Journal of Nursing Education

Major Article 

Review of State Boards of Nursing Rules and Regulations for Nurse Preceptors

Kristine M. L'Ecuyer, PhD, RN, CNL; Shelley von der Lancken, MSN, RN; Diane Malloy, PhD, RN; Geralyn Meyer, PhD, RN, CNL; Matthew J. Hyde, MSN, RN, CNL

Abstract

Background:

The clinical education of undergraduate nursing students relies heavily on the use of staff nurses who assume the preceptor role. The best and most efficient utilization of preceptors is unknown.

Method:

This study reviewed Board of Nursing rules and regulations for all 50 states, the District of Columbia, and the U.S. territories for their published requirements regarding preceptors. Specifically, this review focused on preceptor–student and faculty–student ratios, role responsibilities, and requirements of preceptors and faculty in undergraduate precepted clinical experiences.

Results:

Although some commonalities were noted, such as eligibility (RN licensure), degree requirements (baccalaureate), and years of experience (1 to 3), 11 states had no documented regulations. The existing documents appear to lack depth, specificity, and consistency.

Conclusion:

Because preceptors are utilized to such a great extent, the eligibility, selection, preparation, and expectations of preceptors and faculty who work with them should be more explicit. [J Nurs Educ. 2018;57(3):134–141.]

Abstract

Background:

The clinical education of undergraduate nursing students relies heavily on the use of staff nurses who assume the preceptor role. The best and most efficient utilization of preceptors is unknown.

Method:

This study reviewed Board of Nursing rules and regulations for all 50 states, the District of Columbia, and the U.S. territories for their published requirements regarding preceptors. Specifically, this review focused on preceptor–student and faculty–student ratios, role responsibilities, and requirements of preceptors and faculty in undergraduate precepted clinical experiences.

Results:

Although some commonalities were noted, such as eligibility (RN licensure), degree requirements (baccalaureate), and years of experience (1 to 3), 11 states had no documented regulations. The existing documents appear to lack depth, specificity, and consistency.

Conclusion:

Because preceptors are utilized to such a great extent, the eligibility, selection, preparation, and expectations of preceptors and faculty who work with them should be more explicit. [J Nurs Educ. 2018;57(3):134–141.]

Nurse preceptors have a central role in the clinical education of undergraduate nursing students. Clinical experience with preceptors in practice settings is critical to prepare students for the practice of nursing. Yet, few regulations for qualifications, preparation, training, or role responsibilities have been proposed or standardized. In the United States, the Nurse Practice Act of each state establishes a state board of nursing, which in turn develops the regulations and standards for prelicensure education. In this study, regulations pertaining to the use of preceptors in clinical nursing undergraduate education were reviewed and content analysis was completed to document the current state of U.S. preceptor guidelines. Identifying similarities, differences, and gaps in current guidelines can be a useful framework for nurse educators as they select, train, and support staff nurses who serve as clinical preceptors. Nursing faculty rely on preceptors to create a safe and conducive clinical learning environment. Clearly defined role requirements and responsibilities of preceptors may improve the quality of students learning experiences. In addition, adding structure to preceptor preparation guidelines may advance the development of preceptors as clinical educators and demonstrate the value of the preceptor model of nursing education.

A preceptor has been defined as “an individual at or above the level of licensure that an assigned student is seeking who may serve as a teacher, mentor, role model, or supervisor in a clinical setting” (National Council of State Boards of Nursing [NCSBN], 2012, p. 4). Preceptors are also utilized in practice settings to help orient newly hired nurses, including newly graduated nurses. Because the scope of state board nursing education regulations is limited to education in schools of nursing, the focus of this article is the use of preceptors with students completing undergraduate prelicensure clinicals in academic settings.

