Nurse Reporter Fall 2008 - Wyoming State Board of Nursing

Wy o m i n gPublished by theWyoming State Board of Nursing1810 Pioneer Ave.Cheyenne, Wyoming 82002Phone: 307-777-7601Fax: 307-777-3519Web Address: http://nursing.state.wy.usAgency Mission: The Wyoming State Board ofNursing is responsible for the protection of the public’shealth, welfare, and safety through the regulation ofnursing, nursing education, nursing practice, anddisciplinary standards. The responsibility of the Boardof Nursing is to implement a cost-effective and efficientsystem of regulation, which meets the consumerdemand for safe, competent, ethical practitioners ofnursing which includes advanced practice nurses, registeredprofessional nurses, licensed practical nurses,and certified nursing assistants.WE P O R T E RNurseSpring 2008Vo l. 4 Nu m b e r 1R“protecting the public through excellence in nursing...”T a b l e o f Co n t e n t s3 Disabled Nurses in the Workplace5 Spotlight on Rose Rennell6 Scope of Practice Issues7 From the President of the Wyoming State Board of Nursing12 Disabled Nurses Need GritEx e c u t i v e Di re c t o rMary Kay Goetter, MS, RNC, NEA-BCAssistant Ex e c u t i v e Di re c t o rPr a c t i c e a n d Ed u c a t i o n Co n s u l t a n tMary Beth Stepans, PhD, RNCo m p l ia n c e Co n s u l t a n tBridget Horne, BSN, RNFi n a n c i a l a n d Hu m a n Resources OfficerCindy StillahnEx e c u t i v e AssistantJoAnn ReidLi c e n s i n g Co o r d i na t o rLaVelle OjedaLi c e n s i n g Co o r d i na t o rMaxine HernandezDisciplinary AssistantDebra BallBo a r d o f Nu r s i n g MembersKellie Clausen, FNP, WHCNP, RN PresidentJennifer Zettl, RNVice-PresidentMarguerite Herman, ConsumerSecretaryKim Williamson, LPNMemberMarcie Burr, RNMemberJenny Heuck, MS, RNMemberTracy WasserburgerMemberWyoming Nurse Reporter does not necessarilyendorse advertisements contained herein. Thepublisher reserves the right to accept or rejectadvertisements for Wyoming Nurse Reporter.For Advertising Information:Greg Jonesgjones@pcipublishing.com501.221.9986 or 800.561.4686Created By:Publishing Concepts, Inc.Virginia Robertson, Presidentvrobertson@pcipublishing.comwww.thinkaboutitnursing.comPublishing Concepts, Inc.14109 Taylor Loop RoadLittle Rock, AR 72223EDITION 1417 If You re DisabledGreetingsf r o m t h eE x e c u t i v eD i r e c t o r ,M a r y Ka yG o e t t e rEditorial: Disabled Nurses in the WorkplaceThe fall issue of theWyoming Nurse Reporteris highlighting the topic ofnurses with disabilities andtheir role in continuing tocontribute to the profession.The current shortageof nurses in Wyoming, withits multitude of causativefactors (Gallagher, 2008),prompts the examinationof any and all reasonablesolutions to sustaining andincreasing the workforce.When considering thepool of nurses with varioushealth problems and disabilitieswho still desire tobe active working nurses, allstakeholders need to be proactivein considering howthe profession is supportingthese individuals.As in all matters of regulation,it is necessary to consultthe law. The WyomingNurse Practice Act (NPA)(Wyoming State Board ofNursing, 2003) states in 33-21-146 (a): “The board ofnursing may refuse to issue,or may suspend or revokethe license, certificate, ortemporary permit of anyperson, or to otherwise disciplineany licensee, uponproof that the person: (iv)is unfit or incompetent topractice nursing by reason ofnegligence, habits or othercauses including but notlimited to: (A) Being unableto practice nursing withreasonable skill and safetyto patients by reason ofphysical or mental disability,or use of drugs, narcotics,chemicals or any othermind-altering material” (p.13) and (xi) “Has failed tosubmit to a mental, physicalor medical competencyexamination following aproper request by the boardmade pursuant to boardrules and regulations andthe Wyoming AdministrativeProcedure Act” (p.14). On the first reading ofthe law, it may appear toContinued on next pageW y o m i n g N u r s e R e p o r t e r 3

e fairly unflinching, but in fact, the NPAleaves significant room for interpretationon a case-by-case basis.First and foremost, each case must beconsidered individually to see if the licenseholder is “unfit or incompetent … topractice nursing with reasonable skill andsafety to patients.” Unfortunately, there isno national consensus on what constitutesprofession-wide competencies and skillsfor nurses, which makes legal interpretationof this statement problematic (Helms,Jorgensen, and Anderson, 2006). Thedecision of whether a nurse is unfit or incompetentmust be a joint endeavor of theregulatory agency, in this case the WyomingState Board of Nursing (WSBN), theemployer, the nurse in question, and thenurse’s health care provider.In the event of substance abuse issues,other parts of the NPA become relevant;in many instances, law enforcementagencies are also involved in gatheringevidence and reviewing the case. Currently,45 nurses are enrolled in the WyomingProfessional Assistance Program (WPAP)for treatment of substance abuse/chemicaldependency. At least that many nursesare represented in active open cases underinvestigation by the WSBN. Chemicaldependence is recognized as a disabilityunder the Americans with DisabilitiesAct (ADA); however, the ADA onlyprotects employees from discriminationif they are successfully rehabilitated andno longer abuse the substance in question(Snyder, 2008). Illegal conduct, such asuse of illegal drugs or illegal use of legaldrugs, is not conduct for which the ADArequires reasonable accommodation orpermits a disability discrimination lawsuit.This is an important point when discussioncenters around enfolding nurses withdisabilities back into the workforce; nurseswith chemical dependency must no longerbe engaged in illegal activities and must beenrolled in the WPAP (or other rehabilitationprogram) in order to have the opportunityto retain licensure and be permittedto continue practice.However, there are many disabilityissues other than chemical dependencywhen considering how disabled or health-Continued from previous pagecompromised nurses may remain in theworkforce. In just my own personal experienceas a practicing nurse and nurse educator,I have worked with nurses or taughtnursing students affected by multiplehealth issues, whether or not they fullyqualified or identified themselves as beingdisabled: cerebral palsy, congenital limbreduction, hearing impairment, speechimpediment, musculoskeletal problemscausing chronic pain and compromisinggait or movement, Type I and II diabetes,and various mental health disorders such asattention deficit disorder (ADHD), depressionand bipolar disorder. Some of thesenurses and nursing students needed specialaccommodations (special stethoscopes forIn this issue of the Wyoming NurseReporter, read the stories of nurses herein Wyoming who are struggling with thesevery questions. Ask yourself how youfeel about working with nurses who havehealth problems and/or disabilities. Considerhow each of us can provide “accommodations”for one another … sometimesas simple as offering compassion and anopen mind.hearing impairment or a particular typeof chair to support the back/spine). Mostdid not need anything other than understandingand compassionate peers andco-workers.Under specific circumstances, anemployer could attempt to raise questionsregarding a nurse’s fitness or competencyfor any of these health problems. Forexample, what if a diabetic nurse experiencedan unrecognized hypoglycemicepisode and made an error in caring for apatient? What if the nurse with a chronicback problem experienced a spasm whenmoving a patient and harmed the patientor exacerbated the injury and neededworkmen’s compensation? An employer, oreven co-workers, concerned with liabilitymay fret over any number of potential situationsand fear employing or working withnurses with health problems or disabilities,even if these employees are not asking forspecial accommodations. While employmentlaws and the ADA are designed toprotect the employee’s rights, one cannotlegislate attitudes and beliefs. The grayareas in law, regulation and even our ownpersonal beliefs leave a great deal of spacefor what course of action may be taken.In this issue of the Wyoming NurseReporter, read the stories of nurses herein Wyoming who are struggling withthese very questions. Ask yourself howyou feel about working with nurses whohave health problems and/or disabilities.Consider how each of us can provide“accommodations” for one another …sometimes as simple as offering compassionand an open mind.The WSBN is actively engaged inworkforce issues here in Wyoming. Aspart of our mission of public protection,the board is charged with regulation andlicensure of nursing professionals in thestate to ensure a robust nursing workforcefor all of the people of Wyoming.We challenge all Wyoming employersand nursing professionals to criticallyexamine the issue of including nurseswith health challenges and disabilities asvalued members of the healthcare team.We welcome your comments on this issue.ReferencesGallagher, T. (2008). Nurses in demand:Statement of the problem. Casper,WY: Wyoming Department of Employment,Research and Planning o. DocumentNumber)Helms, L., Jorgensen, J., and Anderson,M. A. (2006). Disability law and nursingeducation: An update. Journal of ProfessionalNursing, 22(3), 190-196.Snyder, E. K. (2008). Chemical dependency:Hospital not required to accommodaterestrictions re narcotics, no disabilitydiscrimination. Legal Eagle Eye for theNewsletter for the Nursing Profession,16(1), 4.Administrative rules and regulations,(2003).4 W y o m i n g N u r s e R e p o r t e r

