Probation Manual by olliegoblue27

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									Probation Manual
 For Licensees and Practice Monitors

       State Board of Nursing




                                       1
                     Mission Statement

                State of Colorado
        Department of Regulatory Agencies
            Division of Registrations


Public protection through effective licensure and
enforcement


    Identify and license qualified practitioners, facilities,
    programs, and equipment.

    Conduct investigations and inspections to ensure
    compliance with generally accepted standards of practice,
    conduct, or safety.

    Restrict, suspend or revoke licenses when generally
    accepted standards of practice, conduct or safety are not
    met.

    Communicate effectively to inform, verify, educate and
    advise.

    Administer the regulatory programs efficiently.




                                                                2
                                         Introduction

Nursing practice is evaluated by comparing the professional nurse’s practice to the Standards of
Care, Standards of Professional Performance (“Standards”), and the Nurses’ Code of Ethics for
professional/registered nurses. A practical nurse’s practice is compared to the Nursing Practice
Standards for the Licensed Practical/Vocational Nurse, and the 2001-2005 Nursing Articulation
Model for practical/vocational nurses.

The State Board of Nursing (“Board”) chose to model the probation process on the Standards
and Nurses’ Code of Ethics to ensure consistency, and to create objective measures to evaluate
the Licensee’s practice.

The Probation Manual for Licensees and Practice Monitors (“manual”) is designed to parallel the
probation process. The phases outlined in this manual include:

   •   Phase 1- Orientation to Probation
   •   Phase 2-Evaluation of Licensee’s Practice
   •   Phase 3-Practice Monitor Plan
   •   Phase 4-Monitoring Practice
   •   Phase 5-Termination of Probation
   •   Appendix-Forms for the Probation Process

Each phase in the manual includes instructions on how to complete the corresponding phase of
probation. The required forms for each phase are in the Appendix. The manual also includes
additional information to support the Licensee and Practice Monitor during the probation
process.

The Board expects that the probationary experience will empower both the Licensee and the
Practice Monitor to uphold, promote, and model the Standards, conduct, and ethics of the
nursing profession in their daily nursing practice.




                                                                                               3
    Phase 1
Orientation to Probation




                           4
Phase I-Orientation to Probation

                                      General Information

   •   Colorado has a Public Records Law. As the Stipulation states, it is a document that is a
       permanent public record. The Public Records Act requires the Board to provide a copy
       of the Stipulation to anyone upon request.

   •   The probation manual is available on the Board’s website,
       http://www.dora.state.co.us/nursing. Click on “Complaints and Public Protection”, click
       on “Probation Manual” to download a copy of the manual and click on
       “Appendix” to download probation related forms. The Practice Monitor Plan Template
       and the Practice Monitor Quarterly Report Form will be e-mailed to the Licensee by the
       Board’s Enforcement Specialist when the Stipulation and Final Agency Order, placing
       the Licensee on probation, has been executed. The Practice Monitor can save the
       probation forms in a Word document or download them and complete them by hand.

   •   Reports must be submitted to the Board by the Practice Monitor.

   •   Reports must be typed, printed, or completed electronically.

   •   Reports may be faxed to 303-894-2821, attention: Ann Marie Sonntag. Electronic reports
       may be e-mailed to annmarie.sonntag@dora.state.co.us

   •   If a practice breakdown occurs, the Practice Monitor must contact the Board’s
       Enforcement Specialist within 24 hours to discuss the practice breakdown and the
       Licensee’s ability to practice nursing safely.

   •   The Practice Monitor must also report the practice breakdown in writing to the Board and
       provide documentation from the medical record(s) that verifies that the Licensee made a
       practice breakdown.

   •   The Licensee should use the Stipulation Requirements Tracking Worksheet to ensure
       that s/he is in compliance with the deadlines specified in the Stipulation. The Stipulation
       Requirements Tracking Worksheet is not submitted to the Board.

   •   All forms used in the probation process and referenced in this manual can be found in
       the Appendix.

   •   It is the Licensee’s responsibility to ensure that probationary reports and documents
       required by the Stipulation are submitted to the Board by the Practice Monitor on time. If
       a report is going to be late, the Licensee must contact the Board Enforcement Specialist
       to provide an explanation and to request an extension.

   •   The Practice Monitor Information and Agreement form must be submitted to the Board
       within 72 hours of the effective date of the Stipulation. See Appendix.

   •   The Nursing Employment form must be submitted within 72 hours of the effective date of
       the Stipulation if the Licensee is employed when the Stipulation is signed, or within 72
       hours of commencing or terminating nursing employment. See Appendix.

                                                                                                     5
Phase 1-Orientation to Probation

                                          Preparation

The Licensee and Practice Monitor will:

   •   Review the Nurse Practice Act, specifically sections 12-38-116.5 and 12-38-117, to
       understand the disciplinary process and the grounds for discipline.

   •   Read the Licensee’s Stipulation and Final Agency Order (“Stipulation”) to better
       understand the practice breakdown(s) that resulted in the violation of the Nurse Practice
       Act.

   •   Professional Nurses: Review Nursing: Scope and Standards of Practice (2004),
       American Nurses Association, to understand the Standards of Practice and Standards of
       Professional Performance.

   •   Professional Nurses: Review Code for Nurses with Interpretive Statements (2001),
       American Nurses Association, to understand the ethical standards for nursing.

