Title: Preferred Educational Methods of RN’s With More Than Ten Years of Inactive Patient Care

Author: Annette Cannon, PhD, MA, RN, MSN

Abstract

Project Title: Preferred Educational Methods of RN’s With More Than Ten Years of Inactive Patient Care

Project Director: Annette Cannon, PhD, MA, RN, MSN, (current) Online RN Refresher Program Instructor for Cannon Health Care Consulting and Education, LLC (previous) Online Program Instructor for University Center at Chapparall / Arapahoe Community College

Project Director’s Affiliation: (current) Cannon Health Care Consulting, LLC (previous) Grand Canyon University

The Colorado State Board of Nursing rules and regulations provide a policy that states that “if you do not have an active license in another state and all of your licenses have been expired two (2) years or more, you must demonstrate competency to practice by successfully completing refresher courses as defined in Nursing - Board Rule 5.6” (CSBON, 2015). According to this policy, the competency is derived from completing an RN refresher program. The objective of this paper is to further define competency through testing RN’s with inactive patient care of more than 10 years, who are enrolled in the online program that contains a hands-on skills lab compared to those who are enrolled in the online program only. This proposal, through solution and problem description, implementation, evaluation and monitoring, will present three levels of testing. These exams are given to gain baseline knowledge from students, knowledge after the online learning portion is finished and knowledge after the skills lab and online are finished. A comparison study of sample students will be reviewed as part of the decision-making. The results of the study and its outcomes will be shared with other educational institutions and state boards of nursing throughout the United States. The desired outcomes are to develop guidelines within Colleges and Universities for admission to the RN refresher program and to implement this evidence-based proposal as a nursing policy within the Colorado State Board of Nursing.

Section A: Problem Description

Currently the Colorado State Board of Nursing (CSBON) rules and regulations provide policy to address professional nurses who have an inactive or a lapsed license, resulting in a lack of patient care. The policy tackles the problem by adoption of continued competency requirements. The policy states the following broad requirement: “if you do not have an active license in another state and all of your licenses have been expired two (2) years or more, you must demonstrate competency to practice by successfully completing refresher courses as defined in Nursing - Board Rule 5.6” (CSBON, 2015). The purpose of this policy is to give nurses a method in which to either reactivate the license or become reinstated. For those nurses who are from another state, endorsement procedures are also explained.

The continued competency requirements are derived from completing an RN refresher program. In the state of Colorado, the Registered Nurse (RN) refresher program is currently offered as two choices. One program offers a non-traditional 120 hour online course with 120 hours of clinical practicum and the other program also offers a non-traditional 120 hour online course with 120 hours of clinical practicum, but also includes a 48 hour hands-on skills lab. “Nurses who have been out of the work force for some time may lack the knowledge of what needs to be included in their program of study” (Davidhizar and Bartlett, 2006, pp185-190). However, the nurse is free to choose which program to take.

To describe the programs further, the online portion of the program contains 120 hours of medical-surgical material required by the CSBON. The program is divided into 5 modules of learning, review and testing and also contains a section on interactive professional development with review and testing. Students are expected to complete the course work within 16 weeks and then take a final exam. The online program is the exact same program for both schools.

Consistent with Current Evidence

According to O’Neil and Fisher (2008), “as more students choose to take online courses and programs, it is necessary to guide them to the learning environment in which they will be most successful (pp53-58). One of the online programs adds an additional hands-on skills lab which provides a student- centered approach to learning with various methods of instruction, such as adult and child mannequins, faculty led instruction and demonstration, role-play with other students, specific task development and video training in classroom. “It can be difficult in many of our self-directed learning formats to incorporate the use of multiple senses, which characterizes adult learners” (Trapp, 2005, pp73-76). Students are provided a near realistic patient care setting in which to develop their patient assessment skills, along with communication and critical thinking skills. According to Bednarz, Schim & Doorenbos (2010), recognizing the common adult learner need for immediate relevance suggests more hands-on, experiential, or immersive educational methods (pp253-260). This environment is a safe place where mistakes can be made and lessons can be learned.

The skills lab is 48 hours and is meshed into a six week time span that overlaps with the 16 week online. Both programs end at the same time period of 16 weeks. An additional week or two is added for study time and the final. After the final exam is passed, the Board of Nursing is notified and students move on to a clinical practicum. Each program requires 120 hours of clinical practicum, where the student attends a clinical setting, with a preceptor, for approximately ten 12 hour shifts, working as an RN with a refresher status license. Once completed successfully and all paperwork is properly submitted, the nurse can obtain an active license (if it was lapsed).

The problem presenting is that the RN refresher programs do not specify a maximum limit to the number of years of lapsed license or number of years of lacking in patient care that the nurse can have to attend. The lack of a maximum limit leads to several issues for the program. For example, an RN could have a lapsed license for 30 years and desire to take the non-traditional online course only, without a hands-on skills lab experience. This can present an issue with being successful, not only in the program with testing and skills, but in the return to nursing practice. The burden rests on the facility that hires the nurse to re-train in patient care and assure patient safety. White, et.al. (2003), states that a comprehensive report shows that “nurses returning to the profession after an absence from the clinical setting typically do not possess current knowledge and skills, making them a liability instead of an asset” (pp59-63). The online program that contains a hands-on skills lab, re-introduces the nurse to the clinical setting for competency, prior to attending the clinical practicum.

The PICO model: (P) Population: RN’s with inactive patient care of greater than 10 years, (I) Intervention: Attending an online learning and hands-on skills lab refresher program, (C) Comparison: Online learning only refresher program, (O) Outcome: Success in passing a final competency exam; is used to formulate the following question: Are RN's with inactive patient care of greater than ten years more successful in passing a final competency exam after attending an online learning and hands-on skills lab refresher program versus an online learning only refresher program.

It is important for nursing to resolve this issue because the present system allows for nurses that have not practiced nursing for 20 to 30 years to take a brief refresher class and obtain an active license again. However, Yancy and Handley (2004) found that the “number of years of inactive practice was negligible in its affect on the refreshed nurses’ successful return to practice, but also found that individualized orientation programs assist with the transition of the refreshed nurse back into nursing” (Hammer and Craig, 2008, pp358-367). This issue can present a patient safety issue and competency issue when the nurse attends the clinical practicum if not addressed. Another issue is the present system places a burden on the school and instructor to decide who should and should not be able to obtain an active license based on current information.

This topic is open to a research-based intervention according to the Board of Nursing. Presently, the Board does not have guidelines or regulations that determine the type of refresher program needed as related to number of years with an inactive license. Therefore, the implementation of such would need to occur within the nurse refresher program itself. Mancuso-Murphy (2007) sites research from Mueller, 2001; Robley, et al., 2004, showing the “necessity to determine which teaching and learning practices produce the best results” (Mancuso-Murphy, 2007, pp252-260). The purpose of resolving this problem is to implement guidelines and requirements within the RN refresher program and to provide guidance to nurses in choosing the correct RN refresher program. Bernardo (2011) mentions the importance of attending a refresher program with a “skills lab to practice nursing skills, including patient assessment common procedures and a simulation lab to practice critical thinking skills related to assessments, interventions and evaluations”. The objectives in addressing this problem are: to determine effectiveness or ineffectiveness of a hands-on skills lab, to develop requirements to address number of years of license inactivity, and to develop guidelines for program admission.

