New York state climbs the steep face of its COVID-19 curve, Gov.
Andrew Cuomo (D) issued
an executive order vastly
widening the scope of practice for some healthcare providers and
absolving physicians of certain risks and responsibilities.
the order’s provisions:
Eliminating physician supervision of physician assistants (PAs), nurse practitioners (NPs), certified registered nurse anesthetists, and others
Enabling foreign medical graduates with at least a year of graduate medical education to care for patients
Allowing emergency medical services personnel to operate under the orders of NPs, PAs, and paramedics
Allowing medical students to practice without a clinical affiliation agreement, and lifting 80-hour weekly work limits for residents
Granting providers immunity from civil liability for injury or death
Suspending usual record-keeping requirements
Allowing several types of healthcare professionals — including NPs, PAs, nurses, respiratory therapists, and radiology techs — with licenses in other states to practice in New York. However, physicians were not specifically included in the order, as the Department of Health and Human Services has not yet issued the necessary regulation
Suspending or revoking hospitals’ operating certificates if they don’t halt elective surgeries
order, which remains in place through at least April 22, was met
mostly with applause, though with some hesitation around work-hour
Michael Gibson, MD, of Harvard, called it “stunning in both the
breadth and depth of recommendations” on
Shamim, MD, described it as a “great move,” with the
exception that trainee work hour limits shouldn’t be scrapped: “They
are already working equivalent to 2 [full-time employees] without
Chinese-style PPE. More hours = more risk of exposure,” he
Gianelli, president of Mount Sinai Morningside hospital in New York
City, told MedPage
his team is “grateful to the governor for throwing the
regulations out the window right now. He’s encouraging us and
enabling us to do what we have to do to get through this. It’s the
right thing to do.”
Puskas, MD, chair of cardiovascular surgery at Mount Sinai
Morningside, agreed that the steps are the right ones given that New
York City “hasn’t flattened the curve adequately to avoid a big
wave crashing. We’re really going to feel it in the next 2 or 3
simultaneously with that, we lost a meaningful number of healthcare
providers to home quarantine, then we’d have a shortage not just of
ventilators, but of people to run them and care for patients,”
by Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today
After years of opposition from the Florida Medical Association and seven years of passing in the state House but not in the Senate, the bill to allow Floridian Nurse Practitioners full practice authority has finally been passed. Starting in July 2020, advanced NPs who have accumulated at least 3,000 hours of experience under physician supervision will have the right to independently operate primary care practices in Florida without an attending doctor. To qualify, they will also have to complete minimum graduate level course work in differential diagnosis and pharmacology.
Under the new law, signed on March 11 by Florida Governor Ron
DeSantis, qualified NPs will be able to independently practice family medicine,
general pediatrics and general internal medicine. House Speaker Jose Oliva, who
made the bill a priority, praised the bill’s passage, saying, “Freeing
(advanced practice registered nurses) of the red tape that has historically
stopped them from working to the full extent of their education and training
will immediately improve access to quality care for all.”
In a compromise between the Florida House and Senate, while the bill grants full practice authority to advanced NPs, it does not cover physician assistants or certified registered nurse anesthetists. Calling the bill “a good first step,” the Florida Association of Nurse Anesthetists commented, “Although we are disappointed that the legislation did not include certified registered nurse anesthetists … we are pleased that some of Florida’s (advanced practice nurses) will be able to practice autonomously.” The group added, “Passage of this bill demonstrates Florida’s commitment to modernizing the way health care is being delivered in our state by ensuring that Floridians have full access to health care, particularly in rural areas that are often underserved.”
Florida Republican Representative Cary Pigman, a physician who has filed the bill multiple times in the state House, noted, “Beyond the classroom, the data from statewide experiments across the nation demonstrate without a doubt that nurse practitioners are highly skilled, highly trained, and highly eager to care for patients independently.” Pigman added, “Advance practice professionals achieve higher marks in patient outcomes, patient satisfaction, and they spend more time actually talking to patients.” For more details, visit here.
The Nurse Practitioner Association New York State (NPA), the only statewide professional association of nurse practitioners, has named Janice Ceccucci, DNP, FNP-BC, Nurse Practitioner of the Year, and Daniel Babcock, MS, FNP-C, NP Student of the Year. The awards were presented at The NPA 35th Annual Conference, held in Verona, NY, and were attended by nearly 500 NPs and NP students from across the state.
