ANA delegates revise bylaws, question “new” certification

ANA delegates revise bylaws,

question “new” certification

Ice cream cones, bicycles, and sunburns were the scene as one walked along the boardwalk during the American Nurses’ As- sociation (ANA) convention in Atlantic City, a historic oceanside resort city in New Jersey.

The theme of the convention, “A past to remember-a future to shape,” marked the Bicentennial year as well as the 80th an- niversary of ANA. A total of 9,271 nurses attended the convention.

Resisting the temptation of ocean breezes and sunny skies and sometimes perspiring under a faulty air-conditioning system, more than 1,000 delegates spent long hours struggling through a major revision of the ANA bylaws and a roster of resolutions. The House of Delegates met in eight-hour sessions Tuesday through Thursday and in scheduled half-day sessions on Monday and Friday.

The debate on the bylaws, scheduled for 16 hours, began Wednesday morning, but by Thursday noon, it was apparent that discussion would go into overtime. The House de- clined to limit debate, but restrained each speaker to one minute and voted to hold an additional session Thursday evening. The final vote on the bylaws came Friday afternoon.

Active debate on the bylaws, other issues marked the daily sessions of the House of Delegates.

It was during the Thursday evening session that the issue of ANAs new approach to certification-an issue that had been smol- dering throughout the convention4ame up for debate. Shortly before the convention, the Divisions on Practice announced that the ANA certification for excellence in nursing practice would be replaced with certification for competence. Nurses holding master’s degrees would be eligible for certification for excellence through diplomate status in a newly created American College of Nursing Practice. (AORN Journal, August 1976, p 203.)

A motion by the Illinois delegate to rescind the new approach to certification was hotly debated for two hours before being called out of order by ANA President Rosamond Ga- brielson. At 10:50 pm, she announced that

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After 40 minutes of debate, ANA delegates voted to establish a Commission on Human Rights.

The Commission will establish the scope of the ANAs responsibility for addressing and responding to equal opportunity and human rights concerns of nurses and health care recipients, with the major focus on ethnic people of color.

A motion opposing formation of the new commission was defeated. It was made by a delegate from Connecticut who believed formation of the Commission “inconsistent” with the delegates’ earlier decision agreeing that “the purposes of ANA shall be unrestricted by consideration of nationality, race, creed, life style, color, sex, and age.”

for the Commission came from Kathryn S Chance of Georgia: “If you don’t see the need today for a human right‘s commission, you’ve got your head in the sand.”

Also defeated was a motion to delete the words, “with the major focus on ethnic people of color,” and insert, “in accordance with the purposes of ANA.” The maker of the motion said the focus may change from time to time. “One year it might be on age, another year, sex, and so on,” he said.

Ethelrine Shaw, chairperson of ANAs Task Force on Affirmative Action, explained

The clincher pursuading delegates to vote

New commission concerned with human rights why the major emphasis is on ethnic people of color. She pointed out that the task force was set up in 1972 to study the concerns, problems, and needs of minority nurses as they relate to ANA and state nurses’ associations. Even though ANA and the National Association of Colored Graduates merged in 1952, it took about ten years for all states to grant membership privileges to black nurses. “It is because of this commitment made over time to a group of nurses disenfranchised to some extent from the association, that (the task force) specified that the Commission focus on this group. The problem is still there,” she said. “We have achieved some of our goals within affirmative action kinds of activities but not human rights kinds of activities.”

In answer to a question, Shaw agreed that implicit in the term human rights, is “concern for recipients of nursing services, students’ rights, patients’ rights, and the rights of human subjects in research as well as rights of ethnic people of color.”

She defined ethnic people of color as “native Americans, such as the American Indian, blacks, and other groups who have been deprived of some of the opportunities within this association as well as social institutions.”

the motion was out of order because the Divisions on Practice, under the existing bylaws, had the power to establish certification.

She told the House, however, that the Divisions heard what the delegates were saying. The issue of certification has been referred to Divisions for reconsideration.

Bylaws changes included change in the representation in the House of Delegates to provide one delegate for every 300 members instead of one for every 200. In addition each delegation has a member-at-large.

A motion to hold annual ANA meetings instead of biennial meetings was defeated.

After lengthy debate, dues were increased from $25 to $35 turning down the proposed increase to $40 suggested by the Board of

Directors. The Board considered this the minimum to maintain current potential opera- tions. The increase for national dues goes into effect September 1976. A note of historical interest: when ANA met in Atlantic City in 1946, the dues were increased from $.75 to $3.

A standing committee on ethics was created to study and interpret the Code for Nurses, recommend any revisions, and provide for enforcement of the code. The committee will study ethical aspects of nursing and health care.

A new Commission on Human Rights will be concerned with the rights of both nurses and consumers of health care with a major focus on ethnic people of color. (See side- bar)


A newly created Committee of Chairper- sons will facilitate communication on public policies in health among ANA units and nurses. It will keep nurses informed about federal legislation, with special concern about national health insurance.

Officers of the Congress for Nursing Prac- tice will be elected rather than appointed. The Congress is a group of elected and appointed members responsible for advanc- ing the practice of nursing through activities dealing with the scope of practice, the ethical and legal aspects of nursing practice, trends in health care with implications for nursing, and public recognition of the significance of nursing practice to health care.

