arizona VOL2 • NO1 • MARCH 2007 1ST QUARTER STATE BOARD OF NURSING REGULATORY JOURNAL Kathy Malloch RN MBA PhD FAAN President Arizona State Board of Nursing 2002, 2003, 2005, & 2006 RN/LPN Renewal - Time to Check Your License Renewal Date PUBLISHED BY ARIZONA STATE BOARD OF NURSING 4747 North 7th Street, Suite 200 Phoenix, AZ 85014-3653 Phone: 602.889.5150 Main fax: 602.889.5155 CANDO fax: 602.889.5238 General e-mail: arizona@azbn.gov Website: www.azbn.gov GOVERNOR The Honorable Janet Napolitano Joey Ridenour, RN, MN EXECUTIVE DIRECTOR VO L 2 • N O 1 • M A R C H 2 0 0 7 1 S T Q UA R T E R 4 F rEoxme ctuhtei v e D i r e c t o r 5 Nurse Legislative Day 6 C N A R o u n d Ta b l e - Lessons Learned Judy Bontrager, RN, MN ASSOCIATE DIRECTOR/OPERATIONS Valerie Smith, RN, MS 8 ASSOCIATE DIRECTOR/INVESTIGATIONS Pamela Randolph, RN, MS ASSOCIATE DIRECTOR/EDUCATION & EVIDENCE BASED REGULATION BOARD MEMBERS Karen Hodges Hardy, RN, MSN PRESIDENT Theresa Crawley, CRNA, MSHSA VICE PRESIDENT Patricia A. Johnson, LPN SECRETARY Constance Woulard, RN, MSN Pictured on the Front Cover, Kathy Malloch, RN, MBA, PhD, FAAN President of the Board 2002, 2003, 2005 & 2006. Case Study: Dishonesty Places Patients at Risk for Harm 10 S t a f f D i r e c t o r y 12 E d u c a t i o n C o r n e r 13 R e g u l a t i o n R u n d o w n MEMBER Denise Link, RNP, DNS, FNAP MEMBER Kathy Malloch, RN, MBA, PhD, FAAN, MEMBER Steven T. Robertson, LPN, CHPLN MEMBER 16 S B A R & H e a l t h c a r e P r o v i d e r s : A Ve r y Good Match 19 S c o p e o f P r a c t i c e Kathryn L. Busby, J.D. PUBLIC MEMBER arizona M. Hunter Perry PUBLIC MEMBER EDITION 5 Committee: Call for Members STATE BOARD OF NURSING CREATED BY: REGULATORY JOURNAL Virginia Robertson, PRESIDENT vrobertson@pcipublishing.com Publishing Concepts, Inc. 14109 Taylor Loop Road Little Rock, AR 72223 FOR ADVERTISING INFORMATION: Steve McPherson smcpherson@pcipublishing.com 501.221.9986 • 800.561.4686 This magazine is mailed quarterly to over 90,000 Arizona licensed nurses and reaches every nursing student, hospital administrator and nursing school administrator in the state 20 I s Yo u r L i c e n s e D u e for Renewal? 21 E f f e c t i v e J a n u a r y 2007: New Electronic Complaint Process 29 D i s c i p l i n a r y Actions From the Executive Director JOEY RIDENOUR, RN, MN Interview with Kathy Malloch RN MBA PhD FAAN PRESIDENT 2002-03 & 2005-06 Dr. Malloch is a nationally known writer and speaker and has been on the Board of Nursing for over seven years. Her primary focus is on consulting and education and is considered an expert in nursing leadership and healthcare innovation. She is highly regarded by nursing leaders internationally and is a regulatory expert in practice breakdown. Dr, Malloch was elected to the National Council State Boards of Nursing, Board of Directors in August 2006 and is currently the Area I Director. During the recent transition in the Board President’s role, I asked Dr. Malloch to share some her “lessons learned” during her tenure on the Board. Q. What have you learned over the past seven years about nursing regulation that you would like to share with your colleagues and nurse leaders? A. The experience I have had in nursing regulation has helped me “close the loop” in better understanding that there is a dynamic relationship between practice, education, research and regulation. I also have learned that the “ownership of nursing regulation” is not well understood. Nurses need to understand that we are all owners of regulation and not just the Board of Nursing. The quality and appropriateness of the changes in regulation is the result of the level of engagement of Arizona nurses in the discussions. Q. What were some of the more significant “lessons learned” during your tenure on the Board? A. 1.) Tell the truth, Tell the truth &, Tell the truth. 2.) Board Members need to keep asking questions until the issues are understood. 3.) Nursing practice is exponentially more complicated than we ever knew in the past. One example is the system contributions to medical errors versus the individual contributions to patient errors. Research on Practice Breakdown is going to make a significant contribution to how we remediate and understand how to improve the competencies of nurses who place the public at risk or harm. Examples of practice breakdown are lack of attentiveness, lack of professional accountability and prevention. 4.) Relationships are “pretty darn important”. How we treat people and honor their individualism matters not only during the board processes but everyday in our daily lives. 5.) Positions on the Board are more powerful than previously understood. I still get comments on statements I have made in board meetings five years ago. Q. What does a “highly functioning” Nursing Board Member look like? The more effective Board Members: 1.) know themselves, their personal biases 2.) analyzes and re-aggregate a large volume of information and facts; demonstrates skill in understanding complex situations 3.) makes tough decisions when the public is at risk or there is high potential for harm 4.) demonstrates competence with email, use of the internet and management of word documents 5.) have the fortitude to speak openly and candidly - the public wants to know what the Board Member is thinking. 6.) focus on Board policy and resist the temptation to get into Board operations 7.) know the Nurse Practice Act 4 arizona STATE BOARD OF NURSING REGULATORY JOURNAL 8.) demonstrates a high level of integrity and builds this into the board processes 9.) questions rather than accepts, together with the courage to ask difficult questions in a constructive way 10.) sees the big picture but knows when to drill down on specifics 11.) is not oriented to past achievements rather than to challenges yet to come Q. What types of cases over the past seven years have been most significant to you? A. Chemical dependency cases and scope of practice cases. Asking for chemical dependency evaluations from experts in the field has been critical to not only protect the public but for those nurses who are chemically dependent so they may begin the treatment and recovery process. Seeking independent expert advice has always been important and will be important in the future in not only CD but also other practice issues. Scope of practice violations continues to challenge me. For example, we have had several cases in which nurses have started IVs on nurse