AORN JOURNAL JULY 1988, VOL. 48, NO I

Legislation

AORNs testimony regarding the nursing shortage, the Nurse Education Act, the Vietnam Women’s Memorial, AIDS

his column features AORN’s growing T involvement in national legislative issues and presents a summary of testimony given at governmental hearings relating to the nursing shortage, the Nurse Education Act, the Vietnam Women’s Memorial, and acquired immune deficiency syndrome (AIDS). AORN either delivered oral testimony at the time of the hearing or submitted written testimony after the hearing.

Elizabeth A. Reed, RN,-CNOR, directorof OR Services, Pacific Presbyterian Medical Center, San Francisco, presented testimony on the nursing shortage on behalf of AORN to the Department of Health and Human Services Commission on Nursing on March 24 in San Francisco. Jean M. Reeder, RN, MS, member of the AORN Board of Directors, presented testimony in favor of the reauthorization of the Nurse Education Act before the Health and Environment Subcommittee of the Energy and Commerce Committee, US House of Representatives, Washington, DC, on April 18. AORN submitted post-hearing testimony on the Vietnam Women’s Memorial to the Public Lands, National Parks, and Forests Subcommittee of the Energy and National Resources Committee, US Senate, Washing- ton, DC, on April 7. AORN submitted written testimony to the Presidential Commission on the Human Immunodeficiency Virus (HIV) Epidemic, in Indianapolis, on May 1 1. The commis- sion, popularly referred to as the AIDS

Commission, has been charged to investigate the spread of the HIV virus and AIDS.

Commission on Nursing

n her testimony before the Department of Health I and Human Services Commission on Nursing, Reed addressed the causes of the nursing shortage as identified by the American Hospital Association Commission on Nursing during the 1979-1981 shortage. Those causes-lack of autonomy, lack of shared governance, strained nurse-physician relations, poor work environment, and insufficient education-are still present, and she also identified some causes unique to the current shortage. These are rising patient acuity, increased specialization, increased career options, wage compression, increased number of part-time employees, and poor image of nursing.

Rising patient acuio. A higher concentration of sicker patients, an aging population, and a steadily improving technology, which enables treatment of a wider range of diseases, have contributed to a rise in patient acuities. This trend has been noted in the operating room as improved techniques and reimbursement changes result in increasingly complex surgical procedures being performed on a same-day basis. Reed said that this creates a need for more experienced and skilled perioperative nurses to provide an acceptable level of care for the same number of patients.

Increased specialization. Perioperative nurses have become more specialized in response to the broader range of treatments and technology. Because of more complex medical devices and

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treatment modalities, OR nurses have to specialize, which in turn, increases the number of nurses required to staff a department, according to Reed. She added that perioperative nurses can no longer be skilled at all surgical procedures.

Increased career options. Women are increasingly choosing alternate careers. “With respect to nursing, the choice of another career often relates directly to issues of earning power and image,” Reed said. “Moreover, as greater numbers of women join the work force, they are more frequently opting for a career rather than just a job, with the recognition that, for many, it will be a lifetime work.”

Reed also said that within nursing, the choices have increased, and that nurses can practice in home health care and independent practices. Instead of working in a hospital, OR nurses have the option of working in freestanding ambulatory surgery units.

Wage compression. Reed pointed out two problems with nurses’ salaries: (1) nurses reach their earning potential within five to seven years, and (2) when adjusted for inflation, salaries for nurses are generally lower than they were 10 years ago.

Part-time employees. Reed attributed the increased number of nurses working on a part- time basis to the economic and societal realities of 1988. For example, more nurses are returning to school to obtain bachelor’s or master’s degrees. Also, there are many nurses who need to contribute to the total family income. “I believe that we have an obligation to respond to these needs and to provide employment opportunities that reflect the reality of the time,” Reed said. “Part-time employment masks the true magnitude of the shortage and results in a need for a greater number of nurses.”

