Using a Nursing Student Conduct Committee to Foster Professionalism among Nursing Students Katherine Kaby Anselmi PhD, JD, FNP-BC, WHNP-BC, Mary Ellen Smith Glasgow PhD, RN, FAAN, Stephen F. Gambescia PhD, MEd, MBA, MHum, MCHES PII: DOI: Reference:
S8755-7223(14)00070-2 doi: 10.1016/j.profnurs.2014.04.002 YJPNU 828
To appear in:
Journal of Professional Nursing
Received date:
30 June 2013
Please cite this article as: Anselmi, K.K., Glasgow, M.E.S. & Gambescia, S.F., Using a Nursing Student Conduct Committee to Foster Professionalism among Nursing Students, Journal of Professional Nursing (2014), doi: 10.1016/j.profnurs.2014.04.002
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Using a Nursing Student Conduct Committee to Foster Professionalism among Nursing Students
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by
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Anselmi, K.K., Glasgow, M.E., & Gambescia, S.F. Submitted to Journal of Professional Nursing—30 June 2013 Revised and Resubmitted 22 January 2014
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JPN-D-13-00117
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Key words: student conduct; professionalism; patient safety
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Katherine Kaby Anselmi, PhD, JD, FNP-BC, WHNP-BC Assistant Dean for Accreditation/Regulatory Affairs & Online Innovation Associate Clinical Professor, Division of Nursing Drexel University College of Nursing and Health Professions 1505 Race Street Philadelphia, PA 10192 (USA) 215-762-8545 phone [email protected]
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Mary Ellen Smith Glasgow, PhD, RN, FAAN Dean & Professor School of Nursing Duquesne University of the Holy Spirit 540B Fisher Hall Pittsburgh, PA 15282 (USA) 412-396-6554 phone [email protected] Stephen F. Gambescia, PhD, MEd, MBA, MHum, MCHES (Corresponding author) Professor, Health Services Administration Assistant Dean of Academic and Student Affairs Drexel University College of Nursing and Health Professions 1505 Race Street Philadelphia, PA 10192 (USA) 215-762-8405 phone [email protected]
ACCEPTED MANUSCRIPT
Abstract
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This article explains how a university nursing program in the United States created and
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implemented a nursing student Code of Conduct and a faculty-led Nursing Student Conduct Committee to review and adjudicate violations of academic or professional misconduct. The
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need for and role of the Nursing Student Conduct Committee in providing substantive and fair
NU
due process is illustrated with two cases. Professional misconduct has been associated with preventable error and patient safety, and is of great concern to nurse educators who are entrusted
MA
with producing the next generation of nursing professionals. Accountability and consequences for violations of professional standards must be an integral part of the nursing education
ED
curriculum throughout the world to ensure quality and safety and mitigate the adverse effects of
PT
nursing error. Given the professional and patient safety implication of such violations, the authors believe it is prudent to have nursing programs adjudicate nursing majors’ professional
AC
CE
violations as an alternative or supplement to the general university judicial board.
ACCEPTED MANUSCRIPT
Using a Nursing Student Conduct Committee to Foster Professionalism among Nursing
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Students
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Nurse educators throughout North America and Europe are concerned with providing a high quality competence-based curriculum and especially one that emphasizes patient safety and
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professional responsibility (Dante, A., Petrucci, C., & Lancia, L., 2013; Killam, L.A., Mossey, S.
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Montgomery, P., & Timmermans, K..E., 2013; Szczerbinska, K. E, Topor-Madry, R., & Niedzwiedzka, B., 2011). Successful nursing student academic performance is contingent upon
MA
an array of variables, which include both academic integrity and ethical and professional conduct. Breaches of academic integrity include, but are not limited to, plagiarism, cheating, and
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misrepresentation. Other serious student conduct issues include behaviors such as inaccurate
PT
reporting of clinical hours, inaccurate information on resumes, clinical compliance documentation, illegal drug possession, diversion of prescription drugs, stalking, forging a
CE
signature, incivility, aggression in clinical sites or class, and medication error (Goodyear, R.K.,
AC
Reynonds, P., & Gragg, J.B., 2010). Moreover, all of the enumerated disciplinary issues are replete with legal ramifications. The school must follow substantive and fair due process when conducting an investigation to protect the student’s rights within the academic institution. (If a matter involves an act of negligence, malpractice, or criminal action, the school should immediately seek legal advice from their legal department.) The underreporting of nursing errors and professional misconduct is well documented in the literature both in North America and Europe (Killam et al., 2013; Pugh, 2012; QSEN, 2012). In 1999, the Institute of Medicine (IOM, 2007) brought to our attention that the leading cause of death in American hospitals was preventable error. Distinctions may be difficult to make between and among what should be best
ACCEPTED MANUSCRIPT practice, what is unprofessional, and what is error that causes harm (Pugh, 2011), however; further research is needed to understand the context within which nurses’ actions constitute
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unprofessional conduct. Lack of adherence to professional standards is directly associated with
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compromised patient safety (Killam et al., 2013; IOM, 2007); therefore, it behooves nurse educators to implement policy and procedures that address violation of academic integrity and
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the professional code of conduct in a nursing student’s academic formation.
