Nursing Program Policies

Progression Policy

1. Purpose

This policy establishes the grading scale, minimum academic standards, and course-repeat, withdrawal, and readmission requirements that govern satisfactory progression through the Nursing Program.

2. Grading Scale

A grade is assigned based on the instructor's judgment of the student's scholarly attainment. Instructors file course grade reports at the end of each term. Points are converted to a letter grade as follows:

Grades are rounded to a whole number using the “0/5” rounding rule. For example, a raw score of 25.5–25.9 rounds up to 26; a raw score of 25.1–25.4 rounds down to 25.

3. Academic Standards for Progression

1. BSN students must achieve a B- or higher grade in all nursing courses and maintain a semester GPA of at least 3.0.
2. Cumulative exam scores must total at least 75% to pass a course.
3. All ATI proctored exams must be passed at Level 2. Students are provided with two attempts to achieve a Level 2 score.
4. Students must score 90% or higher on the fifth semester exit exam on the first attempt to pass.
5. A clinical course and its linked theory course are conceptualized as one class for the purposes of this policy.
6. If a student does not achieve a passing grade (B- or above) in a course, the student may repeat that course once. Students may repeat only one course during the program. A student who fails to pass a second course will be dismissed from the program.
7. At the discretion of the Professional Practice Committee (PPC), a student who does not pass a nursing course may be permitted to repeat one course.
8. At the discretion of the PPC a student with a failure may be moved forward in level 1 and 2 course work with a formal PIP
9. Faculty will review each student's clinical and didactic performance at the end of every course, and/or as needed, using the standard theory and clinical evaluation tools.
10. Each graded assignment includes a point distribution specified in the assignment directions. The final course grade is a compilation of accrued points, converted to a letter grade.

4. Late Work Policy

All assignments are due on the assigned date. Assignments not submitted on the assigned date will accrue a deduction of one (1) point per day late, including assignments with no assigned point value. Deductions continue to accrue daily and may result in a negative score for that assignment (for example, a 5-point paper submitted 8 days late accrues -8 points, for a net score of -8). This negative value is applied to the student's cumulative course grade and may result in a lower course grade, including course failure.

1. All papers must be submitted to pass the course, even those with no assigned point value.
2. Late papers with no assigned point value accrue negative points at the same rate (e.g., 1 day late = -1 point, 2 days late = -2 points).

5. Extra Credit, Make-Up Work, and Absences

1. No extra credit is offered in any nursing course.
2. All required coursework must be completed within the course to progress.
3. Late work accrues a deduction of one (1) point per day, continuing even if the result is a negative score, as described in Section 4.

6. Withdrawal and Readmission

Satisfactory progress and continued progression through the Nursing Program require passing all courses within the nursing major. Because nursing courses are taken as a cohort, students are not permitted to withdraw from an individual nursing course.

1. A student wishing to withdraw from the program prior to the official withdrawal date must submit a request to the PPC, which will determine whether readmission to the program will be permitted.
2. The student must withdraw from all courses in progress in accordance with SMC's institutional policies and processes.

7. Related Policies

Refer to the Student Dismissal Policy and the Identification of Students at Risk of Failure and Notification Policy (BSN-PROG-003) for additional information on progression and readmission.

POLICY & PROCEDURE

Retention Policy

1. Purpose

This policy identifies the strategies used to support the retention of nursing students, encompassing both the activities faculty incorporate into their individual practice and the structured programs the Nursing Department maintains to promote student success and retention.

2. Policy — Student Retention Strategies

1. The Nursing Department maintains the Identification of Students at Risk of Failure and Notification of Risk policy to identify and support at-risk students.
2. The ATI Remediation Policy ensures students are prepared for critical testing moments through required practice testing and remediation.
3. SafeMedicate is utilized to promote numeracy literacy and ensure no student fails solely due to medication calculation errors.
4. The Professional Practice Committee meets with students to support the creation of an individualized developmental plan, which may include:
5. Assignment of mentors to assist with student growth
6. Referrals to Academic Resources, the STEM Center, and/or the Academic Success Office
7. Referrals to Student Disability Services
8. Referrals to Library Services
9. The Director of Nursing works with Data Specialists to gather results from ATI pre-tests and proctored exams to identify group-level learning needs. This data on group knowledge gaps is disseminated to instructors to support just-in-time teaching addressing those gaps.

3. Policy — Faculty Retention Support Activities

1. Faculty receive training  on teaching pedagogy.
2. Faculty receive training on Professional Role and Role Clarity (PRIF).
3. Faculty receive cultural competency and inclusivity training.
4. Faculty participate in PPC process
5. Faculty refer students early to the Professional Practice Committee to support timely intervention.

POLICY & PROCEDURE

Identification of Students at Risk

1. Purpose

This policy serves two purposes: (1) to identify struggling students early and establish a remediation plan, and (2) to provide a formal notification process for students who have failed a course, prior to the posting of their final grade.

For purposes of this policy, “ND” refers to the Director of Nursing (or designee) and “PPC” refers to the Professional Practice Committee.

2. Identification Procedures — Theory Classes

1. Instructors will submit lists of students scoring below 75% on cumulative testing to the ND and Academic Directors after every examination.
2. Excessive tardiness or absence must be reported as a possible risk factor for course failure.
3. Excessive late or incomplete assignments must be reported to the responsible Academic Director.
4. Students scoring below 80% after the semester midpoint will be referred to the PPC for follow-up.
5. The PPC will schedule a meeting with the students to determine possible interventions to support the students’ success.
6. Developmental plans or summative emails will be sent to the students.
7. The ND or designee will monitor results of all ATI practice exams to identify students possibly at risk of failure.
8. At-risk students will be contacted to determine what interventions may help them meet classroom expectations.
9. The Leadership Team will review the information received and reach out to students to discuss results and the risk of failure.

3. Identification of Clinical Failure

1. Clinical faculty will evaluate students during clinical sessions.
2. If a student does not meet expected standards by the mid-semester evaluation, the Simulation Director must be involved in creating the student's developmental plan.

4. Failure of Theory Classes

1. Students who fail a course will be referred to the ND, and a meeting will be scheduled with the faculty member and the PPC.
2. Class exams will be reviewed as follows:
3. Tests will be examined to determine the student's overall average.
4. Tests will be reviewed to confirm the accuracy of the student's percentage standing.
5. Recalculation will be completed if needed.
6. Point deductions for late assignments will be reviewed.
7. The ATI proctored exam will be examined. Both class exams and ATI exam results will be evaluated together to determine whether the course failure is approved.

5. Clinical Failure

1. A meeting will be held with clinical faculty, the Simulation Director, and the PPC.
2. The PPC will evaluate the information presented to determine whether the failure is approved.
3. The PPC may decide to meet with the student.

6. Once Failure Is Approved

1. The student will be notified in writing of the course failure.
2. The students will be informed of any actions needed regarding other courses, which may include dropping a course.
3. The students will meet with the ND or Academic Director to discuss options and steps for re-admission to the program.

POLICY & PROCEDURE

Clinical Preparation and Attendance Policy

1. Purpose

Clinical facility orientation is essential to student success. Faculty require facility orientation, electronic medical record workshops, and laboratory orientation; attendance at all learning activities is therefore mandatory to ensure students are prepared for clinical experiences.

Safe, quality care is the goal in the clinical setting. Students are expected to care for all clients and families, respecting the dignity of each person in accordance with the Saint Mary's Nursing Program Philosophy. Faculty provide guidance to assist students in applying theory and developing the nursing skills needed to become a confident, competent professional nurse. Students are expected to be accountable for their own clinical preparation and to remain open to constructive feedback from faculty and staff nurses in the clinical setting to maximize learning.

2. Clinical Attendance Policy

2.1 Attendance Requirements

Clinical attendance is mandatory. Clinical absences jeopardize a student's ability to meet clinical course expectations. Students must adhere to the policies and procedures outlined in the course syllabus and by clinical faculty and must complete all required clinical hours to pass.

• Students are expected to be prepared for clinical experiences. If a student fails to demonstrate evidence of preparation for the clinical assignment, the student will be dismissed from clinical. Determination of preparedness is made by the clinical faculty member. This is considered an unexcused absence.
• Students may not plan to leave early or arrive late. Travel arrangements must not interfere with clinical attendance.

2.2 Excused Absences

Students are allowed one (1) excused absence per semester (four totals across the program). An excused absence is defined as:

• Medical illness, with a signed note from an MD or NP stating the student may return to the clinical site without restrictions.
• Pregnancy, with a signed note from an MD or NP stating the student may return to the clinical site without restrictions.
• Bereavement of an immediate family member (additional documentation may be required).

2.3 Absence Procedures

For all absences, in addition to the requirements above, the following applies:

1. During each clinical rotation, a student may not miss more than one clinical day; all missed clinical days must be made up. Once a student has missed a total of five (5) clinical days across the program, the student will be referred to the Professional Practice Committee (PPC) for a decision regarding continuation in the program.
2. The students must meet with the PPC, along with any accompanying documentation, to review the absence.
3. The student must complete make-up hours within simulation. Failure or refusal to meet with the PPC and/or complete make-up hours by the required due date may result in failure of the clinical and theory course.
4. If a student does not achieve the required direct-care and indirect-care hours for a course, the student will fail the course regardless of the reason for the missed time.
5. All students must complete a minimum of 864 total clinical hours (at least 500 direct-care hours and up to 364 indirect-care hours, which may include simulation activities) to be eligible to sit for licensure boards. A student who does not achieve these hours will not successfully complete the program or be eligible to sit for boards.

2.4 Tardiness

1. Students are expected to arrive at the clinical site by the time specified by the instructor on each clinical day. “On time” means arriving at the assigned location twenty (20) minutes before the scheduled start time.
2. A student who arrives five (5) or more minutes past the assigned start time will be considered “late,” even if the instructor was notified in advance. Following a student's first tardy incident, any subsequent arrival of one (1) minute or more past the assigned start time will also constitute tardiness.
3. Students will receive a student advisory for the first incidence of tardiness.
4. Students will receive a written warning, as part of the progressive discipline process, for the second incidence of tardiness.
5. On the third incidence, students will be dismissed from clinical, resulting in failure of the clinical course; the student will also be required to drop or will fail the corresponding theory course.
6. Leaving early is not permitted, as all clinical hours must be utilized. Any early release from clinical must be approved by the Program Director.

3. Roles and Responsibilities

3.1 Student Role

The role of a Saint Mary's College nursing student is to participate in, and study, the knowledge of nursing practice — encompassing the incorporation, interpretation, and application of historical and ever-evolving nursing knowledge. To remain knowledgeable, the nursing student also participates in Scholarship for the Nursing Discipline, through which new information improves health and changes healthcare globally. The use of Informatics and Healthcare Technologies enhances student learning through modern data modalities and information that support positive patient outcomes. As an SMC nursing student, the program provides experiences that build understanding of Interprofessional Partnerships and Systems-Based Practice.

The student nurse is preparing for a role that requires Professionalism and Leadership. Cultivating the professional nursing role requires accountability, perspective, collaboration, and behavior that reflects sound values and character; accountability must be demonstrated to the individual, to society, and to the profession. In developing leadership, the student engages in self-reflection and lifelong learning, supports nursing expertise, and demonstrates the affirmation of leadership.

In clinical experience, the nursing student learns and understands their professional role in providing Patient-Centered Care while considering Population Health and practicing disease prevention and management. In focusing on the individual, family, and population levels, the student provides holistic, individualized, just, respectful, compassionate, coordinated, evidence-based, and developmentally appropriate care. Grounded in Dr. Maria O'Rourke's theory of Professional Role Identity, the student understands and practices Quality and Safety through the principle of “do no harm.”

3.2 Faculty Role

The Faculty of Record is responsible for teaching the didactic courses. The Faculty of Record collaborates with clinical faculty to discuss learners' clinical experiences and how they applied course concepts and theories in practice. The Faculty of Record, in consultation with clinical faculty, makes the determination of whether a learner's performance is satisfactory for a passing grade in the course.

3.3 Clinical Instructor Role

Part-time/adjunct Clinical Faculty work directly with learners and evaluate their clinical performance, assessing progress and making recommendations for improvement. They consult with other nursing faculty to validate their findings and discuss ways learners can improve. Clinical faculty coordinate and collaborate with nursing faculty to teach, supervise, and assess nursing students in the skills/simulation laboratory and/or clinical setting, providing excellence in instruction and supporting students in achieving mastery of skill competency, clinical reasoning, and professional practice. The clinical faculty member assists students in applying knowledge and skills to patient and client care and is physically present or immediately accessible to students throughout the clinical experience.

3.4 Role of Simulation Educators and Preceptors

The Simulation Educator, or designated faculty/educator in Simulation, works with content experts, course managers/leaders, and clinical instructors to create simulation experiences reflecting course clinical objectives. Simulation Educators develop, direct, implement, and evaluate the Saint Mary's Nursing Simulation Center's program through student, standardized patient, and educator feedback surveys.

Preceptors are Registered Nurses working in the community whom the Program may assign to a student during their final culminating clinical experience. The respective roles of the preceptor and student (preceptee) are outlined to both parties prior to the start of the preceptorship. Preceptorships may be part of a student's end-of-program clinical experience; however, the Saint Mary's Nursing Program works closely with faculty, community partners, and students to determine the optimal end-of-program clinical experience, which may or may not include a preceptorship. Students do not recruit their own preceptors; the Nursing Program works with clinical partners to identify appropriate preceptors and assign students accordingly.

POLICY & PROCEDURE

Student Orientation Policy

1. Purpose

This policy establishes an organized, consistent approach to the onboarding of newly admitted nursing students, ensuring they are prepared academically, professionally, and administratively for entry into the Pre-Licensure BSN Program.

2. Policy

1. Onboarding begins upon a student's formal acceptance of admission into the Nursing Program.
2. Immediately upon acceptance, students receive all Health and Safety Student Policies and instructions for completing required physical health requirements.
3. After acceptance, students receive the schedule for the required two (2)-day New Student Orientation.
4. A two (2)-day New Student Orientation is held prior to the start of classes each semester/cohort to support an organized transition into the program. Orientation components are listed below and are not presented in a required order:
5. Welcome and introductions by Program Leadership and Faculty
6. Cohort social/community-building time
7. Academic Support Services orientation (including but not limited to the STEM Center, CWAC, TASC, Advising, and Success Coaches)
8. Library resources orientation
9. Career Center orientation
10. Health Center orientation
11. Student Disability Services orientation
12. Financial Aid and Registrar orientation
13. safeMedicate orientation
14. ATI orientation
15. iPad distribution and technology orientation
16. IT Department orientation
17. Canvas (Learning Management System) orientation
18. Student Handbook review
19. Grading Rubrics review
20. Semester Syllabi review
21. Simulation Lab orientation
22. Clinical Orientation
23. Professional Role and Role Clarity (PRIF) orientation

POLICY & PROCEDURE

Student Dismissal from the SMC Undergraduate Nursing Program

1. Purpose

This policy establishes the academic, clinical, and professional conduct grounds for dismissal from the SMC Undergraduate Nursing Program, along with the dismissal process and the criteria under which a student is ineligible for program re-entry.

2. Grounds for Dismissal

A student may be dismissed from the Nursing Program for any of the following reasons:

1. Achieving a C+ or lower in any nursing course.
2. Achieving less than a 75% cumulative course exam average.
3. A student scoring less than 75% on cumulative course exams will receive a maximum final course grade of C+.
4. Scoring less than Level 2 on the second attempt of an ATI proctored exam, resulting in course failure regardless of exam scores.
5. Failing a clinical rotation due to unsatisfactory or unsafe practice, based on clinical evaluation and observed or reported direct and indirect patient care.
6. Excessive absenteeism (see the Clinical Preparation and Attendance Policy and course syllabi for attendance standards).
7. Violation of American Nurses Association (ANA) Standards of Practice, the ANA Code of Ethics, California Code of Regulations Title 16 §2725, Title 22, or other applicable regulations.
8. Unprofessional behavior, as defined by SMC policies or applicable state or national regulations and standards.

All items above are referred to the Professional Practice Committee (PPC), which follows its charter procedures to reach a final decision and determine any action plan.

3. Dismissal Process

1. Following the PPC meeting, the student will meet with the Director of Nursing (ND) to complete any remediation or re-entry action plans.
2. If the student is dismissed from the program, a formal meeting will be held with the ND, or designee, to communicate the final decision.

4. Criteria Ineligible for Program Re-Entry

The following two dismissal criteria do not qualify for program re-entry; students dismissed under either criterion are ineligible for readmission:

1. Use of drugs or other substances during any class, simulation, skills, or clinical activity; or impairment by alcohol, drug abuse, or severe emotional illness during such activities.
2. Plagiarism.

Either of the above will result in dismissal from the program and a meeting with the Director of Nursing.

5. Withdrawal Responsibility

It is the student's responsibility to officially withdraw from or drop all enrolled nursing classes. Students who remain enrolled in a class beyond the published withdrawal deadline, as stated on the SMC student website, will receive an evaluative grade in that class.

Process of Academic appeals concerning a grade or requirement in a particular course:

Step 1. The student will first contact the instructor who assigned the grade in question or is responsible for determining course requirements. This step must be taken no later than the end of the academic term immediately following the term in which the problem arose. Usually, students will resolve their concerns informally at this point.

Step 2. If the question remains unresolved, the student may initiate the formal appeal process by submitting a written appeal to the ND program. The Nursing Director will investigate the matter, meeting with those involved at their discretion. The Nursing Director may convene the PPC to meet with the student(s) and faculty to review the situation in question.

                 Within fifteen (15) working days of receiving the written appeal, the Nursing Director will report to the students in writing their findings and decisions.

Step 3.The student may, within fifteen (15) working days following receipt of the Nursing   Director’s decision, direct a written appeal, including supporting evidence, to the provost.

           Within fifteen (15) working days of receiving the students’ appeal, the provost will respond in writing to the student their findings and decisions. The decision of the provost is final even if a decision against the student will result in academic disqualification. There is no further University appeal.

Academic appeals concerning penalties resulting from violations of academic honesty:

Step 1.  The student will first contact the instructor who assigned the grade in question or is responsible for determining course requirements. This step must be taken no later than the end of the academic term immediately following the term in which the problem arose. Usually, students will resolve their concerns informally at this point.

Step 2. Within fifteen (15) working days of receiving notification of the penalty from the instructor, the student may initiate a formal appeal process by submitting a written appeal to the Nursing Director. The ND will investigate the matter, meeting with those involved at their discretion. This may include activating the PPC committee. Within fifteen (15) working days of receiving the written appeal, the ND will report in writing to the student their findings and decision. A copy of this report will be sent to the Academic Affairs Office and placed in the students’ SMC file and a copy will be added to the student’s nursing file.

Step 3. The student may, within fifteen (15) working days following receipt of the Nursing Director’s decision, direct a written appeal, including supporting evidence, to the provost. The provost will investigate the matter, meeting with those involved at their discretion. Within fifteen (15) working days of receipt of the student’s appeal, the provost will report in writing to the student their findings and decisions. A copy of this report will be placed in the students’ file. The decision of the provost is final even if a decision against the student will result in academic disqualification or dismissal. There is no further University appeal.

Academic appeals concerning academic disqualification from the Department of Nursing:

Step 1. Students who are disqualified from the nursing department will receive a letter within 15 days of the initial event or investigation that led to dismissal.

Step 2. The student may, within fifteen (15) working days following receipt of the Nursing Director’s decision, direct a written appeal, including supporting evidence, to the provost.

Step 3. Within fifteen (15) working days of receiving the students’ appeal, the provost will respond in writing to the student their findings and decision. The decision of the provost is final even if a decision against the student will result in academic disqualification. There is no further University appeal.

Non-academic Student Complaints:

SMC Nursing Program has a Chain of Command document which is included in both Faculty and Student Handbooks that describes the chain of command for any concern; see Chain of Command Policy. This process is used for both academic and non-academic complaints. The student is oriented to this process at the beginning of the program. This information is in the Nursing Student Handbook, SMC Academic Catalog, and the SMC Student Handbook. SMC and the Nursing Program utilize practices from Restorative Justice Principles to address instances of conflict that arise. 

