AACN News—January 2004—Practice

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Vol. 21, No. 1, JANUARY 2004


Public Policy Update

Nursing Coalition Honored by Association Executives
The Americans for Nursing Shortage Relief, a broad-based coalition of nursing and healthcare provider groups, has been added to the American Society of Association Executives’ 2004 Associations Advance America Honor Roll for its program recognizing Army, Navy, Air Force, Public Service Corps and Veterans Affairs nurses for their contributions to homeland security and patient safety. The ASAE honor roll recognizes associations that propel America forward through innovative projects and professional standards. Since its founding two years ago, ANSR has played an active role in the passage of the Nurse Reinvestment Act and efforts to advance nursing through nursing appropriations. The ANSR recognition program was cited by ASAE as an “outstanding program” that has “resulted in significant benefit to American society.” AACN is a founding member of ANSR.

Nurses Again Top List of Most Ethical Professionals
Nurses again topped Gallup’s annual survey on the honesty and ethics of various professions. In the Nov. 14-to-16 CNN/USA Today/Gallup poll, Americans were asked to rate the honesty and ethical standards of people in 23 different professions as very high, high, average, low or very low. In four of the five times they have been included in the poll, nurses ranked higher than any other profession, with 83% of respondents saying the honesty and ethical standards of nurses are “very high” or “high.” Doctors and veterinarians placed second at 68%, followed by pharmacists at 67%.

FY2004 Funding For Nurse Education Programs
As a result of intense advocacy by the nursing community, Congress has approved an additional $30 million in appropriations for Title VIII Nurse Education Programs/Nurse Reinvestment Act funding in FY 2004, bringing the total funding to approximately $142.7 million. Although there were indications that the funding would increase only about $15 million, the funding grew by nearly $50 million in the last year, a significant step toward the $250 million per year that nursing determined was necessary to fully fund the programs.

The House recently passed its version of the Omnibus Appropriations bill, containing Title VIII funding. The Senate has delayed action until later this month. The Health and Human Services appropriations also include $734.6 million for maternal and child health block grants; $39.8 million for rural outreach grants; and $8.9 million for rural health research. The bill’s homeland security/biodefense appropriations include $1.6 billion for National Institutes of Health programs, $1.1 million for the Centers for Disease Control and Prevention and $518 million for hospital preparedness, $305 million for Children’s Graduate Medical Education, $15 million more than last year and $106 million more than the president’s request.

New Study Shows Nursing Shortage Temporarily Slowed
The recent influx of older and foreign-born workers has temporarily slowed the growth of the hospital nursing shortage, according to a new study published in the November/December issue of Health Affairs. However, researcher Dr. Peter Buerhaus of Vanderbilt University and his colleagues warn that, unless policymakers address the challenges that led to the shortage, the problem will continue to worsen.
The article, titled “Is the Current Shortage of Hospital Nurses Ending?” shows that hospital RN employment and earnings rose dramatically in 2002, with more than 104,000 nurses entering the workforce. The demand for hospital RNs pushed earnings up nearly 5%. The research also showed that older, married RNs over the age of 50, and foreign-born nurses accounted for nearly all of the increase in employment. An abstract of the study is available online at www.healthaffairs.org > Departments > Good News for NurseSupply.

Enrollments in Nursing Schools Jump 15.9%
Enrollments in entry-level baccalaureate programs in nursing increased by 15.9% in fall 2003, according to preliminary results released by the American Association of Colleges of Nursing. The increase follows an 8.1% increase in 2002 and a 3.7% increase in 2001, which reversed a six-year period of enrollment declines. However, the association cautions the growth is not sufficient to address the nation’s current shortage of registered nurses, expected to intensify over the next 10 years.

Hospital Injuries Threaten Patients
Medical injuries during hospitalization resulted in longer hospital stays, higher charges and a higher number of deaths in 2000, according to a study from the Agency for Healthcare Research and Quality. The study, “Excess Length of Stay, Charges, and Mortality Attributable to Medical Injuries During Hospitalization,” was published in the Oct. 8, 2003, issue of the Journal of the American Medical Association. Researchers found that the impact of medical injuries varies substantially. Postoperative bloodstream infections had the most serious consequences, resulting in hospital stays of almost 11 days longer than normal, added charges of $57,727 and an increased risk of death after surgery of 21.9%. Based on these data, researchers estimate that 3,000 Americans die each year from postoperative bloodstream infections. The next most serious event was postoperative re-opening of a surgical incision, with 9.4 excess days, $40,323 in added charges and a 9.6% increase in the risk of death. This equates to an estimated 405 deaths from reopening of surgical incisions annually. Birth and obstetric trauma, in contrast, resulted in little or no excess length of stay, charges, or increase in the risk of death.

