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Undergraduate Clinical Compliance (Policy UG-07)

Download a Printable Version of Policy UG-07

Effective Date

July 2013

Last Revision Date

8/22/2024

Responsible Party

School of Nursing Divisional Dean, Chief Nurse Administrator, Program Directors, faculty, staff, and students.

Scope and Audience

All School of Nursing Pre-License and RN BS Program faculty and students.

Additional Authority

CHS: Student Background Check (Policy 313), Student Drug and Alcohol Testing (Policy 314)

Policy Purpose

To define clinical compliance requirements and measures for the School of Nursing Pre- License Program.

Policy Statement

Requirements For Attending Clinical Courses

As per contractual agreements with our clinical partners, background checks, drug screens, CPR certification, tests for tuberculosis and certain vaccinations and immunizations are required. Some, or all, of these requirements may be gathered by an outside company, depending on the program. The company used will be based on contractual agreements in place at the time requirements are due. Students will be kept apprised of specific requirements. For some School of Nursing programs, in addition to an account for background check and drug screens, an account for health requirement completion and tracking may be required. Students may also be required, based on their clinical placement, to have accounts through additional outside vendors, and/or complete additional paperwork, quizzes, education modules, etc., in order to meet the requirements of their clinical placement. Should this be necessary, students will be notified by the program and all costs incurred will be the responsibility of the student.

Verification Of Enrollment in Medical Insurance

Neither the College of Health Sciences, the Departments or Divisions within the College, nor the clinical agencies carry health insurance for students. All students enrolled and
participating in clinical coursework through the College of Health Sciences must be covered by a medical insurance policy. Documentation of current health insurance coverage must
be provided.

Background Check

Students in the School of Nursing Pre-License Program may be required to have and maintain a clean background check. Students are admitted to the School of Nursing Pre-License Program conditionally, pending completion of a clean background check by the deadline date provided by specific programs. Students are responsible for following the program -specific account set-up requirements, arranging payment, and directly handling any disputed results with the vendor at the time of check or recheck. Please note School of Nursing designated staff have access to all results but will not initiate or process appeals or corrections through the vendor. Decisions regarding program eligibility will be made based on background results in accordance with College of Health Science Policy: CHS-313.0.
Background checks performed for previous employment or licensing cannot be used, per contractual agreements with our partnering health care agencies. Students will be required to maintain a clear criminal record during their time in the program and may be required
to complete subsequent background checks every six months, during the time-period directed by the individual program. “Clear criminal background” is defined as a background meeting the criteria as outlined in COHS Policy: CHS-313.0.

Clinical Health Requirements

Students will submit the following health requirements as directed prior to being accepted fully into their specific program. Students may also be required to complete subsequent health requirements (or “serial” health requirements) and re-submit during the time frame indicated by their specific program and in the manner directed at the time of submission

Tuberculosis (TB)

A verified negative baseline 2-Step TB skin test or blood test, such as T-spot or Quantiferon Gold will be required prior to the beginning of the student’s first semester in their specific program. A baseline individual TB risk assessment used in interpreting screening results may be required by the healthcare facility administering the screening. Additional testing may be required as dictated by specific clinical placement requirements.

  • Additional testing/screening may be required as dictated by specific clinical placement requirements.
  • Tine Tests are not accepted
  • If a student has a positive TB test:
    • Students with a positive baseline TB test result will be required to provide documentation of completed Pulmonary TB rule out through a symptom evaluation, a chest x-ray by a healthcare practitioner (Physician, Nurse Practitioner, or Physician’s Assistant). Additional workup may be needed based on those results and/or as directed by the healthcare practitioner.
    • Students with a known latent TB infection or positive baseline TB screening test will be required to complete an annual TB Symptom Screen.
    • If the annual TB symptom screen shows the student has symptoms of TB, the student will be required to provide documentation of completed Pulmonary TB rule-out through a symptom evaluation, a chest x-ray by a healthcare practitioner (Physician, Nurse Practitioner, or Physician’s Assistant). Additional workup may be needed based on those results and/or as directed by the healthcare practitioner.

Measles, Mumps, & Rubella (MMR)

Documentation of positive titers for each (Measles, Mumps and Rubella), OR verification of 2 MMR vaccinations, must be submitted prior to admission unless a severe allergy is documented by a primary care provider.

If any of the titers are “equivocal” or indicate that the student is not protected, and proof of immunization is not available, immunization with 2 MMR vaccinations will be required.