   •   Practical Nurses: Review the Nursing Practice Standards for the Licensed
       Practical/Vocational Nurse (2001) and the 2001-2005 Nursing Articulation Model.

   •   Review the Standards of Practice for any nursing specialty for which the nurse holds
       certification and/or knowledge, per her/his practice area.

   •   Review the terms of the Stipulation, with the Board Enforcement Specialist to ensure an
       understanding of the requirements of the Stipulation, the role and responsibilities of the
       Licensee, and Practice Monitor.

   •   Complete the Stipulation Requirements Tracking Worksheet to ensure compliance with
       the requirements of the Stipulation. See Appendix. The Stipulation Requirements
       Tracking Worksheet should not be submitted to the Board. It is to be used as a reference
       for the Licensee and the Practice Monitor.




                                                                                                    6
   Phase 2
    Evaluation
        of
Licensee’s Practice




                      7
Phase 2-Evaluation of Licensee’s Practice

       Instructions for Completing the Evaluation of the Licensee’s Nursing Practice

Expectations for the Practice Monitor:

   •   Read the admissions in the Licensee’s Stipulation and Final Agency Order (“Stipulation”)
       to better understand the Licensee’s area(s) of practice breakdown that resulted in the
       violation(s) of the Colorado Nurse Practice Act.
   •   List the practice breakdown identified in the “Practice Breakdown Identified in the
       Admissions” section of the template attached to the Stipulation.
   •   Compare the Licensee’s nursing practice to the Standards of Care and Professional
       Performance and Code of Ethics using Nursing: Scope and Standards of Practice (2004)
       and Code of Ethics with Interpretive Statements (2001) for a professional nurse and
       Nursing Practice Standards for the Licensed Practical/Vocational Nurse and the 2001-
       2005 Nursing Articulation Model for a practical nurse.
   •   Evaluate the Licensee’s nursing practice to determine the cause of the practice
       breakdown.

   •   The evaluation process will include

           o   an interview with the Licensee
           o   direct observation of the Licensee’s nursing practice
           o   an audit of the Licensee’s documentation
           o   a review of patient case studies, and subsequent nursing care plans assigned to
               the Licensee by the Practice Monitor
           o   attendance at cross shift report
           o   informal discussions with patients, family, other members of the health care team
               and nursing colleagues about the Licensee’s nursing practice
           o   A review the Licensee’s self-evaluation

   •   Complete a written evaluation of the Licensee’s practice, as required by the Licensee’s
       Stipulation, within 30 days of the effective date of the Stipulation or within 30 days of
       commencing nursing employment, addressing each of the above referenced data
       collection items on the Evaluation of Licensee’s Nursing Practice form. See Appendix.




                                                                                                   8
Phase 2-Evaluation of Licensee’s Practice:

                      Instructions to the Licensee for the Self-Evaluation

Many Licensees experience the complaint to the Board as a crisis and the subsequent
disciplinary process as a continuation of that crisis. This process is intended to provide positive
change and can result in a higher level of functioning for the individual, if the individual is willing
to do the internal and external shifts in practice as a result of this action.

The Board encourages the RN Licensee on probation to take an honest inventory of her/his
practice, on a regular basis, using the Standards of Care, Standards of Professional
Performance, and the Nurses’ Code of Ethics. The PN Licensee should use the Nursing
Practice Standards for the Licensed Practical/Vocational Nurse and the 2001-2005 Nursing
Articulation Model for her/his practice inventory. During the probationary process the Board
expects the Licensee to collaborate with her/his Practice Monitor and construct a support
system that will result in acceptable practice standards. The Board expects that the probationary
experience will provide the Licensee with the necessary tools to practice according to the
current standards despite any encountered challenges.

In order to complete your self-evaluation, you will be expected to:

    •   Objectively reflect on your nursing practice

    •   Compare your practice to the Standards and Nurses’ Code of Ethics

    •   Write down the results of your self-evaluation

    •   Share your self-evaluation with your Practice Monitor

    •   Use the results of your self-evaluation to contribute to the Focused Action Plan in the
        Practice Monitor Plan




                                                                                                          9
    Phase 3
Practice Monitor Plan




                        10
Phase 3-Practice Monitor Plan

                  Instructions for Completing the Focused Action Plan

The Practice Monitor Plan (“PMP”) is a collaborative effort between the Practice Monitor
and the Licensee that is completed after the Practice Monitor’s evaluation of the
Licensee’s nursing practice and after the Licensee has completed a self-evaluation. The
PMP should be a fluid document that is modified, as appropriate, during the probation.
Please note that the Licensee’s nursing practice must be guided by the Standards of
Care. If using a facility policy, the Licensee should identify the Standards of Care
covered in the policy.

The PMP is due 30 days from the effective date of the Stipulation and Final Agency
Order (“Stipulation”) or 30 days from the commencement date of nursing employment.
The Licensee’s current job description must be submitted with the PMP. Both
documents must be submitted directly to the Board by the Practice Monitor.

Attached to the Stipulation is a PMP template based on the Standards of Care (RN) or
the Nursing Practice Standards and the 2001-2005 Nursing Articulation Model (LPN),
approved by the Board specific to the Licensee’s practice breakdown. The Practice
Monitor and Licensee are expected to use the basic PMP in monitoring the Licensee’s
practice. Please note that number four (4) of the Nursing Practice Standards for the
Licensed Practical/Vocational Nurse does not apply to the scope of practice of a
Licensed Practical Nurse in Colorado. The 2001-2005 Nursing Articulation Model and
the Nurse Practice Act describe the scope of practice for a Licensed Practical Nurse in
Colorado.

