Royal College of Surgeons in Ireland School of Nursing Certificate in Nursing (Nurse / Midwife Prescribing) (Minor Award, level 8) Application Form October 2010 Please attach 1 passport photograph to this form (use paperclip only) COMPLETE IN BLOCK CAPITALS Section A Surname/Family Name Home address Male/Female Mr/Mrs/Ms/Miss/Other First Names Home phone including area code Previous surname Mobile Number Date of Birth Email address Nationality An Bord Altranais pin number Country of Birth NCNM Position Code if CNS/CMS/ANP/AMP Country of Permanent residence Do you possess a matriculation cert from the NUI? Yes No Have you previously been a student with the Royal College of Surgeons in Ireland? Yes No If yes, please state course and year Do you have any specific learning difficulty which might affect your studies? Yes No Please state below the nature of your disability and any help you may need Section B:Education and Professional Experience Education ( include major awards, ie. Degree, higher diploma and other education courses successfully completed) Continuing Professional Development is one of the criteria used by the selection committee. Please ensure that this section is completed fully, attaching an additional sheet if necessary.
Professional Experience Number of years qualified: As a nurse As a midwife Current Post Full name and address of current employer Position Title/Role/Brief Details Grade (ANP/AMP/CNS/CMS/ CMM/SN) Starting date (Month and year) Previous Posts Section C Reason for Applying for Certificate in Nursing (Nurse / Midwife prescribing)
Section D Mentor s declaration I confirm my intention to act as Clinical Mentor in the practice setting for I understand my commitment to provide supervision and shadowing opportunities of not less than 12 days throughout the duration of the programme. I also undertake to develop a learning contract at the initial stage, meet formally with the student at both intermediate and final stages of the programme and assess the students assessment skills through the use of OSLER s (3 in total). I understand that the Royal College of Surgeons will provide a mentorship training session which I am invited to attend. Mentor s Name (PLEASE PRINT) Mentor s Email Mentor s Phone Mentor s Signature.. Date. Name of Prescribing Centre (ie. Hospital name/primary care site) Clinical Practice Area in which Prescribing will take place (Specific clinical Practice Area, eg diabetes day centre, ICU, Minor injuries clinic) Site liaison individual (Contact person co-ordinating nurse prescribing on site. This person is an additional contact and should not be an applicant for the education programme or a clinical mentor.) Name Grade Phone Email Employers declaration I confirm my support for... in undertaking the Certificate in Nursing (Nurse / Midwife Prescribing) at RCSI. Director of Nursing Signature. Date DoN Email. Applicant s declaration I confirm that I will have regular access to a reliable computer with reliable internet access. I certify that all information given is correct. I confirm that, to the best of my knowledge, the information given on this form is correct. I understand that the making of false statements may lead to withdrawal of an offer of a place. Applicant s signature Date. Remember! Director of Nursing/Midwifery/Public Health Nursing/or relevant Nurse/Midwife manager to complete and sign page 5, Medical mentor to sign page 5 Applicant to complete checklist on page 5 3
Nurse and Midwife Medicinal Product Prescribing Site Declaration Form Essential Criteria for Site Selection Site Declaration Form to be completed on behalf of the Health Service Provider by the Director of Nursing/Midwifery/Public Health Nursing or relevant nurse and midwife manager and submitted with the college application to the third level institution. Criteria Yes No Comment/Evidence Safe Management Do you have in place an Organisational Policy for Nurse and Midwife Medicinal Product Prescribing (or will a policy be in place by the time the nurse or midwife completes the education programme)? Can you demonstrate an ability to safely manage and quality assure prescribing practices? Do you have risk management systems in place? If yes, is there a process for: Adverse event reporting? Incident reporting? Reporting of near misses? Reporting of medication errors? Practice and Education Development Do you have in place appropriate mentoring arrangements with a named medical mentor? (please identify name). Do you have in place robust and agreed collaborative practice arrangements? (if not already existing, will it be in place by the time the nurse or midwife completes the education programme?) Have you identified a named medical practitioner(s)/mentor who has agreed to develop and agree the collaborative practice arrangements? Do you have in place a commitment to continuing education for staff supporting the prescribing initiative? Health Service Provider Do you have in place or have access to a Drugs and Therapeutics Committee? (If No, please describe how this will be achieved?). Do you have in place local arrangements to oversee the introduction of a new practice in prescribing and ensure local evaluation? Do you have in place a named individual (Prescribing Site Coordinator) delegated by the Director of Nursing to have responsibility for the initiative locally and for liaison with the educational provider? For students employed in the voluntary and statutory services of the HSE the Prescribing Site Coordinator will also liaise with Office of the Nursing Service Director (please supply name). Have you established the clinical indemnity arrangements for nurse/midwife prescribing? (please note the Clinical Indemnity Scheme managed by the Sate Claims Agency covers employees of the voluntary and statutory service of the HSE) 4
Criteria Yes No Comment/Evidence Do you have in place a firm commitment by the hospital/organisation board or Chief Executive Officer or Medical Director/Chairman of Medical Board to support the introduction of this prescribing initiative? For students employed in the voluntary and statutory services (only): will your organisation comply with and ensure data input for Nurse and Midwife Prescribing Data Collection System? For all other health service providers can you confirm that you will have a process for monitoring prescribing activity? For students employed in the voluntary and statutory services (only): can you confirm that the Registered Nurse Prescriber will have access to a computer, email and internet for data input to the Nurse and Midwife Prescribing Data Collection System? Will your organisation share details of the Registered Nurse Prescribers scope of practice and prescriptive authority with relevant health professionals? Audit and Evaluation Do you have in place or are you planning to put in place a mechanism to audit the introduction of nurse/midwife prescribing practices? Printed name of the Director of Nursing/Midwifery/Public Health Nursing/or relevant Nurse/Midwife manager: Name of health service provider: Telephone number: Email: Printed name of the Medical Practitioner/Mentor Name of health service provider: Telephone number: Email: Signed by the Director of Nursing/Midwifery/Public Health Nursing/or relevant Nurse/Midwife manager: Date: Signed by the Medical Practitioner/Mentor: Date: Please check the following: 1. The form is fully completed. Incomplete forms will not be considered 2. Your mentor is aware of the mentorship requirements as set out in Section D of this form. The mentor can contact the programme co-ordinator at chanelwatson@rcsi.ie for further information prior to signing the form 3. The name you give on the application form is the name by which you are registered with An Bord Altranais and which will appear on your student ID card, college records and parchment. The completed form should be returned by July 9 th 2010; to Chanel Watson, Programme Co-ordinator, School of Nursing, RCSI 123 St Stephen s Green, Dublin 2; along with the RCSI Student Application Form 5