Rose Rennell, RN, MS, COHN EmployeeHealth Nurse, Campbell County MemorialHospital, Gillette, Wyo.A Rose is Not Just a RoseRose Rennell, RN, MS, COHNI am a nurse. I have always been a nurse.Even in childhood, when playing withneighborhood friends, I was the nurse bandagingimaginary wounds. I officially beganmy nursing career as a licensed practicalnurse in 1978. I moved to Gillette, Wyo., in1980. I had to wait for the associate degreenursing program to come to the Gillettecampus to continue towards my goal ofbeing a registered nurse. By the time theprogram was ready to accept students, mycredits were too old to transfer. I was ableto earn credits by challenging many of thecourses and clinical requirements, but I stillhad to repeat some classes. As a mother oftwo growing children, maintaining full timeemployment with benefits was essential, soI completed most of the courses by takingnight classes. I enrolled in one or twoclasses a semester until I was accepted intothe associate degree program in January of1989.It was during fall break, Octoberof that year, that my children (now youngteenagers) and I went to Rapid City tospend time with my family. We started ourreturn to Gillette on Sunday evening. Theweather turned colder, forming black ice onthe highway. As we passed the exit of Sundance,Wyo., my little Chevy S-10 pickuptook a sudden slide sideways, landed in theditch, and rolled over onto the roof. I wasthrown partially out of the window. Thetruck rolled across my chest and dumped meface down in the ditch. This shattered myT4 and fractured T5 and T7. Thankfully,my children sustained only minor injuries.At that point, only two months fromgraduation, my world changed. I had a newname, T4 complete paraplegic.My co-workers, fellow students,instructors and friends never wavered intheir support. My rehabilitation includedmore than the physical preparation for mynew life. I was determined to finish my RN.With the help of a fellow nursing studentsending me typed lecture notes weekly andGillette campus instructors creating clinicalrotations, I did finish and graduated May1990. My focus on completing my nursingdegree kept me looking forward.The hospital where I had workedfor nine years did not know what to do withme. The idea of an RN in a wheelchair wasthinking way outside the box, and I kepthearing terms like “patient safety” and “bedsideaccessibility.” Our Infection Controlnurse, always the visionary, stepped forwardand proposed a new position called EmployeeHealth nurse. This would be a nursewho concentrated on meeting the healthand safety needs of the staff and has knowledgeof the Occupational Safety and HealthAdministration (OSHA) and Centers forDisease Control and Prevention (CDC)requirements. I continue to hold this position,and it has proven to be challengingand extremely rewarding. I now take care ofthe staff that took care of me. Believe mewhen I say there is nothing “cushy” about a“desk job.”I continued my education thanksto the support and encouragement frommy manager. I completed my Bachelor ofScience Degree in Nursing through the Universityof Wyoming’s RN to BSN programin 1997 and my Master of Science Degreealso from UW in 2002. I achieved nationalcertification in Occupational Health Nursingin 2001.Along the way, I met a mixture of supportand resistance for nursing from a wheelchair.Stereotypic attitudes are like blinders, preventingthe person from being seen beyondthe disability. I mostly ignore the doubtersand work around them. I have confidencein what I can do and know my limitations.The real beauty of nursing is the vast careerfields that are available. Bedside nursing isnot the only game in town.My disability has given me an insight tothe long lasting effects an injury can haveon the individual, the family, and financialstability. Workplace safety and preventionof work-related injuries is one of the mostimportant functions of my position. Whenan injury does occur, job accommodation isa viable option to keep the valued, skilledworker on the job. This is better for theemployer and the employee. If nothing else,I want to be living proof that working with adisability can be a win-win situation.

S c o p e o f Pr a c t i c e Is s u e s• Advisory Opinion: 04-143, FNP PracticingPsych/Mental Health Setting-APNAlthough members of the Board acknowledgethe barriers to obtaining adequate care forchildren with mental health issues, they reaffirmedAdvisory Opinion Number 04-143 (FNPPracticing Psych/Mental Health Setting-APN).This decision is based upon documents describingthe scope of practice and core competenciesidentified by the National Association of ClinicalNurse Specialists and the National Organizationof Nurse Practitioners. This opinion, drafted July14, 2004, is written as follows: “It is not withina Family Nurse Practitioner’s (FNP) scope topractice as a Clinical Specialist (CS) or NursePractitioner (NP) in Psychiatric/Mental Health(P/MH) nursing. The FNP may only practicewithin the standards of practice promulgated bythe national accreditation agencies representingFNPs. If the FNP wishes to practice as a CS orNP in Psych/Mental Health, they must have theeducational preparation (degree/post graduatecertificate in psych/mental health nursing). Ifthe FNP is appropriately certified by the ANCCfor practice as an Advance Practice Nurse in P/MH nursing, there is no reason that the individualcan not practice in P/MH setting, as certificationis highly recommended.”• Advisory Opinion: 08-186, Procedural Sedationand Analgesia in the Emergency DepartmentFollowing the presentation of the informationfrom the Emergency Nurses Association, thearticle from the American Family Physician(2005) as well as the consensus statement on thistopic, the Board of Nursing made the followingdecisions:1. Rescind Advisory Opinion Number 06-163(Administration of Anesthetic Agents such asPropofol, Etomidate and Ketamine by Rns for IVConscious Sedation).2. Adopt the Procedural Sedation and Analgesiain the Emergency Department Consensus Statementas endorsed by the following organizations:Air and Surface Transport Nurses Association,American Academy of Emergency Medicine,American Association of Critical Care Nurses,American College of Emergency Physicians,American Radiological Nurses Association,American Society for Pain Management Nursing,Emergency Nurses Association, NationalAssociation of Children’s Hospitals and RelatedInstitutions.The Procedural Sedation and Analgesia in theEmergency Department advisory opinion iswritten as follows: “The Wyoming State Boardof Nursing adopted the Procedural Sedation ConsensusStatement as endorsed by the followingorganizations: Air and Surface Transport NursesAssociation, American Academy of EmergencyMedicine, American Association of Critical CareNurses, American College of Emergency Physicians,American Nurses Association, AmericanRadiological Nurses Association, AmericanSociety for Pain Management Nursing, EmergencyNurses Association, National Associationof Children’s Hospitals and Related Institutions.Procedural Sedation Consensus StatementThe immediate availability of interventionsincluding procedural sedation is critical to servingthe needs of our patients. Preserving life,restoring health, and alleviating suffering havebeen fundamental to the practice of nursing andmedicine for centuries. We are challenged ashealth care professionals to provide this care in amanner that meets the Institute of Medicine’s SixQuality Aims of safe, effective, timely, efficient,equitable, and patient centered care. Patientswith emergency medical conditions frequentlyexperience significant treatable pain and anxiety.There is ample evidence to support the routineuse of procedural sedation by appropriatelytrained and credentialed emergency nurses andphysicians.PRINCIPLES FOR PROCEDURAL SEDA-TION IN EMERGENCY CARE SETTINGS➢Patients have a right to expect that:o their survival and recovery will always be toppriorities;o their care will be provided in a safe and patientcentered manner;o their comfort will be assessed and pain managedin an equitable, timely, and efficient manner;o their care in emergency care settings will beconsistent with current medical knowledge andpractice;o their emergency caregivers will be appropriatelytrained and credentialed; ando they will be provided sufficient information,when possible, to allow them to participate intherapeutic decisions and provide informedconsent.➢ The primary goal of procedural sedation forpatients in emergency care settings is to managepain and anxiety while facilitating immediateinterventional procedures.➢ The response to sedating medications followsa broad continuum that varies from patient topatient. Care must be customized to both thepatient and the clinical situation, and caregiversmust be able to recognize and manage potentialcomplications.➢ Procedural sedation is safe and effective whenperformed by appropriately trained, credentialed,and supported emergency nurses and physicians.We, the undersigned organizations, agree:1. Medications including, but not limited to,etomidate, propofol, ketamine, fentanyl, andmidazolam are utilized by healthcare professionalsto facilitate management of a continuum ofpainful conditions. These extend from simplepain management and maintenance sedation tomoderate to deep sedation for painful procedures.Because of the myriad ways these medicationsmight be used, it is best to focus on the goalof the intervention rather than the medicationitself.2. Procedural sedation is defined as a techniqueof administering sedatives or dissociative agentswith or without analgesics to induce a state thatallows the patients to tolerate an unpleasantprocedure while maintaining cardiorespiratoryfunction. (American College of EmergencyPhysicians [ACEP] Clinical Policy for ProceduralSedation and Analgesia in the Emergency Department,Annals of Emergency Medicine 2005)3. Procedural sedation medications may beadministered by a registered nurse (RN) in thepresence of a physician, an advanced practiceregistered nurse, or other health care professionalcredentialed and privileged for procedural sedation.RNs administering such medications mustpossess the training and competencies describedin item four below.4. Administration of medications for proceduralsedation by a RN is a specialized skill thatrequires specific knowledge and competenciesincluding, but not limited to:a. An understanding of the principles of oxygendelivery, transport and uptake, and respiratoryphysiology.b. Demonstrated competency in airway managementappropriate to the age of the patientincluding monitoring patient oxygenation andventilation (e.g. skin color, respiratory rate, pulseoximetry, secondary confirmation of endotrachealtube placement), initiation of resuscitative measures,and utilization of oxygen delivery devices(e.g. nasal cannula, mask, basic airway techniques,oral/nasal airways, bag valve mask).c. Demonstrated knowledge of anatomy, physiology,pharmacology, cardiac dysrhythmia recognition,and complications related to proceduralsedation and analgesia.d. Ability to initiate cardiac resuscitation procedures(e.g. CPR, cardioversion, defibrillation).e. Identification and differentiation of the variouslevels of sedation.f. Demonstrated competence in pre-procedural,procedural, and post-procedural nursing care fromthe initial patient evaluation to patient discharge(e.g. patient assessment and monitoring, IV fluidadministration, medication administration).g. The ability to recognize complications andintervene appropriately.h. Knowledge of the legal/liability ramificationsassociated with an independently licensed RNadministering procedural sedation.5. Procedural sedation requires the presenceof two licensed professionals at the bedside.One licensed professional must be a RN whosecompetency in procedural sedation has been verified.This RN may administer the medication ormonitor the patient and must not be involved inperforming the procedure.Health care professionals monitoring the patientundergoing procedural sedation must not haveother responsibilities that would compromisetheir ability to adequately monitor the patientbefore, during, and after the procedure.6. Resuscitation equipment and supplies must beage appropriate and readily available for the patientundergoing any procedure. At a minimum,equipment should include oxygen and oxygen deliverydevices, suction devices and suction source,cardiac and pulse oximetry monitoring devices,defibrillator, oral/nasal airways, intubation equipment,alternative airways, bag-valve mask device,equipment to allow secondary confirmation ofendotracheal tube placement, reversal agents andACLS medications. (ACEP