Section B: Problem Solution

The proposed solution to this issue is to develop guidelines within a nurse refresher program that addresses the learning needs of the inactive nurse based on the number of years their license has been on inactive status. “Research found that nurses required a good orientation and a preceptor or mentor to teach the refreshed nurse exactly what to do on the job. The refresher course was just the beginning of what the nurse had to learn” (Hammer and Craig, 2008, pp358-367). Both programs, the online only and the online with skills lab, have been very successful in reestablishing nurses’ licenses. The instructional format between the groups has been successful. The same online format and information is used in both programs. “Distance education is included in almost every educational development course around the country, sometimes making them the rule rather than the exception” (White, et al., 2003, pp59-63). The online is currently available to all RN’s to take for license activation no matter how many years of license inactivity are present.

Consistent with resources and the organization

The proposed solution is consistent with the community culture. The country is experiencing a nursing shortage. RN’s returning to the workforce is one way to help resolve it. “A refresher course serves to assist the inactive nurse to return to the nursing profession, as without it nurses typically do not possess enough current knowledge and skills which makes them a liability instead of an asset” (White, et al., 2003, pp59-63). Research has found that due to technological advances, nurses need to be taught the basics all over again, including basic computer skills and electronic medical records. Hospital programs that have developed retraining programs have learned from the students that they are not prepared to re-enter the hospital without certain skills, and have learned there is a disconnect between their past experience and current practice.

The basics included “universal precautions, electronic thermometers, noninvasive blood pressure machines, pulse oximetry and Dopplers, along with dosage calculations”, which are all technologically advanced items and procedures for a nurse who has been inactive for years (Bouwman and Kruithoff, 2004, pp164-169). The proposed solution, which is setting guidelines to address the learning needs of the inactive nurse and develop guidelines within the refresher course to address those needs, will also address the needs of the organization that employs the refreshed RN’s.

The following information in regard to population, intervention, comparison, instrument, and outcome will be used to develop the proposed solution. The population will be 120 RN’s located in the state of Colorado whose license has been at inactive status for ten years or more and enrolled in an RN refresher program to activate their license. The time frame is within one year and includes eight classes.

Intervention for the problem

The intervention consists of program A, which is a 120 hour online only based learning program, and program B, which is a 120 hour online based learning program with an additional 48 hours of hands-on training in a skills lab. The curriculum and content of the 120 hour online based learning is identical to each program and has been approved by the Colorado State Board of Nursing. The 120 hours of online learning includes video instruction with interactive professional development software. The content of the 48 hours of hands-on training contains use of mannequins and video instructions of specific skills. T he skills-lab has been designed by the instructor to touch on skills according to the outline of the online program and to introduce the student to a clinical setting and to provide interaction. To determine the criteria, questions and curriculum for the RN refresher program, evidence-based practice will be used.

For the comparison, two sample groups will be used in a randomized controlled experimental study. The sample groups will be determined by having the first nurse choose to take the online only program or the online with skills lab program. The next nurse will be asked to be in the opposite group. The nurses will continue to be alternated in the programs. Nurses will be informed of the project and determine if want to participate, with the ability to withdraw at any time. Demographic data will be used to identify participants.

The instrument will be a pre-refresher test given to all participants. The test will derive from the competency expectations put forth by the Colorado Board of Nursing and approved by the online curriculum developers. Mid way through the program at 60 hours, the participants will be given a mid-refresher test. At the end of both programs, a final-refresher test will be administered. Both groups of participants will be given the exact same questions. The tests will contain 100 multiple choice questions and will be proctored. The test scores will be compared between the groups to figure the difference. For the outcome, demographic data, such as the participants age, sex, years since graduation, years since last practiced, total years of practice prior to inactivity, level of nursing degree, ages of children at home, and other non-nursing work will be reviewed to see if there are variables that need to be considered.

Section C: Research Support

Research studies were reviewed through an inclusive search of databases via the internet and GCU online library. The following databases were searched: GCU journals @ OVID, All Journals @ OVID, Education Research Complete, and CINAHL. Foreign language articles were not reviewed. Studies range from the years 2008 – 2013 and included these keywords: nurse, refresher, adult learner, skills lab, return to work, competency, testing and online. This search located over 1,000 abstracts and publications. Post screening, 6 studies were found to be relevant for use in this project, focusing on (skills lab, competency scores, learning methods, and online courses) enrolled in an RN refresher program in the State of Colorado. Appendix A provides a summary of relevant findings. These studies included qualitative and quantitative studies, use of a Likert scale, non-probability, one exploratory study and theoretical framework. The criterion for inclusion was that the article was based on research from a clinical and educational perspective.

In the initial searches, studies were found relating to online nurse refresher programs, but offered no specific studies in regard to inclusion of a skills lab versus no skills lab within the program. Therefore parts of the study were significant in application to this study due to findings among participants in the study of what was lacking in their program or information concerning the importance of learning methods. Most all of the research articles addressed the nursing shortage and the need for nurses to return to the workforce by means of a nurse refresher course. Findings implicate a need to focus on “recommendations for future course implementation, including implementing a systematic evaluation of each participant’s knowledge base at the beginning of the course” (Griffiths and Czekanski, 2003, pp162-171). Other research indicates a need for students to have hand-on skills to accommodate their learning style or method.

Studies have been conducted on nurses due to the shortage and target those nurses who have been inactive in practice for 2 or more years. These studies included looking at multiple variables, such as age, family demands, length of time away from practice, previous experience, reasons for leaving the profession, and financial situations. “Several authors attest to refresher programs being effective for reentry to practice, but note that the focus must be on outcome competencies, with the research showing that the completers of that program preferred more time be spent on technical rather than intellectual competency” (Griffiths and Czekanski, 2003, pp162-171).

Summation of the research findings indicate that nurses enrolled in a nursing refresher course should have base knowledge tested, along with testing of preferred learning methods. According to the IOM report (2011), “nursing education must be fundamentally improved both before and after nurses receive their licenses.” The research revealed that refresher courses are valuable to nurses and organizations, input from nurses past experience and knowledge are important, nurses are enthusiastic to learn new skills, and nurses appreciate diverse learning strategies. However, further research revealed that nurses returning to the workforce through a nurse refresher course had many roadblocks such as lack of needed computer skills, lack of technological abilities, general anxiety, a lack of confidence in skills and other variables that prohibited learning. “Continued research is also needed to identify the best teaching and learning practices in distance education” (Mancuso-Murphy, 2007, pp252-260). A problem with current research is that it does not address the addition of a hands-on skills lab to an online program as being of a benefit in increasing competency scores. This study will look at the differences between competency scores in regard to an online nurse refresher program with a hands-on skills lab versus an online only nurse refresher program.

Section D: Implementation

University Center at Chaparral Corporate Learning Center (UCC/CLC) is an extension of the local college and is located in Parker, Colorado (now renamed ACC Parker Campus). UCC describes its mission as a “community-focused, collaborative partnership which prepares individuals and corporations for the future by providing continuing education and training today” (UCC, 2015). The RN refresher program was designed by UCC to provide an innovative educational experience to the RN who desires to activate their nursing license and return to the nursing profession. This RN population consists of nurses who have allowed their license to become inactive or lapsed for more than two years.}

There are presently two types of refresher programs offered, one is online learning only and the other is online with a hands-on skills lab. This proposed study would determine if those RN’s with inactive patient care of greater than 10 years, are more successful in passing a final competency exam after attending an online learning and hands-on skills lab refresher program versus an online learning only refresher program.