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Two nursing student conduct cases are presented below to show the value and use for a Nursing Student Conduct Committee (NSCC), as an adjunct to a university’s extant conduct committee
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(judicial affairs). The facts of each case are followed by a discussion of the process and resolution within the specific nursing program as distinguished from that of the general
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university Office of Student Conduct and Community Standards Judicial Board. Whereas the
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University Office of Student Conduct oversees the violation of university policies, rules, and regulations, the Nursing Student Conduct Committee members are more acutely aware of
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professional misconduct as explicated in the American Nurses Association’s (ANA) Code of
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Ethics and the ANA’s Nursing Scope and Standards of Practice. Two Nursing Student Conduct Cases
Case #1.
The nurse practitioner (master’s degree) students are required to log into a patient management system, using a computer or mobile device, to track progress in fulfilling the course clinical requirements. Students document, for example, the number of patients seen and the number of hours at the clinical rotation site. The nursing school’s accreditation organization requires this important information be documented at each clinical rotation site to maintain
ACCEPTED MANUSCRIPT compliance. At the end of each day, the student asks the preceptor to sign off on work conducted.
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One day, the student signed off as the preceptor in the computer system that tracks the
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student’s clinical progress. The preceptor did not have the opportunity to review and approve the student/patient interactions for that day. When confronted about the fraudulent approval, the
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student ostensibly held that the preceptor was unavailable, and the student had to leave the site.
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A file of documents that included a summary of the facts from the clinical course professor, a written statement by the clinical preceptor, and a written statement from the student was
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submitted to both the University Judicial Board and the Nursing Student Conduct Committee. Upon review by the University Judicial Board, the student was charged with poor judgment and
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asked to review with the department chair the policies and procedures about preceptor approval
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of student clinical hours. At the same time, the NSSCC reviewed the case for a recommendation for disposition. The NSCC unanimously called for the dismissal of the student from the nursing
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student.
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program, given that this was a serious misrepresentation of professional conduct by an APRN
Case #1 discussion. Conduct that is not within acceptable limits should be addressed in the nursing student handbook, course syllabi, and clinical evaluation tools. The most commonly mentioned authority that explicates the professional responsibility and standards of practice for nurses and nursing students is ANA’s Nursing Scope and Standards of Practice and Code of Ethics for Nurses, in addition to each state’s Nurse Practice Act. In the clinical setting, nurse practitioner students may demonstrate misconduct by intentionally failing to follow proper procedure, documenting care activities inaccurately, or misrepresenting activities. Nurse practitioner student
ACCEPTED MANUSCRIPT misconduct may jeopardize the health and welfare of patients. Therefore, faculty have an ethical and legal responsibility to convey unsatisfactory grades/dismissal to students who are not
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capable of meeting standards of nursing practice; in doing so, faculty must also remember to
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provide due process to students at the same time. It is the faculty member who is ultimately responsible for student evaluation and determination of fitness for ethical practice (Smith
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Glasgow, Dreher, & Oxholm, 2012). In the case discussed, the student knowingly
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misrepresented hours, activities, and took on a responsibility belonging to the preceptor, all of which are clear violations of the ANA’s Code of Ethics for Nurses and both University and
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College policies. The NSCC’s sanction was specific to the nursing program and appropriate based on the egregious violation of misrepresentation; whereas, the University sanction was
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applied at the university level, meaning the student was able to continue to attend the University
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but in another school/department. Given the variance between the two sanctions, the student was not permitted to stay in a clinical program but permitted to matriculate in a non-clinical master’s
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Case #2.
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program in the college. The student would also be put on probation if entering another program.
An undergraduate (bachelor’s degree) nursing student reported that one of her roommates in an off-campus apartment often came home drunk, loud, and unruly. This disruptive behavior was affecting her studies in the nursing program. When reviewed, the University Judicial Board required the offending student to attend substance abuse sessions offered at the University and check-in with the Judicial Affairs official at least three times during the term while the student continued with her studies. The Nursing Student Conduct Committee asked the offending student to take a Leave of Absence from the nursing program, effective immediately. Even though the disruptive behavior was not exhibited during ―school hours,‖ expectations in the nursing student
ACCEPTED MANUSCRIPT handbook were clear that such behavior would not be tolerated. Academic administrators had the interests of both students in mind and convinced the student and parent that a leave of absence
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would be best.
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Case #2 discussion.
Substance abuse is an issue that must be managed in nursing education for the safety of
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patients, students, and the nursing profession. ―Clear policies show a commitment to professional
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standards by academic administrators and faculty and specify what occurs when standards are violated‖ (Monroe, 2009, p.276). Substance abuse policies should address the policy and
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procedures related to any unlawful use of drugs or alcohol, as substance abuse may significantly affect the ability of students to administer safe care to patients entrusted to them in a clinical
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health care setting. The development of such a policy should include nursing faculty, substance
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abuse experts, legal counsel, and consultation with clinical affiliates and the governmental oversight boards. Nursing faculty need to be humanistic in their approach to impaired students,
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while removing them quickly from the clinical practice site. It is the goal of schools of nursing to
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ensure patient safety and to promote the student’s well-being (Monroe, 2009). The patient safety implications for an impaired student nurse are fairly indisputable. In this case, the student nurse/nursing major would require a blood alcohol test, self-disclosure, supervisory or peer reports, and due process before a leave of absence would be sanctioned (Cotter & Smith Glasgow, 2012). While most nursing faculty recognize that substance abuse is an illness requiring early intervention, faculty also need to comply with the governmental oversight boards, university policies, and clinical affiliation requirements. For that reason, peer assistance programs are available and re-entry policies need to be developed for students who have separated from the
ACCEPTED MANUSCRIPT university nursing program due to substance abuse issues in consideration of the restrictions of these regulatory bodies/affiliate. With such polices, students may be eligible to reenter the
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nursing program in certain circumstances if the student can demonstrate satisfactory evidence of
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successful completion of treatment and documentation of 12-24-months of sustained recovery/sobriety with associated counseling (Smith Glasgow, et al., 2012). In this case, the
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nursing faculty recognized the impact of confirmed alcohol abuse on patient safety and issued a
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sanction of a leave of absence until such time that the student had completed appropriate counseling and one-year of documented sobriety.