The study used AHRQ’s Patient Safety Indicators and Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample data to identify medical injures in 7.45 million hospital discharges from 994 acute care hospitals across 28 states in 2000.

Advocacy Group Seeks Support For ‘ER’ Campaign
The Center for Nursing Advocacy is seeking to increase public understanding of the pivotal role nurses play in modern healthcare by calling for more accurate, balanced and frequent media portrayals of nurses. The center found that recent episodes of the television drama “ER” have been presenting an inaccurate account of nursing today, an example of media problems that the center identifies as a key factor in the nursing shortage. Research confirms that people take the program’s portrayal of healthcare seriously, and that the show affects how children view nursing. The center is calling for nurses to join its campaign to persuade “ER” to improve their programming by consulting nurses when developing scripts. Additional information is available online at www.nursingadvocacy.org.

AHA Issues Disaster Readiness Advisory
The American Hospital Association has issued a new Disaster Readiness Advisory that recommends steps hospitals should take to prepare for the possible re-emergence of severe acute respiratory syndrome. The advisory is a follow-up to the recent release by the Centers for Disease Control and Prevention of its draft SARS plan. It also discusses the transmission of SARS-associated corona virus and important lessons learned from the global experience with SARS in health settings. The AHA advisory can be accessed online at www.hospitalconnect.com > Key Issues > Disaster Readiness.

Bush Signs Medicare Bill
President Bush has signed the Medicare Prescription Drug and Modernization Act of 2003 authorizing a prescription drug benefit for seniors and millions of dollars in payment assistance for providers, though Democrats continued their push for major alterations to the law. At a recent rally attended by hundreds of seniors, U.S. Rep. Chet Edwards (D-Texas) and U.S. Sen. Edward Kennedy (D-Mass.) said they are sponsoring bills that would allow the federal government to negotiate with drug makers for lower prices for Medicare, currently not allowed under the Medicare law, and would repeal a demonstration project in which Medicare would compete with private health plans in six metropolitan areas. The American Nurses Association also opposed the bill, explaining that the Medicare bill fails to provide reliable access to affordable prescription drugs. The bill relies on private insurers to deliver the drug benefit, requiring traditional Medicare to step in only if two private plans are not available in a given geographic area, a fallback estimated to cover only 5% of beneficiaries. In addition, ANA warned that efforts to privatize Medicare threaten the structure of the entitlement. Specifically, the legislation calls for direct competition between private plans and Medicare starting in 2010, a move ANA predicts will raise premiums for traditional Medicare and force seniors into private plans.

Public Policy Snapshot

Survey Shows Rise In Medication Error Reporting

Buoyed by better surveillance, not more errors, hospitals reported an increased number of errors for 2002, according to a report issued by United States Pharmacopoeia. However, because the reporting system is voluntary, the figures may be low.

The USP report found that:
• Of 192,477 medication errors identified, 3,213, or 1.7%, resulted in patient injury. This compares with 105,000 medication errors identified in 2001, with a 2.4% rate of patient injury.
• Seniors were involved in more than one-third of hospital medication errors affecting patients and 55% of the deaths from medication errors.
• 514 of the errors in 2003 required initial or prolonged hospitalization; 47 required interventions to sustain life; and 20 resulted in a patient’s death.
• The most common types of medication errors among seniors were related to omission of dose (43%), improper dose or quantity (18%), unauthorized use (11%) or prescribing (9.6%).
• Other causes of medication errors were wrong route (7%), such as a tube feeding given intravenously, and wrong administration technique (6.5%), such as not diluting concentrated medications.
• Healthcare facilities attributed medication errors to many reasons, most often citing workplace distractions (43%), staffing issues such as shift changes and floating staff (36%) and workload increases (22%) as contributing factors.
• Although workplace distraction remains the leading factor contributing to medication errors, the data revealed a drop from 47% in 2001.
• Insulin, morphine, two blood thinners and potassium chloride, all “high-alert medications,” made up five of the top six drugs involved in errors reported last year to United States Pharmacopoeia.
• Insulin was involved in 5,583 errors, morphine in 3,919, potassium chloride in 3,771, and the blood thinners heparin in 3,684 and warfarin in 2,564.
• 20 errors were fatal. The drugs that showed up most often in harmful errors—narcotic painkillers sedatives, hypnotics and anti-anxiety drugs, and anticonvulsants—all affected the central nervous system. They accounted for 749 of the harmful errors.
• 5,862 incidents, almost exclusively omission errors, involved liquid albuterol and topped the drug list.