 Reports of Conduct and Student Discipline Hearings (Nursing addendum):

1. Anyone, including but not limited to students, staff or faculty, may make a report of conduct involving a student or student organization that may be in violation(s) of the Code and/or other College policies. A report of such conduct can be made either orally or in writing and shall be sent to the Nursing Director. All reports of conduct must be made prior to the actual physical receipt by the respondent of the terminal degree from the College. A report of conduct should include:

• The name of the student(s), or student organization, alleged to have violated the Code or other College policy.
• A clear factual statement describing the nature of the conduct (date, time, place, witnesses); and
• The name(s), address(es) and telephone number(s) of those filing the report.

2. The Director of Nursing, or designee, will review all reports on conduct to determine which sections of college policies, Code of Conduct, nursing policies or state regulation were allegedly violated. 

 3.   If a nursing student has allegedly violated the code of conduct, the Professional Practice Committee (PPC) will handle the matter. Nursing students are referred to the PPC committee for investigation, decision, developmental plan and actions taken. Students are active participants in this process.

The PPC or designated lead of the Committee will meet with the students who have been alleged to violate the Code of Conduct, other college policy, Hospital policy, ANA standards, ANA code of Ethics or BRN standards.

The PPC will meet with the students to:

• Review and discuss the report of alleged conduct.
• Investigate the case thoroughly and ask questions of the complainant, respondent, and relevant witnesses.
• Burden of Proof- The burden of proof must be established that the individual or group were very likely to have committed the alleged violation prior to determining sanction
• Establish the appropriate findings are violations of specific policies or regulations
• If found responsible, impose appropriate sanctions.
• The outcome will be communicated to the respondent in writing generally in (7) calendar days; however, unavoidable delay in providing notice of outcome is not grounds for appeal.
• For certain cases of violence, the administrative hearing officer for the college will be contacted for assistance in managing the investigation.

Every reasonable and appropriate effort will be taken by all involved staff to protect the privacy of all individuals involved in a student discipline proceeding, as well as the confidentiality of the details and content of the student discipline process, including, but not limited to the preliminary investigation, DHB hearing, appeal process, and except where permitted by College policy and consistent with applicable law, the sanctions imposed and on whom. However, the College cannot guarantee absolute confidentiality. Students involved in the student discipline process, either directly, or as a witness, are expected to maintain the confidentiality of the process and be mindful of the privacy of others involved. Additional Process Information with one additional change.

• Review of Record: due to the nature of an offense, records may be required to be copied and submitted to the Board of Registered Nursing.
• Confidential and Privacy: In addition, the Nursing Program may be required to report occurrences with the Board of Registered Nursing, State regulatory Agencies or Hospitals based on regulations violated and/or where the occurrence took place.
• The professional practice Committee may remove a student from the nursing department for violations.
• Removal from nursing program and referral to SMC for follow-up decision on college standing. It is possible to commit a violation that only results in the dismissal from the nursing program and not the college at large.

Appeal Process 

Students may appeal the decision of the Nursing program or PPC by contacting the provost and filing an appeal. The provost will make the final decision regarding the appeal with no further appeal process available to nursing students. 

This appeals process is for both academic and non-academic concerns. All decisions by the provost are final with no additional appeal process.

Note: The Nursing Program only removes students from the nursing program not from Saint Mary’s College. the school.

POLICY & PROCEDURE

Appeals Process for Nursing Students

1. Purpose 

The Nursing Program adheres to the Saint Mary's College Academic Catalog; however, additional expectations and modifications apply in accordance with Board of Registered Nursing (BRN) guidelines governing the Nursing Program.

The public, community, and healthcare systems form much of their impression of Saint Mary's College and the Nursing Program through the appearance and behavior of its students. SMC nursing students are expected to follow the professional behavior guidelines set forth in the Student Handbook, both on and off campus.

2. Professional Practice Committee (PPC)

The Professional Practice Committee (PPC) addresses informal and formal academic and behavioral concerns within the Nursing Program. The PPC's responsibilities include creating and implementing remediation plans and managing academic and behavioral concerns, as well as receiving and responding to concerns or complaints from students, faculty, and clinical partners. The PPC provides a forum for concerned parties to present opportunities for improvement and to resolve issues; nursing students have the opportunity to respond to concerns, participate in resolution, and provide input.

The PPC's primary focus is student retention through mentoring, Performance Improvement Plans (PIPs), and the formal setting of expectations. The Nursing Program also maintains a chain of command, included in all program handbooks. The PPC follows formal policies and procedures, outlined in the SMC Student Handbook, for filing complaints or concerns.

3. Guiding Principles

SMC is guided by equity and fairness and takes all complaints and concerns regarding the institution seriously. While SMC is committed to the principle of subsidiarity — direct dialogue with those closest to an issue — a more formal process is used when necessary.

The Nursing Program maintains a Chain of Command Policy (BSN-ADMIN-006), included in both the Faculty and Student Handbooks, describing the chain of command for any concern. SMC and the Nursing Program utilize Restorative Justice principles to address instances of conflict.

4. Scope of Authority and Final Appeal

The Nursing Program handles all nursing student concerns through the PPC. All recommendations, discipline, and possible removal from the Nursing Program are handled within the Nursing Department. Removal from the College, however, is not handled within the Nursing Department: if a student is removed from the Nursing Program, the Provost is notified in case the situation warrants further action.

All appeals from nursing students are directed to the Provost, who holds final decision-making authority on the outcome. See Articles II and III of the Saint Mary's College Student Handbook, covering Code of Conduct Authority and Proscribed Conduct.

5. Academic Integrity

Standards of academic integrity must be followed at all times and are detailed in the Saint Mary's College Academic Catalog under the Academic Honor Code. Disciplinary action will be taken against students who do not abide by the Nursing Program Handbook or the SMC Student Handbook. Disciplinary action may include referral to the PPC, which could lead to formal discipline, including removal from the Nursing Program.

6. Academic Student Complaints and Appeals

The Nursing Program's Chain of Command document, included in both the Faculty and Student Handbooks, describes the process for both academic and non-academic complaints. Students are oriented to this process at the beginning of the program; it is documented in the Nursing Student Handbook, the SMC Academic Catalog, and the SMC Student Handbook. SMC and the Nursing Program utilize Restorative Justice principles to address conflict.

For academic questions, as in all other areas of appeal, the intent of the University and the Nursing Program is to first seek an informal resolution among those involved; if this is unsuccessful, more formal steps may be taken. Academic appeals fall broadly into three categories:

1. Those concerning a grade or a requirement in a particular course.
2. Those concerning penalties resulting from violations of academic honesty.
3. Those concerning academic disqualification from the Department of Nursing.
4. Those Concerning Clinical Performance

6.1 Appeals Process — Grade or Course Requirement

Step 1. The student first contacts the instructor who assigned the grade in question or who is responsible for determining the course requirement. This step must be taken no later than the end of the academic term immediately following the term in which the issue arose. Most concerns are resolved informally at this stage.

Step 2. If the matter remains unresolved, the student may initiate the formal appeal process by submitting a written appeal to the Nursing Director (ND). The ND will investigate the matter, meeting with those involved at their discretion, and may convene the PPC to meet with the student(s) and faculty to review the matter. Within fifteen (15) working days of receiving the written appeal, the ND will report to the students, in writing, their findings and decisions.

Step 3. The student may, within fifteen (15) working days of receiving the ND's decision, direct a written appeal, including supporting evidence, to the provost. Within fifteen (15) working days of receiving the student's appeal, the provost will respond to the student in writing with their findings and decisions. The decision of the Provost is final, even if the decision results in academic disqualification. There is no further University appeal.

6.2 Appeals Process — Academic Honesty Penalties

Step 1. The student first contacts the instructor who assigned the grade in question or who is responsible for determining the course requirement. This step must be taken no later than the end of the academic term immediately following the term in which the issue arose. Most concerns are resolved informally at this stage.

Step 2. Within fifteen (15) working days of receiving notification of the penalty from the instructor, the student may initiate the formal appeal process by submitting a written appeal to the ND. The ND will investigate the matter, meeting with those involved at their discretion; this may include convening the PPC. Within fifteen (15) working days of receiving the written appeal, the ND will report to the students, in writing, their findings and decisions. A copy of this report will be sent to the Academic Affairs Office and placed in the students’ SMC file, with a copy also added to the students’ nursing file.

Step 3. The student may, within fifteen (15) working days of receiving the ND's decision, direct a written appeal, including supporting evidence, to the provost. The provost will investigate the matter, meeting with those involved at their discretion. Within fifteen (15) working days of receiving the students’ appeal, the provost will report to the student, in writing, their findings and decisions; a copy of this report will be placed in the student's file. The decision of the provost is final, even if the decision results in academic disqualification or dismissal. There is no further University appeal.

6.3 Appeals Process — Academic Disqualification from the Department of Nursing

Step 1. A student disqualified from the Nursing Department will receive a letter within fifteen (15) days of the initial event or investigation leading to dismissal.

Step 2. The student may, within fifteen (15) working days of receiving the ND's decision, direct a written appeal, including supporting evidence, to the provost.

Step 3. Within fifteen (15) working days of receiving the students’ appeal, the provost will respond to the students in writing with their findings and decision. The decision of the provost is final, even if the decision results in academic disqualification. There is no further University appeal.

7. Non-Academic Student Complaints

The SMC Nursing Program's Chain of Command Policy (BSN-ADMIN-006), describes the chain of command for any concern; this process is used for both academic and non-academic complaints. Students are oriented to this process at the beginning of the program. This information is included in the Nursing Student Handbook, the SMC Academic Catalog, and the SMC Student Handbook. SMC and the Nursing Program utilize practices from Restorative Justice Principles to address instances of conflict that arise.

8. Reports of Conduct and Student Discipline Hearings (Nursing Addendum)

Anyone — including, but not limited to, students, staff, or faculty — may make a report of conduct involving a student or student organization that may be in violation of the Code of Conduct and/or other College policies. A report may be made either orally or in writing and must be sent to the Nursing Director. All reports of conduct must be made prior to the respondent's actual physical receipt of their terminal degree from the College. A report on conduct should include:

• The name of the student(s), or student organization, alleged to have violated the Code or other College policy.
• A clear factual statement describing the nature of the conduct (date, time, place, witnesses).
• The name(s), address(es), and telephone number(s) of those filing the report.

8.1 Initial Review

The Director of Nursing, or designee, will review all reports of conduct to determine which sections of College policies, the Code of Conduct, nursing policies, or state regulations were allegedly violated.

8.2 PPC Investigation and Hearing Process

If a nursing student has allegedly violated the Code of Conduct, the Professional Practice Committee (PPC) will handle the matter. Nursing students are referred to the PPC for investigation, decision, developmental planning, and any resulting actions; students are active participants in this process.

The PPC, or the designated lead of the Committee, will meet with students alleged to have violated the Code of Conduct, other College policy, hospital policy, ANA Standards, the ANA Code of Ethics, or BRN standards, to:

• Review and discuss the report of alleged conduct.
• Investigate the case thoroughly and question the complainant, respondent, and relevant witnesses.
• Establish the burden of proof — that it is more likely than not that the individual or group committed the alleged violation — prior to determining a sanction.
• Establish appropriate findings as to whether specific policies or regulations were violated.
• Impose appropriate sanctions, if the student is found responsible.
• Communicate the outcome to the respondent in writing, generally within seven (7) calendar days; an unavoidable delay in providing notice of outcome is not grounds for appeal.
• For certain cases involving violence, contact the College's administrative hearing officer for assistance in managing the investigation.

8.3 Confidentiality

All involved staff will take every reasonable and appropriate effort to protect the privacy of individuals involved in a student discipline proceeding, and the confidentiality of the details and content of the process — including the preliminary investigation, hearing, and appeal process — and, except where permitted by College policy and consistent with applicable law, the sanctions imposed and on whom. The College cannot guarantee absolute confidentiality. Students involved in the process, whether directly or as a witness, are expected to maintain confidentiality and be mindful of the privacy of others involved.

8.4 Additional Process Information

• Review of Record: Due to the nature of an offense, records may be required to be copied and submitted to the Board of Registered Nursing (BRN).
• Confidentiality and Privacy: The Nursing Program may be required to report occurrences to the BRN, state regulatory agencies, or hospitals, based on the regulations violated and/or where the occurrence took place.
• The PPC may remove a student from the Nursing Department for policy violations.
• Removal from the Nursing Program is referred to SMC for a follow-up decision regarding the student's college standing. It is possible for a violation to result in dismissal from the Nursing Program without resulting in dismissal from the College at large.

9. Appeal Process

Students may appeal a decision of the Nursing Program or the PPC by contacting the provost and filing an appeal. This appeals process applies to both academic and non-academic concerns. The provost will make the final decision regarding the appeal; there is no further appeal process available to nursing students.

Note: The Nursing Program only removes students from the Nursing Program, not from Saint Mary's College.

POLICY & PROCEDURE

Assessment Technologies Institute (ATI) Policy

1. Purpose

This policy establishes the requirements for use of Assessment Technologies Institute (ATI) resources throughout the BSN Program. ATI is a required, program-wide tool that supports students' critical reasoning and clinical decision-making, and evidence demonstrates that consistent use of ATI resources throughout the BSN curriculum significantly increases the likelihood of first-time success on the NCLEX-RN examination. Students are expected to make full use of available ATI resources, including tutorials, videos, and Real-Life scenarios.

2. Required ATI Examinations

The BSN Program currently requires ten ATI examinations, administered at designated points in the curriculum:

• Fundamentals of Nursing
• Nutrition (taken in Care of the adult)
• Mental Health
• Informatics
• Pharmacology (taken In Advanced care of the Adult)
• Medical Surgical (Taken in advanced care of the Adult)
• Community Health
• Maternity
• Pediatrics
• NCLEX-RN Comprehensive Predictor Examination (passing score: 90%)

3. ATI Proficiency Levels

Each ATI proctored exam yields a proficiency level. A Level 2 or higher is required to pass at SMC:

4. Grading Requirements

To pass a course, students must pass the associated ATI proctored exam at Level 2 or higher. Students are given two (2) attempts to achieve Level 2. Failure to reach Level 2 within two attempts will result in failure of both the theory and clinical course associated with that examination.

Students have one (1) attempt on the ATI exit exam (Comprehensive Predictor Examination) to achieve a score of 90% or higher. A score of 90% on the Comprehensive Predictor is indicative of a high probability of passing the NCLEX-RN and should be achieved on the first attempt.

Students are required to use their course textbooks, lectures, and ATI materials to remediate while completing both practice and proctored examinations. Remediation is required after every practice exam and every proctored exam. Failure to remediate will result in referral to the Professional Practice Committee.

5. Remediation Requirements

Students must complete remediation within two (2) weeks of the initial test. Failure to remediate within this window will result in a written statement of concern from the instructor for non-compliance. Continued failure to remediate will result in referral to the Professional Practice Committee, which oversees student progression in the program.

6. Importance of First-Attempt NCLEX-RN Success

First-attempt pass rates on the NCLEX-RN are a significant indicator of student and program success; the likelihood of passing decreases substantially with each additional attempt, and both individual and program NCLEX-RN pass rates are evaluated based on the number of attempts required to pass. Consistent, active use of ATI resources throughout the program — including practice exams, tutorials, and remediation — is central to supporting first-attempt success.

POLICY & PROCEDURE

ATI Assessment and Remediation Policy

1. Purpose

This policy establishes a consistent policy and procedure governing the use of the ATI testing program throughout the Undergraduate BSN Program.

2. Policy

1. All students in the Nursing Program are required to participate in the ATI Testing Program. Each student pays a one-time fee, spread across semesters, which covers 80% of textbook costs, computer tests (practice, proctored, and tutorials), scoring, remediation, study modules, Real-Life scenarios, and data analysis. The ATI package also includes a final Comprehensive Predictor Examination, which must be taken during the final course of the BSN Program.
2. ATI is an online program; each student receives an individual access code. Each student is also provided with a set of ATI books covering all online topics, with additional topic outlines and practice questions. Both the online access code and any hard-copy materials are distributed by the Nursing Program.
3. Students are responsible for reviewing the ATI orientation resources available on their individual home page. Students are strongly encouraged to review these orientation materials (select “How To”).
4. For every course throughout the BSN Program, students are assigned ATI Practice and Proctored Assessments and Tutorials specific to that course's objectives and learning requirements.
5. For each Practice and Proctored Assessment in each course, students must complete an active learning/remediation plan in accordance with the course grading rubric. The remediation plan is specific to each student's individual results and provides a focused review of content that was not learned or not fully understood, as demonstrated by the assessment.

3. Directions for Remediation

1. Log onto ATI.
2. Go to the “My Results” tab.
3. Select the appropriate assessment type tab — either “Proctored” or “Practice” Assessments.
4. Locate and select the specific assessment to review.
5. Select “Focused Review.”
6. Check the box for “review all missed topics.”
7. Select “create review.”
8. The Focused Review will list all topics missed in the assessment, with access to remediation tools for each topic.
9. Follow course faculty requirements for demonstrating completion of remediation.
10. Remediation work may not be copied and pasted; it must be written by the student.

4. Student Acknowledgement

By initialing and signing below, the student confirms the following:

Student Signature

Date

Student Printed Name

POLICY & PROCEDURE

SafeMedicate™ Toolkit Policy

1. Purpose

This policy governs the SafeMedicate™ medication calculation toolkit and the related nursing skills laboratory testing process, ensuring students demonstrate safe, accurate medication administration and clinical skill competency before performing skills with patients.

2. Program Overview

The Medication Simulation/Skills Module (“Toolkit”) is completed every semester in designated theory and simulation courses, totaling 8 hours of instruction. It supports AACN Essential 5 (Quality and Safety) by building students' ability to apply quality-improvement principles and contribute to a culture of patient safety, including recognizing nursing's role in safety and quality, using national safety standards and resources, working within the interprofessional team to prevent errors, and reporting unsafe conditions and near misses.

3. Learning Objectives

1. Students will calculate accurate medication dosages, demonstrating conceptual, calculation, and technical measurement competency (via presentation, the SafeMedicate Essentials Module, and the Simulation/Skills Module).
2. Students will demonstrate safe medication administration, incorporating patient safety and the 7 Rights of medication administration, in a simulation activity.
3. Students will complete the Essentials Skills Module post-test with a score of 100%.

The 7 Rights of Medication Administration:

• Right medication
• Right dose
• Right patient
• Right route
• Right time
• Right documentation
• Right indication

Related concepts covered include use of two patient identifiers, a Just Culture approach to safety, and reporting of events and near misses, consistent with the Clinical Judgment Model — a systematic approach to gathering and using information to plan and provide individualized patient care.

4. Course Completion Requirements

Unless otherwise noted, each course module below requires 100% module completion, a minimum 90% score on the Authentic Diagnostic Assessment (ADA), and a 100% score on the proctored Authentic Assessment (AA), within a maximum of three (3) attempts.

5. SafeMedicate™ Policy Statement

SafeMedicate™ is a required component of clinical courses and must be completed by the semester's specified due date. This policy outlines the process followed when a student:

1. Does not satisfactorily perform a required nursing skill at the clinical site; and/or
2. Receives a “Not Pass” evaluation on a nursing skill in the laboratory setting; and/or
3. Does not pass a SafeMedicate™ Authentic Assessment (proctored exam) at 100%.

A student who is unable to satisfactorily perform a nursing skill, including medication calculations, will be notified in writing by their clinical instructor and given a remediation plan providing additional instruction and practice.

6. Medication Calculation Assessment and Remediation

Before testing, each student must independently complete the assigned self-study/practice modules for the semester, submit written proof of completion (the SafeMedicate™ Passport), and score at least 90% on the assigned ADA. A student who has not met these requirements by the scheduled AA proctored exam date will not be permitted to test and must complete additional practice to 100% before doing so.

Each student must score 100% on the semester's AA (proctored exam) before administering medications in the clinical setting. The remediation cycle, if needed, is:

1. Remediate using the ADA and required modules within 7 days.
2. Achieve a score of at least 90% on the remediation ADA.
3. Retake the proctored AA within 7 days of achieving the 90% ADA score.
4. Achieve a score of 100% on the AA.