Research on the precepted model of nursing education has not defined the most efficient utilization of preceptors, the optimal number of hours students should spend with them, selection and training requirements, or faculty roles in precepted clinical experiences. These questions formed the groundwork for this study. Specifically, this study sought to answer the following research questions:

  • What is the ratio of preceptor–student and faculty–student in a precepted undergraduate educational experience?
  • What are the requirements and role responsibilities of nurse preceptors in nursing education?
  • What are the requirements and role responsibilities of faculty in a precepted educational experience?

Background

The way in which staff nurses perform their role as nurse preceptors is highly relevant in preparing future nurses. This is a stressful and complex role. Preceptors mentor, monitor, teach, provide feedback, and assess undergraduate nursing students (Trede, Sutton, & Bernoth, 2016). Nurse preceptors act as protectors, role models, teachers, guides, supporters, assessors, evaluators, and supervisors (Omer, Suliman, & Moola, 2016; Panzavecchia & Pearce, 2014; Paton & Binding, 2009; Tracey & McGowan, 2015). The preceptor models the role of a professional nurse and is involved in the socialization, education, and overall development of students' confidence, competence, and critical thinking.

The attributes of an ideal preceptor are not clear. Often, preceptor selection criteria include availability, number of years of service, and experience in the profession. Deans and directors ranked clinical competence as the most important factor for selection (Altman, 2006). Selection criteria may also include nurses who are skillful, have attended a preceptor course, or who possess excellent nursing judgment (Omer et al., 2016). It is little wonder that many research studies outline the need for more definitive selection criteria and propose qualities for a good clinical preceptor (Jansson & Ene, 2016). Some of the criteria include a bachelor's degree or higher education (Oermann, 1996), experience as a staff nurse (Oermann, 1996), continuity, adequate time, a positive attitude toward teaching and learning (Jansson & Ene, 2016), professional values and communication skills (Rodrigues & Witt, 2013), and the ability to stimulate critical thinking (Myrick & Yonge, 2002).

The task of being a preceptor may be viewed as both a duty and a burden, indicating ambivalence toward the role (de Fulvio, Stichler, & Gallo, 2015). Some of the struggles that preceptors experience include assessment of student clinical performance, lack of time, and being overwhelmed with an increase in workload (Panzavecchia & Pearce, 2014). Benefits, rewards, supports, challenges, and commitment to the preceptor role have also been assessed. Benefits include sharing knowledge and teaching students, integrating students into the workplace, gaining personal satisfaction from the role, and contributing to the profession; challenges include having unmotivated or disinterested students, workload demands, providing feedback, lack of coworker or faculty support, and unclear expectations (Kalischuk, Vandenberg, & Awosoga, 2013).

As clinical nursing education has evolved, preceptors have been asked to take on more responsibility throughout the nursing curriculum. Although preceptors typically work with students in clinical courses just prior to graduation, the newest model of nursing clinical education, the dedicated education unit, calls on utilization of preceptors in early clinical courses (Krampe, L'Ecuyer, & Palmer, 2013). At the same time, preceptors are challenged with staff shortages, heavy workloads, dynamic clinical environments, and inadequate support from institutions and academic nurse educators.

The selection, education, abilities, and workload of preceptors are important considerations. It cannot be assumed that by virtue of their knowledge and experience, nurses are automatically suited to the preceptor role. Developing standards for selecting nurse preceptors and providing adequate education and mentoring have been described briefly for preceptors of new graduate nurses (Cotter & Dienemann, 2016) but not for working with nursing students. Preceptor selection often includes assessment of preceptor educational background. Deans and directors of nursing were surveyed to assess preceptor selection, orientation, and evaluation. Of the 137 survey respondents, most had preceptor selection criteria (91%) and required preceptors to have a baccalaureate degree (79%); however, most had no requirements for previous teaching experience (83%), and the requirements for years of clinical experience ranged from 1 (30.8%), 2 (32.3%), 3 to 5 (15%), or “not applicable” (18%) (Altman, 2006).