colleagues without an authorized order. It is quite obvious this action is beyond the scope as it involves diagnosis and intervention yet the intention of the nurse was to be helpful to a colleague in need. It is difficult to recommend the required discipline when there is a lack of mal intention but poor judgment. Q. If you were to teach a course to nurse regulators, what would you want to make sure is included in the curriculum? A. Nurse regulators need to be competent in creating a public policy agenda to better protect the public from unsafe practitioners and setting scopes of practice. They also need to know how to develop a strategic plan for implementing the policy agenda. Finally, they need to evaluate the impact of the policy change to have the evidence that the change in the Nurse Practice Act achieved an expected outcome. Joey Ridenour, RN, MN EXECUTIVE DIRECTOR Arizona Nurses Association will be presenting Nurses Legislative Day on March 30th at Banner Desert Medical Center’s new Education Center 1400 S. Dobson Mesa, AZ 85202 Nurses Legislative Day features a new streamlined schedule that includes keynote speaker Anne McNamara, RN, PhD, Treasurer, American Nurses Association, presenting “From the Southwest to Washington DC: Arizona Nurses on the Move.” Other presentations will include information on grass roots lobbying, state board of nursing, using the state legislature website and information on what is happening in the state Legislature from AzNA’s Lobbyist Rory Hays. This is a great opportunity to hear from nursing’s political experts. For more information and to register for this event, visit www.aznurse.org. arizona STATE BOARD OF NURSING REGULATORY JOURNAL 5 Certified Nursing Assistant Educators Round Table “Ah-ha Moments” The Arizona State Board of Nursing’s Fourth Annual Certified Nursing Assistant Educators Retreat was attended by over 135 Certified Nursing Educators! The fifteen speakers/round table leaders were outstanding in their subject areas and made this the most successful retreat in the events four year history. Special thanks to program speakers for their sharing their expertise: Dr. Shiela Sorrentino, Dr. Sue Roe, Jennifer Underwood and Paul Dorrence. Each Round Table at the 2007 CNA Retreat was asked to agree on one major concept learned or shared during the session. Round table leaders capturing these “ah-ha’s” were: Sylvia Balesteri, Janice Bilain, Linda Buchanan-Anderson, Jan Dougherty, Betty Earp, Helen Houser, Jennifer Underwood, Linda Mangerson, Judy Bontrager, Val Smith , Pam Randolph and Joey Ridenour. These are the Twelve 2007 CNA“Ah-ha” Moments for each round table with edititorial changes for grammar and sentence structure for clarity: • Certified Nursing Assistant May Have Unlimited Attempts for Certification: NAs may take the skills and written exams as many times as needed in a 2 year period. • Career Advisors Have Responsibility to Inform Others that CNA Misconduct May Lead to Denial of Certification: Career advisors need to inform potential students that criminal convictions may make them ineligible for employment in the CNA/Nursing field. • Learn from the Students for Enhanced Teaching Methods: Learn about what our students bring with them to the classroom in a “getting to know you” session. • Integrate Standards in High School Programs: State Board of Nursing standards and CTE (Career and Technical Education) Standards can and should be integrated as part of the CNA program. • Combine Skills Testing I & Mock Skills Testing of Students: Have students evaluate fellow students with mock skill testing of competencies. • Skills Testing II: Teach skills from the D & S Diversified Handbook. • Curriculum Creativity = Exciting Curriculums: Be creative in the classroom; use imagination to make curriculum 6 arizona STATE BOARD OF NURSING REGULATORY JOURNAL Dr. Sheila Sorrentino and Pam Randolph content relevant and exciting. • Finding the Connections for Alzheimer’s Patients: Find the connection between the CNA and the resident with dementia. • Continuing Education- CE is driven by staff needs: Try poster board in-services and additional training sessions for evening, night and weekend staff. • Development of Critical Thinking Starts Day 1and continues: Start to focus the student to think critically at the beginning of the CNA program and continue to reinforce throughout the course. • Pilot Study Medication Technician (PSMT) Must Have Clear Expectations Before Acceptance into the Program: In selecting PSMT staff, be very clear about the expectations of the role and administer a pre-test on math skills. • Prevent Confusion for Test Observers: The live patient (model) is trained to react according to the skill but this is not in the role of observer. We want to also extend a special thanks to Pam Randolph and Pam Raman for the outstanding partnerships they have formed with the 150 Certified Nursing Assistant Programs throughout the state. Paul Dorrance from D & S Diversified Technologies shared with the attendees at the conference that “Arizona has the highest first time pass rates in testing of the Certified Nursing Assistants of the 16 states” utilizing D&S as the testing vendor. The past four retreats have been critical in achieving this accomplishment and look forward to the Fifth Annual Certified Nursing Assistant Retreat in 2008! Joey Ridenour, RN, MN EXECUTIVE DIRECTOR Case Study: SISTER M. RACHEL TORREZ RN, MS, NURSE PRACTICE CONSULTANT DISHONESTY PLACES PATIENTS AT RISK FOR HARM Nurse M. was assigned to work in the ICU at a local hospital from 7:00 a.m. to 7:00 p.m. She was assigned two patients. One of her patients was a diabetic who had undergone recent surgery. The patient had orders for an Insulin drip with blood sugar readings by Accu check to be performed every hour. The intravenous Insulin was to be regulated according to a rate which was dependent on the blood sugar readings. The physician was to be notified if there were any questions or problems. The second patient assigned to Nurse M. was stable. According to the medical record for the patient with diabetes, Nurse M. had documented that she had checked the blood sugar for the patient from 11:30 am. until 5:30 p.m. every hour as ordered. Around 6:00 p. m. the patient’s son approached the charge nurse requesting that Nurse M. be removed from his mother’s care. He said Nurse M. had been very rude to him when he inquired about his mother’s condition. The charge nurse