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Development of a Nursing Student Code of Conduct In 2007, the Nursing Student Conduct Task Force (herein Task Force) was convened
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within a University’s Nursing Division of the College of Nursing and Health Professions to
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develop a Code of Conduct and a Conduct Committee for nursing students. The purpose of the student conduct code document was to provide guidelines for nursing students concerning their
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professional conduct and character in the classroom, clinical settings, and online classes and in
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communications. The document explicated the civil, ethical, and respectful behavior expected of all nursing professionals. This code gave more specificity to a nursing student’s professional conduct, compared to the general university’s student code of conduct. The ―purpose‖ section of the Code stated that the Nursing Student Code of Conduct was congruent with University policy; for it states: ―Likewise, Drexel University College of Nursing and Health Professions holds a shared philosophy and purpose as the University. In addition, the Nursing Program has heightened standards of conduct because Nursing is a professional program bound by the American Nurses Association Standards of Practice, Code of Ethics as well as the Pennsylvania Board of Nursing Standards of Practice.” Officials managing the University-
ACCEPTED MANUSCRIPT wide student code of conduct were initially concerned about a “two track” system handling student issues; however, in a short amount of time and after only a few cases, the officials
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agreed to the value of a concurrent review by the NSCC, if the situation was warranted.
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The literature is replete with advice to nurse educators to address professional conduct
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issues during the educational process before students are transferred to the work place environment (Suplee, Lachman, Siebert, & Anselmi, 2008). The Nursing Student Code of
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Conduct (herein, Code of Conduct) initiative was inspired to do the same – address – professional conduct and character during the education process. The Task Force selected the
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ANA’s Code of Ethics for Nurses (2001; herein ANA Code) and the ANA’s Nursing Scope and Standards of Practice (2010; herein ANA Standards) as the authorities for nursing professional
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conduct and practice. These publications set forth the rules for professional responsibility of
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nurses. Most of these rules of conduct and practice are reflected in each states’ Boards of Nursing standards of practice. These rules determine who can be admitted to practice,
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parameters of practice, and removal from practice.
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The Task Force organized and formatted the Code of Conduct similarly to a regulatory document with numbered sections and subsections. Several members of the committee had experience in administrative rulemaking and nursing law practice. The Task Force followed a systematic process of literature review, discussion, analysis and then wrote the Code of Conduct that was specific to the profession of nursing. Eight topical sections subsumed each of the areas identified as necessary for the document: 1. Purpose, 2. Rationale, 3. Student Civility, 4. Classroom Conduct, 5. Clinical Conduct, 6. Academic Integrity, 7. Communication, and 8. Appendices. This document now appears as an appendix in each program’s student handbook.
ACCEPTED MANUSCRIPT Establishing the Nursing Student Conduct Committee The Nursing Student Conduct Committee was established to give a more circumspect
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review of a nursing student’s alleged misconduct in a nursing program and to recommend any
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sanctions or remedial steps to improve a student’s conduct and character. It is important to note
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that cases reviewed by the University’s Judicial Board did not always consider the standards of conduct and character recognized by the nursing profession and, consequently, expected of these
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students. The university’s student conduct committee generally offered best practices in the student conduct review process (e.g. allegations, announcement of charges, investigation,
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hearing, and delivery of sanctions); however, characteristics and virtues of professionalism and conduct expected in a health profession were not necessarily considered. For example, a student
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singing-in for another student not present during a course review session may be considered bad
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judgment by the university conduct committee members, whereas, nursing faculty see this is a serious misrepresentation. After reviewing a few student conduct cases, it became clear to
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nursing program NSCC members that more formal procedures needed to be developed to guide
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the NSCC’s acceptance, review, deliberation, decision(s), and communication of decisions rendered to stakeholders ( i.e. department chair, faculty, student). The NSCC’s purpose was defined as follows:
The purpose of this Committee is to review when asked and if necessary cases of nursing student academic and professional misconduct presented by academic program directors/College administration for recommendations on appropriate remedial action or sanctions. Thus, the NSCC would serve in an advisory role and would review cases when asked by either the academic program directors or the college administrators. Academic administrators may have
ACCEPTED MANUSCRIPT reason to bring suspected misconduct cases to the NSCC that may occur outside of the student’s coursework activities. The NSCC should review cases related to ―professional misconduct‖ as
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determined by nursing profession authorities and by university and nursing student handbooks.
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Other alleged student misconduct issues can be handled by the University’s existing student conduct procedures. The NSCC can choose not to review a case when members feel that the case
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is not necessary or appropriate to be brought to the NSCC for review.
