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Nevada State
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June 2004 Sexual Assault Nurse Examiners Roles of Consultant, Surveyor, and Nurse Educator Your Right to Refuse An Unsafe Assignment Dr. Rosemary Witt Begins Another Chapter Dr. Patsy Ruchala Named Orvis Director Dr. Carolyn Yucha Named First UNLV Nursing Dean Nevada Nursing Schools Offer Innovative Choices
Bridge from education to practice builds confidence, refines skills Confidence. That’s what you get when you work as an apprentice
nurse. Educators, regulators, hospital administrators, and
students have a wealth of perspectives about nursing. Yet on the subject of
apprentice nurse programs, they share a common view: such programs build
confidence—a crucial ingredient to the success of new nurses. They also help students refine the skills they’ve
learned in their nursing education programs, and provide needed support for the
journey toward becoming full-fledged, professional members of a health care
delivery team. Two years ago, the Board put together guidelines for
health care facilities that wished to hire student nurses in apprentice
positions. Many hospitals employed nursing students, but until recently, they
had apprentices performing basic functions rather than the full range of allowed
skills.
Today, several Nevada hospitals have full apprentice nurse programs, and several
more hospitals and long-term care facilities are exploring the possibility of
developing them. Among those with full programs are Washoe Medical Center and
St. Mary's Hospital in Reno; Carson-Tahoe Hospital; Humboldt General Hospital in
Winnemucca; South Lyon Medical Center in Yerington; and St. Rose Dominican
Hospital, Valley Hospital, and MountainView Hospital in Las Vegas. Several more
Las Vegas hospitals are developing, or interested in developing, full programs.
Those include the University Medical Center, Sunrise Hospital and Medical
Center, Summerlin Hospital, Seven Hills Hospital, and Spring Valley Hospital. “It is a win-win for everyone involved,” said
Mary Ann Lambert, MSN, RN, whose roles as a regulator, educator, and nursing
supervisor give her a unique perspective. Lambert is a Board member; an
assistant professor with the University of Nevada, Reno, Orvis School of
Nursing; and a nursing administrative manager at Washoe Medical Center. “While our students receive an excellent education
in the theory and practice of nursing, they need a reality base. There is no
substitute for actually working full shifts under the direction and supervision
of an experienced registered nurse,” Lambert said. She added, “The research
is strongly indicating a need for a bridge between education and practice in
today’s complex healthcare environment. Apprentice nurse programs that allow
students to practice the full range of skills allowed under the Board’s
guidelines serve as that bridge.” It was a student who sparked the expansion of Washoe Medical Center’s apprentice nurse program. The program’s administrator, Karen Winter, MN, RN, director of professional practice, said it sprung from a proposal by Rob Judd, BSN, RN, a graduate student at the University of Nevada, Reno, Orvis School of Nursing. He is also a staff nurse in Washoe’s telemetry unit. In his thesis, Judd proposed expanding the apprentice nurse program to include the Board’s RN Apprentice Nurse Skills List. Winter had been researching the concept herself and found a solid basis for it in the nursing literature. “The Board said we could do more and our students were saying the same thing,” Winter recalled. “We listened, and the program we developed has really taken off.” Washoe added an Apprentice Nurse II (AN II) position in the Spring of 2003. (A student can work as an Apprentice Nurse I (AN 1) after completing the first semester of the first year of a nursing program that includes basic nursing skills education. An AN1 works as part of a healthcare team, providing support for basic functions on the nursing unit). “The AN II position offers senior students the opportunity to really acculturate to the role of professional nurse,” Winter explained. “Students get caught up in tasks such as giving meds, but along the way, we see professional conduct being instilled in them. They are learning how to resolve conflicts, how to get feedback from others. Socialization, which takes a long time, is one of the primary aims of the program.” To further that aim, each AN II works under the direction of an RN preceptor. Once the RN is designated as a preceptor, that RN receives training in adult learning theory, coaching and mentoring skills. If an AN II has been taught a skill on the Board’s skills list, he or she can perform it under the direction and guidance of the RN preceptor, with whom the apprentice nurse is paired at all times. “As we’re learning skills in school, we’re putting all the pieces together here at work,” explained Laurie Daggitt. “I feel like I’m safer, because I know how to take full care of a patient.” Dawn Dollarhide agreed, adding the experience has taught her important organization and prioritization skills. Both are senior TMCC nursing students and AN IIs in Washoe’s intensive care unit. Tammie Brewer, RN, is Dollarhide’s preceptor. “Dawn is comfortable and confident in a setting where the fears are great,” she said. “I think this program gives students a more realistic insight into nursing than they can get just from what they learn in school.” “The apprentice nurses are pretty close to being ready to start work,” added Daggitt’s preceptor, Cindy Pffirmann, RN. “Both Laurie and Dawn are very confident in their skills at this level. There is a huge difference in their confidence compared to other new grads.”