Based on the practice breakdown(s) identified in the Stipulation, the Licensee’s self-
evaluation, the Practice Monitor’s evaluation of the Licensee’s practice, the likely
cause(s) of the Licensee’s practice breakdown can be identified. The Focused Action
sections of the PMP outline the actions to be taken by the Licensee and the Practice
Monitor, to remediate the practice breakdown and to monitor practice.

The Board has identified actions taken by Licensees and Practice Monitors in the past
that have been successful in remediating practice. See Suggested Focused Actions to
Remediate Practice Breakdowns and Suggested Focused Actions to Monitor Practice in
the Phase 3 section of this manual. The Practice Monitor and the Licensee may modify
the suggested actions or use other actions not listed.

                        Components of the Practice Monitor Plan

Practice Breakdown Identified in the Stipulation: Read the section of the Stipulation that
describes the events that lead to the Board’s action and identify the practice breakdown.
(i.e.: Failure to assess, intervene and evaluate a patient after a fall; Administered Ativan
1 mg. rather than .5 mg, failed to administer correct dosage of medication)

Outcome of the Probation: This is the same for all Licensees on probation, specific to
the type of nursing license, and identified in the template.
                                                                                          11
Probation Standards: These are the same for all Licensees on probation, specific to the
type of nursing license, and identified in the template.

Required Actions to Remediate Practice Breakdown: The required actions to remediate
practice breakdown are pre-determined for Licensees and are identified in the PMP
template.

The Board has determined minimum standards, based on common interventions that
assist Licensees in adhering to the Standards of Care.

Focused Actions to Remediate Practice Breakdown: The Practice Monitor and Licensee
identify focused actions necessary to remediate the practice breakdown based on the
Practice Monitor’s evaluation, the Licensee’s self-evaluation and the type of practice
breakdown. The Practice Monitor documents the focused actions on the Practice
Monitor Plan template. For examples, please see Suggested Focused Actions to
Remediate Practice Breakdown in the Phase 3 section of this manual.

Required Actions to Monitor Practice: The required actions to monitor practice are pre-
determined for Practice Monitors and are identified in the PMP template.

The Board compiled common practices of nursing supervisors who have successfully
monitored or supervised Licensees on probation.

Focused Actions to Monitor Practice: The Practice Monitor identifies focused actions
necessary to monitor the Licensee’s practice based on the Practice Monitor’s
evaluation, the Licensee’s self-evaluation and the type of practice breakdown. The
Practice Monitor documents the focused actions on the Practice Monitor Plan template.
For examples, please see Suggested Actions to Monitor Practice in the Phase 3 section
of this manual.

Signatures and Date

The signatures of the Licensee and Practice Monitor, as well as the date the PMP was
signed are required.




                                                                                       12
Phase 3-Practice Monitor Plan


             Suggested Focused Actions to Remediate Practice Breakdowns

The following are suggested focused actions for the Licensee to take to remediate
practice breakdown(s) and to ensure that the Licensee is using the Standards of Care to
guide the Licensee’s practice. The Practice Monitor and Licensee may use any actions
on this list, modify them, or create their own.

   •   Read professional literature articles or professional books as assigned by the Practice
       Monitor.

   •   Complete a class or continuing education credits as assigned by the Practice Monitor.

   •   Collaborate with a mentor to assist the Licensee in developing skills to ensure good
       judgment related to problem solving, communication, etc.

   •   Develop and present an in-service for facility staff on the practice breakdown, based on
       current research and Standards.

   •   Develop and present an in-service for facility staff on the Standards of Care, Standards
       of Professional Performance, and Code of Ethics for nurses, or, for practical nurses, on
       the Nursing Practice Standards for the Licensed Practical/Vocational Nurse and 2001-
       2005 Nursing Articulation Model.

   •   Keep a journal related to how the Licensee is using the Standards of Practice and
       Standards of Professional Performance and Code of Ethics to guide the Licensee’s
       practice or, for practical nurses, on the Nursing Practice Standards for the Licensed
       Practical/Vocational Nurse and 2001-2005 Nursing Articulation Model. Journal contents
       to be reviewed during weekly meetings with the Practice Monitor.

   •   Develop a “safety to practice self check-in” in which the Licensee reviews her/his
       physical, emotional, intellectual, and mental well being before each shift, and in some
       cases, before providing care for a patient. If the safety to practice inventory indicates that
       the Licensee is not safe to practice, then the Licensee should not work until s/he is safe
       to practice.

   •   Develop a self-care plan to address issues identified in the Licensee’s self evaluation,
       e.g., stress management, interpersonal relationships, rest, etc.

   •   Initiate a nursing process group at the workplace to discuss the standards of care,
       standards of professional performance and code of ethics.

   •   Appropriately document all assessments in a timely manner and review the
       documentation with the Practice Monitor.

   •   Write process recordings on nurse-patient interactions, to be reviewed with the Practice
       Monitor during the weekly practice review meeting.


                                                                                                  13
•   Document pain assessments prior to and after administering narcotics.

•   Assure proper documentation and wastage of controlled substances.