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The NSCC members and academic administrators have recognized that cases of alleged student academic misconduct could be reviewed simultaneously by this NSCC and the
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University’s Judicial Board overseen by the Office of Student Affairs. In these cases, the NSCC should not be influenced by the progress and outcome of the Judicial Board’s process; rather,
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they should abide by their own purpose and procedures. For example, a student could be
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exonerated by the Judicial Board for possession of marijuana; however, a nursing student’s possession of illegal drugs is in violation of both the ANA Code and ANA Standards and also has
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professional licensure implications. It is for this reason that an argument was made for the need
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of a review of nursing student transgressions independent of the University’s Judicial Board. Members of the Committee are appointed by the Associate Dean in consultation with the Executive Nurse Council of the College. Members must be chosen from the Nursing Faculty. It was decided that to accomplish its work, there had to be at least five members of this Committee, with a chair, appointed by the Dean. The Assistant Dean for Academic and Student Affairs, who may not necessarily be a member of the nursing faculty, serves as a resource to the committee, but is not a voting member of the Committee or present when members adjudicate a student conduct case. Members of the Committee are appointed for three academic years, with no more than two members rotating off in a given year. The Committee meets at least once each quarter,
ACCEPTED MANUSCRIPT and when the Committee chair requests a meeting to conduct the business of the Committee. The Committee reports to the Dean of the College through the Associate Deans of Nursing.
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The NSCC members designed the policy and procedure for matters that were brought
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before the NSCC for review. The NSCC decided it should serve in an advisory role making recommendations to the academic administrators to make final decisions, thus it is not necessary
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for the student to appear in person before the NSCC, even if the student requests. However, it is
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vitally important that the student be given an opportunity to be heard. This is accomplished via a formal statement and any documentation of the student’s choosing to be submitted in writing to
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the NSCC and to the Assistant Dean of Academic and Student Affairs within seven calendar days of the date of the notification letter informing the student that a review has been initiated.
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The Assistant Dean of Academic and Student Affairs acts as a resource and facilitator to the
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student to iterate the purpose of the NSCC and the procedures that will be followed and to provide appropriate assistance in formulating a student statement to the NSCC. The Assistant
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Dean emphasizes availability to answer any questions or concerns during the review process.
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Furthermore, a student still has a right to appear before the chair of the program to argue the final disposition of any charges and sanctions. The Dean of the college, in consultation with general counsel, saw value in the Committee’s advisory role and did not want to bifurcate decision points and authority already established in the college. After the Committee deliberates and comes to a decision on the case, the academic administrator is formally notified of such in writing. The academic administrator communicates directly to the student in writing of the final decision related to the alleged misconduct. Members of the NSCC do not communicate with the student during this process, and students do not know the identity of their NSCC members. If a student chooses to appeal the decision made by the
ACCEPTED MANUSCRIPT department chair involving the conduct of the student, such an appeal follows the already established appeals process for academic decisions.
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Conclusion
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Since the inception of the Nursing Student Code of Conduct and corresponding Nursing Student Conduct Committee to adjudicate the cases, there has been an overall decrease in the
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number of disciplinary cases rising to the level of the NSCC. Several reasons for the decrease in
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the number of violations of academic and professional standards may be attributed to the widespread publication of the Nursing Student Code of Conduct. While senior university
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administrators were initially concerned about what appeared to be a duplicate judicial affairs system, in time they realized that the faculty led Nursing Student Conduct Committee served a
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useful purpose, given that they reviewed the nature of transgressions with a higher level of
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sensitivity and would provide relatively harsher sanctions if the nursing student’s action breached professional code and practice standards.
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It is recommended that nursing schools establish a nursing student code of conduct and a
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conduct committee to review clinical and classroom conduct issues that otherwise may go unmitigated in a general university judicial review. Professional responsibility and ethics have been linked to patient safety. Characteristics of professionalism are learned behaviors. The onus is upon the nursing program to teach behaviors that constitute compassionate, ethical, and safe practice. A Nursing Code of Conduct explicates the rules, and the NSCC recommends the consequences for poor choices and inappropriate actions. The ANA Code and ANA Standards also indicate patients (by increasing patient safety) are the beneficiary of ethical conduct among and between nurses and the health care team. On the job training of acceptable, safe conduct is too late. The culture of civility, professional
ACCEPTED MANUSCRIPT responsibility, and patient safety must be introduced on the first day of a nursing student’s education. It is incumbent upon schools of nursing to develop policy and procedures to
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adjudicate acts of professional misconduct where due process and student’s rights are protected.
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References
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American Nurses Association. (2001). Code of ethics for nurses. Silver Springs, MD: American
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Nurses Publishing.
American Nurses Association. (2010). Nursing scope and standards of practice. Silver Springs,
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MD: American Nurses Publishing.
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Cotter, V. & Smith Glasgow, M.E. (2012). Student drug testing in nursing education. Journal of Professional Nursing, 28 (3), 186-189. doi: 10.1016/j.profnurs.2011.11.017
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Dante, A., Petrucci, C., & Lancia, L., (2013). European nursing students’ academic success or
doi: 10.1016/j.nedt.2012.10.001
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failure: A post-Bologna Declaration systematic review. Nurse Education Today 33 (1), 46-52.
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Goodyear, R.K., Reynonds, P., & Gragg, J.B., (2010). Student incivility. Concurrent paper
CO, United States.
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presentation at the Annual Meeting of the American Educational Research Association, Denver,
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Institute of Medicine (2007). Preventing medication errors. Washington, DC: The National Academies Press.