Stephen Ferrara, DNP, FNP, FAANP, Associate Dean of Clinical Affairs at Columbia University School of Nursing and Executive Director of the Nurse Practitioner Association New York State, said, “As health care professionals committed to excellence in patient care, nurse practitioners are redefining their role. We’re extremely pleased to recognize Janice Ceccucci and Dan Babcock for their dedication and service.”
Forensic NP and Professor at SUNY Polytechnic Institute Is NP of the Year
Janice Ceccucci is an outstanding Nurse Practitioner and SANE (Sexual Assault Nurse Examiner). Ceccucci began her career working with sexual assault victims in the Emergency Department. Recognizing that there were gaps in services, particularly for child sex abuse victims, she decided to pursue forensic nursing. She is committed to ensuring services for child sex abuse and physical abuse patients are widely available.
“Janice takes nursing to the next level,” says colleague (and nominator) Elizabeth Spooner Dunn. “Her passion for the profession, dedication to her patients and commitment to excellence make her not just a trusted colleague but an example and mentor to all.”
has also received the Joan Unger Memorial Award given by the New
York State Coalition Against Sexual Assault for demonstrating excellence and
innovation in services offered to the community in sexual assault. She has also
been published by the Journal of Forensic Nursing and
is co-founder of Forensic Nurse Practitioners of Schenectady.
On Call, Inside and Out of the Hospital
Outside the confines of Saratoga Hospital, Ceccucci is on call at home 36 hours a month to provide teleconsulting services to hospitals in remote areas that lack access to sexual assault nurse examiners (SANEs). In addition, she conducts sexual assault exams for pediatric patients at child advocacy centers—a service that Ceccucci and a colleague introduced in 2011 to better serve sexually abused children.
A leader in promoting the profession to the next generation, Ceccucci is an assistant professor at SUNY Polytechnic Institute. She is also the co-director and developer of Saratoga Hospital’s Advanced Practice Provider Fellowship Program, which mentors new nurse practitioners and physician assistants, also known as advanced practice providers. And, in case that was not enough to take on, Ceccucci is an assistant professor of nursing for SUNY Polytechnic in Utica and helped pilot a hybrid program that delivers live streaming and on-campus classes.
“I wouldn’t want to do anything else.”
Ceccucci received her master’s degree as a Family Nurse Practitioner from SUNY Poly in 2009, and was awarded her doctorate in Nursing Practice from State University of New York Upstate Medical University in Syracuse in 2016.
“I’m proud to be the recipient of the NP of the Year. There are so many wonderful opportunities in nursing. For newer NPs, I would advise they take advantage of every opportunity that presents itself. I love being an NP. I wouldn’t want to do anything else,” Ceccucci said.
For further information on Janice Ceccucci, visit here.
NP Student of the Year Dan Babcock
Dan Babcock is an Air Force veteran and a former professional fire officer and paramedic who is currently a full-time Graduate Family Nurse Practitioner Student in the Decker School of Nursing at Binghamton University. He holds a BS in Nursing from Empire State College and as a Registered Nurse has worked in the emergency department and diagnostic imaging. After retiring as a lieutenant from the City of Binghamton’s Fire Department with 20 years of service, he decided to become a nurse practitioner. As Babcock grew up in rural Delaware County, New York, he has a particular interest in improving the health of the poor, rural and vulnerable populations that influenced his early life.
an honor to be awarded NP Student of the Year. I chose to become a nurse
practitioner because I love being challenged and love the relationships I form
with my patients. Aside from the need for primary care providers, I chose
family practice to give me a solid foundation for medical mission work. My wife
and I do mission work in Guatemala several times a year, and I would like to do
medical missions as a nurse practitioner,” Babcock said.
Nurse Practitioner Association New York State
Nurse Practitioners (NPs) are registered nurses who have completed advanced education, at a Master‘s or Doctorate level, plus additional clinical preparation. These professionals are authorized to independently diagnose illness and physical conditions, perform therapeutic and corrective measures, order tests, prescribe medications, devices and immunizing agents, and refer patients to other health care providers.
The Nurse Practitioner Association New York State (The NPA), the only statewide professional association of nurse practitioners, promotes high standards of healthcare delivery through the empowerment of nurse practitioners and the profession throughout New York State. For more information, visit: www.TheNPA.org.
When people experience sexual assault,
they may sustain more than just physical injuries; trauma also affects short-
and long-term mental health. The medical treatment needed may require a
provider to examine parts of the body that were recently violated, which can
cause more distress. When reporting an assault, survivors often lack the
information they need about how to proceed.
Sexual assault nurse examiners
(SANEs) are trained to help survivors across this spectrum of patient care.