From the President of the Wyoming StateBoard of NursingKellie Clausen, RN-C, WHCNP, FNPThis issue of the Wyoming NurseReporter begins an effort by the WyomingState Board of Nursing to communicate ourpurpose and message to our license holders.Look for articles during the coming monthsabout the different committees, responsibilitiesand charges of the board. ExecutiveOfficer Mary Kay Goetter will share her experience,education and enthusiasm as well.As we begin another license cycle, Iencourage everyone to renew early. Ournew online renewal for RNs (only) will beavailable this fall, and we look forward toimproved efficiency and ease of use.Several Board members and staff recentlyattended the 30th Annual Meeting of theNational Council of State Boards of Nursing.This is my third year of attendance atthe Annual Meeting, and I am awed by theprivilege and by the people I meet. Althoughour numbers are small in comparisonto many other states, our issues are verysimilar. I am reminded how fortunate we arein Wyoming to have such forward thinkingnursing legislation and also to live in such afiscally sound state.On the issue of nursing legislation, theRules and Regulations of the WyomingState Board of Nursing are being rewrittenas you are reading this magazine. They willbe out for public comment very soon. Pleaseshare your comments on these rules as theybecome available. Although your board ismade up of a diverse group of nurses and anincredibly competent and talented consumermember, we benefit from the input of allthe stakeholders in the state. Nursing isevolving at an ever faster pace, and if we areto keep up, we need input. It is encouragingthat our rules are a living documentand respond to the needs of the people ofWyoming.I was recently attending a non-nursingsocial function, and standing in line at thebuffet, a woman struck up a conversationwith me about my profession. When I toldher I am a Nurse Practitioner, she sharedthis story with me and gave me permissionto share it with you as well: While needingto visit her Nurse Practitioner last year, shewas informed the NP was on vacation butsomeone else would be filling in. She wasshown to an exam room as usual and a veryyoung, well-dressed and obviously nervousMountain ViewRegional Hospitalis the premiereneurosurgical andspine hospital inCasper, WY andthe Rocky MountainRegion. We offerleading-edge surgicaltreatments—andthe highest levelsof comfort andcare—in a healingenvironment.Our incomparablevision of serviceexcellence has leda highly motivatedleadership teamto hand selectexceptional nursesfor our patients.young man came in to see her. In an effortto put him at ease, she asked how long hehad been a Nurse Practitioner, and he toldher, “I am not a Nurse Practitioner, I am aphysician.”At Mountain View Regional Hospital,the patient always comes first.Our nurses want to help, and they believe in the healingpower of human touch. This group of professionalshas come together to make a difference in theirpatient’s lives. At Mountain View Regional Hospital,nurses deliver uncompromised care in an environmentof clinical excellence.We are accepting applications from nurses with 1 to2 years experience in Neurosurgical, Surgical, or CriticalCare/PACU/ER. If you are interested in joining ourmotivated and enthusiastic team, send your resume forconsideration to Jenni Milner at jmilner@nshinc.com

St. John’s Medical Center NursePractitioner, Connie JohnsonSt. John’s Medical Center Nurse Practitioner, Connie Johnson, has been chosen for a one yearOncology fellowship at the M.D. Anderson Cancer Center in Houston, Texas.The appointment will involve directly working with Oncology Nurse Practitioners andOncologists with exposure to the entire spectrum of oncology care from prevention to end of life.The fellowship will also include classes at the University of Texas Health Science Center at Houstonleading to a post-masters oncology degree.Johnson has been employed by St. John’s Medical Center located in Jackson, Wyo., for six years.She also sees patients at the 4 Peaks Clinic in Driggs, Idaho, as a Family Nurse Practitioner. Johnsonplans to return to Jackson upon completion of the fellowship, where she will work as an OncologyNurse Practitioner at the Oncology clinic.Johnson is a board member for the Wyoming affiliate of Susan G. Komen for the Cure. She also isa member of the Susan G. Komen Advocates in Science Program, a committee that reviews nationalbreast cancer research grants.What is NURSYS?Nur Rajwany, MSNCSBN, Director Information TechnologyDawn M. Kappel, MANCSBN, Director Marketing and CommunicationIf your organization has a need to ensure safety and save time while increasing efficiency in regard to verification of a nurselicense and/or checking discipline status for employment decisions, then look no further than the NCSBN Nursys® (www.nursys.com) computer system. Nursys provides licensure verification and discipline status instantly, allowing for faster informedemployment decisions.Nursys contains personal, licensure, education, verification and discipline information supplied as regular updates byboards of nursing in the U.S. and its territories. All boards of nursing, including non-licensure participating boards of nursing,have access to information within Nursys and are able to enter and edit discipline information. Nursys provides centralizedlicense information to boards of nursing, which in turn, use this data to verify applicant license information, enter and reviewdisciplinary actions and send electronic communications between boards of nursing for information requests.NCSBN also provides public access to Nursys for the purposes of licensure verification. Nursys verifies license and disciplinestatus, including discipline against the privilege of working in a Nurse Licensure Compact (NLC) party state.8 W y o m i n g N u r s e R e p o r t e r

The following is an example of verification of a multistate license issued by Arkansas. This nurse has no discipline action taken againsthis license and no privilege to practice discipline taken by any other NLC state.When a licensed nurse applies for licensure in another state, verification of existing or previous licenses may be required. A nurse can useNursys to request verification of licensure from a Nursys licensure participating board. For example, the Wyoming State Board of Nursinglicensure participates in Nursys; therefore, licensed nurses in Wyoming can use Nursys for verifying licensure verification to another boardof nursing by visiting www.nursys.com. If the nurse needs to request license verification from a non-licensure participating board, the nurseshould contact the board of nursing where she/he holds license.Verification can be requested by completing an online Nursys verification request application (there is a $30.00 fee for this service).Once verification has been processed, the verification information is available to all boards of nursing for 90 days. Multiple applications canbe fulfilled by the same verification request and fee, as long as it is accessed by the board of nursing within the 90-day period. Nursys licenseverification is made available to boards of nursing immediately upon completion of the online verification process, which expedites theendorsement process for nurses.Employers can verify multiple licenses including all NLC party states within minutes and pay only for those reports they select. Eachreport is available for printing directly from the Web browser upon payment. A copy of the report and receipt are automatically sent bye-mail upon completion of the transaction. There are additional boards that have signed agreements to provide licensure data throughNursys; this data will be available in the coming months.For more information, e-mail NursysS@ncsbn.org,call 312.525.3780 or visit www.nursys.com.Information on the NLC is available by visiting: https://www.ncsbn.org/nlc.htm.For a list of licensure participating Boards of Nursing, visit: (https://www.nursys.com/includes/processing/psPartState.aspW y o m i n g N u r s e R e p o r t e r 9

Legal Rights for Nurses with DisabilitiesMarcia L. Dale, RN, EdD, FAANThe first legal movement to helppeople with disabilities was the passageof the Rehabilitation Act of 1973. Thiswas followed by the Americans withDisabilities Act of 1990. These two lawsgave nurses weapons with which to fightdiscrimination against practices that keptthem from obtaining or keeping employment.“The Rehab Act prohibits discriminationagainst individuals with anyhandicap by any entity receiving federalfunding. Thus, any healthcare employerreceiving Medicare payments or that is inany way connected to the federal governmentor federal funding is covered underthis law” (Matt, 2006, p. 1). Employersare required to make reasonable accommodationsfor qualified applicants withdisabilities. This means that a nurse whohas the skills, experience, and educationcalled for in an available position, with orwithout reasonable accommodation, maybe considered qualified. But, “for an individualto be protected by the Rehab Actand the ADA, they must have a physicalor mental impairment that substantiallylimits one or more major life activity”(Matt, 2006, p. 3).Reasonable accommodation must beinitiated by the nurse. It might be assimple as making the facility accessible orit might be job restructuring to part-time,modifying equipment, or the provisionof a reader or interpreter. It all mustbalance out in cost versus benefit to theemployer and employee (Lyons, 1995).Lyons. V. (1995). Legal Aid Society.Maheady, D. C. (2006) Leave NoNurse Behind: Nurses Working with disabilities.New York: iUniverse, Inc.Matt, S. B. (2006). Reasonableaccommodation: Legal protectionfor nurses with disabilities in In D.C.Maheady, Leave no nurse behind: Nursesworking with disabilities (pp. 1-7). NewYork: iUniverse, Inc.Ad Space Available10 W y o m i n g N u r s e R e p o r t e r