Killam, L.A., Mossey, S. Montgomery, P., & Timmermans, K..E. (2013). First year nursing students' viewpoints about compromised clinical safety. Nurse Education Today,33(5), 475-480. doi: 10.1016/j.nedt.2012.05.010. Monroe, T. (2009). Addressing substance abuse among nursing students: Development of a Prototype alternative-to-dismissal policy. Journal of Nursing Education, 48 (5), 272-278. Pugh, D. (2011). A fine line: The role of personal and professional vulnerability in allegations of unprofessional conduct. Journal of Nursing Law,14 (1), 21-31. doi: 10.1891/1073-7472.14.1.21
ACCEPTED MANUSCRIPT QSEN:Quality and Safety Education for Nurses. Quality and safety competencies. Retrieved June 4, 2013 from http://qsen.org/competencies/
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Smith Glasgow, M.E., Dreher, H.M., & Oxholm, C. (2012). Legal issues confronting today’s
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nursing faculty: A case-study approach. Philadelphia, PA: F.A. Davis Publishing Company. Suplee, P.D., Lachman, V.D., Siebert, B., & Anselmi, K.K., (2008). Managing nursing student
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incivility in the classroom, clinical setting, and on-line. Journal of Nursing Law 12 (2)68-77. doi:
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10.1891/1073-7472.12.2.68
Szczerbinska, K. E, Topor-Madry, R., & Niedzwiedzka, B., (2012). Competence profile of an in-
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house educator of professionals providing elderly care (ComPro project). Nurse Education
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Today 32 (3) 516-523. doi: 10.1016/j.nedt.2011.08.008
S8755-7223(14)00070-2 doi: 10.1016/j.profnurs.2014.04.002 YJPNU 828
To appear in:
Journal of Professional Nursing
Received date:
30 June 2013
Please cite this article as: Anselmi, K.K., Glasgow, M.E.S. & Gambescia, S.F., Using a Nursing Student Conduct Committee to Foster Professionalism among Nursing Students, Journal of Professional Nursing (2014), doi: 10.1016/j.profnurs.2014.04.002
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Using a Nursing Student Conduct Committee to Foster Professionalism among Nursing Students
T
by
RI P
Anselmi, K.K., Glasgow, M.E., & Gambescia, S.F. Submitted to Journal of Professional Nursing—30 June 2013 Revised and Resubmitted 22 January 2014
SC
JPN-D-13-00117
NU
Key words: student conduct; professionalism; patient safety
PT
ED
MA
Katherine Kaby Anselmi, PhD, JD, FNP-BC, WHNP-BC Assistant Dean for Accreditation/Regulatory Affairs & Online Innovation Associate Clinical Professor, Division of Nursing Drexel University College of Nursing and Health Professions 1505 Race Street Philadelphia, PA 10192 (USA) 215-762-8545 phone [email protected]
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CE
Mary Ellen Smith Glasgow, PhD, RN, FAAN Dean & Professor School of Nursing Duquesne University of the Holy Spirit 540B Fisher Hall Pittsburgh, PA 15282 (USA) 412-396-6554 phone [email protected] Stephen F. Gambescia, PhD, MEd, MBA, MHum, MCHES (Corresponding author) Professor, Health Services Administration Assistant Dean of Academic and Student Affairs Drexel University College of Nursing and Health Professions 1505 Race Street Philadelphia, PA 10192 (USA) 215-762-8405 phone [email protected]
ACCEPTED MANUSCRIPT
Abstract
T
This article explains how a university nursing program in the United States created and
RI P
implemented a nursing student Code of Conduct and a faculty-led Nursing Student Conduct Committee to review and adjudicate violations of academic or professional misconduct. The
SC
need for and role of the Nursing Student Conduct Committee in providing substantive and fair
NU
due process is illustrated with two cases. Professional misconduct has been associated with preventable error and patient safety, and is of great concern to nurse educators who are entrusted
MA
with producing the next generation of nursing professionals. Accountability and consequences for violations of professional standards must be an integral part of the nursing education
ED
curriculum throughout the world to ensure quality and safety and mitigate the adverse effects of
PT
nursing error. Given the professional and patient safety implication of such violations, the authors believe it is prudent to have nursing programs adjudicate nursing majors’ professional
AC
CE
violations as an alternative or supplement to the general university judicial board.
ACCEPTED MANUSCRIPT
Using a Nursing Student Conduct Committee to Foster Professionalism among Nursing
T
Students
RI P
Nurse educators throughout North America and Europe are concerned with providing a high quality competence-based curriculum and especially one that emphasizes patient safety and
SC
professional responsibility (Dante, A., Petrucci, C., & Lancia, L., 2013; Killam, L.A., Mossey, S.
NU
Montgomery, P., & Timmermans, K..E., 2013; Szczerbinska, K. E, Topor-Madry, R., & Niedzwiedzka, B., 2011). Successful nursing student academic performance is contingent upon
MA
an array of variables, which include both academic integrity and ethical and professional conduct. Breaches of academic integrity include, but are not limited to, plagiarism, cheating, and
ED
misrepresentation. Other serious student conduct issues include behaviors such as inaccurate
PT
reporting of clinical hours, inaccurate information on resumes, clinical compliance documentation, illegal drug possession, diversion of prescription drugs, stalking, forging a
CE
signature, incivility, aggression in clinical sites or class, and medication error (Goodyear, R.K.,
AC
Reynonds, P., & Gragg, J.B., 2010). Moreover, all of the enumerated disciplinary issues are replete with legal ramifications. The school must follow substantive and fair due process when conducting an investigation to protect the student’s rights within the academic institution. (If a matter involves an act of negligence, malpractice, or criminal action, the school should immediately seek legal advice from their legal department.) The underreporting of nursing errors and professional misconduct is well documented in the literature both in North America and Europe (Killam et al., 2013; Pugh, 2012; QSEN, 2012). In 1999, the Institute of Medicine (IOM, 2007) brought to our attention that the leading cause of death in American hospitals was preventable error. Distinctions may be difficult to make between and among what should be best
ACCEPTED MANUSCRIPT practice, what is unprofessional, and what is error that causes harm (Pugh, 2011), however; further research is needed to understand the context within which nurses’ actions constitute
T
unprofessional conduct. Lack of adherence to professional standards is directly associated with
RI P
compromised patient safety (Killam et al., 2013; IOM, 2007); therefore, it behooves nurse educators to implement policy and procedures that address violation of academic integrity and
SC
the professional code of conduct in a nursing student’s academic formation.
