''PURLIC HEAITH LIBRARY ''ASSESSING HEALTH CARE NEEDS IN SKILLED NURSING FACILITIES: HEALTH PROFESSIONAL PERSPECTIVES Long Term Care Facility Improvement Campaign Monograph No.1 March 1976 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Office of Nursing Home Affairs ''The views expressed in this monograph by the members of the Ad Hoc Nurse-Physician Advisory Group are their own and do not necessarily reflect the official views of the Office of Nursing Home Affairs, U.S. Public Health Service, Department of Health, Education, and Welfare. Diagrams that appear in Appendix D are reproduced with the permission of the author and the American Nurses’ Association. ''NURSE-PHYSICIAN ADVISORY GROUP Office of Nursing Home Affairs 1975-1976 Barbara Bates, M.D. Professor of Medicine The University of Rochester Rochester, New York 14620 Pearl Dunkley, R.N., Ed.D. Deputy Executive Director American Nurses’ Association Kansas City, Missouri 64108 Eleanor C. Lambertsen, R.N., Ed.D. Dean, Cornell University—NY Hospital School of Nursing Professor of Nursing New York, New York 10021 U.S. Public Health Service Lucille E. Notter, R.N., Ed.D. Editor New York, New York Rozella M. Schlotfeldt, R.N., Ph.D., F.A.A.N. Professor, Case Western Reserve University Frances Payne Bolton School of Nursing Cleveland, Ohio 44106 Sister Marilyn R. Schwab, R.N., M.S.N. Administrator Benedictine Nursing Center Mt. Angel, Oregon 97362 ae Eq Us STAFF PARTICIPANTS Faye G. Abdellah, R.N., Ed.D., LL.D., F.A.A.N. Assistant Surgeon General Chief Nurse Officer, Public Health Service (PHS) and Director, Office of Nursing Home Affairs DHEW Rockville, Maryland Dorothy Aird, R.N., M.S. Chief, Training Support Section Division of Provider Standards and Certification Bureau of Quality Assurance DHEW Rockville, Maryland Jean L. Bainter, R.N., M.S.N. Nurse Consultant National Center for Health Services Research DHEW Rockville, Maryland PUBL Rita Chow, R.N., Ed.D., F.A.A.N. Deputy Chief Nurse Officer, PHS and Deputy Director, Office of Nursing Home Affairs DHEW Rockville, Maryland Helen V. Foerst, R.N., M.A. Assistant Chief Nurse Officer, PHS DHEW Rockville, Maryland K. Mary Straub, R.N., Ed.D. National Center for Health Services Research DHEW Rockville, Maryland ili ''Foreword On June 21, 1974, the Department of Health, Education, and Welfare announced a national campaign to improve long-term patient care in nursing homes. One of the projects in this cam- paign was a survey of skilled nursing facilities. The report of this survey was published by the Department in July 1975 and is entitled Long- Term Care Facility Improvement Study: Intro- ductory Report. It is generally agreed that an effective way of improving the quality of care provided to long- term care patients is to increase the involvement of health professionals in the supervision, pro- vision, and accountability for the services pro- vided. Thus, this is the first of three monographs based on the /ntroductory Report that discusses in more depth important issues in long-term care. Assessing health care needs from the per- spective of key health professionals on the health team, with particular emphasis on the physician and the nurse, is addressed in this monograph. Although the significant contributions to the health care team of other health professionals (e.g. physical therapists, speech therapists, occu- pational therapists, activities directors, nutrition- ists, pharmacists, social workers) are fully recog- nized, they are not addressed in this monograph. The rationale for focusing initially on the physi- cian and nurse is that the total plan of care for each patient must be developed cooperatively and initiated by these individuals. The nurse in particular is the one member of the team who is present during each 24 hour period and must serve as the health coordinator on the team to see that other health professionals are involved in the plan of care. The issues facing the elderly, the mentally re- tarded, and developmentally disabled exist be- cause these individuals have been ignored by the health professions and society at large. Accept- ing this as fact, what can be done to change the situation? iv In an effort to explore multiple approaches to involving health professionals in the care of the long-term care patient, the Office of Nursing Home Affairs assembled an Ad Hoc Nurse- Physician Advisory Group to consider the issues concerning the assessment of health care needs in Skilled Nursing Facilities. Subsequently, one physician and four nationally recognized nurse leaders were invited to state their views, identify the issues, and specify what steps would have to be taken to achieve a commitment of the health professions in the care of the long-term patient. Examples of what they said, which we will elaborate upon later in this monograph, are as follows: e Only when more professionals are involved in care will our institutions be limited to - those persons who really need them. e Attention to the care of the long-term pa- tient is related to the value practitioners place upon the care of these individuals. e Problems of long-term care are serious but can be resolved in part by changes in public policies and by forthright action of health professionals to accept the commitment to care for the long-term patient. e The roles of medicine and nursing on the health care team are complementary. e The standards of geriatric practice are based on the premise that care of older people is different. e Interprofessional planning for education of practitioners is essential. e The nurse practitioner such as the PRIMEX nurse can serve as a key health professional in the care of the long-term patient. e The goal is to have all undergraduate nurs- ing programs prepare professionals who pos- sess a gamut of practitioner skills at accept- able levels upon graduation and programs of continuing education available. ''e Institutional reimbursement has encouraged We hope that practitioners, educators, Fed- the availability of only minimal and highly — eral, State, and local planners will give serious inadequate supervision of care by the Regis- consideration to the written perspectives pre- tered Nurse. sented by the authors and their recommenda- e A key to resolution of many of the prob- tions for improving long-term care. lems is to relate educational and service agencies in the medical and health care fields by rationally balancing privileges and responsibilities of persons served by the health care system with those of staff mem- Faye G. Abdellah bers in service agencies and students and Assistant Surgeon General faculties in health science schools. U.S. Public Health Service e There is a need for a complete network of health care services, and the institutions and agencies through which they are provided, brought into relationship with educational institutions offering pre-service and ad- vanced preparation for health professionals. ''''Contents Nurse-Physician Advisory Group .... . U.S. Public Health Service Staff Participants ................. Foreword .................... Chapter 1. Issues in Long-Term Care and Im- plications for the Nursing Profes- SION cute nikueeanewnsvsag Ambiguity about what constitutes quality ................., Rising cost of long-term care Holistic versus medical focus of care wee ee ee ee, 2. The Physician and the Health Care Team Approach to Long-Term Care .........2........., Medicine and nursing: comple- mentary roles .........., The nurse practitioner-physician team .... ee, Nurse practitioner role problems . 3. The PRIMEX Role in Long-Term Care .................., Alternatives to institutional care . Continuing education PRIMEX projects ............... Conclusion .............. 4. Problems and Issues in Long-Term Care: Implications for Nursing Education ............... Inter-institutional arrangements Inter-professional planning for ed- ucation of practitioners .... . Changes in undergraduate nursing curricula. ............., Nurses’ opportunities for special- ization in long-term care ‘ Nurses’ investments in scholarship and research ............ iv 18 19 21 24 26 27 28 29 5. The Nursing Profession’s Role in PSRO Utilization Review in Long-Term Care: ANA’s Certifi- cation Program ............ Nursing’s interest in professional standards review organizations and utilization review ...... Nursing and PSRO/UR: basic is- SUES cic bee eae nee Role of ANA in Facilitating nurs- ing involvement in PSRO ANA certification .......... Page 31 32 33 36 39 Vil ''Appendix A. Cornell University—New York Hospi- tal School of Nursing: Objectives for Nursing Practice B. Cornell University—New York Hospi- tal School of Nursing: Model for Identification of Scope of Practice (Definitions) C. The Division of Ambulatory Services at New York Hospital—Cornell Medical Center: Family Nurse Practitioner Protocol D. Diagrams to Illustrate the Nursing Profession’s Role in PSRO Figure 1. Model for quality assurance: im- plementation of standards Vili Page 42 44 48 50 50 2. Use of model in an institution which provides nursing care 3. Use of model in the nursing care of a specific client 4. Use of model in private practice 5. Use of model in a school of nursing 6. Use of standard V in an institu- tional setting 7. Use of standard II in a nursing school setting E. Preliminary Report: Survey of State Nurses’ Associations Nursing In- volvement in PSRO F. Family/Adult/Geriatric Nurse Practi- tioner Programs Page 51 52 53 54 55 56 58 60 ''CHAPTER 1 Issues in Long-Term Care and Implications for the Nursing Profession Sister Marilyn Schwab, O.S.B., R.N., M.S.N. A variety of important issues currently con- front the field of long-term care in this country. Sensational scandals and serious investigations alike uncover problems and inadequacies on lev- els of management, financial control, policies, regulations, and most importantly, on the level of patient care. Still other issues are more subtle, and do not constitute matter for scandals, but are important for the future direction and phil- osophy of long-term care. This paper will con- fine itself to-issues concerning patient care, pri- marily, and the implications of these issues for the profession of nursing. Three major categories of issues will be dealt with, although more could no doubt be found. The three issues are: 1) the present ambiguity about what constitutes quality of care; 2) the rising cost of care, both in and out of institu- tions; and 3) the holistic approach versus a purely medical focus of care and services to long-term patients. Each of these issues has pro- found and far-reaching implications for the prac- tice of nursing. Before addressing these issues, it is important to explore briefly the relationship that can be seen between nursing and long-term care. Nurs- ing has, at least potentially, the most to offer the long-term care scene of any of the helping professions, because of the close relationship be- tween the needs of long-term patients and the nature of nursing. One way of describing nursing is as the art and science of assessing and treating human response to variations in an individual’s state of health. Thus, nursing deals with the re- sponse or the effects of the altered state of health. To put it another way, nursing deals with the residual pathology, or the incurable pieces of pathology, rather than only assists the physician as he arrives at his diagnosis and treatment of the pathology directly. Nursing is helping the patient deal with his pain, rather than naming the cause of the pain only. Nursing is dealing with confusion, when the cause is known but cannot be reversed. When one uses this focus of nursing, the activ- ities of nursing which are often seen as custodial or “merely” personal-care tasks, take on new significance. Nursing has tended to de-emphasize the importance of physical and personal-care tasks, and has often delegated them to unskilled workers. Thus, these patient needs have become fragmented from other more sophisticated needs, for example, the patient’s acceptance of his disability. In long-term care, patients often experience overwhelming effects of disease, residual path- ology, and irreversible disability. In other words, they have overwhelming needs for nursing. In long-term care, there is an enormous need to integrate the physical, pathological and the psychosocial care to patients. Because of the strong component of physical, personal-care needs in the patient, no other profession is more suited to meet the integrative function that is required, than nursing. The fact that all nurses may not now be prepared to function in this central care role is really not relevant. The point is that the nature of nursing is such that the role and functions of nursing are ideally suited to meet the needs of long-term care patients. This is so true, in my opinion, that for nursing to ignore the opportunities in long-term care would be to deny at least one important focus of nurs- ing, and one of the basic purposes for its exis- tence as a helping profession. All of this is not to say that nursing meets all the needs of long-term patients alone. The col- laborative role with medicine and other health care professions is essential to total care. How- ever, we can best be collaborative when we have clear ideas of the unique contribution each col- laborator has to offer. ''AMBIGUITY ABOUT WHAT CONSTITUTES QUALITY An issue that is not widely recognized, and thus has not been widely addressed, is that there is real ambiguity and confusion, even among pro- fessionals in the field, about what really consti- tutes “‘quality care.”’ This ambiguity is more ap- parent among the general public, who make demands on regulatory agencies and legislators to improve quality, without knowing for sure what it is they expect. Some expect newer build- ings, absolute safety, and environmental ste- rility. However, it should be recognized that nursing homes are not and should not be modeled on hospitals. Others might want more diagnostic thoroughness, more vigorous medical treatment, and life-saving machines and _ tech- niques available and used. At the same time, all recognize the lack of quality inherent in the re- striction or denial of human rights, personal choice, comfort, and ordinary human relation- ships. All of these expectations are good and desirable, but sometimes they are mutually ex- clusive, at least in practice. Priorities of values and needs may be in conflict, and who sets pri- orities is often unclear. Our expectations of what constitutes a desired outcome of care is also unclear. The acceptance of cure as the only acceptable outcome, even when this expectation is only implicit, makes it difficult to see how chronicity, deterioration, and death can ever be dealt with in a positive manner. An added com- plication to this picture of confusion about ex- pectations of quality, is the possibility that much of our discomfort and outrage about qual- ity of long-term care has to do with our collec- tive guilt and rage that any of us has to become disabled, deteriorate, or die. Nursing shares in the responsibility to clarify desirable outcomes of care, and the nature of true quality of care. Nursing, as one of the main givers of care, must identify more specific and useful measures of quality of nursing care, and teach nurses how to use these measures. Meas- urement should probably have more to do with things like coping abilities of patients, total functional capacity (which goes beyond assess- ment of isolated and individual physical func- tions), pain and comfort levels, and with dignity in the dying process. Nursing would fail the long-term patient, if desired outcomes and measurements of quality were limited to cure and restoration goals of acute medicine. RISING COST OF LONG-TERM CARE Just as the nurse and the profession must share in the accountability for quality of care, so must we share in the accountability for cost. Nurses often want to deny that they have any- thing to do with cost of care, as they feel they are cast in a powerless role in this regard. But nursing must recognize and assume its responsi- bility for cost. Nursing must be more involved in teaching the public that long-term care of quality will cost money. It is something of an insult to nursing that so much of the general public seems to think that long-term care should cost so little, usually based on the notion that anyone can care for old people, especially if they ‘‘just” need personal assistance and custodial care. Even efforts to train the large numbers of nurses’ aides now in long-term care institutions is based on this notion. It is as if this kind of nursing can be taught in a few weeks to any well-meaning person. Thus, at times, one senses more pressure to train unskilled people than to recruit more trained and skilled people into the field. Nurs- ing, in speaking to the quality and cost of care, must defend the need for more professional in- volvement as being both quality and cost ac- countable. Nursing must prove that the more skilled the care-giver, the less waste of time, the fewer costly mistakes in care, and the greater the possibility of restoration of the patient. Only when more professionals are involved in care will our institutions be limited to those persons who really need them, and more patients with long- term problems will be maintained successfully in their communities. All of this is difficult to prove prospectively; nursing cannot just keep saying that it is true but must prove it to be so. It has been demonstrated in isolated instances very convincingly, but more nurses need to make it real in their own practice settings. HOLISTIC VERSUS MEDICAL FOCUS OF CARE A third issue that has implications for the pro- fession of nursing is the tendency to want to improve long-term care by bringing it into closer conformity to the medical care system as we know it from acute care. That is, the medical diagnosis is used to justify need for