Andrea Bourque, a senior Orvis nursing student and AN II on the general surgical unit, said, “It’s a really good foundation for things you don’t have time to become an expert in while you’re in school—things like confidence, organization skills, time management, therapeutic relationships, and clinical skills.” Andrea Adams, a senior TMCC nursing student, said she feels very well prepared, and very fortunate, to be in the program. “I’m applying the theory that I’m learning in school right away--in full, 12-hour shifts,” she said. “You don’t get that kind of unfragmented time in clinicals.” Adams is an AN II in Washoe’s telemetry unit. Wendie Rains, is a senior Orvis nursing student, an AN II who is paired with Deb Salaber, BSN, RN, in Washoe’s oncology department. She said, “This experience has given me confidence in the knowledge I acquired at UNR. It’s reinforced everything I’ve learned.” To Rains, being an apprentice nurse is meaningful on a personal level, as well as a professional one. “Everyone in oncology has been very nurturing and supportive, “ she said. “And since apprentices are not included in the staff count, we can truly make a difference in our patients’ lives, because there are two of us, where normally there would be only one.” Reflecting on the often stressful and difficult nature of a nurse’s job, Rains said she believes the apprentice program will help avoid the burnout new nurses often experience. “If you go straight from school to your first full shift as a nurse, the stress can be overwhelming,” she explained. “I can’t imagine what it would be like not having gone through this program.” These words are music to Winter’s ears. “So far, we’ve had great success, great quality, and high retention,” she said. In its first full year, 60 students have been employed as AN IIs, and of those, 51 are working, or planning to work at Washoe after they graduate. Graduation does not mark the end of their education, however. To Winter, it is just the first step. “We look upon professional nursing as a life-long process of education. Our philosophy is to focus on and promote evidence-based practice,” she said. Winter added that the apprentice nurse program is a key part of Washoe’s goal of attaining magnet hospital status. It is also something that will continue to grow—she said she will be soon hiring a dedicated educator to oversee the program. Confidence is a shared trait among the apprentice nurses interviewed for this story. So is leadership. Andrea Bourque is the president, and Wendie Rains is the treasurer of the Orvis Student Nurses Association. Dawn Dollarhide is president of TMCC’s graduating nursing class. Wendie Rains and Sheila McFall are both leadership students at the Board. Their preceptors are, respectively, Executive Director Debra Scott, MS, RN, APN, and Associate Director for Compliance Chris Sansom, RN. At the time of this writing, all the apprentice nurses featured in this article were still students. By the time this magazine is published, they will have graduated from their nursing education programs. The Nevada State Board of Nursing thanks them for sharing their experiences and congratulates them on their graduation! SIDEBAR The Apprentice Nurse Program is designed to allow a nursing student, currently enrolled in a nursing program, to work at a health care facility providing nursing care following the board’s approved skills list. The program offers the student the opportunity to practice their clinical skills and to acclimate to the role of the professional nurse. Recently, the Board removed the restriction that program enrollment was limited only to students in Nevada nursing programs. The current approved RN Apprentice Nurse Skills List can be found on the board’s website www.nursingboard.state.nv.us. It is the responsibility of the hiring facility Director of Nursing to: Ensure the student (in-state or out-of-state) is currently enrolled in a program of professional nursing that is approved by that state’s board of nursing or appropriate state agency authorized to approve nursing programs. Ensure the nursing program (out-of-state) is also nationally accredited through either the National League for Nursing Accrediting Commission (NLNAC) or the Commission on Collegiate Nursing Education (CCNE). Ensure the student (in-state or out-of-state) is currently enrolled in a program of professional nursing and maintains enrollment during participation as an Apprentice Nurse. Verify the skills the student (in-state or out-of-state) has been authorized to perform are on the Board-approved skills list. Accountability for compliance with all program requirements remains with the Director of Nursing, as this individual has responsibility for all nursing activities within their facility. A student’s enrollment in the Apprentice Nurse Program ends upon graduation from the nursing program. At that time, the student becomes a graduate nurse and must possess an Interim Permit to practice nursing. It is the responsibility of the Director of Nursing to ensure that after graduation, the student no longer practices nursing as an Apprentice Nurse. It is also the responsibility of the Director of Nursing to ensure that all graduate nurses have active Interim Permits authorizing the practice of nursing.