Disabled NursesNeed GritMarcia L. Dale, RN, EdD, FAANMarcia L. Dale, RN, EdD, FAANIn the last issue of Wyoming NurseReporter, there was a letter to the editorwritten by Trudy Craft, a nurse witha significant hearing problem. Shebrought to light that a disability doesnot end the contribution a nurse canmake to the profession. She is an exampleof a nurse who has found a nichefor her skills, in spite of being hearingimpaired. The question she raises is,why are disabled nurses not granted theopportunity to practice when a nursingshortage exists and will continue toonly get worse? A 2002 U.S. CensusBureau report stated that 56 percent ofpeople ages 21 to 64 who had a disabilitywere employed at some point duringthe year prior to the report, comparedto an 88 percent employment ratefor those with no disabilities (Spader,2007). This issue of The WyomingNurse Reporter addresses severalareas concerning disabilities.The number of nurses whoare disabled is not known,and these data are notavailable in Wyoming.Some nurses and/or students do not want to disclosetheir disability for fear of terminationor denial of admission to a school ofnursing. Others may be involved in alawsuit and are not at liberty to discusstheir disabilities. The term “be ableto perform the essential functions” ofa nurse is frequently used as a criterionfor acceptance into a position ofemployment or into a nursing programand is the criterion for whether or not aperson is disabled. The reasons for thisgroup of nurses not being utilized toaddress the nursing shortage are numerous,but the safety issue is the most predominant.Barriers are set up becauseof the essential functions identified byemploying agencies.The recent emphasis on veteransreturning from war with severe disabilitieshas shown how survivors adaptto their afflictions. It is amazing whatthey can accomplish through sheereffort. Nurses are no different. Theyare problem solvers who can overcometheir disability with innovation.However, because of the emphasis onpatient safety, regulations became morestringent. In 1990, the Americans withDisabilities Act was passed. This wasintended to make life more equal forpeople with disabilities. However, thelegal interpretation and the meaningof reasonable accommodations havebeen interpreted so differently thatadmission to schools and hiring byemployers has been inconsistent.Somestudents with disabilities have beenadmitted and graduated only to havedifficulty finding employment becausethe institution is unwilling to makeaccommodations.The disabilities that nurses havemay result from a birth defect, injuriesfrom lifting a patient, violence inflictedby patients, exposure to latex, hepatitis,HIV, a car accident, or on andon. These disabilities are no differentthan those found in the general public.However, what these nurses do havegoing for them is an understanding ofwhat it is like to navigate the healthcare system, how to adjust to a disability,the feelings and concerns of livingwith a disability, and the mind set ittakes to overcome the imposed limitations.Education and accommodationare the keys for disabled nurses to opennew doors.ReferencesSpader, C. (2007, January 1).disAbled nurses: Education andaccommodation are the keys toincorporating RNs with disabilities.NursingSpectrum NurseWeek. RetrievedJune 23, 2008, from http://include.nurse.com/apps/pbcs.dll/article?AID=200761225005Carol, R. (n.d.). Nurses with disabilities.Minority Nurse.com. RetrievedJune 23, 2008, from http://www.minoritynurse.com/features/nurse_emp/01-27-02h.html

THE STRENGTH TO HEALand focus on what matters most.If what matters most to you is the care of your patients, we’ve got an extra bonus for you. Asign-on bonus of $20,000 to $30,000. Or you can opt for a $10,000 bonus and up to $114,900to repay your education loans. Qualified nurses can continue their education and earn amaster’s or doctoral degree. You’ll serve our Soldiers, their Families and yourself.To learn more about the U.S. Army Health Care Team, call SFC Kristine Kettlewell at 303-873-0491, email kristine.kettlewell@usarec.army.mil, or visit healthcare.goarmy.com/info/ncra1.© 2007. Paid for by the United States Army. All rights reserved.The Beaches of CorpusChristi TXAll RNs & New Grads!Up to $7,500 Sign-on/Relo Pay up to $39.25 (w/Shift Diff)Ask about $11hr premium15% eves, 25% night Shift Diffs,Day Shifts Available!24hr Onsite DaycareClin Adv Pgm–to $500 monthExcellent Benefits Package!3k yr Tuition AssistanceNo State Income Taxes=more $San Antonio and Houston alsoavailableThe Beach – You Deserve ItContact Jeff Martin1-800-304-3095, x16jmartin@beck-field.comCONTINUING EDUCATION COURSES @ LEARNINGEXT.COMAcclimation of International Nurses intoUS Nursing Practice6.6 Contact Hours | $40Confronting ColleagueChemical Dependency3.3 Contact Hours | $20Delegating Effectively4.2 Contact Hours | $25Disciplinary Actions: What Every NurseShould Know4.8 Contact Hours | $29Diversity: Building Cultural Competence6.0 Contact Hours | $36UNLIMITED, 24-HOUR ACCESSTO ENGAGING NURSING CE CONTENT@ LEARNINGEXT.COMDocumentation: A Critical Aspect of Client Care5.4 Contact Hours | $32End-of-Life Care and Pain Management3.0 Contact Hours | $18Ethics of Nursing Practice4.8 Contact Hours | $29Medication Errors: Detection & Prevention6.9 Contact Hours | $41Nurse Practice Acts CE CoursesParticipants: AR, IA, ID, KY, MA, MN,MO, NC, ND, NM, NV, OH, VA, WV-PN/RN2.0 Contact Hours | $12Patient Privacy5.4 Contact Hours | $32Professional Accountability& Legal Liability for Nurses5.4 Contact Hours | $32Respecting Professional Boundaries3.9 Contact Hours | $23Sharpening Critical Thinking Skillsfor Competent Nursing Practice3.6 Contact Hours | $22E-LEARNING FOR THE NURSING COMMUNITYW y o m i n g N u r s e R e p o r t e r 13

S c o p e o f Pr a c t i c e Is s u e sGuidelines for Equipment and Supplies forUse in Pediatric Patients in the ED, 2000;Alaska Board of Nursing Advisory Opinionon Nurse Administration of Sedating andAnesthetic Agents, 2007.)7. Written policies, procedures, clinicalguidelines, and protocols for proceduralsedation should be in place in the institution.These policies should be age appropriate andshould include, but not be limited to:➢Equipment and supplies➢Mandatory education and competencyvalidation➢Risk management➢Quality monitoring to include patientoutcomes➢ Required documentation********************************ADDENDUMProcedural Sedation Consensus StatementDefinitions:Advanced Practice Registered Nurse (APRN)is an umbrella term given to a RN whohas met advanced educational and clinicalpractice requirements beyond the two to fouryears of basic nursing education required ofall RNs. APRNs include nurse practitioners,clinical nurse specialists, nurse anesthetists,and nurse midwives. Nurse practice acts varywidely among states. They define the scopeof practice for APRNs within that particularstate. (American Nurses Association [ANA]Nursing Facts, www.nursingworld.org)Certified Registered Nurse Anesthetists aremaster’s prepared advanced practice nurseswho provide anesthetics to patients in everypractice setting and for every type of surgeryor procedure. (http://www.aana.com)Credentialing is a term applied to processesused to designate that an individual, program,institution or product have met establishedstandards set by an agent (governmental ornon-governmental) recognized as qualifiedto carry out this task. The standards maybe minimal and mandatory or above theminimum and voluntary. Licensure, registration,accreditation, approval, certification,recognition or endorsement may be used todescribe different credentialing processes, butthis terminology is not applied consistentlyacross different settings and countries. Credentialsare marks or “stamps” of quality andachievement communicating to employers,payers, and consumers what to expect froma “credentialed” nurse, specialist, course orprogram of study, institution of higher education,hospital or health service, or healthcareproduct, technology, or device. Credentialsmay be periodically renewed as a means ofassuring continued quality, and they may bewithdrawn when standards of competenceor behavior are no longer met. (Styles andAffara, 1997, International Council of NursesFact Sheet, http://www.icn.ch/matters_credentialing_print.htm)Deep sedation/Analgesia is a drug-induceddepression of consciousness during whichpatients cannot be easily aroused but respondpurposefully following repeated or painfulstimulation. The ability to independentlymaintain ventilatory function may be impaired.Patients may require assistance inmaintaining a patent airway, and spontaneousventilation may be inadequate. Cardiovascularfunction is usually maintained. (AmericanSociety of Anesthesiologists [ASA] policystatement on Continuum of Depth of SedationDefinition of General Anesthesia andLevels of Sedation/Analgesia, Approved byASA House of Delegates on October 13,1999, and amended on October 27, 2004.)Dissociative agents/dissociative sedation isdescribed as a “trancelike cataleptic statecharacterized by profound analgesia andamnesia, with retention of protective airwayreflexes, spontaneous respirations, and cardiopulmonarystability. (American Collegeof Emergency Physicians [ACEP] ClinicalPolicy for Procedural Sedation and Analgesiain the Emergency Department, Annals ofEmergency Medicine 2005.)General anesthesia is a drug-induced loss ofconsciousness during which patients are notarousable, even by painful stimulation. Theability to independently maintain ventilatoryfunction is often impaired. Patients oftenrequire assistance in maintaining a patentairway, and positive pressure ventilation maybe required because of depressed spontaneousventilation or drug-induced depressionof neuromuscular function. Cardiovascularfunction may be impaired. (ASA policy statementon Continuum of Depth of SedationDefinition of General Anesthesia and Levelsof Sedation/Analgesia, Approved by ASAHouse of Delegates on October 13, 1999, andamended on October 27, 2004.)Minimal sedation (Anxiolysis) is a druginducedstate during which patients respondnormally to verbal commands. Althoughcognitive function and coordination maybe impaired, ventilatory and cardiovascularfunctions are unaffected. (ASA policy statementon Continuum of Depth of SedationDefinition of General Anesthesia and Levelsof Sedation/Analgesia, Approved by ASAHouse of Delegates on October 13, 1999, andamended on October 27, 2004.)Moderate sedation/Analgesia (ConsciousSedation) is a drug-induced depressionof consciousness during which patientsrespond purposefully to verbal commands,either alone or accompanied by light tactilestimulation. No interventions are required tomaintain a patent airway, and spontaneousventilation is adequate. Cardiovascular functionis usually maintained. (ASA policy statementon Continuum of Depth of SedationDefinition of General Anesthesia and Levelsof Sedation/Analgesia, Approved by ASAHouse of Delegates on October 13, 1999, andamended on October 27, 2004.)Presence as used in the statement “in thepresence of a physician, advanced practiceregistered nurse, or other health care professionaldescribes the location of the healthcare professional” as being physically presentat the patient’s bedside or within the confinesof the patient’s immediate treatment space.Privilege is an exceptional or extraordinaryright, immunity or exemption belonging toa person in virtue of their office or status.Clinical privileges include, as appropriate tothe organization, privileges, membership onthe medical staff and other circumstancespertaining to the furnishing of medical careunder which a physician, dentist or otherlicensed health care practitioner is permittedto furnish such care by a health plan or by afederal or state agency that either administersor provides payment for the delivery of healthcare services. (http://www.oig.hhs.gov/authorities/docs/datacollection.pdf)Procedural sedation is defined as the techniqueof administering sedatives or dissociativeagents with or without analgesics toinduce a state that allows the patient to tolerateunpleasant procedures while maintainingcardiorespiratory function. (ACEP clinicalpolicy for procedural sedation and analgesiain the emergency department – Annals ofEmergency Medicine 2005.)Six Quality Aims as defined by the Instituteof Medicine are:• Safe: Avoiding injuries to patients fromthe care that is intended to help them.• Effective: Providing services based onscientific knowledge to all who could benefitand refraining from providing services tothose not likely to benefit, thereby avoidingunder use and overuse, respectively.• Patient-centered: Providing care that isrespectful of and responsive to individualpatient’s preferences, needs, and values andensuring that patient values guide all clinicaldecisions.• Timely: Reducing waits and sometimesharmful delays for both those who receiveand those who give care.• Efficient: Avoiding waste, including wasteof equipment, supplies, ideas, and energy.• Equitable: Providing care that does notvary in quality because of personal characteristicssuch as gender, ethnicity, geographiclocation and socioeconomic status. (Crossingthe Quality Chasm, IOM Report. NationalAcademies Press, 2001.)Continued on page18

