Camp nursing: Student internships.

Allyson, a nursing student who has completed two years of her four-year BSN program, is hired as the "assistant nurse" at a summer camp for chronically ill children. Susan, the "head nurse," was also the nurse for the camp last year immediately following her own nursing graduation.

The residential camp serves approximately sixty-five chronically ill children each week and has thirty staff on-site. The campers' health concerns vary, but most weeks there are numerous children with autism, learning disabilities, and cerebral palsy. The camp is located just outside a small community with medical doctor offices and the local hospital within a ten-minute drive.

Allyson was required to have current first aid and CPR certificates. Upon hiring, she was provided a practice guideline document identical to that of the Camp RN's. Susan has one day per week off-site, and Allyson is expected to handle all the clinics and health care independently on those days. Staff training focused on first and fire situations -- no specific training was given regarding camper assessment or usual health conditions or concerns.

Experienced camp administrators appreciate that camp nursing is more than applying bandages and passing pills. Quality camp nursing draws upon a blend of nursing assessment and skills and requires knowledge, attitudes, and judgment specific to the unique needs of the camp clientele. For many reasons, camp administrators are finding it more challenging to maintain a healthy camp environment and insure quality health care delivery in the camp setting. Camps are experiencing an environment of increasing societal and parental expectations regarding camp health care while grappling with the growing worldwide nursing shortage. Camp administrators need to be creative and flexible in providing for camp health care, while thinking proactively about the future supply of camp nurses.

Student nurse internships (SNIs), in a variety of models, are described in this article as offering an opportunity to achieve current camp health care requirements while providing for development and recruitment of future camp nurses.

Camp settings have many attributes that make them attractive clinical sites for nursing education. The trick, however, is to explain this to nurse educators; more of whom have limited camp experience and just do not understand how rich a camp clinical experience would be for their nursing students. So tell them. First, most camp settings are dynamic pediatric and community health learning opportunities. Second, most camp health centers are nurse-managed health care environments, a valued environment in nursing education today. This means that nursing care and assessments, the heart of nursing education, can be experienced. Third, students experience a variety of nursing roles while at camp: caregiver, educator, consultant, manager, and decision-maker, to name a few. Lastly, student nurses appreciate opportunities for supervised practice in nontraditional clinical settings that offer course-elective credits.

Recognizing that every camp is unique in organization and programs, the camp administration team, camp health care coordinators, and nursing faculty members would need to creatively brainstorm to determine if an SNI could offer mutually desired outcomes. Camp administrators might also want to know that nurse educators have been challenged in recent years to meet their need for clinical experiences in community and pediatric practice settings. Knowledge of these dynamics will empower camp administrators when approaching a nursing program to negotiate SNIs.

In addition to the obvious benefits of having additional health care trained personnel at the camp setting and equipping student nurses for future camp nursing roles, the preceptoring experience offers current camp nurses a sense of increased job satisfaction and affirmation of their professional role.

Models for Student Nurse Internships in Camp Settings

Various models for camp SNIs have been used, and three are described here. Factors such as camper demographics, camp setting and programming, attributes of the nursing program, and learning goals for the specific nursing course will combine to create the design for an SNI in each camp setting. Variations and expanded discussion of models for nursing student clinical experiences at camp settings are featured in McClure (2001), Praeger (1997), and Maheady (1991).

Preceptored student

The first model for a camp SNI is that of a nursing student preceptored by an onsite registered nurse hired as the camp nurse. In this model, the nursing student can be hired as a "first-aider" or "health-center assistant" under the supervision of the camp RN for all or a portion of the camping season. Alternately, students may negotiate with their nursing faculty member to be assigned to the camp setting for a shorter duration as a course elective within their nursing program - at no cost to the camp other than the student's room and board. Camp settings for which accreditation criteria require more than one onsite health care provider offer the ideal environment for this model.

Under the camp RN's supervision, the student nurse's practice is supervised until the student is deemed competent to function independently. Some student nurse actions require RN supervision each time. Within this model the nursing faculty member is not on-site, but is available for phone consultation and occasional site visits. The faculty member's role involves all the precamp negotiations, including determining the student's boundaries of practice and expectations for the practice experience; marking of written assignments; and availability for consultation by student or camp staff. After the camp RN determines that the student is competent with basic camp nurse role expectations, the student may provide relief breaks for the RN, so long as the RN remains accessible or written care protocols that adhere to the student's boundaries of practice are left regarding allowable actions. Communication tools such as walkie-talkie coverage facilitates the student's collaboration with the camp nurse or administration when situations arise necessitating their involvement.