•   Interview other nurses, frequency to be documented in the Practice Monitor Plan, dialog
    about how the nurse uses the Standards of Care to guide her/his practice and how s/he
    avoids the practice breakdown that led to the Licensee’s disciplinary action.

•   Review the daily medication pass with Practice Monitor or designee, frequency to be
    determined by the Practice Monitor, before administering medications.

•   Develop and implement a professional self-care contract, identifying strengths and areas
    in which professional development would be beneficial. The contract should include
    goals and time frames. The Licensee should discuss the plan with her/his Practice
    Monitor and schedule an evaluation of the professional self-care plan with the Practice
    Monitor at regular intervals. For example, goals could include obtaining a professional
    certification, participation in quality improvement activities, becoming active in a
    professional organization, etc.




                                                                                          14
Phase 3-Practice Monitor Plan

Suggested Focused Actions to Monitor Practice

The following are suggested actions for Practice Monitors to take to monitor the Licensee’s
practice. The Practice Monitor and Licensee may use any actions on this list, modify them, or
create their own.

   •   Audit documentation regarding the practice breakdown and the Standards of Care,
       frequency to be documented in the Practice Monitor Plan.

   •   Audit documentation regarding administration of controlled substances, frequency to be
       documented in the Practice Monitor Plan.

   •   Observe Licensee providing direct patient care.

   •   Obtain informal feedback from patients and staff on Licensee’s nursing care.

   •   Observe Licensee’s interactions with other members of the health care team.

   •   Observe for “Warning Signs of Chemical Dependency.” See Appendix.

   •   Assign Licensee professional literature articles to read that pertain to the practice
       breakdown and discuss during weekly practice review meetings.

   •   Assign Licensee an in-service, to be given to facility staff, on the practice breakdown.

   •   Assign Licensee an in-service, to be given to facility staff, on the standards of care and
       professional performance, and the code of ethics.

   •   Review and provide feedback regarding journal entries during weekly practice review
       meetings.

   •   Assign the Licensee to interview other nurses about how they prevent the practice
       breakdown from occurring, how they use the Standards of Care to guide their nursing
       practice and discuss during weekly practice review meetings.

   •   Discuss a legal/ethical situation that arose on the unit during the week previous to the
       weekly practice review meeting.

   •   Require Licensee to prepare a case study on one patient, assigned by the practice
       monitor, and review the case study for how the Licensee is practicing to the standards of
       care. Provide feed back during weekly practice review meetings.

   •   Assign Licensee to observe an expert nurse providing patient care. Review the
       Licensee’s observations during the weekly practice review meetings.

   •   Require Licensee to attend a course or continuing education classes that pertain to
       remediation of the practice breakdown. Obtain feedback from the course instructor on
       the Licensee’s participation and likelihood of incorporating the new knowledge into
       practice.
                                                                                                    15
•   Assign a mentor to assist the Licensee in developing skills to ensure good judgment
    related to problem solving, communication, assertiveness, etc. Obtain feedback from the
    mentor.

•   Require Licensee to keep a journal related to how the Licensee is using the standards of
    practice and professional performance, and code of ethics to guide the Licensee’s
    practice. Review at weekly practice review meeting.

•   Assign process recordings on nurse-patient interactions. Review at weekly practice
    review meeting

•   Assign the Licensee to review the facility policy that relates to the practice breakdown
    and correct the policy, if necessary, to reflect the Standard of Care.




                                                                                               16
  Phase 4
Monitoring Practice




                      17
Phase 4-Monitoring Practice

               Instructions for Completing the Practice Monitor Report

It is the responsibility of the Licensee to ensure that all reports are submitted pursuant to the
schedule determined by the Board.

The Practice Monitor Report is due quarterly, i.e. 90 days from the effective date of the
Stipulation, or 90 days from the commencement of nursing employment.

The Practice Monitor is required to submit the report directly to the Board via US Mail, facsimile,
or e-mail.

The Practice Monitor Report, along with the Practice Monitor Plan, should be used as a tool
during the weekly practice review meetings. Portions of the Practice Monitor Report can be
completed during the weekly practice review meetings.

Documents that support the Practice Monitor’s statements may be submitted with the Practice
Monitor Report, e.g. in-service outline, examples of medical record documentation, etc. The
Licensee and Practice Monitor should keep a folder of the documents that will be submitted with
the Practice Monitor Report and of notes that will assist the Practice Monitor in writing the
report.

The Practice Monitor should review the report with the Licensee before mailing it to the Board,
and the Licensee should make a copy of the report for the Licensee’s personal files.

Please ensure that the report is legible. The Practice Monitor may scan the report form into a
word document or PDF document and type the report, using whatever space is necessary. If
handwriting the report, please print to ensure the accuracy of the information in the report. If
additional space is necessary to complete any section of the report, please use a plain sheet of
white paper to print the additional information. Write the Licensee’s name on the paper as well
as the number of the report section.

The Practice Monitor must notify the Board’s Enforcement Specialist if it is expected that the
report will be late. An extension will be given if the explanation for the late report is reasonable.

See Appendix for the Quarterly Practice Monitor Report form.




                                                                                                    18
     Phase 5
Termination of Probation




                           19
Phase 5-Termination of Probation

             Instructions for Submitting Termination from Probation Requests

To complete probation, the Stipulation requires that a request for termination of probation be
submitted to the Board by the Practice Monitor and the Licensee. The decision to request
termination of probation must be based on a collaborative review of the Licensee’s successful
completion of the Practice Monitor Plan by the Licensee and the Practice Monitor.