From providing evidence-based treatment to performing assessments to collect
forensic evidence that can be used in a criminal trial, these nurses play a
critical role in supporting survivors at the beginning of their recovery
What Is the Role of a Sexual Assault Nurse Examiner?
When a sexual assault survivor comes to a SANE-certified hospital or community health center, a sexual assault nurse examiner is the first point of care, according to Kim Day, forensic nursing director for the International Association of Forensic Nurses (IAFN). SANEs ask the patient if they would like a forensic exam, which can be completed even if the patient decides to not report their assault to law enforcement.
“Just going through the process with
someone and providing holistic patient-centered care for that patient during a
traumatic time in their life can really impact the way they leave the
hospital,” Day said.
Forensic exams are meant to document
trauma from the assault and collect evidence that could be used in a criminal
trial. This includes taking a medical history; documenting scratches, bruises,
abrasions, and other injuries on a body map diagram; taking photos of injuries;
collecting DNA swabs to be processed; and observing the patient’s behavior. In
cases where toxicology information is relevant, SANEs will also perform those
tests on a patient.
In addition to performing a forensic
exam, the main duty of a SANE is to provide holistic nursing care for the
patient. Survivors of assault may need access to testing for pregnancy, as well
as prophylactic antibiotics to prevent the contraction of diseases. Depending
on the patient’s needs, SANEs also provide referrals to see other specialists,
such as a licensed professional counselor, who can help them in their recovery
The SANE in Court: It’s Not Like “Law and Order”
Beyond working in the clinical
setting, SANEs are qualified to testify in court if a patient’s case goes to
trial. The specialized training SANEs receive prepares them to effectively
answer questions regarding evidence discovered during a forensic exam. However,
while SANEs can play a critical role in the trial process, the legal aspect of
the job is not the main focus, Day said.
“If the nurse goes into this work
thinking that they’re going to get the bad guy and put him behind bars, they
will fail at this… because that is not what we do,” she said. “The work we do
is nursing. We take care of the patients.”
This is a key factor to consider when choosing to become a SANE. Nearly 80 percent of sexual assaults are not reported to law enforcement, according to a Justice Department analysis of violent crime in 2016 (PDF, 669 KB). While performing a forensic exam and being prepared to provide evidence in court is a requirement of the job, the emotional and medical needs of a patient come first.
SANEs are trained to work within a multidisciplinary team, also known as a Sexual Assault Response Team (SART), which includes survivor advocates, members of law enforcement, and mental health providers. Together, these professionals coordinate the response to survivors of sexual assault.
What Is a Sexual Assault Response Team?
SANEs and other trained health care
providers: When an individual decides they
would like to have a sexual assault forensic exam (SAFE), health care providers
like Nurse Practitioners (NPs) or SANEs address the initial physical and
psychological needs the patient might have as a result of their assault.
Survivor advocates: Individuals who need access to information and emotional
support can work with an advocate to navigate their path to recovery. A
survivor may reach out to an advocate via a crisis center, or one may be
brought in to support someone who has decided to seek treatment at a hospital
or report their assault to the police.
Law enforcement: In cases where an individual decides to report their
assault, police officers and detectives are responsible for taking statements,
coordinating with the hospital to receive the results of the forensic exam, and
investigating the alleged assault.
Prosecutors: In cases where the survivor has chosen to report their
assault and enough evidence is present, prosecutors are tasked with making the
decision on whether to bring the case to court.
Therapists and counselors: In the aftermath of an assault, whether a case goes to trial
or not, survivors need additional support to continue their recovery process.
Mental health professionals trained in working with sexual assault survivors
may provide care at any step in the recovery process, from coping with the
immediate aftermath of an attack to navigating long-lasting trauma.
SANE education programs are designed
to train nurses to address survivors’ specific needs. After completion of this
training, SANEs become uniquely qualified to treat this vulnerable patient
group. This means that they can provide trauma-informed care to minimize the
harm of invasive exams that may trigger a patient. In doing so, they can also
equip their patients with forensic evidence that can be used if they decide to
report their assault.
One of the key challenges of
completing a sexual assault forensic exam (SAFE) is examining a patient’s
physical injuries without retraumatizing them. To help survivors feel
comfortable, SANEs ask for consent during each step of the way while providing
information on why they are doing each test.
“Consent is not just a piece of
paper with a signature on it,” Day said. “It’s a process throughout the exam.”