services and levels of care provided, and diagnostically re- lated needs are seen as primary and basic to all ''other needs. The newly required medical direc- tion in skilled nursing care facilities could be significant, and the way that the medical di- rector role will evolve in practice is going to be an important influence on the total approach to care. While admitting that long-term care has suf- fered severely from lack of medical care, both in terms of careful diagnosis and adequate treat- ment, the introduction of an administrative medical component to long-term care could be detrimental to a “holistic” approach, an ap- proach that is absolutely essential if the needs of long-term patients are to be met at all. More accurate and thorough diagnostic work is needed for long-term patients, and they require much better medical care than they have been receiv- ing. However, their medical problems are only one piece of the picture, not the point from which all else flows. Involvement of medicine in an administrative role could have the tendency to define all needs in terms of medical diagnosis and medical management. It is true that the holistic approach is not now present in most long-term care facilities, and that, in spite of its shortcomings, the medical model is the tried and true method with which all the health disciplines feel most comfortable. The medical model is well-developed, and the holistic model is not. De- spite this, it is believed that the holistic approach, which can be described as balancing equally the emotional, social, physical, and path- ological needs of patients as a basis for care, is the model which must be created and used if we are to achieve improvement in long-term care. The holistic approach means that psychologi- cal and social needs of people are seen to be as important as their disease-related needs, rather than just interfering factors in the course of an illness. In acute care situations, for instance, there is truly compassionate awareness of the patient’s psychosocial needs, but rarely is a visit from the grandchildren seen to be as _ thera- peutically important as the taking of the right medicine. In long-term care, there must be an apprecia- tion of the need to weigh and balance the patient’s needs in all aspects of his life, and help must be directed to meeting those needs in the priority that the person himself gives to them. Long-term care is not managing disease processes, but whole persons, who are experiencing threats on several levels. Nurses and physicians, and all the health professionals must work together to further de- velop this kind of interdisciplinary model, since by its very definition, it cannot be developed by any one profession alone. The role of nursing in the creation of the ideal long-term care concept is an exciting challenge. Nursing has the potential ability to integrate the physical and pathological needs of patients in proper relationship with their social and emo- tional needs in a way that no other profession can. This calls for that which is precisely and uniquely nursing—dealing with the person’s total response to his altered state of health. Nursing alone cannot meet all the needs, but the nurse must recognize and use the skills she has to offer as an integrator and facilitator of the many serv- ices needed by the long-term care patient. If nursing is to exert maximum influence on the direction of long-term care in our society, nurses must become more involved in making full use of community services designed to keep long-term patients in their own homes and com- munities. This means that nurses must actively support the development of community services, teach and counsel about health maintenance, and assist patients and their families to use com- munity resources. Nurses in institutions must be- lieve in the value of returning and maintaining people in their own homes. Nurses must become more influential in decisions about where pa- tients are cared for; for example, appropriate- ness of admissions to nursing homes. Nurses should work toward assuming a greater role in admission screening activities in all kinds of in- stitutions and agencies, in utilization review ac- tivities, placement and referral mechanisms, and quality assurance programs. Nurses need to be there to speak to the nursing considerations in each case in a holistic fashion, and thus to help make the shift from strictly diagnostically- related justification for care and services, to the more integrated consideration of all the interre- lated needs of the patient. Without that empha- sis, great gaps will exist in our effort to serve the long-term care patient in this country. The most important immediate task of nurs- ing is to dream about the ideal long-term care model and not to be content to react to trends and regulations as they develop. Nursing practice in long-term care must take an aggressive role in shaping and achieving the dream. ''CHAPTER 2 The Physician and the Health Care Team Approach to Long-Term Care Barbara Bates, M.D. The team approach to health care is not a new idea (1). Large numbers of people have worked in health care teams, studied them, taught them, written and preached about them and sometimes left them in despair. What more is there to say? Borrowing a lesson from anthropology, it might be useful to look at health care teams by exam- ining another setting or another culture. Al- though generalizations from such an examina- tion may be unintentionally misleading or even odious, I shall take the risk and present to you ‘*A Football Fable.” Once upon a time there was a professional football team that wasn’t doing very well. It had too heavy a schedule, it fumbled the ball too frequently, it lost too many games and the fans were voicing their displeasure with increasing bitterness. For some reason the crowds kept coming to the games—in fact the stadium was overflowing and some people couldn’t even get in—but they wanted more satisfying action. If things didn’t improve soon, they threatened, they would ask the government to take over the team, if not all of football. Sportswriters echoed these complaints almost daily in their columns. Some of them, further- more, analyzed the situation quite well. How could the football team ever be successful with the training and organization that tradition dic- tated? Each team member—each of the linemen, the halfbacks, the quarterbacks, and so forth— was trained in his own separate school. Although each had become quite skillful in his own posi- tion, he also brought to the team his own idea of how to play, his own peculiar values and his own objectives. Since each had been trained sepa- rately, no one had become very knowledgeable about his fellow team mates, and communica- tion was difficult. Some were intimidated by others who were stronger; some simply with- drew. Isolation was intensified by the fact that each was paid by a different boss. Salaries de- 4 pended on the hours worked or the numbers of plays made but not upon the quality of team- work nor upon the numbers of games won. The quarterback was particularly trouble- some. He was paid the most, he had had the longest training, and he called most of the plays. But despite his intensive training, he had never developed any real understanding of what his team mates could do. Acquiring a quarterback degree had depended not at all on successful teamwork. The science of quarterbacking had been much more important. Many people blamed the quarterback for the team’s problems; and besides, his high salary was forcing up the price of football tickets. Back in the training camps the football train- ers decided that change was mandatory. Because of their background they believed the answer to the football team’s problems lay in new kinds of training. They could take some linemen, they reasoned, and give them some of the skills of the quarterback. Linemen were already quite expert in most of the strategies of football, their skills were often underutilized, and furthermore there were more linemen than quarterbacks. This plan, therefore, seemed logical. By melding these two traditional positions, they argued, they could improve team performance, win more games, and even save some money since the team would need the quarterback less often. They dubbed this new player a lineback practitioner. With government funds they trained a group of them and sent them back to the team. Unfortunately there were a number of prob- lems. Although the crowdsliked the new players, problems in teamwork remained. The quarter- back especially didn’t know how to behave. Most annoyingly, he insisted on calling them quarterback assistants, or QBA’s. More impor- tantly though, he often went right on receiving the ball himself from the center, refusing to pass it on to the lineback practitioners. The lineback ''practitioners then had too little to do. At other times, perhaps out of weariness since he really did work hard, the quarterback