A SafeMedicate™ Passport is required prior to each assessment attempt. This cycle may be repeated up to three (3) total attempts. A student who does not achieve 100% on the AA after the third attempt will not be permitted to attend clinical until the requirement is met, and is at risk for an unsatisfactory clinical grade, course failure, and removal from the program, due to the inability to complete clinical course objectives.

7. Nursing Skills Laboratory and Clinical Testing

1. Students must complete all assigned clinical ATI modules at 85% or higher, and complete all assigned work, modules, and simulation assignments prior to attending simulation.
2. Students must complete peer observation of a skill before instructor testing. Clinical instructors test one student at a time, and students must perform the skill without prompting from the instructor or notes.
3. Clinical skills tests are graded pass/no-pass. Students must pass all course skill sets identified in the syllabus.
4. A “no-pass” on a skill set requires successful remediation of that skill before testing on subsequent skill sets. Continued failure to remediate results in course failure and dismissal from the program.
5. Students must pass the clinical skills laboratory test, and the associated ATI module post-test at above 85%, before performing that skill with patients/clients at the clinical site.

8. Clinical Skills Remediation Process

If a student unsatisfactorily performs a previously tested skill in the clinical setting, or fails a skills test for the first time, a nursing skills remediation is initiated:

• The student remediates and retests the skill(s) within 7 days.
• Remediation is conducted with a designated skills lab instructor.
• Retesting is conducted by a different faculty member than the one who issued the original no-pass.

POLICY & PROCEDURE

Professional and Safe Practice Policy

1. Purpose

Providing safe nursing care for clients is an ethical and legal responsibility of the Nursing Program, applying to both faculty and students. This policy covers all Nursing Program contexts — including all class types and situations, and all clinical settings. Safe practice is mandated by the California Board of Registered Nursing's Nurse Practice Act (rn.ca.gov) and supported by the American Nurses Association (ANA) and individual professional nursing organizations.

Individuals who do not meet the stated professional standards for ethical and legal conduct are held accountable to the College's and the Nursing Program's policies and procedures; sanction procedures are identified within both the Department of Nursing and the College. The Nursing Program seeks consultation with the California Board of Registered Nursing (BRN) on matters affecting nursing practice, and those that challenge ethical standards, involve criminal conduct or unsafe clinical practice, and/or implicate potential legal standards of the profession. Unprofessional conduct in any venue related to the Nursing Program's functioning, as well as situations that jeopardize others, are grounds for disqualification from the nursing major.

2. Policy Statement

If a student fails to maintain professional conduct or is considered unsafe by faculty and/or the agency in which the student is enrolled (classroom, simulation, or clinical), the student is removed from that setting or agency. If a student is found unsafe or unprofessional, this constitutes a No Credit or non-passing final grade (e.g., C or below) for the course in question. Refer to the Nursing Program's current grievance and disqualification policy located in the Student Handbook. Unsafe clinical and/or classroom practices are managed at the administrative level to preserve maximum learning opportunities for the student and classmates, while adequately protecting others, including faculty and staff.

If, in the opinion of the Professional Practice Committee (PPC), a student fails to follow the ethical or legal guidelines of the profession and the Nursing Program, disqualification from the major may be recommended. If the student wishes to contest this outcome, the student must follow the College's grievance policies and procedures outlined in the SMC Student Handbook and the SMC Nursing Handbook.

Students are oriented to the Professional and Safe Practice Policy during their first semester in the major, and both faculty and students review the policy prior to beginning all clinical rotations. All nursing students have access to the Student Handbook, which sets out these policies in full (see the Nursing website). Drug testing and criminal background checks are required for all nursing students prior to beginning clinical rotations.

3. Policy

1. A student whose pattern of behavior is found to be unsafe or unprofessional may be terminated from a clinical or classroom setting for unsafe/unprofessional practice at any time during the semester, and will receive a grade of No Credit, non-passing, or Failure (F) for the course.
2. If a student fails to maintain professional conduct, the student may be disqualified from the program, or other sanctions may be determined by appropriate parties.
3. Unsafe or unprofessional behavior deemed egregious by the PPC may be cause for immediate removal, even on a first violation (e.g., violence, taking photographs in a healthcare setting, or discussing patient information on social media even without using a patient's name). These are illustrative examples and not an exhaustive list.

4. Definitions of Professional and Safe Practice

Students are expected to demonstrate patterns of professional behavior that follow the legal and ethical codes of nursing; promote the actual or potential well-being of clients, healthcare workers, faculty, fellow classmates, and self across biological, psychological, sociological, and cultural realms; demonstrate accountability for meeting course objectives; and show respect for the human rights of individuals.

The following indicators guide the evaluation of safe practice and professional conduct in a clinical, classroom, or simulation setting; these lists are illustrative and not exhaustive.

4.1 Guidelines

Students practice within the boundaries of the California Nurse Practice Act (§2725), the ANA Code of Ethics, and the guidelines and objectives of the Nursing Program, and follow the rules and regulations of the healthcare agency and all SMC Nursing guidelines. Students are bound by both (a) the rules and regulations of healthcare agencies and (b) the Nursing Program. Examples of deviations from these standards include, but are not limited to:

1. Failure to notify the agency and/or instructor of a clinical absence (or violation of the absence policy in course syllabi for non-clinical courses).
2. Failure to adhere to the Nursing Program dress code.
3. Presenting under the influence of drugs and/or alcohol.
4. Failure to make up for missed clinical experiences when required.
5. Habitual tardiness, in either the classroom or clinical setting.
6. Excessive utilization of faculty time by one student to the detriment of other students.
7. Inadequate or poor preparation for clinical or class.
8. Abandonment of a patient care assignment.
9. Language, behavior, or conduct inconsistent with the profession, including harassment, bullying, gossiping that could be interpreted as hurtful, acting aggressively, confronting others inappropriately, using a phone or laptop after being informed this is not acceptable, being unresponsive to directions, lying, cheating, or stealing.

4.2 Ethical

Students practice according to the ANA Code of Ethics, Standards of Practice, and the California Nurse Practice Act. Examples of unsafe practice and/or unethical behavior include, but are not limited to:

1. Inappropriate behavior in a classroom, clinical, or simulation setting.
2. Ignoring unethical behavior by others in the clinical, classroom, or simulation setting.
3. Violating policies or guidelines for academic integrity (see the College's Academic Integrity Policy on the College website).

4.3 Biological, Psychological, Social, and Cultural Realms

Examples of unsafe practice or violations of this policy include, but are not limited to:

1. Failure to display stable mental, physical, or emotional behavior that may affect others' well-being.
2. Failure to follow through on suggested referrals or interventions intended to correct deficit areas that may result in harm to others.
3. Acts of omission or commission in client care, including but not limited to physical abuse, placing clients in hazardous positions or conditions, mental or emotional abuse, and medication errors.
4. Interpersonal relationships with agency staff, co-workers, classmates, or faculty that result in miscommunication or disruption of clinical, classroom, or simulation functioning.
5. Promoting lateral violence, displaying bullying, discriminating against others based on lack of awareness of diversity among classmates, clients, faculty, or staff, or violating diversity, equity, and inclusion policies in the classroom, clinical, or simulation setting.
6. Placing fellow classmates, faculty, and/or staff at personal or professional risk.

For further information regarding weapons, firearms, or controlled substances, see the College's policies.

4.4 Accountability

Students are responsible for the preparation, documentation, and continuity of client care. Accountability also extends to academic matters outside the clinical area. Examples include, but are not limited to:

1. Inability to communicate effectively.
2. Attempting activities without adequate orientation, theoretical preparation, supervision, or appropriate assistance (applies primarily to skills, simulation, and/or clinical settings).
3. Dishonesty.
4. Failure to take responsibility for corrective action.

4.5 Human Rights

Student conduct must show respect for the individual, client, healthcare team member, faculty, classmates, and self, including legal, ethical, and cultural considerations. Examples of unsafe practice include, but are not limited to:

1. Failure to maintain confidentiality of interactions.
2. Failure to maintain confidentiality of records.
3. Dishonesty in relationships and/or actions.
4. Use of stereotypical assessments that are detrimental to others.
5. Failure to recognize and promote the rights of others.
6. Failure to report client abuse across the lifespan, or abuse involving faculty, classmates, or other professionals, whether physical or verbal.

5. Procedure

A student whose pattern of behavior or lack of academic integrity endangers the safety of, or threatens the integrity of, a patient, peer, staff member, clinical or simulation instructor, faculty member, fellow classmate, or agency personnel will receive a verbal and written warning from the instructor, the Nursing Program Director, or a representative. Potential critical episodes require immediate action; documented evidence from the student, faculty, and/or staff will be considered in the decision to terminate a student from a clinical practicum, classroom, or simulation setting, and in determining whether disqualification from the Nursing Program is warranted. Students may be required to complete a medical and/or behavioral health evaluation before returning to the learning environment.

5.1 Disqualification Determination

1. If circumstances warrant disqualification, the Director of Nursing (ND) has decision-making authority, in consultation with the Professional Practice Committee (PPC).
2. The student is referred to the Special Progression/Disqualification Policy in the Student Handbook.

5.2 Instructor Responsibilities

The primary instructor in the designated course will:

1. Provide instruction, guidance, and interpretation regarding the student's failure to meet course objectives or a violation of professional/safe practice standards.
2. Suspending the student from the course if the safety or conduct issue is of significant magnitude, or potentially jeopardizes the well-being of patients, staff, faculty, or classmates, until a decision is reached through the conflict resolution process.
3. Document patterns of behavior related to attainment of course objectives, which may include direct observation by the course instructor (or, in a clinical situation, agency personnel and patient comments), and evaluation of written work.
4. Provide a verbal and written warning for unsatisfactory performance or remove a student from a situation in which the student is placing others at risk. The written warning will:
5. State the specific facts of problem areas or deficiencies relative to course objectives, evaluation tools, and performance.
6. Delineate corrective action and expected outcomes in writing, with copies provided to the student and course instructor; the Undergraduate Coordinator is notified, and a copy is placed in the student's file. Both student and instructor sign the written warning; if the student declines to sign, the instructor documents that the student had the opportunity to sign and declined, along with pertinent discussion at the time the warning was reviewed. Copies are provided to the Nursing Program Director and Assistant Directors.
7. Set a specific timeframe within which the required change in behavior is to be accomplished.
8. Refer the situation to the suitability-to-practice committee (PPC) for determination of further action.
9. Reevaluate the student's progress. If attainment of the expected outcome is positive, the student is allowed to continue in the course; the written warning remains in the student's file until completion of the program.
10. Provide the student an opportunity for input and/or data regarding the evaluation of their performance.
11. Consult with the Semester Chair and/or Director as needed for problem-solving and guidance.

5.3 Conflict Resolution

The Nursing Program's conflict resolution process is used for unresolved situations (see the Nursing Student Handbook and the SMC Student Handbook).

COMMITTEE CHARTER

Professional Practice Committee — Professional Practice and Capacity to Practice as a Registered Nurse

Purpose

This committee and policy serve three purposes.

1. Students are referred to this committee if they are struggling academically for support and identification of a targeted plan to assist the student in being successful within the program.
2. Students will be informed when they are sent to this committee for support prior to attendance.
3. A development plan will be created with the students.
4. Students who have not been successful within the program, i.e. failing a class, will be referred to by this committee to review options for possible return to the program (first failure) or identification of alternative plans (second failure).
5. Students who are identified as not demonstrating professional practice and are identified as potentially not having the capacity to practice as a Registered Nurse will also be sent to this committee.
6. Students may receive a performance improvement plan, suspension, or termination depending on the circumstances around the actions.

Process

Students are referred to this committee to provide information and participate in the process.

• Documentation of these meetings is completed and placed in the student file. Students are provided with copies of all documentation.

Members of Committee

• Director of Nursing
• Assistant Director of Nursing 2 (only one needs to attend the meeting)
• Faculty member involved with the current referral
• Data and Compliance Officer
• Simulation Director
• Faculty/administrator outside of nursing, for any egregious events non clinical

Professional Practice Expectations

The following expectations are used as a guideline for assessing Professional Practice and capacity to practice as a Registered Nurse. Students applying to and continuing in the Nursing Program at Saint Mary's College (SMC) are expected to:

• Practice using Dr. Maria O'Rourke's Practice Model.
• Demonstrate honesty, integrity, and ethical principles.
• Follow the ANA Code of Ethics, Standards of Practice, and Section 2725 of the Nursing Practice Act.
• Represent Saint Mary's College in any setting where they are identified as an SMC nursing student.
  • Speaking poorly of other students, faculty, staff, or the university in any clinical/class setting is prohibited.
• Be respectful of class colleagues, faculty, and staff with respect to communication and actions.
• Relate to people with warmth and empathy, communicating feelings appropriately.
• Recognize the essential worth and dignity of all human beings; appreciate the value of human diversity.
• Serve, in an appropriate manner, all persons in need of assistance regardless of unique characteristics — for example, those related to race, religion (or lack of religion), gender, disability, political affiliation, sexual orientation, and value system.
• Express thoughts with clarity in both written and verbal form.
• Be open to change in themselves and others.
• Take responsibility for their own actions.
• Follow instructions and adhere to the expectations and objectives outlined in the syllabus for each theory and clinical course.
• Identify personal strengths, limitations, and motivations.
• Follow the Code of Conduct for nursing students at SMC.
• Refusal of a clinical assignment, abandonment of a clinical site, or failure to comply with Health and Safety requirements will result in a referral to the committee and may result in removal from the program.

Procedure

1. If a faculty member identifies a student struggling academically, the student will be informed by the faculty member that they are being referred to this committee. This referral is for support and early intervention to support student success within the program. While documentation of support will be generated with student participation, this is not a disciplinary process.
2. If a faculty member identifies inappropriate behavior on the part of a student, the behavior will be discussed with the student, and a Performance Improvement Plan (PIP) will be put in place describing the behavior and expected corrective action within a timeframe and placed in the student's record.
3. If the student receives more than one PIP at any time during the program, the information will be forwarded to the Professional Practice Committee.
4. The student may be asked to leave the program if the PIP has not been satisfactorily completed within the specified timeframe.
5. If a student's behavior is egregious, the student will be immediately referred to the committee for a formal investigation and decision. Egregious actions or behaviors that violate the ANA Code of Ethics, ANA Standards, or Section 2725 may lead to immediate removal from the Nursing Program.
6. Removal under this circumstance precludes readmission to the Nursing Program in the future.

POLICY & PROCEDURE

Dress Policy

1. Purpose

The public, community, and healthcare systems form much of their impression of the Nursing Program through the appearance and behavior of its students. As a nursing student, each student represents the image of the profession and is expected to maintain a positive, neat, professional appearance.

2. Uniform and Identification Requirements

Students are expected to wear the full program-purchased uniform to all patient care clinical experiences. Uniforms are to be purchased through the vendor link provided by the Nursing Program.

All students must obtain an ID badge through the Nursing Program office, to be worn during all clinical experiences, including simulation. Students are also required to wear any facility-required ID as instructed by that site.

Clinical faculty will not allow a student to remain in the clinical setting if the student arrives in inappropriate attire or without the assigned ID badge. The student will be sent home, which will count as a clinical absence, and the student will be referred to the Professional Practice Committee (PPC).

3. General Dress and Grooming Standards

All students in clinical settings must follow the dress code and behavioral expectations of the clinical facility. A professional standard of dress and demeanor is expected to maintain client and student safety:

1. Students' dress, personal appearance, and grooming must not disrupt or detract from the educational process or constitute a threat to the health or safety of the student or others.
2. Closed-toe shoes are always required, including in class. High heels and slippers are not allowed in class or simulation activities.
3. Appropriate footwear is required in the clinical setting. White shoes must have closed toes; clogs are not allowed. Footwear should be tied, fastened, or buckled as appropriate.
4. Nails must not extend beyond the tips of the fingers. Artificial nails, fill, gel, and/or nail polish are not allowed in the classroom or clinical setting.
5. In certain settings, students will be instructed to wear “street clothes” rather than a uniform. Jeans are not allowed; street clothes consist of black or blue pants and an appropriate top. The clinical instructor will advise on colors permitted based on site-specific safety requirements.
6. Sunglasses are not allowed in the clinical, simulation, or classroom setting.
7. No pins, promotional buttons, or decorative items may be worn in class, simulation, or clinical settings.
8. Students must comply with applicable health, safety, and sanitation standards. Good daily personal hygiene is required, including a daily bath, use of effective deodorant, and good oral hygiene; fingernails must be short, clean, and free of acrylics or polish.
9. Chewing gum and the use of lipstick or Chapstick are not allowed in the clinical or simulation setting.
10. Tattoos must be always covered in clinical settings.
11. Make-up must be conservative.
12. Body jewelry is limited to a watch, a wedding/engagement ring (if appropriate and safe for the clinical setting), and one pair of small post earrings that do not extend beyond the earlobe. No jewelry is allowed in obstetrics, nursery, or mental health settings. No other jewelry is permitted.
13. Hair must be clean, simply styled, and off the collar while in uniform. Beards and mustaches must be neatly groomed. Barrettes, bows, clips, ribbons, and hairnets are not allowed in the clinical setting.
14. Perfumes and scented lotions are not permitted in the clinical setting, as many individuals are allergic to these compounds.
15. No false eyelashes
16. When in SMC uniform it is not appropriate to wear other tops and have your stomach showing

If a student’s clothing/appearance does not comply, the student will be sent home and will receive an absence for the day. This absence will count against regular attendance and could result in dismissal from the program. The student is expected to correct their appearance/dress violations and return the next scheduled day.

4. Non-Compliance

If a student's clothing or appearance does not comply with this policy, the student will be sent home and will receive an absence for the day. This absence counts against the student's regular attendance record and could result in dismissal from the program. The student is expected to correct the appearance or dress violation and return on the next scheduled day.

Refusal to comply with the dress code will result in a referral to the Professional Practice Committee and may result in removal from the program.

5. Smoking

Smoking is not permitted in the clinical or simulation setting. Students may only smoke in designated areas, if permitted by the hospital, and only during their 30-minute break time. See the Residential Living Spaces section of the Saint Mary's College Student Handbook for policies on smoking/vaping in campus housing.

Smoking

Smoking is not permitted in the clinical nor simulation setting. Students may only smoke in designated areas if the hospital allows it and during their 30-minute break time.

Please see Residential Living Spaces in reference to smoking/vaping in St. Mary’s College Student Handbook.

POLICY & PROCEDURE

Technology, Social Media, and Cell Phone Policy

1. Purpose

This policy establishes guidelines for the appropriate and professional use of electronic devices and social media (e.g., cell phones, smartphones, tablets, computers) during clinical use by nursing students. “Clinical” is defined as any setting utilized in a clinical nursing course, including but not limited to the skills laboratory, acute care facilities, sub-acute care and rehabilitation facilities, long-term care facilities, clinics and physician offices, and community settings.

2. Social Media

Social media presents a challenging area for nurses and nursing students to navigate, as the line between a personal story and a professional one can become blurry; nurses across the country have lost their jobs in connection with social media posting activity.

Students are not permitted to post any information regarding clinical or simulation experiences. Public posting or privately posting in a manner that could become public, will result in a referral to the Professional Practice Committee (PPC); such information may also be required to be reported to the Board of Registered Nursing (BRN). Students should refer to the NCSBN's (National Council of State Boards of Nursing) Nurses Guide to the Use of social media (https://www.ncsbn.org/public-files/NCSBN_SocialMedia.pdf). All violations of this social media policy are referred to the PPC.

3. General Technology Use

Cell phones, tablets, and computers are incorporated into class, simulation, and clinical settings throughout the Nursing Program to enhance learning. This equipment may not be used for personal purposes in these settings — for example, checking social media accounts during class time is a prohibited activity.

4. Cell Phone Use in the Classroom and Simulation Setting

• Cell phones must be placed silently in class, simulation, and clinical settings.
• Cell phones should not be removed from a student's pocket unless being utilized as part of the educational experience, such as:
  • Participating in a Kahoot activity
  • Text messaging the clinical instructor
  • Looking up a medication during simulation

5. Cell Phone Use in the Clinical Setting

Cell phones within the clinical setting may only be used to:

• Text message the clinical instructor.
• Access wireless glucose monitoring, for a student with diabetes who has provided documentation of this condition to the Director of Nursing.
• Use for a clinical purpose under the direct supervision of, and at the direction of, a faculty member.