In the United States, preceptor guidelines have been established by the NCSBN (2012), the American Association of Colleges of Nursing (AACN, 2008), and the Commission on Collegiate Nursing Education (CCNE, 2013). Their roles and authority are briefly described in this article, and guidelines for the use of clinical preceptors are summarized in Table 1 for comparison. The AACN is responsible for establishing national standards for nursing education. The CCNE is the autonomous accrediting agency of baccalaureate and graduate nursing programs. Finally, the NCSBN is a national council comprising state-level boards of nursing, which both outlines standards for safe nursing care and issues licenses to practice nursing.

Summary of Preceptor Qualification and Role Expectations

Table 1:

Summary of Preceptor Qualification and Role Expectations

Only one study was found that explored state boards of nursing documents for rules and regulations concerning the use of preceptors in nursing education (Packard, Polifroni, & Shah, 1994). Only 18 of the 38 boards of nursing documents reviewed in their study contained criteria for preceptors. Inconsistencies have been described on a global level as well, where in the United Kingdom preceptors are defined as RNs with a minimum of 1 year of experience (Panzavecchia & Pearce, 2014), and in Taiwan RNs are required to have at least 3 years of clinical experience and attend 10 hours of education (Tsai et al., 2014).

The scope of professional responsibility placed on nurse preceptors assumes that they should function effectively as preceptors; however, many receive minimal preparation or support for that role. Although some preceptors report confidence in their knowledge and ability to guide students, they also describe the need for additional support for their teaching roles, evaluation roles, conflict resolution strategies, and space and time to communicate confidentially (Dahlke, O'Connor, Hannesson, & Cheetham, 2016). Preceptors have stated the need for more preparation (Bengtsson & Carlson, 2015; de Fulvio et al., 2015; Panzavecchia & Pearce, 2014), and they are more effective if they have received preparation for their role (Cotter & Dienemann, 2016; Horton, Depaoli, Hertach, & Bower, 2012; Mårtensson, Löfmark, Mamhidir, & Skytt, 2016).

Preceptor training courses via onsite or online modules have shown to increase preceptor role effectiveness (Bengtsson & Carlson, 2015; Condrey, 2015; Kang, Chiu, Lin, & Chang, 2016). These courses often review preceptor roles and responsibilities and discuss identification of learning styles, personality differences, teaching–learning strategies, critical thinking, tools for giving feedback and evaluation, and student issues in clinical education (Clipper & Cherry, 2015; Horton et al., 2012; Krampe et al., 2013). The nursing profession has a responsibility to prepare qualified educators in both academic and clinical settings. Although much of nursing education is regulated, the role of the nurse preceptor is not well defined, standardized, or regulated. Clinical preceptors would benefit from clearly defined expectations to provide structure, support, and verification of their contributions to nursing education. Academic nurse educators should be sensitive to the needs of nurse preceptors, their reasons for assuming the role, and their stressors and challenges. Mentoring, continuing education on the teaching role, and improved skills regarding providing feedback and evaluation of students would improve preceptor efficacy.

Method

The research team reviewed rules and regulations regarding the use of staff nurse preceptors in prelicensure nursing education programs across the United States, including the District of Columbia, and the U.S. territories that are members of the NCSBN. An online search for each jurisdiction's Board of Nursing rules and regulation documents for education of nursing students was completed. Jurisdictions for which documents were missing were contacted directly. The final sample consisted of rules and regulations of all 50 states plus the District of Columbia, and four U.S. territories (American Samoa, Guam, Northern Mariana Islands, and U.S. Virgin Islands). Each research team member searched a group of selected documents, extrapolated applicable preceptor requirements, and entered the data into a database. The final database was verified by another team member in June 2016 to ensure accuracy. Content analysis commenced by team members' independent reviews of the collected data. The team met periodically to discuss findings and formulate a table to organize findings (Table 2). Notations were made for jurisdictions that did not have preceptor information, define the preceptor role, require a preceptor orientation, discuss preceptor qualifications, or require an RN license. Additional findings were categorized into three major areas to align with the research questions: description of preceptor qualifications and role responsibilities, description of faculty expectations and role responsibilities, and ratios of preceptor-to-student and faculty-to-student.