This article spotlights just one of the many success stories associated with the Apprentice Nurse Program. Students praise the program for enhancing their nursing skills and confidence, while giving them the opportunity to familiarize themselves with their future professional roles. Directors of Nursing have found the program a valuable recruiting, retention, and professional development tool. If you have any questions about the Board’s RN Apprentice Nurse Skills List, the responsibilities of a Director of Nursing regarding apprentice nurses and graduate nurses, or other general questions about nursing education programs, please feel free to contact the Board’s Licensure, Certification and Education Office in Las Vegas.
Board
Adopts Practice Decision Regarding Sexual
Assault Nurse Examiners Acting upon the recommendation of its Nursing Practice Advisory Committee, the Board at its March meeting adopted a practice decision regarding Sexual Assault Nurse Examiners. Below is the text of the decision, which is also on the Board’s web site www.nursingboard.state.nv.us in the Practice Information section. The Nursing Practice Advisory Committee spent more than a year reviewing, discussing and revising the SANE practice decision adopted in 1991. The process was wide-ranging and thorough, involving several meetings in both Las Vegas and Reno with representatives from law enforcement, nurses, doctors, victim advocates, and professional associations. The committee also conducted extensive research to define parameters for SANE practice regarding age, competency, referral, and collaboration among the sexual assault team members. Public comments were taken by the committee in September 2002, December 2002, February 2003, June 2003, August 2003, October 2003, and December 2003. The practice decision is the result of gathering national information, Nevada-specific information, and current best practices from the International Association of Forensic Nurses (IAFN) and other highly regarded individuals in the field of forensic nursing. The IAFN provides for a SANE-A certification for nurses which allows RNs to collect evidential material on adult and adolescent victims. The increased scope of practice includes utilizing a colposcope which is ordinarily out of the scope of practice for RNs. Other changes incorporated in the practice decision include a separation of adult/adolescent and pediatric SANE practice, the deletion of a definition of “acute,” deletion of the requirement that the SANE call a physician or an APN prior to doing a pediatric assessment, an effective date of January 1, 2005 for the required SANE certification, the requirement for appropriate referral, the requirement for all pediatric cases to be peer-reviewed, and a narrower definition of the expanded SANE practice. The rationale for these revisions is generally based on the philosophy that the SANE is first an RN and then has a narrowly expanded practice based on the SANE certification and competency. Sexual Assault Nurse Examiner Practice Decision An
RN may function as a sexual assault nurse examiner provided the following
guidelines are followed:
Additional
requirements for pediatric cases (individuals of less than thirteen years of
age) include:
(4/04) For information on SANE certification, please visit IAFN.org.
Board
Addresses Roles of Consultant,
Surveyor, and Nurse Educator Acting upon the recommendation of its Nursing Practice Advisory Committee, the Board at its March meeting adopted a practice decision regarding persons acting in the role of consultant, surveyor, or nurse educator. Below is the text of the decision, which is also on the Board’s web site www.nursingboard.state.nv.us in the Practice Information section. A person who practices nursing or delivers patient care in relation to patients who are located within the State of Nevada must be licensed by the Nevada State Board of Nursing. The following activities include, but are not limited to, conduct that is considered to be delivering patient care in role of the licensed nurse: 1.
Any intent to enter into a therapeutic relationship with the patient. 2.
Any notation or documentation in an individual patient’s medical
record.