simply left the field and went off for a beer, leaving the line- back practitioners to run the whole game them- selves. Then the lineback practitioners felt anx- ious, inadequately prepared, insufficiently supported and insufficiently paid. Some of them yearned for the good old days in the line. A few suggested that the quarterback be fired. The quarterback was not the only barrier, however, to realizing the goals of the lineback practitioners, namely winning the game for the team. Despite the great skill and high motivation of the trainers, they had not had the political clout to change the rules of the football game. Many of the plays that the lineback practitioners had been trained to perform were not in fact considered quite legal in most stadiums. Every- one was hoping the referees wouldn’t notice, but the players were nervous and the penalties for illegal plays were severe. Nor did the trainers have sufficient economic clout. Sometimes when a lineback practitioner instead of the quarter- back was running with the ball, the team couldn’t collect any ticket money for the game. This was a major annoyance, and it was hard on morale. All of these problems were especially frustrat- ing when the team was playing certain oppo- nents who chose to fight a complex, sustained battle of attrition. In these situations it was clear that the most successful strategy was to utilize fully all the skills of the linemen, the backs, and the lineback practitioners, orchestrated into a group effort. Although the quarterback would be needed from time to time, his usual aggressive and personally flashy style of offense was likely to be inappropriate. Yet even here, teamwork was difficult, and some of the most skillful plays were considered illegal and were not reimbursed. What should the football team, its trainers, its managers and the crowd do now? All stories beginning with “once upon a time” are supposed to have happy endings, but the end of this fable has yet to be written. Since we in the health care professions have had similar ex- periences and since we face similar questions, perhaps we shouldlook now at our own situation and try to sketch out some solutions. In addressing the problems posed by the long- term care of the chronically ill, it is abundantly evident that we are not now doing a good job in this field (2). Yet few areas offer greater poten- tial for the full use of the health care team and for the contributions of at least one new care provider—the nurse practitioner. MEDICINE AND NURSING: COMPLEMENTARY ROLES What are the needs of these patients? They have, of course, traditional medical needs, for the diagnosis and management of diseases, al- though few definitive cures may be possible. Many of these problems are pathophysiologi- cally complex and require complex pharmaco- logic and prosthetic interventions. They require careful supervision and monitoring, time- consuming patient education and supportive care. Many other needs have fallen traditionally within the direct purview of nursing, for example, problems with mobility, ambulation, feeding, skin care, bladder and bowel function. Finally, such patients have enormous psycho- social needs. Through death or geographic isola- tion they have often lost the significant inter- personal relationships that previously sustained them. These relationships, or some substitute for them, are essential if the person is to retain his will to live and his capacity to enjoy life. Contin- uity between patient and provider is needed to sustain such meaningful relationships. It also is important to the efficiency of the care system itself. Significant amounts of time and energy must be spent in grasping the problems and the care plans and the personal idiosyncrasies of each individual patient. Every change in a pro- vider introduces an inefficiency, or worse, an in- adequacy into the system. If these are the needs of chronically ill pa- tients, logic dictates that nurses must play an important, and indeed a critical, role in meeting them. Although the intent is not to belittle the importance of physicians, social workers, dieti- tians and other members of the health care team, it is believed that nurses are in the key position to meet many or most of the patients’ needs, whether physical, functional or psycho- social. It is not an accident that facilities for such patients are called nursing homes. Too often, however, the nurse’s role has been subordinate to that of the dominant and some- times geographically and organizationally remote physician. Such a position is scarcely conducive to the creativity, decision making, and innova- tion that patient care requires. A basic change in ''the authority, accountability and reward system of nursing, vis-a-vis medicine, is necessary to un- leash the full capacity of nursing. In some settings this change has been accom- plished by a deliberate change in philosophy and decision-making power within an organization. At the Loeb Center for Nursing and Rehabilita- tion in New York, for example, patients are ad- mitted to the unit primarily for nursing care and only after explicit review and approval by nurs- ing. Each patient is assigned to an individual nurse who works out with the patient suitable goals and plans. Although medical regimens are implemented and monitored, they are not the single controlling force in the care plan (3,4). The success of this system has been documented in a number of studies. THE NURSE PRACTITIONER- PHYSICIAN TEAM Another approach, still new but more widely spread, is educational, that is, the development of nurse practitioners. While maintaining her tra- ditional nursing knowledge and skills, the nurse practitioner has acquired additional skills in in- terviewing, physical assessment, the diagnosis, and treatment of common health problems. Al- though these new practitioners have important new knowledge, and knowledge has long been equated with power, I suspect that the authority and power of the nurse practitioner derive not so much from her education but from the organ- izational changes that it promotes. Insofar as the nurse practitioner can substitute for a physician in any given patient encounter, she gains access to that patient and she gains at least partial control over how to use that visit. Because her interests and skills may well match the chronically ill patient’s needs better than do the interests of the physician, the encounter can be more productive and satisfying for both pa- tient and provider. In addition, by working in a team or collegial relationship with a physician and with their com- mon group of patients, the nurse practitioner is somehow freed from some of the bureaucratic restraints and from the dependence on policies that inhibit decision making for many nurses. Nurse practitioners are expected by the system to take initiative, to accept responsibility, to make independent and interdependent judg- ments. They also expect it of themselves and develop the ego strength to behave that way. Developing successful nurse practitioner- physician teams, however, is not an easy human task. Nurse practitioners must integrate their new medical skills with their previous skills with- out losing their professional identity. They must also learn to take a more assertive, articulate stance in support of their own opinions and values, not just play an assistive role to the dom- inant physician. Physicians, on the other hand, must learn to relinquish some of their authority and decision making and must learn to encour- age and listen to the contributions of others. They must share their patients without abandon- ing them entirely to someone else (5). Many of these changes run counter to the influences of social class, sex, education, and traditional pro- fessional power. Yet they must and can be made. If we are to form such teams in the nursing homes, intermediate care facilities, and home care programs across the country, what factors should we consider in planning them? Among the most important are composition of the team and the amount of time they can work together. Beckhard has pointed out that each health team must negotiate answers to a series of questions: Who will do what work? How will this be decided? What problems must be dealt with by the team as a group? What are the role expecta- tions, each of the other? What information must be communicated? What does each need in the way of professional development? (6). These questions cannot be answered through brief cor- ridor contacts, telephone conversations, or visit- ing nurse referral forms. They cannot be answered when one nurse must work with 20 or 30 or more doctors, as does the public health nurse or visiting nurse in traditional practice, or when one doctor must work with 20 or 30 nurses as in a conventional hospital organization. At least under these circumstances the answers are doomed to a rigid bureaucratic pattern, mini- mally responsive to the individual needs of pa- tients. The ratio