Two controversial resolutions related to the

bylaws. The approval of Resolution 42, “ANA is a Multipurpose Organization,” rejected the concept proposed by the bylaws committee that representation on the Board of Directors, House of Delegates, and nominating committee be based proportionately on managerial and nonmanagerial positions.

The resolution established that the ten directors of the Board, delegates, and nominating committee be elected at large. In doing so, the delegates left the question of representation to be decided at the local level and affirmed that no structure was needed to ensure the rights of members.

Resolution 46 proposed direct membership at the national, state, and district levels. The motivation for the resolution was the failure of ANA membership to increase despite an increasing number of nurses and the loss of membership due to the ANA Economic and General Welfare Program. Proponents of direct membership asserted that all levels of membership are viable and that the organization would be strengthened by the involvement of nurses at some levels, but not all three. Opponents argued that the “district organizations will die if nurses are allowed to join only the national organization.”

As approved, the resolution removes the 1972 moratorium on alternative membership projects and permits state nurses associa-

AORN President Barba J Edwards (right) confers with former A 0 R N President Patricia Rogers during the Delegates meeting.

tions to work with ANA on direct membership projects but does not open direct membership at different levels.

The principle of trilevel membership was strongly endorsed, however, when the delegates voted to make it a requirement for election to the House of Delegates and Board of Directors.

A resolution was approved opposing training programs that prepare nursing assistants to administer medication and recommending that ANA pursue federation regulations rela- tive to administration of medication. Recent federal regulations for Medicare and

532 AORN Journal, September 1976, Val 24, No 3

Code for nurses 1. The nurse provides mice6 with respect

for human dignity and the uniqueness of the client unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.

privacy by judiciously protecting information of a confidential nature.

3. The nurse acts to safeguard the client and the public when health care and safety are affected by the incompetent, unethical, or illegal practice of any person.

4. The nurse assumes responsibility and accountability for individual nursing judgments and actions.

5. The nurse maintains competence in nursing.

6. The nurse exercises informed judgment and uses individual competence and qualifications as criteria in seeking

2. The nurse safeguards the client's right to

wnsultatbn, accepting responsibilities. and delegating nursing activities to others.

7. The nurse participates in activities that contribute to the ongoing development of the profession's body of knowledge.

profession's efforts to implement and improve standards of nursing.

9. The nurse participates in the profession's efforts to establish and maintain conditions of employment conducive to high quality nursing care.

10. The nurse participates in the profession's effort to protect the public from misinformation and misrepresentation and maintain the integrity of nursing.

11. The nurse collaborates with members of the health professions and other citizens in promoting community and national efforts to meet the health needs of the public.

8. The nurse participates in the

Medicaid programs have permitted the administration of medications by nurse's aides in long-term care settings.

The House passed a resolution that ANA actively support and protect the nursing service administrator's right to remain members of the association. Resolutions were also passed on involvement of nurses in health planning, family planning, child abuse and neglect, community abrnatives to mental hospitalization, and representation of ANA on the Joint Commission on Accreditation of Hospitals.

Keynoter charts course for future for nursing

in the keynote speech at the opening of the ANA convention, President Rosamond Ga- briilson looked to ANAs future as it nears its 80th birthday.

"We have a past worth remembering. but, more importantly. we have a future to shepe."

Citing ANAs record in nursing research, nursing practiie legislation, development of advanced and continuing education programs, the implementation of standards of nursing education, pracl i i , and sewice. and the economic general welfare of nurses, she affirmed that ANA will continue to promote the educational and professional advancement of nurses to ensure quality nursing care for the American public.

The key to nursing's power is unity, said Gabrieison, who served as ANA president from 1972 to 1976. "Society bears witness to the fact that if a group fails to establish its own controls and safeguards, the rules and regulations of others will be imposed upon it, and the group will cease to function as a distinct body of practitioners."

She urged the 1.3 million nurses of America to pool resources and organize efforts to anticipate health care demands for the next 30 years and initiate innovative nurs-

534 AORN Journal. September 1976, Vol24, No 3

ity, illness, and death. “Can nursing move innovatively to counsel, advise, and assist individuals to cope with new and changing anxieties, new body images, new environmental controls, and increased longevity?”

Urging the profession to find its risk-takers and leaders who have the ability to change future directions for the profession and association, Gabrielson said, “The foremost priority must always be the advancement for the greater good of nursing.” ANA members must realize that what is good for the profession may not always be immediately advan- tageous for them, and that what is best for the public may on occasion, conflict with the vested interests of nursing.

Zimmerman takes presidency for next biennium

Outgoing ANA President Rosamond Gabrielson addresses the opening session of the 50th ANA convention.

ing programs to satisfy projected demands. In charting a future course for nursing,

Gabrielson said it is crucial to identify issues confronting nurses such as standards for educational preparation, legal safeguards, and recognition of levels of competency, and to predict socioeconomic, political, and scien- tific trends and how they will affect the profession.

Citing “the experts,” she said the future will see increased governmental regulation and control of the health care system, proliferation of knowledge, and a longer life span.