Representing the Public as a Consumer on theState Board of NursingMarguerite HermanI represent the consumer on the WyomingBoard of Nursing and am constantlyimpressed with the commitment of theboard to the goal of assuring public healthand safety through regulation of the nursingprofession.I came to the board with a high regardfor nurses, derived from my work withthem on breastfeeding issues (I am astrong advocate), and that regard hasonly been enhanced during my 1 ½ yearson the board. I continue to admire boardmembers, the new and past executive officersand staff.What I bring to the board is a backgroundin journalism, education, lobbyingand other advocacy work. I bring theviewpoint of the consumer who may notknow all the technical details of medicalcare but who appreciates nurses’ pride intheir profession and in giving quality care.I have an undergraduate degree in Englishfrom Colorado College and masters’degrees in journalism (University of SouthCarolina) and education (University ofChicago).After six board meetings, I am becomingfamiliar with the vocabulary, acronymsand abbreviations that are specific to theworld of medicine, nursing and nursingschool. I am on the education committee,and it is a relief to no longer have to stopand mentally translate when I hear NCLXor ADN or CNA or APN – and so on. Ido occasionally have to interrupt the discussionfor explanations of practice terms,but everyone is patient and understanding.Working on creation of new rules togovern CNA IIs helped me understand theextent to which nurses are very concernedabout competence to perform certain tasksand their own accountability for what isdone under their delegated authority. Therules approval process also was revealingabout the political nature of regulatingthe practice of nursing – not by the nursesor even necessarily by their patients butby those who employ nurses. Everyone isinterested in the practice of nursing, andrightly so.The pressure to contain medical costs isin a constant tension with the insistenceon high standards, and the political realityinvolves more negotiation on the point ofstandards than I had suspected. As a consumer,I am sympathetic to the desire tocontain expenses, especially as that affectsthe accessibility and affordability of healthcare in Wyoming. However, I never wantthat pressure to compromise the qualityof nursing care Wyoming citizens receive.Decisions made by the Board of Nursingto license, discipline and define scope ofpractice are ultimately guided by the goalof quality care for Wyoming citizens.Availability of nursing educationdirectly affects the accessible/affordable issue.It also is a concern when you considerWyoming’s obligation to provide as muchopportunity as possible for residents to getthe education and skills to earn a licenseor certificate. The current shortage ofskilled nurses turns up the pressure evenmore. The board relies on the Nurse PracticeAct, rules and regulations to ensurethe success of nursing programs and theirstudents in Wyoming.I enjoy my role on the Board of Nursingand hope it makes a difference to residentsof Wyoming.Beautiful Phoenix, AZUp To $8,000 Relo BonusHouston Available also! Join A Medical Center rated “Best in the Nation”-Teaching Campus, Magnet Status! $3,000 additional Relo Bonus Comprehensive Benefits w/401k Ask about Free Medical Plan! Base up to $38.90 per hour Plus 20% ShiftDiffs!, Double time!! Full-Time RN Positions-not travel Day Shiftsavailable…Call now! Phoenix, Glendale, Mesa, more 300 + SunnyDays per yearJeff Martin 800.304.3095 Ext-16jmartin@beck-field.com

What is yourHandicap?Interview with Melanie PalluckMarcia L. Dale, RN, EdD, FAANWhether we like it or not, each andevery one of us has a handicap. Yes, thereare things that we do very well, and thereare things that we don’t do well at all. Wecompensate, ask for help, win at the gameof life in spite of the flaws or give in andblame failure on the imperfection.Lynne Shaw in Leave no nurse behind:Nurses working with disabilities (2006),made the statement that life is not fairnor is anyone perfect. How right shewas. Each of us has struggled with ourimperfections, some more predominantthan others. One particular nurse whowas gracious enough to tell her story toldof fighting the battle of obesity her entirelife. However, she worked three nights aweek in obstetrics and/or the operatingroom for 36 years. The nights fit her lifestyle, as she also took care of her grandchildrenduring the week. Cognizantof the old saying, “old nurses eat theiryoung,” this “old” nurse thought she wasassisting the young nurses by relievingthem for lunch and coffee breaks, andoffering a helping hand. Much to heramazement, two complaints were filed bythese young nurses who reported that thenurse was “hiding out” in the nursery.After much soul searching andheartache, the nurse decided to undergogastric bypass surgery but was told thather oxygen saturation levels were too low.Not to be waylaid, she went on oxygen,only to be told that she could not workin the nursery, as she might drop a baby.Being floated to a medical floor added toher grief, as there she was told to go homeon sick leave.The gastric bypass was performed.Ironically enough, care was given by anurse on oxygen. Life isn’t fair! Thesurgery has been successful in that the“patient” lost 120 pounds, has an acceptableoxygen saturation level, has nojoint pain, and can walk and handle stairswithout getting out of breath. Life shouldbe good, but for this nurse, it is not. Shehas sent out numerous letters of applicationand has had no calls for interviews.The problem now might be age discrimination,as 62 years of age is consideredold by those who have not reached thatage. It is indeed sad to know that a registerednurse who overcame obstacles nowworks for $10 an hour in a position that aless well educated person could do. Shehas a pension that covers her mortgage,but the belief that she can’t afford to liveout the extended life her gastric bypassmade possible is reducing the enjoymentof what could be the golden years.Within the white paper titled Wisdomat Work (Robert Wood Johnson Foundation,2008, April), problems of an agingworkforce, challenges that health carefaces when nurses retire early, and possibilitiesfor retaining nurses were identified.It is a fact that older workers stayon the job longer after training, reducingturnover costs. (Memory impairment isless than five percent in people 65-69,and learning new things is a part of anideal job.) Staffing and workload are twoother factors affecting retention of nurses.Rosenfeld (2007) indicates that creating“‘caregiver-friendly’ practices such as creative,flexible scheduling, access to socialworkers, financial and legal services, andincreased awareness among managersabout caregiver strains were recommended”as ways to retain older, experiencednurses (p. 120). Those same strategiesshould be used to retain nurses with adisability. Assessment of the “disabilityclimate” is another way to determinewhether the work setting is conducive tothe success of the disabled nurse.Disability climate is a key determinantof the successful integration of individualswith disabilities into the work forceand a major influence on the level ofoccupational stress experienced by thispopulation. Industry-specific attitudesregarding disabilities have an effect ondisability climate as perceived by workers,as do formal and informal policies,procedures, and practices. Occupationalhealth nurses can impact organizationaldisability climates through implementationof disability climate programs, thusimproving workplace conditions forworkers with disabilities and reducingoccupational stress (Matt and Butterfield,2006, p. 129).Whether one identifies the agencyas “care-giver friendly” or as having apositive “disability climate,” the workplace environment is so important to theretention of nurses. Each nurse must beeducated about these issues and assumea lead role in the creation of a positiveworkplace. The responsibility fordeveloping a work environment wheresensitivity, compassion, respect andconsideration for others are prime valueslies with everyone, not just the employer.The inclusion of nurses with disabilities,however those may be described orinterpreted, can only lead to the diversitythat makes our occupational life rich andsatisfying.ReferencesMatt, S. B. and Butterfield, P. (2006).Changing the disability climate: Promotingtolerance in the workplace. AmericanAssociation of Occupational HealthNurses, 54(3), 134-135.Robert Wood Johnson Foundation(2008, April). Featured Research: Wisdomat work. New research provides solutionsto the nursing shortage: Improvingretention of older and experiencednurses in the workforce, 6, 3-8.Rosenfeld, P. (2007). Workplace practicesfor retaining older hospital nurses:Implications from a study of nurses witheldercare responsibilities. Policy, Politicsand Nursing Practice, 8(2), 120-129.Shaw, L. (2006). Hill, what hill?Nursing with Guillain-Barre’, osteoarthritisand lifelong obesity. In D. C. Maheady,Leave no nurse behind: Nurses workingwith disabilities, (pp.19-25). New York:iUniverse Inc.16 W y o m i n g N u r s e R e p o r t e r

