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by Catherine Hoe Harwood, RN, MScN and Lynn Van
Hofwegen, RN, MN
Allyson, a nursing student who has completed two years
of her four-year BSN program, is hired as the “assistant nurse” at a summer
camp for chronically ill children. Susan, the “head nurse,” was also the
nurse for the camp last year immediately following her own nursing graduation.
The residential camp serves approximately sixty-five
chronically ill children each week and has thirty staff on-site. The campers’
health concerns vary, but most weeks there are numerous children with
autism, learning disabilities, and cerebral palsy. The camp is located
just outside a small community with medical doctor offices and the local
hospital within a ten-minute drive.
Allyson was required to have current first aid and CPR
certificates. Upon hiring, she was provided a practice guideline document
identical to that of the Camp RN’s. Susan has one day per week off-site,
and Allyson is expected to handle all the clinics and health care independently
on those days. Staff training focused on first aid and fire situations
— no specific training was given regarding camper assessment or usual
health conditions or concerns.
Experienced camp administrators appreciate that camp
nursing is more than applying bandages and passing pills. Quality camp
nursing draws upon a blend of nursing assessment and skills and requires
knowledge, attitudes, and judgment specific to the unique needs of the
camp clientele. For many reasons, camp administrators are finding it more
challenging to maintain a healthy camp environment and insure quality
health care delivery in the camp setting. Camps are experiencing an environment
of increasing societal and parental expectations regarding camp health
care while grappling with the growing worldwide nursing shortage. Camp
administrators need to be creative and flexible in providing for camp
health care, while thinking proactively about the future supply of camp
nurses.
Student nurse internships (SNIs), in a variety of models,
are described in this article as offering an opportunity to achieve current
camp health care requirements while providing for development and recruitment
of future camp nurses.
Camp settings have many attributes that make them attractive
clinical sites for nursing education. The trick, however, is to explain
this to nurse educators; more of whom have limited camp experience and
just do not understand how rich a camp clinical experience would be for
their nursing students. So tell them. First, most camp settings are dynamic
pediatric and community health learning opportunities. Second, most camp
health centers are nurse-managed health care environments, a valued environment
in nursing education today. This means that nursing care and assessments,
the heart of nursing education, can be experienced. Third, students experience
a variety of nursing roles while at camp: caregiver, educator, consultant,
manager, and decision-maker, to name a few. Lastly, student nurses appreciate
opportunities for supervised practice in nontraditional clinical settings
that offer course-elective credits.
Recognizing that every camp is unique in organization
and programs, the camp administration team, camp health care coordinators,
and nursing faculty members would need to creatively brainstorm to determine
if an SNI could offer mutually desired outcomes. Camp administrators might
also want to know that nurse educators have been challenged in recent
years to meet their need for clinical experiences in community and pediatric
practice settings. Knowledge of these dynamics will empower camp administrators
when approaching a nursing program to negotiate SNIs.
In addition to the obvious benefits of having additional
health care trained personnel at the camp setting and equipping student
nurses for future camp nursing roles, the preceptoring experience offers
current camp nurses a sense of increased job satisfaction and affirmation
of their professional role.
Models for Student Nurse Internships
in Camp Settings
Various models for camp SNIs have been used, and three
are described here. Factors such as camper demographics, camp setting
and programming, attributes of the nursing program, and learning goals
for the specific nursing course will combine to create the design for
an SNI in each camp setting. Variations and expanded discussion of models
for nursing student clinical experiences at camp settings are featured
in McClure (2001), Praeger (1997), and Maheady (1991).
Preceptored student
The first model for a camp SNI is that of a nursing student preceptored
by an on-site registered nurse hired as the camp nurse. In this model,
the nursing student can be hired as a “first-aider” or “health-center
assistant” under the supervision of the camp RN for all or a portion of
the camping season. Alternately, students may negotiate with their nursing
faculty member to be assigned to the camp setting for a shorter duration
as a course elective within their nursing program — at no cost to the
camp other than the student’s room and board. Camp settings for which
accreditation criteria require more than one on-site health care provider
offer the ideal environment for this model.
Under the camp RN’s supervision, the student nurse’s
practice is supervised until the student is deemed competent to function
independently. Some student nurse actions require RN supervision each
time. Within this model the nursing faculty member is not on-site, but
is available for phone consultation and occasional site visits. The faculty
member’s role involves all the precamp negotiations, including determining
the student’s boundaries of practice and expectations for the practice
experience; marking of written assignments; and availability for consultation
by student or camp staff. After the camp RN determines that the student
is competent with basic camp nurse role expectations, the student may
provide relief breaks for the RN, so long as the RN remains accessible
or written care protocols that adhere to the student’s boundaries of practice
are left regarding allowable actions. Communication tools such as walkie-talkie
coverage facilitates the student’s collaboration with the camp nurse or
administration when situations arise necessitating their involvement.