went into the patient’s room to assess the situation. The charge nurse performed a blood sugar reading on the patient and found that the patient’s blood sugar was 71. The recording prior to this was documented in the medical record as 250 by Nurse M. and the Insulin intravenous was infusing at 15 drops a minutes. The order reflected that the Insulin was to be stopped if the blood sugar was less than 120. Nurse M. could not explain why she was infusing the Insulin at 15 drops a minute. The charge nurse stopped the Insulin, called the doctor, and assumed the care of the patient. The hospital staff reported Nurse M. to the Board of Nursing after they had conducted a thorough internal investigation. It was determined that Nurse M. could not explain why she was infusing the Insulin at an unacceptable rate. She was also unable to show evidence that she had completed a blood sugar testing at 1:30 p.m., 2:30 p.m., and 3:30 p.m. since the accu machines used for the testing did not reflect any stored data for those times. The laboratory retrieved all the stored data from the two accu dose machines used in the ICU and neither had any stored data reflecting that Nurse M. had tested the blood sugars for these three events. All incoming complaints are assigned to a Nurse Consultant/ Investigator who are then charged with the responsibility of conducting complete and thorough investigations. Nurses are encouraged to provide information regarding the allegations, share their perspectives regarding the incidents or events, and provide any documents that may further explain or refute the allegation. All these opportunities were provided to Nurse M. She was confident and very sure she recalled the details of her assignment very well. She denied that she could possibility have falsified any 8 arizona STATE BOARD OF NURSING REGULATORY JOURNAL documentation. In a face to face interview with the Nurse Practice Consultant, Nurse M. was asked to explain the discrepancies that were identified in the patient medical record. Nurse. M. asked to see the medical record before she answered the question and then admitted she had falsified at least three of the blood sugar readings that she had documented in the medical record. She said since she had not reviewed the medical record prior to submitting her written response, she was now able to see that there was no possible explanation for the discrepancies. Nurse M. had not been honest with her employer or the Board of Nursing staff until she was confronted with the facts in which she had no explanation except that she had falsified her oral and written statements and the documentation in the medical record. When this case was presented to the Board, Nurse M. was present. After the Board deliberated, the decision was made to place Nurse M. on probation for two years so that her nursing practice could be monitored. In addition the Board also fined (Civil Penalty) Nurse M. for her dishonesty. NURSE M. HAD NOT BEEN HONEST WITH HER EMPLOYER OR THE BOARD OF NURSING STAFF UNTIL SHE WAS CONFRONTED WITH THE FACTS IN WHICH SHE HAD NO EXPLANATION EXCEPT THAT SHE HAD FALSIFIED HER ORAL AND WRITTEN STATEMENTS AND THE DOCUMENTATION IN THE MEDICAL RECORD. ! Nurse M. violated the following Rules (A.R.S. 32-1601(16) (d)(j): (d) Any conduct or practice that is or might be harmful or dangerous to the health of a patient or the public. (j) violating a rule that is adopted by the board pursuant to this chapter. R4-19-403 Unprofessional Conduct (B) (5)(6)(25)(26): 5. Failing to maintain for each patient a record which accurately reflects the nursing care and treatment provided to a patient. 6. Failing to take appropriate action to safeguard a patient’s welfare or to follow policies and procedures of a nurse’s employer designed to safeguard the patient. 25. Practicing in any manner which gives the Board reasonable cause to believe that the health of a patient or public may be harmed. 26. Making a written false or inaccurate statement to the Board or the Board’s designee in the course of an investigation. STAFF DIRECTORY ADMINISTRATION Joey Ridenour, RN, MN Executive Director 602.889.5200 jridenour@azbn.gov Judy Bontrager RN, MN Associate Director-Operations & Licensing 602.889.5204 jbontrager@azbn.gov Valerie Smith RN, MS Associate Director-Nursing Practice, Complaints & Investigations 602.889.5206 vsmith@azbn.gov Pamela Randolph RN, MS Associate Director Education & Evidenced Based Regulation 602.889.5209 prandolph@azbn.gov Lila Wiemann Administrative Assistant to the Executive Director 602.889.5202 lwiemann@azbn.gov Dolores Hurtado Assistant to Associate Director/Nursing Practice, Complaints & Investigations 602.889.5158 dhurtado@azbn.gov Thereasa Huff Assistant to Associate Director/Nursing Practice, Complaints & Investigations 602.889.5208 thuff@azbn.gov EDUCATION Pamela Raman, RN, MS Nurse Practice Consultant/Education 602.889.5176 praman@azbn.gov Karen Gilliland 602.889.5187 kgilliland@azbn.gov FISCAL SERVICES Norma Salter Accounting Technician 602.889.5211 nsalter@azbn.gov HEARINGS Susan Barber, RN, MSN Nurse Practice ConsultantHearing Dept 602.889.5151 sbarber@azbn.gov Debra Blake, Paralegal Legal Assistant -Hearing Dept. 602.889.5183 dblake@azbn.gov Vicky Driver Admin. Assistant-Hearing Dept 602.889.5162 vdriver@azbn.gov INVESTIGATIONS NURSE PRACTICE CONSULTANTS Betty Nelson, RN, MS 602.889.5169 bnelson@azbn.gov Cristina Oates Administrative Assistant to Associate Director Operations/Licensing 602.889.5205 coates@azbn.gov Jeanine Sage, RN, MSN 602.889.5174 jsage@azbn.gov ADVANCED PRACTICE Karen Grady, MS, RN, FNP, BC Advanced Practice/RN/LPN 602.889.5182 kgrady@azbn.gov Nan Twigg, RN, MSN 520.615.4945 ntwigg@azbn.gov CANDO Connie Linck, RN, MN, CNAA, BC Nurse Consultant – CANDO 602.889.5156 clinck@azbn.gov 10 Olga Zuniga Administrative Secretary – Monitoring & CANDO 602.889.5157 ozuniga@azbn.gov Mary Rappoport, RN, MN 602.889.5184 mrappoport@azbn.gov Sister Rachel Torrez, RN, MS 602.889.5180 srachel@azbn.gov Stephanie Nelson, RN, MS 602.889.5179 snelson@azbn.gov arizona STATE BOARD OF NURSING REGULATORY JOURNAL Sydney Munger, RN, MS 602.889.5186 smunger@azbn.gov SENIOR INVESTIGATORS Duncan “Cory” Polak 602.889.5172 cpolak@azbn.gov James Williams 602.889.5167 jwilliams@azbn.gov Jeanne Crain 602.889.5178 jbauer@azbn.gov Kirk Olson 602.889.5171 kolson@azbn.gov Ronald “Ron” Lester 602.889.5159 rlester@azbn.gov LEGAL SECRETARIES Barbara Melberg 602.889.5193 