PRIMARY HEALTH CARE NURSE PRACTITIONER CERTIFICATE

(1)

2016 - 17

PRIMARY HEALTH CARE

NURSE PRACTITIONER

CERTIFICATE

(2)

1

Clinical Placement Guidelines

To help you complete your Clinical Placement Package we have created a documents guide. Upon accessing the Clinical Placement Guide you will see information and instructions on both the required supporting documents and the submission process.

All placements are facilitated by the Clinical Placement Coordinator Stacey Maximo in consultation with the Site Coordinator. Placement assignment takes into consideration an appropriate match between the student’s needs and the clinical site, as well as the date in which the Clinical Placement Package is submitted by the student and processed by the program.

There are Two Steps to completing and submitting your Clinical Placement Package:

STEP I Students will download the online 2016-17 Clinical Placement Package (This can be found by going to http://www.ryerson.ca/graduate/programs/nursing/current_students/index.html). Students have the option of populating the fields using the fillable pdf. Version or by printing the document and populating the fields by writing the text. You can also pick up a hard copy from the PHCNP Administrative Office located at POD 448. STEP II Students are required to submit in-person their complete Clinical Placement Package to Clinical

Placement Coordinator Stacey Maximo. Note that faxed, scanned, or e-mailed version will not be accepted – no exceptions. In order to have your package processed you will need to e-mail Stacey Maximo at

smaximo@ryerson.ca to schedule a 15 minute in-person appointment time. You will need to bring to your scheduled appointment all completed package forms and supporting documentation. The scheduled

appointment time is used to review your package submission and to confirm that all required documentation has been included. The deadline date for the program to receive your complete Clinical Placement Package is Thursday, August 11th_{, 2016. Missing the submission deadline date will result in a delayed placement}

assignment decision.

List of Required Forms & Supporting Documentation

The following is a list of the required clinical placement forms and supporting documentation that must be included with your Clinical Placement Package submission. Note that only original documents will be accepted.

 Practice Information Record Form  Practice Requirement Form  WSIB Form

 Police Check  CPR Card  Mask Fit Card

 Vaccination records and recent Bloodwork

 Signed and Dated Documents Checklist and Declaration

 Email Stacey Maximo an updated resume (please save file as Firstname-Lastname-Resume) IMPORTANT:

 Please submit your complete package in person to Stacey Maximo by Thursday, August 11th_, 2016

(4)

3  Students that submit a complete package by the deadline date will be given full placement

assignment consideration

 Incomplete packages will not be considered for processing

 Please make a copy of this package and all supporting documents for your records

PHCNP Certificate Clinical Placement Terms & Conditions

Clinical Placements typically commence mid-to-end of September. Emphasis is on community and primary health care settings (e.g. CHCs, GP offices); this is a ‘generalist’ program, therefore clinical placement

assignments reflect this foundational aspect. Please make sure that you have reviewed and that you understand the following Clinical Placement Terms & Conditions:

 Stacey works at the university part-time; emails and voicemails will be responded to within three business days.

 Regarding clinical placement geographical restrictions (there are clear boundaries for the central

region), students residing outside of the GTA will not be guaranteed a placement outside of the Ryerson boundaries as defined by the central region. Please go to http://np-education.ca/ to view the Regional Map for the central region.

 All students are expected to travel to seminars and clinical placements; LOCATION (where you reside) is not a factor - NO EXCEPTIONS.

 It is the student’s responsibility to adapt their personal schedules (i.e. work and family), to accommodate the requirements of the clinical placement; including the preceptor’s schedule.  You must be preceptored by at least one NP during the duration of the program. The student’s own

workplace is not suitable for clinical placements and will not be considered – NO EXCEPTIONS.

 Placements are not subject to student approval; if a student chooses to not “accept” their placement, the student will forfeit the clinical placement. This action will jeopardize progress in the program by preventing continued enrollment in the clinical course.

 Clinical placements are non-negotiable; once you are placed there will be NO CHANGES unless there are extenuating circumstances that have been discussed with and approved by the Program Director.  Never contact any agency that is listed on the Central Registry Data Base. Prospective agencies and

preceptors that have not first been cleared by Stacey are not eligible for placement consideration. If you have already made contact and/or arrangements with a potential preceptor, cancel them and email Stacey.

 Not all learning needs are necessarily met at one particular clinical setting; other opportunities during the program will help facilitate with learning needs.

 Once a placement is confirmed, and only when contact information is forwarded to the student by Stacey, may the student contact the preceptor to arrange an interview or placement start-date.

(5)

4  If you drop a course with a clinical component or withdraw from the program, it is your professional

responsibility to communicate this with your preceptor, faculty, and NP office staff.