Summary of Current Board of Nursing Rules and Regulations Regarding Preceptors in the United States and Territories That Are Members of the National Council State Board of Nursing (NCSBN)Summary of Current Board of Nursing Rules and Regulations Regarding Preceptors in the United States and Territories That Are Members of the National Council State Board of Nursing (NCSBN)

Table 2:

Summary of Current Board of Nursing Rules and Regulations Regarding Preceptors in the United States and Territories That Are Members of the National Council State Board of Nursing (NCSBN)

Results

As expected, variability was found across the rules and regulations of all states regarding preceptor guidelines (Table 2). Nine states and two U.S. territories in the sample had no mention of preceptors in their regulations. Fourteen states and two territories clearly defined the term preceptor. Some of the definitions of preceptor were simple and straightforward, such as that found in the Missouri regulations: “registered professional nurse assigned to assist nursing students in an educational experience which is designed and directed by a faculty member.” North Carolina defines the preceptor as a “highly qualified professional with specific clinical expertise and knowledge in the teaching/learning process” who “agrees to serve as a role model, resources person and to provide support for a nursing student….” Wyoming calls preceptors “partners in education.”

Preceptor Qualifications and Role Responsibilities

Basic qualifications for the preceptor role were prescribed in some states. The most basic qualification, indicated by 29 states and two territories, was that preceptors hold a professional license in the state in which they were practicing. As expected, this was typically defined as an RN license, although four states (Georgia, Iowa, North Dakota, Texas) declare that the preceptor can be a non-nurse.

After licensure, the most frequently defined qualification for preceptors was years of experience as an RN. Seven states (Arkansas, California, Colorado, Georgia, Mississippi, Missouri, Oklahoma) require preceptors to have a minimum of 1 year of experience. In most of these states, such as Arkansas, this year of experience must be in the “area of clinical specialty for which the preceptor is utilized.” In California, the preceptor must be employed by the health care agency for a minimum of 1 year. Other states require more than 1 year of experience for the nurse to function as a preceptor. In seven states (Louisiana, Maryland, Nebraska, Ohio, South Carolina, Washington, D.C., Wyoming), 2 years of experience as an RN is required. Washington, D.C. further states that preceptors should have “experience providing direct care during the five years immediately preceding” the preceptorship. In Indiana, preceptors are required to have 3 years of experience as an RN.

Other basic qualifications for preceptors were also defined by some states. Three states require preceptors to hold a minimum of a BSN degree (Delaware, Louisiana, North Carolina), and three states note that a BSN is preferred (Maryland, Nebraska, Ohio). Other states merely state that preceptors should hold comparable or greater education than the student they are precepting (Arizona, Colorado, Georgia, Mississippi, North Dakota, Oklahoma, West Virginia). Some regulations contained specific requirements for preceptors, such as having a “philosophy of health congruent with that of the nursing program” (Maryland, Texas, Washington, D.C.) or being interested in assuming the role of preceptor (Nebraska, North Carolina).

The actual work of the preceptor was also defined by state regulation. Florida, Nevada, and South Carolina require that a preceptor be physically present and available to the student when the student is performing nursing services to patients. Massachusetts calls the preceptor a direct supervisor. Oklahoma specifically states that medication administration may be supervised by the preceptor. Arkansas and New Hampshire note that preceptors should participate in evaluation of the student, whereas Missouri and Vermont require that preceptors provide written documentation to faculty regarding a student's performance. A few states discuss the use of backup, relief, or designated preceptors (California, Florida), and Vermont notes that preceptors may not further delegate the duties of preceptorship. Finally, the Northern Mariana Island territory specifically outlined the preceptor role in a dedicated education unit clinical model.