The Practice Monitor’s Recommendation for Termination of Probation form must accompany the
scheduled Practice Monitor Report and include the following:

   •   The Practice Monitor’s evaluation of the Licensee’s practice and successful completion
       of the Practice Monitor Plan
   •   Specific examples of how the Licensee’s practice has improved.
   •   The Practice Monitor’s opinion about the Licensee’s ability to practice nursing safely
       without monitoring and a supporting rationale.
   •   Other information that the Practice Monitor deems appropriate.

The Licensee’s Request for Termination of Probation must include the following:

   •   The Licensee’s statement of how her/his practice is meeting the expected outcome of
       the Practice Monitor Plan.
   •   What changes the Licensee has made in her/his nursing practice as a result of the
       Practice Monitor Plan.
   •   What strategies the Licensee plans to use in the future to avoid practice breakdown.
   •   Other information as the Licensee deems appropriate.

Both the Practice Monitor’s Recommendation for Termination of Probation form and the
Licensee’s Request for Termination of Probation form must be used to provide the Board with
the above reference information. These forms are available electronically on the Board’s
website.




                                                                                                 20
Appendix




           21
                                   Stipulation Requirement Due Dates

Licensee Name:           ______________________________________________________

Effective Date of the Stipulation:               ___________________
Date of Commencement of Employment:              ___________________

    FORM or NOTIFICATION              REQUIREMENT TIME              EXAMPLE for an       DUE DATE for
                                           FRAME                    effective date of   this Stipulation
                                                                        7/1/2007
Commencement/Termination           Due within 3 working days    7/4/2007
from Employment (FORM)             of effective date or the
                                   Stipulation or the date of
                                   employment
                                   commencement or
                                   termination
Practice Monitor Information and   Due three (3) days after     7/4/2007
Agreement (FORM)                   the effective date of the
                                   Stipulation or three(3)
                                   days after commencement
                                   of employment
Job Description (COPY)             Due 30 days after the        8/1/2007
                                   effective date of the
                                   Stipulation or 30 days
                                   after the commencement
                                   of employment
Practice Monitor Evaluation        Due 30 days after the        8/1/2007
(FORM)                             effective date of the
                                   Stipulation or 30 days
                                   after the commencement
                                   of employment
Practice Monitor Plan (FORM)       Due 30 days after the        8/1/2007
                                   effective date of the
                                   Stipulation or 30 days
                                   after the commencement
                                   of employment
Quarterly Practice Monitor         Due 90 days after the        10/1/2007
Report (FORM)                      effective date of the        1/1/2008
                                   Stipulation and every        4/1/2008
                                   quarter thereafter; or 90    7/1/2008, etc.
                                   days after the
                                   commencement of
                                   employment and every
                                   quarter thereafter
Recommendation for                 Pursuant to the length of    7/1/2009 if 2 year
Termination (Practice Monitor)     probation required by the    probation and all
and Request for Termination of     Stipulation, submit with     reports were accepted
Probation (Licensee) (FORMS)       last Quarterly Practice      by the Board
                                   Monitor Report
Practice Monitor Information and   Due three (3) days after     7/4/2007
Agreement (FORM)                   the effective date of the
                                   Stipulation or three(3)
                                   days after commencement
                                   of employment




                                                                                                       22
                                       OTHER DUE DATES

For change in the Practice Monitor
    • Notify the new Practice Monitor of the Stipulation within 24 hours of the Practice Monitor
       change
    • Practice Monitor Information and Agreement form is due within 7 days of the Practice
       Monitor change

Change of Address and/or Phone Number
   • Due within 3 days of the change

Relocation to Another State
   • Due within 30 days of the change




                                                                                                   23
Phase 1-Orientation to Probation

                         Practice Monitor Information and Agreement*

Licensee’s Name: ___________________________________

Practice Monitor’s Name: _________________________________

Practice Monitor’s business phone number: __________________
       cell phone number: ____________________
       pager number: ____________________
       home phone number: ____________________

Practice Monitor’s Home Address:       _____________________________________
                                       _____________________________________

Facility Name:         ______________________________________

Facility Address:      ___________________________________
                       ___________________________________

Facility Phone Number: _______________________

Does the Facility have any current deficiencies with the Department of Public Health and the
Environment? No ____ Yes ____ If yes, please explain any deficiencies pertaining to patient care.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Practice Monitor’s states of licensure and license number in each state
           STATE                             LICENSE #                 STATUS (Active/Expired)



I do _____, do not _______have a personal relationship with the license whose practice I will be
monitoring.

I do_____, do not _____ have supervisory experience that qualifies me to serve as a Practice
Monitor. Please attach your resume or curriculum vitae.

***************************************************************************************************
By my signature, I certify that I have read the Licensee’s Stipulation and Final Agency Order
(“Stipulation”) and agree to monitor the Licensee’s nursing practice in accordance with the terms
of the Stipulation and pursuant to the Standards of Care, Standards of Professional Performance,
and Nursing Code of Ethics (RN) or Nursing Practice Standards for the Licensed
Practical/Vocational Nurse (LPN). I understand that I am to provide the Board with written
notification of termination of this agreement within 72 hours of the termination. I understand that
if I aid or knowingly permit the Licensee to violate the terms of the Stipulation, I may be
sanctioned pursuant to section 12-28-117 (1)(e) of the Nurse Practice Act.