No photographs or recordings of any kind may ever be taken within the walls of a clinical, skills, or simulation setting.

6. iPad Use

iPads are used in class, simulation, and a variety of clinical settings. These devices should be used only for academic purposes, within the listed settings, and under faculty instruction. The following activities are not permitted when using these devices:

• Taking pictures or video of any kind, unless approved by a faculty member.
• Taking pictures or video in a clinical setting, under any circumstance.
• Accessing personal sites unrelated to academic experience.

Students found accessing sites unrelated to the educational experience will be reported to the PPC for further consequences.

7. HIPAA/HITECH and Patient Confidentiality

• Students are responsible for adhering to the federal Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Health (HITECH) regulations regarding protected health information.
• Students may only view their assigned patient's record. Viewing any patient chart other than an assigned patient's is a violation of HIPAA.
• Students may not download or store any confidential client data on a personal electronic device.

8. Additional Regulations

• Faculty members may, at any time, determine that cell phones may not be used at all within a given learning environment.
• Cell phones and other electronic devices, including watches, are not permitted during testing. A student observed with any such device during testing will receive an automatic failure and referral to the PPC.
• Clinical sites may direct the Program that cell phones are prohibited on-site. Students will be notified of any such requirement and must follow the clinical site's policy.
• Students may not charge any devices in clinical settings.
• Students may never use hospital computers for personal activities.

9. Violations

Violations of this policy and/or the policy of the clinical facility may result in clinical remediation or course failure.

POLICY & PROCEDURE

Testing Policy

1. Purpose

This policy establishes the rules and regulations governing a fair, secure testing environment and process.

2. Testing Environment

1. All class exams and ATI proctored exams are administered on campus, in person, and supervised by faculty or designated personnel.
2. No water, food, or other outside items are allowed in the testing area.
3. No coats or backpacks are allowed in the testing area.

3. Restroom and Water Access

A student who needs to use the restroom or access water during testing will be assisted by a staff member outside the testing area. A secure bathroom will be provided, with escort if needed.

4. Prohibited Personal Items

No cell phones, smart watches, or other personal belongings are allowed in the testing area, including:

1. Earbuds
2. Notes
3. Watches
4. Phones
5. Computers
6. Tablets
7. Sunglasses
8. Smart glasses
9. Glasses designed to record or access AI

5. Violations and Consequences

1. Any prohibited item discovered in a student's possession will be confiscated by the faculty member or designated person administering the exam and provided to the Professional Practice Committee (PPC).
2. The student will be referred to the PPC.
3. A student who violates this policy will be disqualified from the Nursing Program and will not be eligible for readmission.

6. Faculty Monitoring

Faculty will monitor testing to ensure cheating is not occurring.

7. Disability Accommodations

Student accommodation needs are addressed each semester to ensure the Program meets the needs of the student while maintaining the integrity of testing.

1. This may mean the student tests in a different location.
2. This may mean the student tests at a different time.
3. All accommodation must be arranged through the Disability Office.

8. Medical Accommodations

Medical accommodation is made in accordance with Board of Registered Nursing (BRN) accommodation standards.

1. Medical accommodation needs are addressed with the Director of Nursing each semester.
2. A 504 Plan must be in place for the student to receive medical accommodation.

Nursing Program Organizational Chart (Part I of II)

Nursing Program Organizational Chart (Part II of II)

POLICY & PROCEDURE

Nursing Program Admission & Process

1. Purpose

“Health inequities persist in underserved communities where access to care is limited and social determinants impact health outcomes. These areas tend to be poorer and more diverse than communities that are well-served. Currently, health care providers who come from more diverse backgrounds provide the bulk of care for this population of patients in the United States. Language and cultural barriers limit providers’ ability to serve the needs of minority patients in ways that are linguistically and culturally relevant. 

 

Diversity benefits all students – not just those who are underrepresented minorities. Educating students in environments that value diversity and inclusion produce graduates better prepared to practice in underserved communities and whose understanding of the cultural needs of patients improves patient satisfaction and trust. 

Nursing students should possess the background, qualities and skills to provide culturally effective care and meet the needs of a rapidly diversifying patient population. These skills cannot be detected from grades and test scores alone. Holistic review can help programs identify key applicant experiences and attributes that will contribute to a more diverse class and a more effective nursing workforce.” AACN

Principles:

1.     Saint Mary’s College selection criteria for admission to the nursing program are broad based. The admission process aligns with the mission and is focused on promoting diversity as an essential component in achieving excellence.

2.     The selection process uses a variety of criteria as part of the process. The intent of creating a richly diverse candidate pool and cohort; is applied equitably across the entire candidate pool. Admission is not solely on academic standing.

3.     Faculty and staff who participate in the admissions process examine all the students’ attributes and examine how each applicant would contribute to the class experience and the profession.

2. Policy

AACN identified diversity and inclusion as one of its strategic goals. To actively incorporate this goal into our nursing program here at Saint Mary’s College we have a holistic approach to our admission process.

3. Requirements

Pre-Nursing

For an SMC student to declare they are a Pre-Nursing Student they must have a 2.8 GPA.

Minimum requirements to apply for the BSN Nursing Program:

• Overall, 2.8 GPA
• Minimum grade of C- or better in Chemistry and Statistics, 
• Minimum grade of C or better Writing as Inquiry
• All prerequisite courses must have a letter grade
• 2.8 GPA cumulative in the required sciences (Microbiology, Anatomy, Physiology, Nutrition, Sociology, and Psychology)
• Anatomy, Physiology, and Microbiology courses must have been completed in the last 7 years.
• B- grade or higher in Anatomy, Physiology, and Microbiology.
• If a C is in one of the 3 courses (Anatomy, Physiology, or Microbiology) you may apply to the program. If accepted, you may be required to complete a Nursing Science preparation course or assigned remediation during the first semester at SMC
• Classes may be retaken with no deduction of points, and the committee will view most recent grade
• Passing a diagnostic entrance exam (ATI-TEAS Test) with 70% or higher with 2 attempts
• If you did not achieve 70% you may still apply for consideration by submitting a letter requesting consideration with rationale.
• See grading rubric for more information on points awarded

4. Procedure

Students need to submit documents to the nursing program:

• High School Diploma/GED or equivalent
• College Transcripts
• 2.8 GPA from all prerequisite coursework
• 2-Letters of recommendation (one faculty, one professional)
• TEAS Score 70% or higher, or a petition for consideration.
•  Personal Statement

Students’ initial documents will be reviewed:

• Students who are selected will come for an in-person Group Panel Interview

5. Selection

Students will get an acceptance letter from the nursing department, with instructions to complete the admission process with SMC School Admissions team. Students must complete all required paperwork to be accepted to the College. Students are also required to complete a deposit to hold their spot within the nursing program

• Complete all required Health and safety within 45 days of notice to be formally accepted and have received your SMC email.
• Pass background check within 20 days of receiving your SMC email
• Complete and pass drug test soon after acceptance (details TBA)

Admission is to a cohort

• Admission is made to a designated cohort
• If for any reason you are not wanting to proceed with the cohort accepted into you must re-apply to the nursing program and go through the process again
• no guarantee a student will be accepted on subsequent application cycles

POLICY & PROCEDURE

Transfer Challenge Advanced placement into Undergrad Nursing Program

1. Purpose

This policy establishes the criteria and process by which transfer, challenge, and advanced placement credit may be granted toward the Pre-Licensure BSN Program, ensuring equivalent competency attainment for all applicable coursework. It is maintained in compliance with California Board of Registered Nursing (BRN) requirements governing the evaluation and acceptance of prior academic credit into an approved nursing program.

2. Policy

Under certain circumstances, academic credit earned in regionally accredited institutions of education for comparable pre-licensure courses will be accepted for transfer.

1. Transfer Credit may be granted for related previous education in the following courses.
   1. Accredited registered nursing courses
   2. Other courses determined by the college to be equivalent to courses in the undergraduate nursing program
2. Equivalency is determined based on catalog course descriptions. This includes hours, number of units and the syllabus content in comparison to the classes offered at SMC
3. Applicants must meet all general admission requirements of the SMC undergraduate nursing program.
4. Acceptance of transfer students is based on current space availability.
5. Who is eligible for advanced placement
   1. Individuals who have successfully completed, within one year the following        
      1. Nursing courses from other accredited RN nursing programs
      2. Or other courses which the college has determined as an equivalent to current courses in the undergraduate program

Transfer Process:

1. Applicants interested in this process must email all transcripts to the director of nursing for preliminary evaluation of eligibility.
2. Applicants applying for transfer credit must submit the following materials verifying courses
   1. Official transcripts from institution showing successful completion
   2. Catalog description with equivalent course
   3. Additional documents as requested: syllabi content outlines and letters of reference.
   4. After the review of the applicant’s record, the student is required to take a competency examination using ATI and a drug calculation exam using safeMedicate
3. Students will enter the undergraduate program at the point where equivalency has been determined and competency demonstrated.

Challenge by examination:

Credit via challenge by examination is available to qualified applicants of the undergraduate nursing program.

1. The challenge examination for credit based on previous education/experience must be accredited by the student at least eight weeks prior to admission to the nursing program.
2. Students requesting this must meet all the admission requirements
3. A maximum of 15 units may be challenged by examination
4. Acceptance of students wishing to challenge by examination is contingent on space availability

Process:

1. Individuals interested in the challenge by examination must schedule an appointment with the director of nursing to determine eligibility.
2. Students must file a written request to the director of nursing requesting to complete a course by challenge exam
3. Applicants with health-related education or experience, within one year wanting to complete a course with the challenge by examination, must submit the following documentation as part of the process
   1. Letter of reference from current employer attesting to applicants’ knowledge and ability related to course expectations
   2. Official transcripts from appropriate institutions demonstrating satisfactory completion of course work
   3. Students must submit a written statement indicating the reason for the challenge
4. Upon confirmation that you may complete the challenge process the student must complete the following:
   1. File with the SMC admission department a petition for credit and pay the fee: once the school has sent confirmation to the nursing program the following items will be made available to the student for preparation of the challenge exam:
      1. Course Syllabus; including course objectives
      2. Content outline
      3. Textbook and article list used within the class
      4. A practice exam for the content area they are testing in (a fee is charged for the student to take ATI practice and Challenge exams as well as SafeMedicate exams.)
      5. Students must obtain level 2 on core-content challenge exams in ATI- 
         1. Core content areas include classes that have both a theory and clinical section
      6. Clinical challenges will need to pass a proctored simulation and skills exam. This exam needs 80% to pass and receive credit
      7. Students must pay SafeMedicate fee and complete challenge exam with 100%
      8. For a theory or clinical exam challenge the student
      9. All challenge exams are in person and supervised
5. After the results are confirmed, students will be notified of their results in writing. If applicants meet the minimum standards and pass the challenge exams credit will be awarded.

Policy

POLICY & PROCEDURES

Challenge-Advanced Placement for Military & Trained Healthcare Professionals

1. Purpose

This policy establishes the criteria and process by which military service members and trained healthcare professionals (e.g., military medics, LVNs/LPNs, EMTs/paramedics) may challenge or receive advanced placement credit for prior clinical training and experience within the Pre-Licensure BSN Program. It ensures equivalent competency attainment through standardized evaluation, consistent with California Board of Registered Nursing (BRN) requirements for granting credit toward an approved nursing program

2. Policy

Individuals who have held Military Health Care positions i.e. Basic Technician Corpsman, Army Healthcare Specialist or other like position may achieve advanced placement into the second semester of the nursing program. The individual will need to provide documentation of education and experience that qualifies them for this placement. Upon review of the documents and approval the individual may take challenge exams for all 1^st semester level one classes, Fundamentals, Health Assessment, Pharmacology, Pathophysiology. Students are not allowed to challenge the Professional Role Class. Accommodation would be made for the students to complete this along with their second semester classes.

1. Applicants must meet all the admission requirements for SMC undergraduate nursing program, this includes all prerequisites.
2. Acceptance of “challenge” students is always based on space availability.
3. Military must pass change written exams at 75%, ATI proctored exams at level 2 and SafeMedicate calculation exams at 100% with 3 attempts.
4. Military personal who has failed or withdrawn from another nursing program are not eligible for this option.

Process:

Students interested in exploring this option need to meet with the Director of Nursing, or designee, at least 8 weeks prior to the application period to determine possible eligibility.

1. Applicants must have all the prerequisites required already completed or will be completed prior to semester starting.
2. Applicants must meet all the admission requirements.
3. Applicants should have experience as Basic Medical Technician Corpsman, Army Healthcare Specialist or Air force Independent Duty Medical Technician.
4. All official transcripts from appropriate education programs for transfer credit must be submitted
5. Documentation of any military education training must be submitted
6. Documentation of military hands-on experience must be submitted
7. Letter of reference supporting the students’ acceptance from the military

Documents will be reviewed to determine if the applicant meets the qualification for admission and then determine if the student has satisfied the eligibility for completion of challenge exams.

If the student is determined to meet the qualification to take the challenge exams the following will occur.

1. The following materials will be available to the applicant
   1. Syllabi and course objectives for Pharmacology, Pathophysiology, Fundamentals and Health Assessment.
   2. Content outline for each of the above 4 classes
   3. Textbooks and list of any other resources utilized for the classes
   4. Practice tests with answers so students can see the style and format of exams.
2. Exams given for each challenge exam. This must be completed 6 weeks prior to the semester start date
   1. One Pharmacology exam, need 75% to pass
   2. One Pathophysiology exam, need 75% to pass
   3. Fundamentals ATI proctored exam level 2 achievement (2 attempts)
   4. Simulation/skills exam includes the demonstration of a head-to-toe exam- this fulfills the health assessment class and fundamentals clinical, 80% required.
   5. SafeMedicate calculation exam 100% 3 attempts provided
3. If the student passes the above exams, advanced placement will be given and a letter of confirmation of this placement will be sent.

Charlie 68 Science Challenge

Students who have graduated within the last 6 years from the Charlie 68 program and have a CA LVN license in good standing are eligible to apply with the Director of Nursing for possible science credit for classes taken.

1. If all science requirements were completed within this military program it is possible to receive credit for Anatomy (4), physiology (4), microbiology (4) Nutrition (3) and statistics (3)

POLICY & PROCEDURE

LVN 30-Unit Option

1. Purpose

To ensure Saint Mary’s College in compliance with CCR-1429 provides a 30-unit option to complete the RN degree program.

• Written information regarding this option for LVN’s can be found on our website and within the nursing student handbook and within this policy.

2. Policy

Application requirements and process:

1. The applicant must have a valid California LVN license in good standing at time of application. 
2. Applicants must have a valid BLS-for healthcare card
3. Must complete all the Health and Safety requirements for nursing students (see policy)
4. Must have completed Microbiology and Physiology Prior to application
5. Testing will be completed using ATI to provide the student with information regarding current gaps in knowledge. These testing results will be reviewed with the students to assist them in making an informed decision regarding this option.
6. New applicants must specify this option prior to entry and enrolled students may not switch to this option. 
7. Counseling of potential students wanting this option will be completed by the Director of Nursing.
   1. Completion of this option does not equal a degree from the College.
   2. Completion of this option means furthering your career through education will be extremely difficult
   3. You will not be eligible for the public health certificate.
   4. We do offer the ability for an LVN to complete a challenge exam to reduce the number of classes required
   5. This RN license is not recognized outside of California
   6. LVNs are welcome to apply for the traditional RN program and are given additional points for previous work experience
8. LVN students must pass the classes in the same manner as traditional students. This includes testing requirements, performance and behaviors.
9. LVN students must complete a Challenge exam in the simulation lab to obtain credit for 1 unit of Mental Health Clinical.
   1. The 30-unit option only requires the LVN to take 2 units of Mental Health Clinical. This concept is based on your training within the LVN program

Curriculum:

1. All theory and Clinical classes are concurrent and must both be passed to progress.
   1. Failure of clinical results in failure of Theory
   2. Failure of Theory results in Failure of Clinical
2. Classes must be taken with the cohort you enter with in time.
3. Basic Sciences- must be completed prior to starting the program
   1. Biology 250/250l
   2. Biol 140/140l

POLICY & PROCEDURE

Nursing Structure, Committees and Faculty Shared Governance

1. Purpose

Saint Mary's College of California uses Dr. Maria O'Rourke's Professional Role and Role Clarity framework for all nursing program courses. As part of “owning” our profession as nurses and educators, we embrace shared governance as the leadership style, structuring the nursing program through committees that engage faculty, staff, and students in collaborative decision-making, curriculum oversight, and program improvement. This structure also governs faculty/student preceptorship ratios in accordance with Title 16, CCR §1426.1(c), which requires ratios to be determined by: (1) student/preceptor needs; (2) faculty's ability to effectively supervise; (3) the student's assigned nursing area; and (4) agency/facility requirements.

2. Policy

Saint Mary's College of California's Pre-Licensure BSN Program operates under a shared governance model in which faculty, staff, and students hold defined roles in decision-making, curriculum oversight, and continuous program improvement, consistent with Dr. Maria O'Rourke's Professional Role and Role Clarity framework. The Program's organizational chart establishes the reporting lines and shared decision-making authority among Program Leadership, faculty, staff, and students, including Simulation staff oversight of the Shared Governance Committee in which students participate.

Program effectiveness is evaluated through the Comprehensive Evaluation Plan (CEP), a systematic and continuous quality improvement process aligned with Commission on Collegiate Nursing Education (CCNE) standards. Responsibility for reviewing and disseminating evaluation data rests with the Accreditation Committee, the Quality and Curriculum Committee, and Program Leadership, with faculty and student participation in reviewing results and identifying opportunities for improvement.

The Program shall maintain defined Program Objectives, evaluated annually against established benchmarks, including NCLEX-RN pass rates, program completion rates, and post-graduation employment outcomes. Faculty/student ratios for preceptorship shall be determined in accordance with Title 16, California Code of Regulations §1426.1(c), based on student/preceptor needs, faculty's ability to effectively supervise, the student's assigned nursing area, and agency/facility requirements.

This policy shall be reviewed on an annual basis, or as regulatory, accreditation, or programmatic changes require, to ensure ongoing compliance with BRN and CCNE standards.

3. Organizational Structure and Shared Governance

The Nursing Program's organizational chart delineates the reporting lines and shared decision-making authority among Nursing Program Leadership, faculty, staff, and students. Shared decision-making extends across staff roles, ensuring that operational, curricular, and program-level input is gathered from those directly involved in program delivery.

Simulation staff provide oversight of the Shared Governance Committee in which students participate, ensuring that student voice is integrated into decisions regarding simulation and skills lab operations, scheduling, and continuous improvement, consistent with the program's broader shared governance model.

4. Program Objectives and Program Evaluation

1. Nursing students will graduate with role clarity, understanding their role in the delivery of high-quality health care and the importance of "do no harm."
2. NCLEX-RN licensure examination pass rates will meet or exceed 80%.
3. At least 90% of students will complete the program within five (5) semesters.
4. At least 90% of graduates will be employed within six (6) months of graduation.

Saint Mary's Nursing Program maintains a Comprehensive Evaluation Plan (CEP), established in 2024, as a systematic and comprehensive written plan for assessing the quality and effectiveness of the undergraduate Nursing Program. The CEP is aligned with Commission on Collegiate Nursing Education (CCNE) standards in support of SMC's application for CCNE accreditation. The plan identifies the elements to be evaluated, the assessment methodology used, and the level of achievement to be reached.

Responsibility for reviewing and disseminating evaluation data will rest with the Accreditation Committee (launch August 2026), the Quality and Curriculum Committee (launch 2027), and Program Leadership (Launch 2025).

Consistent with SMC's shared governance model, both faculty and students participate in reviewing results and identifying opportunities for improvement. CEP comprises several working documents aligned with CCNE Standards, including tables that aggregate and trend data for analysis. A complete list of these tables, along with the corresponding standard and element each supports, is provided below:

• Standard I outlines the measures used to assess the mission and governance of all programs.
• Standard II describes the continuous evaluation of ongoing institutional commitment to, and support of, the Director of Nursing in terms of resources.
• Standard III addresses undergraduate and graduate curricula and teaching-learning practices.
• Standard IV, addressed through the CEP, evaluates four areas: administrative performance, evaluation outcomes, student outcomes, and program outcomes.