Faculty Expectations and Role Responsibilities

Several curricular issues were identified within the theme of faculty responsibilities. For example, some states limit the percent of total clinical time that can be precepted to a “small percentage of total clinical hours” (Oklahoma), 20% (Montana), 20% of non-Capstone hours (Kansas), or 25% of total clinical weeks (Louisiana). A few states note that preceptors cannot be used for fundamental clinical rotations, in foundational courses, or with beginning students (Arkansas, Missouri, Nebraska, North Carolina, North Dakota), whereas Louisiana specifies that preceptor experiences shall only occur during the last two academic semesters of a baccalaureate program. Only two states require written policies for the use of preceptors (Arkansas, Indiana), such as written criteria for selecting preceptors and the duties, roles, and responsibilities of the faculty, the student, and the preceptor, including the communication process and evaluation process. Many states require a written agreement with the agency that delineates the responsibilities of the program, the student, the preceptor, and the faculty (California, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Nebraska, South Carolina, Texas, Utah, Vermont).

Regulations regarding an orientation for preceptors were found in many states. Most of those require that course objectives are provided to the preceptor (Florida, Indiana, Missouri, Nebraska, Nevada, Northern Mariana Islands, South Dakota, Texas, Virginia, Washington). More specifically, South Dakota notes that during orientation, preceptors should be given any information regarding the individual student's knowledge, abilities, and skills needed to ensure safe patient care. The state of Virginia requires a skills checklist detailing the performance of skills for which the student has had in faculty-supervised clinical and didactic courses.

Expectations of faculty were found in only a few state regulations and centered on availability of faculty. Although some states said faculty should be readily available (Arkansas, Georgia, North Carolina, Texas) or available by telephone or telecommunication (Indiana, Idaho, South Carolina), others said faculty should meet with preceptors and students prior to and throughout the learning activity (Georgia) or periodically (Indiana, Missouri, Texas, Washington, Wyoming). Florida requires faculty to be readily available on site for level-one students and available by telephone for level-two students. Louisiana requires that faculty confer daily with the preceptor and student. Most states that included responsibilities of faculty agreed that faculty maintain the responsibility for final student evaluations.

Ratios of Preceptor-to-Student and Faculty-to-Student in Precepted Clinical Experiences

The number of students who can be assigned to a preceptor at any one time was defined by 19 states. Idaho simply states that the preceptor-to-student ratio should be “appropriate.” Louisiana, Nebraska, and Wyoming call for a one-to-one ratio, whereas the other 16 states that specify a ratio use one preceptor to two students as the maximal number.

Some states also define the number of precepting students that can be assigned to a faculty member for oversight. California holds that the faculty-to-student ratio for preceptorship must be based on the student-to-preceptor needs, faculty's ability to effectively supervise, students' assigned nursing area, and agency or facility requirements. Ten states and two territories defined specific faculty-to-student ratios in precepted courses. The maximum mandated ratios ranged from one faculty to 10 precepted students (Indiana, North Carolina) to one faculty to 24 students in Texas.

Discussion

A review of available U.S. states and U.S. territories board of nursing rules and regulation documents and their language pertaining to the use of preceptors in the clinical education of undergraduate nursing students was completed. Although some common guidelines were noted, overall we found the documents lacking specificity. It was concerning that 11 states or territories had no mention of preceptors in their nursing education guidelines; however, this does mean that more jurisdictions have preceptor information than was found in 1994 by Packard, Polifroni, and Shah. Some states were more explicit than others and aligned with the 2012 NCSBN model rules of clinical nursing education. There is room for improvement in many states.

Criteria for preceptor selection must be well defined to ensure appropriate preceptors are chosen and used. Desired preceptor characteristics have not been fully addressed in the literature beyond availability, willingness, skill, attendance at a preceptor course, nursing judgment, positive attitude toward teaching, communication skills, and the ability to stimulate critical thinking (Jansson & Ene, 2016; Myrick & Yonge, 2002; Omer et al., 2016; Rodrigues & Witt, 2013). Most documents reviewed in this study had little guidance beyond the basic licensure, educational, or experiential qualifications, a “philosophy of health congruent with that of the nursing program,” or being interested in assuming the role of preceptor. Many layers exist between the student and the preceptor assignment. They are rarely matched for other reasons besides availability and location. Often, faculty work through liaisons in both schools of nursing and in health care agencies to recruit and assign preceptors. Therefore, preceptors are less often selected and more often assigned. This arrangement is efficient, yet relies on the system to prepare preceptors and the faculty to ensure that the student–preceptor–faculty triad functions in a meaningful way.

