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WELCOMES YOU TO THE NURSING PROFESSION

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Contact: NCSBN 111 E. Wacker Drive, Ste. 2900, Chicago, IL 60601 | 312.525.3600 www.ncsbn.org | [email protected] 1st edition: 03.11.16; 2nd edition: 02.10.18

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WELCOME TO THE NURSING PROFESSION

C ongratulations on your new nursing license. NCSBN welcomes

you to the nursing profession and offers you this booklet of

resources and information.

A companion piece to our popular video, “New Nurses: Your License to

Practice,” this booklet can help you to understand nursing regulation and

your board of nursing (BON), and provides links and suggestions that will

assist you as you begin your career.

Nursing is a dynamic profession that will offer you many opportunities

in the future. You know that you have entered a respected and honored

profession but did you know that the nursing profession has consistently

been rated by a national Gallup poll as number one in honesty and ethical

standards? In 2017, 82 percent of the respondents rated nurses as “very

high” or “high” for honesty and ethical standards, while the next closest

profession was military officers with 71 percent of the respondents rating

them as “very high” or “high.” As a nurse, you should be quite proud, while

also acknowledging you have quite an esteemed reputation to uphold!

NCSBN Welcomes New Graduates to the Nursing Profession

WELCOME

WELCOME

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YOUR LICENSE TO PRACTICE NURSING

Your education has provided you with the tools you’ll need to practice

safely and competently and has now brought you to the point of being

newly licensed. As with other health professions, nursing is regulated

by law to ensure safe practice. One of nursing’s most respected nurse

leaders, Dr. Julie Sochalski, PhD, RN, FAAN*, eloquently explains why your

license is so important:

You do not become a registered nurse because you pass the NCLEX®.

Yes, you need to pass it, but that’s because a recognized authority, the

state board, has been empowered to determine the qualifications for

you to sit for licensure as a registered nurse. Your opportunity to become

licensed as a registered nurse is something that has been granted by the

public. It is, in fact, an agreement with the public. The public has deemed

that the practice of nursing is something of such value, something of such

significance, something that embodies such expert knowledge, something

where they engage with you in their most vulnerable state, that they have

decided to establish an agreement with you, your license, that allows

you to minister your best to them. It is not something to take lightly, but

rather something that calls you to recognize your practice as a sacred

commitment to the public.

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RECOGNIZE YOUR PRACTICE AS A

SACRED COMMITMENT TO THE PUBLIC

Dr. Julie Sochalski, PhD, RN, FAAN

*Julie Sochalski, PhD, RN, FAAN, is an Associate Professor of Nursing at the University of Pennsylvania School of Nursing. Prior to her current role, Dr. Sochalski worked for the U.S. Department of Health and Human Services where she served as the Director of the Division of Nursing and Principal Advisor for Health Workforce Policy at the Health Resources and Services Administration. In this capacity, Dr. Sochalski was responsible for directing initiatives to advance research and programs to effectively develop a highly- skilled health care workforce.

You’re going to be there

when a lot of people are born,

and when a lot of people die.

In most every culture, such moments are

regarded as sacred and private,

made special by a divine presence.

No one on Earth would be welcomed,

but you’re personally invited.

Thom Dick Author, People Care and Street Talk

What an honor that is.

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If you think about Dr. Sochalski’s statement, you will realize why nursing

is regulated. Patients and families are in their most vulnerable states

when they rely on your expert nursing care. Now you can see how very

important your license is. Take your license to practice nursing very

seriously throughout your career.

Licensure does have its responsibilities. In most states now you

will need to have a criminal background check done before you can

receive your first license. You must renew your license periodically,

depending on the laws, or the nurse practice act (NPA), in your state.

On www.ncsbn.org/npa.htm, you can access your state’s NPA, and the

administrative rules that clarify the law and make it more specific, and

learn about renewal requirements in your state. For example, in many

states you will need a certain number of continuing education hours

before you can renew your license.

FAMILIES . . . ARE IN THEIR MOST

VULNERABLE STATES WHEN THEY RELY ON YOUR

EXPERT NURSING CARE

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In most states, your license will be renewed every two years, while in others

it is every year or some other interval selected by the state. You will need

to pay a licensure fee to renew your license. Again the renewal amount will

vary among the states, though the most

common licensure fee is in the range of

$51–$100. There are consequences

for not renewing your license in a timely

manner. These consequences can range

from fines to having to retake the NCLEX®.