of physicians to nurse practi- tioner, or of nurses to physicians, should be kept as small as possible. There are just so many styles of practice that another can learn. There are just so many people with whom one can communicate. There are just so many individuals with whom one can build an efficient and trust- ing team relationship. And it takes time! It is exceedingly helpful, but perhaps not es- sential, that the physician and nurse work within the same organization. First, this pattern facili- tates a reasonable frequency of contact so that ''communication is possible and trust and mutual respect may be nurtured. Second, it helps to avoid possible economic conflicts between one system and another. It should be no surprise that the practicing physician characteristically underutilizes visiting nurses or public health nurses, especially perhaps for his paying pa- tients. Not only does he have few opportunities to develop a productive team relationship with one or two nurses; he also may lose income when the nurse does something for the patient he himself could do instead. He also lacks a sense of team identity that could give him pleas- ure when his patient responds well to the care of one of his team mates. When the nurse practi- tioner works in the same office with the physi- cian, this team relationship and team identity develop more easily. Both should profit, person- ally and economically, from the optimal use of each other’s skills. When both physicians and nurses work for the same organization, larger than the two of them, similar potentials exist. Other economic issues have to be resolved, however. Medical and nurs- ing budgets are usually separate and may be jealously guarded by their respective directors. When nurse practitioners perform conventional medical tasks, the nursing director may legiti- mately request that her budget be enhanced pro- portionately. A few fiscal skirmishes are inevi- table. Planning in such a way that nurse practitioner and physician can work within the same organi- zation is important not only in the care of pay- ing patients. It is perhaps even more important in the care of the poor. Here medical possessive- ness may give way to medical abandonment, de- spite the presence of Medicaid and Medicare benefits. If the chronically ill patient is home- bound, too often he is relegated almost com- pletely to the care of the public health or visiting nurse. Communication between doctor and nurse is usually limited to the telephone or to a piece of paper. From the physician’s view- point, the nurse’s call may be perceived as an interruptive nuisance in his busy day. She either wants another form completed or is reporting a new and difficult problem, perhaps in inade- quately descriptive terms. From the nurse’s viewpoint, the physician may respond with pre- mature and superficial assessments, followed by therapeutic orders of uncertain worth. Compa- rable interactions abound between practicing physicians and nurses based in nursing homes. These situations are almost hopeless unless honest and competent practitioners of both pro- fessions work together, know each other and are rewarded for their response to each other’s needs in patient care. NURSE PRACTITIONER ROLE PROBLEMS No matter how motivated team members may be, however, no matter how good their organiza- tion, they cannot be expected to function opti- mally in a hostile economic, bureaucratic, and legal environment. In our own region of Western New York, dozens of nurse practitioners are now active. A number are working with the chronically ill: in a chronic disease hospital, in nursing homes, in the health, department, in clinics, and private medical offices. Some of these nurse practitioners are expert teachers and practitioners of geriatric nursing. Most have high motivation and extended experience with the aged and chronically ill. To at least this observer their conversations and their patient records in- dicate that they bring to their patient care a different dimension of understanding and inter- est than does the traditional health care system. Yet the legality of their work is questioned by state and local officials. The county health de- partment has no official job classification for nurse practitioners and must call them some- thing else. The legitimacy of including nurse practitioners’ salaries in nursing homes’ costs has been questioned. When a practitioner sees pa- tients in a satellite health center remote from the backup physician, her services are not eligi- ble for reimbursement. It makes no sense that government funds are spent in the training of nurse practitioners when reimbursement is with- held from them when they provide the services they have been trained to give. We need changes in the laws and regulations concerning the practice of nursing and the prac- tice of medicine; we need changes in our re- imbursement systems; we need changes in the bureaucratic organization of our health depart- ments; we need changes in our cost accounting rules; we need changes in our malpractice insur- ance policies. We need new forces and new en- ergies to improve what we know to be poor care systems, and we need new methods to assure that high quality is maintained. There is undoubtedly still a place for good projects demonstrating new methods of care and new organizational approaches, although the leap from specially funded demonstration proj- ects to common community pattern seems often ''too much for our muscles or nerves. Home care programs have been in existence for a long time. Yet the description of a new one, using doctors, a nurse practitioner and social workers, justifi- ably warrants publication in one of our prestigi- ous 1975 medical journals (7). Why is this so? Why doesn’t a university school of nursing work with a nursing home and establish an aca- demic nursing center? Such a center could serve as a model of practice, an ideal setting in which its students could learn, and a clinical laboratory in which to try out and evaluate new methods of care. The school could contract with physicians and other health professionals for the services needed. Somehow, if we had the will, we could do all of these things. If we do not, if we in health care teams and in conference rooms across the land do not bring substance to some of these ideas, we become like the hollow men of T. S. Eliot: We are the hollow men We are the stuffed men Leaning together Headpiece filled with straw. Alas! Our dried voices, when We whisper together Are quiet and meaningless. . . Shape without form, shade without colour, Paralysed force, gesture without motion .. .(8). We must do better than the hollow men. References 1. Tichy, M.K. Health Care Teams. An Annotated Bibliography for Health Professionals. New York, N.Y., Prager Publishers, 1974. 2. U.S. Department of Health, Education, and Welfare. Public Health Service. Office of Nursing Home Affairs. Long-Term Care Facility Improvement Study: Interim Report. Rockville, Md., DHEW, March 1975. 3. Hall, L. ‘‘A Center for Nursing.” Nursing Outlook, 11:805-806, November, 1963. 4. Alfano, G.J. “The Loeb Center for Nursing and Rehabilita- tion. A Professional Approach to Nursing Practice.” Nursing Clinics of North America, 4:487-493, September, 1969. 5. Bates, B. ‘Physician and Nurse Practitioner: Conflict and Re- ward.” Annals of Internal Medicine (In press). 6. Beckhard, R. “Organizational Issues in the Team Delivery of Comprehensive Health Care.: Milbank Memorial Fund Quar- terly. Part 1. 50:287-316, July, 1972. 7. Brickner, P.W., et. al. “The Homebound Aged. A Medically Unreached Group.” Annals of Internal Medicine, 82:1-6, Jan- uary, 1975. 