Specialization of health care workers will be markedly increased due to proliferation of knowledge and extensive use of technology. The majority will become “mere technicians,” due to dependence on technology. This is predicted to remove incentives for innova- tion, creativity, and personalization of health care services.

In light of these changes, Gabrielson asked if nursing can remain the constant in maintaining humanitarian care vital to patients and families as they cope with disabil-

~~~~ ~~

Anne Zimmerman, Chicago, 111, executive administrator of the Illinois Nurses Associa- tion, has been elected president of the American Nurses’ Association.

In discussing her goals for ANA during her two-year term, Mrs Zimmerman emphasized that “every nurse is a member of a nursing collective, regardless of his or her specialization. It is important to keep that collective intact, and not have it weakened. . . . I will try to protect it and . . . inject more ‘tensile’ strength into the ANAs overall power position as one of my primary goals.”

Regarding national issues, the new ANA president said the association “must strengthen its ability to establish nursing policies that will influence such issues as National Health Insurance, Medicare, education, and others. We will make every effort to release, quickly, ANA position statements on all issues that relate to public health. National policies should be arrived at thoughtfully and democratically and, once pronounced, they should be promulgated consistently and with confidence. Yet there must always be room within ANA for debate, dissent, and minority views.” She added that additional membership in ANA would give the organization

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New ANA President Anne Zimmerman’s goal is more tensile strength in ANA’s overall power position.

stronger bargaining power in addressing national issues and that an additional goal would be to increase substantially the number of members in the next two years. At present, ANA has about 200,000 members.

Born in Helena, Mont, Mrs Zimmerman earned her diploma in nursing at the Sisters of Charity of Leavenworth in Helena, and spent seven years as a staff nurse in that city. She has served on several ANA committees and commissions and is vice-president of the AJN Company. She has been executive secretary of the Montana Nurses’ As- sociation, associate director of the California Nurses’ Association, a member of the board of directors of ANA, and chairman of its Commission on Economic and General Wel- fare.

The new ANA president represented the United States at a special World Health Con-

ference in Geneva in 1973 and was one of two ANA representatives who participated in 1975 in an international conference on the life and work of health workers in Moscow.

Other new ANA officers Other officers elected are Evelyn Peck, first vice-president; Muriel Poulin, second vice- president; Gayle Pearson, third vice- president; Joan Guy, secretary; Harold MacKinnon, treasurer.

Five directors elected are: Mary Patton, general duty; Ruth Benson, occupational health; Loretta Graf, private duty; Ray Show- alter, CESR; Clifford Jordan, other.

Elected to commissions are: Virginia Cle- land, Judith Grybowski, Louise Landis, economic and general welfare; Doris Blaney, Maura Carroll, Rose McKay, nursing education; Barbara Horn, Nola Pender, Barbara Walike, nursing research; Rosamond Gab- rielson, Gertrude Hotaling, Jannetta Mac- Phail, nursing services.

Elected to the nominating committee were Billye Brown, Jean Grimsley, Dorothea Novak, and Audrey Spector.

Results of division elections are: Raymond Cink, Frances Devlin, Ruth Hutchison, Caro- lyn Whitaker, Jean Williams, community health nursing practice; Sally Buseck, Sylvia (Drass) Schraff, Patricia Mary Lentsch, Caro- lyn Oglesby, Eldonna Marie Shields, geriatric nursing practice; Kathryn Barnard, Ruth Redmann, M Elaine Wittman, Ann Clark (the fifth position will be decided by a draw by lot between Donna Nativio and Carolyn Stoll, who tied), maternal and child health nursing practice; Elizabeth Giblin, Magdalen (Mar- row) Stafford, Cynthia Scalzi, Margaret Staf- ford, Mary Wagner, medical-surgical nursing practice; Jackie Belcher, Elizabeth Carter, Betty Evans, Martha Mitchell, Oliver Os- borne, psychiatric and mental health nursing practice.

AORN Journal, September 1976, Vol24, No 3 539

Accreditation of Continuing Education in Nursing National Accreditation Board for Continuing 1 Education

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5 Regional National Accrediting Committees Review Committee

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District #99

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\ Programs Prepairing

Nurses for Expanded Roles

I National Specialty

Used with permission of the American Nurses’ Association from Accredita- tion of Continuing Education in Nursing, p 5.

Alexander was chairperson of the ANA ad hoc committee on accreditation of continuing education and is a current member of the

Alexander presents ANA mechanism for accreditation ANA National Accreditation Board. She is

AORN director of education.

With the rapid proliferation of continuing IS accreditation necessary? Explaining the education activities, many Offerings Of Clues- ANA mechanism for accreditation of continu- tionable nature have arisen, according to ing education in nursing, Carol Alexander Alexander. Accreditation is necessary to told an ANA audience that the answer is an assure participants that the quality of an emphatic yes. offering has been monitored and minimal

540 AORN Journal, September 1976, Vol24 , No 3

Entering the convention center, one runs a gauntlet of ANA members electioneering for their favorite candidates.

standards of continuing education have been met.

Nurses have demanded, said Alexander, that continuing education be monitored by the nursing profession, itself, through a voluntary process. They would prefer to not have an external agency such as the federal government impose an accreditation process which allowed minimal input by nurses themselves.

Citing reasons why nurses wanted ANA to be involved in accreditation, Alexander stated that nurses did not want a myriad of approaches from a number of organizations that “wanted a piece of the action.” For example, different approaches by 50 state nurses associations (SNA) are not effective. Neither are numerous approaches by various specialty nursing organizations.

She referred to the ongoing dispute between ANA and the National League for Nursing as to which organization should accredit continuing education programs based within university or college settings.

“Nurses want interstate transferability and a uniform system of record keeping,” Alex- ander pointed out. She added that there is a close correlation between continuing education and practice. Because of ANAs emphasis on nursing practice, it seems logical to enhance the above correlation by institut-

