Public Policy Update
Nursing Coalition Honored by
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
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
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
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
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
Enrollments in Nursing Schools
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
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
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
AHA Issues Disaster Readiness
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
• 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
• Although workplace distraction remains the leading
factor contributing to medication errors, the data revealed a drop from 47% in
• 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
For more information about these and other issues,
AACN Web site.
How Do You Define the Clinical
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 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
• 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
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.
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.
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;
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
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
Outcome Identifies expected outcomes for patients,
family members nursing personnel, and organizational systems
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
Evaluation Evaluates progress towards attainment of
expected outcomes for patients, family members, nursing personnel, and
Table 2: Standards for
Professional Performance for the Critical Care CNS5
Quality of Care Systematically develops criteria for
and evaluates the quality and effectiveness of nursing practice and
Individual Evaluates his or her practice in relation
to professional practice standards and relevant regulations
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
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.
AACN offers a variety of small and large research
grants. Following is information about grants for which application deadlines
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
Practice Resource Network
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?
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