Most people are hardworking and often pretty good folks, and then there are the others like those caught up in a scheme uncovered in January where several people allegedly faked diplomas and transcripts and sold them to nurses—many of whom had allegedly used them to sit for their licensing and work as nurses.
The thought that this could happen is absolutely horrific.
Daily Nurse interviewed Jennifer Flynn, CPHRM, Risk Manager, Nurses Service Organization (NSO), to learn how it could affect nurses who have done nothing wrong and how they could protect themselves in the future.
What follows is our interview, edited for length and clarity.
What was the scheme for nurses who haven’t heard about the scandal? Why were people doing this? How could they pass the national nursing board exam if they didn’t have diplomas/credentials?
Earlier this year, the Justice Department announced it had uncovered a scheme involving the sale of more than 7,600 fake diplomas and transcripts from several now-shuttered nursing schools in Florida. These alleged actions allowed individuals who aspired to become nurses to bypass the courses and clinical work required to sit for the National Council Licensure Examination (NCLEX). Since then, 25 individuals have been charged for their involvement in the fraud scheme.
The alleged scheme sold fake and fraudulent nursing degree diplomas and transcripts from accredited Florida-based nursing schools to those wishing to seek licensure as Registered Nurses (RNs) and Licensed Practical/Vocational Nurses (LPN/LVNs).
The individuals who allegedly acquired the fake nursing credentials used them to qualify to sit for the NCLEX. If they successfully passed the exam, they became eligible to obtain licensure in various states to work as an RN or an LPN/LVN. According to a representative from the HHS Office of the Inspector General, about 2,800 people— or 37 percent of those who bought fake documents — passed the test. Many individuals who passed the NCLEX and obtained licensure could then secure employment in the healthcare field.
State Boards of Nursing (SBONs) from Delaware, New York, New Jersey, Texas, and Florida, have launched their investigations into individuals tied to the scheme.
However, attorneys representing nurses now linked to the scheme said that not all students attending those Florida nursing schools purchased fraudulent documents. An attorney representing several affected nurses in New York has stated that many affected nurses are immigrants who assert that they attended classes and may also have completed training or education to become nurses in their home countries before coming to the U.S.
Additionally, according to The National Council of State Boards of Nursing, many individuals who allegedly paid for the fraudulent documents had experience working in healthcare as certified nursing assistants or other positions, which may help explain how so many were able to pass the NCLEX.
Licensing boards are investigating nurses who graduated from the schools allegedly involved in the scheme. If nurses received their diplomas/credentials ethically, why must they protect themselves? As in defending themselves?
Yes, nursing students who attended the identified Florida schools are worried about their careers. In some cases, the SBONs sent letters to licensees who attended those schools allegedly tied to the scheme and their employers, asking them to submit proper documentation or surrender their licenses. In New York state alone, the SBON identified more than 900 nurses asking them to prove their credentials are legitimate or surrender their licenses.
There are potential liability issues on both the employer and individual sides. Depending on the unique facts of the case, and state law, healthcare facilities that employed these nurses could face medical malpractice actions from patients who these individuals treated. Further, they could face allegations of improper hiring practices as they employed improperly credentialled providers. Healthcare employers must verify a nurse’s competence in performing essential functions — and are vicariously liable for anything that happens under their facility name.
For individual nurses, if a patient injury occurred during treatment, the patient could bring a claim against them related to professional negligence. The patients cared for by one of these nurses could claim the care they received was negligent because the nurse was not properly licensed. Again, these cases would depend on the patient’s allegations of injury, the unique facts of the case, and state law.
Why would they need lawyers if they haven’t done anything wrong?
Any nurse who receives a letter from the SBON should have an attorney to help them defend themselves against allegations or complaints against their license. The SBONs’ missions are to protect the public, and they have the authority to enact sanctions that range from fines up to and including more severe actions such as license probation, surrender, or revocation
When a complaint is made against a nurse to the SBON, nurses must be equipped with the resources to defend themselves adequately. Being unprepared may represent the difference between a nurse retaining or losing their license. Therefore, NSO’s policies include license defense protection which reimburses insured nurses up to the applicable limit for their defense of disciplinary charges and other covered expenses arising out of a covered incident if a complaint is brought against you before a state licensing board.
What can nurses do to protect themselves in the future? Aren’t they covered under their employers’ insurance? If not, why not?
