1. Harding, Andrew D. MS, RN, CPHQ, NEA-BC, FACHE, FAEN, FAHA
  2. Batista, Christine S.

Article Content

When an error occurs and it's determined that the cause is a nurse's lack of knowledge, skill, ability, or judgment, the education provided to correct this deficit is called remediation.1-4 The goal of remedial education is for the nurse to gain the knowledge and/or behaviors necessary to perform competently, safely, and successfully as a professional.

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The intersection of nursing administration and regulation is felt acutely when a nurse is reported by an employer to his or her state board of nursing for unsafe, illegal, or incompetent practice. It's been suggested that nurses receive a tailored remedial education plan to prevent future practice errors.5 However, in one study, only 10% of nurses reported to state boards of nursing for professional misconduct had education included as part of their remediation actions.4 This leaves healthcare organizations and third parties, such as colleges, universities, and online learning management systems, to provide remedial education as approved by the state board of nursing.


Whose responsibility is it?

Professional nurse remediation is an educational technique used by many nurse administrators and executives when addressing poor performance in the workplace.6 Remedial education to correct unsafe or incompetent practice is used relatively frequently for nurses who've been disciplined by their state boards of nursing as a probationary measure.7 However, in-service education isn't highly valued as an effective teaching method.8 And the responsibility for providing remedial education for nurses found to be unsafe or incompetent in their professional role isn't always clear and varies depending on the state's regulations.9,10


The American Nurses Association (ANA) and the National Council of State Boards of Nursing both affirm that nurses are responsible and accountable for their own competent practice; that is, the ability to perform what's professionally expected.1,3,11 The ANA's Nursing Administration: Scope and Standards of Practice states that nurse administrators are responsible for ensuring the competence of the nurses whom they supervise.12 Healthcare organizations should provide routine and ongoing education to keep staff competent.13 However, there are various instances of poor professional practice that may require you to report a nurse to the state board of nursing.


Nurse administrators may report nurses who act unethically, incompetently, or illegally to the state board of nursing. Due process is given to nurses who are reported to state boards of nursing. The use of just culture is a necessary method for instilling effective reporting and learning within organizations.14 Behaviors determined to be reckless require punishment, such as revoking the nurse's license or legal action.15 The board's investigation may recommend remediation when it's determined that there's an opportunity for the nurse to improve his or her practice.3 An area for review and further development is the routine and consistent application of just culture and a culture of safety by state boards of nursing.16,17


When remediation is necessary, the state board of nursing and the employer can partner to provide a structured education intervention and oversight. There's an opportunity to include nursing colleagues from academia to assist in developing and delivering remedial education to professional nurses. Although, this isn't currently found in the literature, it's another path to explore in the academic-practice partnership.


What's the law?

Each state has a unique set of laws and regulations that make up its nurse practice act. This variation adds to the complexity and anxiety over not only complying with the state's requirements, but also doing the ethical thing. The authors have reviewed each state board of nursing, asking: "Is a formal remediation program offered to professional nurses who've been reported to the board of nursing for practice incompetence?"


Fifty-one state boards of nursing were reviewed. All of the boards acknowledged using education when discipline wasn't appropriate and a gap in competence was identified. Only six state boards of nursing indicated that they currently offer a formalized remediation program. These states directly engage the nurse in remediation; other states will either contract with employer healthcare organizations or use online learning management systems to deliver remedial education to the affected nurse.


State boards of nursing are looking to expand the provision of nonpunitive approaches to modifying a nurse's practice patterns:


* Arizona is testing the Nursing Performance Profile model, a standardized competency evaluation of nurses reported to the board of nursing for a clinical practice issue that incorporates the Taxonomy of Error, Root Cause Analysis, and Practice Responsibility; high-fidelity simulation; and the Clinical Competency Assessment of Newly Licensed Nurses to help develop tailored remediation.18-22


* North Carolina has successfully implemented its Practitioner Remediation and Enhancement Partnership, or PREP, program.23


* Pennsylvania has completed a Practice, Education, Remediation and Collaboration pilot, implementing a program to support nurses reported for minor practice violations.24


* Ohio uses the Practice Intervention and Improvement program.25


* Texas has a group of circumstances that dictates its provision of remedial education.26


* Washington state offers an early remediation plan for nurses.17


* Vermont has a pilot in process to evaluate its role as a regulator in remediation.27



Partnership for success

A partnership is necessary between nurse administrators and regulators, with strong communication and collegiality between healthcare organizations and regulatory bodies. The opportunity for remediation is warranted for nurses who are reported to state boards of nursing and found to have an educational deficit. This collaboration will foster the ability to properly protect our patients, our organizations, and the integrity of our profession.




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