The biggest areas of concern pertain to preceptor orientation, preceptor-to-student ratios, and student evaluation. As the national faculty shortage continues and results in increased needs for preceptors, caution must be observed to ensure that preceptors are prepared for their responsibilities. Missing from the NCSBN model rules, but discussed in 16 of the reviewed documents, is an orientation for preceptors. Preceptor expectations and role responsibilities should be explained clearly at the beginning of the clinical experience by the clinical faculty. Preceptor orientation is critical, and faculty must ensure that preceptors have a thorough understanding of their job requirements. Preceptors have often cited a lack of preparation for their role (Bengtsson & Carlson, 2015; Panzavecchia & Pearce, 2014), and nurse faculty who work with preceptors can fill this void. In a recent integrative review of the relationship between nurses and students in a clinical setting, the authors conclude education for preceptors validates their role and having time to teach facilitates their clinical teaching role (Rebeiro, Edward, Chapman, & Evans, 2015). Once oriented or prepared for their role, faculty can facilitate a supportive relationship with ongoing communication and sensitivity to the needs of the preceptors as they monitor the progress of the students in the clinical setting.

After a preceptor has been selected and oriented and is in place, the relationship between the preceptor and the faculty needs to be cultivated. Faculty responsibilities have not been clearly defined. There was some variation in the states' ratios for faculty and students, as well as their frequency of preceptor-to-faculty contact. Although most states suggest a 1:2 preceptor-to-student ratio, there was variability in the faculty-to-student ratio, which ranged from 1:10 to 1:24. It is a concern whether faculty in a 1:24 ratio would have sufficient knowledge of student performance to complete a valid clinical evaluation. Ratios are not outlined in the NCSBN model rules, yet smaller ratios would allow faculty to have greater contact with preceptors and thus provide more support to the preceptor. Regarding evaluation, all jurisdictions with guidelines for student evaluation agreed that it is the role of nursing faculty to evaluate the student; however, a process needs to be in place to solicit input from the preceptor.

The work of preceptors is a difficult and complex process, and they must be given the tools they need to accomplish their responsibilities. In addition, they must be monitored, nurtured, and supported. This review provides numerous implications for future research. One issue that has not been fully discussed is the number of precepted clinical hours with preceptors. Some states specified the percentage of clinical hours that could be precepted, but a suggested dose of preceptorship has not been identified. With a great reliance on the use of preceptors, this is an important consideration that may ease the burden placed on preceptors.

After reviewing all states' rules and the model rules for clinical nursing education, we propose that a minimum set of items be included in rules and regulations concerning the use of staff nurses as preceptors in clinical settings. Although most jurisdictions had some information to guide the use of preceptors, gaps were noticed. Regulations should define the role of the preceptor and delineate the role responsibilities. Requirements for licensure, years of expected clinical experience, and competency expectations could be better defined. A purposeful orientation should be conducted to outline student, preceptor, and faculty expectations and role responsibilities to facilitate communication.

Faculty in schools of nursing look to their state boards of nursing rules and regulations documents for guidelines regarding nursing education. These documents should clarify how preceptors are selected, prepared, used, and supported in the clinical education of nursing students. Preceptors are a crucial component of clinical nursing education, and their role should be well defined and respected.