The CEP is an ongoing, continuous quality improvement process that guides the systematic and comprehensive evaluation, analysis, and refinement of all facets of the program through established review practices.

Nursing Program Organizational Chart Part 1 of 2

Nursing Program Organizational Chart (Part II of II)

Chain of Command Policy

1. Purpose

This policy establishes the Chain of Command for resolving concerns within the Pre-Licensure BSN Program, ensuring that issues are addressed at the most appropriate level, in the timeliest manner, and are escalated in a consistent, predictable sequence when they cannot be resolved at the point of occurrence.

2. Regulatory and Accreditation Alignment

A defined chain of command supports the Program's compliance with CCNE Standard I (Program Quality: Mission and Governance), which requires evidence of clear organizational structure, governance, and defined lines of authority, and with California BRN requirements (Title 16, CCR) for an identifiable administrative structure and accountable program leadership. This policy should be read alongside the Program's organizational chart and the Nursing Program Structure, and PPC process.

3. Chain of Command

Concerns should always first be addressed at the point of occurrence, following the sequence below:

1. Faculty who oversees the class.
2. If the occurrence is in a co-taught class, there will be a lead faculty member to go to as a second step.
3. For clinical concerns, the theory faculty is responsible and should be the second step.
4. Clinical Coordinator or Academic Director responsible for the content area.
5. Director of Nursing 
6. Provost, who holds final decision-making authority for matters escalated beyond the Nursing Program (consistent with BSN-PROG-010, Section 4).

Nursing Organization Structure

POLICY & PROCEDURE

Prohibition of Photographs, Videos, and Recordings Policy

1. Purpose

The purpose of this policy is to ensure the privacy and confidentiality of patients, faculty, and students; maintain professional standards; and comply with legal and ethical guidelines in clinical and academic settings. This policy prohibits students from taking photographs, recordings, screenshots, and videos in all clinical environments and classroom activities associated with the Nursing Program.

It is understood that faculty may permit audio recordings of classroom activities for a student's personal use in preparing academically for exams and nursing activities. It is also understood that audio and/or video recordings may sometimes be taken by faculty in simulation environments for educational purposes associated with the Program and consistent with SIM educational practices.

2. Scope

This policy applies to all nursing students.

3. Policy Statement

3.1 Prohibition of Photographs

The taking of photographs, recordings, screenshots, and videos — including but not limited to images of patients, staff, faculty, students, or clinical environments — is strictly prohibited in all clinical settings and during class time. This includes the use of personal devices such as smartphones, tablets, and cameras.

3.2 Rationale

• The prohibition of such content is essential to protect patient, student, and faculty privacy and confidentiality, as mandated by the Health Insurance Portability and Accountability Act (HIPAA), the Family Educational Rights and Privacy Act (FERPA), and other relevant regulations.
• Photographs may inadvertently capture sensitive information or identify patients, students, or faculty in a way that breaches confidentiality and trust.
• Maintaining a professional environment is critical to the integrity of the nursing profession and the educational experience.

3.3 Exceptions

The only exceptions to this policy are content taken for educational purposes that has received prior written approval from the clinical instructor and the facility administration. Such content must not include identifiable patient information and must adhere to all applicable privacy regulations.

3.4 Consequences of Policy Violation

Any individual found in violation of this policy may face disciplinary action, which may include, but is not limited to:

• Verbal or written warnings
• Suspension from clinical practice
• Dismissal from the Nursing Program

Because such violations risk causing substantial legal and reputational harm to the College, the Nursing Program, and the nursing profession, the nursing administrative team has broad discretion to determine the appropriate disciplinary action based on the facts.

3.5 Reporting Violations

Any suspected violation of this policy should be reported immediately to the relevant faculty member and the Program Director. All reports will be taken seriously and investigated appropriately.

3.6 Training and Awareness

This policy will live within forward-facing published Program content that nursing faculty and students are held responsible for reviewing.

4. Implementation

This policy will be implemented in all clinical and classroom settings associated with the Nursing Program. Faculty and staff are responsible for ensuring compliance and addressing any violations.

POLICY & PROCEDURE

Graduation Policy

1. Purpose

The purpose of this policy is to provide a procedure for the submission of Board-required forms for graduates of the Program, and to ensure students understand the process for scheduling the NCLEX examination.

2. Policy

1. Students will follow the SMC Student Handbook for submitting graduation forms to the College.
2. The Nursing Department does not submit any graduation requests to the College. Saint Mary's students will follow the policy set forth by the College for petitioning for graduation. See: Undergraduate Graduation Information.
3. Graduation from Saint Mary's College is separate from the Department of Nursing Pinning Ceremony.
4. The Nursing Department will provide an orientation on how to complete the process to become eligible to sit for the NCLEX.
5. A presentation will be given as part of the Leadership course.
6. This presentation will be posted within the Leadership course.
7. The presentation will cover how to complete the BRN application and the Pearson Vue registration to sit for the NCLEX.
8. Four weeks prior to the established graduation date, the Director of Nursing will submit to the Board a roster of student names and their expected graduation date.
9. The Director of Nursing will submit the names of students who have successfully completed the program immediately upon confirmation from the Registrar that the student is cleared for graduation.
10. The Department of Nursing will begin working with the Registrar's Office at the start of the final semester to verify that all requirements are cleared and in place for the expected graduation date.
11. All students who have successfully graduated will be submitted to the Board of Registered Nursing online platform within 5 days of the graduation date.

POLICY & PROCEDURE

Clinical Placement of Nursing Students Policy

1. Purpose

To provide a structured, transparent, and equitable process for the clinical placement of nursing students, ensuring they receive high-quality experiential learning opportunities that meet educational standards and program requirements.

2. Scope

This policy applies to all nursing students enrolled in the clinical phase of the Nursing Program, faculty, and clinical placement coordinators responsible for assigning, supervising, and evaluating clinical experiences.

3. Policy Overview

The Nursing Program will arrange clinical placements in collaboration with partnering healthcare organizations to support students' learning objectives and clinical competencies. Placements will adhere to the Program's educational standards, accreditation requirements, and the policies of healthcare facilities.

4. Responsibilities

• Clinical Placement Coordinator: Responsible for managing clinical placements, liaising with healthcare facilities, coordinating schedules, and ensuring placements meet Program objectives.
• Nursing Faculty: Evaluate students' clinical performance, provide mentorship, and ensure adherence to ethical and professional standards. Faculty meet all Health and Safety requirements.
• Students: Meet all placement prerequisites, including immunizations, health screenings, background checks, and clinical competency requirements.

5. Placement Eligibility Requirements

To be eligible for clinical placement, students must:

1. Successfully complete prerequisite coursework.
2. Provide proof of required immunizations, TB screening, and health assessments.
3. Complete a criminal background check and drug screening (as required by healthcare facilities).
4. Maintain current CPR/BLS certification.
5. Attend an orientation session on clinical expectations and responsibilities.

6. Clinical Placement Process

Step 1: Student Preferences and Program Assessment

• The Clinical Placement Coordinator will assess clinical sites based on their alignment with educational objectives and student competencies.
• Students may submit placement preferences, which will be considered based on availability, program needs, and student progression.

Step 2: Assignment of Clinical Placement

Placements will be assigned considering the following factors:

• Student learning needs and academic progress
• Site availability and capacity
• Skill and competency requirements for the specific clinical rotation
• Location and accessibility of the clinical site

Step 3: Communication of Placement Assignment

• The Clinical Placement Coordinator will inform students of their placements at least 2–4 weeks before the start of the clinical rotation.
  • There may be delays in this timeline based on clinical site changes.
• Students will receive a clinical placement packet with relevant site information, contact details, expectations, and any site-specific requirements.

Step 4: Pre-Placement Orientation

All students must attend a mandatory orientation specific to their clinical placement. Orientation will cover:

• Students and faculty attend an orientation day in the Simulation Center prior to clinical site orientation.
• Clinical objectives and competencies for the rotation.
• Professionalism and conduct expectations.
• Health and safety protocols, including infection control.
• Confidentiality and patient privacy policies (HIPAA compliance).

Step 5: Evaluation and Feedback

• Mid-Rotation Check-In: Nursing faculty or preceptors will conduct a mid-rotation evaluation to review student progress and provide feedback. Students in danger of failing will be reported to the Simulation Director for support in promoting student success through early intervention.
• Final Evaluation: At the end of each placement, a comprehensive evaluation will assess the student's achievement of clinical competencies, adherence to professional standards, and areas for improvement.
• Student Feedback: Students are encouraged to complete a post-placement survey to provide feedback on the:
  • Site
  • Faculty support
  • Overall learning experience

7. Placement Changes or Cancellations

If a clinical placement site becomes unavailable, the Clinical Placement Coordinator will make every effort to secure an alternative placement. If a student experiences conflicts or concerns at a placement site, the student must notify the Coordinator as soon as possible. Reassignments will be considered based on the following:

• Availability of alternative sites
• Feasibility of meeting clinical requirements within program timelines
• Specific circumstances and safety concerns of the student or site

8. Code of Conduct and Professionalism

Students are expected to adhere to the highest standards of professionalism, including:

• Punctuality and reliability in attendance
• Respectful and ethical behavior toward patients, staff, and colleagues
• Adherence to healthcare facility policies and procedures
• Proper attire and use of program- or facility-issued identification

Failure to comply with these standards may result in disciplinary action or removal from the clinical placement.

9. Health and Safety Policies

Students are required to follow all health and safety guidelines, including infection prevention and control protocols. Personal protective equipment (PPE) must be worn as directed by the facility and Nursing Program policies. Any injury or exposure incident must be reported immediately to the clinical instructor and facility supervisor.

10. Documentation and Records

The Clinical Placement Coordinator will maintain records of all student placements, evaluations, and any incidents related to clinical placements. Records will be securely stored in accordance with FERPA regulations and Program policies.

11. Appeals Process

Students who wish to appeal their clinical placement assignment must submit a written appeal to the Clinical Placement Coordinator and Simulation Director within one week of the placement announcement. The appeal will be reviewed by the Nursing Program Director, who will make a final decision based on the student's circumstances and Program requirements.

POLICY & PROCEDURE

Role and Responsibilities of Clinical Faculty and Preceptors Policy

1. Purpose

The purpose of this policy is to define the roles and responsibilities of clinical faculty and preceptors in the Saint Mary's College Nursing Program, to ensure high-quality clinical education that aligns with program objectives and supports student success.

2. Scope

This policy applies to all clinical faculty, preceptors, and students participating in clinical courses within the Saint Mary's College Nursing Program, including Community Health and Leadership courses. Clinical faculty may only supervise students within the program assigned to them through a clinical rotation or preceptorship by SMC.

3. Role of Clinical Faculty

Clinical faculty are part-time or adjunct faculty responsible for working with students in clinical, skills, and simulation settings. Their primary roles include instruction, supervision, assessment, and facilitation of clinical learning experiences.

3.1 Responsibilities of Clinical Faculty

1. Instruction and Supervision:

• Teach and demonstrate nursing skills, clinical reasoning, and professional practice.
• Supervise students in clinical settings, ensuring patient safety and professional standards.
• Assist students in applying theoretical knowledge to practical clinical scenarios.

1. Student Assessment:

• Evaluate student clinical performance, including skills competency and professional behaviors.
• Provide timely feedback and recommendations to students for improvement or enhancement.
• Validate findings and discuss student progress with other nursing faculty to ensure consistency in evaluations.

1. Collaboration and Coordination:

• Coordinate with nursing faculty to align clinical experiences with course objectives.
• Collaborate with clinical agencies to support student learning opportunities.

1. Presence and Accessibility:

• Be physically present or immediately accessible to students during clinical assignments to provide guidance and address concerns.

4. Role of Preceptors

Preceptors play an essential role in the educational process by serving as mentors, role models, and facilitators of learning. They support students' clinical learning experiences, especially in Community Health and Leadership courses, and guide them in applying their nursing knowledge to real-world settings.

4.1 Responsibilities of Preceptors

1. Mentorship and Role Modeling:

• Demonstrate excellence in nursing practice and leadership.
• Provide guidance, support, and advocacy to students, helping them achieve their learning goals and course objectives.

1. Facilitating Learning Experiences:

• Review course objectives and student goals to align clinical assignments with educational outcomes.
• Orient students to the clinical agency, including policies, procedures, and expectations.
• Help students understand the roles and responsibilities of nurse managers/leaders and other healthcare professionals.

1. Performance Evaluation:

• Provide ongoing feedback to students about their clinical performance.
• Offer constructive suggestions for improvement and celebrating successes.
• Complete a comprehensive evaluation of the student's performance, including its impact on patients and the clinical setting.

4.2 Preceptor Qualifications

• Hold active licensure and experience as a clinician in the designated nursing area.
• Demonstrate a commitment to student learning and professional development.
• Possess strong communication and evaluative skills, providing actionable and positive feedback.
• Maintain a willingness to continue learning and adapt to students' unique approaches, provided safety and professional principles are upheld.

5. Collaboration Between Clinical Faculty and Preceptors

Clinical faculty and preceptors collaborate to provide a cohesive learning experience for students:

1. Clinical faculty supports preceptors by offering guidance, answering questions, and providing feedback.
2. Preceptors share insights and evaluations with clinical faculty to ensure alignment with program objectives.
3. Both roles work together to ensure students meet competency standards and progress successfully through the program.
4. See preceptor documents for students, preceptors, and faculty (BSN-PREC-001).

6. Implementation

1. Orientation: Clinical faculty and preceptors will participate in an orientation process that includes a review of program goals, policies, course objectives, and evaluation methods.
2. Resources: Clinical faculty and preceptors will have access to the Faculty Handbook, Preceptor Handbook, course syllabi, and evaluation tools.
3. Ongoing Support: Faculty and preceptors will receive regular check-ins, professional development opportunities, and mentorship to maintain high standards of clinical education.

POLICY & PROCEDURE

Faculty Qualifications and Approval Policy

Purpose

To establish that Nursing education at Saint Mary's College will follow all BRN regulations 1424 and 1425, for supervision, qualification, approval, and resignation of faculty.

Policy

1. All faculty will submit their documentation through the BRN portal for teaching approval for content specific areas.
2. [Placeholder — no content provided in source]
3. All directors and assistant directors will have EDP-P-03 submitted prior to assuming a leadership role.

Supervision — 1424(j)

The assistant director shall function under the supervision of the director. Instructors shall function under the supervision of the director or the assistant director. Assistant instructors and clinical teaching assistants shall function under the supervision of an instructor.

Director of the Program — 1425(a)

Director of the Program shall meet the following (1425A):

1. A master's or higher degree from an accredited college or university which includes course work in nursing, education or administration.
2. One (1) years’ experience as an administrator with validated performance of administrative responsibilities consistent with section 1420(h).
3. Two (2) years' experience teaching in pre- or post-licensure registered nursing programs; and
4. One (1) year's continuous, full-time or its equivalent experience direct patient care as a registered nurse; or
5. Equivalent experience and/or education, as determined by the board.

Assistant Director — 1425(b)

The assistant director shall meet the education requirements set forth in subsection (a)(1) above and the experience requirements set forth in subsections (a)(3) and (a)(4) above, or such experience as the board determines to be equivalent.

Instructor — 1425(c)

An instructor shall meet the following minimum qualification (1425C):

1. The education requirements set forth in subsection (a)(1); and
2. Direct patient care experience within the previous five (5) years in the nursing area to which he or she is assigned, which can be met by:

• One (1) year's continuous, full-time or its equivalent experience providing direct patient care as a registered nurse in the designated nursing area; or
• One (1) academic year of registered nurse level clinical teaching experience in the designated nursing area or its equivalent that demonstrates clinical competency; and

3) Completion of at least one (1) years’ experience teaching courses related to registered nursing or completion of a post-baccalaureate course which includes practice in teaching registered nursing.

Assistant Instructor — 1425(d)

An assistant instructor shall meet the following minimum qualifications (1425d):

1. A baccalaureate degree from an accredited college which shall include courses in nursing, or in natural, behavioral or social sciences relevant to nursing practice.
2. Direct patient care experience within the previous five (5) years in the nursing area to which he or she will be assigned, which can be met by:
3. One (1) year's continuous, full-time or its equivalent experience providing direct patient care as a registered nurse in the designated nursing area; or
4. One (1) academic year of registered nurse level clinical teaching experience in the designated nursing area or its equivalent that demonstrates clinical competencies

Clinical Teaching Assistant — 1425(e)

A clinical teaching assistant shall have at least one (1) year continuous, full-time or its equivalent experience in the designated nursing area within the previous five (5) years as a registered nurse providing direct patient care.

Content Expert — 1425(f)

A content expert shall be an instructor and shall possess the following minimum qualifications (1425f):

1. A master's degree in the designated nursing area; or
2. A master's degree that is not in the designated nursing area and shall:

• Have completed thirty (30) hours of continuing education or two (2) semester units or three (3) quarter units of nursing education related to the designated nursing area; or have national certification in the designated nursing area from an accrediting organization, such as the American Nurses Credentialing Center (ANCC); and
• Have a minimum of two hundred forty (240) hours of clinical experience within the previous three (3) years in the designated nursing area; or have a minimum of one (1) academic year of registered nurse level clinical teaching experience in the designated nursing area within the previous five (5) years.

POLICY & PROCEDURE

Lead Faculty Policy and Procedure

1. Purpose

• To ensure coordination of content and teaching between clinical and theory classes.
• To ensure uniformity in content being delivered in nursing classes.
• To ensure one person is responsible for all activities performed within theory and matching clinical rotations.
• To ensure one person is responsible for reviewing/improving curriculum for the course before, during, and after the semester.

2. Policy

The following classes will have lead faculty:

• Classes that have clinical sections.
• Nursing classes that have separate sections being taught by different instructors.
• This designation may change from semester to semester; however, the lead faculty will be notified four (4) weeks in advance that they are the lead faculty.

3. Scope

• All faculty assigned to be lead faculty must have appropriate training and expertise for this role.
• Completed competency evaluation tool.
• Each course requiring BRN “content expert” approval will have one designated content expert, who is responsible for overseeing the curriculum feedback provided by the lead faculty at the end of the semester.

4. Procedure

4.1 Before Course Starts

1. Review all syllabi and course schedules and update as appropriate, four (4) weeks prior to the course.
2. Ensure the current syllabus format is being used.
3. Ensure there is a signature assignment within the course and that it is identified.
4. If the course has a designated “content expert,” this person must be contacted with any recommended changes or clarifications needed.
5. Ensure all material is posted on Canvas three (3) weeks before the course starts.
6. Ensure all assignments are posted in the appropriate location on the Learning Management System, with due dates.
7. Ensure all PowerPoints and other student materials are posted prior to the class in which they will be used.
8. Ensure that ATI/APEA is embedded within both class and home activities.
9. If another instructor is teaching/co-teaching, complete orientation to all of the above items prior to the course beginning.
10. Ensure all instructors teaching theory or clinical understand the expectation and importance of using ATI/APEA.

4.2 During Course

1. Monitor that all class material is being posted ahead of time.
2. Ensure faculty are reviewing ATI/APEA assignments prior to students assigned dates.

• All ATI/APEA assessments, or other items receiving points, must have a corresponding area under assignments for the item to be uploaded.
• All assignments need due dates.

1. Review tests prior to administration; ensure they are being given on the ATI platform.
2. Complete test analysis post-exam.

• If another instructor is teaching the course, this should be completed together with that instructor.
• If co-teaching, this should be completed together.

1. Verify that papers are being corrected on the Learning Management System.

4.3 Co-Instructors

At times, two instructors will be designated to co-teach a class. This is done to facilitate the learning process of the student and provide more support during lecture hours.

1. One instructor will be designated as the lead instructor.
2. Co-teachers are expected to teach together, not independently.
3. The work should be divided fairly between the two co-instructors, including lecture time and grading papers.
4. Both instructors should be present together during class at least 80% of the time.