Keep your physical and/or email address

current at your board of nursing (BON)

so that you will be notified of licensure

renewal — and renew your license as soon

as you are notified so that you don’t forget.

What if you practice in several states? Will you need to have a license in

every state where you practice? According to every NPA, nurses need

to be licensed to practice nursing in the state where their patients are

located. Therefore, if you practice in three states, you would need a

license in all three states and you’d need to know the NPA of each of those

states as well. However, there is one important exception to needing a

separate license to practice in every

state where the patient is located. If

your state is a member of the Nurse

Licensure Compact (NLC), you would

be licensed in your state of residency,

and then you could have a privilege

to practice in all other NLC states. For example, if you practice in your

home state and across the border in three other NLC states, you would

still only need one license, obtained in your state of residence. You would,

however, have to know the NPA in all three states, as well as in your home

state.

Find out more about the NLC and learn about the current initiative to

expand the number of states participating in multistate licensure at

www.ncsbn.org/enlc.

Did you know that

in some states

you might have to

retake the NCLEX

if you do not renew

your license?

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Protecting your license from potential fraud or identity theft should be

a priority for you and one of the best ways to safeguard your license

is to enroll in NCSBN’s Nursys e-Notify®. Powered by the U.S. boards

of nursing (BONs), Nursys e-Notify is the only national database for

licensure verification of registered nurses (RNs), licensed practical/

vocational nurses (LPN/VNs) and advanced practice registered nurses

(APRNs).

Quick, easy, secure and free, your enrollment takes just a few minutes and

you can then receive licensure status updates including multistate and

single-state changes within the NLC. You can track licensure verifications

for endorsement and manage multiple licensure verifications. Keeping

on top of your license status can help you prevent fraudulent licenses or

certificates being issued in your name.

Learn more about Nursys e-Notify by viewing an introductory video at

www.nursys.com/enotify-video or by visiting www.nursys.com.

For questions, contact [email protected].

Enroll at www.nursys.com/e-notify and select “As a Nurse” to complete

the registration process.

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BOARDS OF NURSING (BONs)

According to the 10th Amendment, the legal authority to practice nursing

comes from each state or territorial government. More than 100 years ago,

BONs were established to protect the public’s health and welfare. While

there is a variation in BONs across the U.S., generally each BON has hired

staff and a voluntary board that is appointed by the governor. Read your

NPA to find out how your BON is structured. There are many functions of

the BON, but the most important include granting and renewing licenses,

writing administrative rules and policies, disciplining unsafe nurses,

approving nursing programs and developing practice standards. BONs often

have open meetings and you are encouraged to attend these to learn more

about your BON. Consider becoming a board member in your state as you

become more seasoned in your profession.

We previously referred to the NPAs and the administrative rules. While the

NPA varies from state to state, there are three basic components

of each:

1. Standards and scope of nursing practice

2. Requirements for licensure

3. Grounds for disciplinary action

Be sure to read your NPA rules and become familiar with them. New nurses

often wonder about what constitutes a violation of the NPA. The BON will

review each complaint thoroughly and is required by law to give the nurse

a chance to respond. Included in this booklet are a few examples of actual

cases that BONs have reviewed. Names and specific details have been

altered to maintain privacy. Access your NPA at www.ncsbn.org/npa.htm.

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TO FIND YOURSELF THE BEST WAY

IS TO

13

Mahatma Gandhi

LOSE YOURSELF SERVICE OF OTHERS IN THE

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SUBSTANCE USE DISORDER

Probably the most common complaint seen at BONs relates to substance

use disorder. Addicting substances, alcohol, prescription or illegal drugs,

pose a serious risk to patient care. The behavior that results has far-

reaching and negative effects, not only on the nurses themselves but also

on those who depend on the nurse for safe, competent care. Substance

use disorder among health care providers also creates significant

legal and ethical responsibilities for colleagues who work with these

individuals. All nurses should be aware of the behavioral changes that

can result from substance use disorder as they have a professional and

ethical responsibility to report a colleague’s suspected drug use to their

nurse manager or supervisor, and in some states or jurisdictions, to the

BON. It is also important that nurses are honest about their substance

use disorder if asked about it on a renewal application, and this includes

any conviction for driving under the influence (DUI or DWI). Even though

a DUI occurs outside the workplace setting, it is a criminal conviction and

must be reported to the BON.