Because of nursing shortages or other factors, some camp
settings have hired student nurses in a “first-aider” role to act as their
sole health care provider. This practice is not one that we want to promote
or endorse; rather we present it to acknowledge concerns regarding such
an arrangement. Numerous cautions must be raised about the inherent risks
for both the camp setting and the student.
Sole health care provider model
To turn the arrangement of hiring a student nurse in a first-aider role
as the camp’s sole health care provider into a second model for student
nurse internships, several considerations and preparations can be made.
Camp administrators considering hiring student nurses in the first-aider
role are strongly urged to review the student characteristics listed in
Figure I and obtain an employment referral
from the student’s nursing program specifically regarding the qualities
cited. With advance planning and cooperation with the student’s nursing
faculty, camp administrators may be able to arrange nursing faculty supervision
and student preparation for this role. Students may be able to earn an
elective credit course within their nursing program for their independent
study experience at camp.
When a student nurse is functioning as the sole health
care provider at a camp setting, titles such as “camp nurse,” “assistant
nurse,” or “student nurse” must not be used by camp staff or in camp literature
in reference to the first-aider. Nursing registry bodies have strict guidelines
as to who may use the title “nurse.” A student nurse hired in the capacity
of first-aider cannot be referred to by the title “nurse,” as the student
is not registered, nor licensed (Mass, 1998). In such a role the student
must minimally hold a current first-aid certificate; additional wilderness
or industrial first-aid certificates, and a medication management course
(if the student has not completed a nursing pharmacology course) are strongly
recommended.
Camp staff, administration, and the student nurse must
all be clear about and support the boundaries of practice for the first-aider
role. Practice boundaries for first-aiders are not the same as for registered
nurses. Camps can develop written job descriptions for first-aiders to
distribute medications that have been medically ordered or that parents
direct their camper to receive. However, when acting as a first- aider,
the student is constrained from using nursing judgment (except in emergency
situations) such as assessing emerging illnesses, withholding a medication
dose, or providing any medication that has not been medically ordered
or the camper’s parents have not specifically directed be given. This
includes common over-the-counter medications such as Tylenol® and ibuprofen.
Should a camp misrepresent the qualifications of its
health care provider(s), or if the first-aider does not adhere to the
practice boundaries of the first-aid certificate, both the camp and the
student nurse are legally liable should concerns arise about the student’s
practice or judgment. While not one we recommend, this model of student
nurses hired as “first-aiders,” — to be the sole health care provider
at a camp setting — would be best suited to day or resident camps with
physician and hospital services available in the immediate locale. Prior
arrangement for nursing faculty supervision and student nurse preparations
is strongly recommended.
Negotiated clinical experience
model
A third design for SNIs is most suited to those camp settings serving
campers with a chronic health challenge, such as diabetes, kidney failure,
asthma, or cancer. In this model a nursing faculty member accompanies
a group of student nurses to the camp setting for a negotiated clinical
experience. The nursing faculty member is contracted to act as one of
the on-site camp nurses. The student nurses (group of eight to ten is
ideal for the clinical supervision requirements) can attend as camp counselors
or attendants to the campers.
The level of care required by the camper population determines
the expectations for student experiences. Students could be responsible
for assessing the camper(s) in their care and providing for campers’ health
care requirements under the faculty member’s supervision. Variations in
student nurse assignment can be arranged to capture the full dimension
of the nursing role in these settings. Since most camps serving campers
with chronic health challenges typically take place during a set time
frame each year, this model of clinical internship could have long-term
benefits to the camp and nursing programs if an annual arrangement is
negotiated.
The Basics about Nursing Education
Most camp administrators don’t know a lot about nursing
education and how to go about arranging for student nurse internships
at camp settings. Administration may lack awareness of how to locate nursing
programs or an understanding of the various types of nursing programs
that exist, the level of nursing student which might best fit into a student
internship model, and how internships can work.
Various types of nursing programs exist for those who
desire to become registered nurses (RNs), the minimal level of nursing
preparation required for independent nursing practice such as at a camp
setting. Figure II lists the most usual
types of nursing education delivery in North America.
Most camp settings serve healthy campers. The challenges
of camp nursing in generalist camp settings, with their preventative health
care focus, and the need for independent problem solving and critical
thinking ability, probably are best suited to students from a baccalaureate
nursing program. Post-RN students already have their nursing licensure
so would be able to be employed as a camp nurse, so long as they have
current licensure in that state or province. All types of nursing students
would benefit from the model of the SNI offered in camp settings serving
children with chronic health challenges.