4.4 Clinical Faculty

1. Meet with faculty for orientation to the expectations of the course, assignments, Canvas, resources, and questions.
2. Ensure clinical faculty are prepared for the start of clinical, including understanding of the schedule and hours required.
3. Ensure clinical faculty have read and understand the student responsibilities and absence policy.

• Student Absence: The student must complete a makeup assignment equivalent to the missed hours.
• For the undergraduate program, only 3 clinical days may be missed for the entire program.

1. Clinical faculty must report the following to the lead instructor:

• If a clinical day must be canceled due to the facility/instructor, the lead instructor and Simulation and Academic Director must be informed so clinical hours can be rescheduled if indicated.
• If a clinical instructor is aware of a conflict in advance, they must inform the lead instructor immediately so a replacement can be arranged.

1. Ensure faculty understand that all clinical days missed by students, or canceled by faculty/hospital, must be reported to the Chair.
2. Ensure weekly evaluations, and midterm and final evaluations, are completed.
3. Ensure students complete evaluations of faculty, preceptors, and clinical sites.
4. Ensure all faculty complete their self/course evaluation and submit it to the Academic Director.
5. Ensure all grades are entered on time.

4.5 Post-Class Lead Faculty Responsibilities

1. Review the course, along with feedback, and analyze whether changes need to be made.
2. Create and present a summary report evaluating the course curriculum at the annual curriculum meeting.
3. This includes recommended changes, or a statement that no changes are needed.
4. Review signature assignments, evaluate whether the assignment's objectives are being met, and report to the curriculum committee.
5. Make any needed changes to the course and submit them to the Director of Nursing after they have been approved by the curriculum committee.
6. Review all students and faculty feedback.

POLICY & PROCEDURE

Non-Faculty Clinical Instruction Policy

Policy for Compliance with Section 1424(i)

1. Purpose

To ensure clarity, accountability, and compliance with Section 1424(i) regarding the involvement of non-faculty individuals in the instruction and supervision of nursing students during clinical experiences. This policy outlines the process for documenting their responsibilities and maintaining records within the Nursing Program.

2. Policy Statement

Non-faculty individuals who participate in the instruction and supervision of nursing students during clinical experiences must have their roles, responsibilities, and scope of supervision described in writing. This documentation will be reviewed, approved, and maintained on file by the Nursing Program.

3. Definitions

• Non-Faculty Individual: Any professional who is not employed as a nursing faculty member but participates in clinical instruction or supervision of students, including but not limited to clinical preceptors, adjunct clinical instructors, or healthcare staff.
• Clinical Experience: Any educational experience occurring in a healthcare setting, designed to provide students with practical, hands-on nursing practice.

4. Procedure

4.1 Identification and Selection

• Non-faculty individuals participating in clinical instruction must be identified and approved by the Nursing Program administration.
• Qualifications must align with the clinical experience requirements and ensure alignment with program outcomes.

4.2 Written Documentation

A formal document will be created outlining the following:

1. Title and Role: The individual's title and the capacity in which they will contribute.
2. Responsibilities: Specific instructional and supervisory duties assigned to the individual, including expected contributions to student evaluation and skill development.
3. Limits of Supervision: Clearly defined boundaries of authority and areas requiring faculty oversight.
4. Expectations: Requirements for adhering to program policies, ethical standards, and confidentiality guidelines.

The document must be signed by:

1. The non-faculty individual.
2. The Nursing Program Director or designated representative.

4.3 Record Maintenance

• The signed documentation will be stored in a secure file by the Nursing Program for the duration of the individual's involvement, and for at least five (5) years thereafter.

4.4 Orientation and Training

The Nursing Program will provide orientation to non-faculty individuals, covering:

1. The Program's educational objectives.
2. The clinical evaluation process.
3. Legal, ethical, and safety requirements.

4.5 Monitoring and Evaluation

• Faculty members will periodically observe and assess the non-faculty individual's adherence to the outlined responsibilities.
• Any concerns or changes in responsibilities must be documented and updated in writing.

4.6 Compliance and Review

• This policy will be reviewed annually to ensure compliance with regulatory requirements and alignment with program goals.

5. Non-Compliance

Failure to document or maintain written descriptions of responsibilities for non-faculty individuals participating in clinical supervision will result in corrective actions, including but not limited to:

• Immediate suspension of the individual's participation.
• Review and amendment of internal policies and procedures.

POLICY & PROCEDURE

Content Expert Policy

1. Purpose

This policy is aimed at identifying the requirements and expectations of the BRN as the Program of Nursing at SMC identifies the role of the Content Expert in the areas of Medical-Surgical, Obstetrics, Pediatrics, Geriatrics, and Mental Wellness.

2. Faculty Content Expert — Definition

The Board of Registered Nursing explains that ‘Content Expert’ means an instructor who has the responsibility to review and monitor the program's entire curricular content for the designated nursing area of Geriatrics, Medical-Surgical, Mental Health/Psychiatric, Obstetrics, or Pediatrics.

3. BRN Qualification Requirements — Regulation 1425(f)

Per the BRN, Regulation 1425(f) states that a content expert shall be an instructor with:

1. A master's degree in the designated nursing area; OR
2. A master's degree that is not in the designated nursing area and shall:
3. Have completed thirty (30) hours of continuing education or two (2) semester units or three (3) quarter units of nursing education related to the designated nursing area; or have national certification in the designated nursing area from an accrediting organization, such as the American Nurses Credentialing Center (ANCC); And…
4. Have a minimum of two hundred forty (240) hours of clinical experience within the previous three (3) years in the designated nursing area; or have a minimum of one (1) academic year of registered nurse level clinical teaching experience in the designated nursing area within the previous five (5) years.

4. Nursing Program Expectations

• The Director of Nursing will identify the content experts for each content area.
• Content Experts will serve on the Quality and Curriculum Committee.
• Identification of the content expert(s) will be placed on the Program of Nursing's website.
• Content experts will lead a collaborative content review meeting at least once a year with faculty teaching in their specific content areas.
  • Theory and Clinical Faculty will participate in these meetings to discuss current curriculum and review the need for changes pertaining to syllabi, textbooks, teaching methodology, testing, remediation, etc.
• The Content Expert will report to the scheduled Quality and Curriculum Committee for any recommendations to the course(s).
• All changes are approved within the Quality and Curriculum Committee meetings and reported to the Leadership Committee.
• Communication is then delivered to faculty and students as indicated.

POLICY & PROCEDURE

Faculty Mentorship in the Nursing Program Policy

1. Purpose

To establish a structured mentorship program for new and junior nursing faculty members that supports their development, facilitates professional growth, and fosters a collaborative learning environment. This policy provides guidelines for assigning mentors, defining their roles, and outlining the mentorship process to ensure consistent support for faculty success.

2. Scope

This policy applies to all new and junior nursing faculty members, as well as experienced faculty designated as mentors within the Nursing Program.

3. Policy Overview

The faculty mentorship program is designed to support new and junior nursing faculty members by pairing them with experienced faculty mentors who provide guidance on teaching practices, academic responsibilities, and professional development. The program aims to foster an environment of mutual support, skill-building, and continuous improvement in nursing education.

4. Responsibilities

• Nursing Simulation Director: Oversees the mentorship program, assigns mentors, and ensures compliance with mentorship objectives.
• Mentor Faculty: Provides consistent guidance, feedback, and support to mentees, helping them integrate into the Nursing Program and develop as effective educators.
• Mentee Faculty: Actively participates in the mentorship program, seeks feedback, and works toward achieving professional goals.

5. Mentor Selection and Assignment Process

• Eligibility: Mentors must be experienced faculty members who have completed at least two years of teaching in the Nursing Program and demonstrated excellence in teaching, leadership, and professionalism.
• Assignment: The Nursing Program Director or Simulation Director assigns mentors to new faculty members based on factors such as teaching specialty, schedule compatibility, and mutual professional interests.
• Duration of Mentorship: Each mentorship relationship will last for a minimum of one academic year, with an option to extend based on the needs of the mentee.

6. Mentor and Mentee Roles and Responsibilities

6.1 Mentor Responsibilities

• Orientation Support: Assist the mentee in understanding program policies, faculty expectations, and administrative procedures.
• Teaching Guidance: Provide feedback on lesson planning, classroom management, clinical supervision, and student assessment methods.
• Professional Development: Encourage mentees to engage in professional development opportunities such as workshops, conferences, and continuing education.
• Evaluation and Feedback: Regularly review the mentee's teaching materials, offer constructive feedback, and observe classroom or clinical sessions (when feasible).
• Goal Setting: Work with the mentee to set realistic short-term and long-term professional goals and create a plan for achieving them.

6.2 Mentee Responsibilities

• Engagement: Actively participate in all mentorship activities, including scheduled meetings and professional development sessions.
• Feedback and Reflection: Be receptive to feedback and engage in self-reflection to improve teaching practices and professional skills.
• Goal Development: Collaborate with the mentor to establish clear, achievable goals and actively work towards them.
• Program Participation: Attend required orientation, training, and professional development events as directed by the mentor and program leadership.

7. Mentorship Process and Structure

The mentorship program is organized in phases to provide structured support and foster effective communication between the mentor and mentee.

7.1 Phase 1: Initial Orientation (First Month)

• Introductory Meeting: Mentor and mentee meet to discuss the mentee's background, goals, and expectations for the mentorship relationship.
• Program Overview: Mentor provides an overview of program policies, clinical requirements, and available resources.
• Initial Goal Setting: Mentor and mentee collaboratively set short-term goals for the first semester, focusing on teaching, student engagement, and program integration.

7.2 Phase 2: Ongoing Support and Check-Ins (Months 1–6)

• Regular Meetings: Mentor and mentee meet to discuss progress, address challenges, and review teaching experiences.
• Classroom/Clinical Observations: Mentor observes the mentee's teaching sessions at least once per semester, providing constructive feedback on strengths and areas for improvement.
• Resource Sharing: Mentor introduces mentee to teaching materials, instructional resources, and technology tools to enhance their teaching.

7.3 Phase 3: Mid-Year Review and Developmental Feedback (Month 6)

• Formal Evaluation Meeting: Mentor and mentee conduct a mid-year review to assess progress toward goals and identify any additional support needs.
• Adjust Goals as Needed: Mentor assists mentee in revising or setting new goals for the remainder of the year, based on observed progress and mentee reflections.

7.4 Phase 4: End-of-Year Reflection and Program Feedback (Month 12)

• Final Evaluation: Mentor completes an end-of-year assessment, reflecting on the mentee's growth, accomplishments, and areas for further development.
• Self-Assessment by Mentee: Mentee completes a self-assessment to reflect on their professional growth and the effectiveness of the mentorship program.
• Program Feedback: Mentor and mentee provide feedback to the Nursing Program Director on the mentorship experience, offering suggestions for program improvement.

POLICY & PROCEDURE

Nursing Faculty Orientation Policy

Orientation for New Nursing Faculty

1. Purpose

The purpose of this policy is to establish a standardized orientation process for new nursing faculty members to ensure they have the knowledge, resources, and support needed to succeed in their roles. The orientation will introduce the Program's mission, policies, instructional methods, and evaluation standards, supporting faculty in delivering high-quality nursing education.

2. Scope

This policy applies to all new nursing faculty members, including full-time, part-time, and adjunct instructors, at the beginning of their employment.

3. Policy Overview

The Nursing Program will conduct a structured orientation for all new faculty members to promote a smooth transition into the academic environment. The orientation process will address the faculty member's teaching responsibilities, program expectations, clinical coordination, and the use of educational technology, as well as introduce resources for faculty development.

4. Responsibilities

• Nursing Program Director: Responsible for overseeing the orientation process and ensuring that all new faculty receive appropriate training.
• Assistant Directors and Simulation Director: Manage and coordinate orientation activities, ensuring faculty access to resources, training sessions, and mentorship.
• Mentor Faculty: Assigned to each new faculty member to provide guidance, answer questions, and support teaching responsibilities during the first semester.
• New Faculty Member: Actively participates in orientation activities and completes all required training sessions.

5. Orientation Goals

The orientation process aims to:

1. Familiarize new faculty with the Program's mission, goals, and values, and ensure faculty understand and practice using the Professional Role Model the Program of Nursing uses to guide all educational experiences and program operations — Dr. Maria O'Rourke's Model of the Professional Role, Role Clarity.
2. Introduce key policies, procedures, and resources for classroom and clinical instruction.
3. Provide training on educational technologies and student assessment tools.
4. Establish mentorship support to facilitate a smooth transition.
5. Address the expectations for student support, feedback, and professional development.

6. Orientation Timeline and Structure

The orientation process will occur in three phases: Pre-Orientation, Formal Orientation, and Ongoing Support.

6.1 Phase 1: Pre-Orientation (Prior to Start Date)

• Welcome Packet: New faculty receive a digital packet that includes:
  • Welcome letter from the Nursing Program Director
  • Faculty Handbook, including academic policies, program goals, and ethical guidelines
  • Student Handbook link
  • Nursing Student Handbook Addendum link
  • Course syllabi, instructional resources, and curriculum overview
• Pre-Orientation Checklist: New faculty will complete tasks such as setting up email accounts, reviewing online resources, and submitting necessary HR documentation.

6.2 Phase 2: Formal Orientation (First Two Weeks)

• Program Overview and Mission:
  • Introduction to the Nursing Program's mission, goals, values, and educational philosophy.
  • Review of the American Nurses Association (ANA) Code of Ethics, Standards of Practice, and the Program's approach to professional role development.
• Policies and Procedures:
  • Detailed review of policies, including attendance, grading, assessment, and academic integrity.
  • Discussion of clinical placement policies, student health and safety, and evaluation standards.
• Instructional Methods and Curriculum:
  • Overview of instructional methods, including classroom, lab, and clinical teaching strategies.
  • Orientation to course syllabi, lesson planning, and curriculum mapping.
• Student Assessment and Evaluation:
  • Training on student assessment tools, including exams, clinical evaluations, and grading rubrics.
  • Overview of Canvas for tracking student progress, posting grades, and facilitating feedback.
• Educational Technology:
  • Training on the use of Canvas, simulation technology, online assessment tools, and other classroom technologies.
  • Introduction to telehealth and virtual learning resources, as applicable to the curriculum.

6.3 Phase 3: Ongoing Support (First Semester)

• Mentorship Program:
  • New faculty members are paired with experienced mentor faculty to provide guidance and support.
  • Mentors meet with new faculty at least bi-weekly during the first semester to answer questions and address challenges.
• Monthly Check-Ins:
  • Monthly meetings with the Simulation Director to review progress, discuss teaching experiences, and provide additional resources.
• Professional Development Opportunities:
  • Access to ongoing training in teaching methodologies, clinical supervision, and student support.
  • Information on workshops, webinars, and conferences related to nursing education and clinical practice.

7. Orientation Content and Modules

The orientation will cover the following modules, each with specific training sessions and resources:

1. Introduction to Nursing Education Principles: Overview of the pedagogical foundations of nursing education, including adult learning theory, critical thinking, and evidence-based practice.
2. Program Curriculum and Course Objectives: Detailed review of curriculum structure, course outcomes, and alignment with national nursing education standards.
3. Clinical Teaching and Coordination: Instructions on supervising clinical rotations, evaluating clinical competencies, and collaborating with clinical site staff and the Simulation Center.
4. Professional Role: Understanding Professional Role and Role Clarity in relation to Dr. Maria O'Rourke's Professional Role Model.
5. Student Support: Strategies for providing academic support, addressing student concerns, referring students to additional resources, remediation, referral to the Professional Practice Committee (PPC) for student success, and retention goals.
6. Ethics and Professional Standards: Training on ethical standards in nursing education, cultural competency, and maintaining professional boundaries with students.
7. Faculty Expectations and Evaluation: Overview of performance expectations, faculty evaluation processes, and opportunities for feedback and improvement.

8. Evaluation of New Faculty Orientation

To ensure the effectiveness of the orientation program, new faculty will be asked to complete an evaluation survey at the end of orientation. This feedback will help identify areas of improvement for future orientations and address any gaps in the orientation content.

Evaluation Elements

• Clarity and relevance of orientation materials.
• Effectiveness of mentorship and support provided.
• Adequacy of training in educational technology and assessment tools.
• Suggestions for additional resources or support.

9. Policy Review and Updates

This orientation policy will be reviewed annually by the Nursing Program Director and Orientation Coordinator to ensure it meets the Program's evolving needs and aligns with best practices in nursing education. Revisions will be made based on feedback from new faculty, mentor evaluations, and program objectives.

10. Pre-Orientation Checklist for New Nursing Faculty

This checklist is designed to guide new nursing faculty members through essential tasks to complete before the formal orientation begins. Completing these tasks will ensure that faculty have access to necessary resources, systems, and support.

POLICY & PROCEDURE

Faculty Clinical Instructor Orientation Policy for Simulation-Clinical Rotations

1. Purpose

This policy is to ensure that Nursing Program faculty who are providing simulation educational content to nursing students have appropriate expertise relevant to simulation pedagogy.

2. Policy

1. Faculty must be Board of Registered Nursing (BRN) approved for the content area to provide support in managing simulation activities.
2. Faculty must have completed competency validation with the Director of Simulation or designee, confirming they are competent to provide care to a specific population.
3. Faculty must have completed the orientation on Role Competency.
4. Any BRN-approved faculty may provide support for a fundamentals simulation activity if a Medical-Surgical BRN-approved faculty member is also in attendance, for any specific questions or support needed for medical-surgical content beyond the typical scope of a fundamentals class.
5. Faculty must have completed their TeamSTEPPS training.
6. All clinical and simulation faculty must have reviewed the simulation training manual and completed the required facilitator training.
7. Training requirements are developed by the Simulation Department and approved by the Simulation Committee and the Quality and Curriculum Committee.
8. Simulation Department staff, or approved faculty who have validated competency, will provide these training classes.
9. Clinical/simulation instructors are required to review the simulation template and teaching materials provided to students prior to the simulation day.
10. Clinical/simulation instructors will complete a competency check, during which they are assessed while teaching or debriefing during simulation, a minimum of three (3) times.
11. Clinical/simulation instructors will be trained in the utilization of space, and the cleaning and care of equipment.
12. Clinical/simulation instructors will be evaluated by lead faculty and students every semester.

POLICY & PROCEDURE

Student Teacher Ratio in Clinical Setting Policy

1. Purpose

This policy establishes the criteria used to determine safe and appropriate student-to-faculty ratios in the clinical setting, excluding preceptorships, based on patient acuity, learning objectives, student level, geographic placement, and teaching method.

2. Policy

Student/teacher ratio in the clinical setting (excluding preceptorships) will be based on the following criteria:

2.1 Patient Acuity Within the Clinical Setting

• Within an acute or subacute hospital setting:
  • 1:8
  • Faculty may have 1:10 students with a rotation model that maintains 1:8 on the floor (Fundamentals may use a 1:10 on-the-floor model).
• Within community settings with specific faculty supervision on site:
  • 1:10
• Rounding clinical model:
  • 1:5 to 1:10; the level of the student will determine the ratio.

2.2 Objective of the Learning Experience

• Ratios may be adjusted based on the learning objectives for the clinical experience planned for the day.
• Students assigned to a clinical experience may be rotated to reduce the ratio for learning opportunities.

2.3 Level of Students

• Level 1 students require more direct observation.
• Level 2 students require intermittent observation.
• Based on the geography of the unit to which students are assigned, the ratio may be decreased to accommodate student learning needs.
• Ratios may also be decreased based on the learning objectives of the clinical rotation or for specific clinical days.
• Students may be rotated as needed to accommodate a decreased ratio.

2.4 Geographic Placement of Students

• Clinical rotations involving multiple units assigned may have an adjusted ratio based on student level and clinical objectives.
• Students assigned to clinical rotations outside the Bay Area will have a designated SMC nursing faculty member who oversees the rotation, along with additional RNs providing support.

2.5 Teaching Methods

Traditional

• Clinical rotation in which faculty directly oversee students who are assigned to registered nurses for the experience.
• Faculty ratios are determined by student level, course objectives, learning needs, and facility resources.