The following activities include, but are not limited to, conduct that is NOT considered to be delivering patient care in role of the licensed nurse:
The Board Supports Your
Right to Refuse An Unsafe Assignment The
mission of the Nevada State Board of Nursing is to protect the public’s
health, safety and welfare through effective nursing regulation. The Board,
backed by Nevada nursing law, strongly supports the right of nurses and nursing
assistants to refuse assignments they believe to be unsafe. We
realize this issue is of great concern to Nevada nurses and CNAs, who are
dedicated to providing safe, competent care to their patients. In addition to
answering calls and emails about unsafe assignments, Board staff members give
presentations on this topic to nursing associations, nursing conferences,
nursing schools, and at health care facilities across the state. We have also
published articles in past issues of the Board’s newsletter, and we distribute
fact sheets outlining the process described below. Helping
Nevada nurses and CNAs understand both their rights and obligations when it
comes to refusing unsafe assignments helps the Board fulfill its mission of
protecting the public. We all share
the goal of ensuring safe, effective, quality health care for the citizens of
Nevada. The Board receives many calls from nurses and nursing assistants who feel they are being asked to choose between placing their patients at risk or putting their licenses in jeopardy. Many think they have no choice but to accept assignments they are unable to safely manage, to perform acts they aren’t qualified to do, or to work longer hours than they believe they can physically or mentally endure.
Often, refusing an assignment does not seem an option for these who believe
either the patients would be endangered or they would lose their jobs if they
simply said “No.” Yet,
all licensed nurses and certified nursing assistants in Nevada are subject to
the Nurse Practice Act that holds them responsible and accountable for nursing
judgments, actions, and competence, and requires them to safeguard the patient.
Accepting an assignment that the nurse or CNA knows she or he is not qualified
for, and/or accepting an assignment that places a patient in jeopardy, are
violations of the Nurse Practice Act and may result in disciplinary action. However,
the Board has never disciplined a nurse or CNA for properly refusing an unsafe
assignment. How
can nurses and nursing assistants protect their patients and protect their
licenses and certificates? Prevention and early intervention are always a place
to start. Nurses and CNAs should know the laws and regulations that govern their
practice and clearly understand what constitutes a violation of the Nurse
Practice Act. For example, nurses and CNAs may be told that refusing to accept
an assignment is “wrongful abandonment,” but in fact, the Nurse Practice Act
cites three conditions that must exist before such an action would be considered
abandonment by the Board. Specifically, according to NAC 632.895(6): “An
act of patient abandonment occurs if: (a) A licensee or holder of a certificate has been assigned and accepted a duty of care to a patient; (b)
The licensee or holder of a certificate departed from the site of the assignment
without ensuring that the patient was adequately cared for; and (c)
As a result of the departure, the patient was in potential harm or actually
harmed.” Evidence
of all three conditions must be shown before the Board may consider disciplinary
action against a nurse or CNA for patient abandonment. (During
fiscal year 2002-2003, one complaint against a nurse met this legal requirement
and resulted in disciplinary action. The nurse left her shift after being on
duty for a few hours, did not have permission to leave, and did not give report
on her patients to anyone before leaving. In other words, she met all three
legal criteria for patient abandonment.) Also,
nurses and CNAs may be disciplined if they accept assignments they are not
competent to perform. If they do, they
may place the patient in danger, and they’re in violation of the Nurse
Practice Act (NAC 632.890 (4), assuming duties and responsibilities within the
practice of nursing if competency is not maintained, or the standards of
competence are not satisfied, or both.) It should be noted that the
Board has no jurisdiction over employment or contract issues. Well-intentioned nurses and CNAs may feel like they’re in a “Catch
22,” where if they practice in accordance with the law, they will keep their
licenses or certificates but lose their jobs. Unfortunately, sometimes leaving a
position is the only option. Here are some things to consider— ·
Place patient safety and well-being
first. Act in good faith. ·
Know the laws and regulations that
govern your practice. ·
Build a defense for why an action
(or act of omission) was unavoidable. Document carefully. Be able to demonstrate
that the course of action was what would have been followed in a similar
situation by a reasonable and prudent nurse with similar education and
experience. ·
Continue to advocate for safe
nursing care for patients. If you have a question about how to refuse an unsafe assignment, contact the Reno office.