Students may be in progress but must follow standard immunization timeline protocols, as recommended by the CDC.

Varicella (chicken pox)

Documentation of a positive antibody, a statement of history of illness from a primary care provider, or proof of two doses of the varicella vaccine will be accepted.

Hepatitis B

Documentation of complete Hepatitis B Vaccination series and positive Hepatitis B titer drawn at least 1-2 months after completion of the initial series is required. Series may be two-step, or three-step series as recommended by the student’s primary care provider.

  • If the titer drawn 1-2 months after completion of the initial series does not show immunity, the student will be required to complete a revaccination series and repeat titer 1-2 months after completion of the second series.
  • Students may be in progress with documentation of at least one dose of the Hepatitis B Vaccines. These students must follow CDC guidelines for completion of the series. If the student’s provider is recommending a schedule outside of the standard CDC guidelines, a written explanation from the provider must be submitted. The series and subsequent titer must be completed within 8 months.
  • Some students may be “non- converters,” despite following proper protocol. In order to demonstrate “non-converter” status, the student must provide verification of 2 complete series with 2 negative titers, 1 at the end of each series. Series must be done within the CDC recommended timeframe in order to qualify. Students who do not have protective concentration of anti-HBs (>10 m IU/ m l) after revaccination (i.e ., after receiving a total of 6 doses) should be tested for HBs Ag and anti-HBc to determine their infection status (Holm berg, Suryaprasad & Ward, 2012).
Management of Hepatitis B Virus-infected student
  • Students must provide documentation stating that they are under care and receiving guidance with regard to management of the Hepatitis-B viral infection. This must be signed by their healthcare practitioner, state that viral load testing and other appropriate assessments will occur every 6 months, and be provided to the School of Nursing prior to the student’s first semester in the program or within 7 days of diagnosis if diagnosed while in the program.
  • HBV-infected students can conduct exposure prone procedures if a low or
    undetectable HBV viral load is documented by regular testing at least every 6 months (Holmberg et a l., 2012).
  • Students with active HBV infection (i.e., those who are HBs Ag-positive) who do not perform exposure-prone procedures but who practice non or minimally invasive
    procedures should not be subject to any restriction of their activities or study (Holmberg et al., 2012).
  • Students with a positive HBe Ag or circulating HBV burden of greater than or equal to 10(4) genome equivalents (GE) per mL of b loo d or approximately 2,000 IU/ml will be prohibited from performing certain pre-defined high -risk (Category III) exposure-prone procedures (EPP) (Lewis , Enfield & Sifri, 2015). The list of Category III exposure-prone procedures is found in Tab le 3 of the following reference.
  • Students will use double-gloving for all invasive procedures, for all contact with mucous membranes or non-intact skin, and for all instances in patient care for which glo vin g is recommended (Le wis et a l., 2015).

Please see relevant tables and charts, found in the following link to summarize the recommendations, guidelines, screening, vaccination, viral load threshold and restrictions for students.

Tdap (tetanus, diphtheria, and pertussis)

Documentation of Tdap vaccination received within the past 10 years. Vaccination expiring during the program will require documentation of a booster prior to expiration.

Influenza (flu)

Proof of seasonal flu vaccination must be received upon entry for Spring start cohorts and annually for all students by the program established deadline every October. Exemptions may be requested for the influenza vaccine under the following circumstances:

  • Medical Exemption – Requires the signature of a licensed healthcare provider (Physician, Nurse Practitioner, or Physician’s Assistant)
  • Religious Exemption
COVID-19

Proof of COVID-19 vaccination compliance may be required by participating healthcare agencies. As such, proof of vaccination or documentation of exemption upon entry to the program is required. Exemptions may be requested for the COVID-19 vaccination under the following circumstances:

  • Medical Exemption– Requires the signature of a licensed healthcare provider (Physician, Nurse Practitioner, or Physician’s Assistant)
  • Religious Exemption
CPR

Students must, upon entry to the program, have and maintain current Healthcare Provider (HCP) Basic Life Support (BLS) Certification.

  • Certification must be an HCP BLS course by the American Heart Association(AHA).
  • Initial certification must be obtained in an in-person/hands-on class, however, recertification can be obtained online. Providing proof of initial, in-person, certification will be necessary.