8. Eliot, T.S. “‘The Hollow Men.” In The Complete Poems and Plays, 1909-1950. New York, N.Y., Harcourt, Brace and World, Inc., 1971, pp. 56-59. ''CHAPTER 3 The PRIMEX Role in Long-Term Care Eleanor C. Lambersten, R.N., Ed.D. Nursing practice, like medical practice, has re- tained a base of general knowledge and skill con- sidered to be universal to clinical judgment and clinical competence for generalized services to individuals and families. The central focus of the practice of nurses has been perceived to be care, comfort, guidance, counseling, and helping indi- viduals and families to cope with health prob- lems that lie along a health-illness continuum. The functions of nurses, including those in the field of long-term care, have encompassed assess- ment, case finding, health counseling, health education, and preventative, restorative, and cu- rative measures. The Family Nurse Practitioner (PRIMEX) is polyvalent in that the scope of practice melds many of the traditional respon- sibilities and skills of the disciplines of nursing and medicine and reorders priorities for nursing care services. PRIMEX or Family Nurse Practitioner Pro- grams represent an approach to the development of an extended scope of practice for nurses in the assessment and management of primary care problems in complementary care roles with physicians. The programs were designed to build upon the previous academic and professional ex- periences of registered nurses. It was assumed, therefore, that there was a core of knowledge and skills (cognitive, affective, and psycho- motor) considered to be inherent in the domain of nursing practice as endorsed through custom and usage as well as through general legal sanc- tion. The scope of practice and optimal role of the family nurse practitioner was deemed to be inclusive of the customary domains of nursing practice with an emphasis upon the extension of the scope of practice. Objectives for nursing practice (Appendix A) were derived by the au- thor from the analysis of nursing care plans over an extended period of time, analysis of selected nursing care conferences, analysis of selected case data, review of the professional literature and critique by selected groups of practitioners and faculty members of undergraduate and grad- uate programs. The most recent critique and modification was by the faculty of the Cornell University-NewYork Hospital School of Nursing Undergraduate program and the faculty of the PRIMEX program of the Division of Continuing Education. The objectives are guides for action and represent the framework within which the nurse plans, provides, manages, and evaluates a health care regimen for individuals, families, or special population groups. The issue in clarifying legal constraints is that of the strategies nurses employ in achieving the objectives and the de- pendent, independent, and interdependent rela- tionship of the nurse with a physician in the actual performance of selected tasks or strate- gies. An illustration is the following objective customarily considered to be a responsibility of nurses: To identify deviations from [the normal or] predictable physiological response of the indi- vidual to potential or actual illness or disabil- ity (See Appendix A) Nurses have been held responsible for assess- ing the physical status of patients and for judg- ing the gravity of symptoms. The “physical ex- amination” performed customarily by the nurse has been extended in programs preparing family nurse practitioners and specifies inspection, pal- pation, percussion and ausculation and making use of such instruments as the ostoscope, oph- thalmoscope and stethoscope. Nurses, for exam- ple, have customarily used the stethoscope to listen to the heart beat of the fetus and to infer judgment as to the well-being of the fetus in utero. Nurses in Family Nurse Practitioner Pro- grams are being prepared to use the stethoscope on the chest of an individual to detect deviations from a normal or stabilized condition of the heart or lungs. The capacity for listening (auscul- tation) is extended through the use of the steth- oscope and the purpose is that of training for ''competence in the detection of sounds indica- tive of normal heart sounds and deviations from normal. An example of an objective in teaching physi- cal examination in the unit—Auscultation of the Heart—is the achievement of the ability to sys- tematically auscultate the heart and to identify correctly: 1.) S, 2:) Sp 3.) physiologic splitting 4.) presence or absence of a murmur—if present to note timing in the cardiac cycle and correctly describe sounds indicative of: 1.) S3; and S, 2.) rate and rhythm of the heart These objectives clearly delineate the scope and limitations of the practices of family nurse prac- titioners, trained in this program, in auscultation of the heart. Core objectives for the PRIMEX programs identify areas of an extended scope of practices similar to the example just cited. Assessment of the psychosocial health status of individuals and families has been traditionally within the scope of nursing practice. But assess- ment of the physical health status has generally been limited or defined as “reporting signs or symptoms” and has been interpreted to be lim- ited to techniques of observation, inspection, interviewing, and making use of such instrumen- tations as the thermometer and the sphygmoma- nometer with the use of the stethoscope gener- ally limited to blood pressure readings or monitoring the status of the fetus in utero. The scope of practice and optimal role of the family nurse practitioners was deemed to be in- clusive of the customary domains of nursing practice with an extension of this role as described in the report of the Secretary’s (HEW) Committee to Study Extended Roles for Nurses: (1) 1. Assess the physical and _ psychosocial health status of individuals and families through health and developmental history taking and physical examination. 2. Discriminate between normal or abnormal findings on the screening assessment. 3. Evaluate the assessment data in order to make prospective decisions about treat- ment independently or in collaboration with physicians and other health profes- sionals. 10 4. Manage the care of selected patients within protocols mutually agreed upon by medical and nursing personnel, including prescribing and providing care; making ad- justments in medications; initiating re- quests for certain laboratory tests and in- terpreting these tests; making judgments about the use of accepted pharmaceutical agents as standard treatments in diagnosed conditions; assuming primary responsi- bility for determining possible alternatives for care settings (institution or home) and for initiating referral. Clinical Judgment It was hypothesized in the research associated with our nurse practitioner programs in primary care that the issues of potential scope of practice were those related to the nature and scope of clinical judgment influenced by the complexity of the phenomenon rather than to task delega- tion as has been the prior general orientation to manpower personnel. The concept of extended scope of practice infers a depth in clinical com- petence in diagnosing and initiating, as well as managing health care services.' The concept of extended scope of practice also infers a depth of competence in the techniques of physical and psychosocial assessment and the ability to em- ploy a variety of instrumentations and technolo- gies. The measurement of clinical judgment (decision-making abilities) of the family nurse practitioner was considered in the following four areas: 1. Identification of new findings 2. Alteration or initiation of a regimen 3. Nature of referrals to physicians 4. Nature of referrals by physicians to nurses It is the nature of clinical judgment and the development of protocols to measure this that received priority. Task inventories disassociated from task analysis are inappropriate. The larger issue is the purpose of a particular task and the expected outcomes as related to either a diag- nostic or therapeutic regimen. The background of clinical judgment is clini- cal experience; the things practitioners have learned in practice. In acquiring experience 1 Diagnosis is the scientific appraisal of and decision making about the health status of individuals. ''every practitioner has to use some sort of intel- lectual mechanism for organizing and remember- ing his observation. A modification of Feinstein’s classification of the three different types of data a clinician in medicine observes was a useful model for our purposes: 1. The first type of data describes a disease in morphologic, chemical, microbiologic, physiologic, or other impersonal terms; 2. The second type of data describes the host in which the disease occurs. This de- scription of the host’s environmental background includes both the personal properties of the host before the disease began (such as age, race, sex, and educa- tion) and also the properties of the host’s external surroundings (such as geographic location, occupation, and financial and social status). 