Methods

The implementation of this study will consists of four main steps. “These organized methods will follow a specific procedure to study the issues, therefore lending to the idea that the results will be more accurate and are not influenced by opinion or belief” (Potter, 1995, p265). First, the specific population will be identified. The selection will be 120 RN’s in the state of Colorado who have been inactive in patient care for greater than 10 years, and are returning to an RN refresher program with the intent of returning to the nursing workforce. The study will be conducted over one year time.

Second, the nurses will be divided into two sample groups, for comparison purposes. The sample groups will be determined by having the first nurse choose to take the online only program or the online with skills lab program. The next nurse will be asked to be in the opposite group. The nurses will continue to be alternated in the programs. Nurses will be informed of the project and determine if want to participate, with the ability to withdraw at any time.

Third, the demographic data of participants will be identified and posted as student plus their zip code, for example, Student 12345. If more than one student is in the same zip code, a letter of the alphabet will be added to the zip code, for example, Student 12345a. The variables will include age, sex, years since graduation, years since last practiced, total years of practice prior to inactivity, level of nursing degree, ages of children at home, and other non-nursing work that will be reviewed to see if there are other variables that need to be considered (see Appendix B and C for both sample groups).

Fourth, the instrument will be a pre-refresher test given to all participants at the beginning of the program, with the same test given mid-way through and then another test as the final. All participants will be given the exact same test questions of 100 multiple choice. The tests will include patient scenario-based questions. The tests will be developed and reviewed by the online instructor prior to admission. All tests will be paper and pencil, allowing the student 1 hour and 30 minutes to complete. The instructor will record all grades and deliver to the administrative assistant. The administrative assistant will collect all data on enrolled students both prior to the class (i.e. zip codes) and maintain data according to test grades (see Appendix D and E). The information gathered will be placed into this table by the administrative assistant for viewing. Other appendices are: Appendix F - pre-test exam; Appendix G – mid-test exam; and Appendix H – final exam. A comparison of all grades will be conducted post final between the groups to determine an increase in scoring among groups. Other methods of data collection may be reviewed for use in future research.

Overall Plan

The plan is to develop a data collection plan whereas the data can be analyzed with accuracy. “The tasks of defining research variables and selecting or developing appropriate methods for collecting data are among the most challenging in the research process” (Polit and Beck, 2007, p4). The overall plan for implementing the proposed solution is to work with the University Center in identifying the students, administering the tests and collecting the data. The information will be shared with other refresher programs in the state of Colorado and the Colorado State Board of Nursing. The plan is to identify and develop guidelines and regulations in addressing the educational needs of RN’s who have been inactive in patient care for greater than 10 years, both at the education and Board of Nursing level. The plan is to also provide the RN refresher student with evidence-based research to be able to reach an appropriate decision based on educational need levels. The present curricula within the RN refresher program will also be reviewed and evaluated for needed changes.

Resources

Resources for conducting this project come from the University Center at this point in time. This includes administrative support, supplies and staff time. Administrative support is required to conduct the enrollment process and separate students into sample groups, per the study protocol. Administrative support will collect data regarding students’ demographic information. The questions may be added as part of the enrollment package. This will require printed forms and time for designing the form, collecting the form once completed and transfer of data. Financially speaking, this will involve the cost of printing. Staff costs are included in current expenditures and account for approximately 4 hours a week of time to conduct the study.

Two nursing staff members are needed to design the pre and mid exams. The current final exam will be used. The two other exams, pre and mid, can be derived from previously tested questions within the program. The time for developing the exams is approximately six hours. One staff member is required to administer and proctor the exam for one and one half hours for each sample group at three different times for a total of six administered testing times. The first pre-test can be given during orientation. The mid-test can be given prior to the skills lab beginning. The final is given after all online and skills lab work is completed successfully.

There is no cost involved for class space to administer the test, as this is figured in with program enrollment. The cost of printing the tests, along with envelopes for delivery needs to be accounted for. Other costs to be included are: nursing staff time for two employees, six hours total for test development; nursing staff time for one employee, eight and one half hours for test administration, along with three hours of prep time; and administrative time of six hours for mailing and data entry.

Monitoring

Each test will be scheduled at the same time for all students. All tests will be proctored and hand-delivered in a sealed envelope to administrative support. Tests will be graded by administrative support within 48 hours after the test has been delivered. The administrative support will notify the instructor of all grades and will apply the data to Appendix D and E.

Students will be given their test results by the online instructor. Other monitoring will be done in relation to the revisions and processes involved through use of the theoretical framework.

Theoretical Framework

Several theoretical models were reviewed for the development of the implementation plan. “Developing the framework is an important step in designing the study and providing structure for selecting the variables by showing the relationship to one another” (Melnyk and Fineout-Overholt, 2005, p254). Kitson’s framework was chosen for this study because of the emphasis placed on the organization. If research demonstrates that a change is needed, then this model will support the organizations role in research utilization.

The framework will assist the organization in successful transformation of strategic approaches to nursing students, development of guidelines and requirements, policy changes, decision-making abilities of nurses, change in curricula, overall organizational change and insight into further need for research on the topic. The model will support present and future changes, by promoting and supporting critical thinking among staff to reflectively identify and evaluate nursing refresher programs on all levels and to eventually put the ideas in motion. The continual collection of data or collection of evidence and placing it into context, will contribute to the research utilization.

Research utilization decisions are made through the components of the model working together to find balance and to implement the research findings. “In Kitson’s model, the context refers to the elements of the organization; facilitation refers to the way information is communicated; and successful implementation occurs when the evidence is strong, the context is receptive to change and there is proper facilitation of the change process” (Melnyk and Fineout-Overholt, 2005, p203). Evidence-based practice is based off of all three of these components working together to obtain change.

In applying the context portion of the model, the organizations systems will be need to be analyzed. The review will include the University’s relationship with the State Board of Nursing, the Area Health Education Center, and other academic institutions. The culture of the University and those employed by the university will be evaluated for acceptance towards use of evidence-based research. The examination and assessment of these elements are important steps in which to base the implementation on.

The facilitation portion of the model will assist in delivery of the research findings and in facilitating the change needed. Communication of the findings is a key component. “Communicating research findings involves the development and dissemination of a research report to the appropriate audiences, including nurses, health professionals, educational institutions, and policy makers, through presentations and publications” (Burns and Grove, 2004, p44). Transferring of the research information in an understandable, clear way and gaining support and commitment from users is critical to the implementation phase.

Successful implementation, the third component of Kitson’s model, can occur once the context and facilitation have occurred. Various strategies will be used to increase facilitation and evaluate context to make needed changes throughout the study. “Kitson’s model can be used much like the “situational analysis” (Cochrane Review Group on Effective Practice and Organization of Care, 1999) to assess potential barriers and facilitators within the elements of the evidence, context, and facilitation” (Melnyk and Fineout-Overholt, 2005, p204). The model requires continual re-examination of all elements to keep the process moving and working, especially towards future research needs.

Feasibility

The proposal is feasible in that the approach used can become a part of the RN refresher program and not be seen as a separately conducted task. The results will prove to be practical information to be used by those offering RN refresher programs within the state of Colorado. This includes independent companies, policy making entities, education centers, corporate learning centers, colleges and universities. The proposal will prove useful to RN’s who are enrolling in an RN refresher program, through use of evidence-based research to guide personal decision making.

