Discipline Process of the Idaho Board of Nursing

The Idaho Board of Nursing was created to protect the public. To that end, the Board is appointed to review complaints against nurses and determine disciplinary actions when necessary. Being investigated by the Board can be very stressful. Ideally, nurses would never find themselves in the position of being investigated by the Board.

This article aims to educate nurses on the complaint resolution process at the Idaho Board of Nursing.  The Board receives complaints through the Board of Nursing website.  Those complaints, if found in violation of statute or rule, are presented to the Board.  The Board then determines disciplinary action.  Most cases result in a letter of concern and/or an agreement in lieu of discipline (AILD). The AILD may require continuing education, monitoring, and/ or mentoring.    The licensee may also receive a fine. In these cases, the discipline is not made public.   On occasion, the Board may determine the conduct warrants formal discipline, which may include a public reprimand, an AILD, fines, and license restrictions (probation, suspension, or revocation).

The best way to avoid disciplinary review is to understand a nurse's scope of practice, know the Nursing Practice Act (statute) and rules, and the policies and procedures of your facility/clinic.  If you have any questions, don't hesitate to contact the Idaho Board of Nursing (HP-Licensing@dopl.idaho.gov ). We can direct you to the statute(s) or rule(s) that may help guide your inquiry.

Recent Discipline Cases Reviewed by the Board

Recently, the Board was presented with several complaints involving false documentation.  Nurses are required to document often, clearly, precisely, and honestly.  Nurses are usually very busy, and although, ideally, documentation should occur directly after a task is completed, realistically, documentation may not occur until later in the shift due to various factors.  No matter when the documentation occurs, the nurse should only document what was completed during that task.  A nurse should never report anything that did not occur.  Although charting/documentation per se isn't currently explicitly defined in The Nurse Practice Act or the Rules of the Idaho Board of Nursing (IDAPA 224.34.01) as a reason for discipline, falsely documenting information can lead to reasons for disciplinary action.   The following examples may help clarify. 

Example #1.

A nurse reports forgetting to document a client's 1400 head-to-toe assessment.  The task was documented several hours later, indicating in the note that the assessment occurred at 1400.  Two issues were noted with the nurse's documentation. 

• The client had eloped before 1400.

• The nurse reported the head-to-toe assessment was based on information gathered from seeing the client walking in the hallway earlier in the day. 

The nurse was terminated by her employer.  A complaint was filed with the Board. The possible violations include Idaho Code 54-1413(1)(d) for negligence and/or recklessness, Idaho Code 54-1413(g) standards of conduct, IDAPA 24.34.01.200.02(b)(vi) to observe the condition and signs and symptoms of a patient, record the information and report... significant changes, and IDAPA 24.34.01.200.03(c) for responsibility and accountability. 

Example #2.

A nurse worked for a home care health service. Within nearly two years, the nurse had seen close to 30 clients.  The nurse charted visits with all clients.  Several issues were discovered:

• The nurse documented a visit with a patient on the same day the nurse was on vacation

• Many clients stated that they were never seen by nor had they ever met the nurse

The employer terminated the nurse.  A complaint was filed with the Board.  Possible violations included (the rules noted were in place at the time of the complaint) IDAPA 24.34.01.100.12 Failure to cooperate with authorities, IDAPA 24.34.01.101.04d Abandonment of Patients, and IDAPA 24.334.01.101.05e Record Keeping. 

Example #3

A nurse worked for a home care health service.  The nurse charted the visits, including vital signs for all clients.  Several issues were noted:

• One client had a video of the nurse's visit. The nurse entered without any medical equipment, and no vital signs were taken.

• Several other clients indicated vital signs were not taken.

The employer terminated the nurse.  A complaint was filed with the Board.  The possible violations include Idaho Code 54-1413(1)(d) for negligence and/or recklessness, Idaho Code 54-1413(g) standards of conduct, IDAPA 24.34.01.200.02(b)(vi) to observe the condition and signs and symptoms of a patient, record the information and report... significant changes, and IDAPA 24.34.01.200.03(c) for responsibility and accountability. 

Each complaint and the discipline assigned is specific to the information presented to the Board.  Although complaints brought to the Board can appear similar, various factors are assessed before a particular discipline has been assigned.  Thus, the disciplinary action may be very different for similar complaints.  