bmelberg@azbn.gov Dorothy Lindsey 602.889.5177 dlindsey@azbn.gov Esther Garcia 602.889.5173 egarcia@azbn.gov Karen Gilliland 602.889.5187 kgilliland@azbn.gov Trina Smith 602.889.5175 tsmith@azbn.gov INFORMATION TECHNOLOGY Cory Davitt Network Operations Director 602.889.5213 cdavitt@azbn.gov Adam Henriksen Information Technology Director/Webmaster 602.889.5231 ahenriksen@azbn.gov LICENSING Becky Melton RN/LPN Exam 602.889.5190 baranyos@azbn.gov Debbie Kunkle RN/LPN Renewals 602.889.5195 dkunkle@azbn.gov Cristina Oates Advanced Practice/School Nurses 602.889.5205 coates@azbn.gov Donna Frye Fingerprints/Endorsements 602.889.5191 dfrye@azbn.gov Helen Tay CNA Exam/Endorsements 602.889.5189 htay@azbn.gov Jene Martinez RN/LPN/CNA 602.889.5224 jmartinez@azbn.gov Paula Delphy RN/LPN Endorsements 602.889.5192 pdelphy@azbn.gov Rhonda Rogers CNA.Renewals 602.889.5188 rrogers@azbn.gov MAILROOM Derek Hardin 602.5215 dhardin@azbn.gov MONITORING Erica Bailey Senior Investigator 602.889.5160 ebailey@azbn.gov Brent Sutter Legal Secretary Monitoring & CANDO 602.889.5168 bsutter@azbn.gov RECEPTIONISTS Marlane Brosseau 602.889.5199 mbrosseau@azbn.gov Susan Kingsland 602.889.5197 skingsland@azbn.gov Tawni Rowen 602.889.5196 trowen@azbn.gov RECORDS Anne Parlin 602.889.5207 aparlin@azbn.gov Education Corner Systems, Inc. (HESI) and PAMELA RANDOLPH RN, MS Educational Resources (ERI) exams. Programs ASSOCIATE DIRECTOR/EDUCATION report that the tests help AND EVIDENCE BASED REGULATION build student confidence, encourage critical thinking, reinforce key conStatewide Educator’s cepts, contribute to higher NCLEX® pass Meeting rates, and provide data for program evaluation. Disadvantages included expense, facOn October 12, 2006, 67 persons repreulty time commitment, data management, senting all nursing education programs in technical problems, monitoring retakes, Arizona attended the Annual Statewide and content differing from course content. Educator’s meeting at Rio Salado College. Board staff presented survey information from nursing programs in Arizona regarding patient care hours, use of clinical simulation, and standardized testing. A discussion of barriers to nursing program expansion was a focus of the meeting. For further information on the meeting or surveys reported, please e-mail prandolph@azbn.gov. Patient Care Hours A survey of nursing programs revealed that patient care hours range from: 284 to 312 with a mean of 294 in PN programs, 521 to 1048 with a mean of 743 hours in associate degree RN programs, and 365 to 1158 with a mean of 901 in BSN programs. Clinical Simulation There was a lack of consensus in defining the term, “clinical simulation”. Hours spent in clinical simulation activities range from 0 to 256 across all programs. When simulation was used, it frequently occurred in basic nursing courses, although some programs employ simulation across the curriculum. The faculty debriefing process was considered crucial to student learning. Advantages of stimulated clinical experiences are increased student confidence and preparation for patient care experiences. Negative factors include increased faculty time, student anxiety, and students not taking it seriously. Standardized Testing A survey on the use of standardized testing revealed that the most frequently used standardized tests for progression and graduation are the Health Education 12 Nursing Program Expansion Meeting participants discussed barriers to nursing program expansion. Lack of clinical placements in specialty areas of nursing is a major challenge. With the geographic expansion of current programs and the establishment of new programs, participants feared that existing local programs will cut admissions due to lack of appropriate clinical placements or faculty. Clinical facilities are limiting placements due to fatigue of nurses already working within the context of a nursing shortage, the need to utilize staff to orient newly licensed nurses, the level of student not appropriate to the clinical area, and large numbers of students during daytime hours. Another barrier to program expansion is lack of qualified faculty. Utilizing facility based nurses as clinical faculty is one solution, however these nurses frequently require extensive mentoring in teaching and evaluating pre-licensure students. Clinical faculty members may teach for only one rotation, requiring the program to engage in ongoing hiring and orientation of clinical faculty. Strategies to recruit and retain faculty were discussed. All participants agreed the day was successful for sharing information and offered suggestions for next year’s meeting. NCLEX® Item Development The following Arizona nurses represented Arizona in the NCLEX item development process for the second through fourth quarters of FY 2006: Dina Faucher, Jane Lacovara, Carol Delafontaine, Loria arizona STATE BOARD OF NURSING REGULATORY JOURNAL Hute, Bridget Jablonski, Deborah Evinrude, Cheryl Kelly, Marilyn Whittenton, Pamela Raupp, Manora Maddela, and Charles Silveri. The Board thanks all persons who volunteered to participate in the NCLEX process. It is through their contribution and expertise that NCLEX remains legally defensible and psychometrically sound and is considered the “gold standard” for licensing exams. BOARD ACTIONS ON EDUCATION MATTERS November 2006 • Applications for program change were approved from Grand Canyon University (geographical location), Central Arizona College (increase enrollment), and Mohave Community College (paramedic to RN program). • Northland Pioneer College was granted 2 year nursing program approval with a report to the Board in six months • The Board adopted the proposed “Competency to Practice Nursing Evaluation Criteria” as a working document. Train the Trainer An educational session for Pilot Study Medication Technician (PSMT) Instructors will be held at the Board offices on March 1-2, 2007. PSMT instructors are RNs working at one of the 6 pilot long-term care facilities who will participate in the education of C.N.A.’s selected to assume the role of medication technician. There are a limited number of seats available to other nurse educators who would like additional education in classroom management, test item construction, teaching methods, selection of appropriate students and other topics of interest to C.N.A. and nursing instructors. The first day will focus on general teaching effectiveness and the second day will consist of (PSMT) curriculum review