If you are DisabledAdapted from Career Fitness Tips for Disabled Nurses by ValerieRestifo, Nurse Week, February 20, 2001Disabilities can happen at any stage in one’s life. Be prepared toavoid as many as possible by staying healthy. An attitude of beingflexible, continuing to earn certifications and degrees, and beingpositive will help to avoid being defined by a disability. It is howyou handle the disability that makes the difference.The right strategies will help get a promotion, a new position, or acareer transition after an injury or illness.1. See yourself as a problem solver! Focus on the things you cando well. Sell your qualifications, strengths, achievements, andcareer goals.2. Don’t mention your limitations or inabilities in your cover letteror application. When asked if you can perform certain dutiesof the position, state what reasonable accommodations you willneed. Focus on what you can do, not what you cannot do.3. Use your professional contacts. Many jobs are found throughnetworking. Tell all the professionals you know what you arelooking for and what your qualifications are.4. Think positively. Your enthusiasm, optimism, and positiveapproach will get you far. Answer questions with a positiveresponse.5. Do your homework about the position for which you are applying.Ask for a tour to see if you can handle the layout. The moreyou know, the easier it will be to make a decision about an offer.6. Seek out employees of the organization where you want towork to determine if they are open to professionals undergoingrehabilitation.7. Look your best and be as healthy as you can be. Schedule theinterview when you are at your best. Clothes, cosmetics, and accessoriescan give you a business and confident look.8. If you didn’t sell yourself for the position, reassess and try again.Remember, you have something to offer. Matching your assets tothe job is the winner.Student Nurses with DisabilitiesMartha Smith, coordinator of the HealthSciences Faculty Education Project at theOregon Health & Science University inPortland is working to increase the retentionof students with disabilities in health scienceprograms through a federally funded program.The purpose is to educate and train faculty tounderstand students’ needs. In most cases ofnurses or students with disabilities, the biggestobstacle is attitude. Usually, the initialreaction of seeing someone with a disabilityis that the person needs to be fixed. Not so!The person can be competent as a healthcare professional. Whether voiced or not,the common thought is that a nurse with adisability may not be able to provide safe,competent care. This thought is prevalentamong nursing faculty, students, nursingpeers, physicians and patients. No secondchance is given. If a mistake is made, the assumptionis that it was because the performerwas disabled.The University of Wyoming Fay W.Whitney School Of Nursing has a statementMarcia L. Dale, RN, EdD, FAANin their admission policies that states: “Allstudents must be able to perform the essentialfunctions of a student nurse. Reasonableaccommodations will be afforded to studentnurses with disabilities as required under theAmericans with Disabilities Act of 1990;Faculty and staff from the School of Nursingwill work with staff from the University DisabilitySupport Services to determine whatconstitute reasonable accommodations.”The ADA allows schools to list technicalstandards or essential functions -abilities thata potential student must possess to succeed.These can prohibit some students from beingadmitted, the opposite of the intent of theADA. Students have been known to have toapply to several schools before being admitted.Be persistent. Usually, the faculty tendsto expect the student to be more limitedthan they are. Don’t let them decide whatcan and cannot be done. Not admitting toa disability is not uncommon, as that mightcontribute to admission. This however, onlydenies special accommodations to which thedisabled are legally entitled. Some specialequipment such as amplified stethoscopes, vibratingpagers, automatic blood pressure cuffsand digital thermometers have helped nurses.Being given more time to take an exam orto perform a skill might be necessary. Askingfor an interpreter or reader might solve aproblem. These solutions are not beyond areasonable accommodation.ReferencesCarol, R. (n.d.). Nurses with disabilities. MinorityNurse.com. Retrieved June 23, 2008 from http://www.minoritynurse.com/features/nurse_emp/01-27-02h.htmlDenver’s Nursing Star (2008, June 23). Disablednurse succeeds despite hurdles, attitudes. RetrievedJune 23, 2008 from http://www.denvernursingstar.com/newsletterMaheady, D. C. (2006) Leave No NurseBehind: Nurses Working with disabilities. New York:iUniverse, Inc.www.ExceptionalNurse.comwww.healthsciencefaculty.orgDisciplinary ActionsRuth KearneyLetter of Reprimand Drug Diversion 7/08/2008