Because of nursing shortages or other factors, some camp settings have hired student nurses in a "first-aider" role to act as their sole health care provider. This practice is not one that we want to promote or endorse; rather we present it to acknowledge concerns regarding such an arrangement. Numerous cautions must be raised about the inherent risks for both the camp setting and the student.

Sole health care provider model

To turn the arrangement of hiring a student nurse in a first-aider role as the camp's sole health care provider into a second model for student nurse internships, several considerations and preparations can be made. Camp administrators considering hiring student nurses in the first-aider role are strongly urged to review the student characteristics listed in Figure I and obtain an employment referral from the student's nursing program specifically regarding the qualities cited. With advance planning and cooperation with the student's nursing faculty, camp administrators may be able to arrange nursing faculty supervision and student preparation for this role. Students may be able to earn an elective credit course within their nursing program for their independent study experience at camp.

When a student nurse is functioning as the sole health care provider at a camp setting, titles such as "camp nurse," "assistant nurse," or "student nurse" must not be used by camp staff or in camp literature in reference to the first-aider. Nursing registry bodies have strict guidelines as to who may use the title "nurse." A student nurse hired in the capacity of first-aider cannot be referred to by the title "nurse," as the student is not registered, nor licensed (Mass, 1998). In such a role the student must minimally hold a current first-aid certificate; additional wilderness or industrial first-aid certificates, and a medication management course (if the student has not completed a nursing pharmacology course) are strongly recommended.

Camp staff, administration, and the student nurse must all be clear about and support the boundaries of practice for the first-aider role. Practice boundaries for first-aiders are not the same as for registered nurses. Camps can develop written job descriptions for first-aiders to distribute medications that have been medically ordered or that parents direct their camper to receive. However, when acting as a first-aider, the student is constrained from using nursing judgment (except in emergency situations) such as assessing emerging illnesses, withholding a medication dose, or providing any medication that has not been medically ordered or the camper's parents have not specifically directed be given. This includes common over-the-counter medications such as Tylenol(R) and ibuprofen.

Should a camp misrepresent the qualifications of its health care provider(s), or if the first-aider does not adhere to the practice boundaries of the first-aid certificate, both the camp and the student nurse are legally liable should concerns arise about the student's practice or judgment. While not one we recommend, this model of student nurses hired as "first-aiders," - to be the sole health care provider at a camp setting - would be best suited to day or resident camps with physician and hospital services available in the immediate locale. Prior arrangement for nursing faculty supervision and student nurse preparations is strongly recommended.

Negotiated clinical experience model

A third design for SNIs is most suited to those camp settings serving campers with a chronic health challenge, such as diabetes, kidney failure, asthma, or cancer. In this model a nursing faculty member accompanies a group of student nurses to the camp setting for a negotiated clinical experience. The nursing faculty member is contracted to act as one of the onsite camp nurses. The student nurses (group of eight to ten is ideal for the clinical supervision requirements) can attend as camp counselors or attendants to the campers.

The level of care required by the camper population determines the expectations for student experiences. Students could be responsible for assessing the camper(s) in their care and providing for campers' health care requirements under the faculty member's supervision. Variations in student nurse assignment can be arranged to capture the full dimension of the nursing role in these settings. Since most camps serving campers with chronic health challenges typically take place during a set time frame each year, this model of clinical internship could have long-term benefits to the camp and nursing programs if an annual arrangement is negotiated.

The Basics about Nursing Education

Most camp administrators don't know a lot about nursing education and how to go about arranging for student nurse internships at camp settings. Administration may lack awareness of how to locate nursing programs or an understanding of the various types of nursing programs that exist, the level of nursing student which might best fit into a student internship model, and how internships can work.

Various types of nursing programs exist for those who desire to become registered nurses (RNs), the minimal level of nursing preparation required for independent nursing practice such as at a camp setting. Figure II lists the most usual types of nursing education delivery in North America.

Most camp settings serve healthy campers. The challenges of camp nursing in generalist camp settings, with their preventative health care focus, and the need for independent problem solving and critical thinking ability, probably are best suited to students from a baccalaureate nursing program. Post-RN students already have their nursing licensure so would be able to be employed as a camp nurse, so long as they have current licensure in that state or province. All types of nursing students would benefit from the model of the SNI offered in camp settings serving children with chronic health challenges.

Camp SNIs, done under the supervision of the camp RN, or independently as a first-aider, of necessity require a mature and self-directed, upper-level (third-year) student. Internships conducted with a nursing faculty member on-site for the duration of the experience could draw upon students earlier in their nursing program. When negotiating a camp SNI with nursing programs, the camp administrator could describe desirable student nurse characteristics and abilities. Figure 1 lists suggested student nurse attributes for a camp SNI conducted without on-site faculty supervision. Figure III lists attributes of camp settings most likely to support successful, independent SNIs.