 The program reserves the right to remove any student from placement whose performance does not meet the expected standards of practice for a student at that level of the course at that point in time; and/or where patterns of behaviour fail to demonstrate successful progress towards meeting the course objectives. This situation is not considered to be unsafe practice unless it refers to patterns of behaviour or an incident that puts self, patient/client and/or others at a risk that is both imminent and of a

substantive nature. The program is under no obligation, in these cases, to find an alternative placement.

 If, after discussions between student, preceptor and site coordinator, it is determined that a student’s patterns of behaviour have resulted in the clinical practice agency terminating the placement, the student may be advised to drop the course or if the student is deemed to have jeopardized her/his opportunity to complete the objectives of the course she/he will receive an F grade. The agency is not obligated to meet with the student.

(6)

5

(7)

(8)

(9)

(10)

(11)

(12)

11

PHCNP Practice Requirement Record

Please complete the questions below: Your response to questions #2 and #3 does not guarantee that you will be placed in those areas of practice - they are simply used as guidelines.

1. Please indicate any previous work experience (please select all that apply with an “X”).

Geriatrics Women’s Health Neurology

Pediatrics Men’s health Cardiology

Emergency Youth Oncology

Intensive Care Unit Mental Health Gastroenterology

Cardiac Care Unit Family Health Team Nephrology

Trauma Community Health Center Respirology

Urology Public Health Rehabilitation

Marginalized Population Long Term Care Medicine

Other:

2. Select which practice areas you would like to be considered for your clinical placement (please select all that apply with an “X”).

Geriatrics Women’s Health Neurology

Pediatrics Men’s health Cardiology

Emergency Youth Oncology

Intensive Care Unit Mental Health Gastroenterology

Cardiac Care Unit Family Health Team Nephrology

Trauma Community Health Center Respirology

Urology Public Health Rehabilitation

Marginalized Population Long Term Care Medicine

Other:

3. Please select the following geographical area that best represents the current city that you wish to be placed in with an “X”

(please select all that apply with an “X”).

Central Toronto East Toronto Peel Region Durham Region

North Toronto West Toronto Halton Region York Region

Simcoe County Dufferin County Hamilton Region Waterloo Region Other:

(13)

12

5. If you have a specific clinical placement in mind that will meet your needs, please provide the following: Organization Address Description of placement Preceptor Name Contact Information Professional Designation

(14)

13

1st_{Dose Date : ___/___/______ 2}nd_{Dose Date: ___/___/_____}

mm/ dd/ yyyy mm/ dd/ yyyy

HCP Signature: _____________ HCP Signature : ____________

PHCNP Practice Information Record

Last Name: First Name:

Student # Email: @ryerson.ca NOTE TO STUDENT AND HEALTH CARE PROVIDER (HCP)

Ontario legislation specifies certain surveillance requirements for those entering into healthcare practice settings. The Nursing Program policy was developed in accordance with the communicable disease surveillance protocols, specified under the Public Hospitals Act, to meet the requirements of our students’ placement settings. This process is necessary to ensure that our students protect their health and safety, and the health and safety of patients, visitors, employees and other students. Other than the influenza vaccine, the completion of this information is not optional, and all sections must be completed as outlined. Our placement partners have the right to refuse students who have not met their immunization standards

1. DIPHTHERIA, TETANUS, PERTUSSIS, POLIO

Date of last Diphtheria Booster : _____/_____/_______ HCP Signature: ___________________________________ mm / dd / yyyy

Date of last Tetanus Booster : _____/_____/_______ HCP Signature: ___________________________________ mm / dd / yyyy

Date of last Pertussis Booster : _____/_____/_______ HCP Signature: ___________________________________ mm / dd / yyyy

Date of last Polio Booster : _____/_____/_______ HCP Signature: ___________________________________ mm / dd / yyyy

2. COMMUNICABLE DISEASES

Note: laboratory evidence is required to prove immunity for sections below; you must attach a copy of blood work. I. Measles, Mumps, Rubella (MMR)

Laboratory evidence of immunity or

Documentation of 2 doses of MMR vaccine after 1st_birthday

II. Varicella (Chicken Pox)

Laboratory evidence of immunity or

Documentation of 2 doses of Varicella vaccine given at least 4 week apart

3. HEPATITIS B

Note: laboratory evidence is required to prove immunity for Hepatitis B; you must attach a copy of blood work. Laboratory evidence of immunity

and

Documentation of Hepatitis B vaccination series

Please check vaccination dose schedule:

2 Dose 3 Dose

Students on 3 dose vaccination schedule must receive at least 2 doses of the vaccine in order to attend practice. Students should submit proof of final dose of series as soon as it is received. Hepatitis B chronic carriers are not required to disclose status to placement sites.