When documenting, be diligent and truthful. Saying nurses are busy is an understatement, but no matter how busy, only chart what has occurred. If something is charted that didn't occur, the nurse taking over is at a disadvantage, and so is the patient. False documentation not only harms a patient but can also impact the nurse's career.

When involved in an investigation, it is important to respond to the Board of Nursing promptly and show the appropriate level of attention to the matter. At the same time, participating in an investigation should not cause despair or hopelessness.

The Board of Midwifery Consolidated with the Idaho Board of Nursing

This past legislative session resulted in the passage of House Bill 437, which merges midwifery regulation into the Board of Nursing. This legislation also created three additional seats on the Board: a second position for an Advanced Practice Registered Nurse (APRN) and two licensed midwife positions. The Board currently consists of five Registered Nurses, two Licensed Practical Nurses, one APRN, and one public member.

The changes will go into effect July 1, 2024. The Board looks forward to this merger as it continues to work to protect the health and well-being of the people of Idaho

NCSBN Releases a New Guidance Document

NCSBN released a Fraud Detection Guidance Paper in May 2024. The document is tailored to those who employ or educate nurses and offers recommendations to further protect institutions and employers from nursing applicants providing fraudulent information. The guidance document can be found on the Idaho Board of Nursing Website under Board News or in the accordion drop-down under Fraudulent Schools.

Nurse Licensure Compact (NLC) -- New Rule

When a nurse with a multistate license changes their state of residence to a different compact state, the NLC rules require the nurse to apply for licensure by endorsement in their new state of residence within the first 60 days of moving.  The nurse can practice on the license from their former state until the license from their new state of residence is issued. Once the new license is issued, the previous license will be deactivated.  A nurse should not let their prior state of residence license expire before obtaining their new license.  In Idaho, a nurse cannot obtain a license by endorsement without a current unencumbered license from another state of residence.  Once that license expires in the previous state of residence, that state will not renew the license because the licensee is no longer a resident.  Be aware of when your license expires so that there is plenty of time to obtain a license in the new state of residence before the expiration of the previous license.  For more information, see the NLC Frequently Asked Questions sheet.

What if you could have the soothing voice of Morgan Freeman to help facilitate your advanced care planning (ACP) discussions with patients? I held a community movie day event that did just that. Working as a nurse in hospice, oncology, and skilled nursing settings, I recognized the need to improve readiness for advance care planning among members of my community. Current research about ACP shows that fun and engaging community-based ACP interventions make discussions less intimidating while improving knowledge and reducing misconceptions (Eneslätt et al., 2021; Van Scoy et al., 2017; Huang et al., 2020; Bravo et al., 2016).

Planning the Event

After brainstorming ways to improve ACP readiness in my community, I decided to host a free community movie day at a local theater. The concept of the community movie day was adapted from the Conversations of Your Life Taskforce Toolkit (New Jersey Health Care Quality Institute, 2020). This toolkit has a variety of great ideas and resources to host ACP events in the community. For my event, community members were invited to watch a free screening of the 2007 film “The Bucket List” starring Morgan Freeman and Jack Nicholson and listen to a 10-minute presentation about ACP. Once the movie was scheduled, I advertised the event throughout my community. I advertised at the senior center, on social media, at local doctor’s offices, and through word of mouth.

To cover the cost of this event, I partnered with local businesses and organizations, including a hospice company, a funeral home, and a senior care company. The companies who sponsored this event were invited to set up information tables in the lobby of the movie theater to provide attendees with information about their services.

Day of the Event

The morning of the movie, I received a phone call letting me know that there was an unexpected power outage at the movie theater. After several panicked moments and a phone call to the power company, I learned that the power was not expected to be turned back on until mid-morning. I headed to the movie theater, greeted guests as they arrived, and let them know that the power outage may last an hour or so.

            Upon hearing about the delay, most people decided to stay and wait it out. I had 91 people gathered in the dim lobby of the movie theater: standing room only. While attendees waited, they spoke with the community partners about their services and were entered to win donated door prizes. After that, I gave the ACP presentation in the lobby. The power came back on after about an hour of delay, and those still in attendance were able to enjoy the film and complimentary concessions.

Lessons Learned and Next Steps

            This event, overall, was very well received by my community. Many attendees voiced that the event was both informative and enjoyable. One participant said, “This event made me realize I need to start sharing my wishes with my family and putting them in writing. I also realized I need to be actively working on my own bucket list. No more waiting until the end!”.