ing an ANA accreditation mechanism for continuing education.

Listing other objectives of accreditation, Alexander stated it stimulates improvements in the design of continuing education offerings and also provides support to educators in documenting budget, staff, and service needs. Accreditation can reinforce to institutions the value of continuing education and identify institutions for investment of public and private funds.

The speaker shared with the audience some issues the committee on accreditation of continuing education faced when it was formed in 1973 to develop the current accreditation mechanism.

The first challenge, she said, was to design a national system that encompassed accreditation on national, regional, state, and district levels. A second problem was the relationship between ANA and other accrediting bodies, especially NLN.

“We found that we had to develop a mechanism despite our inability to resolve historical organizational conflicts,” she told the audience.

The third problem was collaboration with various nursing groups. “How do we address the needs of federal services, state boards of nursing, and specialty nursing organizations?” Alexander asked.

642 AORN Journal, September 1976, Val 24, No 3

“And how does one collaborate with these various groups and bring them together as a unified force? How do we provide a way for these groups to collaborate effectively with a sharing of the workload and financial costs, yet recognize their individual expertise?”

One issue Alexander confessed the committee did not know how to handle was the effect of the ANA program of economic security on the accreditation process. She acknowledged that some hospital administrators saw a conflict of interest between ANA as a bargaining agent and as an ac- creditor of continuing education but that ANA did not because it is a multi-purposed organization.

The committee also dealt with the issue of who should accredit university continuing education programs. Should there be a sepa- rate mechanism for that process, or should these programs be approved by the state nurses associations? “As you know,” she told the audience, “this question was re- solved by having university programs accredited by the regional accrediting committee rather than state nurses associations.”

She explained that although state nurses associations objected to having universities exempt from working with them, “we heard from university people of conflicts between universities and state nurses associations.”

Alexander also raised questions about the competence of some state nurses associations to accredit continuing education. “What if they don’t have adequate staffing, funds, or expertise to implement the accreditation process?” she asked. The committee looked at but rejected the idea of consortiums of SNAs that would approve offerings in several states.

The mechanisms for accreditation had to be workable in states with mandatory continuing education as well as those with voluntary systems, Alexander explains. Inter- relationship with the US Office of Education was also essential.

Presenting the mechanism, Alexander explained that the national accreditation board for continuing education is responsible for monitoring five regional accreditation committees and the national review committee. The Board oversees the delineation and enforcement of criteria and develops policies

and procedures, monitoring them on an ongoing basis to make sure that the mechanism is being properly interpreted and implemented.

The Board, Alexander said, also accredits ANA. Alexander noted that the committee believed that no organization should be exempt. In turn ANA will approve district #99, or nurses who work overseas and are ANA members.

The five regional accrediting committees accredit three primary groups: university and colleges; state nurses associations; and national specialty nurses organizations, federal nursing services, and state boards of nursing.

Organizations such as state nurses associations, federal services, state boards of nursing, and specialty nursing organizations can be accredited for two purposes: 1) to conduct their own continuing education program, and 2) to approve their sponsors and constituents. A program is an ongoing series of educational offerings; an offering is an individual educational activity. An example of a constituent would be a district of a state nurses association; an example of a sponsor might be a local heart association offering a single educational activity.

Referring to the controversy regarding accreditation of university and college programs, Alexander commented that the mechanism is flexible. “The committee knew,” she explained, “that some universities and colleges would seek accreditation through the National League for Nursing. We are not mandating that colleges and universities use ANAs mechanism. We are saying that there are alternatives and you must assess the pros and cons of the existing accreditation systems.”

The committee also considered some of the issues regarding continuing education programs for preparing nurses for expanded roles. Alexander raised the questions of whether expanded role programs should be taught in nondegree settings, and whether physicians and nurses should be collaborat- ing in these programs.

In closing, Alexander said that the mechanism for accreditation of continuing education will be monitored through a system set up by the ANA Commission on Nursing

’


Those who did not have to attend meetings could head for a pleasant afternoon of building sandcastles on the beach under sunny skies.

Education and the Council on Continuing Education. The monitoring will be for five years, and Alexander said, “We anticipate that changes will be made.”

Nurses’ own mental health linked to human liberation

Although nurses are forging ahead and to some degree have achieved a more substan- tial role in providing health care, the resolution of some issues linking the profession of nursing and the human liberation movement will improve the mental health of nurses.

This was the message of Hildegard E Pep-

lau to the Advanced Practitioners in Psychiatric-Mental Health Nursing at the ANA convention. Professor emeritus at Rut- gers University, Peplau is currently visiting professor at the University of Leuven, Bel- gium.

One ‘‘lingering’’ issue is the connection of nursing to its roots in the mothering function. Peplau pointed out the necessity of distin- guishing nursing as an autonomous professional service practiced in the community and requiring an academic-based education as opposed to nursing as a universal function of all women, learned from other women, not requiring any education and practiced at home under the protection of husbands, and if necessary, male physicians.