According to the National Practitioner Data Bank, nursing professionals were more than 43 times more likely to have an adverse licensing action reported to the NPDB than a medical malpractice payment in 2022.*
Further, an SBON complaint can be filed against a nurse by anyone–for example, a patient, a patient’s family member, a colleague, or an employer. You may or may not know the identity of your accuser, and the complaint may be filed anonymously.
Nurses should ask their employers about the coverage afforded to them as an employee to identify if there are any gaps in coverage. If employers do not cover you for complaints made against your license to the SBON, they may wish to purchase professional liability insurance that includes coverage for license protection and safeguards nurses against licensing board complaints.
*Division of Practitioner Data Bank, Bureau of Health Workforce, Health Resources and Services Administration. Generated March 31, 2021, using the Data Analysis Tool at https://www.npdb.hrsa.gov/analysistool.
Data source: National Practitioner Data Bank (2022): Registered Nurse and Practical Nurse State Licensure/Certification Adverse Action and Medical Malpractice Reports (January 1, 2022 – December 31, 2022).
What most surprised you about this scheme?
As of today, from what I read about these cases, the SBON is not differentiating nurses who did attend these schools while they were accredited from those nurses who purchased fraudulent documents. The notices/letter sent to nurses by their SBON asking them to prove their credentials are legitimate were given very short response times to engage with an attorney, review the allegations, gather the required documents, and still meet this compliance deadline, which may raise questions about due process and their ability to be heard in these cases.
The NCSBN is launching the Next Generation NCLEX (NGN) on April 1, 2023. NGN is fostering a new way of testing clinical judgment. With NGN upon us, nurse educators must ensure now, more than ever, that our students are learning the content and grasping the concepts we teach. We need sticky learning! Sticky learning is what I call true learning or deep learning, not just surface learning. One way to make learning sticky is through the use of visual aids.
Why Multimedia Matters in Nursing Education
You can’t open a nursing textbook without seeing lots of images, charts, and graphs. Why? Complex content requires simplified explanations. One of the best ways to simplify complex content is through visuals. The nursing curriculum involves:
Learning knowledge and skills.
Applying learned knowledge and skills.
Ultimately making clinical judgments about patient care.
Nursing is a hands-on profession full of procedures, interactions, and memorization.
Nursing content is made for the use of visuals!
The most important thing for educators to remember is that the mode of instruction must match the content being taught. Only include visuals when they simplify, complement, and/or provide a memorization cue for the content. When providing visuals, you should provide both the words and the visuals. This maximizes the impact on the student and follows Mayer’s Principles of Multimedia, which explains that students learn better from words and visuals than from words alone. There are many reasons to use visual aids.
Pictures are more easily processed in the brain than words.
Images cue memories.
Visuals can simplify complex processes.
Images can decrease boredom and increase engagement.
Most students prefer images to words.
The Power of Pairing Words and Images
The human brain can process pictures more quickly and easily than words. Think back to when you were a child learning to speak. You weren’t taught the alphabet and how to read first. Instead, you were taught what objects were by being shown the actual object or pictures of the object. Look at the example below. Which is easier to process and remember?
Students often remember high-quality clinical images and medical illustrations more than text. The connection between the visual and the text makes the experience more meaningful and likely to be stored in long-term memory. Have you ever forgotten some of the text of something you read but remembered the image explaining the text, including exactly where it was located on the page? This is because visuals are easier to learn and quicker to cue memories. The combination of text and visuals provide more of an opportunity for the reader to make connections and engage in deeper learning.
Making the Complex Simple
The right visuals can break down and simplify complex processes. For example, a flow chart that simplifies diabetic ketoacidosis with arrows indicating what happens next provides an image for the brain to remember and retrieve than long paragraphs of text more easily. It also organizes the information and offers simplified explanations for easier processing. See the example below.
Why Students Prefer Visuals
Visuals can help with boredom and increase engagement. When students open a reading assignment and see visuals instead of texts, from my experience, nursing students feel less dread in engaging with the content. Visuals are less daunting and provide more motivation to engage than text. Breaking up text with good visuals also decreases the likelihood of getting bored. Students like visuals!
Of course, surveys and literature may tell us that students do not always know what is best for them when it comes to learning, but we can’t completely ignore what they like. The right visuals give the students what they want and help them learn!
Finally, visuals cause a stronger and faster reaction than words. Because emotions and memories are created in the same part of the brain, emotional responses can influence information retention. Remember Maya Angelou’s quote: “People will forget what you said, people will forget what you did, but people will never forget how you made them feel.”