Nursing image. Recruiting people into nursing will become even more difficult as long as the public perceives the nurse as a “submissive and obedient handmaiden” as described by Philip A. Kalisch, PhD, and Beatrice J. Kalisch, EdD. Other problems that relate to a poor nursing image are being short staffed and downsizing in response to reimbursement changes. These changes result in working conditions that are demoralizing and

Elizabeth A. Reed, RN, CNOR, bti- ties on the nursing shortage before the Department of Health and Human Services Commission on Nursing.

unrewarding, Reed said at the hearing. A related issue is the relationship between nurses

and physicians. As a matter of survival, hospitals must create effective partnerships with physicians. At the same time, hospitals must also continue to support their primary “product line”-patient care, said Reed. Because nurses are the principle providers of patient care, ways must be devised to create collaborative nurse-physician partner- ships, forged on mutual respect and trust.

Reed suggested potential solutions for the current nursing shortage including increased autonomy, improved salaries and benefits, increased recognition, and establishing the baccalaureate as the education basis for entry into practice.

To increase nursing autonomy, Reed said the nurses must be viewed as equal partners in the administration-medicine-nursing triad. Because of economy, nurses are being asked to gather supplies, clean floors and furniture, dispose of surgical waste, find surgeons, and locate equipment. This leads to job dissatisfaction because those duties detract from their primary responsibilities of conducting

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preoperative assessments, giving patients emo- tional support, and planning nursing care regarding the surgical procedure.

As ways to improve salary and benefits, Reed suggested establishing higher shift differentials and salaried positions. Strategies to increase opportun- ities for professional growth and recognition include tuition reimbursement, sabbaticals, career ladders, professional recognition programs, pay- for-performance programs, funding for contin- uing education, and opportunities for in-house transfers. “The employment climate must be one that encourages risk-taking, rewards success, and tolerates failure.”

Although progress is being made toward establishing the baccalaureate as the basis for entry into practice, Reed warned of a trend in which educational standards are lowered to allow more entrants into academic programs. She gave an example of a Regent scholarship program in New York that has slightly lower requirements for obtaining a nursing scholarship than for obtaining a general scholarship.

In conclusion, Reed said that progress toward these goals depends on nursing’s movement toward a place of professional maturity. By obtaining a greater sense of self-worth and confidence, nursing will be able to achieve its goals, she said.

Nurse Education Act

ongress is considering the reauthorization of C the Nurse Education Act (NEA), S 2231 introduced by Sen Edward Kennedy (D-Mass). Currently, the federal government has authorized $54 million to fund nursing education programs. The proposed legislation would provide more than $94 million for the various nursing education programs for fiscal year 1989. The NEA currently provdes institutional and student support for advanced nurse education, nurse practitioners, nurse anesthetists, nurse midwives, special projects, traineeships. fellowships, and loans.

Included in the NEA are initiatives that address the nursing shortage; these initiatives could encourage Congress to increase the current authorization level. Several nursing organizations testified at the Congressional hearing about the

nurse staffing crisis, available solutions, and how the federal government can help alleviate the nursing shortage.

Kaye Lani Rae Rafko, RN, the current Miss America, testified on behalf of the American Nurses’ Association and presented an overview of the nursing shortage. She reported that a study by the American Hospital Association showed that 50% of all hospitals are experiencing a shortage of staff nurses. According to the study, two thirds of the hospitals reported that they needed more than 60 days to fill RN vacancies in medical/ surgical areas, ORs, emergency rooms, and psychiatric units. According to Rafko, the survey concluded that there were approximately 138,OOO budgeted unfilled RN positions in 1987.

After the overview, Reeder, testifying for AORN, told committee members how the shortage directly affects O R nurses. Using Reed‘s testimony that she presented at the Commission of Nursing hearing as a base, Reeder told of the problems that nurses continue to face. In addition, nurses must deal with limited autonomy and difficult working conditions because of stress, overwork, and occupational risks.

According to Reeder, nurses have to specialize because they are involved with complex proce- dures such as laser surgery, lithotripsy, microneu- rovascular surgery, intrauterine fetal surgery, and multiple organ transplants. Reeder said that nurses are shifting their practice locations from traditional hospital O R suites to freestanding or hospital- based ambulatory surgery centers, and that nurses are moving to more lucrative career opportunities with consulting firms, surgical equipment and supply corporations, insurance companies, risk management and law firms, computer companies, and nursing pool agencies.

“Practicing nurses are being enticed to other fields, such as health care industries where the opportunities for salary advancement and job enrichment are greater,” she said. “These alternatives allow nurses to use their expertise to increase their earning power, experience profes- sional growth, and enhance their life-styles.”