Only recently, Peplau noted, “has professional nursing asserted and implemented its claim of freedom from male protection.” As women at home deferred to men, nurses in hospitals invented the “nurse-doctor’’ game and clung to their role as being little more than the extension of the universal nursing function of all women. As a result, nurses failed to study the impact of their practices on human processes and their effects upon health, according to Peplau.

With the knowledge explosion of the past 30 to 40 years, customary nursing functions were replaced by modern medical technology and became a function of physicians employing machines and drugs.

“Without quite appreciating the nature and extent of nursing’s identity crisis, nursing clung to the traditional practices, fought the movement of nursing education into academia, and had many new medical- assisting functions thrust upon them,” Peplau explained.

She concludes, “Except for the few nurses who sought to redefine nursing and/or who fought to continue the advancement of the profession along several new lines of development, most nurses acquiesced to the

, prevailing tendency-to work under the male protection and guidance of physicians and hospital administrators.”

Pointing out that nursing is still sex typed and that while no direct efforts have been made to exclude male recruits, Peplau stated, “There is a possibility that many


nurses prefer to work under rather than with men.”

Suggesting that nursing attempt to com- bine male and female attributes of nurtur- ance and empathy with male attributes of intelligence, assertiveness, independence, and self-discipline, Peplau states “many women nurses . . . hide their intelligence, fail to recognize and assert their autonomy, and in these ways fail to develop themselves fully as whole persons. . . .

“The development of a collaborative, col- league relationship between nurses and physicians calls for more ‘tough-minded- ness,’ competition, and aggressive action to bring it about, and willingness to take risks and make decisions and take responsibility for them,” Peplau asserted.

Peplau believes that nurses, like most women, fear both success and failure, but their greatest fear is not being liked. Nurses aim to please men, even preferring to give direct care to male rather than to female patients.

She told nurses that career commitment calls for full participation in the profession’s work including contributing to its advances through intellectual activity. She pointed out that nurses rarely build on each other’s pub- lished works, nor do they rely on each other for new insight. “Look at any textbook and most journal articles written by nurses about nursing,” she suggested, “and you are likely to find a preponderance of nonnursing refer- ences to male authors.”

Nurses, she adds, are reluctant to learn and use theory in relation to nursing practice. They are also ambivalent about those who introduce “noise” into the system.

In conclusion, Peplau challenged nurses to “strengthen themselves and their positions so as to be able to take stands that count in support of fully operative humanism in health care systems.

“Nurses must become the clearest possible models, demonstrating humane care. The dimensions of such care include com- passion and tenderness, but also more than that. Illness provides an opportunity for learning about oneself and for taking new growth steps in personal development.”

OR Forum dissolved

The OR Forum of the American Nurses’ As- sociation was dissolved at a brief meeting attended by 25 operating room nurses.

The move to dissolve was initiated at the 1974 meeting of the Forum in San Francisco when an ad hoc committee was established to consider the disbanding.

After a brief discussion, those attending this year’s meeting accepted the ad hoc committee’s recommendation that:

The ANA Forum for Operating Room Nurses be dissolved; and that Joint membership in ANA-to meet the professional needs-and AORN-to meet the clinical needs-be promoted. The a d hoc committee discussed the pos-

sibility of establishing an operating room nursing practice council with an assessment of $25 for membership. The committee believed, however, that OR nurses would not support financially ANA, an OR Council, and AORN. It was pointed out that AORN is the organization that ANA recognizes for expert advice. The committee felt an OR Council would promote duplication of services and fragmentation of nursing.

Proper practice protection against damage suits

The nurse’s best protection against damage suits is the consistent practice of her/his profession in the proper manner, according to Helen Creighton, RN, JD, attorney and professor of nursing, University of Wisconsin, Milwaukee.

“Professional negligence is synonymous with malpractice,” she said, explaining that the difference between malpractice and negligence is not well distinguished.

“Malpractice (is) any professional miscon- duct, unreasonable lack of skill or fidelity in


professional or judiciary duties, evil practice, or illegal or immoral conduct,” Creighton explained. “Negligence has been defined as omission to do something which a reasonable person, guided by those ordinary considerations which ordinarily regulate human affairs, would do, or as something which a reasonable and prudent person would not do.”

Creighton said an understanding of the nature of malpractice and the acts of commission or omission that give rise to suits may help the nurse “cooperate with doctors and others in minimizing the problem.”

Tracing the growth of the malpractice prob-

lem from the 1930s to the present, Creighton noted that malpractice suits increased markedly after World War II. The rising standard of living has enabled an increasing number of people to receive medical and nursing care. This has automatically increased expo- sure to incidents that could lead to suits.

Other contributing factors are increasing complexities of medicine, nursing, and the health care system; unrealistic expectations by the public about the capabilities of medicine; and less personal care resulting from treatment by teams.

Another factor leading to increased malpractice suits is the growing interest in consumer rights and compensation for injuries.

Creighton cited a number of cases illustrat- ing that nurses are not immune to lawsuits. The first $1 million malpractice award against a nurse and her employer was made in July 1974. No damages were assessed against the physician. This case involved the Hol- linger baby who was examined by a physician and sent to the hospital for severe croup or cough. Upon his arrival, the nurse, without authorization, placed him in a steam room where his heart stopped beating for several minutes. He suffered permanent brain dam-

Attorney Helen Creighton warns nurses of necessity for liability insurance.