Dr.
Rosemary Witt Begins Another Chapter How do you describe the
accomplishments of someone like Dr. Rosemary Witt, PhD, RN, who has served
Nevada’s nursing population for three decades? Someone who has been a leader
in nursing education, regulation, and professional advancement during the
state’s most rapid period of growth and change? You ask her to tell her own story, in her own words. In 1970, I was contentedly teaching at the University of Washington, Seattle, when I came to a conference on “loss” in Las Vegas. The conference was being held at UNLV. I sat in the Moyer Student Union looking down the mall and thought ”what a neat place,” besides I had been in town a whole week, and it hadn’t rained once! Also, on that plane trip, I met this fellow who worked for the Environmental Protection Agency and we started this long distance relationship. After a year, I thought, “Why not move to Las Vegas?” So I applied at UNLV, and as luck would have it, the Department of Nursing’s Associate Degree program needed an instructor for psychiatric nursing. I accepted the offer of a position, and have been affiliated with the nursing program ever since. Oh yes, to answer your question, the relationship was much better long distance than up close! He left town and I stayed. After I had been on campus two years, the Chair of the Department was selected to be the Dean of the College of Allied Health. I was asked to serve as Chair, probably because I had experience in baccalaureate education and the Department was launching an RN to BSN program. I loved the administrative role and remained in it for 31 years. Effective July 1, I am stepping out of the leadership position. The role has provided me with a wealth of growth-producing experiences. Academically, I have had the privilege of working with faculty who demonstrated the ability and willingness to move from an associate degree program to a generic baccalaureate program, then to add a master’s program, offer the BSN and MSN program via distance education, devise an RN to MSN program, and effective Fall, 2004 initiate the new Ph.D. in Nursing program. Professionally, I was part of the steering committee to obtain the charter to start Zeta Kappa, the local chapter of Sigma Theta Tau, which began in 1982. I was privileged to serve as the first president of Zeta Kappa. I served in several state level positions in the Nevada Nurses Association, including the most time-consuming job of secretary. For several years I had the privilege of serving as an accreditation site visitor for the National League for Nursing. The last couple of years I have served as member of the site review team for the Northwest Accreditation Association and look forward to continuing that role, now that I will have new duties. A professional highlight was serving on the Nevada State Board of Nursing. I served on the Board seven years in the 80s, and was President five of those years. At that time we thought we were writing cutting-edge regulations. Now, of course, when you examine decisions in retrospect, they look rather timid, and in some cases you would like to ask for “do overs.” I was on the Board when the rules and regulations for certifying nurse practitioners were developed. We had many an interesting meeting with the Board of Medicine and the Board of Pharmacy in our quest to get prescriptive privileges approved. During my time on the Board, we also made many changes related to how the Board would assist chemically dependent nurses, moving away from a strict disciplinary model to a model which would assist the nurse and the profession. And of course, I had a great interest in nursing education regulations, and was part of the group that helped to reduce the faculty to student ratio to 1:8. I remain on the Board’s Nursing Education Advisory Committee. The role of Chair also provided me the opportunity to collaborate with the health care leaders in the Southern Nevada, as we weathered various nursing shortages and challenges. One time, when I was on the Board of Nursing, student nurses were inadvertently dropped from a law when it was being rewritten and student nurses were not allowed to give medications! The leadership position has provided an opportunity to work with a wide variety of community leaders in the Southern Nevada Medical Industry to find ways to address the current nursing shortage. Serving on the Board of Directors of HealthInsight continues to broaden my knowledge base about issues in health care. Do I have regrets about my career path? Absolutely not. I think I have had the best of all worlds. I have been able to assist in the development of a strong nursing program, assist students grow and change, be involved in activities that matter to nurses and patients, and by periodically teaching clinical courses, keep my psychiatric clinical nursing skills acceptable, if not cutting edge. Am I retiring? No, not yet. I will continue teach some of the courses in the RN to BSN degree program and clinical courses in psychiatric nursing. In the immediate future, I will be offering Dean Yucha assistance to make the transition as seamless as possible. Dr.
Patsy Ruchala Named Director of Orvis School of Nursing
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