NU
Two nursing student conduct cases are presented below to show the value and use for a Nursing Student Conduct Committee (NSCC), as an adjunct to a university’s extant conduct committee
MA
(judicial affairs). The facts of each case are followed by a discussion of the process and resolution within the specific nursing program as distinguished from that of the general
ED
university Office of Student Conduct and Community Standards Judicial Board. Whereas the
PT
University Office of Student Conduct oversees the violation of university policies, rules, and regulations, the Nursing Student Conduct Committee members are more acutely aware of
CE
professional misconduct as explicated in the American Nurses Association’s (ANA) Code of
AC
Ethics and the ANA’s Nursing Scope and Standards of Practice. Two Nursing Student Conduct Cases
Case #1.
The nurse practitioner (master’s degree) students are required to log into a patient management system, using a computer or mobile device, to track progress in fulfilling the course clinical requirements. Students document, for example, the number of patients seen and the number of hours at the clinical rotation site. The nursing school’s accreditation organization requires this important information be documented at each clinical rotation site to maintain
ACCEPTED MANUSCRIPT compliance. At the end of each day, the student asks the preceptor to sign off on work conducted.
T
One day, the student signed off as the preceptor in the computer system that tracks the
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student’s clinical progress. The preceptor did not have the opportunity to review and approve the student/patient interactions for that day. When confronted about the fraudulent approval, the
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student ostensibly held that the preceptor was unavailable, and the student had to leave the site.
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A file of documents that included a summary of the facts from the clinical course professor, a written statement by the clinical preceptor, and a written statement from the student was
MA
submitted to both the University Judicial Board and the Nursing Student Conduct Committee. Upon review by the University Judicial Board, the student was charged with poor judgment and
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asked to review with the department chair the policies and procedures about preceptor approval
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of student clinical hours. At the same time, the NSSCC reviewed the case for a recommendation for disposition. The NSCC unanimously called for the dismissal of the student from the nursing
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student.
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program, given that this was a serious misrepresentation of professional conduct by an APRN
Case #1 discussion. Conduct that is not within acceptable limits should be addressed in the nursing student handbook, course syllabi, and clinical evaluation tools. The most commonly mentioned authority that explicates the professional responsibility and standards of practice for nurses and nursing students is ANA’s Nursing Scope and Standards of Practice and Code of Ethics for Nurses, in addition to each state’s Nurse Practice Act. In the clinical setting, nurse practitioner students may demonstrate misconduct by intentionally failing to follow proper procedure, documenting care activities inaccurately, or misrepresenting activities. Nurse practitioner student
ACCEPTED MANUSCRIPT misconduct may jeopardize the health and welfare of patients. Therefore, faculty have an ethical and legal responsibility to convey unsatisfactory grades/dismissal to students who are not
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capable of meeting standards of nursing practice; in doing so, faculty must also remember to
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provide due process to students at the same time. It is the faculty member who is ultimately responsible for student evaluation and determination of fitness for ethical practice (Smith
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Glasgow, Dreher, & Oxholm, 2012). In the case discussed, the student knowingly
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misrepresented hours, activities, and took on a responsibility belonging to the preceptor, all of which are clear violations of the ANA’s Code of Ethics for Nurses and both University and
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College policies. The NSCC’s sanction was specific to the nursing program and appropriate based on the egregious violation of misrepresentation; whereas, the University sanction was
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applied at the university level, meaning the student was able to continue to attend the University
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but in another school/department. Given the variance between the two sanctions, the student was not permitted to stay in a clinical program but permitted to matriculate in a non-clinical master’s
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Case #2.
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program in the college. The student would also be put on probation if entering another program.
An undergraduate (bachelor’s degree) nursing student reported that one of her roommates in an off-campus apartment often came home drunk, loud, and unruly. This disruptive behavior was affecting her studies in the nursing program. When reviewed, the University Judicial Board required the offending student to attend substance abuse sessions offered at the University and check-in with the Judicial Affairs official at least three times during the term while the student continued with her studies. The Nursing Student Conduct Committee asked the offending student to take a Leave of Absence from the nursing program, effective immediately. Even though the disruptive behavior was not exhibited during ―school hours,‖ expectations in the nursing student
ACCEPTED MANUSCRIPT handbook were clear that such behavior would not be tolerated. Academic administrators had the interests of both students in mind and convinced the student and parent that a leave of absence
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would be best.
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Case #2 discussion.