Future Planning

Following a successful implementation, steps will be taken to analyze and evaluate the results and determine if further revision is needed to the current proposal or if to discontinue the proposal and concentrate on other needed research. Support for the proposal requires that those involved in the project remain committed. Encouragement and empowerment to other educators and clinicians will be important in gaining interest towards further research on RN refresher programs in the state. “The evolution of nursing will continue to provide the foundation for educational curricula and the research necessary for nurses to lead and manage both clinical and non-clinical environments of the future (Cherry and Jacob, 2005, p25). This requires a commitment to be made towards improvement in the RN refresher program, promoting safety in patient care among nurses, and providing for nurses educational needs.

Section E: Evaluation

The goal of this proposed project is to identify the preferred method of education for RN’s who have been away from practicing as a bedside nurse for over ten years. “Justifying the rationale for this study and the decisions made to conduct this study are key components” (Polit and Beck, 2007, p636). Once that information is identified, it will be shared with other refresher programs within the state and the Colorado Board of Nursing. In evaluating the obtained data, application will be made to review present rules and regulations, both within a program and at the board of nursing. Application of data will also be made to review present curricula within the refresher program and make the needed preferred changes.

Measurement of Objectives

The evaluation plan is comprehensive and concise in that it includes steps for identifying students, development of tests and data collection, staff to administer tests and collect data and forms of data collection. The outcome measures will provide a means to evaluate the objectives. The plan includes sharing of evidence-based research and findings with others and discusses possible changes to be made, along with further research. These methods of testing will be sufficient to measure the test scores of students (see Appendix D and E). The testing (Appendix F, G, H) will measure the students knowledge prior to the course, midway through the course and at the end of the course, providing scores for comparison. This scoring will be measured in percentages, showing the percentage of change from the pre-test to the post-test.

The identification of the RN refresher students who enroll into the program will be selected and then those who have more than 10 years of patient care inactivity will be chosen for the project. These nurses will be divided into two groups. For fairness, the selection will be alternating picks. All students will be asked to complete the demographic data sheet (Appendix B and C) and identified under zip code. Comparisons will be made of the demographic information and the test scores to see if there are further variables or any patterns present.

Support, Monitoring and Collection

“It is critical that adequate means to collect and manage data, along with analysis is in place” (Polit and Beck, 2007, p637). The University Center presently has the staff to gather this data through enrollment forms and process and has staff to administer the exams. Appendix B and C, demographic collection tools, are valid and reliable tools in that the information is collected directly from the students and checked for accuracy by the administrative assistant. The variables are sensitive to change and are appropriately used for this type of study. Appendix D and E are measurement tools to record actual scoring of tests taken by both samples of students. The form will collect scores for students, identified by zip code, on all three tests and provide a percentage rating of increase or decrease. These forms collect valid and reliable data from exams and are appropriate to use for this study.

Actual exams (Appendix F, G and H) will be tested for validity and reliability through national standards by nursing staff at the University Center and the Area Health Education Center. The exams are written to test the knowledge of the student prior to the course, midway through the course and at the end of the course. The exams are sensitive to change according to content of curricula in the future, but are presently appropriate for use in this study.

Evaluation of the monitoring process shows that other methods of data collection may be reviewed for use in future research. The present method of data collection is valid and reliable. However, it is sensitive to change through use of technology. The current method of data collection is appropriate for use with this study.

Resources

The University Center will provide all resources for conducting the project. It is to their advantage to learn of this information as to better their program and/or change requirements. In addition, another school may be interested in participating in this study or conducting their own side by side study. It is possible that the measurement tools for data collection and testing may be shared.

Feasibility

In evaluating the feasibility plan, it is found to be comprehensive and concise. The method for choosing the sample groups is sound and offers the enrollees the option of declining or withdrawing from the study. In the case of ending up with more students in one group than the other, participants will be asked if they would volunteer to change groups to even the number out. Use of the demographic information for data collection protects the confidentiality of the participants, by use of zip codes. Also, use of sealed envelopes with hand delivery of tests and test results, secures confidentiality further. The use of identical tests, on all three exams for both sample groups, insures fairness in testing. Finally the costs associated with this study are found to be minimal and within the program budget.

Dissemination

Dissemination of information will involve several major steps. Step one will be presenting the evidence-based research to the University Center staff and decision-makers. A presentation of the study, along with outcomes and plans for implementation can be delivered during a planning meeting through the use of PowerPoint. Strategies to secure buy-in and ongoing support from the decision-makers and policy-makers will be used to ensure the success of implementation. Updates of the project will be provided throughout each course.

Step two will be to make the policy change within the University programs according to the study outcomes. “Interest in effectively applying information and knowledge to improve policy and practice across a range of fields, has grown and evolved in recent years” (Chaskin and Rosenfeld, 2008, p3). These changes can be communicated through email to all staff involved. Students will be notified at enrollment time of changes.

Step three will be to continue to re-evaluate the program under the new policy. Other measures to be taken include informing the Colorado State Board of Nursing through formal communication with the Regulations Director and informing of changes within the program, either in person, through a formal letter or a formal presentation with PowerPoint. Outcomes will be also be shared with Board of Nursing Directors from other states, through email or formal communication and with other schools that provide a nurse refresher program, through email, formal communication or formal presentation of PowerPoint. Research shows that there is a “developing interest in adapting and applying the orientations, strategies and technologies of one sector to the needs of another, such as approaches to organizational learning” (Chaskin and Rosenfeld, 2008, p4). Dissemination will occur through formal presentations at meetings, such as for the Colorado Center for Nursing Excellence, the Colorado Nurses Association and various other nursing groups and committees; and the continuance of program and policy evaluations through further evidence-based research. “Communicating the outcomes of research will continue to present a challenge, however, and ensuring that the key messages are in a form accessible to industry will mean using new and innovative strategies to get the word out” (Rauner and MacLean, 2009, p36). Therefore, consideration will be made to present through a Webinar session and through poster presentations at nursing conventions. Plans are to publish this information within the University’s publications and the State Board website for others to use and make changes to guidelines, regulations, requirements, policies and procedures. Conclusion

In conclusion, continued nursing research is a critical component to the survival of the nursing profession. The influence of research on nursing education and nursing practice is immense and will forever change the overall advancements of the nurse. Conducting studies will allow the use of evidence-based research to make the needed adjustments and changes necessary for the ongoing improvement of nursing. This study will address the preferred learning needs of nurses who are returning to nursing practice after being inactive more than ten years. By sharing these learning experiences with others, changes and improvements can be made to nursing education. By sharing the outcomes, the opportunity is set forth for further research and to eventually make a difference in the nursing profession as a whole.

Appendix A

Research Support Table

Author Purpose Sample Design Intervention Result Strengths and Limitations

Hawley, J. and Foley, B. (2004)

The study examines the effectiveness of a structured nurse refresher course to return nurses to employment and to prepare them for effective clinical practice.

This course was successful in returning respondents to nursing employment and in preparing these nurses in the six areas included in the course. This refresher course may serve as a model for the development of more structured refresher courses for inactive nurses. 78% (n = 37) of the 1990–2000 graduates of the Nursing Update registered nurse refresher course.

Mix of qualitative and quantitative

The survey tool was similar to the one used for the 5- and 10-year follow-up studies conducted with new questions added to examine the effectiveness of the course in preparing graduates to return to clinical practice. The surveys reflected the value of this course, with 92% (n = 33) of respondents rating it as “very valuable” in helping them to gain the confidence and competence needed to return to nursing practice.

S: surveys reflected the value of this course

L: low response rate and too many years between graduation and the survey. 10 years is a long time between course graduation and this survey.

In the future, the survey will be conducted every 5 years, which may increase the response rate.

Cundall, R., et.al. (2004).