To offset nursing migration, Reeder said there must be improvements in nursing salaries commensurate with a nurse’s education, expe-

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Jean Reeder, RN, MS, offers testimony in favor of reauthorization of the Nurse Education Act before a House of Representatives subcommittee. (Photograph courtesy of American Nurses’ Association)

rience, and responsibilities; adequate remuneration for long oncall hours in emergency surgery; and benefits that are competitive with other professions.

Reeder also outlined the initiatives AORN has undertaken to offset the nursing shortage such as Project Alpha, OR Nurse Day, the Invitational Nurse Educator Conference, and the Ad Hoc Committee on Critical Issues. Reeder explained that because of the Invitational Nurse Educator Conference, there is a renewed interest in including OR content in nursing curricula. “The educators realize that the operating room offers one of the best laboratories for student learning,” she said.

The Ad Hoc Committee on Critical Issues, convened by the AORN Board of Directors following the 1988 AORN Congress, will be addressing the nursing shortage as well as other issues critical to perioperative nursing and health care.

Reeder also addressed indirect ways that the federal government could alleviate the causes of the nursing shortage. She urged the federal government to continue to support nursing education programs such as the NEA. While the existing NEA supports those nurses who want to earn advanced degrees, AORN believes that more emphasis should be placed on undergraduate

education, and that the current authorization level should be increased to do so, according to Reeder.

Reeder also explained that HR 2918, sponsored last session by Rep Cardiss Collins (D-Ill), which would have provided Medicare reimbursement to the employer of an RN first assistant at surgery, might have made a career as an operating room nurse more attractive. “The federal government must show its support for the concept of reimbursing nursing services by adopting legisla- tion such as HR 2918,” Reeder said. “Unless nursing services are reimbursed, a career in a health care profession that does get federal reimbursement for its services will continue to be more attractive than nursing.”

Reeder also fielded questions from committee members about how the shortage is affecting the Army and what it is like to work with AIDS patients. Regarding the shortage, she restricted her answer to the Army Nurse Corp, and said that according to its current authorized budget, there is not an overall shortage. She added, however, that shortages exist within specialties such OR, anesthesia, and critical care nursing as well as in the reserves and the National Guard.

Regarding AIDS, Reeder told the committee members about her experiences working directly with AIDS patients. “My first AIDS patient was

AORN JOURNAL JULY 1988. VOL. 48. NO I

Unquestionably, the Memorial Wall would include many more names if it had not been for

the professionalism and sacrifices of women.

a 29-year-old white female, divorced, with two children, a 3-year-old and a 5-year-old. I began to realize that this was affecting everybody.”

Reeder said that she follows blood-and-body precautions when working with AIDS patients. ‘‘I do not wear a mask and gloves every time I sit in a room and hold a patient’s hand who has the disease,” she said. “I took an oath when I graduated as a registered nurse to care for mankind, and that oath does not rule out any certain or particular disease.”

In response to a question about knowing whether a patient is HIV positive, Reeder said that as an OR nurse it is helpful for her to know if a patient has a positive HIV test, but it is not necessary to know because AORN standards of practice state that nurses must follow the same precautions regardless of the patient’s disease.

Vietnam Women S Memorial

ORN submitted post-hearing testimony in A support of S 2042, sponsored by Sen David Durenberger (R-Minn) and Sen Alan Cranston (D-Calif), that would authorize the establishment of the Vietnam Women’s Memorial. At the 1986 Congress in Anaheim, the House of Delegates adopted a resolution that supported the Vietnam Women’s Memorial Project.’

In its statement, AORN said, “The Memorial is necessary to publicly acknowledge the valuable contributions made by nurses and other women in Vietnam. Regrettably, the women who served in Vietnam have never been recognized and honored.”

The AORN statement described what it was like for women serving in Vietnam. The following is a summary of the statement.

Between 7,000 and 20,000 women in the US military service served in Vietnam. A majority of the women who served were nurses; other women were physical therapists, air traffic

controllers and Red Cross volunteers. Nurses served when the war began in 1962 until the troops were withdrawn in 1973; but often OR nurses returned to Vietnam for a second tour because they were needed.

The names of both men and women who died in Vietnam are etched into the Vietnam Veteran’s Memorial Wall, Washington, DC. The names represent only 2% of the actual numbers of casualties wounded and disabled in Vietnam. The 98% survival rate, the best record for any war, can in large part be credited to those women who risked serving in the Vietnam War.