Substance abuse is an issue that must be managed in nursing education for the safety of
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patients, students, and the nursing profession. ―Clear policies show a commitment to professional
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standards by academic administrators and faculty and specify what occurs when standards are violated‖ (Monroe, 2009, p.276). Substance abuse policies should address the policy and
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procedures related to any unlawful use of drugs or alcohol, as substance abuse may significantly affect the ability of students to administer safe care to patients entrusted to them in a clinical
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health care setting. The development of such a policy should include nursing faculty, substance
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abuse experts, legal counsel, and consultation with clinical affiliates and the governmental oversight boards. Nursing faculty need to be humanistic in their approach to impaired students,
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while removing them quickly from the clinical practice site. It is the goal of schools of nursing to
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ensure patient safety and to promote the student’s well-being (Monroe, 2009). The patient safety implications for an impaired student nurse are fairly indisputable. In this case, the student nurse/nursing major would require a blood alcohol test, self-disclosure, supervisory or peer reports, and due process before a leave of absence would be sanctioned (Cotter & Smith Glasgow, 2012). While most nursing faculty recognize that substance abuse is an illness requiring early intervention, faculty also need to comply with the governmental oversight boards, university policies, and clinical affiliation requirements. For that reason, peer assistance programs are available and re-entry policies need to be developed for students who have separated from the
ACCEPTED MANUSCRIPT university nursing program due to substance abuse issues in consideration of the restrictions of these regulatory bodies/affiliate. With such polices, students may be eligible to reenter the
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nursing program in certain circumstances if the student can demonstrate satisfactory evidence of
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successful completion of treatment and documentation of 12-24-months of sustained recovery/sobriety with associated counseling (Smith Glasgow, et al., 2012). In this case, the
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nursing faculty recognized the impact of confirmed alcohol abuse on patient safety and issued a
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sanction of a leave of absence until such time that the student had completed appropriate counseling and one-year of documented sobriety.
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Development of a Nursing Student Code of Conduct In 2007, the Nursing Student Conduct Task Force (herein Task Force) was convened
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within a University’s Nursing Division of the College of Nursing and Health Professions to
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develop a Code of Conduct and a Conduct Committee for nursing students. The purpose of the student conduct code document was to provide guidelines for nursing students concerning their
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professional conduct and character in the classroom, clinical settings, and online classes and in
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communications. The document explicated the civil, ethical, and respectful behavior expected of all nursing professionals. This code gave more specificity to a nursing student’s professional conduct, compared to the general university’s student code of conduct. The ―purpose‖ section of the Code stated that the Nursing Student Code of Conduct was congruent with University policy; for it states: ―Likewise, Drexel University College of Nursing and Health Professions holds a shared philosophy and purpose as the University. In addition, the Nursing Program has heightened standards of conduct because Nursing is a professional program bound by the American Nurses Association Standards of Practice, Code of Ethics as well as the Pennsylvania Board of Nursing Standards of Practice.” Officials managing the University-
ACCEPTED MANUSCRIPT wide student code of conduct were initially concerned about a “two track” system handling student issues; however, in a short amount of time and after only a few cases, the officials
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agreed to the value of a concurrent review by the NSCC, if the situation was warranted.
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The literature is replete with advice to nurse educators to address professional conduct
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issues during the educational process before students are transferred to the work place environment (Suplee, Lachman, Siebert, & Anselmi, 2008). The Nursing Student Code of
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Conduct (herein, Code of Conduct) initiative was inspired to do the same – address – professional conduct and character during the education process. The Task Force selected the
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ANA’s Code of Ethics for Nurses (2001; herein ANA Code) and the ANA’s Nursing Scope and Standards of Practice (2010; herein ANA Standards) as the authorities for nursing professional
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conduct and practice. These publications set forth the rules for professional responsibility of
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nurses. Most of these rules of conduct and practice are reflected in each states’ Boards of Nursing standards of practice. These rules determine who can be admitted to practice,
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parameters of practice, and removal from practice.
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The Task Force organized and formatted the Code of Conduct similarly to a regulatory document with numbered sections and subsections. Several members of the committee had experience in administrative rulemaking and nursing law practice. The Task Force followed a systematic process of literature review, discussion, analysis and then wrote the Code of Conduct that was specific to the profession of nursing. Eight topical sections subsumed each of the areas identified as necessary for the document: 1. Purpose, 2. Rationale, 3. Student Civility, 4. Classroom Conduct, 5. Clinical Conduct, 6. Academic Integrity, 7. Communication, and 8. Appendices. This document now appears as an appendix in each program’s student handbook.
ACCEPTED MANUSCRIPT Establishing the Nursing Student Conduct Committee The Nursing Student Conduct Committee was established to give a more circumspect
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review of a nursing student’s alleged misconduct in a nursing program and to recommend any
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sanctions or remedial steps to improve a student’s conduct and character. It is important to note
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that cases reviewed by the University’s Judicial Board did not always consider the standards of conduct and character recognized by the nursing profession and, consequently, expected of these
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students. The university’s student conduct committee generally offered best practices in the student conduct review process (e.g. allegations, announcement of charges, investigation,
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hearing, and delivery of sanctions); however, characteristics and virtues of professionalism and conduct expected in a health profession were not necessarily considered. For example, a student
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singing-in for another student not present during a course review session may be considered bad
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judgment by the university conduct committee members, whereas, nursing faculty see this is a serious misrepresentation. After reviewing a few student conduct cases, it became clear to
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nursing program NSCC members that more formal procedures needed to be developed to guide
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the NSCC’s acceptance, review, deliberation, decision(s), and communication of decisions rendered to stakeholders ( i.e. department chair, faculty, student). The NSCC’s purpose was defined as follows:
The purpose of this Committee is to review when asked and if necessary cases of nursing student academic and professional misconduct presented by academic program directors/College administration for recommendations on appropriate remedial action or sanctions. Thus, the NSCC would serve in an advisory role and would review cases when asked by either the academic program directors or the college administrators. Academic administrators may have
ACCEPTED MANUSCRIPT reason to bring suspected misconduct cases to the NSCC that may occur outside of the student’s coursework activities. The NSCC should review cases related to ―professional misconduct‖ as
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determined by nursing profession authorities and by university and nursing student handbooks.