Clinical Immersion Model (New)

Within some clinical rotations, students may participate in an immersive clinical experience for two weeks straight. Students attend for five days at the beginning of the semester and another five days toward the end of the semester, completing 100 hours during these two weeks. During these weeks, the following may occur with theory classes:

• Hybrid classes are created.
• Courses are designed so that no teaching occurs during that week.
• At times, the semester is structured so that several rotations are scheduled in this format, using four weeks to rotate students; under this model, theory classes are built with repeated lectures. See your Assistant Director for further information.

Clinical Rounding Model (New)

• The rounding model is one in which a faculty member takes students into patient care rooms to complete direct patient care based on the established objectives of the clinical partner.
• Students are taken in a 1:5 or 1:10 ratio, based on their level, planned activities, and objectives.

Preceptorships

• Students are assigned to a registered nurse who directly oversees the student's performance.
• Faculty are traditionally not on site but have designated time with the RN overseeing the student.
• Faculty members may be assigned 15–20 students.

3. Requirements of the Clinical Partner

Procedure

• Clinical placement partners are approved by the Board of Registered Nursing.
• Contracts are in place with each partner utilized.
• The Clinical Coordinator, under the supervision of the Assistant Director, manages the scheduling of clinical rotations and coordinates the faculty assigned to the rotation.
• The number of students assigned to a clinical facility and a particular unit is determined in collaboration with the organization's designated individuals.

COMMITTEE CHARTER

Nursing Program Accreditation Committee (NPAC)

1. Purpose

The Nursing Program Accreditation Committee (NPAC) is established to ensure compliance with accreditation and regulatory standards for the undergraduate Registered Nursing (RN) program. This includes adherence to California Board of Registered Nursing (BRN) requirements and AACN Essentials Level 1 standards. The committee will lead efforts to maintain accreditation, foster program excellence, and support continuous quality improvement.

2. Scope

This charter applies to all faculty and staff involved in the undergraduate RN Nursing Program and governs the activities of the NPAC.

3. Policy Statement

The NPAC, led by nursing faculty with the Nursing Program Director serving as a key member, is responsible for overseeing the accreditation process, ensuring program compliance with California BRN and AACN Essentials Level 1 standards, and supporting ongoing program evaluation and improvement.

4. Responsibilities of the Committee

1. Regulatory Compliance:

• Ensure alignment with California BRN regulations for undergraduate RN programs.
• Interpret and implement AACN Essentials Level 1 standards across the curriculum and program practices.

1. Accreditation Preparation and Maintenance:

• Develop and maintain an accreditation timeline and action plan.
• Coordinate the preparation and submission of required reports, self-studies, and documentation to the California BRN and AACN.
• Lead the Program through site visits and accreditation reviews.

1. Program Evaluation and Improvement:

• Regularly review program outcomes and student performance to ensure compliance with accreditation standards.
• Facilitate data collection and analysis for ongoing program assessment and improvement.
• Recommend changes to the curriculum, policies, or processes to address identified gaps or emerging standards.

1. Communication and Reporting:

• Provide updates to the Nursing Program Director and relevant stakeholders on accreditation progress.
• Develop clear communication channels to disseminate accreditation-related information to faculty and staff.

5. Committee Structure

1. Membership:

• The committee shall consist of at least 3 nursing faculty and one Assistant Director.
• The Nursing Program Director shall serve as an ex-officio member, providing guidance and institutional oversight.
• Additional members may include clinical partners and student representatives.

1. Leadership:

• A Chairperson will be elected from among the nursing faculty members annually.
• The Chairperson will coordinate committee activities, liaise with the Nursing Program Director, and lead meetings.

1. Meetings:

• The NPAC will meet monthly, or as required, to address critical accreditation deadlines and updates.
• Minutes will be recorded and distributed to all members and the Nursing Program Director.

6. Reporting and Accountability

• Quarterly Reports: The committee will submit progress updates to the Nursing Program Director, outlining activities, challenges, and next steps.
• Annual Review: The committee will provide a comprehensive report on accreditation status, program compliance, and improvement recommendations at the annual retreat.
• Action Plan: The NPAC will maintain a detailed action plan that aligns with California BRN and AACN accreditation cycles.

COMMITTEE CHARTER

Faculty Development Committee (FDC)

1. Purpose

The Faculty Development Committee (FDC) was established to oversee and facilitate faculty orientation, mentoring, and development activities. This committee supports the professional growth and effectiveness of faculty members in alignment with institutional goals and standards, reporting directly to the Simulation Director.

2. Scope

This policy applies to all faculty members within the Nursing Program and governs the operations of the Faculty Development Committee.

3. Policy Statement

The FDC shall be responsible for:

1. Faculty Orientation:

• Designing, implementing, and updating a comprehensive faculty orientation program.
• Ensuring new faculty understand the institution's mission, policies, simulation-based learning practices, and role expectations.
• Providing resources to help new faculty transition effectively into their roles.
• Reviewing and updating the orientation policy and training program annually.

1. Faculty Mentoring:

• Establishing a structured mentoring program that pairs new or junior faculty with experienced mentors.
• Monitoring mentor-mentee relationships to ensure alignment with professional growth objectives.
• Providing ongoing training and resources for effective mentorship.
• Reviewing and updating the Faculty Mentoring Program policy and monitoring the mentoring program throughout the year.

1. Faculty Development:

• Identifying and addressing faculty development needs, including teaching, research, and simulation pedagogy.
• Organizing workshops, seminars, and continuing education programs.
• Evaluating the effectiveness of faculty development initiatives through feedback and performance metrics.

4. Committee Structure

1. Membership:

• The FDC will consist of 3 nursing faculty members; one member must be part-time.
• Members will serve a two-year term, with staggered appointments to ensure continuity.
• This group may be increased to 5, and then 7, as the program size increases.

1. Leadership:

• A Chairperson will be elected from among the committee members annually.
• The Chairperson will liaise with the Simulation Director and oversee the committee's operations.

1. Meetings:

• The FDC will meet monthly, or as needed, to review progress, address challenges, and plan activities.
• Minutes will be documented and submitted to the Simulation Director.

5. Responsibilities

• Faculty Development Committee:
• Develop and execute faculty development programs.
• Evaluate the success of orientation, mentoring, and development initiatives and report findings to the Simulation Director.
• Ensure alignment of faculty programs with institutional standards, including NCSBN and CCNE guidelines.
• Simulation Director:
• Provide strategic direction and oversight to the FDC.
• Review and approve committee recommendations.
• Advocate for resources and institutional support for faculty development initiatives.

6. Reporting and Accountability

The FDC will provide:

• Quarterly Reports: Updates on orientation, mentoring, and development activities to the Simulation Director and the Quality and Curriculum Committee.
• Annual Review: A comprehensive review of faculty development initiatives, outcomes, and future plans, provided at the annual retreat.

COMMITTEE CHARTER

Community of Interest Board Charter

Background and Formation

The Saint Mary's College Nursing Program is newly established. To date, input from clinical partners, community stakeholders, and other members of the community of interest has been garnered primarily through one-on-one meetings for Needs Assessment data collection and review of program curriculum congruence. This advisory will evolve into an on-going collective advisory process during the biannual meetings occurring in December and June each year. This charter establishes the Community of Interest Board as a structured, collective forum, consolidating this feedback process going forward as the Program formalizes its external and internal community engagement structure.

I. Purpose

The Community of Interest Board works collaboratively with the nursing faculty to promote excellence in nursing education by providing practice-relevant insight that has the potential to shape the direction of the nursing program. The Community of Interest Board is composed of leading health care and academic leaders, community healthcare systems, and internal stakeholders. Through strategic guidance, this board aims to enhance curriculum development, technology utilization, shape clinical experiences, and educational outcomes. Early needs assessment results have already fostered innovation in nursing and health science education through the 5-day block rotation model.

II. Function

The SMC Nursing Program Community of Interest’s role is purely advisory. The group has no administrative, management, personnel, budgetary authority, or responsibility, and is not a policy-making body. Its sole function is to provide support and advice for nursing program curriculum design.

III. Defined

The community of interest is defined as an internal and external group with shared values and mutual investment in the improvement of nursing education and the health of the surrounding community. The internal community is composed of current students, faculty, donors, and the University at large. The external community includes nurses, nursing leaders, allied health, local care agencies, community health care agencies, funders, health care associations, designated community groups.

IV. Authority and Scope

The Community of Interest advisory provides information on the needs of clinical partners and the community in relation to students transitioning to the professional nursing workforce. This committee helps provide support and direction for nursing program curriculum transformation, with the goal of providing excellence in healthcare education, leading to a healthier community.

V. Reporting Structure

The Director of Nursing oversees the Community of Interest. Information gathered from these meetings is disseminated to the Leadership Committee and the Quality and Curriculum Committee.

VI. Priorities and Goals

• Identify the needs of our community and clinical partners.
• Identify innovative technology or opportunities for our program to streamline learning and care delivery.
• Identify additional educational opportunities we can provide, or participate in, within our community.
• Provide a forum for our clinical partners to engage with us and share different perspectives.
• Identify possible new partnerships or ventures.

VII. Identify Opportunities

• To promote and improve upon evidence-based practice.
• Determine the effectiveness of our curriculum as students and faculty complete clinical rotations.
• Gain anonymous feedback regarding new graduates hired by our partners.
• Evaluate prospective services to ensure there is a current need, goodness of fit, and quality is maintained.

VIII. Meeting Frequency

• Bi-annually
• Additional focused meetings may occur for targeted projects; these activities will be reported back to the larger committee as well as Leadership and Quality and Curriculum Committees.

IX. Membership 

Chair: Director of Nursing

Co-Chair: Clinical Coordinator

Nursing Faculty designee

IT department support designee

Health Science Faculty designee

Administrative Assistant designee

Student Representative designee

SVP of Academic Affairs and Provost (ad hoc)

Clinical Partner designee

Apple Representative

Other internal/external stakeholders

COMMITTEE CHARTER

Quality and Curriculum Committee

The Nursing Program Quality and Curriculum Committee is a standing committee of the Nursing Program.

1. Purpose

The purpose of this committee is to establish a group of faculty who oversee the quality and curriculum within the program and classes in a proactive manner. Data from testing, evaluations, and other metrics gathered will be used to make evidence-based decisions regarding adjusting the curriculum on an ongoing basis. This group, along with the content experts, is responsible for introducing new emerging technology or care practice changes that should be updated within the curriculum.

2. Responsibilities of the Committee

The responsibilities of the Nursing Program Quality and Curriculum Committee are to:

2.1 Monitor the Content of the Curriculum and Identify Opportunities for Improvement

• Review syllabi annually for recommended changes.
• Review end-of-course evaluations from both students and faculty.
• Review class and ATI testing results to determine areas where the curriculum should be enhanced for student learning.
• Audit the curriculum to ensure mapped concepts are being included (e.g., pain, communication, abuse).
• Review signature assignments and gather exemplars.

2.2 Ensure the Program Reflects Current Relevant Standards

1. AACN Essentials
2. NCLEX Test Plan 2023
3. Title 22
4. Title 16
5. Section 2725
6. Professional Practice Model
7. DEI-focused standards

2.3 Act on Recommendations to Establish, Terminate, or Change Curriculum Content

Documentation of curriculum evaluation and changes made:

1. All classes will be reviewed once a year to determine changes needed.
2. Student outcomes will be assessed as part of the decision-making process for recommendations and decisions.
3. Faculty teaching the classes will complete an evaluation of the class taught and make recommendations.

2.4 Monitor the Quality of the Curriculum Using Data to Make Decisions

1. Review NCLEX program reports.
2. Create a yearly summary and action plan.
3. Review ATI data to determine benchmark-worthy recommended changes.
4. Review data from graduate surveys.
5. Track RN licensing and employment rates within 6 months.

2.5 Oversee the Content Expert Meeting Process

Gather information regarding recommended changes and disseminate information regarding changes to all faculty:

1. Ensure one meeting a year occurs for each content expert group.
2. Report out to the Leadership Committee on recommended changes, challenges, and opportunities for improvement.
3. Ensure there is an updated content expert list annually:
4. Medical Surgical and Geriatrics
5. Mental Health
6. OB
7. Pediatrics

2.6 Support BRN Curriculum Change Submissions

Participate in completing the documentation needed, with the Director of Nursing, to submit requested curriculum changes to the Board of Registered Nursing, following applicable rules and regulations.

3. Committee Membership

1. The membership of this committee will include one Director and five (5) faculty members elected by their peers.
2. Terms will be for two (2) years.
3. Faculty may serve multiple terms with no term limits.
4. Monthly meetings will occur 10 months of the year.
5. July and August will not have scheduled meetings.
6. If there is an urgent need, a meeting can be added during these months.

Nursing Program Faculty Full-time and Part-Time 

The Nursing Program will use the workload sheet approved by the Academic Senate.

Nursing Faculty workloads fit into 3 faculty classifications: 

Distribution of responsibilities for a faculty member is dependent upon each person’s faculty classification, however, final responsibilities for each faculty member are determined in collaboration with the Director of Nursing.

• Both Fulltime and Part time positions follow the SMC faculty handbook with some minor alterations listed within this policy
• Tenured/Tenure-Track: 50% - 75% teaching, including mentoring/advising; 15-40% intellectual contributions; 5-10% service.
• Non-tenure Track: 75 - 100% teaching, including mentoring/advising plus required basic service obligations.
• Part time Faculty 100% teaching 

A full time, nine-month workload is defined as 24 workload units per academic year.

A full-time twelve-month workload is defined as 28 workload units per academic year.

Teaching methods can vary widely and may include co-teaching, traditional teaching, supervision of internships, supervision of practical, online and blended course delivery, and site-based courses. 

Workload Units

• A three-unit theory course is equivalent to three workload units. 
• A clinical course where the instructor is always present at the clinical site is worth one additional workload Unit for Full-time Faculty. Part-time staff are paid the listed unit amount
  • 303L
  • 304L
  • 310L
  • 311L
  • 320L
  • 402L
  • 403L
• Preceptorship classes or clinical classes where an instructor is not onsite the entire rotation will be paid at 0.33 per student.
  • 321L
  • 401L

Mentoring and Advising (a component of teaching) 

Description: Faculty members of the Nursing Program are expected to mentor and advise students in their respective fields. 

Undergraduate Advising and Mentoring: 

SMC assigns every student to a major advisor (faculty member) and a Success Coach (staff), who work together to support the student in complementary ways.  Nursing faculty collaborate with students and, when appropriate, refer students to appropriate support services to ensure that students receive timely resources to facilitate success during the nursing program.  

Intellectual Contributions Description: 

SMC Nursing Program has adopted AACN recommendations in “Defining Scholarship for Academic Nursing-Task Force Consensus Position Statement, 2018” as the foundation for identifying intellectual contributions.

Purpose 

“As a practice discipline, nursing scholarship informs science, enhances clinical practice, influences policy, and impacts best practices for educating nurses as clinicians, scholars, and leaders. Addressing the complexities of contemporary practice, education, and research is typically interprofessional, involving scholars from many disciplines with a variety of terminal degrees (e.g., MD, PharmD, and DPT). The complexity of health services requires that nurse scholars engage in a high level of teamwork that is multidisciplinary (knowledge stays within disciplinary boundaries), interdisciplinary (harmonization and synthesis between disciplines in a coordinated and coherent whole), and transdisciplinary (integrating sciences that transcend disciplinary boundaries; Choi & Pak, 2006). 

The preferred state is to create a system of recognition for nursing faculty who are scholars in research, practice, policy, and/or education. The system should value all scholarly contributions. To that end, the purpose of this position statement is to: 

1) create a definition of scholarship that is inclusive and supports multiple ways of knowing. 

2) address the scholarship of discovery or scientific inquiry, the scholarship of practice, and the scholarship of teaching; and 

3) describe the integration of scholarship across institutional missions and how scholarship is promoted alignment with AACN, SMC Nursing Pragram has adopted AACN definition:” AACN, 2018

SMC Nursing Program has also adopted the four standards: scholarship of discovery or scientific inquiry, scholarship of practice, scholarship of teaching, and advancing the scholarship of discovery.

Every year, all full-time faculty members will determine with the director of nursing what his/her individual Intellectual Contributions will be for the purpose of meeting his/her intellectual scholarship activities. Documentation of scholarship and research must be provided. These individual Intellectual Contribution expectations will be included in the faculty member’s workload document. 

• Service Description: Service encompasses a faculty member’s contributions to the nursing program, college, and/or university activities and/or to a faculty member’s academic and professional community beyond SMC. Required basic service obligations include participating in program, school, and college-wide functions, faculty committees, advising and mentoring, and academic ceremonies and/or events. 
  • Examples of service activities which count toward the service expectations include, but are not limited to, serving on School or University committees, service to the individual faculty member’s professional community, Faculty Senate, Faculty sponsorship of university programs or committees, student recruiting and participation in community organizations as a representative of the School or University. These individual Service expectations will be included in the faculty member’s workload document.
• Administration Description: Examples of administrative responsibilities include but are not limited to program director; program assistant director; and simulation director. 
• Workload reductions appropriate for each of these positions shall be negotiated with the director. The reductions will be included in the faculty members’ workload document.

Policy Implementation Faculty Workload Document

As part of annual strategic planning efforts, the Director of Nursing, in consultation with faculty, is charged with determining and explicating the specific, collective expectations for the faculty’s teaching, research, service, or other activities in the Program for the coming year. Typically, these expectations are established as multi-year expectations with little variation on a year-to-year basis. From those expectations, the Program Director will develop, in consultation with each individual faculty member, a written workload plan for each year. The workload plan is documentation of a faculty member’s complete responsibilities for an academic year that includes a distribution of duties relating to teaching (including mentoring/advising), intellectual contribution, service, and administration, Reference.

American Association of College of Nursing “Defining Scholarship for Academic Nursing Task Force Consensus Position Statement March 26, 2018” Retrieved from Defining Scholarship for Academic Nursing Task Force Consensus Position Statement (aacnnursing.org)

Student Orientation Simulation

Purpose

To ensure that students are provided with information regarding the purpose of simulation and are prepared to participate in the activities in a safe and professional manner.

Policy

1. At the beginning of each new cohort Team Steps training will be provided and incorporated into simulation/skills/ theory activities during the first semester to assist with students’ performance in communication
2. At the beginning of each new cohort students will receive a general orientation that includes
   1. Tour of physical space
   2. Hours spaces are available for utilization
   3. Contact information for the director of simulation
   4. Use of space and equipment
   5. Review of all pertinent policies and procedures related to clinical and simulation
   6. Sign the Simulation confidentiality agreement 
3. Prior to each simulation event, staff/faculty will provide students with a pre-brief which will include
   1. General objectives
      1. To provide a safe place to practice assessments, skills, communication while demonstrating professional role behaviors appropriate to their level of training
      2. To provide an opportunity for student growth through discussions and reflections during the pre-brief, simulation and formal debriefing.
   2. Staff/faculty will review the agreement of confidentiality, and this is to be a physical and psychological safe space
   3. Staff/faculty will review the professional role and expectations of behaviors throughout the experience
4. Prior to each simulation scenario an orientation will occur to the learning environment, manikin, capability and purpose of the equipment being used in the simulation room. Below is a basic guidelines and other items may also need to have orientation.
   1. Bed Operation
   2. Bedside cart & supplies
   3. Working Headwall
   4. Equipment & Monitors
   5. Task Trainers 
   6. Observers behind the one-way mirror
   7. Location of orders/Mar
   8. Medication dispensing Machine
5. The following resources will be included in simulation, debriefing and Skills sessions
   1. Resource book in the room
   2. TeamSTEPPS tools
   3. Patient Report and Patient Orders
   4. Student roles and responsibilities (review prior to event starting)
   5. Review time out process and time that will be allotted for group huddle as needed

POLICY & PROCEDURE

Faculty Clinical Instructor Orientation Policy for Simulation-Clinical Rotations

1. Purpose

This policy is to ensure that Nursing Program faculty who are providing simulation educational content to nursing students have appropriate expertise relevant to simulation pedagogy.