1st_{Dose Date : ___/___/______ 2}nd_{Dose Date: ___/___/_____}

mm/ dd/ yyyy mm/ dd/ yyyy HCP Signature: _____________ HCP Signature : ____________ [ T y p e a q u o [ T y p e a q u o

1st_{Dose Date: ___/___/_____ HCP Signature: _____________}

mm/ dd/ yyyy

2nd_{Dose Date: ___/___/_____ HCP Signature: _____________}

mm/ dd/ yyyy

3rd_{Dose Date: ___/___/_____ HCP Signature: _____________}

(15)

14 4. INFLUENZA VACCINE (Recommended)

Influenza virus vaccine is available free of charge from health services in the fall or can be obtained from your healthcare provider. Students are encouraged to submit evidence of the vaccination. Note: if you know or suspect that you have an allergy to eggs or other vaccination preservatives, please discuss your options with your HCP.

I understand that the influenza vaccine is not mandatory; however, if an outbreak occurs at my assigned agency and I did not receive the flu vaccine, I may be denied access to the facility, thus jeopardizing successful completion of my practice.

Student Signature ______________________________________ Date ___________________________________________ 5. YEARLY TUBERCULOSIS SCREENING

Note: If your step 1 test is positive or have tested positive anytime in the past, proceed to section B. Positive skin tests do not require TB skin testing.

Section A: Mantoux Test

If there is documentation of a previous 2-Step TB test within the last 12 months, proceed with 1-Step test only. Otherwise, if the 1st_{test is} negative, a 2nd_{test is given in the opposite arm at least 1 week and no more than 4 weeks after the 1}st_test.

You must be tested for TB annually, and you must be covered while you are in clinical practice.

Step 1 Test Date: ____/____/______ Date Read: ____/____/______ Induration: _______ mm HCP Name: _________________________ mm dd yyyy mm dd yyyy

Signature : __________________________

Step 2 Test Date: ____/____/______ Date Read: ____/____/______ Induration: _______ mm HCP Name: _________________________ mm dd yyyy mm dd yyyy

Signature : __________________________ Section B: CXR - only for positive skin tests: complete below sections AND attach a copy of chest x-ray report:

Chest x-ray Date ____/____/______ Result: _____________________ Signs & symptoms of active TB: Yes No mm dd yyyy

Assessment Date: ____/____/______ HCP Name: _____________________________ HCP Signature: __________________________ mm dd yyyy

Note: Yearly chest x-rays are not required unless clinical status changes or advised by HCP. You can therefore attach a report from a previous chest x-ray taken within last 2 years. The HCP must still indicate and sign that there are no signs and symptoms of active TB (above). TB testing should be completed prior to the administration of any live vaccines or 4 weeks post receiving live vaccine.

SIGNATURE OF HEALTHCARE PROVIDER(S) Instructions:

If you have documented on these forms please complete the section below or stamp and provide your signature. Please print clearly.

Name of Healthcare Provider (please print)

Address (street)

Address (city & postal code)

Telephone Number

Signature of HCP

Date Title (i.e. MD, RN)

Address (street)

Telephone Number

Signature of HCP

Address (street)

Telephone Number

Signature of HCP

[ T y p e a q u o t e f r o m t h e d o c u m e n t o r [ T y p e a q u o t e f r o m t h e d o c u m e n t o r

(16)

15 6. MASK FIT

All students must be tested and fitted for an appropriate mask (respirator) in the event of flu (or other airborne/droplet) outbreak. Cards must clearly state the mask type (model) and size. Please ensure you carry your mask fit card at all times during practice. Mask fit cards are valid for 2 years after the issue date. Your Mask Fit card must be valid for the entire time that you are in clinical practice. Please present your original Mask Fit card to Stacey Maximo with this form.

7. VULNERABLE SECTOR SCREENING (VSS) POLICE CHECK

All students are required to obtain a yearly VSS police check which must be valid for the entire time that you are in clinical practice. You will need to present your original VSS police check as soon as you receive it. STUDENTS CANNOT ATTEND PLACEMENT UNTIL SUBMSSION OF YOUR ORIGINAL VSS POLICE CHECK REPORT -- APPLY WELL IN ADVANCE.

If you reside in Toronto, you must come to the NP office to complete a consent form. The completed consent form is then mailed to Police Headquarters to apply for your VSS police check. Note: Toronto Police Services can take up to 8 weeks or longer to process your VSS police check. If you live in other municipalities (e.g. York Region, Peel Region), please go directly to your police headquarters.

Please check the CPO website for updates related to the police check process.  Please present your original VSS police check to Stacey Maximo with this form.

If you did not receive your police check by the submission deadline, please submit as soon as you receive it.

If your police check is positive, please contact Luisa Barton ASAP at 416-979-5000 ext. 6560 or at luisa.barton@ryerson.ca 8. CPR CERTIFICATION (HCP Level)

Cardio Pulmonary Resuscitation (CPR) Healthcare Professional (HCP) level – for placement purposes, your certification must be HCP-level and expires one year from the issue date. CPR re-certification is therefore required on a yearly basis and must be valid for the entire time that you are in clinical practice. Please present your original CPR card to Stacey Maximo with this form.