This rings true for learning also. Visuals can trigger memories that trigger emotions—and therefore increase retention. During the closures caused by the pandemic, online learning based on strong visuals helped bridge the gaps for nursing students who cannot do internships, volunteer, or complete their clinical rotations. As these students prepare for NGN, continuing to provide visually driven online learning as an extra resource will shift the focus from the soft skills provided by clinical rotations to the hard skills that every nurse will need to know to thrive in the workplace. The hard skills students learn from visual eLearning will give them the “hands-on” experience they need to integrate successfully into the clinical setting—even before they leave the classroom.
The South College Asheville Physician Assistant program officially launched with the first class of 84 students pursuing a Master of Health Science in Physician Assistant Studies.
“We have eagerly anticipated welcoming the first group of students in the Physician Assistant program in Asheville,” says South College Chancellor Steve South. “Our team is committed to developing these students through our comprehensive student support system, course instruction, and clinical training to help communities through the addition of qualified health professionals.”
The South College Physician Assistant Program previously earned provisional accreditation status from the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) for its master’s program in Physician Assistant Studies. This is the accreditation status initially awarded to new programs.
The Commission is the accrediting agency that protects the interests of the public and physician assistant profession by defining standards for education and evaluating programs in the United States to ensure compliance.
Enrollment is open for the next cohort, which starts in January 2024. The program can be completed in as little as 27 months, with 15 months in didactic instruction followed by 12 months in supervised clinical practice experiences (SCPEs).
South College students who qualify for financial aid have access to various programs, as do members of the U.S. military, veterans, and their families. The institution offers both student and career services.
A virtual reality (VR) simulation helps undergraduate nursing students experience an emergency-care scenario from the perspective of an intubated patient. The scenario is intended to instill empathy that, contrary to popular belief, is a skill that can be acquired and strengthened.
“Many of us have experience with loved ones interacting with the healthcare system and not receiving the kind of care we felt they needed in terms of empathy,” reflects Clinical Assistant Professor Lori Sprague, also assistant director of the Innovative Simulation and Practice Center at Binghamton University’s Decker College of Nursing and Health Sciences. “And we thought, ‘Maybe we can help people understand what it’s like to be that person going through the experience.’”
VR is an Innovative Solution
“You need to be able to reach the masses, so we came up with this idea of creating a virtual reality simulation that is easy and accessible,” says Patrick Leiby, Decker’s director of technology and innovation. “You can get a $3 cardboard headset, put your phone in it, and have 100 students all sitting in a room at the same time, doing the same virtual reality simulation.”
Collaborative Research in Simulation and Practice (CRISP), a research group that includes both Sprague and Assistant Professor Rosemary Collier, won a SUNY Innovative Instruction Technology grant for the project. Collier and Sprague are also part of an interdisciplinary research group on tobacco use. They drew on their knowledge to create the vaping scenario in partnership with nursing programs at SUNY Delhi, SUNY Broome, and SUNY Brockport.
“It was right around this time that we were seeing some of these lung-injury cases, such as young people getting ‘popcorn lung’ and ending up in the ICU after using vaping products,” says Collier, also an emergency care nurse in the Binghamton area.
Unlike traditional video production, VR must be shot in a single take; to stay out of the scene, Leiby worked in a separate room, operating the camera from an iPad. The parts were played by faculty members, who practiced during several dress rehearsals before Leiby filmed the scenario with an Insta360 camera.
The faculty members drew on aspects of their own experience for their roles. The day before the filming, Sprague’s daughter was admitted to the hospital for a medical emergency; captured in the video, her feelings as a distraught mother were fresh and raw. Likewise, Collier, who played the lead physician, is deeply familiar with the communication blind spots that can sometimes occur in an emergency setting.
“If you’re ever in a critical care unit, physicians walk around with these teams of residents, respiratory therapists, and a nurse, going from room to room,” Collier recounts. “They have a job to do, and the job isn’t always therapeutic communication with the patient and family.”
Empathy in the Curriculum
So far, the VR simulation has been part of the Introduction to Professional Nursing course, where goggle-wearing students watch and then discuss the simulation together.
Empathy and emotional intelligence are part of the nursing curriculum and are developed in diverse ways. For example, nursing students learn how to physically transfer patients to a bed while practicing on each other, which not only imparts skill but also gives them insight into what a patient feels: empathy.
“I’m comfortable in a healthcare setting; it’s my home base. But for every patient who comes through that door, it’s a terrible day, their worst day. It can be hard to remember to put yourself in their shoes and to remember that this isn’t their home base,” Collier says. “You have to go out of your way to create connection and comfort.”