and application of concepts. The cost is $50.00 per day. Participants may register for one or both days. Please contact Karen Gilliland at kgilliland@azbn.gov or 602-889-5187 for registration information. Regulation RUNDOWN Rulemaking R4-19-215; R4-19-301; R4-19-302; R4-19-505; R4-19-506; R419-507; and R4-19-508. These individual rules need revisions to address issues that have arisen since their adoption. A rulemaking docket was filed and published the Administrative Register on March 3rd, 2006. Amendments to Article 2 (R4-19215) will incorporate a process for rescinding the approval of an out-ofstate nursing program that does not substantially meet Board standards. An open public hearing was held on January 17, 2007 with no persons testifying against the rulemaking. The notice of final rulemaking was adopted by the Board and submitted to the Governor’s Regulatory Review Council. Rule changes are summarized below: Amendments to Articles 2 and 3 (R419-302) provide the Board process for revoking approval of an out of state nursing program and the authority to prescribe additional licensure requirements for an individual who graduates from a revoked nursing program. by Pamela Randolph RN, MS ASSOCIATE DIRECTOR/EDUCATION AND EVIDENCE BASED REGULATION Amendments to Article 5 (R4-19-505) will extend the waiver of certification for clinical nurse specialists practicing in the area of maternal/infant health or women’s health since there is no certification exam. Standards for keeping an advanced practice certificate active and arizona STATE BOARD OF NURSING REGULATORY JOURNAL 13 for education to increase competency within an advanced practice specialty (R4-19-508) are incorporated. Advanced practice nursing practice within a specialty area similar to the 960 hour (in 5 years requirement) for RNs and LPNs will be required. Other rules were revised to make technical and grammatical changes to improve clarity and internal consistency (R4-19-506; R4-19-507). The proposed rules are posted on the website. Articles 1 and 4 Extensive revisions of Articles 4 (Regulation) and 1 (Definitions and Time-frames) are underway. A preliminary review will be conducted by Board staff, Board members, Education Committee, and Scope of Practice Committee. Following these reviews, a notice of proposed rulemaking will be placed on the Board website for general public review and comment. The person to contact at the Board regarding rules is: Pamela Randolph Nurse Practice Consultant 602-889-5209 e-mail: prandolph@azbn.gov Fax: 602-889-5155 Notice of Address or Name Change with the Arizona State Board of Nursing If you have moved or had your name changed, please notify the Arizona State Board of Nursing as soon as possible. 4747 North 7th Street Suite 200 Phoenix, AZ 85014 Phone: 602.889.5150 Main fax: 602.889.5155 arizona@azbn.gov www.azbn.gov 14 arizona STATE BOARD OF NURSING REGULATORY JOURNAL SBAR & HEALTHCARE PROVIDERS: A VERY GOOD MATCH SUBMITTED BY: BARB AVERYT, PROJECT DIRECTOR, PATIENT SAFETY INITIATIVES, ARIZONA HOSPITAL & HEALTHCARE ASSOCIATION Joint Commission reports that communication breakdown is the leading root cause of sentinel events reported from 1995-2006. In healthcare, accurate communication is not just essential during critical events such as cardiac arrests, surgeries or trauma cases, but is also critical in day-to-day operations, such as the “handoff communications.” Safe, effective clinical care depends on reliable, flawless communication between caregivers. Communication breakdowns between healthcare providers are a central feature in episodes of avoidable patient harm. For this reason, the Joint Commission issued a new requirement as part of its National Patient Safety Goal 2, requiring facilities to implement a standardized approach to handoff communications. Because the work of healthcare often occurs in hurried, time-crunching interactions involving human beings with varying styles of communication and cultural differences, a standardized approach to information sharing will ensure that patient information is consistently and accurately imparted. The Arizona Hospital and Healthcare Association (AzHHA) Patient Safety Steering Committee believes employing “SBAR communication” among all healthcare providers would make a significant and positive impact on professional-to-professional communication and ultimately, patient safety. Originating from the nuclear submarine service, SBAR stands for: • S – Situation: What is happening at the present time? • B – Background: What are the circumstances leading up to this situation? • A – Assessment: What do I think the problem is? • R – Recommendation: What should we do to correct the problem? SBAR creates a shared mental model for effective information transfer by providing a standardized structure for concise factual communication among clinicians. Consider the many SBAR communication opportunities that involve transferring important patient information: • nurse-to-nurse such as change of shift report or patient transfer; • physician-to-physician; and 16 arizona STATE BOARD OF NURSING REGULATORY JOURNAL Because the work of healthcare often occurs in hurried, time-crunching interactions involving human beings with varying styles of communication and cultural differences, a standardized approach to information sharing will ensure that patient information is consistently and accurately imparted. • nurse-to-physician. Additionally, SBAR would improve other workplace communication, such as staff education, policy briefings, information on new procedures, administrative team meetings and even email communication. AzHHA’s Patient Safety Steering Committee—as part of its patient safety initiative, Safe & Sound—is creating a new SBAR tool kit, which will be available in spring 2007. AzHHA’s goal is to facilitate statewide implementation of SBAR with all healthcare providers. Healthcare professionals can learn to communicate in ways that are effective and meaningful, which will lead to a reduction in harm, increased satisfaction for providers and overall better outcomes for our patients. SCOPE OF PRACTICE COMMITTEE JUDY BONTRAGER, RN, MN ASSOCIATE DIRECTOR OF OPERATIONS CALL FOR MEMBERS The Scope of Practice Committee is currently recruiting for nurses who are clinical experts in a specialty area and interested in volunteering to serve on the committee for a two-year term beginning June, 2007 through June, 2009. The committee has a rich and diverse membership that includes staff nurses, administrators and faculty members from the various agencies and health care settings throughout the state. Arizona is recognized nationally for their excellent advisory work. The Board would encourage each of you to consider this “growth experience” in being part of a constituency that provides advice/recommendations regarding RN/LPN scope of practice. Examples of the work product of the committee are found in the Advisory Opinions on the ASBN website: www.azbn.gov. For 2007, goals of the Scope of Practice Committee are to: 1. Review and revise current advisory opinions. 