____________________________________                  ____________________
Practice Monitor’s Signature                          Date

*This form is due 3 working days after the effective date of the Stipulation or
3 working days after the commencement of employment.


                                                                                                   24
Phase 2-Evaluation of Licensee’s Nursing Practice

Evaluation of Licensee’s Nursing Practice*

Licensee Name ___________________________________

Practice Monitor Name ________________________________

Date ______________

                             The Evaluation Includes:

   •   An interview with the Licensee
   •   Direct observation of the Licensee’s nursing practice, to include a review of the
       Licensee’s documentation
   •   An assessment of how the Licensee functions as a member of the health care
       team
   •   A review of the Licensee’s self assessment
   •   A final conclusion about the identified cause of the Licensee’s practice
       breakdown that resulted in the Stipulation

Practice Monitor’s Interview with the Licensee:

1. What is the Licensee’s nursing education and practice experience? (Please submit the
Licensee’s resume or curriculum vitae with the evaluation.) Please ask the Licensee how
his or her various work settings has affected the Licensee (i.e. trauma, ICU, ED, LTC,
etc.).




2. What actions has the Licensee taken to maintain competency? For example,
continuing education, self-study, etc.




3. What is the Licensee’s statement of what contributed to her/his practice breakdown?
Licensee’s description should include, but not be limited to the following:
    • why the Licensee’s practice did not meet the current expected Standards of Care
    • practice setting
    • role and responsibility at the time of the practice breakdown
    • staffing for the shift when the practice breakdown occurred
    • acuity of the patients on unit at the time of the practice breakdown
    • systems issues that may have contributed to the practice breakdown
    • relationship with Licensee’s supervisor, patient’s physician, co-workers, and
      patient at the time of the practice breakdown
    • cultural or gender issues
    • use of controlled substances at the time of the practice breakdown
    • number of hours on duty prior to the practice breakdown

                                                                                           25
   •   stressors that the Licensee was experiencing at the time of the practice
       breakdown (at work and at home)
   •   collaboration/problem solving techniques
   •   what was the Licensee’s understanding of the Standards of Care at the time of the
       practice breakdown
   •   Licensee’s behavior when the practice breakdown was discovered, i.e. did s/he
       take responsibility, tried to cover up the practice breakdown
   •   history of previous practice breakdown and Licensee’s response

(Please write the results of the interview on a separate document and attach it to this
form.)


Practice Monitor’s Direct Observation of the Licensee’s Nursing Practice and
Documentation

Describe the following:

1. How does the Licensee form therapeutic nurse-patient relationships?




2. How does the Licensee use the Standards of Care, Standards of Professional
Performance and the Nursing Code of Ethics for professional nurses or Nursing Practice
Standards for the Licensed Practical/Vocational Nurse to guide her/his nursing practice?
For registered nurses, require the Licensee to complete a case study of a patient and a
subsequent nursing care plan, based on the Standards of Care. For practical nurses,
evaluate how the Licensee contributes to the nursing plan of care for a patient




3. How does the Licensee communicate with patients, families and other members of the
health care team?




                                                                                          26
4. Describe how the Licensee educates patients and families about health care topics or
the patient’s medical condition.




5. How does the Licensee administer medications, including narcotics? Does the
Licensee use the 7 Rights when administering medication?




6. How does the Licensee’s documentation meet the Standards of Care. For example, did
the Licensee document on both the Medication Administration Record and the Narcotic
Log when administering a narcotic? Does the Licensee document a pain assessment
prior to and after administering narcotics for pain? How does the Licensee describe a
change in the patient’s condition? Does the Licensee transcribe orders accurately?




7. How does the Licensee complete a head to toe assessment of a patient?




8. How does the Licensee respond in emergencies? For example, a fall, a sudden critical
change in condition, a COR.




                                                                                      27
9. How does the Licensee advocate for patients?




10. If the Licensee is an RN-how does the Licensee (RN) demonstrate use of the nursing
process?




11. If the Licensee is an LPN-how does the Licensee contribute to the nursing process or
plan of care?




12. Does the Licensee demonstrate the following:
  Please explain each answer.

   Critical thinking skills                   yes no



   Intact memory                              yes no



   Good nursing judgment                      yes no



   Good problem solving skills                yes no



   Ability to reflect on practice             yes no


                                                                                      28
   Good decision making skills                  yes no



   Good time management/ organizational skills           yes no




13. If the Licensee is a professional nurse, how does the Licensee’s nursing practice,
including documentation, currently meet the Standards of Care? Please explain.




14. If the Licensee is a practical nurse, does the Licensee’s nursing practice, including
documentation, currently meet the Practice Standards for the Licensed
Practical/Vocational Nurse? Please explain.




Assessment of how the Licensee Functions as a Member of the Health Care Team:

1. Describe how the Licensee communicates during shift report




with other team members




with patients/families


                                                                                            29
2. Describe how the Licensee functions in multi-disciplinary team meetings.




Review of the Licensee’s Self-Assessment

1. What information was obtained from the Licensee’s self-assessment that was not
obtained during the evaluation of the Licensee?




2. What is the Licensee’s identified concerns in the Licensee’s self-assessment?




3. How was the Licensee’s identified concerns incorporated into the conclusions of the
evaluation?




Conclusion (What are the identified causes of the Licensee’s practice breakdown based
on the information gathered?)