In practice, the process of asking for consent may resemble the following:
will inform the patient what body part they will examine and ask permission to
do so. “I’m going to examine your neck now
to see if there are any injuries. Do I have your permission to do so?”
patient grants this permission and the SANE notices something that may require
a sample collection, the nurse will again ask for permission to collect a
specimen and explain why collecting that evidence is appropriate. “I notice a scratch that wasn’t
mentioned when I documented your health history. There may be DNA or other
materials near this wound, so I would like to swab it. Is that OK with you?”
In any instance where the patient
does not want a test performed, the SANE is directed to honor the patient’s
request. This integration of consent throughout the exam is meant to give the
patient a sense of control, a feeling that may have been lost during their
What Are the Requirements to Become a SANE?
Because SANEs work with a patient population that requires specialized care, nurses are required to meet certain expectations in order to take on this role. While some nurses go through training at the local level or through smaller programs, IAFN offers the most recognized certification for SANEs. Nurses can become certified as a SANE-A to care for adults and adolescents or a SANE-P to work in pediatrics. Some nurses elect to pursue both certifications so they can provide care to patients across all age groups.
Steps to SANE Certification
Education: To become a certified SANE, a nurse must have the minimum of a registered nursing (RN) license.
Experience: Prior to starting the certification process, a nurse must have at least two years of clinical experience working as an RN or at a higher level, such as an NP.
Training: As part of the certification process, nurses are expected to complete 300 hours of SANE clinical skills training.
Testing: The final requirement to become a certified SANE is to pass a certification examination. IAFN holds exams two times a year.
Palliative care nursing mainly revolves around enhancing the quality of life of seriously ill patients and their families during life-sustaining treatment and at the end of life. Whether or not they have been trained in palliative care, critical care nurses frequently have patients who are in need of such care. How prepared do they feel?
DailyNurse: What are some examples of palliative care nursing practices a critical care nurse might perform?
Alexander Wolf: Critical care nurses are regularly tasked with assessing and managing the distressing physical, psychological, and spiritual symptoms of critical illness. Those of us who are palliative care specialists can benefit from critical care nurses’ insight into patient/family dynamics, psychosocial situation, and cultural background.
In addition, these nurses frequently have a difficult job of bearing witness to suffering, providing a therapeutic presence in difficult circumstances, and employing two-way communication skills to help determine the treatment goals of the patient and family. These nurses must also be adept in ethical and legal aspects of care, for instance. They also need to be able to help interpret patients’ advance directives and to advocate for the wishes that patients have outlined, when appropriate.
Critical care nurses are also instrumental in providing expert, compassionate end-of-life care in the intensive care unit, which may involve the careful withdrawal of life-sustaining treatments such as dialysis and mechanical ventilation. This often requires thoughtful preparation and culturally sensitive communication with patients and family members, and skilled symptom management throughout the dying process.
DN: What is the phenomenon of “moral distress” that affects many palliative care providers?
AW: Nurses and other providers frequently report episodes of moral distress, in which an individual identifies the morally correct action to take, but feels unable to take it due to some type of constraint. Helplessness or frustration are just a few of the many emotions that an individual might feel as a result — others might include outrage or guilt, among others.
“Critical care nurses tend to experience frequent and intense moral distress in situations pertaining to the end of life, such as providing treatment perceived as inappropriate or futile, prolongation of life or death and lying to or withholding information from patients or family members.”
Alexander Wolf, Palliative Care and Moral Distress, Critical Care Nurse, Vol. 39.5, October 2019
Previous studies have also indicated that these feelings don’t seem to entirely go away either. “Moral residue” often remains, and repeated episodes of moral distress often remind an individual of the previous episodes, causing their distress to intensify. As a result, an individual may try to protect themselves by avoiding or withdrawing emotionally from ethically challenging situations, or by quitting their job.
DN: Is palliative care training appropriate only for certain providers?
AW: Palliative care has evolved so much in recent years — it is no longer solely a subspecialty — now it is an important skill set for all healthcare providers, including nurses and physicians.
In addition, there is a continued shortage of specialists relative to the number of patients with palliative care needs. This really underscores the importance of nurses and other healthcare providers to be proficient to provide basic palliative care. In 2014, the National Academies of Medicine recommended taking measures to improve the palliative care knowledge base of all clinicians.
Numerous medical professional societies recommend timely access to palliative care, including for patients in the intensive care unit, but the lack of provider training remains a significant barrier. Our study indicates that many critical care nurses have not had much palliative care education, so we still have to work hard to better prepare nurses to meet patients’ care needs.
DN: Ideally, what changes would you like to see result from your study?
AW: There are many changes we would love to see, but here are a select few.