Camp SNIs, done under the supervision of the camp RN,
or independently as a first-aider, of necessity require a mature and self-directed,
upper-level (third-year) student. Internships conducted with a nursing
faculty member on-site for the duration of the experience could draw upon
students earlier in their nursing program. When negotiating a camp SNI
with nursing programs, the camp administrator could describe desirable
student nurse characteristics and abilities. Figure
I lists suggested student nurse attributes for a camp SNI conducted
without on-site faculty supervision. Figure
III lists attributes of camp settings most likely to support successful,
independent SNIs.
Figure IV notes suggestions
for locating and contacting nursing programs within your area. Because
of licensure issues, nursing faculty must hold current licensure within
the same state or province as the camp location in order to provide on-site
care or supervise SNIs at a specific camp setting. This means that nursing
faculty members must hold state or provincial nursing licensure for the
territory that the camp is situated in, even if the camp is just “across
the state line.”
Negotiating Initial Student Nurse Internships
Camp SNIs are undertaken by nursing students and their
faculty to meet educational goals, not merely “meet the need” of the camp
setting. Strong camp administrators appreciate the mutual, long-term benefits
when all the parties consider that their goals are attained. Negotiations
for an SNI should specify clear guidelines for the nursing student’s title
and scope of practice, which are then written into a clinical learning
contract. When nursing faculty members provide on-site supervision in
a camp nurse role, there needs to be clear identification of role expectations
for the faculty member so that both camp health and clinical teaching
goals can be attained.
SNIs require advanced planning. The potential benefits
and future supply of qualified camp nurses can justify the investment
of energy. Some nursing programs will be able to facilitate approval of
course objectives, credits, and contracts within their nursing education
department. In other settings the home university or college may have
a complex administrative bureaucracy that requires new course offerings
(such as when a student internship is first negotiated) be approved not
only by the nursing department but also by academic administration departments.
Additionally, some educational facilities require that a central office
approve student internship placements. Needless to say, adequate time
must be allowed for the bureaucratic steps when first time camp student
nurse internships are negotiated. An eight-to-twelve-month timeline is
recommended to negotiate new partnerships with nursing programs that then
result in an SNI.
So what about Allyson, the second-year nursing student
from our nursing program, who was hired as “assistant nurse” at the summer
camp for children with chronic health concerns? She phoned from camp recently
and was thrilled with all the experience she was gaining at the camp setting.
She expressed disappointment when told that with advance notice our nursing
program could have designed learning activities to provide her with an
elective course credit for her summer work.
Strong cautions were given to her about the camp designated
title of assistant nurse. We urged that she insist that her title be first-aider
or camp health assistant and that all camp personnel be apprised of that
distinction. Similar cautions were given about the lack of a distinct
job description to distinguish between the camp RN and first-aider roles.
In anticipation of Susan’s weekly day off-site, Allyson was advised to
have specific written care directives within the first-aider’s boundaries
of practice for all caregiving responsibilities.
Campers and their parents choose this camp setting for
the total camp experience, rather than just the camp health clinic; yet
overreliance on a student caregiver could leave this camp setting liable
for litigation related to potentially poorly managed care or misrepresentation
of camp health care staff qualifications.
This camp is fortunate to have hired a nursing student
who demonstrates most of the characteristics noted in Figure
I. Unless content to leave camp health care to such good luck, camp
administrators can secure a reference from the nursing program as to the
student’s clinical abilities prior to making the offer of employment.
Indeed, Allyson has not yet completed her pediatric nursing course, a
course that her nursing faculty would have strongly recommended before
undertaking this role at the camp setting.
With careful precamp preparation and appropriate supervision,
student nurse internships offer the opportunity for student nurses to
contribute to camp health care delivery and prepare for future independent
camp nursing roles. The camp setting provides the nursing student with
unique opportunities for community health nursing practice and nurse-led
primary health care delivery.
References
Gray, Lynne (1999). Camp nursing, Nursing BC, 31(3) 12. (online copy available:
www .rnabc. bc.ca/practice/campnurs.htl1l )
Maheady, D. (1991) Camp nursing practice in review, Pediatric
Nursing 17(3) 247-250
Mass, H. (1998) When can you call yourself a nurse? Nursing
BC, 30(2) 27-8 (online copy available: www.rnabc.bc.ca/practice/callnurs.htm)
McClure, S. (2001). Bringing student nurses to a camp
health center. ( 11(2),2-3.
Praeger, S. (1997). Establishing camps as clinical sites.
Journal of Nursing Education, 36(5),236-7.
The authors gratefully acknowledge and thank Linda Ebner
Erceg, RN, MS, Executive Director of the Association of Camp Nurses (ACN)
for her input and review in the preparation of this manuscript.
Originally published in the 2002 March/April
issue of Camping Magazine. |