Figure IV notes suggestions for locating and contacting nursing programs within your area. Because of licensure issues, nursing faculty must hold current licensure within the same state or province as the camp location in order to provide on-site care or supervise SNIs at a specific camp setting. This means that nursing faculty members must hold state or provincial nursing licensure for the territory that the camp is situated in, even if the camp is just "across the state line".

Negotiating Initial Student Nurse Internships

Camp SNIs are undertaken by nursing students and their faculty to meet educational goals, not merely "meet the need" of the camp setting. Strong camp administrators appreciate the mutual, long-term benefits when all the parties consider that their goals are attained. Negotiations for an SNI should specify clear guidelines for the nursing student's title and scope of practice, which are then written into a clinical learning contract. When nursing faculty members provide on-site supervision in a camp nurse role, there needs to be clear identification of role expectations for the faculty member so that both camp health and clinical teaching goals can be attained.

SNIs require advanced planning. The potential benefits and future supply of qualified camp nurses can justify the investment of energy. Some nursing programs will be able to facilitate approval of course objectives, credits, and contracts within their nursing education department. In other settings the home university or college may have a complex administrative bureaucracy that requires new course offerings (such as when a student internship is first negotiated) be approved not only by the nursing department but also by academic administration departments. Additionally, some educational facilities require that a central office approve student internship placements. Needless to say, adequate time must be allowed for the bureaucratic steps when first time camp student nurse internships are negotiated. An eight-to-twelve-month timeline is recommended to negotiate new partnerships with nursing programs that then result in an SNI.

So what about Allyson, the second-year nursing student from our nursing program, who was hired as "assistant nurse" at the summer camp for children with chronic health concerns? She phoned from camp recently and was thrilled with all the experience she was gaining at the camp setting. She expressed disappointment when told that with advance notice our nursing program could have designed learning activities to provide her with an elective course credit for her summer work.

Strong cautions were given to her about the camp designated title of assistant nurse. We urged that she insist that her title be first-aider or camp health assistant and that all camp personnel be apprised of that distinction. Similar cautions were given about the lack of a distinct job description to distinguish between the camp RN and first-aider roles. In anticipation of Susan's weekly day off-site, Allyson was advised to have specific written care directives within the first-aider's boundaries of practice for all caregiving responsibilities.

Campers and their parents choose this camp setting for the total camp experience, rather than just the camp health clinic; yet overreliance on a student caregiver could leave this camp setting liable for litigation related to potentially poorly managed care or misrepresentation of camp health care staff qualifications.

This camp is fortunate to have hired a nursing student who demonstrates most of the characteristics noted in Figure I. Unless content to leave camp health care to such good luck, camp administrators can secure a reference from the nursing program as to the student's clinical abilities prior to making the offer of employment. Indeed, Allyson has not yet completed her pediatric nursing course, a course that her nursing faculty would have strongly recommended before undertaking this role at the camp setting.

With careful precamp preparation and appropriate supervision, student nurse internships offer the opportunity for student nurses to contribute to camp health care delivery and prepare for future independent camp nursing roles. The camp setting provides the nursing student with unique opportunities for community health nursing practice and nurse-led primary health care delivery.

References

Gray, Lynne (1999). Camp nursing, Nursing BC, 31(3) 12. (online copy available: www.rnabc.bc.ca/practice/campnurs.htl11)

Maheady, D. (1991) Camp nursing practice in review, Pediatric Nursing 17(3) 247-250

Mass, H. (1998) When can you call yourself a nurse? Nursing BC, 30(2) 27-8 (online copy available: www.rnabc.bc.ca/practice/callnurs.htm)

McClure, S. (2001). Bringing student nurses to a camp health center. (11(2),2-3.

Praeger, S. (1997). Establishing camps as clinical sites. Journal of Nursing Education, 36(5),236-7.

The authors gratefully acknowledge and thank Linda Ebner Erceg, RN, MS, Executive Director of the Association of Camp Nurses (ACN) for her input and review in the preparation of this manuscript.

RELATED ARTICLE: Recommended Resources for Camp Health Centers

(For a broader listing, consult the Association of Camp Nurses (ACN) Web site: www.campnurse.org.)

Association of Camp Nurses (ACN) (2001) The Standards and scope nursing practice. Bemidji, MN: Association of Camp Nurses.