The purpose is to offer a nurse refresher course curriculum and describe the process by which it was designed. Designed a nurse refresher course Curriculum framework; designed a nurse refresher program and enrolled 12 students.

The course covered a 5-week time-span of102 hours. Fifty-four hours were allocated to classroom theory, with 18 of the hours spent in simulated laboratories. The clinical portion of the course was allocated 48 hours during 2 weeks

S: The faculty shared their knowledge and expertise; Gained a valued finished product.

L: addition of more orientation time in the beginning of the course to help dissipate student anxiety.

Griffiths, M. and Czekanski, K (2003)

To focus on recommendations for future course implementation, including implementing a systematic evaluation of each participant's knowledge base at the beginning of the course and an extended course time frame to allow for greater integration of content.

To provide inactive nurses with a review and update of their nursing knowledge, to refine skills

A Likert scale measured levels of satisfaction with all program components;

Mixed Qualitative and Quantitative Study

15 participants evaluated over 1 year 15 participants were enrolled into the nurse refresher program Our course was designed to present all of the content, complete the requisite testing, and then move the returning nurse into the practice environment

S: course participants expressed enthusiasm for learning and appreciation for the diverse strategies

L: Perceptions and expectations of the learners, communication, evaluation forms, recruitment process was not conducted in a timely manner

Mancuso-Murphy, J. (2007)

Study provides an integrative review of the nursing literature to ascertain the student perspective of distance education To develop an instrument that measures students' perceptions to determine the best practices for Web-based nursing courses. Studies were qualitative research (79%, n = 11), using interview and survey techniques identified as descriptive design (36%, n = 4), phenomenological (27%, n = 3), individual and focus group interviews (18%, n = 2), naturalistic/constructivist (9%, n = 1), and qualitative description (9%, n = 1) research methods The study conducted three in-depth focus group interviews; Questions were developed from the responses and later used in focus groups. Data were analyzed using the criteria of naturalistic/constructivist inquiry. The nursing literature on distance education and professional socialization reveals positive outcomes; Shows that further study in a variety of areas is needed. S: convenience accessibility and flexibility

L: small samples (5, 15, and 15), self-report data collection methods, and the subjective nature of qualitative research; failed to indicate the kind of computer software and hardware programs used in their online course or program

O’neil, C. and Fisher, C. (2008)

Study on Nurse residency program for med-surg and critical care nurses. To describe characteristics that can serve as useful criteria for predicting student success in an online course. 19 students in the online course and 15 students in the traditional course using an exploratory study

Qualitative/Quantitative mix

Quantitative data were analyzed using SPSS software. The numeric grades on the midterm and final were compared using a t test for equality of means, and the numeric project grades were compared using the chi-square test of significance.

Studied the differences between traditional classroom and online learners. using five study variables. Although this study resulted in additional findings, not all findings were required to answer the initial question. The additional findings suggest areas for further study.

S: multiple factors were considered

L: no pre-course assessment of computer skills; due to self selection, random assignments to groups were not possible

Rochford, R. and Mangino, C. (2006)

The study examined the learning-styles of two distinct community college populations, education majors and remedial students. The purpose of this study was to ascertain if these two groups of students exhibited significantly different learning-style preferences that could have the potential to inhibit or enhance their performance.

176 from two different urban community colleges; Group 1: education majors; Group 2 remedial reading and writing student; a non-probability or convenience sample was employed

The PEPS was administered to identify each student's learning-style preferences among engineering, law, nursing, and allied health students; the ACT Compass Reading and the ACT Writing Sample Assessment exams were collected for this analysis. These associations suggest that the more visual a student is, the more likely he/she is to benefit from structured, persistent learning, background noise, the manipulation of objects, and/or movement during class.

S: Instrument established good reliability and predictive validity

L: multiple variables among students

Appendix B

Sample Group 1 – Variables

Factors Age Gender Years since graduated Years since practiced Years practiced prior to inactivity Level of Nursing Degree Ages of children at home Other non- nursing work

Student (zip code)

Student (zip code)

Student (zip code)

Student (zip code)

Student (zip code)

Student (zip code)

Student (zip code)

Student (zip code)

Appendix C

Sample Group 2 - Variables

Factors Age Gender Years since graduated Years since practiced Years practiced prior to inactivity Level of Nursing Degree Ages of children at home Other non- nursing work

Student (zip code)

Student (zip code)

Student (zip code)

Student (zip code)

Student (zip code)

Student (zip code)

Student (zip code)

Student (zip code)

Appendix D

Sample Group 1 – Test Scores

Test Scores by Percentage Pre-Test Mid-Test Final Exam Increase/Decrease

Student (zip code)

Student (zip code)

Student (zip code)

Student (zip code)

Student (zip code)

Student (zip code)

Student (zip code)

Student (zip code)

Appendix E

Sample Group 2 - Test Scores

Test Scores Pre-Test Mid-Test Final Exam Increase/Decrease

Student (zip code)

Student (zip code)

Student (zip code)

Student (zip code)

Student (zip code)

Student (zip code)

Student (zip code)

Student (zip code)

Appendix F

Pre-test Exam

The pre-exam will consist of 100 multiple choice questions. The multiple choices will be either a, b, c, or d. Questions will be standardized test questions taken from several resources and will cover the topic of medical-surgical nursing. The pre-exam assumes that the RN refresher students come to the program with prior subject knowledge. This exam will be given to all enrollees in both sample groups in the study.

Appendix G

Mid-test Exam

The mid-exam will consist of 100 multiple choice questions. The multiple choices will be either a, b, c, or d. Questions will be standardized test questions taken from several resources and will cover the topic of medical-surgical nursing. The mid-exam assumes that the RN refresher students have obtained certain nursing knowledge throughout the course and this material will be included in the testing. This exam will be given to all enrollees in both sample groups in the study.

Appendix H

Final Exam

The post-test or final exam will consist of 100 multiple choice questions. The multiple choices will be either a, b, c, or d. Questions will be standardized test questions taken from several resources and will cover the topic of medical-surgical nursing. The mid-exam assumes that the RN refresher students have obtained certain knowledge throughout the course and this material will be included in the testing, along with additional hands-on practical nursing questions (that may or may not have been learned by the skills-lab or some other means of nursing experience). This exam will be given to all enrollees in both sample groups in the study.

References

Bednarz, H., Schim, S., and Doorenbos, A. (2010). Cultural diversity in nursing education:

Perils, pitfalls, and pearls. Journal of Nursing Education, 49(5). 253-260.

Doi:10.3928/01484834-20100115-02

Bernardo, L. (2011). Ready, set, go! How to return to the nursing workforce. American Journal

of Nursing. 6(8).

Bouwman, K. and Kruithof, J. (2004). Teaching old dogs new tricks: RN returnship program.

Journal for Nurses in Staff Development - JNSD. 20(4), pp164-169.

Burns, N. and Grove, S. (2004). The Practice of Nursing Research: Conduct, Critique, and

Utilization. Publisher: Elsevier Health Sciences.

Chaskin, R. and Rosenfeld, J. (2008). Research for Action: Cross-National Perspectives on

Connecting Knowledge. Publisher: Oxford University Press.

Cherry, B. and Jacob, S. (2005). Contemporary Nursing: Issues, Trends, & Management.

Publisher: Elsevier Health Sciences.

Colorado State Board of Nursing (CSBON). (2015). Continued competency requirements for

practical and professional nurse. Nursing Board Rule 5.6. Retrieved Jan. 1, 2015 from

http://www.dora.state.co.us

Cundall, R., Emert, B., Gowens, D., Hedrick, C., Phillips, M., Schulze, B, and Sredl, D. (2004).

