursing at your licensure |
| level under NPA 301.002? [STOP if no] |
| | |
| v |
| LAYER 2 -- IS IT SUPPORTED BY AUTHORITY AND EVIDENCE? |
| Is it consistent with Board position statements and guidelines, |
| with your employer's policies and procedures, and with current |
| evidence-based practice and the standard of care? [STOP if no] |
| | |
| v |
| LAYER 3 -- IS THERE A VALID ORDER WHERE ONE IS NEEDED? |
| For acts beyond independent nursing practice, is there an order |
| from a practitioner legally authorised to prescribe, and have you |
| clarified anything questionable about it? [STOP if no] |
| | |
| v |
| LAYER 4 -- ARE *YOU* COMPETENT AND SUPPORTED? |
| Do you have the education, training, and demonstrable current |
| competence? Do you have the resources, supervision, and ability |
| to manage foreseeable complications? Are you fit to perform it |
| safely right now? [STOP if no] |
| | |
| v |
| NO STOP SIGN REACHED --> the model guides you to PROCEED, |
| accepting accountability under 22 TAC 217.11(1)(T). |
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Documenting Competence
The Board's commentary on the model is practical about what "current competence" means. Education may come from a nursing programme, continuing nursing education, or national certification. Evidence a nurse can retain includes performance evaluations, skills check-offs, competency validation forms, and records of having performed, observed, been evaluated on, or taught the activity. On the exam, the correct answer to "how does the nurse establish competence?" is documentary evidence of education and validated performance — never seniority, confidence, or the fact that a colleague does it.
Why Scope Is Individual
This is the single idea the DMM exists to teach, and it is heavily tested.
| Two nurses, same act | Why the answers differ |
|---|---|
| RN A has completed the facility's validated moderate-sedation competency; RN B has not | Layer 4 stops RN B. The act is within the RN category scope, but not within RN B's individual scope today |
| RN C works where policy authorises the procedure; RN D's employer prohibits it | Layer 2 stops RN D. Employer policy may be stricter than the NPA, and the model tells the nurse to respect it |
| RN E has a valid order; RN F is asked to proceed without one | Layer 3 stops RN F |
| RN G is well; RN H is post-call, ill, or impaired | Layer 4 asks whether the nurse is fit to perform the act safely — a question about this shift, not this career |
[!NOTE] Accountability travels with acceptance. Under 22 TAC §217.11(1)(T) each nurse is accountable for the assignments they accept. Running the DMM and proceeding is a decision the nurse owns. "The charge nurse told me to" does not appear anywhere in the model.
The Separate APRN Model
APRNs use an expanded APRN DMM built on nine questions. It keeps the same architecture but adds constraints specific to advanced practice, including whether the act is:
- Consistent with APRN education in the role and population focus of the nurse's Texas APRN licensure;
- Consistent with interpretations from advanced practice nursing organisations or national specialty organisations representing that role and population focus; and
- Supported by a written delegation mechanism with an appropriate physician providing authority for the performance of relevant medical aspects of care.
That last question is the structural one: because NPA §301.002 excludes medical diagnosis and prescription from nursing, an APRN's authority over medical acts rests on delegation and prescriptive authority under 22 TAC Chapter 221 and TOC Chapter 157, not on the APRN licence alone (Section 2.8).
Realistic Clinical Scenario & Legal Analysis
Scenario
Nurse Adeola, an RN on a busy outpatient infusion unit, is asked by her manager to begin performing ultrasound-guided peripheral IV insertions because the hospital wants to reduce PICC placements. Adeola has watched the procedure many times and is confident she could do it. There is no facility policy addressing it, no competency validation programme, and no protocol. Her manager says, "It's within RN scope in Texas — just start doing them."
Legal Analysis Using the DMM
- Define the act precisely: ultrasound-guided peripheral IV insertion by an RN in an outpatient infusion setting.
- Layer 1 — legality. Nothing in the NPA or Board rules categorically prohibits RNs from vascular access. No stop sign yet. Note that "it's within RN scope" is where the manager stopped reasoning — and where the model has seven questions left.
- Layer 2 — authority, policy, evidence. There is no facility policy or procedure for the act and no protocol. The BON directs nurses to consider employer policies and procedures and evidence-based guidelines. The absence of any institutional framework is a stop sign.
- Layer 4 — individual competence. Adeola has observed the procedure but has no education, training, or validated competency in it, and there is no mechanism to obtain validation. That is an independent stop sign.
- Conclusion. The act is outside Adeola's individual scope today. It is not permanently outside RN scope — the correct route is for the facility to develop a policy, an evidence-based protocol, and a competency validation process, after which Adeola can rerun the model and reach a different answer.
- If pressed to proceed anyway, performing an act she lacks the basic knowledge and skills to perform competently is precisely the third condition in 22 TAC §217.20(g), and she should request Safe Harbor peer review before engaging in the conduct.
A nurse begins working through the Board's Scope of Practice Decision-Making Model and reaches a stop sign at the third question. What does the model direct her to conclude?
Two registered nurses on the same unit hold identical Texas licences. One has completed validated competency training for a specialised procedure; the other has not. What does the DMM establish about their scopes?
An APRN is considering whether a particular medical aspect of care falls within her scope. Which requirement appears in the APRN Decision-Making Model but not in the model used by RNs and LVNs?