Casey, M. (1997). Camp Health Care. Waterloo, ON: Conestoga Printing

Erceg, L. (1999). The basics of camp nursing: medication management. CompassPoint, 9(3), 5-8.

Erceg, L. & Pravda, M. (2001). The Basics of Camp Nursing. Martinsville, IN: American Camping Association.

Lishner, K. & Bruya, M. (new edition anticipated Jan 2002). Creating a Healthy Camp Community: A Nurse's Role. Martinsville, IN: America Camping Association.

Lishner, K. & Busch, K. (1994). Safe delivery of medications to children in summer camps, Pediatric Nursing, 20(3), 249-253.

Your State or Provincial Nursing Registry. Ask if there is a Policy Statement on Camp Nursing

Nursing Student Competence Characteristics

Assess student nurses for potential camp nurse internships at your camp by evaluating the following competencies: (Applicable to student nurses supervised by a camp nurse or acting independently.)

* Current CPR and first-aid certificate; (*) wilderness or industrial first-aid certificates recommended.

* Preference to student having three years completed toward a four-year degree program; ideally completed pediatric and pharmacology nursing courses.

* Prior experience with youth activities or camp settings; independent judgement and personal maturity. (**)

* Strong written and verbal communication skills, including collaborative skills.

* Evidence of organizational abilities. (**)

* Evidence of physical capabilities to manage the requirements of the setting (e.g., wilderness camp setting). (***)

* Willingness to support/abide by camp standards (e.g., substance use, confidentiality).

(*.) photocopies of certificates submitted with application

(**.) these attributes noted on student's clinical nursing evaluations

(***.) doctor's examination to support that student's immunizations are current and that (s)he is in good physical health

Figure I

Types of Nursing Education Programs

Registered Nurse licensure may be gained through varied educational routes

* AD (Associate Degree)/RN Diploma - typically two-year program at college level.

* BSN (Bachelor of Applied Science in Nursing) or BScN (Bachelor of Science in Nursing) - four-year degree program.

* Post-RN (Diploma qualified RN, additional university studies for baccalaureate degree).

* RNA or LPN Registered Nursing Assistant or Licensed Practical Nurse (NOT an RN) - Approximately one year of education for practice under the supervision of an RN. Unless the RNA or LPN has additional medication course certification, typically they are not licensed to dispense medications.

Figure II

Figure III

Camp Characteristics Supportive of Successful Individual SNIs (*)

* Well-equipped health center with written policies guiding practice and documentation.

* Policies designating boundaries of practice for the camp nurse and first-aider role functions. (Note: two separate job descriptions).

* Available resources to guide practice - current protocols and texts relevant to usual and anticipated health challenges (e.g., pediatric and emergency nursing texts, current pharmacology text).

* Well-established relationships and ready access to support resources: medical clinics, pharmacy, and hospital.

* Settings with multiple health professions on site are ideal (e.g., student intern supervised by camp RN); on-site administration provided by experienced administrator.

* Assumption is made that the Camp Health Center complies with all accreditation standards for the camp jurisdiction.

Figure IV

Strategies for Negotiating SNI Programs

1. Contact your state or provincial nurse licensure body.

* Obtain a list of all nursing programs in your state or province.

* Initially contact those closest to the locale of your camp or year-round camp administration offices.

2. Contact selected nursing programs.

* Undergraduate nursing program secretaries can identify faculty members likely to be receptive to discussion of SNI settings.

* Nursing faculty members to target include: course coordinators for pediatric or community nursing courses, community clinical experiences coordinator, or the undergraduate program coordinator.

3. Career center at selected university or college.

* Many career centers facilitate establishment of internships and preceptorships. If the nursing faculty indicates an interest but lacks the resources to establish internships, the career center may have an established format for development of internship and allocation of course credits.

4. If your camp is under the auspices of a denominational/religious group.

* Contact colleges and universities sponsored by or having values compatible with your religious affiliation to determine if they have a nursing program (e.g., Christian camps -- could contact CCCU at www.cccu.org to determine member agencies with programs).

Catherine Hoe Ha rwood grew up spending summers at camp and has experienced various camp roles, including counselor, canteen coordinator, and assistant cook, and camp nurse. Harwood is an Associate Professor in the nursing department of Trinity Western University, Langley, British Columbia.

Lynn Van Hofwegen experienced camp work in Colorado and the Appalachian Mountains. Her experience as an emergency room nurse practitioner has made her see the importance of healthy camp environments as a priority. Van Hofwegen is an Assistant Professor in Nursing at Trinity Western University, where she teaches in community and pediatric nursing courses.