Designing a nurse refresher course curriculum. Journal of Continuing Education in Nursing.

35(4), pp164-175. Retrieved Jan. 1, 2015 from OVID database.

Davidhizar, R. and Bartlett, D. (2006). Re-entry into the registered nursing workforce: We did it!

Journal of Continuing Education in Nursing. 37(4), pp185-190. Retrieved from,

http://web.ebscohost.com.library.gcu.edu

Griffiths, M. and Czekanski, K. (2003). Meeting the needs of the health system: A refresher

course for registered nurses. Journal of Continuing Education of Nursing. 34(4), pp162- 171.

Retrieved on Jan. 1, 2015 from CINAHL databases.

Hammer, V. and Craig, G. (2008). The experiences of inactive nurses returned to nursing after

completing a refresher course. Journal of Continuing Education in Nursing. 39(8), pp358-

367. Retrieved from, http://ovidsp.tx.ovid.com.library.gcu.edu

Hawley, J. and Foley, B. (2004). Being refreshed: Evaluation of a nurse refresher course. Journal

of Continuing Education in Nursing, 35(2), pp84-88. Retrieved Jan. 1, 2015, from PUBMED

IOM (2011). Future of Nursing: Focus on Education. Retrieved Jan. 1, 2015 from

http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-

Health/Report-Brief-Education.aspx

Melnyk, B. M. & Fineout-Overholt, E. (2005). Evidence-Based Practice in Nursing and

Healthcare: A Guide to Best Practice. Philadelphia, PA: Lippincott Williams & Wilkins.

Mancuso-Murphy, J. (2007). Distance education in nursing: An integrated review of online

nursing students’ experiences with technology-delivered instruction. Journal of Nursing

Education. 46(6), pp252-260. Retrieved from, http://web.ebscohost.com.library.gcu.edu

O’Neil, C. and Fisher, C. (2008). Should I take this course online? Journal of Nursing

Education. 47(2), pp53-58. Retrieved from, http://web.ebscohost.com.library.gcu.edu

Polit, D. and Beck, C. (2007). Nursing research: Generating and assessing evidence for nursing

practice. Philadelphia, PA: Lippincott Williams & Wilkins.

Potter, P. (1995). Potter and Perry's Foundations in Nursing Theory and Practice.

Publisher: Elsevier Health Sciences.

Rauner, F. and Maclean, R. (2009). Handbook of Technical and Vocational Education and

Training Research. Publisher: Springer

Rochford, R. and Mangino, C. (2006). Are you teaching the way your students learn? Radical

Pedagogy. 8(1), pp9-9. Retrieved Jan. 1, 2015 from Education Research Complete.

Trapp, P. (2005). Engaging the body and mind with the spirit of learning to promote critical

thinking. The Journal of Continuing Education in Nursing. 36(2), pp73-76. Retrieved from,

http://web.ebscohost.com.library.gcu.edu

University at Chaparral Center (UCC). 2015. Retrieved Jan. 1, 2015 from website:

http://www.the-university-center.org/index2.html

White, A., Roberts, V., and Brannan, J. (2003). Returning nurses to the workforce: Developing

an online refresher course. Journal of Continuing Education in Nursing. 34(2), pp59-63.

Retrieved from, http://web.ebscohost.com.library.gcu.edu

Author: Annette Cannon, PhD, MA, RN, MSN

     This story begins when Eva Henry, a single mom, and her children, Maurice and Danielle were without health insurance, although Eva was working here in Colorado. She worked in financial services, but was unable to afford the health insurance benefits offered by her employer. She was facing the decision of whether to feed her children and pay the rent or pay for health care benefits on her wages of $15,000 a year. What happened next in Eva’s life, was driven by what happened to her children while being uninsured. She recall’s her son having severe burns on his hands and not being able to afford to take him to the emergency room, thus hearing him cry many nights from the pain. Her daughter, from the age of 6 months was plagued with chronic ear infections. Because she was unable to afford tubes to be placed in her ears, she continued to give her child antibiotics. By age ten, her daughter had lost her hearing in the left ear. Eva’s dilemma was that she was not eligible for Medicaid, but at the same time, she could not afford private insurance. Eva and her children fell through the cracks!

     Quality health care that once seemed reliable is quickly being priced out of reach for millions of hardworking, taxpaying Americans. The health care crisis affects us all regardless of age, race or employment. (Colorado for Health Care, 2008) Eva states that the “focus should not be so much on having health insurance, but what is the coverage of that health insurance”. “What good does it do to have insurance if it doesn’t cover what you need or you can’t afford the deductibles?” she said. In Colorado, 772,000 are uninsured, with 37% of that number being hispanic, 13% whites, and 19% women (CHC, 2008). These numbers of uninsured raise the health care premiums for private employer coverage. However, Eva says that underneath all of this, she believes the main political issue is the underinsured population.

     Eva became a ‘health care voter’ with Colorado for Health Care. She said that she doesn’t want another family to ever go through what she and her family did and be faced with the difficult decisions that she once had to make. She had already worked many years in financial, helping families who needed consumer loans, so she began to get involved with several groups that focused on matters that were important to the working family. Her interest was to take on projects that examined health care reform and education. With Eva’s passion for her community, she then became involved with volunteering for schools, being a campaign manager for Colorado State Representative Judy Solano and became a community leader by serving on the City council.

     Eva became a supporter of HB 1389. This bill was introduced by two Democrats, Representative Morgan Carroll and Senator Paula Sandoval and is supported by many. The bill summary is as follows:

“Requires each insurance carrier to file with the commissioner of insurance a detailed description of its rating and renewal practices for health and automobile insurance. Requires such information to be public when filed. Requires each insurance carrier to file annually with the commissioner the number of lives insured in the previous year. Requires requested rate filing increases for health and automobile insurance to be submitted to the commissioner at least 60 days prior to the proposed implementation date. Allows the rates to be implemented if the commissioner does not approve the rates within the 60-day period. Allows the commissioner to disapprove the rates upon later review. Requires the commissioner to disapprove the rates for health and automobile insurance if certain conditions apply. Requires insurance carriers to report to the division of insurance (division) if specific reasons apply to an increase in rates for health and automobile insurance. Requires the division to track such information and make it public. Prohibits persons from willfully withholding information that will affect rates or premiums charged or from giving false or misleading information. Creates penalties for a violation. Requires that use of credit information for underwriting purposes be open to the public” (Second Regular Session, 2008).

     Eva tells me that Colorado has the seventh highest insurance premium among the states, rising at a 98% rate, stating that the money is going for profits to the insurance companies and not into the healthcare of individuals. She states that we are higher than average when it comes to the number of uninsured (800,000 in Colorado) and that over 80% of those numbers come from working families. This bill will effect our insurance rates in the future, by decreasing the discrimanatory acts of insurance companies, decrease profits into their pockets and will assist with getting our claims paid in a timely manner, which will assist in protecting individuals credit from being harmed. It will take away the control power of insurance companies.

     Eva’s commitment to her community has led her to a position on the Thornton City Council, Ward Two in Adams County, here in Colorado, which now provides a Democratic majority for the council. She is out there ‘walking for votes’, holding demonstrations, having her voice heard, and fighting for health care reform. Eva believes that “if you want to do something to make sure that everyone gets comprehensive, quality, affordable healthcare, then there are ways to make that happen.” She says to first “become a health care voter, make sure you are informed, become active by spreading the word, talking to candidates and making your voice heard”. Eva said that becoming a volunteer on local and state levels with healthcare campaigns is another way to be involved and make a difference.