3. The third type of data describes the illness that occurs in the interaction between the disease and its environmental host. The ill- ness consists of clinical phenomena; the host’s subjective sensations, which are called “‘symptoms” and certain findings, called “signs”, which are discerned objec- tively during the physical examination of the diseased host(2). Feinstein states that the clinician uses these three types of data to make decisions about the present, past, and future of the patient. “‘The decisions consist of determining a present diag- nosis (which tells what is wrong), a past etiology and pathogenesis (or how it got that way), and a future prognosis and therapy (or what to do about it)’(3). More specifically the differences are influ- enced by the degree to which the practitioner can predict the outcomes of his services. The processes involved are cognitive and dependent upon the following characteristics: 1. recall and understanding of substantive bodies of knowledge 2. speed and accuracy with which new knowledge is acquired 3. strategies of inquiry the learners are pre- disposed to pursue. Issues of Scope of Practice The interdependence as well as the comple- mentary nature of the independent areas of the practice of nurses and physicians is clearly evi- dent in any analysis of the nature of services provided in a holistic approach to health care. The position of the majority of nurses has been that traditionally they have forwarded the pur- poses and programs of the physician but that, in addition, they have the potential to function with autonomy in selected areas of the health care spectrum and to function in a collegial rela- tionship. Health care is the sum total of care provided by all health disciplines and comprises more than diagnosis, prescription, and treatment of ill- ness and disability; health care assumes the pro- vision of service directed toward health mainte- nance, prevention of disease and disability, as well as diagnostic, curative, and restorative serv- ices. The central focus of nursing is care, comfort, guidance and assisting individuals to cope with problems that lie along the health-illness contin- uum. It is the concept of the degree and nature of the deviation from a normal life process or the degree or nature of deviation from a predict- able psychological or physiological response to illness or disability that distinguishes nursing practice from medical practice. The intent is to distinguish nursing practice from that practice of nurses which includes the ministration of medi- cal acts delegated by the physician to the nurse. It is the overlapping areas of components of practice involving diagnosis and therapy that are at issue. The orientation of physicians and nurses is similar yet dissimilar. Medical educa- tion traditionally has been oriented toward diag- nosis and treatment and nursing education tradi- tionally has had a psychosocial orientation. This is not to say that medical education does not place emphasis on the psychosocial needs of pa- tients or that nursing education does not place emphasis upon physical illness and disability, but there is a different order of magnitude in the priorities. Health counseling and health education have in the majority of instances been recognized as within the prerogatives of nurses. There has al- ways been an overlap in the treatment areas or modes of intervention common to nursing and medical practice in preventive, restorative or cu- rative services. The physician, under certain cir- cumstances, may execute the prescribed regi- men; under other circumstances delegate the prescribed regimen to the nurse for execution; in still other circumstances the same regimen may be prescribed and executed by the nurse. The instances of a nurse prescribing and executing a 1] ''regimen is most common in the areas of preven- tive and restorative services and remains contro- versial in the area of curative services. It has been the observation of our nursing and medical faculty that issues of medical supervi- sion, delegation or perceptions of individual physicians of the potential for relative degrees of independent scope of practice for nurses are neg- ligible and non-controversial when the scope of practice: is specialized and therefore circum- scribed; can be described with precision and tasks can be programmed procedurally; depends upon overt rather than covert descriptions and interpretations of signs and symptoms; requires constant monitoring of patient progress; encom- passes tasks at high frequency intervals and thereby are inordinately time consuming; and is based in a hospital or the physician’s office. It might be hypothesized that hazards of human error are perceived by physicians to be minimized and, therefore, patient safety and welfare assured under the above circumstances, but that hazards of human error and consequent patient safety and welfare are of critical concern in the most ambiguous areas of general practice in primary care. The nature of the dependence, independence, and interdependence of the nurse practitioner, inherent in the concept of an ex- tended role, continues to have an isolated task orientation. It is the author’s premise that the area of mu- tual concern of physicians and nurses should be the scope and nature of clinical judgments in- volved and under what circumstances the nurse practitioner would select and implement a pro- tocol or plan for management and therapy. Although nursing and medical faculty in a controlled educational environment may en- dorse a specific level of responsibility in selected problem management, it has the experience of the project staff that when the graduate returns to the practice setting, the practicing physician, with whom the nurse practitioner relates, may have a higher or lower expectation than that of the medical faculty. This is equally true of the nurse practitioner and nurse faculty. There are numerous variables in the various settings that must be identified before any conclusive infer- ences can be made. The levels of responsibility for selected problem management that were adopted as guidelines in the various practice set- tings are: Level 1. Problems referred immediately to the physician either at the time the 12 patient presents his chief complaints, or after limited preliminary historical data have been gathered. Level 2. Problems referred to the physician after the basic history, physical ex- amination, and order of laboratory tests. Level 3. Problems for which the nurse practi- tioner would propose a protocol or plan for management and therapy, but then would seek consultation with the physician prior to the im- plementation of the plan. Level 4. Problems which the nurse _practi- tioner would independently select and implement a protocol or plan for management and therapy. ? Scope of Practice The major functions of nursing are perceived to be assessment (physiological and psycho- social), health counseling, health education, and preventive, restorative, and curative measures. Innovative practices in nursing are emerging within three domains of practice for Primary Care, Long-Term Care and Acute Care Services. In each of the three domains the similarities are the nursing process, the nursing functions, the nature of the presenting problems, and the type of problem-related intervention required. Basic to the decision to use any problem-related inter- vention is an ability to assess response patterns.? A model was developed for identifying the nature of the potential populus for Primary Care, Acute Care and Long-Term Care Services; behavioral and physiological indices of an adapt- ive or maladaptive state; and problem-related in- tervention indicated in the functional areas of health counseling, health education, and preven- tive, restorative, and curative measures. The model is inclusive of mental health-psychiatry or behavioral disorders, as well as physical illness or physical disorders for all age groups (Appendix B). 2 Adapted from numerous sources in the literature on mid-level health workers, 3 Assessment is the process of ordering phenomena through the processes of identifying physiological and behavioral indices to determine if the organism is in an adaptive or maladaptive state. ''The model is intended to serve as a scheme for categorizing the nature and scope of nursing in- terventions prescribed as a result of the assess- ment of the health status of selected population groups. The data recorded, therefore, are de- scriptive and predictive of staffing requirements and standards of care required for the various settings in which care is provided. The data secured through assessment of the physical and psychosocial health status of indi- viduals or selected population groups, such as the aged experiencing long-term illness, are re- corded objectively. These data describe the clini- cal phenomena: the subjective sensations, symptoms, or presenting complaints secured through a psychosocial history and physical findings or signs secured through a physical ex- amination. Problem-related interventions indicated as a result of the initial and ongoing assessment are categorized under the functional areas of health counseling, health education, and preventive, re- storative, and curative measures. (Definitions are included in Appendix B). Experience in the test- ing of this model clearly identifies the particular emphasis or strategies indicated for individuals or special population groups. In selected in- stances the nursing intervention may consist pri- marily of health counseling, in other instances, assessment of the ability to cope with basic liv- ing activities such as bathing, dressing, toileting, eating or ambulation nursing interventions may be inclusive of preventive, restorative, and cura- tive measures as well as health education and counseling. This is particularly true of patients incontinent of urine and feces with needs for bladder and bowel training. Skin care in these instances or for the chair or bed-bound patient places emphasis upon preventive measures whereas the presence of bedsores places empha- sis On curative and restorative measures. It should be noted