NCSBN offers the e-learning online “Understanding Substance Use

Disorder in Nursing” and “Nurse Manager Guidelines for Substance Use

Disorder” courses free of charge. CE contact hours are awarded upon

successful completion of the courses.

Register for the course at learningext.com. NCSBN also has brochures

for nurses and nurse managers on substance use disorder, which can be

found at www.ncsbn.org/substance-use-in-nursing.htm.

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Substance Use Disorder Case Study William, a newly licensed RN, recently attended an in-service on substance

use disorder (SUD) conducted by the nurse manager on his unit. After

completing the training, he has started to wonder about one of his

colleagues. Though cheerful and reliable when William started on the

floor six months ago, Karen has been acting different lately. She is often

short-tempered and forgetful, yet she seems to pay extra attention to

patients who have been ordered pain medication. William first thought

he wasn’t experienced enough to make judgments about the behaviors of

fellow nurses, but after the in-service, he realizes that Karen’s actions fit

many of the criteria in the SUD presentation. He knows that speaking up

is the right thing to do and talks to the nurse manager about what he has

observed. The nurse manager completes an audit of the unit’s medication

records. During her investigation of the medication records for Karen’s

patients, the nurse manager discovers numerous discrepancies and

falsified medication reports. Per hospital policy, she notifies her supervisor

and appropriate hospital staff. Karen is removed from practice to receive

treatment and a report is made to the board of nursing.

Nursing Takeaway: Keeping abreast of topics surrounding nursing

practice offered by employers as well as those sought out by the nurse

outside of the work environment are an important component of lifelong

learning and part of the responsibility of nursing practice. Nurses,

regardless of whether they are a new grad or have years of experience,

have a professional and ethical responsibility to report a colleague’s

suspected substance use to a nurse manager or supervisor, and in some

states or jurisdictions, to the board of nursing.

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PROFESSIONAL BOUNDARIES AND SOCIAL MEDIA

Other common complaints to BONs relate to boundary issues and

inappropriate use of social media. When maintaining appropriate

boundaries with patients, the nurse must be aware of either being too

involved with the patient, or being under-involved. Most boundary

violations occur when the nurse is overinvolved and cannot maintain

a therapeutic relationship with the patient. For example, the nurse

should avoid situations where he or she has a personal, professional or

business relationship with the patient whenever possible. While this

may not be possible in small communities, the nurse must maintain a

professional relationship and always be cognizant of the possibility of

boundary violations. Similarly, the nurse should be careful about personal

relationships with patients who might continue to need nursing services

(such as those with mental health issues or oncology patients).

The following are some warning signs of possible boundary violations that

you should be aware of:

• Engaging in behaviors that could reasonably be interpreted as flirting;

• Keeping secrets with a patient or for a patient;

• Believing that you are the only one who truly understands or can help

the patient;

• Spending more time than is necessary with a particular patient;

• Showing favoritism for a particular patient; and

• Meeting a patient in settings other than those used to provide direct

patient care or when you are not at work.

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Professional Boundaries Case Study Lisa is a community health nurse who has frequent home visits with

Mrs. Greene, a diabetic, dealing with complications arising from her

disease. During a visit, Lisa received a personal call that appeared to upset

her. When she hung up, Mrs. Greene asked her what was wrong and

Lisa said that her mortgage payment was overdue and she didn’t know

whether she could make the payment. Mrs. Greene offered to lend her

money. At first Lisa refused, but eventually accepted the check.

Mrs. Greene’s son found out and reported Lisa to the BON. After a

thorough investigation, Lisa attended a hearing and was sanctioned for

violating the NPA. She was sent a letter of reprimand and directed to take

a course on boundary violations.

Principles Violated: Actions that overstep established boundaries to

meet the needs of the nurse are boundary violations.

Nursing Takeaway: Nurses should avoid situations where they have a

personal, professional or business relationship with the patient.

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SOCIAL MEDIA

Social media is an exciting and valuable tool when used wisely. However,

the inappropriate use of social media can violate patients’ privacy and

confidentiality, and violations are often reported to the BON. The very

nature of this medium can pose a risk as it offers instantaneous posting

opportunities that allow little time for reflective thought, and carries the

added burden that what is posted on the Internet is discoverable by a

court of law even after it has been deleted.