___________________________________
Practice Monitor Signature                        Date

___________________________________               ______
Licensee Signature                                 Date

* This form is due 30 days after the effective date of the Stipulation or 30 days from the
commencement of nursing employment.
Phase 2-Evaluation of Licensee’s Practice:

Licensee Self Evaluation Tool



                                                                                             30
It is the Licensee’s responsibility to evaluate what practice/professional performance issues
contributed to the practice breakdown area(s) resulting in disciplinary action by the Board and to
take appropriate corrective actions to decrease the risk of future practice problems

                                   Standards of Care Issues

The Board has identified the following practice behaviors that may contribute to nursing practice
problems:

The Licensee should address each of the following behaviors in relation to the Licensee’s
practice. Please explain each answer.

       Failing to practice nursing using the Standards of Care and Standards of Professional
       Performance



       Assuming responsibility for patient care with an inadequate orientation to the practice
       setting



       Assuming responsibility for patients who require nursing care that is beyond the
       Licensee’s nursing knowledge, judgment and skills



       Accepting responsibility for a unit when the acuity of the patients was high and the
       staffing was inadequate



       Failing to collaborate with colleagues and other members of the health care team



       Engaging in “work arounds”-This is a practice behavior that results in the Licensee
       attempting to comply with requests of the system while doing what the Licensee believes
       is best for the patient. An example is borrowing a medication from one patient to give to
       another patient because the pharmacy delivery system is not working properly and has
       not delivered the medication to the patient for whom it was prescribed.



       Failing to adequately communicate with physicians




                                                                                                 31
       Feeling confusion about the Licensee’s role and responsibility



       Allowing stress to affect the Licensee’s nursing judgment



       Demonstrating ineffective problem solving skills

If the Licensee has identified any of the above-described practice behaviors, the
Licensee may be at continued risk for practice breakdown. The Licensee should address
these behaviors with the Practice Monitor when collaborating on the Practice Monitor
Plan.

Standard of Professional Performance Issues/or for the LPN, Legal and Ethical Issues:

It is the Licensee’s responsibility to evaluate what professional performance issues contributed
to the practice breakdown and to take appropriate corrective actions to decrease the risk of
future practice breakdown.

The Licensee should answer yes or no as to whether the Licensee believes any of the
following issues/behaviors have affected the Licensee’s professional performance. If the
answer is yes, please explain what the affect has been on the Licensee’s nursing
practice.

      Yes     No      Lack of ongoing continuing education



      Yes      No     Failure to evaluate my nursing practice by seeking supervision, engaging
   in peer review, or conducting a self-evaluation of my nursing practice by comparing it to the
   Standards of Care



     Yes      No     Lack of healthy self-care skills, i.e. inability to say “no” when it exceeds
   your physical capabilities?



      Yes     No      Lack of assertiveness skills.



     Yes        No      Symptoms from personal health conditions that may interfere with my
   ability to safely practice nursing.


       Yes     No     Hesitation to contact or report findings to persons in “authority,” especially
   if they have been angry in the past for doing so. (i.e. physicians, supervisor, etc.)

                                                                                                    32
     Yes     No      Personal issues or distractions outside of the workplace that may affect
   my professional performance (i.e. divorce, financial problems, health issues, etc.)



      Yes     No     Inadequate sleep on a routine basis.



      Yes      No    Use of drugs, including but not limited to controlled substances and/or
   alcohol, in a manner that has caused me negative consequences.



     Yes      No    Conflict with nursing colleagues, supervisor and/or other members of the
   health care team




Conclusion (What are the causes of my practice breakdown that I have identified based
on the information gathered?)




___________________________________
Practice Monitor Signature                                  Date

___________________________________                ______
Licensee Signature                                  Date

* This form is due 30 days after the effective date of the Stipulation or 30 days from the
commencement of nursing employment.

Note to the Practice Monitor: If the Licensee has engaged in the above-described behaviors, the
Licensee may be at continued risk for practice problems. The Licensee should address these
behaviors with the Practice Monitor when collaborating on the Practice Monitor Plan.




                                                                                                33
Phase 5-Termination of Probation
                           Request for Termination


Licensee Name: _________________________________

Practice Monitor Name: _________________________________

Date: __________________________


I have successfully completed the Practice Monitor Plan in the following ways:




I have made the following changes in my practice to ensure I am meeting the Standards
of Care when I practice nursing:




The following are the strategies I have developed for ensuring that my nursing practice is
guided by the Standards of Care:




Comments:




________________________________________________________
Licensee Signature                   Date




                                                                                        34
Phase 5-Termination of Probation


Recommendation for Termination of Probation


Licensee Name: _____________________________

Practice Monitor Name: _______________________________

Date: _________________


Please provide your evaluation of the Licensee’s current nursing practice and describe how the
Licensee’s practice has changed/improved in response to the Practice Monitor Plan-use specific
examples:




Please list your reasons for supporting the Licensee’s termination of probation at this
time:




In your opinion, is the Licensee currently safe to practice nursing with reasonable skill
and safety without continued monitoring? Yes         No
Explain:




Other comments:




__________________________________________
Practice Monitor Signature    Date


                                  Nursing Employment*
                                                                                            35
_________________________________________
Licensee’s Name

Type of Change:

       Termination of Employment

       Date of Change: ___________________

       Former Employer: ___________________________________

       Former Supervisor: __________________________________



       Notification of Employment or

       Commencement of Employment

       Date of Employment: _________________

       Employer’s Name: _______________________________________

       Address: _______________________________________________

                 _______________________________________________

       Phone Number: (       )___________________________

       Licensee’s Position: _______________________________________

       Supervisor’s Name: _______________________________________

       Supervisor’s Phone Number: ___________________________




____________________________________________________________________________
Licensee’s Signature                                             Date


*This form must be submitted to the Board within 72 hours of the commencement of or
termination from employment or within 72 hours of the effective date of the Stipulation if the
Licensee is employed as a nurse.