To receive a copy of the 2002 data report, e-mail mediarelations@usp.org.

For more information about these and other issues, visit the AACN Web site.
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How Do You Define the Clinical Nurse Specialist?

Mary Lou Sole, RN, PhD, CCNS, FAAN
Advanced Practice Work Group

As nurse practitioner programs were implemented and expanded in recent years, fewer students chose the clinical nurse specialist tracks. At the same time, with the complexity of care in acute care agencies continuing to increase, the CNS role can support and enhance patient care.

As a result, an increasing number of agencies are again seeking CNSs, a fact reflected by an increase in the number of advertisements to fill CNS positions. Search firms are also seeking individuals to fill CNS roles at agencies throughout the United States.

This increased demand for CNS-prepared nurses corresponds to an increase in programs to educate nurses in this role.1 A recent survey reported that 183 schools in the United States offered CNS programs.2 A listing published in the July 2003 issue of Clinical Nurse Specialist is a good resource for those thinking about pursuing CNS education.3

Best of Both Worlds
Nurses who like involvement in direct care but enjoy influencing patients, nurses and the system at large should consider the CNS role when pursuing graduate education. In my role as a nurse educator, I have seen graduate students who pursue the nurse practitioner role for “career advancement,” but are unhappy in their educational program. They are nurses who enjoy working in acute and critical care settings and who prefer dealing with complex patients and healthcare systems to caring for individual patients. If this describes how you feel, talk with CNSs as well as representatives of educational programs in your area to explore opportunities for education as a CNS.

CNS is just one of four categories of advanced practice registered nursing. The others are nurse practitioner, nurse midwife and nurse anesthetist. Each has a unique scope of practice. The CNS has a graduate degree in nursing as a CNS, and is a clinical expert in theory and research-based practice within a specialty area.3 Nurses with educational preparation in acute and critical care are eligible for CCNS certification through AACN Certification Corporation.

Recognition of CNS practice varies from state to state, ranging from no recognition to designation, registration, certification or advanced licensure. The National Association of Clinical Nurse Specialists recommends protecting the CNS title by state statute, because lack of protection means that nurses without formal education as a CNS use the title. To practice and implement the role, the critical care CNS must have adequate education and clinical experience. A master’s degree without CNS didactic content and clinical experience does not prepare the nurse to work as a CNS. The agencies that certify CNSs require a master’s degree in nursing from an accredited program, with evidence of CNS theory and clinical concentration in a specialty. CNS graduates should have master’s core courses in research, theory, ethics and health promotion; advanced practice core courses in pathophysiology, pharmacology and health assessment; and courses in the CNS clinical specialty. Programs should include 500 hours of clinical practice in the CNS role.4

What Do CNSs Do?
Following are some of the roles of CSN practice:
• Integrate knowledge of disease and treatments in a holistic assessment.
• Design, implement and evaluate population-based programs of care to enhance patient outcomes.
• Serve as a leader, consultant, mentor and change agent to achieve quality cost-effective outcomes.
• Lead multidisciplinary groups in designing and implementing innovative solutions that address system problems and patient care issues.

The critical care CNS manages, supports and coordinates the care of acutely and critically ill patients and their family members. The critical care CNS improves outcomes of acute and critically ill patients through three spheres of influence: the patient and family, nursing personnel and the organizational system. AACN’s Scope of Practice and Standards of Professional Performance for the Acute and Critical Care Clinical Nurse Specialist5 guides CNS practice in critical care. Tables 1 and 2 summarize these standards, which can also be used to guide clinical experiences for students enrolled in CNS master’s programs.

References
1. National Association of Clinical Nurse Specialists. Regulatory Credentialing of Clinical Nurse Specialists. Clinical Nurse Specialist. 2003;17:163-169.
2. Walker J, et al. A description of clinical nurse specialist programs in the United States. Clinical Nurse Specialist. 2003;17:50-57.
3. National Association of Clinical Nurse Specialists (NACNS). Statement on Clinical Nurse Specialist Practice and Education. Glenville, Ill: NACNS; 1998.
4. Gerard P, Walker J. Charting a course for your future: A directory of clinical nurse specialist programs in the United States. Clinical Nurse Specialist. 2003;17:211-220.
5. Bell, L. Scope of Practice and Standards of Professional Performance for the Acute and Critical Care Clinical Nurse Specialist. Aliso Viejo, Calif: American Association of Critical-Care Nurses; 2002.