When Jenny Nigro lifted the goggles to her eyes, she was already feeling stressed from competing deadlines and a big test later that afternoon. Yet, as she watched the scenario unfold, she was struck by the patient’s vulnerability.
“It was a meditation on empathy to see how the care team’s brusqueness and lack of warmth resulted in (the patient’s) experience of helplessness,” says Nigro, who graduated with her nursing degree in May 2022. “In the post-brief, I noted how timely it was that our empathy VR simulation was occurring on a day when we were feeling overworked and tired. It offered an opportunity to reflect on how we might manage these feelings that will likely come up in nursing practice, so that we do not disempower our clients.”
Plans are in the works to create additional VR scenarios, such as ones involving patients who don’t understand English or situations that might require conflict-resolution skills. Leiby has also used the 360 technology on other projects, such as a virtual tour of Decker’s new Motion Analysis Research Laboratory.
Collier points out that virtual reality scenarios can play an important role for future nurses, allowing them access to experiences they may not encounter during their clinical time and sharing those experiences with classmates. At its heart, sharing is the foundation of empathy.
“Patients don’t always remember the clinical complexities occurring behind the scenes, but they will remember how their nurse or provider cared for and treated them,” Sprague says. “Sometimes it’s just a matter of pulling up a chair or changing your body language and respectfully giving a few moments of your time.”
The South College campuses in Knoxville and Nashville, Tennessee, are launching an Associate of Science in Nursing (ASN) program upon approval by the Tennessee Board of Nursing.
This is the institution’s first ASN program to launch, offered through campus instruction over seven quarters. Students work to build a strong academic foundation and learn fundamental skills required of a nurse generalist, including the basics of medical care, critical thinking, interpersonal skills, and technical competence necessary for taking the National Council Licensure Examination (NCLEX-RN) exam.
“South College remains in tune with the great needs throughout healthcare fields for trained and qualified practitioners and is committed to launching relevant programs such as the Associate of Science in Nursing to positively impact healthcare education,” South College Chancellor Stephen A. South said. “The ASN program opens the door for students to enter the field faster, which saves both time and money while pursuing a degree.”
The prerequisite courses for the new Associate of Science in Nursing program begin in January 2023 in Knoxville and Nashville, and enrollment is now open. Graduates may pursue the Bachelor of Science in Nursing RN to BSN option upon completion.
South College offers multiple healthcare programs across disciplines, from certificate to doctoral levels. In addition, South College students who qualify for financial aid have access to various programs, as do members of the U.S. military, veterans, and their families. The institution offers both student and career services.
The Emergency Nurses Association (ENA) and Kaiser Permanente Southern California are partnering to bring the association’s fast-growing Emergency Nurse Residency Program to 15 of the health system’s emergency departments.
Introduced in April, ENRP offers a dynamic new approach for ED leaders looking to develop the critical-thinking, problem-solving, and communications skills of a new graduate nurse or nurse transitioning into the emergency department before they practice independently.
The program provides didactic learning with dedicated time for nurses with educators and clinical preceptors to create a progressive, immersive experience that ultimately benefits a nurse’s ability to provide patient care.
After piloting the 18-week program at 10 hospitals in 2021, ENA has reached agreements with nearly 30 hospitals to bring ENRP into emergency departments across the country this year – with Kaiser Permanente Southern California representing the largest partnership to date.
“From the beginning, ENA recognized how valuable the Emergency Nurse Residency Program could be to hospitals looking at innovative ways to attract nurses to the emergency department and retain them – especially at a time when staffing concerns are so prevalent,” says ENA President Jennifer Schmitz, MSN, EMT-P, CEN, CPEN, CNML, FNP-C, NE-BC. “ENA is proud to welcome Kaiser Permanente Southern California to the growing list of partners who have invested in the future of emergency nursing by bringing ENRP to their emergency nurses today.”
Dr. Greg Kelman, regional medical director of operations at Kaiser Permanente Southern California – the nation’s largest not-for-profit integrated healthcare system – says the organization welcomes the opportunity to implement new ways of hiring and retaining emergency department nurses.
“The Emergency Nurse Residency Program is another step Kaiser Permanente is taking to ensure we can strengthen our nursing staffing levels at our emergency departments at a time when there’s an acute nursing shortage across the United States,” Kelman says. “We believe we are now in a stronger position to meet our patients’ needs.”