The free movie was a great way to get the ACP information to my community members in a fun and approachable way. I have had several people reach out and ask me if I’ll be hosting this event again next year with a different movie. I hope to be able to hold similar events in the future to continue to get the word out about the importance of ACP to my community.

            If you are looking for ways to improve readiness for ACP in your community, I would encourage you to try hosting your own community movie day. Although my event was held at a theater, you could also show a film in someone’s home, the park, the library, or local senior or community center. Hosting a community movie day is a great way to break the ice and get the ACP conversation started.

Author Note: This event was held as part of the author’s Doctor of Nursing Practice project. If you would like additional information about the project, you may reach out to the author at emily.harames@gmail.com

Delirium is a significant concern in hospitalized patients, particularly among surgical patients. Delirium affects about seven million hospitalized patients annually (Hebert, 2018) and 37% of postoperative patients (Yang et al., 2020). Delirium is linked to prolonged hospital stays, higher mortality rates, and increased discharges to nursing homes or other long-term care facilities (Di Santo, 2019; Ha et al., 2018). The costs associated with delirium range from $1,555 to $23,698 per hospital stay, contributing to an annual expense of up to $152 billion (Ha et al., 2018; Mosharaf et al., 2022).

Nurses play an indispensable role in managing delirium, being at the forefront of identifying early signs, formulating comprehensive care plans, and implementing targeted interventions (Di Santo, 2019; Jung & Zhao, 2022). The American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults (2014, reaffirmed in 2021) underscores the importance of nursing practices in improving patient outcomes. However, the literature exploring the impact of these practices on outcomes remains sparse. This pilot study aims to examine the factors, particularly nursing interventions, that influence the length of hospital stays for adults experiencing postoperative delirium.

Methods

This was a retrospective chart review of electronic health records (EHR) of adult patients admitted to the medical-surgical units in five networked hospitals in the Mountain West. We included surgical patients aged 65 and above with symptoms of delirium for a continuous 24-hour period. Out of the eligible records, 75 were randomly selected for analysis. The study received ethical clearance as exempt research. The analysis focused on hospital length of stay (LOS). Independent variables included demographic characteristics, clinical factors such as laboratory values, perioperative factors, and specific nursing interventions. We used descriptive statistics and multinomial logistic regression to explore the relationships between LOS and these variables.

Results

More than half of patients had a prolonged LOS (≥ 7 days) with most (32%) spending at least 10 days in the hospital. Most patients were female (58.7%) and had an American Society of Anesthesiologists (ASA) Physical Status Classification System score below IV (58.7%). Most surgeries were completed within 120 minutes (64%) with general anesthesia (80%), and most patients received sleep promotion (85.3%) and pain management nursing interventions (69.3%). Early mobilization was common (70.7%), and family visits were observed in a significant portion (61.3%). About one-third of patients had their indwelling urinary catheter removed early (Table 1).

Table 1 Sample Characteristics

Total Length of Stay

N (%) n (%)

Note: ASA = American Society of Anesthesiologists

The final regression analysis revealed that patients who received general anesthesia were at increased risk for experiencing a prolonged LOS compared to those with other types of anesthesia. Specifically, for LOS durations of 7-10 days and LOS exceeding 10 days, the relative risk ratios (RRRs) were 26.58 (p = 0.015) and 10.92 (p = 0.037), respectively. Early urinary catheter removal emerged as a significant factor. Patients who experienced delayed urinary catheter removal were more likely to experience prolonged LOS, especially for LOS exceeding 10 days (RRR = 25.01, p = 0.018), compared to those with early urinary catheter removal (Table 2).

Table 2 Predictors of LOS in Patients with Postoperative Delirium

Note: RRR = Relative Risk Ratio; CI = Confidence Interval; * p value <0.05

Discussions and Implications for Nursing Practice

Our findings indicate that patients who received general anesthesia were at a substantially higher risk of experiencing an extended LOS compared to those with other types of anesthesia. This finding aligns with previous research that general anesthesia was significantly associated with longer LOS (Matharu et al., 2022). However, a randomized controlled trial by Li et al. (2022) and a systematic review by Zhou et al. (2023) showed no significant difference. These inconsistent results emphasize the importance of considering anesthesia type and other related factors in the preoperative planning process. For patients with general anesthesia, nurses should utilize evidence-based practice in delirium screening and management.