Mary Lou Sole is a professor at the University of Central Florida School of Nursing, Orlando, where she coordinates the CNS track.

Table 1: Standards of Practice for the Critical Care CNS5

Component Activity

Assessment Collects data relevant to three spheres of influence: patient and families, nursing personnel and organizational systems

Diagnosis Analyzes the assessment data to determine the needs of patients, family members, nursing personnel, and organizational systems

Outcome Identifies expected outcomes for patients, family members nursing personnel, and organizational systems
Identification

Planning Facilitates a plan that prescribes interventions to attain the expected outcomes for patients, family members, nursing personnel, and organizational systems

Implementation Implements the interventions identified in the plans for patients/family, nursing personnel and organizational systems

Evaluation Evaluates progress towards attainment of expected outcomes for patients, family members, nursing personnel, and organizational systems

Table 2: Standards for Professional Performance for the Critical Care CNS5

Component Activity

Quality of Care Systematically develops criteria for and evaluates the quality and effectiveness of nursing practice and organizational systems

Individual Evaluates his or her practice in relation to professional practice standards and relevant regulations
Practice
Evaluation

Education Acquires and maintains current knowledge and competency in the three spheres of influence

Collegiality Contributes to the professional development of peers, colleagues, and others

Ethics Decisions and actions are made on behalf of patients and their family members, nursing personnel, and organizational systems and are determined in an ethical manner.

Collaboration Collaborates with patients and their family members and healthcare personnel in creating a healing and caring environment

Research Utilizes, participates in, and disseminates research to enhance practice

Resource Influences resource utilization in order to promote safety, effectiveness, and fiscal accountability in the planning and delivery of patient care.
Utilization

Grants

AACN offers a variety of small and large research grants. Following is information about grants for which application deadlines are approaching:

AACN Critical Care Grant—This grant awards up to $15,000 to support research focused on one or more of AACN’s research priorities. The proposed research may not be used to meet the requirements of an academic degree. Grant applications must be received by Feb. 1.

AACN Mentorship Grant—This grant awards up to $10,000 to support research done by a novice researcher working under the direction of a mentor with expertise in the area of proposed investigation. The novice researcher will be the principal investigator and will receive the award. The novice researcher may be conducting the research to meet requirements for an academic degree, but the mentor may not. The mentor may not be a mentor on an AACN Mentorship Grant in two consecutive years. Grant applications must be received by Feb. 1.

Hospice in Critical Care—This one-time, $4,700 grant will be awarded to a qualified individual carrying out a project that focuses on end-of-life or palliative care outcomes in the critical care area. A broad range of topics may be addressed. However, special consideration will be given to projects that focus on implementation of palliative care or hospice in the critical care unit. Proposals are due Feb. 15.
Evidence-Based Clinical Practice Grant—This grant awards $1,000 to cover direct project expenses, such as printed materials, small equipment and supplies. Eligible projects can include research utilization studies, CQI projects and outcome evaluation studies. Collaborative projects are encouraged. Grant applications must be received by March 1.

To find out more about AACN’s research priorities and grant opportunities, visit the AACN Web site or e-mail research@aacn.org.
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Practice Resource Network

Q: In preparation for the JCAHO survey, we need to develop a policy addressing critical alarms. What does this standard encompass? Does AACN have standards that address this issue?

A: After a review of ventilator-related patient deaths or injuries found problems with alarms in 65% of the cases, JCAHO made alarm safety part of its National Patient Safety Goals for 2003. This goal recommends that hospitals implement regular testing and maintenance of alarm systems and that they ensure all alarms are activated with appropriate settings and sufficiently audible with respect to distances and competing noise within the care area. The JCAHO recommendations apply to alarm systems triggered by a physiological change in the patient that is measured by medical equipment. Included are hemodynamic monitoring alarms, cardiac monitoring alarms, apnea alarms, infusion pump alarms and ventilator alarms for pressure, FIO2, or exhaled CO2.

AACN does not have a standard addressing monitoring alarm limits. However, ECRI, an independent, nonprofit health services research agency formerly known as the Emergency Care Research Institute, addressed this question in an article titled “Critical Alarms and Patient Safety: ECRI’s Guide to Developing Effective Alarm Strategies and Responding to JCAHO’s Alarm-Safety Goal,” which appeared in its Health Devices journal. Additional information is available online at www.ecri.org. Search for “alarm safety.”

If you have a practice-related question, call AACN’s Practice Resource Network at (800) 394-5995, ext. 217, or e-mail your question to practice@aacn.org.

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