2. Respond to the changing health care environment by addressing scope of practice issues and developing advisory opinions when appropriate. 3. Discuss and deliberate scope of practice issues when requested and make recommendations to the Board regarding specific issues. The committee meets four times per year, usually in March, June, August and November from 10 am – 2 pm in the Board Room at 4747 North 7th Street, Suite 200, in Phoenix. If you are interested in applying to serve on the Scope of Practice Committee, please submit your resume by March 16, 2007 to: Judy Bontrager, RN, MN Arizona State Board of Nursing 4747 N. 7th Street, Suite 200 Phoenix, Arizona 85014 Telephone interviews will be conducted in March and April. The Board will formally appoint the scope of practice committee members at their May, 2007 Board meeting. arizona STATE BOARD OF NURSING REGULATORY JOURNAL 19 Is Your License Due for Renewal? Question: What percentage of the Nurses Due for Renewal by June 30, 2006 Renewed on Time? Answer: 95% If the date on your license renewal is 6/30/2007, you may renew your license NOW and receive a license valid until 6/30/2011. Last year over 800 nurses whose license was due for renewal in June, 2006 had already renewed their license by March. For online renewal follow these steps: Simply access the internet & board website: www.azbn.gov and have your Visa or MasterCard credit card available for payment. This is also your opportunity to update your demographic information as well as completing data not previously captured in prior renewals. Five Immediate Benefits to you for renewing online are: 1.) Faster processing time of “minutes” versus days required for hard copy processing. 2.) Immediate printout that your renewal is being processed. 3.) Renew anytime 24/7 – anyplace and anytime of the day that works for you. 4.) Your direct online entry of information is immediate and reduces the potential for errors in transcribing the information. 5.) Save money – there is a $10 reduction in the renewal fee due to completing the process online. Please Note: Reminders for you to renew are now through the AzBN Journal for the first two quarters of 2007 as well as notification for renewing through your email address. Please check to see if your email address is current when updating your demographic information. For those approximate 5% who did not renew by July 15, 2007, a letter will be sent stating that your renewal process had not been completed by June 30, 2007. In 2006, approximately 10% did not need to renew for a number of reasons; i.e. you moved to a new home state and no longer need the license or perhaps you requested to inactivate your license. Finally, if you do not have access to a computer, you may request a hard copy of the renewal application from the Board. AzBN Welcomes New Board Member: Ms. Constance Woulard RN MSN We are pleased to announce that Governor Napolitano has appointed Ms Constance Woulard to the Board effective February 2007. Ms. Woulard is currently employed at Carl T Hayden VA Medical Center in Nursing ADPAC/Nursing Recruitment. She has had 13 years of experience in home care, acute care, long term care and hospice. She is also knowledgeable and experienced in nursing education and informatics. Ms Woulard also is currently providing clinical instruction for senior level students at Grand Canyon University and clinical instruction for entry-level medical surgical students at Rio Salado Community College. Ms. Woulard relocated to Arizona from Mississippi after Hurricane Katrina in November 2005. She replaces Judith Rich on the Board and her term expires 6/30/2010. New Associate Director Appointed Pamela Randolph RN MSN WE ARE ALSO PLEASED TO ANNOUNCE THAT MS. PAMELA RANDOLPH, Nurse Practice Consultant, Education/CNA Training Programs, has been appointed to the Associate Director for Education & Evidenced Base Regulation position. Over the past 7 years in her role as Education Consultant, Pam has been involved in collecting data related to student enrollments, attrition, capacity and other “evidence” on which the education committee has made decisions. She will take the lead in the partnership with ASU workforce studies and also combine the position with education and doing studies related to evidenced based regulation, i.e. similar to the pilot study on medication technicians and TERCAP. Currently Pam oversees the Medication Tech Pilot Program which will examine the impact to patient safety of allowing CNA’s who complete a 100 hour course, to administer medications to stable residents in 6 long term care facilities, as well as developing new recommendations to Rules & Regulations. 20 arizona STATE BOARD OF NURSING REGULATORY JOURNAL Effective January 2007: New Electronic Complaint Process The purpose of instituting the electronic complaint process is to make the submission of complaints easier for you to complete as well as streamlining the process. We continue to be committed to having most complaints to the Board for review in a 6 month cycle time. The following pages illustrate the pertinent screens used in the process. Upon receiving the information, you will receive a confirmation that the complaint has been received. Please let us know if you have any suggestions or recommended changes to the process. AzBN Nurse Practice Consultants and Senior Investigators NEW ELECTRONIC COMPLAINT PROCESS CONTINUED>> arizona STATE BOARD OF NURSING REGULATORY JOURNAL 21 Effective January 2007: New Electronic Complaint Process Questions & Answers to Properly Submit Complaints to the Arizona State Board of Nursing THEREASA BERRY ASSISTANT TO ASSOCIATE DIRECTOR/NURSING PRACTICE, COMPLAINTS & INVESTIGATIONS VALERIE SMITH RN, MS ASSOCIATE DIRECTOR, NURSING PRACTICE, COMPLAINTS & INVESTIGATIONS 1. Who can file a complaint? Anyone can file a complaint, however, law mandates certain individuals and institutions. Pursuant to 32-1664 (B): “ A licensee, a certificate holder, and a health care institution as defined in §36-401 shall, and any other person may, report to the board any information the licensee, certificate holder, health care institution or individual may have that appears to show that a licensee or certificate holder is, was or may be a threat to the public health or safety.” Sources of complaints related to licensees/certificate holders may include employers, coworkers or other healthcare professionals, patient or family members, law enforcement, selfreports, and/or other regulatory agencies. Sources of complaints related to applicants for licensure/certification may include responses to questions asked on the application, information related to a current or prior investigation and discipline in another state, and/or information received as a result of a criminal background check. 