age and lost the use of his limbs as a result. Experts testified at the trial that the boy had epiglottitis, a severe form of croup that can cause a child to strangle. The baby should have been intubated to allow breathing.

In Ray v Loretto Hospital (Ill Cir Ct, Cook Co, Nov 1975, Citation, 32323-4, March 15, 1976) a patient died of cardiac arrest during surgery. The 30-year-old man was given a general anesthetic to repair a lacerated finger, but no one checked the chart to find out when the patient last ate a large meal. (It was recorded in the chart that the patient had eaten five hours before surgery.) “While


Boston attorney Virginia Hall suggests changes in nurse practice acts should be studied carefully.

vomiting was noted on his chart, anesthesiologist gave him more sodium penthot- ha1 when he became restless during surgery. The patient was not intubated and sustained a fatal cardiac arrest,” Creighton related. The nurse was implicated equally with the hospital and anesthesiologist. Each had to pay $61,666.

Creighton described two cases in which nurses had to pay damages for a sponge count error. In Martin v Perth Amboy Hospi- tal, et al, (1969 CCH Neg 4385, NJ) a scrub nurse and circulating nurse each had to pay $4,000. In Hestbeck v Hennepin County (212 NW 2d 361 Minn 1973) a sponge count error resulted in a judgment of $8,125 against the defendant surgeon. The nurses employed by the hospital were assessed $4,375 or 35% of the total verdict.

As protection against possible financial loss from malpractice claims, Creighton urged nurses to obtain liability insurance. She pointed out that a nurse may be sued for malpractice or negligence both on-the-job or

while off duty in a Good Samaritan situation in which he/she is called upon to give nursing services.

“Many nurses work under the impression they are protected by their employer’s insurance policy. Before relying entirely on such coverage, Creighton advised the prudent nurse to examine her employer’s policy to determine if it provides adequate coverage.

She noted that students of diploma schools of nursing are covered by the spon- soring hospital’s policy whereas bac- calaureate and associate degree students are not. She advised the latter students to purchase professional liability insurance.

Enumerating benefits of professional liability insurance, Creighton said it pays damages within the specified limits of the policy; it pays the cost of a lawyer to defend the person sued in civil court for alleged injury resulting from his/her professional work, and it will pay bond for a nurse if required during an appeal.

“Soothing the patient’s psyche has been suggested to reduce lawsuits,” Creighton said. “lnservice programs and continuing education workshops and seminars aimed at minimizing lawsuits might well include in- struction in administrative, environmental, and psychologic factors that influence the suit-prone patient as well as principles of professional liability law.”

Attorney advises caution in revising nurse practice acts

Encouraged that many states have attemp- ted to update their nurse practice acts to keep in line with current developments in nursing, Virginia C Hall, a Boston attorney, nevertheless cautioned the nursing profession in states where the law has not been changed not to summarily push for the amendment simply because it is new and superficially sounds more modern.

The nursing profession should “be very clear, first, as to just what its present law says and does not say and, second, as to

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662 AORN 3ourna1, September 1976, Vol24 , No 3

just what a proposed amendment will and will not do for them.” Hall based her opinions on a 1974 survey of nurse practice acts she prepared for the National Joint Practice Commission concerning the legal scope of nursing practice in the medical area.

Of the 51 jurisdictions, 22 had amended their definitions of nursing practice within the previous five years and at least two others have followed suit since then, Hall said. “Amendment of the statutory definition of nursing is not . . . a strictly academic exer- cise; it has a very utilitarian purpose. The practice of nursing has significantly changed in many ways recently and . . . is continuing to evolve, but from a legal point of view, the significant change is in the area of medical decision-making. Where once the nurse acted in a strictly delegated medical capacity, the nurse today, who practices in the so- called extended or expanded role, exercises far more autonomy within a limited medical sphere. The significance . . . from a legal point of view is that it involves the nurse at least arguably in the practice of medicine, which has traditionally been illegal in virtually all the states. . . . Thus, the new nurse practice acts should be judged on how suc- cessfully they dispel this traditional taboo, while at the same time retaining responsible control over the practice of nursing and not merely giving carte blanche for a medically advanced sort of practice to those who are not qualified for it.”

In the performance of acts recognized as proper by professional nursing and medical opinion and in areas that overlap, Hall warned that nursing cannot continue to evolve in the medical area as it is now doing unless the two professions work together to effectively and efficiently use the abilities of both professionals. She sees nothing de- meaning for nurses to acknowledge that physicians should share in the determination of their medical roles.

Hall commended the new ANA model definition that is not yet law in any state. Other than minor criticism, she feels that the definition is simple and comprehensible and broadly outlines what nursing is all about.

Hall elaborated on three types of provi- sions appearing in some nurse practice acts

that are or could be relevant to the legal scope of nursing practice and spoke of their implications. They are a flat prohibition against the practice of medicine, sections dealing with a particular nursing specialty, and a grant of general regulatory power to the board of nursing apart from a special grant of regulatory authority in an additional acts amendment such as appears in some states.

In her discussion of the relevance of medical practice acts to nursing practice, Hall declared there is not a great deal of consis- tency about what the two acts permit or prohibit nurses to do.

She suggested that those states that have not yet amended their nurse practice acts proceed with caution, consider revising all parts that may prove troublesome, and examine all statutes that bear on nursing, working to assure that they and the nurse practice act as amended “speak with one voice.”

Sabbatical suggested as viable way of lifelong learning

“In the past ten years, we’ve had to run to keep in place. Now quantum leaps are required,” said Vernice Ferguson, Fellow of the American Academy of Nursing, chief, Nurs- ing Department, Clinical Center, National In- stitutes of Health, Bethesda, Md.