9. STUDENT DECLARATION

Please print out a copy of the “Student Declaration of Understanding Workplace Safety and Insurance Board Coverage

Unpaid Student Trainees in Clinical Placements” form. Make sure you have read and signed a copy. This is to ensure that you have understood that you are covered under the WSIB while you attend your clinical practice.

 Please present a signed copy to Stacey Maximo with this form. 10. CNO ANNUAL REGISTRATION LICENCE

Your CNO registration license will be verified at www.cno.org

License Number: ________________________ Name as it appears on your license: _________________________________

To be completed by Stacey Maximo: RN Entitled to practice: without restrictions with restrictions not entitled to practice

[ T y p e a q u o t e f r [ T y p e a q u o t e f r [ T y p e a q u o t e f [ T y p e a q u o t e f

(17)

16

NOTICE TO STUDENTS

COMPLETION OF THE PRACTICE REQUIREMENTS RECORD IS REQUIRED IN ORDER TO ATTEND PRACTICE.

When you have completed ALL practice requirements, submit this Practice Requirements Records Package together with all original

documentation in person to Stacey Maximo by 3pm on THURSDAY AUGUST 11th_{, 2016}_.

Do not fax, scan, or electronically send your records.

Please ensure you keep of all your documents; the NP office does not keep copies of students immunization records, bloodwork, CPR, Mask Fit, or Police check and are not responsible if you misplace your documentation.

Please keep a copy of this Practice Requirements Record; you may need to present it to your preceptor or to the agency that you are attending.

Please be aware that you’re VSS, CPR, and Mask Fit expires, and TB requires annual testing. You may be required to renew these in the middle of clinical practice (depending on when you got them done). It is the student’s responsibility to ensure they know when they expire and when they need renewal. You must be covered throughout your clinical practice.

Failure to comply with these instructions will jeopardize your placement.

Name:_________________________

Signature:______________________

Date:__________________________

The information on this form is collected under the authority of the Ryerson University Act and is required to process your application for your practice placement course. The information will be used in connection with placement negotiations and communication with placement agencies. If you have any questions about the collection, use, and disclosure of this information by the Daphne Cockwell

School of Nursing, please contact Stacey Maximo via telephone at 416-979-5000 ext. 4176, or via email at smaximo@ryerson.ca, or

(18)

17

PHCNP WSIB Student Declaration of Understanding

Workplace Safety and Insurance Board (WSIB) Coverage for Unpaid Student Trainees in Clinical Placements Student Declaration of Understanding

Students of health sciences programs as identified by their university or college are eligible for Workplace Safety Insurance Board (WSIB) coverage of claims while on unpaid placements required by their program of study.

Ministry of Training, Colleges and Universities ensures that students on work placements receive WSIB insurance coverage for injuries or disease incurred while fulfilling the requirements of their placement. Declaration

I have read and understand that WSIB coverage will be provided through the Ministry of Training, Colleges and Universities while I am on training placements as arranged by the university or college as a requirement of my program of study.

I understand the implications and have had any questions answered to my satisfaction.

I agree to immediately report any placement related injury or disease to the placement employer. Release of Information

I understand that my personal information will be released to the placement employer in the event of a workplace injury or disease at the placement employer’s workplace during an unpaid placement.

I understand that the Ministry of Training, Colleges and Universities, the college or university and placement employer will be required to release relevant personal information with each other and to the WSIB.

Student name (print):________________________ Student signature: _________________ Program/School: _________________________ Date: ___________________________

Parent/Legal Guardian’s Signature (for student less than 18 years of age)

Name (print): ________________________________Date:__________________________

(19)

18

PHCNP Clinical Placement Package Documents Checklist

Please submit this completed package by August 11, 2015 to Stacey Maximo. Please make sure to include the following:



Practice Information Record Form



Practice Requirement Form



Signed WSIB Declaration Form

Please also bring the following Supporting Documentation to your scheduled in-person appointment:



Police Check



CPR Card



Mask Fit Card



Vaccination records and recent Bloodwork



Signed and Dated Documents Checklist and Declaration



Please email Stacey Maximo an updated resume (please save file as Firstname-Lastname-Resume)

IMPORTANT:

 Please submit your complete package in person to Stacey Maximo by Thursday, August 11th_, 2016

 Students that submit a complete package by the deadline date will be given full placement assignment consideration

 Incomplete packages will not be considered for processing

 Please make a copy of this package and all supporting documents for your records

By signing this form, I am declaring that I have read and understand this Clinical Placement Package in its entirety, and that I am agreeing to the terms and conditions outlined in the document.

Last Name First Name

Student Signature Date

PRIMARY HEALTH CARE NURSE PRACTITIONER CERTIFICATE

2016 - 17