S c o p e o f Pr a c t i c e Is s u e sBIBLIOGRAPHYCLINICAL and ORGANIZATIONAL POSI-TION STATEMENTSACEP Policy Statements. Procedural Sedationin the Emergency Department (2004) andDelivery of Agents for Procedural Sedation andAnalgesia by Emergency Nurses (2005).ACEP Clinical Policy: Procedural Sedationand Analgesia in the Emergency Department.Ann Emerg Med. 2005 Feb; 45(2):177-196.ACEP Clinical Policy: Evidence-Based Approachto Pharmacologic Agents Used inPediatric Sedation and Analgesia in the EmergencyDepartment. Ann Emerg Med. 2004 Oct;44(4):342-377.ACEP Guidelines for Equipment and Suppliesfor Use in Pediatric Patients in the ED (2000).Available at http://www3.acep.org/practres.aspx?id=29134Alaska Board of Nursing Advisory OpinionNurse Administration of Sedating and AnestheticAgents (2007). Available at http://www.dced.state.ak.us/occ/pub/nur1809.pdfAmerican Nurses Association (ANA). (1991).Endorsement of position statement on the roleof the registered nurse in the management ofpatients receiving IV conscious sedation forshort-term therapeutic, diagnostic, or surgicalprocedures. Available at www.ana.org/readroom/position/joint/jtsedate.htmAmerican Society of Anesthesiologists (ASA).(2004). Continuum of depth of sedation: Definitionof general anesthesia and levels of sedation/analgesia.Available at http://www.asahq.org/publicationsAndServices/standards/20.pdfENA Position Statement: Procedural Sedationand Analgesia in the Emergency Department(2005).ENA and ACEP Joint Position Statement:Delivery of Agents for Procedural Sedation andAnalgesia by Emergency Nurses (2005).Institute of Medicine. (2001). Crossing theQuality Chasm, IOM Report. National AcademiesPress.International Council of Nurses. (1997). Stylesand Affara, Credentialing Fact Sheet. Availableat http://www.icn.ch/matters_credentialing_print.htmJoint Commission on Accreditation of HealthcareOrganizations (JCAHO). (2005). Comprehensiveaccreditation manual for hospitals: Theofficial handbook. Oakbrook Terrace, IL.CLINICAL PRACTICE AND RESEARCHARTICLESAnderson, J. L., Junkins, E., Pribble, C., andGuenther, E. Capnography and Depth of SedationDuring Propofol Sedation in Children.Ann Emerg Med. 2007 Jan; 49(1): 9-13.Bassett KE, Anderson JL, Pribble CG, GuentherE. Propofol for Procedural Sedation in Childrenin the Emergency Department. Ann Emer Med.2003 Dec; 42(6): 773-782.Burton JH, Bock AJ, Strout TD, Marcolini EG.Etomidate And Midazolam for Reduction ofAnterior Shoulder Dislocation: A Randomized,Controlled Trial. Ann Emerg Med. 2002 Nov;40(5): 496-504.Burton JH, Miner JR, Shipley ER, Strout TD,Becker C, Thode HC. Propofol for EmergencyDepartment Procedural Sedation and Analgesia:A Tale of Three Centers. Acad Emerg Med.2006 Jan; 13(1):24-30.Campbell SG et al. Procedural Sedation andAnalgesia in a Canadian Adult Tertiary CareEmergency Department: A Case Series. Can JEmerg Med. 2006 Mar; 8(2):85-93.Chudnofsky CR et al. A Combination of Midazolamand Ketamine for Procedural Sedationand Analgesia in Adult Emergency DepartmentPatients. Acad Emerg Med. 2000 Mar; 7(3):228-235.Dickinson R, Singer AJ, Carrion W. Etomidatefor Pediatric Sedation Prior to Fracture Reduction.Acad Emerg Med. 2001 Jan; 8(1): 74-77.DiLiddo L, DAngelo A, Nguyen B, Bailey B,Amre D, Stanciu C. Etomidate Versus MidazolamProcedural Sedation in Pediatric Outpatients:A Randomized Clinical Trial. AnnEmerg Med. 2006 Oct; 48(4): 433- 440.Falk J, Zed PJ. Etomidate for ProceduralSedation in the Emergency Department. AnnPharm. 2004 Jul/Aug; 38: 1272-1277.Frank LR, Strote J, Hauff SR, Bigelow SK,Fay K. Propofol by Infusion Protocol for EDProcedural Sedation. Am J Emerg Med. 2006;24: 599-602.Godambe SA, Elliot V, Matheny D, PershadJ. Comparison of Propofol/Fentanyl VersusKetamine/Midazolam for Brief OrthopedicProcedural Sedation in a Pediatric EmergencyDepartment. Pediatrics. 2003 Jul; 112(1): 116-123.Green SM. Research Advances in ProceduralSedation and Analgesia. Ann Emerg Med. 2007Jan; 49(1):31-36.Green SM, Krauss B. Clinical Practice Guidelinefor Emergency Department KetamineDissociative Sedation in Children. Ann EmergMed. 2004 Nov; 44(5):460-471.Green SM, Hummel CB, Wittlake WA, RothrockSG, Hopkins GA, Garrett W. What is theOptimal Dose of Intramuscular Ketamine forPediatric Sedation? Acad Emerg Med. 1999 Jan;6(1): 21-26.Guenther E, Pribble CG, Junkins EP, KadishH, Bassett KE, Nelson DS. Propofol Sedationby Emergency Physicians for Elective PediatricOutpatient Procedures. Ann Emerg Med. 2003Dec; 42(6): 783-751.Hunt GS, Spencer MT, Hays DP. Etomidate andMidazolam for Procedural Sedation: Prospective,Randomized Trial. Am J Emerg Med. 2005;23: 299-303.Miner JR, Biros M, Krieg S, Johnson C, HeegaardW, Plummer D. Randomized ClinicalTrial of Propofol Versus Methohexital for ProceduralSedation during Fracture and DislocationReduction in the Emergency Department. AcadEmerg Med. 2003 Sept; 10(9): 931-937.Miner JR, Danahy M, Moch A, Biros M.Randomized Clinical Trials of Etomidate VersusPropofol for Procedural Sedation in the EmergencyDepartment. Ann Emerg Med. 2007 Jan;49(1): 15-22.Miner JR, Martel ML, Meyer M, Reardon R,Biros M. Procedural Sedation of Critically IllPatients in the Emergency Department. AcadEmerg Med. 2005 Feb; 12(2): 124-128.Parlak M, Parlak I, Erdur B, Ergin A, Sagiroglu.Age Effect on Efficacy and Side Effects of TwoSedation and Analgesia Protocols on PatientsGoing Through Cardioversion: A RandomizedClinical Trial. Acad Emerg Med. 2006 May;13(5): 493-499.Roback MG, Wathen JE, MaKenzie T, Bajaj L.A Randomized, Controlled Trial of IV VersusIM Ketamine for Sedation of Pediatric PatientsReceiving Emergency Department OrthopedicProcedures. Ann Emerg Med. 2006 Nov; 48(5):605-612.Roback MG, Wathen JE, Bajaj L, Bothner JP.Adverse Events Associated with ProceduralSedation and Analgesia in a Pediatric EmergencyDepartment: A Comparison of CommonParenteral Drugs. Acad Emerg Med. 2005 Jun;12(6): 508-513.Ruth WJ, Burton JH, Bock AJ. IntravenousEtomidate for Procedural Sedation in EmergencyDepartment Patients. Acad Emerg Med.2001 Jan; 8(1): 13-18.Sacchetti A, Senula G, Strickland J, DubinR. Procedural Sedation in the CommunityEmergency Department: Initial Results of theProSCED Registry. Acad Emerg Med. 2007 Jan;14(1): 41-46.Taylor D, OBrien D, Ritchie P, Pasco J, CameronP. Propofol Versus Midazolam/Fentanyl forReduction of Anterior Shoulder Dislocation.Acad Emerg Med. 2004 Jan; 12(1): 13-19.Vinson, Bradbury. Etomidate for ProceduralSedation in Emergency Medicine. Ann EmergMed. 2002 Jun; 39(6): 592-598.Willman EV, Andolfatto G. A ProspectiveEvaluation of “Ketofol” (Ketamine/PropofolCombination) for Procedural Sedation andAnalgesia in the Emergency Department. AnnEmerg Med. 2007Jan; 49(1):23- 30.Zink BJ, Darfler K, Salluzzo RF, Reilly KM.The Efficacy and Safety of Methohexital in theEmergency Department. Ann Emerg Med. 1991Dec; 20(12): 1293-1298.Above information taken directly fromthe Consensus Statement (Air and SurfaceTransport Nurses Association, AmericanAcademy of Emergency Medicine, AmericanAssociation of Critical Care Nurses, AmericanCollege of Emergency Physicians, AmericanNurses Association, American RadiologicalNurses Association, American Society for PainManagement Nursing, Emergency Nurses Association,National Association of Children’sHospitals and Related Institutions, 2008, March20. Procedural Sedation Consensus Statement.Retrieved July 1, 2008, from the EmergencyNurses Association Web site: http://www.ena.org/about/position/PDFs/0A5C7974136746E19C28A8E48116994D.pdf).The following is taken directly from the EmergencyNurses Association Web site (http://www.ena.org/about/position), retrieved July 29, 2008.STATEMENT OF PROBLEMContinued on page 20

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S c o p e o f Pr a c t i c e Is s u e sEmergency nurses are increasingly involved inthe administration and monitoring of sedation,with or without analgesia, for many emergentand urgent procedures in the emergencydepartment. Common conditions that call forprocedural sedation include those that necessitatepain and/or anxiety control to successfullyadminister therapeutic, diagnostic, or surgicalprocedures (e.g., bone fracture reduction,laceration repair, and burn debridement).1-5Procedural sedation also may be of benefit topatients, such as children and mentally challengedadults, who experience extreme anxietyor behavioral upset during procedures thatrequire them to remain still (e.g., diagnosticimaging for children).2-4According to the American College of EmergencyPhysicians (ACEP), procedural sedationis defined as “a technique of administeringsedatives or dissociative agents with or withoutanalgesics to induce a state that allows thepatient to tolerate unpleasant procedures whilemaintaining cardiorespiratory function.”1 Thelevels of sedation are classified as:3,6,7• Minimal sedation (anxiolysis): A medication-inducedstate during which cognitivefunction and coordination may be impaired butcardiovascular and ventilatory functions remainunaffected.• Moderate sedation/analgesia (formerly called“conscious sedation”): A medication-induceddepression of consciousness during whichpatients can respond purposefully to verbalcommands and independently maintain acontinuous airway. Cardiovascular function isusually maintained and spontaneous ventilationis adequate.• Deep sedation/analgesia: A medicationinduceddepression of consciousness duringwhich patients cannot be easily awakenedbut can respond purposefully after repeated orpainful stimulation. Cardiovascular function isusually maintained, but spontaneous ventilationmay not be adequate and airway patencymay require assistance.• General anesthesia: A medication-inducedloss of consciousness during which patients cannotbe aroused, even with painful stimulation.Cardiovascular function may be impaired, spontaneousventilation is frequently inadequate,and assistance is usually required to maintainairway patency.The various levels of sedation comprise a continuum,and because it is not always possible topredict how each patient will respond, patientsmay abruptly enter into a deeper level of sedationthan intended.6 For this reason, healthcare providers who administer and monitorprocedural sedation should be proficient inairway management and cardiovascular supportto rescue patients who enter into a deeper level,for example, from moderate sedation into deepsedation.1,2,7 In addition, complications mayarise during the procedure such as vomiting,respiratory depression and loss of protectiveairway reflexes, hypoxia, hypotension, allergicreaction, and cardiac arrest.1,2,8 Institutionalpolicy may require providers to be trained inbasic cardiac life support (BCLS), advancedcardiac life support (ACLS), and if appropriate,pediatric advanced life support (PALS) inorder to administer procedural sedation andanalgesia.4,9Compliance with regulatory, statutory, andprofessional standards of care for the administrationof procedural sedation and analgesiais necessary to ensure patient safety.4,8-10 Forinstance, the Joint Commission on Accreditationof Healthcare Organizations (JCAHO)outlines sedation and anesthesia standardsthat include a requirement for qualified andcompetent individuals to perform proceduralsedation.7,9 These qualified individuals mustbe able to perform rescues outlined in the standardsand manage the patient at whatever levelof sedation and analgesia is achieved.7 If statelaw and institutional policy permit, registerednurses can administer some forms of proceduralsedation and analgesia.4,10-12 According tothe American Nurses Association (ANA), itis within the scope of practice for a registerednurse to administer medications and managepatient care for patients receiving minimal ormoderate sedation/analgesia.10Procedural sedation and analgesia involvesthe use of pharmacological agents that maybe administered by different routes includingintravenous, intramuscular, inhalation, nasal,oral, and rectal administration.13 ENA andACEP support the delivery of medicationsused for procedural sedation and analgesia bycredentialed emergency nurses working underthe direct supervision of an emergency physician.These agents include but are not limitedto etomidate, propofol, ketamine, fentanyl, andmidazolam.14 Many hospitals require nurses tocomplete an educational program and demonstratethe competencies necessary to administerand manage procedural sedation and analgesia.11Programs may include instruction in thepharmacology of drugs used for procedural sedationand analgesia, supervised clinical exercisesin upper airway management and resuscitation,and a competency exam.1,4,15The process of procedural sedation and analgesiabegins with a patient evaluation involvinga physical examination as well as a medicalhistory that covers previous adverse experienceswith sedation/analgesia and time and nature oflast oral intake.1,15 The American Society ofAnesthesiologists (ASA) recommends a sixhourfast for food and a two-hour fast for clearliquids before procedural sedation; however,these guidelines may not always be possible inthe emergency care setting.2,15,16Prior to the procedure, the patient shouldreceive counseling regarding risks, benefits,and alternatives to sedation and analgesia.1,15In addition, protocols and appropriately-sizedequipment for both pediatric and adult patientsshould be readily available and in place so thatthe patient’s condition can be monitored andpossible complications managed throughout theprocess. Appropriate equipment includes oxygen,suction, and advance life support equipmentsuch as medications, a bag-valve-maskdevice, and intubation equipment.1,15Patients undergoing sedation and analgesiarequire frequent assessments of their vital signs,such as heart rate, blood pressure, respiratoryrate, and pulse oximetry; cardiopulmonarystatus including cardiac monitoring, breathsounds, skin color, oxygen saturation, andexhaled carbon dioxide; and level of consciousness(e.g., ability for patient to respond toverbal commands).1 Monitoring and documentationof vital signs should occur before, during,and after procedural sedation and analgesia.1The registered nurse who monitors the patientshould have no other duties to perform duringthe sedation and recovery process.1,10,15Monitoring should continue post-procedureuntil the patient returns to his or her baselinelevel of function and is ready for discharge.2,8The ANA recommends that registered nurseswho administer and monitor procedural sedationand analgesia be able to: (a) identify anddifferentiate the various levels of sedation;(b) demonstrate the acquired knowledge ofanatomy, physiology, pharmacology, cardiacdysrhythmia recognition, and complicationsrelated to procedural sedation and analgesia;(c) demonstrate competence in pre-procedural,procedural, and post-procedural nursing carefrom the initial patient evaluation to patientdischarge; (d) anticipate, recognize, and addresspotential complications during the process;and (e) understand the medical/legal aspects ofprocedural sedation and analgesia.8,10ASSOCIATION POSITIONIt is the position of ENA that:1. It is within the scope of practice for aninstitutionally-credentialed registered nurseworking in the emergency department to delivermedications used for procedural sedationand analgesia under the direct supervision of anemergency physician.2. Health care organizations should haveeducational and credentialing mechanisms inplace that include a process for evaluating anddocumenting the registered nurse’s knowledge,skills, and abilities related to the managementof patients receiving procedural sedation andanalgesia. Evaluation and documentation ofcompetency should occur on a periodic basisaccording to institutional policy.3. Health care organizations should involvenurses in the development of guidelines andprotocols for drug administration, patient