2. What conduct should be reported? Conduct that violates expected standards of care that may result in various degrees of harm. There is no list of what should be reported, as it is a matter of judgment for the person making the report based on all the relevant factors. Examples of conduct that demonstrates poor judgment or skill resulting in violations of the Nurse Practice Act that are reportable to the board are: suspected drug diversion, failing to account for wastage of control drugs/falsification of documents, impairment, positive drug screen without a valid prescription, misappropriation/theft, exploitation of a vulnerable patient, physical/verbal abuse, patient neglect, sexual abuse/boundary violations, falsification of documents, single serious medication errors or repeated medication errors or charting errors, giving medications without an authorized order, criminal charges/convictions, failing to assess or intervene in behalf of a patient. Please note, violations are NOT limited to direct patient care or incidents occurring while on duty as a nurse/CNA. Effective September 18, 2003,and pursuant to HB 2361, license and certificate holders are required by law to report criminal charges that may affect patient safety to the board, in writing, within ten days from when the 22 arizona STATE BOARD OF NURSING REGULATORY JOURNAL charge(s) are filed. You are encouraged to become familiar with the laws and rules of the Board of Nursing. The “The Nurse Practice Act” is available (at no charge) on our website at www.azbn.org or may be purchased by contacting the board by phone or in writing. 3. What conduct is not typically reportable to the Board? Examples of low risk issues not involving patient care, professional judgment or wrongdoing that do not require reporting to the Arizona Board of Nursing are: rudeness to peers, coworker disputes, personality conflicts, absenteeism, tardiness, labor-management disputes such as work schedules/wages/wrongful termination. Facility specific operational issues that are under the jurisdiction of the Arizona Department of Health Services or other state agencies should not be reported to the Board of Nursing. 4. When should a report be made? Emergent matters involving suspected drug diversion or chemical impairment may be reported immediately to the CANDO Nurse Consultant, Connie Linck, RN, MN, CNAA, BC by calling the number listed under contacts on www.azbn.org or 602 889-5156. The call should be followed with a written complaint stating the “who, what, where and when” of the events. Written complaints should be reported as soon you have substantiated or otherwise have reasons to believe that a violation of the Nurse Practice Act has occurred and you have followed the policies within your facility regarding mandatory reporting. If the facility or agency’s administrators refuse or delay reporting, it is appropriate for a staff nurse or nurse manager to take responsibility for reporting to the Board. 5. Where should the complaint be sent? You can Submit your complaint Online at www.azbn.gov Select the Resource tab and choose Discipline & Complaints. At the bottom of your screen, select the “Submit a New Complaint” button. You may also Submit your complaint in writing to: Arizona State Board of Nursing Complaints/Investigations 4747 North 7th Street, Ste. 200 Phoenix AZ 85014 Complaint forms can be found on our website or by email request at arizona@email.gov or requested by calling 602.889.5150 6. How do I file a complaint? Initial reports to the Board should be in writing except for emergent matters such as suspected drug diversion /impairment or sexual abuse complaints. Provide as much detail as possible regarding the “who, what, where, why and how”. Identify the nurse or certified nursing assistant involved, including the correct spelling of the name, license or certificate number, last four digits of the social security number (if available) to assist in identifying the correct individual. If available, provide last known address and phone number of the individual. Provide a detailed summary of each allegation of the Nurse Practice Act, including dates of each alleged incident and the medical record number or name of the patient involved. Supplying the medical record number or name of the patient is not a violation of confidentiality or HIPPA. Be very specific in describing the event including the date and location of incident. Provide a list of any witnesses. The Board is interested in first hand observations based on personal knowledge and not on hearsay from others. Provide legible copies of relevant records/information. Be sure to include your contact information. Reporting forms are not required, but are available on our website (www.azbn.org) or can be sent to you via fax or mail by calling 602-889-5150. Additionally you may now submit complaints by email to complaints@azbn.gov. 7. Is a failure to report those who may be a risk to the public a violation of the Nurse Practice Act? In addition to the mandatory reporting law, 32-1664(B), failure to report is a violation of the nurse practice act, A.R.S. §32-1601 (16) (k) and A.A.C. R4-19-403 (7,8): §32-1601Unprofessional conduct includes the following whether occurring in this state or elsewhere: (16) (k) Failing to report to the board any evidence that a professional or practical nurse or nursing assistant is or may be: (i) Incompetent to practice (ii) Guilty of unprofessional conduct (iii) Mentally or physically unable to