Additional Pre-license Program Requirements and Information

Vaccine exemptions may result in clinical sites refusing to accept the exempted student and may limit clinical placement options. If no other placement option is available, the student may be delayed or prevented from meeting the requirements for progression within the program and/or graduation from the program. For information on the exemption process, please contact the Student Services Compliance Team at nursingcomm@boisestate.edu

Serial health requirements are to be satisfied by deadlines as determined by the individual program in collaboration with the Clinical Compliance team. Any student not in compliance past the program specific deadline dates may not attend class or clinical rotations until all requirements are satisfied.

This policy is applicable to incoming and continuing students. Additionally, incoming students must be aware that their admission is conditional per their offer letter and may be revoked for missed compliance deadlines or failure to meet requirements.

All Clinical Health requirements, processes, and procedures are subject to change based on contractual agreements with clinical partners and/or CDC recommendations. Should changes occur after normal Health Requirement cycles, students will be informed by the Clinical Compliance team and given clear directions, to include deadlines for compliance, in order to remain eligible for program participation. Continuous compliance with clinical
health requirements is mandatory for the School of Nursing Pre-License Program. Failure to maintain continuous health requirements is grounds for dismissal from the program.

For assistance and questions contact the Student Services compliance team at nursingcomm@boisestate.edu.

Pre-license Program Compliance Accountability

Because continuing compliance is such a crucial component to the integrity of Boise State University’s School of Nursing Pre-License Program and is required for continued clinical affiliation agreements, the following steps will be implemented leading up to the School of Nursing’s dismissal process:

Compliance with clinical requirements is determined by the Clinical Operations Team.
Unless an approved extension is granted by the Clinical Operations Team, students will be considered out of compliance for any missed deadline.

  • The first time a student is out of compliance after the deadline, they will be issued a letter of warning from the Compliance Team Manager.
    • Student will be required to meet with their Academic Advisor to create a compliance support plan. If the student has not com p le ted the requirements prior to the deadline, they will not be permitted to attend either class or
      clinical rotations. This includes practice and simulation labs. At this point, written notification from the Clinical Support Team or Student Services with proof of compliance is required to join in class and clinicals. It is up to the
      faculty to determine whether the missed attendance can be made up.
  • The second time a student is out of compliance after the deadline, they will be issued a second letter of warning.
    • As in step 2, if the student has not completed the requirements prior to the first day of class, they will not be permitted to attend either class or clinical rotations. This includes practice and simulation labs. As this is the second
      time a student has not m e t the compliance requirements prior to the deadline, the student must meet with the Compliance Team Manager to discuss the Compliance support p la n from prior noncompliance and what steps need to be taken to not be late again. The Compliance Team Manager will then determine if the student has permission to rejoin class and clinicals. It is up to the faculty to determine whether the missed attendance can be made up.
  • After the 3rd time a student is out of compliance after the deadline, they will be issued a letter of warning stating potential dismissal.
    • The student will be not permitted to attend classes and clinical rotations and will be required to meet with the Program Director to request permission to re Jo in classes. Prior to scheduling a meeting with the Program Director,
      students will be required to watch an educational video assigned by the Compliance Team Manager.
  • After the 4th or any subsequent ep is odes of non-compliance, the student will be referred to the School of Nursing’s Dean’s office for a case review.

RN BS Program Clinical Compliance

Due to the nature and variability of the clinicals in the RN-BS program, regular records of the compliance items are not maintained by the School of Nursing. If records for the items listed above or other requirements are requested by a clinical site, it will be the student’s responsibility to meet those requirements. Ample time and communication will be provided.

Forms

N/A

Related Information

BSU: None

CHS: Student Background Check (Policy 313), Student Drug and Alcohol Testing (Policy 314)

SON: None

Last Review Date

07/02/2024

Revision History

August 2013, Spring 2015, Summer 2017, Fall 2019, October 2021, April 1st 2022, Fall 2022,
February 2023, August 2023, April 2024, July 2024

References

Holmberg, S. D., Suryaprasad, A., & Ward, J. W. (2012). Updated CDC recommendations for the management of hepatitis B virus-infected health-care providers and students. Centers for Disease Control and Prevent Morbidity and Mortality Weekly Report, 61(3), 1–12.

Lewis, J. D., Sifri, C. D., & Enfield, K. B. (2015). Hepatitis B in healthcare workers: transmission events and guidance for management. World Journal of Hepatology, 7(3), 488–497. https://doi.org/10.4254/wjh.v7.i3.488