It is noteworthy that early removal of indwelling urinary catheters emerged as a significant factor among the nursing interventions. A systematic review suggests that early postoperative urinary catheter removal can shorten the patient's hospital stay (Nollen et al., 2023). This highlights the importance of nurses adhering to best practices in urinary catheter management to promote better patient outcomes.

To promote evidence-based practice (EBP) in postoperative delirium screening and management, nurses should focus on a multifaceted approach. Nurses can utilize tools such as the Confusion Assessment Method (CAM) tool for delirium screening. CAM is a widely recommended and validated tool for the early detection of delirium (Inouye et al., 1990). In addition, nurses should prioritize early urinary catheter removal, encourage early mobilization, promote sleep, nutrition and fluid repletion, and manage pain among postoperative patients (Hebert, 2018; Jung & Zhao, 2022). The American Geriatrics Society (2014, reaffirmed in 2021) guidelines for postoperative delirium prevention and management also highlight these nonpharmacologic interventions and their effectiveness in delirium management.

The study's limitations stem from its retrospective design, potentially leading to unavailable or missing information in the EHR. Additionally, its findings might lack generalizability since the study was conducted within a single healthcare system

Conclusion

The study findings highlight the significant associations between patient LOS and anesthesia types and early urinary catheter removal. Healthcare professionals, especially nurses can significantly impact patient outcomes, reduce hospitalization durations, and improve quality of care through optimizing nursing interventions.

Yunchuan Zhao, Ph.D., MSN, MPAff, RN

Associate Professor

Boise State University, 1910 University Drive, Mail Stop 1840, Boise, ID 83725

208-426-3731

lucyzhao@boisestate.edu

Anna Quon, MBA HM, BSN, RN, AMB-BC, NEA-BC

Manager Nursing Research

St. Luke's Health System, 190 E Bannock St., Boise, ID, 83712

208-381-7427

delcida@slhs.org

Laura J. Tivis, Ph.D., CCRP, LSSGB

Director Nursing Research

St. Luke's Health System, 190 E. Bannock, Boise, ID 83712

(208) 381-9278

tivisl@slhs.org

Corresponding author:

Yunchuan Zhao, Ph.D., MPAff, RN

Associate Professor

Boise State University, 1910 University Drive, Mail Stop 1840, Boise, ID 83725

208-426-3731

lucyzhao@boisestate.edu

Conflict of Interest Declaration: The Authors have no conflict of interest to declare.

Lyndsee C Scott

Madison Memorial

Rexburg

Lyndsee was the nurse caring for our baby the day I was discharged from the hospital. As a mom, this was the worst day of my life; I had to leave my baby and go home. Going to the NICU that day was a difficult experience. There were so many thoughts and fears going through my mind. When I walked into the NICU, Lyndsee was working with my daughter. She greeted us with a warm, friendly smile. I don't know if she knew I was going home and had been discharged or if she knew how nervous I was, but she was able to gain my confidence and trust that no matter what or who was caring for our daughter, she was in good hands. Her faith and confidence in her colleagues gave me a sense of relief. Lyndsee has many years of experience in the NICU, and because of that, she exudes mastery of caring for pre-term babies. She took time to answer all my questions, and her vast knowledge and confidence put my mind at ease. Leaving the hospital that day became less daunting because Lyndsee's skill set, professionalism, and experience gave me confidence. Her confidence and trust in those she works with are evident in everything she says. I trust her and her colleagues to care for my baby.

Neutropenia is an abnormally low number of neutrophils in the blood (Justiz Vaillant & Zito, 2022). This condition is often secondary to other diseases in vulnerable immunocompromised populations, like oncology. This adverse state leads to increased susceptibility to infections and, in certain populations, is compounded by immunosenescence, a weakened immune response noted with aging (Holtzclaw, 2020 & Rink & Wessels, 2022). Depending on severity, febrile neutropenia is associated with an 11-50% mortality rate (Baluch & Shewayish, 2019). People with hematologic malignancies are at increased risk for neutropenia owing to the complex disease process and treatment side effects (National Cancer Institute, 2024a & 2024b; Osmani et al., 2017).