Speaking on the future of continuing education, she described the implications of the knowledge and technology explosion.

“I foresee more activated consumers who will know more, do more, and ask penetrat- ing questions of care providers.” She explained that in the future, less care will be given by physicians than is given now. A little more might be given by nurses, but much more will be given by consumers themselves-the activated ones.

“Care givers must have higher levels of competence, greater knowledge and skill, and be able to communicate well, to inter-

556 AORN Journal, September 1976, VoL 24, No 3

view, to assess, and to problem solve, individuality and insularity. “That might sound sometimes over distance and without the heretical, but the need of knowledge is so consumer in sight.” great and so little is enclosed in each of us,

we have to cross institutional lines to collabo- to know that the role of the health care rate in planning, in learning, and evaluating.”

According to Ferguson, “Consumers need

provider is rapidly changing, that all care givers are responsible for their acts, that accreditation and credentialing are a way of life and will be more and more necessary to assure safe and adequate care. They need to know we make policy, shape decisions, conduct studies, teach, and evaluate our efforts to improve care.”

Ferguson said nurses must accept the

She sees the sabbatical as a viable way of continued lifelong learning. “I see a great need for sabbaticals so nurses on all levels can get away for protracted periods of time to enhance their competency. How about a trip to the Middle East, for example, to study patterns of health care delivery to see what we can use in our practice?” she asked.

need for lifelong learning and assume some She suggested that continuing education responsibility for financing, planning, and also include courses such as economics, evaluating their education. which are tangential, yet essential, to the

health care field. continuing education, she predicts loss of Ferguson was a panelist at a program

To implement innovative ideas needed in

PSROs as of July 7976 PSROs created by Public Law 92-603 (1 972 amendment to the Social Security Act) Responsibility of PSRO is to determine if care is medically necessary, is provided in the most appropriate setting for the proper length of time, and is of acceptable quality PSROs will conduct three types of review: concurrent, medical care evaluation studies, and hospital, practitioner, and patient profiles It is intent of the law that each PSRO will be responsible for the development/adaptation/adoption of norms, criteria, and standards to be used in its review system Methodologies acceptable for conducting medical care evaluation studies include Joint Commission on Accreditation of Hospital’s Performance Evaluation Procedure, American Hospital Association’s Quality Assurance Program for Medical Care in the Hospital, and American Nurses’ Association‘s Guidelines for Review of Nursing Care at the local Level

0 55 PSROs in planning stage, 28 anticipated to become conditional by July 1976 By end of fiscal year 1977, it is hoped there will be a funded PSRO in each area

0 National Professional Standards Review Council reviews guidelines and regulations for PSRO; composed of 11 physicians

0 Office of Professional Standards Review (OPSR) establishes PSRO policy and Bureau of Quality Assurance (BQA) administers PSRO each PSRO statewide council and each PSRO in states without councils have advisory groups established by law; they include nonphysicians and assist in developing standards and recommending policy

PSRO . . . should seek the participation of all health care practitioners in the development of criteria and standards and the selection of norms for these professions, in the establishment of mechanism to review

0 PSRO Program Manual states “the

203 PSRO areas designated 0 65 conditional PSROs in various stages

the care provided by each type of practitioner, and in the actual review of

of performing reviews that care.”

558 AORN Journal, September 1976, Vo l24 , No 3

sponsored by the Council for Continuing Education.

According to another speaker on the panel, Cloace McGill, “the task in continuing education now is not to predict the future, but to enable it.” She urged nurses to use a combination of methods to provide continuing education including the traditional teacher-pupil classroom arrangement and new modes such as telephone conferences, videotape, computer-assisted programming, closed circuit television, and satellites. She emphasized that “the most accessible continuing education program will not be successful unless nurses are motivated to participate.”

McGill is associate professor and director of continuing education, the University of Texas School of Nursing, San Antonio, Tex, and cochairperson, Continuing Education Approval Committee.

According to Margretta Styles, dean, Col- lege of Nursing, Wayne State University, De- troit, the primary aim of continuing education is to improve health care. Urging nurses to work with imagination and diligence to develop effective tools, she said “evaluation will serve as the important link between health care delivered and health care education.”

Ellis reviews recent developments in PSRO program

Recent developments on the national scene suggest that nonphysician health care practitioners are or will soon be evident in the Professional Standards Review Organization (PSRO) program.

This was stated by Geraldine L Ellis in her address, “Update on the PSRO program: structure and function of the PSRO and the role of the nonphysician health care practitioner in PSRO.” Ellis is acting chief, allied health and training branch, Division of Peer Review, Bureau of Quality Assurance (BQA), US Department of Health, Education, and Welfare.

“My advice to nurses is to use the interim

Congressional PSRO bills Bills have been introduced in the US Congress to assure appropriate participation by professional registered nurses in the peer review and related activities authorized under Public Law 92-603 establishing Professional Standards Review Organizations.

The House Bill, HR 14173, introduced by Rep Martha Keyes (D-Ark), on June 3,1976, was referred jointly to House Committees on Ways and Means and Interstate and Foreign Commerce.

The companion Senate bill, S 3606, was introduced by Sen Daniel K lnouye (D-Hawaii) on June 22, 1976.

1976, by Rep Edward Roybal (D-Calif) also calls for involvement of RNs in PSROs. However, the Keyes bill calls for more active participation of registered nurses, adding three RNs to the national council, (one R N in Roybal’s bill), two RNs to the state council, and 30% RN participation within local PSROs.

An earlier House bill, submitted on May 24,