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Other alleged student misconduct issues can be handled by the University’s existing student conduct procedures. The NSCC can choose not to review a case when members feel that the case
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is not necessary or appropriate to be brought to the NSCC for review.
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The NSCC members and academic administrators have recognized that cases of alleged student academic misconduct could be reviewed simultaneously by this NSCC and the
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University’s Judicial Board overseen by the Office of Student Affairs. In these cases, the NSCC should not be influenced by the progress and outcome of the Judicial Board’s process; rather,
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they should abide by their own purpose and procedures. For example, a student could be
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exonerated by the Judicial Board for possession of marijuana; however, a nursing student’s possession of illegal drugs is in violation of both the ANA Code and ANA Standards and also has
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professional licensure implications. It is for this reason that an argument was made for the need
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of a review of nursing student transgressions independent of the University’s Judicial Board. Members of the Committee are appointed by the Associate Dean in consultation with the Executive Nurse Council of the College. Members must be chosen from the Nursing Faculty. It was decided that to accomplish its work, there had to be at least five members of this Committee, with a chair, appointed by the Dean. The Assistant Dean for Academic and Student Affairs, who may not necessarily be a member of the nursing faculty, serves as a resource to the committee, but is not a voting member of the Committee or present when members adjudicate a student conduct case. Members of the Committee are appointed for three academic years, with no more than two members rotating off in a given year. The Committee meets at least once each quarter,
ACCEPTED MANUSCRIPT and when the Committee chair requests a meeting to conduct the business of the Committee. The Committee reports to the Dean of the College through the Associate Deans of Nursing.
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The NSCC members designed the policy and procedure for matters that were brought
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before the NSCC for review. The NSCC decided it should serve in an advisory role making recommendations to the academic administrators to make final decisions, thus it is not necessary
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for the student to appear in person before the NSCC, even if the student requests. However, it is
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vitally important that the student be given an opportunity to be heard. This is accomplished via a formal statement and any documentation of the student’s choosing to be submitted in writing to
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the NSCC and to the Assistant Dean of Academic and Student Affairs within seven calendar days of the date of the notification letter informing the student that a review has been initiated.
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The Assistant Dean of Academic and Student Affairs acts as a resource and facilitator to the
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student to iterate the purpose of the NSCC and the procedures that will be followed and to provide appropriate assistance in formulating a student statement to the NSCC. The Assistant
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Dean emphasizes availability to answer any questions or concerns during the review process.
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Furthermore, a student still has a right to appear before the chair of the program to argue the final disposition of any charges and sanctions. The Dean of the college, in consultation with general counsel, saw value in the Committee’s advisory role and did not want to bifurcate decision points and authority already established in the college. After the Committee deliberates and comes to a decision on the case, the academic administrator is formally notified of such in writing. The academic administrator communicates directly to the student in writing of the final decision related to the alleged misconduct. Members of the NSCC do not communicate with the student during this process, and students do not know the identity of their NSCC members. If a student chooses to appeal the decision made by the
ACCEPTED MANUSCRIPT department chair involving the conduct of the student, such an appeal follows the already established appeals process for academic decisions.
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Conclusion
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Since the inception of the Nursing Student Code of Conduct and corresponding Nursing Student Conduct Committee to adjudicate the cases, there has been an overall decrease in the
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number of disciplinary cases rising to the level of the NSCC. Several reasons for the decrease in
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the number of violations of academic and professional standards may be attributed to the widespread publication of the Nursing Student Code of Conduct. While senior university
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administrators were initially concerned about what appeared to be a duplicate judicial affairs system, in time they realized that the faculty led Nursing Student Conduct Committee served a
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useful purpose, given that they reviewed the nature of transgressions with a higher level of
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sensitivity and would provide relatively harsher sanctions if the nursing student’s action breached professional code and practice standards.
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It is recommended that nursing schools establish a nursing student code of conduct and a
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conduct committee to review clinical and classroom conduct issues that otherwise may go unmitigated in a general university judicial review. Professional responsibility and ethics have been linked to patient safety. Characteristics of professionalism are learned behaviors. The onus is upon the nursing program to teach behaviors that constitute compassionate, ethical, and safe practice. A Nursing Code of Conduct explicates the rules, and the NSCC recommends the consequences for poor choices and inappropriate actions. The ANA Code and ANA Standards also indicate patients (by increasing patient safety) are the beneficiary of ethical conduct among and between nurses and the health care team. On the job training of acceptable, safe conduct is too late. The culture of civility, professional
ACCEPTED MANUSCRIPT responsibility, and patient safety must be introduced on the first day of a nursing student’s education. It is incumbent upon schools of nursing to develop policy and procedures to
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adjudicate acts of professional misconduct where due process and student’s rights are protected.
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References
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American Nurses Association. (2001). Code of ethics for nurses. Silver Springs, MD: American
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Cotter, V. & Smith Glasgow, M.E. (2012). Student drug testing in nursing education. Journal of Professional Nursing, 28 (3), 186-189. doi: 10.1016/j.profnurs.2011.11.017
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Dante, A., Petrucci, C., & Lancia, L., (2013). European nursing students’ academic success or
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ACCEPTED MANUSCRIPT QSEN:Quality and Safety Education for Nurses. Quality and safety competencies. Retrieved June 4, 2013 from http://qsen.org/competencies/
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Smith Glasgow, M.E., Dreher, H.M., & Oxholm, C. (2012). Legal issues confronting today’s
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