Bedside nurses — particularly those who have had palliative care education — need to be empowered as leaders for integrating palliative care in their practice environment. They would be in an ideal position to educate their peers and interprofessional team members. We need to better recognize nursing excellence. Physician and nurse leaders need to collaborate to ensure that bedside nurses have a voice when they feel their patients’ needs are not being met.
The critical care nurses in our study seemed to highly value palliative care, but few felt highly competent, and even fewer reported having any recent education in palliative care. Many nursing programs have done a great job in recent years to include palliative care in school curricula and in student clinical experiences, but it cannot just be “squeezed in”. There is clearly still a lot we need to do to integrate palliative care as a key competency area for nurses across specialties, particularly in critical care.
“Nearly half of respondents [in this study] rated themselves as not competent or somewhat competent in knowledge of advance directives, living wills, and do-not-resuscitate order policies. Previous studies have illuminated knowledge gaps among acute and critical care nurses in this domain…. Given the legal and ethical implications, this knowledge gap should be a key focus of palliative care education initiatives…”
Wolf, Palliative Care and Moral Distress, Critical Care Nurse, Vol. 39.5, October 2019
Additionally, the nurses in our study placed a high value on interprofessional collaboration. In continuing education for nurses it would be wise to be inclusive of other healthcare professionals. This could help foster increased recognition of patients’ palliative care needs by all team members.
For more information on Critical Care Nurse and the AACN, visit http://ccn.aacnjournals.org/.
Thanks are extended to Alexander Wolf, DNP, RN, APRN, Nurse Practitioner, Palliative Care, at TriHealth
Pursuing jobs in the field of psychotherapy isn’t just for doctors; nurses can do it too. Benjamin Evans, DD, DNP, RN, APN, past president of the New Jersey State Nurses Association, has his own practice as a nurse psychotherapist in addition to consulting. He made the change in the 1980’s after he had completed his nurse practitioner training. Based on his work with people living with chronic and catastrophic illnesses, he decided to earn a master’s degree in counseling because it would be a good fit.
talked with us about what a nurse psychotherapist does and what nurses who are
thinking of entering this area of the field should keep in mind.
What exactly does a nurse psychotherapist do?
A nurse psychotherapist does the same work as any other educated psychotherapist — using psychological and counseling methods to assist in behavior and mental health changes. Usually the state board of nursing incorporates some form of health counseling within the definition of nursing practice. Psychotherapy can be done with individuals, families, and groups.
What should nurses keep in mind if they are thinking of becoming a nurse psychotherapist?
need to understand their reasons for wanting to become psychotherapists.
Psychotherapy is not about “fixing” others who have similar issues to the
is not solely health counseling for issues like nutrition, stress, or weight
control. It is not nurse coaching. Psychotherapy is undergirded with
theoretical frameworks that are used by the psychotherapist to help in the
who wish to become psychotherapists will be integrating nursing theories with
theoretical frameworks from psychology, psychiatry, social work, and other
Psychotherapy education is usually done at the graduate level. For this reason, the nurse wishing to do psychotherapy needs to determine if she or he will pursue psychotherapy education through a graduate nursing program like a psychiatric mental health nurse practitioner/clinical nurse specialist role or through another discipline like psychology, educational counseling, or social work.
kind of certification or other education would they need?
Certification can be obtained by credentialing organizations like the American Nurses Credentialing Center or through various certifying bodies outside of nursing. Some types of psychotherapy have non-degree supplemental experiential training and then “certify” the practitioner in a particular modality — for example, training in cognitive behavioral therapy.
else should they do?
nurse wishing to become a psychotherapist should meet with and shadow a nurse
psychotherapist to really learn all that the specialty initials. She or he
should become familiar with modalities of psychotherapy and vet programs for
What are the greatest challenges to being a nurse psychotherapist?
include training (time and cost), building a practice, obtaining referrals, and
ongoing maintenance of competency.
reimbursement issues play into the challenges of practice as many insurers do
not cover nurses for psychotherapy.
are the greatest rewards?
are many rewards to being a nurse psychotherapist, including watching as behavior
changes and mental health improvements are accomplished by the patients.
Is there anything else important for our nurse readers to know?
The practice of psychotherapy as a nurse is quite rewarding. The nurse who chooses to go into psychotherapy practice must want to help others to make behavioral or mental health changes. The nurse must have clear boundaries — being able to be empathic and not take on the issues of the client. Nurse psychotherapists must be mindful of self-care and to develop a sound network for referrals when the issues presented are outside of the psychotherapist’s area of expertise.