     She adds that she has taken many lessons from those in the area and has also taught her children to become strong community leaders through giving back. Her son, Maurice, is in his tenth year of serving in the US Army and her daughter, Danielle, graduated with a Political Science degree, is involved with the SEIU and fighting for workers rights regarding health care.

In return, where is this policy today? The Colorado House Bill 1389 (The Fair and Accountable Insurance Act) has been approved by the House Business Affairs and Labor Committee. It will now be going to the House Appropriations Committee. According to the Colorado for Health Care group,

     “The efforts of health care voters paid off as HB 1389 passed the Labor and Business Affairs committee and now heads to the House Appropriations Committee on Thursday, April 17th. Health care voters testified and lobbied in support of this bill which prevents excessive, unnecessary insurance rate increases by allowing our division of insurance the same power that 38 other states have - the power to review the reasons for a proposed increase and approve or deny the hike. If we are going to effectively tackle spiraling health care costs in Colorado, we need to know where the money is going and have the power to tame the excesses. As a prior approval state, we can lay the foundation for future health care reform that will lower costs and increase access” (CHC, 2008).

     Eva adds that she is looking forward to continuing to fight for future health care interests in regards to our federal funding issues. Eva is concerned about the recent Medicaid funding cuts and how that would impair our Colorado hospitals. The cuts would reduce payments to Denver Health, the city's safety-net hospital, and cut funds for medical education, reducing low-income patients' access to teaching hospital clinics (CHC, 2008) Denver Health and other hospitals generally get more of a reimbursement than some because they treat Colorado’s uninsured and poor. By cutting the funds, it will cost individual states into the billions of dollars, which will certainly shake their financial stability.

     Colorado is in no position to make up the difference in funding levels as we are wrestling with our own budget problems. Again, the people on Medicaid are primarily children, the disabled, and elderly; they will not find an alternative health care plan. They will become uninsured, but the need will not disappear. Increasing the number of uninsured leads to more uncompensated care for hospitals and providers, which leads to higher premium cost for the insured (Colorado Consumer Health Initiative, 2008). It will also leave it up to the state to figure out how to treat those people who are part of the budget cuts.

     Eva is out campaigning this week against these cuts and the Republican proposal that would force those with existing health insurance through an employer, out in the cold to fend for themselves, leaving millions of people in loss of benefits. This also leaves those with chronic diseases out of insurance too, due to being denied insurance due to pre-existings. “When people don't have health insurance, we all pay the price. Uninsured people put off care until they have to go to the emergency room, but if they can't pay the cost, it gets passed along to those of us who do have insurance” (CHC, 2008).

     The sub-system theory in regards to Sabatier’s model seems to have the greatest relevance to this case study. “The greatest advantage of sub-system throry is that like the alliance it models, it cuts across innumerable dimensions of policy makding” (Lee & Estes, 2003) All of the non-governing entities, such as Eva’s involvement in consumer groups and political advocacy groups have shown how their interactions with each other and with larger governing bodies can communicate and interact. She continues to debate the healthcare reform issue and lack of financing with policymakers to come to a workable policy solution.

References

Colorado Consumer Health Initiative. Medicaid cuts at the Federal level would hurt Colorado. Retrieved April 11, 2008 from http://www.cclponline.org/pubs/medicaidcuts4-06-05.pdf

Colorado for Health Care. Claims DENIED: McCain’s Proposal Would Cost More and Cover Less. Retreived April 20, 2008 from http://www.coloradoforhealthcare.org/

Colorado for Health Care. Medicaid Funding Cuts Would Impair Colorado Hospitals. Retrieved on April 17, 2008 from http://www.coloradoforhealthcare.org

Colorado for Health Care. Project of Service Employees International Union, CtW, CLC. Retreived April 17, 2008 from http://www.coloradoforhealthcare.org/facts/

Lee, P. R. & Estes, C. L. (Eds.). (2003). The nation’s health (7th ed.). Sudbury, MA: Jones & Bartlett

Second Regular Session. Sixty-sixth General Assembly. State of Colorado Premended. A Bill for an Act 101 Concerning Increased Oversight of Health Insurance Rates. http://www.leg.state.co.us/clics/clics2008a/csl.nsf/billcontainers/A9D0C892B8408F21872573680059F8CC/$FILE/1389BA_01.pdf

Author: Annette Cannon, PhD, MA, RN, MSN

     Advanced nursing practice in the state of Colorado is described as a registered professional nurse who is currently licensed to practice in the State of Colorado and who meets the qualifications established by the Nurse Practice Act (CDHCPF, 2008). The Colorado State Board of Nursing (CSBON) identifies those who fall under the title of Advanced Practice Nurse (APN), as being a nurse who is listed in the advanced practice registry. Within the advanced practice registry, a nurse can use the title of APN or can use other titles of CNM (Certified Nurse Midwife), NP (Nurse Practitioner), CNS (Certified Nurse Specialist) or a CRNA (Certified Registered Nurse Anesthetist) if the board has given them authorization to do so.

     To be included into the advanced practice registry, the nurse must meet the requirements. The Nurse Practice Act states requirements for those who were recognized as APNs on and after July 1, 1995 until July 1, 2008, were to either pass a nationally accredited education program for APN or pass a national certification exam. The new requirements, which start on July 1, 2008, state that the nurse must successfully complete a graduate degree in the appropriate specialty to be in the registry. It also notes that those who were in the registry previously, prior to June 30 that have not completed the degree. On all APN applications found on the CSBON website, they now state that a Master’s degree is required on or after July 1, 2008.

     The basic requirements for APNs are the same. It states that all applicants must hold a current and valid Colorado Registered Nurse license, in good standing and without discipline OR a valid multi-state Compact Registered Nurse license in good standing, without discipline (Colorado Division of Regulations, 2008). However, it also states that each application requires its own documentation. Further down on each application, the requirements change to fit the discipline.

     The requirements for the CNS and NP are different from that of the CRNA and CNM, noting a further difference in requirements for the CNS and NP. For example, all applications require the documents submitted, be original and come from the applicant. Both the CNS and NP applications require verification (official transcripts) from a CNS Program or NP Program that was passed successfully or verification of a national certification as a CNS or NP. However, in looking at the scope of practice for these two roles, there is a noted difference.

The application for the CNS identifies the area of practice as the focus of the CNS program or the area in which you are certified. For the NP, it states that the area of practice for the Nurse Practitioner (NP) is the focus of the NP program (for example: FNP, PNP, GNP, WHNP) or the area in which you are certified (CDR, 2008). The CRNS and the CNM applications are different in that they only require official verification of the certification and require that it comes directly to the BON through the mail or email from the certifying body.

The Nurse Practice Act also states what the practice of professional nursing means

 …the performance of both independent nursing functions and delegated medical functions in accordance with accepted practice standards. Such functions include the initiation and performance of nursing care through health promotion, supportive or restorative care, disease prevention, diagnosis and treatment of human disease, ailment, pain, injury, deformity, and physical or mental condition using specialized knowledge, judgment, and skill involving the application of biological, physical, social, and behavioral science principles required for licensure as a professional nurse pursuant to section 12-38-111 (Nurse Practice Act, 2008).

     The practice act also describes what services are included in this practice, such as evaluating health status, health teaching, counseling, therapy, evaluation and treatment. It addresses those nurses whose license has been suspended, revoked or expired and that practice would be unauthorized in these cases.