The National Comprehensive Cancer Network (NCCN, 2022) offers recommendations on treating neutropenic fever (NPF) when an oral temperature is greater than or equal to 38.3° C or greater than or equal to 38° C over one hour. The NCCN guidance triggers the collection of blood cultures every 24 hours, along with other specified diagnostic tests for infection. However, today's temperature standards date back to Wunderlich's work in the early 1900s, which labeled axillary fever onset at 38° C and has since become seminal work (Wunderlich & Woodman, 1871). Literature on NPF prevention and treatment is limited, and critics like Mackowiak et al. (2021) question the reliability of temperature thresholds as a hallmark of systemic infection due to individual variance. Thus, this study's purpose was to explore the associations between fever status and blood culture results in the hematology patient whose health status may further impact their ability to mount a response to infection.

Methods

A retrospective chart review was conducted following approval from the Institutional Review Board. The study was classified as exempt, therefore informed consent exemption, and a waiver of informed consent were not applicable. All adult hospitalized patients meeting inclusion criteria within three hospitals in the northwestern United States from December 2018 to November 2021 were eligible. Inclusion criteria included hospitalized patients 18-89 years old diagnosed with acute leukemia or NHL who experienced neutropenia during admission (absolute neutrophil less than 1500/uL) and received blood culture testing. Data extracted from the electronic health records included demographics, blood culture results from the first blood collection during hospitalization, and temperature measurements (measured by staff or self-reported) before the initial blood culture collection. Febrile cases were defined as those with a documented temperature recording of 38.0℃ or greater in 24 hours preceding blood culture collection. For analysis, we employed descriptive statistics and Fisher's Exact test.

Results

A total of 27 independent cases from December 1, 2018, and November 30, 2021, met the inclusion criteria for analysis. Most patients were male (51.9%) and had a leukemia diagnosis (70.4%). Approximately half of the patients had a documented fever in the hours preceding blood culture collection, and over three-quarters had a negative initial blood culture result (See Table 1). Of those with a fever, 29% had a positive blood culture result, while 15.4% of patients had a positive blood culture without a preceding fever (See Table 2). We found no significant association between fever status and blood culture results (p = .0648, α = .05).

Table 1

Sample Descriptive Statistics (N = 27)

Table 2.

Frequency of Blood Culture Results by Fever Status

(+) blood culture

N

(-) blood culture

N

Discussion and Implications for Practice

This study suggests clinicians should not rely solely on temperature as a trigger for systemic infection surveillance. The results contribute to our collective understanding of NPF and temperature thresholds that have not been widely studied or published (Chesnutt et al., 2008). Although we found no significant association between fever status and blood culture results in our small sample size, clinicians are encouraged to remain vigilant in screening for systemic infection, given the population's high mortality rate in the context of infection (White & Ybarra, 2017). Individual factors likely play a role in each person's baseline and fever thresholds, clinicians should apply critical thinking to guide infection workup rather than fever alone.

Conclusion

For patients with cancer and neutropenia, the risk of a fatal systemic infection is significant. Clinicians play a crucial role in spotting potential systemic infections to help mitigate adverse and fatal outcomes. Future studies could help replicate these findings on a larger scale and shape clinical practice guidelines that encourage clinicians to use other signs of infection as an indication for intervention rather than waiting for fever.

Elena Jacobs, BSN, RN, OCN

Nurse Scientist Apprentice

Nursing & Patient Care Center of Excellence; 4 South Medical-Surgical Oncology

St. Luke's Health System, 190 E Bannock St., Boise, ID, 83712

208-381-2510

bairdel@slhs.org

Anna Quon, MBA HM, BSN, RN, AMB-BC, NEA-BC

Manager Nursing Research

Nursing & Patient Care Center of Excellence

St. Luke's Health System, 190 E Bannock St., Boise, ID, 83712

208-381-7427

delcida@slhs.org

Direct correspondence to: Elena Jacobs, 4 South Medical-Surgical Oncology, St. Luke's Health System, 190 E. Bannock St., Boise, ID 83712; bairdel@slhs.org; Telephone: (208) 381-2510

Conflict of Interest Declaration: The Authors have no conflict of interest to declare.

Acknowledgments: The authors thank Colette Leingang for contributing to this work. Thanks to Drs. Laura J. Tivis and Susan Tavernier for their mentorship. This study could not have been done without the support of St. Luke's Data & Analytics and Inpatient Oncology leadership.

RN Idaho

In Memoriam August 2024 Edition

RN Idaho is pleased to honor Registered Nurses and Licensed Practical Nurses who served the profession and are now deceased. The names are also submitted annually for inclusion in the Idaho section of the nursing memorial of the American Nurses Association. Inclusion dates are 1 March 2024 through 31 May 2024.