Unquestionably, the Memorial Wall would include many more names if it had not been for the professionalism and sacrifices of women. They dealt with the 24-hour care of enormous numbers of patients with injuries of a nature that had seldom been experienced by nurses in previous wars. When multiple casualties were being received during prolonged fighting, OR nurses worked sometimes for days with only catnaps to sustain them.

In addition to being wounded, permanently disabled, and killed in action, women were stigmatized for serving in the war when they returned home, which drove many nurses to quit nursing. Many nurses experienced posttraumatic stress syndrome, as evidenced by chronic fear, guilt, and anger, that persists today.

In summary, AORN stated, “This project is an effort to restore American pride and gratitude for the heroism demonstrated by women. As the Vietnam Veteran’s Memorial allowed us as a nation to begin the healing process, the Vietnam Women’s Memorial would allow a deeper, more complete healing to finally occur.”

AIDS Cornmiision

ORN presented written testimony at the A AIDS Commission hearing on May 11. In

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its statement, AORN said that with the ratification of the “Statement on Perioperative Nursing Care of the Patient with Acquired Immune Deficiency Syndrome,” the Association reaffirmed the ongoing commitment of its members to render safe, high quality, individualized care to all patients undergoing surgical intervention. Because of increasing prevalence of HIV, there is an increased risk to perioperative nurses and other health care providers of exposure to blood from patients infected with HIV or other blood-borne pathogens.

The Association also realizes that risks exist because the surgical patient may be a known or an unknown camer of HIV or hepatitis B-bld- borne diseases that cannot be reliably identifed through medical history and examination.

The AORN Standards and Recommended Practices for Perioperative Nursing address patient care concerns and provide an outline for effective environmental sanitation within the surgical suite. The basic premise of these practices is that “all surgical cases should be considered potentially contaminated.”2 By directing efforts at confining contamination throughout the surgical procedure, AORN recommended practices are intended to be achievable recommendations for an optimal level of practice.

The Association also reaffirmed its support of the Centers for Disease Control (CDC), Atlanta, guidelines for caring for patients who are HIV positive and for any other potentially infectious patient. The CDC encourages the use of universal blood and body-fluid precautions to prevent transmission of HIV or other blood-borne pathogens. AORN, therefore, encourages health care institutions to develop policies and procedures that address infection control and safety for patients and staff. In its education efforts, AORN continues to encourage implementation of the recommended practices. In conclusion, AORN continues to emphasize

the need to treat blood and other body fluids from all patients as potentially infective. The Association also continues to be committed to providing high- quality care to all surgical patients.

SUSAN SCHLEPP ASSISTANT EDITOR

Notes 1. ‘‘Support of Vietnam women’s memorial project,”

AORN Journal 43 (May 1986) 1046. 2. “Recommended practices for OR sanitation,” in

AORN Standardr and Recommended Ractices for Perioperative Nursing (Denver: Association of Operating Room Nurses, 1988) Ik8-1.

Use of AIDS-Safety Products Questioned Health care workers are using several products that are said to protect them from acquired immune deficiency syndrome (AIDS), according to the April 4,1988, issue of American Hospital Associaton News. These safety items include rubber, latex, and metal-mesh gloves; plastic face shields and goggles; sheathed needles; puncture- proof used-needle containen; moisture-resistant gowns and aprons; and disinfectant sprays.

fied potential problems with the AIDS-safety products. For example, the rubberllatex gloves protect hands from body fluids, but do not p r e vide protection against needle sticks. Metal-mesh gloves also do not provide protection against needle sticks, but they protect against scalpel cuts. These gloves also cost more than $250 a pair.

executives should ask for clinical evidence that the products actually protect employees from infectious diseases. Another factor they should consider is the expense versus the need for the equipment, according to the article. Instead of relying on these safety products, the

chairman of the Infectious Control Committee at San FranciscO General Hospital Medical Center recommends that hospital executives develop rational policies for safe use of AIDS-related products. He also promotes use of universal pre- cautions that dictate treating all body fluids as infectious, regardless of patients’ AIDS and AIDS-antibody status.

The American Hospital Association has identi-

Before purchasing any of these items, hospital

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