                                                                                                 36
                                       Resources

Ann Marie Sonntag, Enforcement Specialist
Address: Colorado Board of Nursing
          1560 Broadway, Suite 1370
          Denver, CO 80202
Phone Number: 303-894-2416
E-mail: annmarie.sonntag@dora.state.co.us
Fax: 303-894-2821 (attention: Ann Marie Sonntag)

The Nurse Practice Act, Board rules, and policies can be downloaded from the Board’s
website, www.dora.state.co.us/nursing.

American Nurses Association
8515 Georgia Avenue, Suite 200
Silver Springs, MD 20901
Phone Number: 301-628-5000
Toll Free: 1-800-274-4ANA (4262)
www.nursingworld.org

National Federation of Licensed Practical Nurses, Inc.
605 Poole Drive
Garner, NC 27529
Phone Number: 919-779-0046
Fax Number: 919-779-5642
www.nflpn.org

Colorado Nurses Association
1221 South Clarkson Street, #205
Denver, CO 80210
Phone Number: 303-757-7483
CNA@nurses-co.org

Colorado Federation of Licensed Practical Nurses
Gretchen McIntosh
7013 Winona Court
Westminster, CO 80030-5828

Colorado Center for Nursing Excellence
5290 East Yale Circle
Denver, CO 80222
Phone Number: 303-715-0343
info@coloradonursingcenter.org

Work, Education and Lifelong Learning Simulation Center (WELLS Center)
1703 Quentin Street
Aurora, CO 80045
Phone Number: 303-326-0674 x10
wellsadmin@coroadonurseingcenter.org



                                                                                       37
Nursing Peer Health Assistance or Nurse Alternative to Discipline Program
Currently:
Colorado Nurse Health Program
44 Union Blvd., Suite 505
Lakewood, CO 80228
Phone Number: 303-716-0212, ext. 102
Toll Free: 1-877-716-0212, ext. 102
www.cnhp.com

2001-2007 Nursing Articulation Model
www.uchsc.edu/ahec/cando




                                                                            38
                 Warning Signs of Chemical Dependency*

Listed below are some signs and symptoms that may indicate a nurse is experiencing
problems with drugs or alcohol and needs to be referred for help.

Job Performance
      Inconsistent work quality, alternate periods of high and low efficiency.
      Increased difficulty meeting deadlines.
      Unrealistic excuse for lowered work quality.
      Job shrinkage, doing the minimum work necessary for the job.
      Sloppy or illogical charting.
      An excessive number of mistakes or errors of judgment in patient care.
      Long breaks or lunch hours.
      Frequent or unexplained disappearances during the shift.
      Lateness for work and/or returning from lunch.
      Volunteering to work overtime despite difficulty showing for scheduled shifts.
      Excessive use of sick time, especially following days off.
      Absences without notice or last minute requests for time off.
      Repeated absences due to vaguely defined illnesses.

Behavior, Attitude, Mood, and Mental Status
      Wide mood swings from isolation to irritability and outbursts.
      Difficulty in concentration.
      Marked nervousness on the job.
      Decrease in problem solving ability.
      Diminished alertness, confusion, frequent memory lapses.
      Difficulty in determining or setting priorities.
      Isolates from others, eats alone, avoids informal staff get-togethers, or requests
      transfer to night shift.
      Unwillingness to cooperate with co-workers or inability to compromise.
      Avoids contact with supervisor.
      Over reaction to real or imagined criticism.
      On the unit when no on duty.

Medication Centered Problems
      Consistently volunteering to be the medication nurse.
      Offering to hold narcotic keys during report.
      Volunteering to work with patients who receive regular or large amounts of pain
      medication.
      Frequently found around medication room or cart.
      Insists on administering drugs via IM when other nurses give it PO to the same
      patient.

                                                                                           39
        Patient charting reflects excessive us of PRN medications compared to shifts
        when other nurses are assigned to the same patient.
        Patients complaining of little or no relief from pain medications when nurse is
        assigned to patient.
        Use of two smaller tablets of medication to give prescribed dose (two 30 mg
        codeine tablets instead of one 60 mg tablet.
        Use of larger than necessary dose, wasting the rest (100 mg Demerol when
        patient is to receive only 50 mg).
        Missing drugs or unaccounted doses.
        Frequently reporting spills, wastage or breakage of medications.
        Charting errors include medication errors.
        Defensive when questioned about medication errors.




*Adapted from Hughes, TL, Smith, LL, Is Your Colleague Chemically Dependent? Am J Nurs 94(9): 31-35, 1994,
and Catanzarite, A, Managing the Chemically Dependent Nurse: A Guide to Identification, Intervention, and
Retention, AHA Books, 1992.




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