S c o p e o f Pr a c t i c e Is s u e smonitoring, and hospital discharge, as well asfor management of potential complicationsand emergency situations related to proceduralsedation and analgesia. These guidelines andprotocols should be developed in accordancewith accepted standards of practice and madeavailable to all health care professionals involvedin procedural sedation and analgesia.4. Nurses managing the care of patients undersedation and analgesia should have no otherresponsibilities during or after the procedurethat would compromise the nurse’s ability toadequately monitor the patient.5. Emergency nurses need to be activelyinvolved in research that contributes toevidence-based standards for safe and effectivepractices of procedural sedation and analgesia.6. Emergency nurses must maintain ongoingcontinuing education to acquire and enhanceknowledge and skills related to proceduralsedation and analgesia.RATIONALEThe administration of procedural sedationand analgesia for therapeutic, diagnostic, orsurgical procedures is a specialized skill thatrequires specific knowledge and competencies,including the ability to recognize and interveneshould complications occur. It is withinthe scope of practice for credentialed registerednurses in the emergency department to manageprocedural sedation and analgesia under thedirect supervision of an emergency physiciangiven compliance with regulatory, legislative,institutional, and professional standards ofcare. Emergency nurses have an important rolein promoting patient safety while minimizinganxiety and/or pain for patients undergoingstressful and/or painful procedures in the emergencydepartment.REFERENCES1. American College of Emergency Physicians(ACEP). (2005). Clinical policy: Proceduralsedation and analgesia in the emergencydepartment. Annals of Emergency Medicine,45, 177-196.2. Brown, T. B., Lovato, L. M., and Parker, D.(2005). Procedural sedation in the acute caresetting. American Family Physician, 71, 85-90.3. Krauss, B., and Carroll, P. (2000, June/July). Procedural sedation and analgesia: Anevolving role for RCPs. RT. Retrieved February21, 2005, from http://www.rtmagazine.com/Articles.ASP?articleid=R0006F024. O’Donnell, J. M., Bragg, K., and Sell, S.(2003). Procedural sedation: Safely navigatingthe twilight zone. Nursing2003, 33(4), 36-44.5. Pitetti, R. D., Singh, S., and Pierce, M. C.(2003). Safe and efficacious use of proceduralsedation and analgesia by nonanesthesiologistsin a pediatric emergency department. Archivesof Pediatrics & Adolescent Medicine, 157,1090-1096.6. American Society of Anesthesiologists(ASA). (2004). Continuum of depth of sedation:Definition of general anesthesia andlevels of sedation/analgesia. Retrieved February22, 2005, from http://www.asahq.org/publicationsAndServices/standards/20.pdf7. Joint Commission on Accreditation ofHealthcare Organizations (JCAHO). (2005).Comprehensive accreditation manual forhospitals: The official handbook. OakbrookTerrace, IL: Author.8. Kost, M. (2002). Administration of conscioussedation/analgesia. Nursing Spectrum:Education/CE. Retrieved February 21, 2005,from http://nsweb.nursingspectrum.com/ce/ce159.htm9. Catalano, K. (2002). What is in a name—sedation or anesthesia. AORN, 75, 550-553.10. American Nurses Association (ANA).(1991). Endorsement of position statement onthe role of the registered nurse (RN) in themanagement of patients receiving IV conscioussedation for short-term therapeutic, diagnostic,or surgical procedures. Retrieved February 24,2005, from http://www.ana.org/readroom/position/joint/jtsedate.htm11. American Association of Nurse Anesthetists(AANA). (2003). Considerations forpolicy guidelines for registered nurses engagedin the administration of sedation and analgesia.Retrieved February 28, 2005, from http://www.aana.com/practice/conscious.asp12. National Council of State Boards ofNursing (NCSBN). (n.d.). State updates onconscious sedation. Retrieved February 28,2005, from http://www.ncsbn.org/news/stateupdates_state_sedation.asp13. American Academy of Pediatrics, Committeeon Drugs. (2002). Guidelines for monitoringand management of pediatric patientsduring and after sedation for diagnostic andtherapeutic procedures: Addendum. Pediatrics,110, 836-838.14. Emergency Nurses Association (ENA).(2005, March). Joint statement by ENA andthe American College of Emergency Physicians(ACEP) on the delivery of agents forprocedural sedation and analgesia by emergencynurses. Des Plaines, IL: Author.15. American Society of Anesthesiologists(ASA). (2002). Practice guidelines for sedationand analgesia by non-anesthesiologists.Anesthesiology, 96, 1004-1017.16. Green, S. M. (2003). Fasting is a consideration—nota necessity—for emergencydepartment procedural sedation and analgesia.Annals of Emergency Medicine, 42, 647-650.References2005 Mosby’s Drug Consult. (2005). Etomidate(1235). Retrieved April 25, 2005, from www.mosbydrugs.com2005 Mosby’s Drug Consult. (2005). Fentanylcitrate (1254). Retrieved April 25, 2005, fromwww.mosbydrugs.com2005 Mosby’s Drug Consult. (2005). Ketaminehydrochloride (1604). Retrieved April 25, 2005,from www.mosbydrugs.com2005 Mosby’s Drug Consult. (2005). Midazolamhydrochloride (1810). Retrieved April 25, 2005,from www.mosbydrugs.com2005 Mosby’s Drug Consult. (2005). Propofol(2132). Retrieved April 25, 2005, from www.mosbydrugs.comColl-Vinent, B., Sala, X., Fernandez, C.,Bragulat, E., Espinosa, G., Miro, O., Milla, J.,and Sanchez, M. (2003). Sedation for cardioversionin the emergency department: Analysis of effectivenessin four protocols. Annals of EmergencyMedicine, 42, 767-772.EMSC Grant Panel (Writing Committee) onPharmacologic Agents Used in Pediatric Sedationand Analgesia in the Emergency Department.(2004). Clinical policy: Evidence-based approachto pharmacologic agents used in pediatric sedationand analgesia in the emergency department. Journalof Emergency Nursing, 30, 447-461.Green, S. M., and Krauss, B. (2002). Proceduralsedation terminology: Moving beyond “conscioussedation.” Annals of Emergency Medicine,39, 433-435.Green, S. M., and Krauss, B. (2003). Propofolin emergency medicine: Pushing the sedationfrontier. Annals of Emergency Medicine, 42,792-797.Zempsky, W. T., Cravero, J. P., and the Committeeon Pediatric Emergency Medicine andSection on Anesthesiology and Pain Medicine.(2004). Relief of pain and anxiety in pediatricpatients in emergency medical systems. Pediatrics,114, 1348-1356.Developed: 1992.Approved by the ENA Board of Directors: September1992.Reviewed and Approved by the ENA Board ofDirectors: September 1994.Revised and Approved by the ENA Board ofDirectors: May 1996.Revised and Approved by the ENA Board ofDirectors: July 1998.Revised and Approved by the ENA Board ofDirectors: December 2000.Revised and Approved by the ENA Board ofDirectors: July 2005.© Emergency Nurses Association, 2005Continued on page 22

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