~~~ ~

for constructive purposes, such as developing or refining their knowledge and skills in audit and strengthening their relationships with physicians and other health care practitioners in their local community. One must keep in mind that the PSRO is a locally organized and administered program for review, and it is at the local level that true involvement will occur.”

She cited, as one development, statewide Professional Standards Review Councils that will be established in states with three or more PSROs to coordinate the activities of the local PSROs in the state. Currently pro- grammed for six states, “they will be required to organize advisory groups to assure effective involvement of nonphysician health care professionals” once they are established.

Advisory groups to individual PSROs, another development, have been or are in the process of being organized in 21 PSRO areas, according to Ellis. “Since the advisory group represents the required statutory mechanism for (nonphysician practitioner) input into the PSRO program, this is an important development for nonphysician


health care professionals,” commented the speaker.

Ellis noted that guidelines for long-term care review by PSROs are currently being developed by the Bureau of Quality Assur- ance, which expects a number of PSROs to move into that area shortly. This aspect of PSRO review will affect nurses, “since nonphysician health care practitioners play an important role in the provision of care in long-term settings.”

“The draft manual, Guidelines for Review of Nursing Care at the Local Level, . . . was approved by the National Professional Stan- dards Council. . . . All PSROs will receive a copy of the manual,” Ellis said.

The speaker reported that as a result of a BQA contract with a coalition of independent health care practitioners, more than 100 practitioners were exposed to the techniques of patient care audit. Several of these member organizations used their own resources to conduct audit workshops for their own memberships, Ellis said, thus training individuals in the techniques of reviewing their own specialty as a prelude to participat- ing in PSRO reviews.

As the final development, Ellis noted, “The National Professional Standards Review Council, at its May 3, 1976, meeting, voted to establish a liaison network of representatives of nonphysician health care practitioner organizations to provide advice to Council on issues pertinent to review in their respective areas of practice. BQA staff is presently developing a list of pertinent organizations whom we shall contact regarding the desig- nation of a liaison person. To provide the necessary coordination, it is planned that a specific individual will be selected by the organizations to serve as the focal point for contacts to and from department staff as well as for coordination of comments from the organizations. This does not mean that only this individual will speak for the organizations. If an issue involves one specific group, a representative of that group may be selected to present their view to the Council.”

Ellis discussed why legislation creating PSROs was enacted and the purposes and basic premises underlying the program. She stated the PSRO hospital review system

is based on three interrelated review mechanismsdoncurrent review including admission certification and continued-stay review through discharge; retrospective medical care evaluation studies encompassing such terms as patient care audit, medical audit, health care audit, and nursing audit; and analysis of hospital, practitioners, and patient profiles.

“The PSRO review component that will include the most widespread involvement of nurses and other nonphysicians will be in the review of quality of care rendered through medical care evaluation studies.” She further commented, “This is consistent with the guidance provided in the PSRO Program Manual, which specifies that the PSRO is expected to provide evidence, overtime, that where care provided by nonphysician health care practitioners is being reviewed, such practitioners are involved in (1) the develop ment of norms, criteria, and standards for their areas of practice; (2) the development of review mechanisms to be used for peer assessment; (3) the conduct of review of nonphysician practitioners by peers of their own discipline; and (4) working with existing sponsors of continuing education programs, etc, professional schools and practitioner organizations, to assure that deficiences identified in review become incorporated into appropriate educational programs.”

However, since PSROs have leeway in time until evidence is shown that health care practitioners other than physicians perform reviews, other required activities will take precedence initially. She called upon nurses to be more informed and to be ready to respond and willing to work with the PSRO when appropriate to do so.

AORN Journal staff Photos: Rose Lee, RN


Documents

ANA delegates revise bylaws, question “new” certification