The following are some guidelines for using social media appropriately:

• Nurses have an ethical and legal obligation to maintain patient privacy

and confidentiality at all times;

• Nurses are strictly prohibited from transmitting by way of any

electronic media any patient-related image. In addition, nurses are

restricted from transmitting any information that may be reasonably

anticipated to violate patient rights to confidentiality or privacy, or

otherwise degrade or embarrass the patient;

• Nurses must not share, post or otherwise disseminate any

information or images about a patient or information gained in the

nurse/patient relationship with anyone unless there is a patient-care-

related need to disclose the information or other legal obligations to

do so;

• Nurses must not identify patients by name, or post or publish information

that may lead to the identification of a patient. Limiting access to postings

through privacy settings is not sufficient to ensure privacy;

• Nurses must not refer to patients in a disparaging manner, even if the

patient is not identified;

• Nurses must not take photos or videos of patients on personal

devices, including cell phones. Nurses should follow employer policies

for taking photographs or videos of patients for treatment or other

legitimate purposes using employer-provided devices;

• Nurses must promptly report any identified breach of confidentiality

or privacy;

• Nurses must consult employer policies for guidance regarding work-

related postings;

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• Nurses must be aware of and comply with employer policies regard-

ing use of employer-owned computers, cameras and other electronic

devices, and use of personal devices in the workplace;

• Nurses must not make disparaging remarks about employers or

coworkers. Do not make threatening, harassing, profane, obscene,

sexually explicit, racially derogatory, homophobic or other offensive

comments; and

• Nurses must not post content or otherwise speak on behalf of the

employer unless authorized to do so.

NCSBN has valuable resources that will assist you to maintain

professional boundaries and to use social media appropriately that can be

accessed at www.ncsbn.org/professional-boundaries.htm.

Related to boundary violations is sexual misconduct with patients.

This is an extreme case of nurses not maintaining professional

boundaries and is a serious violation of the NPA. This resource

(www.ncsbn.org/Sexual_Misconduct_Book_web.pdf) will provide some

guidelines on what BONs consider about sexual misconduct cases, and it

presents some unfolding cases.

SOCIAL MEDIA IS AN

EXCITING AND VALUABLE TOOL WHEN USED WISELY.

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Social Media Case Study Jane, a nurse at a long-term care facility, arrived at work one day and

found a photo of one of the residents’ buttocks on her computer screen.

Jane sent the photo to several colleagues who also forwarded the

photo. One nurse posted the photo to her Facebook page, saying, “This

is what we have to deal with on a daily basis!” By noon, all the nurses

and unlicensed personnel were snickering and talking about the photo,

and eventually their supervisor was alerted. Being concerned about

protecting the residents’ rights, the facility began an investigation

and alerted the BON. Local media reported on the incident and law

enforcement became involved to investigate whether sexual exploitation

had been committed. By the end of the day, it made national news and

the family threatened a lawsuit. The nurses involved were fired and had

to appear before the BON. All of this could have been avoided if the first

nurse had promptly reported finding the photo to her supervisor and not

shared it.

Principles Violated: Nurses must recognize that they have an ethical and

legal obligation to maintain patient privacy and confidentiality at all times.

Nursing Takeaway: Nurses are strictly prohibited from transmitting by

way of any electronic media any patient-related information. Nurses must

promptly report any identified breach of confidentiality or privacy.

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SIGNIFICANT PRACTICE ERRORS

Recklessness, abuse, intent to harm and gross negligence are all

examples of significant errors that may be reported to a BON. Errors

that a reasonably prudent nurse wouldn’t make and that would put a

patient at substantial risk for an adverse outcome would have more

serious repercussions than those that result from a human error that

a reasonably prudent nurse might make. More information on practice

breakdown (errors) and their root cause analysis can be accessed on

NCSBN’s website (www.ncsbn.org/3668.htm).

CRIMINAL BACKGROUND

Most BONs require criminal background checks of all new graduates,

and when there are hits, they are considered on a case-by-case basis. It

is very important that all nurses are honest when reporting any criminal

background on their applications. Falsehoods on an application will be

taken very seriously by BONs.

The actions that BONs may take when there is a violation of the NPA

will depend on the severity of the violation and may include reprimands,

probation, remediation, fines, license suspension or even license revocation.

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Significant Practice Erro

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