Battle, Angela, 1981-2024, Garden City.

Angela was a dedicated and smart woman, serving as a Licensed Practical Nurse, a role that perfectly reflected her compassionate nature. She was the epitome of the saying, "Nurses dispense comfort, compassion, and caring without even a prescription," by Val Saintsbury.

Bartholomew, Jerry Alan, 1951-2024, Post Falls.

A devoted servant to both his country and community, Jerry honorably served in the US Air Force.

His military tenure instilled in him a profound sense of duty and reverence for life, which he

carried into his career as a highly-skilled vascular access nurse at the Veterans Administration

Hospital.

Davis, Kristin, 1943-2024, Boise.

Kristin was a dedicated Registered Nurse, serving at various hospitals throughout her career, including Magic Valley Hospital, Twin Falls ID, Alta View Hospital, Sandy UT, Overlake Hospital, Bellevue, WA and Los Gatos Community Hospital, Los Gatos, CA.

Fuerbringer, Barbara A., 1964-2024, Kellogg.

Barbara worked in the healthcare industry as a registered nurse for the Aurora Group.

Garrison, Ruth Harriet, 1927-2024, Boise.

Ruth worked as a registered nurse throughout her life in surgical, emergency room, and psychiatric nursing. She also made trips to China as part of a group of psychiatric nurses.

Jelka, Ty, 1989-2024, Shelley.

Ty's educational journey took him to Utah State University and Weber State University which culminated in his achievement of becoming a registered nurse. His strong work ethic and commitment to continuous learning were the driving forces behind his successful career in healthcare. In his role as a caring nurse, Ty's passion for helping others shined brightly. His innate patience and boundless kindness touched the lives of many as he became not only a healer but also a teacher. Ty was always willing to share his knowledge and extend a helping hand to those in need, leaving a mark on the hearts of both colleagues and patients alike.

Johansen, Nancy Ellen Chandler, 1940-2024, Coeur d'Alene.

In 1978, Nancy relocated to Coeur d'Alene, Idaho, with her two daughters and began a fulfilling career as a nurse at Kootenai Medical Center's transitional care unit, retiring in 2003. She truly loved being a nurse and was the last nurse at Kootenai who wore her nursing cap every day.

Nevarez, Mary Alice, 1971-2024, Meridian.

Mary Alice began to work as a CAN. With further education she landed in the Nursing Program as an LPN (Licensed Practical Nurse). She was known to be a selfless, giving, hard worker and great friend to many.

O'Sullivan, Mary Margaret "Peggy," 1955-2024, Sandpoint.

Peggy wanted to spread her love for others and pursue nursing, she began her studies at University of Montana and was a lifelong Griz fan. She continued at St. Patrick's School of Nursing earning her nursing degree in 1978. As a traveling nurse, she journeyed from Montana to Hawaii to Texas and finally to Idaho. In 1982 she drove across the Long Bridge to Sandpoint, fell in love with the lake, put down roots, and made it her home until her earthly departure. She served and cared for the community over four decades at Bonner General Hospital and Kaniksu Community Health and was a proud member of Teamsters Local 690.

Perryman, Thelma, 1928-2024, Soda Springs.

Thelma Perryman, a devoted mother, grandmother, accomplished nurse, and talented knitter, peacefully passed away at the age of 95, on April 23, 2024. After graduating from nursing school in Idaho Falls in 1949, she embarked on a remarkable career in healthcare, touching the lives of countless patients with her expertise and professionalism. Thelma's legacy as a nurse extended far beyond the walls of the hospitals she served in; she was a pillar of strength and compassion to all who knew her.

Rimac, Nicole Marie, 1972-2023, Boise.

After graduating from the University of California Santa Clara with her bachelor's degree in English Literature, Nicole embarked on a new path towards nursing. Fueled by this passion, she enrolled at Creighton University in Omaha, Nebraska, graduating with a Bachelor of Science in Nursing (BSN) and became a registered nurse (RN). She continued her medical education and graduated with honors from the University of California Los Angeles with a master's degree in nursing (MSN) and nurse practitioner (NP) license. Notably, she was inducted into the esteemed Sigma Theta Tau International Honor Society of Nursing. Following her calling, Nicole dedicated her career to Gerontological Nurse Practice. With a servant's heart, she brought compassionate care to palliative and hospice patients in their homes, skilled nursing facilities, assisted living communities, in-patient centers, and outpatient clinics.

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