     The Colorado Department of Health Care Policy and Financing (CDHCPF) gives a definition of a nurse/nurse practitioner as a registered professional nurse who is currently licensed to practice in the State of Colorado and who meets the qualifications established by the Nurse Practice Act and defines a nurse midwife as a registered professional nurse currently licensed to practice in the State of Colorado who meets the following requirements: is certified as a nurse-midwife by the American College of Nurse-Midwives; is authorized under state statute to practice as a nurse-midwife; and whose services are rendered pursuant to the Colorado Medical Practice Act (CDHCPF, 2008). The Nurse Practice Act states that a certified nurse midwife shall practice in accordance with the standards of the American college of nurse-midwives including, but not limited to, having a safe mechanism for consultation or collaboration with a physician or, when appropriate, referral to a physician (Nurse Practice Act, 2008).

     In addition, the Nurse Practice Act covers the scope of prescribing privileges in the state. These rules are more extensive in nature than the others previously mentioned. To obtain prescribing privileges, it is required that an advanced practice nurse who is listed on the advanced practice registry, have a license in good standing without disciplinary sanctions issued pursuant to section 12-38-111, and fulfill requirements established by the board pursuant to this section may be authorized by the board to prescribe controlled substances or prescription drugs as defined in article 22 of this title (Nurse Practice Act, 2008). The Act lists the rules added to this section, which include description of types of persons who can be prescribed prescription drugs and controlled substances and gives some legal coverage of actions under that authority. It also lists what requirements will be provided to the board as evidence, such as the graduate degree in a nursing specialty, additional education requirements for use of substances and drugs, post graduate experience of not less than 1800 hours in a relevant clinical setting within a preceding 5 year period. The nurse must have completed a satisfactory structured plan that is regulated by the Colorado Nurse Practice Act. The plan must prove adequate interaction with the physician, have a written collaborative agreement, experience with specific drugs according to the nurse’s scope of practice, and provide the name and identifier of the physician.

     In conclusion, every state’s Nurse Practice Act has different rules and recognizes certain roles of the nurse. This has historically created confusion for the patient, insurers, and health care professionals. The American Nurses Credentialing Center (ANCC) put new credentials into effect this year and sent notice out to the Boards of Nursing. They previously had credentialed nurses as APRN, BC which meant Advanced Practice Registered Nurse, Board Certified. Now, they have created new credentials which separate and identify the CNS and NP roles. For example, one of the new titles for CNSs would be GCNS-BC, meaning Geontological CNS – Board Certified. An example of a new title for NPs would be FNP-BC, signifying a Family Nurse Practitioner – Board Certified. This was all done to help eliminate the confusion of the roles and to differentiate them.

     This seems to be a more simple solution to the problem than trying to ‘blend the roles’. The journey to the blended CNS/NP role can be long and painful (Hamric, Spross, Hanson, 2005). The CNS role has gone through many changes over the years and almost eliminated, however, now seems in a position to stand on its own. The State Board of Nursing in Colorado has not yet adopted or changed this new credentialing on their website.

References

Colorado Nurse Practice Act. Colorado Revised Statutes. Title 12. Professions and Occupations Article 38 Nurses Effective July 1, 2007.

http://www.dora.state.co.us/nursing/statutes/NursePRacticeAct.pdf

Colorado Division of Registrations (CDR) State Board of Nursing http://www.dora.state.co.us

Colorado Department of Health Care Policy and Financing (CDHCPF). Clinic Services – Certified Health Agencies

http://www.chcpf.state.co.us/HCPF/Pdf_Bin/560clinic-cha.pdf

Hamric, A., Spross, J., & Hanson, C. (2005). Advanced nursing practice: An integrative approach (3nd ed.). Philadelphia: W.B. Saunders.

 Author: Annette Cannon, PhD, MA, RN, MSN

            What is the new skills-based model of organizational leadership? How does this apply to your current organization and professional life?

            Katz’s (1974) seminal article on the skills approach to leadership suggested that leadership (i.e., effective administration) is based on three skills: technical, human, and conceptual. The technical skill derives from specific knowledge or competence in regards to a specific type or area of work, along with knowing the necessary information about the organization and how it operates. In contrast, human skill is more about the ability to work with people, rather than things. It is a set of skills that requires the worker to know about human behavior, techniques in working with groups, effectively influencing others with a high level of ability to relate to others. Last, the conceptual skills are what allow the worker to think through and formulate all types of ideas, which is said to be a skill that can be learned. Basically, this approach implies that there are many people who can become leaders, especially if they can learn from their experiences (Rowe,2007).

           Katz explains that where one is in an organization is determined how important their skills are. How this fits into organizational leadership is that a supervisor would find having technical skills as an important part of their job, whereas upper and middle management would not. Interpersonal skill is needed at all levels of management, whereas conceptual skill may be less important for lower management, it is still important to be promoted to a higher level, so it is to the workers advantage to learn it (Rowe, 2007). This can be applied in my workplace on different levels. As a nurse, you would need a blending of all three skills to perform your job, technical for having the knowledge to perform duties and within guidelines of your license, human is needed to deal with patients and families, along with being able to delegate orders to those within your team, and conceptual in that a nurse must be able to have the whole picture to be able to understand different concepts and approaches to care and diagnosis.

          However, at the same time, the nurse who is supervisor may not physically use the human skill, but must have knowledge of all three to perform the job, while the technician may have to only grasp the human skill and can learn the technical and conceptual. All three are important though for the job to function effectively and everyone to have a leader within.

In the early 1990’s, led by Mark Mumford, the U.S. Army and the Defense Department took on a human performance model to look at competencies, attitudes and what things drive performance. The skills model or Capability model that was developed consisted of three different components: Individual Attributes, Competencies, and Outcome, which all feed into each other. Individual attributes, being different from competencies, were described as intelligence, acquired intelligence, motivation and personality which had an affect on the organization. They noted that competencies were the heart of the model and involved skills at problem solving, social judgment skills and knowledge. Outcomes related to the success of the person towards a task, according to their attributes and competencies. So without the ability to solve problems, or be able to learn knowledge about the task, or use good social judgment skills, the outcome will not be successful.

        On the other hand, you can have all of these competencies and not have the motivation or personality to succeed but can be taught intelligence over time. This applies to my current organization in that these leadership capabilities can be learned over time through experience and education/training. In nursing, everyone is considered capable of learning to be a leader. The focus is on how to be effective by using your knowledge, problem-solving skills and social judgment skills.

        In nursing, it also involves use of evidence-based learning from which to base decisions and nursing practice on. The (heart of the model) skills of the nurse can address many organizational problems, while learning and gaining more experience will allow the nurse to increase their conceptual ideas to address more complex organizational problems. In the professional realm, obtaining more education with a Master’s degree will allow the nurse to work at a higher level within the organization to address the issues, while still needing to maintain skills, knowledge and judgment to be able to guide and teach the other nurses.

References

McClelland, D.C. (1973). Testing for competence rather than for intelligence. American

Psychologist, 28, 1-14.

Northouse, P. (2004). Leadership Practice and Theory. Thousand Oaks, CA.:

Sage Publications. Retrieved January 12, 2009 from http://www.nwlink.com/~donclark/hrd/case/capability_model.html

Rowe, W.G.. (2007). Cases in Leadership. Thousand Oaks, CA: Sage Publications.

Retrieved January 12, 2009 from http://books.google.com/books?id=Rb8totrPHG0C