Conclusion

Preceptorships are an integral part of nursing education and are regulated by the state boards of nursing. How preceptors are actually used in clinical settings and by schools of nursing needs to be better understood and defined. States that have not reviewed their rules and regulations for preceptor guidelines might consider using the findings of this study to update their regulations to provide clear guidelines for both faculty and preceptors. Other states that do not have rules and regulations may benefit from this review by drafting new rules and regulations to address the gaps. Preceptor guidelines are important because they protect the preceptor, the student, the faculty, and, most importantly, the patients. Rules and regulations outline the responsibilities of both faculty and preceptors and promote a positive experience for all those involved in this critical educational endeavor.

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Summary of Preceptor Qualification and Role Expectations

OrganizationPreceptor QualificationRole Expectation and Implications for Faculty
National Council of State Boards of Nursing (2012)

Have an unencumbered license to practice as a nurse at or above the level for which the student is being prepared, in the jurisdiction where they are precepting students

Demonstrate competencies related to the area of student assignment

Serve as role models and educators for students

Precepted experience is directed by faculty.

Commission on Collegiate Nursing Education (2013)

Academically and experientially qualified for their role in assisting in the achievement of the mission, goals, and expected student outcomes

The roles of the preceptors should be clearly defined, congruent with the mission, goals, and expected student outcomes, and congruent with the relevant professional nursing standards and guidelines.

Preceptor expectations are clearly communicated to preceptors and are reviewed periodically.

American Association of Colleges of Nursing (2008)

Hold a minimum of a baccalaureate degree in nursing

Work under the guidance of nursing faculty

Serve as role models for the design, organization, and implementation of patient care

Clinical instructors are expected to coach and mentor preceptors to facilitate critical thinking and clinical decision making.

Summary of Current Board of Nursing Rules and Regulations Regarding Preceptors in the United States and Territories That Are Members of the National Council State Board of Nursing (NCSBN)

U.S. StateNDOQLP:SF:SPeFe
AlabamaX
AlaskaX
ArizonaXXXX
ArkansasXX1:2XX
CaliforniaXXXXX
ColoradoXX
ConnecticutXX1:21:16XX
DelawareXXXXX
FloridaX1:21:12/1:18XX
GeorgiaXXX1:2X
HawaiiX
IdahoXXXXX
IllinoisXXX1:12XX
IndianaXX1:10X
IowaXXX
KansasXXX
KentuckyXXX1:2X
LouisianaX1:11:12X
MaineXX
MarylandXXXX
MassachusettsX1:2XX
MichiganX
MinnesotaX
MississippiX
MissouriXXXX1:2XX
MontanaX
NebraskaXXX1:1XX
NevadaXX1:2XX
New HampshireXXX1:2X
New JerseyX
New MexicoXXXX
New YorkX
North CarolinaXXXX1:21:10XX
North DakotaXX1:2X
OhioXXX1:2X
OklahomaXX
Oregon1:8XX
PennsylvaniaX
Rhode IslandXXXX
South CarolinaXXX1:2XX
South DakotaXXXX
TennesseeX
TexasXX1:21:12 to 1:24X
UtahXXX1:2XX
VermontXX
VirginiaXXX1:21:15XX
WashingtonXXXX
Washington, D.C.XX
West VirginiaXX
WisconsinXXXX
WyomingXXX1:11:15X
U.S. territories that are members of NCSBN
American SamoaX
GuamXXXX
Northern Mariana IslandsXXXXX
U.S. Virgin IslandsX
Authors

Dr. L'Ecuyer is Associate Professor of Nursing, Ms. von der Lancken is Instructor of Nursing, Dr. Malloy is Assistant Professor, Emeritus, and Dr. Meyer is Professor of Nursing, Saint Louis University; Mr. Hyde is Staff Nurse, Barnes-Jewish Hospital, St. Louis, Missouri.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Kristine L'Ecuyer, PhD, RN, CNL, Associate Professor of Nursing, School of Nursing, Saint Louis University, 3525 Caroline St., St. Louis, MO 63104; e-mail: Kris.lecuyer@slu.edu.

Received: May 05, 2017
Accepted: September 21, 2017

10.3928/01484834-20180221-02

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