safely practice nursing or to perform nursing related duties. A nurse who is providing therapeutic counseling for a nurse who is in a drug rehabilitation program is required to report that nurse only if the nurse providing therapeutic counseling has knowledge that patient safety is being jeopardized. A.A.C. R4-19-403 For the purposes of A.R.S. §32-1601, a practice that is or might be harmful of dangerous to the health of a patient or the public includes the following: 7) Failing to report to the Board a licensed nurse whose work history includes conduct, or pattern of conduct, which leads to actual or potential adverse patient consequences threatening public health and safety; 8) Failing to take action in a health care setting to protect a patient whose safety or welfare is at risk from incompetent health care practice, or to report such practice to employment or licensing authorities; are violations of the Nurse Practice Act. 8. Will the person know that who filed a complaint? The applicant/licensee/certificate holder may be furnished with a copy of the complaint upon request. However, if disclosure of the name will pose a risk to the person making the complaint, a copy of the complaint with redacted ID information may be provided. If in the Board’s discretion, there is a risk of identification, the Board reserves the right to refuse furnishing a CONTINUED>> copy of the complaint. arizona STATE BOARD OF NURSING REGULATORY JOURNAL 23 9. Will the public be aware a complaint or self-report has been received? Once a complaint is received, the license/certificate or application will be identified, as “complaint/self report received” should anyone should contact the Board via the online verification or by phone to check the status. Specific information regarding the allegation is not provided to the public. As required by ARS §32-1664(L) ‘information received and records kept by the Board as a result of an investigation are not available to the public.” 10. What happens with the complaint? When a complaint or self-report is received by the Board, it is first reviewed to determine jurisdiction. If the Board has jurisdiction, the license/certificate or application is flagged with a status of “Complaint/Self Report”, an investigator and a case number are assigned. Notification letters are sent and an investigation begins. The respondent is made aware of the allegations and is given an opportunity to respond with information regarding the event. The investigator collects objective information from a number of sources, interviews the subject of the complaint (“the respondent” or the “applicant”) and other witnesses, and then compiles the findings into an investigative report to present at a board meeting for review and action. 11. How long does the investigative process take? This process takes an average of six to nine months to complete, depending on the complexity and seriousness of the alleged conduct. Some high risk/ high harm investigative cases have been completed in 1 month. 12. Can the license/certificate holder or applicant work while they are under investigation? The ability to work as a nurse or CNA is unrestricted during the investigation, as long as the license or certificate remains active. However, Applicants are not issued a license/certificate until the conclusion of the investigation. 13. What can the subject of the complaint or people making the complaint do to assist in the investigative process? If you are the subject of the complaint: keep the board apprised of any changes in your address and phone number, and respond promptly to any requests for information or documents. If you have filed a complaint: submit all written documentation regarding your concerns and record any observations and impressions concerning the incident. 14. What happens when the case is presented to the Board Members? The Board meeting is an open public meeting where investigative reports related to complaints that have been received and investigated by staff are reviewed to determine, based upon evidence in a case, whether there has been a violation of the Nurse Practice Act. Board members will deliberate and make a motion, stating what action should occur. 15. Who can address the Board Members? 24 arizona STATE BOARD OF NURSING REGULATORY JOURNAL If you have submitted a complaint or you have had a complaint submitted against your application or your license/certificate, you are welcome to attend the Board meeting to hear the discussion and board decision. The Board Meeting is not a hearing but you may choose to give a verbal presentation (up to 5 minutes), providing information you feel is pertinent for the Board to consider. You may also choose to just be available to respond to their questions, or you may be present and not speak at all. 16. What are the possible Board Members decisions or actions? Board actions are categorized as: Dismissal, Non-disciplinary Action, Disciplinary Action, and Administrative Violations. This information is available to the public. Once the case has gone to Board and action is taken, the complaint/self report status is closed and the licensee/certificate holder’s record updated to reflect the Board’s action or pending action. DISMISSAL Dismissal- Evidence does not support that the case has merit or that there has been a violation of the Nurse Practice Act. NON-DISCIPLINARY Letter of Concern - A letter from the Board expressing concern that a licensee, certificate holder or applicant may have been engage in questionable conduct that is considered low risk or harm to the public. A letter of concern issued by the Board is not an appealable agency action. DISCIPLINARY ACTIONS Civil Penalty- A monetary fine issued by the Board, not to exceed $1,000, given singly or in combination with any disciplinary action for a violation of the Nurse Practice Act. Decree of Censure-This is an official discipline by the Board that the nurse’s conduct violated the Nurse Practice Act but does not represent a continued risk to the patient/public. Probation-This action allows the nurse to continue working during the period of probation subject to compliance with the terms and conditions. During the period of probation the nurse must be supervised in their practice and complete certain requirements which are aimed at rehabilitation or educating the nurse in his/her area(s) of practice. For example, a nurse with a subNEW ELECTRONIC COMPLAINT PROCESS CONTINUED ON PAGE 26>> <