2. Policy

1. Faculty must be Board of Registered Nursing (BRN) approved for the content area to provide support in managing simulation activities.
2. Faculty must have completed competency validation with the Director of Simulation or designee, confirming they are competent to provide care to a specific population.
3. Faculty must have completed the orientation on Role Competency.
4. Any BRN-approved faculty may provide support for a fundamentals simulation activity if a Medical-Surgical BRN-approved faculty member is also in attendance, for any specific questions or support needed for medical-surgical content beyond the typical scope of a fundamentals class.
5. Faculty must have completed their TeamSTEPPS training.
6. All clinical and simulation faculty must have reviewed the simulation training manual and completed the required facilitator training.
7. Training requirements are developed by the Simulation Department and approved by the Simulation Committee and the Quality and Curriculum Committee.
8. Simulation Department staff, or approved faculty who have validated competency, will provide these training classes.
9. Clinical/simulation instructors are required to review the simulation template and teaching materials provided to students prior to the simulation day.
10. Clinical/simulation instructors will complete a competency check, during which they are assessed while teaching or debriefing during simulation, a minimum of three (3) times.
11. Clinical/simulation instructors will be trained in the utilization of space, and the cleaning and care of equipment.
12. Clinical/simulation instructors will be evaluated by lead faculty and students every semester.

Scheduling a Simulation Policy

Purpose

This policy is designed to provide instructions on how to plan and schedule a simulation or skills activity either on SMC Campus or off site at another partner site.

Policy

Every simulation event is planned with the director of simulation and staff within this department. Each clinical course has a simulation schedule which provides the simulation and skills activities that are planned for the semester

• Core Classes planned simulations already have completed all forms necessary for the planned events
• Content experts review and approve these scenarios once a year for modifications needed 
  • Simulation scenarios
  • Simulation Scripts
  • Simulation student materials
  • Debriefing Guidelines

All simulation events are completed using the Simulation Planning Form, Simulation Template and Simulation debriefing log

1. The simulation planning event scheduling forms are completed 8 weeks prior to the semester starting
   1. This form is used for scheduling when these will occur and location (on site or off site)
   2. Offsite locations need to be coordinated 8 weeks in advance to ensure dates and times are available

(SMC Physical) Self Health Assessment Form and Physical Form 

Student Name__________________                        Email: __________________

Contact Numbers: (home)         ________________(cell)         _____________________

BLS Expiration Date________________________

Check the boxes below as the information applies to your health. Have you ever had problems, past or present, related to the following medical conditions? If so, state the year.

Please list below all operations (surgeries) performed on you. State the year.

         Year

         Year

         Year

Are you under a health provider’s care at this time for any ongoing health conditions?

Yes         No         

(If yes, please explain.)

Are you taking any drugs or medicines now? Yes         No         (If yes, please list all drugs or medicines)

Please describe your present state of health:  Excellent         Good _         Fair         Poor          

If less than good, please explain:

Declaration: I have clearly understood the above questions, and the answers given by me are true and correct to the best of my knowledge and belief. I consent to a complete medical examination by a healthcare provider; this examination will include and may not be limited to laboratory and x-ray testing.

I authorize the Nursing Program at St. Mary’s College to share information regarding my health data (including but not limited to immunization status, immunity titers, and/or testing for x-rays for tuberculosis) that is requested by clinical agencies in which I am a student nurse.

Student         __________________         Date_         

Signature

Student        _________________________ (print)

               First        Middle                   Last
 

Appendix P

Physical Examination Form

To be completed by Health Care Provider

Medical History:

Systems Review (within normal limits (wnl) /abnormal (abn)

Clinical Findings

Medications and/or Treatments

In my opinion this applicant does not have any health conditions that would create a risk to him/her, patients, or fellow students or employees. Therefore, this student is clear for clinical without any limitations

Provider Signature:                                         Date                                          

Provider Printed Name:                                 Title                                          

Address:                                                 Phone (        )                          

PLEASE PROVIDE OFFICIAL AGENCY AND/OR HEALTH CARE PROVIDER SIGNATURE STAMP.

Saint Mary’s College of California

BSN-HS-01 Health and Safety Requirements-Policy

All students and clinical faculty must meet the following health and safety requirements prior to admission and before the first day of clinical rotations. Requirements must remain current throughout enrollment. Documentation is submitted and tracked through the program’s designated compliance platform.

1. Immunization and Titer Requirements

Titers are blood tests that confirm active immunity. All students must submit titer results for Hepatitis B, MMR, and Varicella — vaccination records alone are not sufficient for these three. Titer results must be IgG (not IgM) and must include the laboratory reference range alongside the student’s result. Students/Faculty name must be present on the lab document

2. Tuberculosis (TB) Screening

Initial Baseline Screening (new students): Choose one of the following:

• Two-Step TST (Mantoux skin test): Two skin tests placed at least 1 week and no more than 3 weeks apart. Results must be read by a licensed provider 48–72 hours after each placement (four total office visits).
• QuantiFERON-TB Gold Plus (QFT) blood test: A single blood draw; acceptable for all students and faculty. Results must be within the last 12 months.

Note: If a TB skin test has been administered within the last 12 months, one additional step test within 12 months of that result may satisfy the two-step requirement depending on the clinical site.

Annual Requirement: One-step TST or single QuantiFERON-TB Gold blood test. Results may not expire at any time during clinical rotations.

Re-screening: TB screening must be repeated if a student has had a known TB exposure since their last documented results.

Clinical Site Requirements – 3-Month Window: Some clinical sites require proof of a negative TB result within a 3-month window prior to the start of a rotation. Students and faculty should be aware that their annual TB result may not satisfy this shorter window, and a repeat screening may be required to meet individual site compliance standards. Students and faculty are responsible for verifying site-specific TB requirements in advance of their rotation start date.

Positive TB History: If a student has a documented history of a positive TB test, the following must be provided:

• Chest X-ray (within the last 5 years) with written radiology report
• Completed Healthcare Personnel (HCP) Annual TB Symptom Screening Form, renewed each year, provided by SMC

SMC requirement: Chest X-ray must be within the last 5 years. This requirement is unchanged from current program policy. 

3. Basic Life Support (BLS) Certification

• Required certification: American Heart Association (AHA) BLS for Healthcare Providers only.
• Online-only certifications are not accepted. Hands-on skills component required.
• Renewal: every 2 years based on card expiration date.

4. Physical Examination

• Required upon program entry; valid for 1 year initially. If enrolled in a multi-year program, renewal is required every 2 years.
• Preferred form: Students must use the Saint Mary’s College of California Nursing Program Physical Exam Form. Non-SMC provider forms will be accepted only if the provider insists on using their own documentation; however, the provider’s form must contain all information required by the SMC Nursing Program. Incomplete non-SMC forms will not be accepted.
• Must include a signed clinical clearance by a licensed healthcare provider.
• N95 respirator fit testing if required by clinical site and physical clearance form required prior to first clinical rotation.
• For Faculty, a letter from your primary physician/provider that states you are in good health or a physical exam document dated within 6 months to a year demonstrating good health.

Important: Students are required to complete the following sections of the SMC Physical Exam Form before the provider appointment:

• Self-Questionnaire: Must be completed in full by the student prior to the provider visit.
• Latex Allergy Questionnaire: Must be completed in full by the student prior to the provider visit.

The licensed healthcare provider must review and sign the form where indicated. Forms returned without a provider signature will not be accepted.

***If it is identified you have a latex allergy, it is recommended for your safety to wear a medical identifier such as a bracelet indicating you have a latex reaction/allergy.

5. Background Check and Drug Screening

• Required of all students and clinical faculty upon admission and prior to the first day of class.
• Must be completed through the program-designated agency only. Results from other vendors will not be accepted.
• Drug screening: Negative urine drug screen required. If prescribed medication may affect results, notify the Director of Nursing or CNA Director prior to testing. Refer to the Background Policy for details.

6. Health Insurance

• Proof of current health insurance coverage required prior to clinical placement. Students without coverage should contact the Student Health Center for options.

.

POLICY & PROCEDURE

Latex Safe Environment Policy

1. Purpose

The Saint Mary's College (SMC) Nursing Program ensures a safe learning and working environment for faculty, staff, and students. The Nursing Program's goal is to protect staff and students from unnecessary exposure to latex, and to control, within limits, exposure to latex and latex-based products.

2. Policy

To assure a “latex safe environment,” the SMC Nursing Program limits the use and direct exposure of latex-based products. In accordance with this policy, latex balloons and latex-based powdered gloves are not allowed in any lab, class, or skills area. All gloves utilized are latex-free.

3. Student Latex Allergy Screening and Reporting

If a student reports having a latex allergy, the student will be required to complete the latex screening tool with their medical provider. This tool provides assessment documentation and formal diagnosis, along with medications being utilized for treatment.

It is the personal responsibility of individuals with latex allergies to inform their Dean and Director, so additional precautions can be taken as needed.

4. Latex-Containing Products and Protective Measures

Products produced with latex will be limited. If a product used does not have a latex alternative, the student should wear protective barriers to reduce exposure.

Items within the lab that may contain latex include, but are not limited to:

• Personal Protective Equipment (PPE)
• Tourniquets
• Band-Aids
• Stethoscopes
• Wound drains
• Blood pressure cuffs

5. Simulation Environment

Within the simulation room, human simulators may contain latex parts; students should wear gloves for all contact with the simulators.

6. Emergency Preparedness

Individuals allergic to latex should wear a medical-alert bracelet and carry any medications prescribed for treatment at all times. These medications should be available in both clinical and simulation settings. Any student with a latex allergy requiring possible epinephrine must always wear a medical-alert bracelet at clinical sites. If a student's allergy requires the use of an epinephrine pen, it is also imperative that the instructor in simulation/skills know where the epinephrine pen is located for potential emergencies.

POLICY & PROCEDURE

Reasonable Suspicion Testing Policy

1. Purpose

The Nursing Program at Saint Mary's College requires that all potential nursing students applying to any of its nursing programs submit to a drug screen, as outlined in this policy, and test negative before participating in any clinical activity associated with the Nursing Program at SMC. This testing is required by clinical partners as well as state regulations. Clinical sites have the right to decline any student for clinical placement based on concerns about that student's ability to deliver safe practice.

Practicing safe delivery of care across all patient/client populations is the reason for drug testing.

2. Policy Statement

The Saint Mary's College (SMC) Student Handbook contains specific policies addressing the use of alcohol, drugs, and cannabis; please review the College's policy on Alcohol, Drugs, and Cannabis. It is the policy of SMC's Nursing Program to fully comply with federal and state laws and regulations regarding the usage and detection of drugs. This policy is subject to change at the sole discretion of the College and the Nursing Program, and is meant to supplement the alcohol, drug, and cannabis policies located in the SMC Student Handbook.

3. Applicability

This policy is in force whenever nursing students are engaged in any nursing academic setting, including classes, simulation, skills, and clinical activity at hospitals, clinics, nursing homes, or other facilities on behalf of the College.

4. Required Testing Circumstances

All nursing students will be required to submit to alcohol/drug screens and are expected to test negative for drugs at certain times in their nursing education. When testing is ordered, it will be completed within 120 minutes:

• As requested by the Nursing Program for reasonable suspicion of use or being under the influence;
• As requested by a clinical site; or
• After a major clinical event.

Unannounced drug testing may occur based on reasonable suspicion.

5. Reasonable Suspicion Testing Procedure

1. When a student is suspected of being under the influence based on behavior or strong odor, the student will be informed that they need to be tested immediately.
2. If a clinical partner requests testing due to their own suspicion, the results are reportable to the clinical site.
3. The student will be escorted to the testing location and will not be allowed to drive.
4. The Program Director of Nursing and Assistant Program Directors will be notified.
5. The student will provide consent for the test.
6. If the student does not consent, the student will be excused from clinical/class and must have arrangements for getting home that do not include driving.
7. Faculty will document the event and submit it to the Professional Practice Committee (PPC).
8. The student will be informed that this may lead to expulsion from the Nursing Program.
9. Positive results for illegal substances must be reported to the Board of Registered Nursing (BRN).

6. Alcohol and Cannabis Use Restriction

Students should not consume any alcohol or cannabis within 12 hours of simulation or clinical activities.

7. Prescription Medications

1. Students must notify the Director of Nursing and the Clinical Coordinator of any prescribed medications considered “mind-altering” or that interfere with operating a motor vehicle or similar activities.
2. Students must provide a note from the prescribing physician.

While a student may be taking medications for a variety of medical conditions, the consumption of these medications may not jeopardize patient safety.

• If a student is tested for suspicion of being under the influence and only a prescribed medication result is returned, this will be referred to the PPC for a decision on next steps.

8. Consent and Reporting

By participating in the drug screening process, the student authorizes release of the drug test results in accordance with this policy. In addition, a Reasonable Suspicion Determination Report will be completed by the individual who observed the suspicious behavior.

POLICY & PROCEDURE

Background Check Policy

1. Purpose

The purpose of this policy is to describe the background check requirements for all Nursing Programs at Saint Mary's College (SMC).

2. Background Check Requirements

Background checks are required for all SMC Nursing students. BSN students must have a completed background check prior to beginning their first nursing class, and annually thereafter. It is the student's responsibility to ensure their background check is completed and maintained throughout the program. The fee for the background check is paid by the student.

3. Designated Agency

The Nursing Program will provide designated agency information for completing background checks. The Nursing Program will not accept background checks from any other agency.

4. Non-Compliance

A student who does not complete their background check as indicated in this policy, or by the date specified by the Nursing Program, may be dismissed from the program and may not be allowed to proceed with clinical studies.

5. Review of Results and Clinical Eligibility

Results of background checks are made available for the Nursing Program to review. If a student is not cleared, the record will be reviewed by the Director of Nursing (ND) or designee.

If a student's background check is not cleared, the student may still enroll in theory classes; however, clinical agencies retain the right to refuse to allow the student to complete clinical rotations at their institution. Failure to comply with this policy will jeopardize the student's status in the program.

Student Faculty Injury Policy (Clinical)

If a student is injured while performing clinical duties, the student must report injuries immediately to the Clinical Instructor, to the emergency Clinic at the clinical facility or call 911.  Please check with the Clinical Instructor and the facility regarding specific student 

Injury Reporting Instructions 

In the event of a serious injury or illness requiring emergency medical attention and on Campus, 911 should be called immediately (x4282 from internal phone, 911 from cell phone). In addition, Campus Safety and Human Resources should be notified. 

Non-Emergency Procedures 

To report a work-related injury: 

• Notify your manager and contact Human Resources, x4457. 
• Complete mandatory California State form, DWC-1. Return DWC-1 form to Human Resources within 24 hours of injury or illness. 
• This form will provide the information needed to submit a claim to the worker’s compensation administrator
• SMC worker Comp Policy # is SATIS057790. The policy is handled by Service Insurance and California Injury claims are handled by LWP Claims Solutions.
• HR will submit a Report of Claim to LWP Claims and give you a claim number to use when you visit a clinic for treatment. 
• SMC’s Medical Provider Network (MPN) preferred provider is: 

Kaiser On-The-Job Occupational Health Center (Oakland)

3701 Broadway Ste 501 

Oakland, CA 94611 

(510) 752-1244 

Kaiser On-The-Job Occupational Health Center (Walnut Creek)

320 Lennon Ln, Bldg. 3

Walnut Creek, CA 94598

(925) 906.2060

Kaiser On-The-Job Occupational Health Center (Santa Clara)

10050 N Wolf Rd, Sw1

Cupertino, CA 95014

(408)236.6160

Kaiser On-The-Job Occupational Health Center (Redwood City)

1400 Veterans Blvd 1^st Floor

Redwood City, CA  

(650)299.4785

• Refer to form Notice to Employees – Injuries Caused by Work for information about worker’s compensation rights and benefits. This is for information only. 

Safety: Blood Borne Pathogen Exposure

1. Provide First AID 
2. Notify Charge nurse on Unit. 
3. Immediately contact Dean and appropriate director of the program (chair of NP program, GBSN assistant director, MSN coordinator) 

EVALUATION: 

1. Extent of exposure          
   1. Intact skin 
   2. Mucous membranes 
   3. Puncture with sharp object.  
2. Examine the wound. 
3. Determine if more First Aid or more extensive treatment is needed. 
4. Find out the results of current labs: Hep B, Hep C, HIV and dates of labs. 
5. Find the results of the source patient labs (just drawn if returned, the only lab results you will get immediately is the rapid HIV) 
6. Determine the risk of transmission. 
7. Determine if post-exposure prophylaxis (PEP) is indicated. 

TREATMENT      

1. First Aid as needed. 
2. Discuss the risks of transmission. 
3. Initiate PEP, if indicated. 
4. Discuss the follow-up necessary, if indicated.  
5. Determine student risk. 
   1. HEP B Series status 
6. Source patient labs need to be drawn ASAP. Hepatitis B, Hep C and Rapid HIV 
7. Hep B treatment if no immunity: 
   1. INITIAL VISIT* 
   2. HBIg dose 
   3. HB Vaccine dose #1 
8. HIV:  IF unable to obtain HIV status or patient is known HIV positive status, drugs for prevention need to be started within 3 hours. 
   1. If PEP INDICATED- no HIV status attainable, or HIV positive. 
   2. INITIAL VISIT: 
      1. MD and student determine if PEP will be started. 
      2. Baseline labs 
      3. Begin PEP starter kit if have not already. 
      4. Discuss PEP regimen.
      5. Prescribe the remaining PEP regimen. 
9. Hep C treatment: there is no prophylaxis for Hepatitis C exposure! 
   1. INITIAL VISIT: 
      1. Baseline lab 
      2. If source patient HCV RNA Quant is not detected, there is no need for continued surveillance.
      3. Will follow the student at intervals up to six months if source patient is positive for Hep C.  
10. Complete Nursing Program incident report (below) 
11. Students must complete Workers Comp forms through HR within 24 hours of incident 8.         Send student to ______________________ or Kaiser Oakland ER for treatment. 

RISK OF TRANSMISSION: 

1. Hepatitis B 
   1. 0% if immune 
2. Hepatitis C 
   1. 1-7% with an average of 1.8% via percutaneous injury (mostly HB needles) 
   2. <1% transmission from mucous membrane exposures 
3. HIV 
   1. 0.3% via percutaneous injury 
   2. 0.09% via mucous membrane exposure 
   3. <0.09% with non-intact skin exposure References 

Resources: 

• PEP Hotline: 1-888-448-4911 
• Hepatitis Info www.cdc.gov/hepatitis&nbsp;
• HIV Risk Assessment Stratification Protocol http://emupdates.com/wpcontent/uploads/2009/11/pg461.pdf&nbsp;
• HIV and pregnancy http://www.apregistry.com/Patients.aspx&nbsp;
• Drug Reactions http://www.hiv-druginteractions.org.&nbsp;

  Nursing Program Incident Report  Part 1: Instructor Statement 

Nursing Program Incident Report- Student Statement Part 2 

Instructor’s Responsibility:

1. For SERIOUS injuries/incidents in the classroom, skills lab, or clinical setting:
   • Send the student to the hospital ER or CALL 911.
   • Notify campus services if the injury/incident occurs in a clinical or healthcare agency and the student is treated in the Hospital ER (see #3).
2. For MINOR injuries/incidents in the classroom, skills lab, or clinical setting:
   • Offer the student treatment and, if desired, refer them to the Kaiser on the Job Occupational Health Center at one of the locations.
   • If on campus, send minor injuries to the student health center if during normal business hours.
3. For ALL injuries/incidents:
   • Immediately notify the Director of Nursing: 408-409-0215 and/or Director of Simulation: 510-703-3858. Leave a message if after hours and if both numbers go to voicemail.
   • If a student received medical treatment for any injury or incident that occurred in a classroom, skills lab, or clinical setting, the student is required to go to the Saint Mary’s Human Resources Office to complete a required Workers’ Compensation claim form. These forms MUST be completed and submitted to the Human Resources Office within 24 hours of the incident or on the College’s next regularly scheduled workday.
   • Complete Part 1, Instructor Statement, of the incident report. Give Part 2, Student Statement, to the student to complete and return to you, even if treatment is declined.
   • Submit Parts 1 and 2 to the Saint Mary’s College Simulation Center (Fax: number TBA). The office will also notify Human Resources.
4. Students may read their Workers Compensation Rights:
    Workers Compensation Rights