in this model that the pop- ulus requiring long-term nursing care services are identified in the domain of primary care with services provided in a variety of ambulatory care settings; in the domain of acute care for the homebound or those requiring admission to a health service institution; in the separate domain of long-term care for the homebound or those requiring admission to a health service institu- tion or community social service agencies. The characteristics of long-term care are: 1. Long-term illness or disability—phenome- non is reversible and has potential for cure; 2. Chronic illness or disability—phenomenon is irreversible and has either a potential for becoming stabilized or progressive; and 3. Acute exacerbations of long-term or chronic illness. Assessment of the psychosocial and physical status of a patient with a diagnosed long-term illness or disability also results in particular em- phasis or concentrations in one or more of the functional areas of the model. A patient may, for instance, have long standing chronic illness in good, fair, or poor control. In other instances, a patient may be coping adequately with con- trolled or reversible long-term illness and the em- phasis for nursing intervention is to conserve their present state of health or to maintain a plateau as long as possible. The emphasis on the functional areas differs. This type of analysis and recording of data will be predictive of the nature of personnel re- quired for staffing services and the amount of staff required. Exact patient-staff ratios are not possible without such an analysis of a popula- tion of patients served in the various institutions or community agencies. Long-Term Care—The Aged The role of the nurse in the clinical manage- ment of patients with long-term or chronic ill- ness is generally noncontroversial because the condition has been diagnosed, a medical regimen established and potential complications are pre- dictable. The orientation of nurses has been that of supportive management of the functional lim- itation of the patient or assessment of needs for care on the basis of the degree of limitation (physiological or psychosocial) imposed upon the patient by his health condition. Functional limitation scales in general practice define activ- ity levels appropriate to the patient’s life stage as well as life style. Impaired functioning as a result of illness can be scaled to correlate activity level with need for care:(4) Level 1. Needs care to reduce the risk of fu- ture impairment or to control exist- ing impairment. 13 ''Level 2. Condition does not yet require sig- nificant reduction of usual life activi- ties. Needs care to eliminate or ame- liorate his symptoms. Level 3. Must cut down on the usual life ac- tivities and are, therefore, seriously restricted. Distinction is made _ be- tween those who can perform usual activities only partially or not at all but can care for themselves. Level 4. Dependent upon others, wholly or in part, for ambulation, personal care and certain vital life functions. Level 5. Dependent upon others wholly for all vital life functions.* The functional limitation scale uses the pa- tient’s perception evidenced by his behavior as compared to clinical test results. A basic reason for using the patient’s perception as the measure for care required is that this approach encom- passes the psychosocial components as well as the process elements of care. Functional limita- tion is a reflection of the patient’s contribution to the healing process, a contribution that is often just as important as—and sometimes more important than—the medical care contribu- tion(5). The coronary patient is one example of a patient whom the physician knows to be physically able to resume his normal routine but whose shattered psyche prevents him from func- tioning as a whole person(6). A debility index for long-term care patients is an influential factor in determining whether the patient should be discharged from a hospital to a nursing home or referred for supportive manage- ment in an ambulatory care (primary care) set- ting, for home care, or other community service agencies(7). The determining factor is the rela- tive dependence of the patient in the perform- ance of activities of daily living (ADL) such as feeding, continence, ambulation, transfer to and from bed, dressing, and bathing, his rehabilita- tion potential and personal resources for adapt- ing to his environment. Assessment of the behavioral response of indi- viduals to functional limitation and supportive management of patients with certain chronic and progressive illness has by custom been en- dorsed by the concepts of skilled nursing care in nursing homes, organized home care programs 4 Level Four was modified by nursing service staff and Level Five added. 14 and services of visiting nurses. In primary care settings there is increasing evidence of the in- volvement of nurse practitioners in the assess- ment and management of this group of patients; patients whose care needs are time consuming, repetitious and do not require the services of physicians except for periodic appraisal. Long-term or chronic illness can affect any age group but this paper is limited to the aged— the aged who have suffered a decline in physical or mental functional status to a degree that in- terferes with the socially acceptable perform- ance or for adapting to his environment. Because of our mass society, we have a tend- ency to categorize a person in terms of his chronological age. “The great differentiation through life experiences of older persons of the same categorical age means they are more indi- vidualized and more unique than persons of ear- lier age groups.” The processes of aging— biological, psychological, sociological—interact with physical and social environment. Individu- alization is the result(8). Biological aspects of aging refers to those physical characteristics which are affected by time and determined largely by genetic and environmental influences brought to bear upon the individual(9). Psychological aspects of aging refers to those functions used by the individual in adapting to his environment—his senses and perception, his ability to learn and remember, his re- sponses and his personality(/0). Sociological aspects of aging refers to the ad- justment of the aged individual to society, with consideration given to the degree to which he is, or can be, influenced by family, friends, and community(//). Health problems of the aged may have their origin in the biological, psychological or socio- logical aspects of aging. Certainly one should be aware of the impact of poverty on health with inadequate nutrition; of the impact of social iso- lation upon psychological well being; of environ- mental safety and the accident toll of the aged; of degenerative changes and the impact on social functions. It has been estimated that only 14 percent of the aged have no chronic conditions, diseases, or impairment of any kind and that the vast major- ity that do have such conditions still manage by themselves. This generalization should be chal- lenged for it is well known that some aged ''people believe that symptoms of illness are nor- mal and inevitable results of aging and do not seek help, and others are aware of their need for help but lack the knowledge, energy, or re- sources required to secure essential services. Aged persons as a group have a greater proba- bility for long-term or chronic illness. They have a greater risk of having more than one illness, and their illnesses are more likely to be associ- ated with or lead to the inability to carry out such functions of self-care as bathing, dressing, walking, and meal preparation. Weakness and de- creased physical and mental tolerance to stress are more apt to cause geographic confinement and curtailed social interaction (/2). Three- fourths of all deaths among persons over 65 are due to heart disease, cancer, and stroke. Heart conditions, arthritis, and rheumatism cause the greatest amount of disability. Further, on any given day approximately two million aged persons experience the effects of injuries, two-thirds of which occur in the home. Premonitory accidents (ones which occur as the first manifestation, or shortly after the onset, of an illness) are frequent causes of falls and inju- ries in the aged. Degenerative changes of the cen- tral nervous system may result in prolonged re- action time. The physical deterioration which accompanies chronic brain syndrome, together with chronic illness and malnutrition, result in decreased alertness and ability for self-care and a sense of detachment, which cause falls, burns, and pedestrian accidents. In addition, as homeostasis becomes less effi- cient in the aged, stress will cause increased de- grees of departure from normal limits and a pro- longed recovery time.’ For example, in cases where the blood pressure becomes very low the individual may experience vertigo or fainting. ALTERNATIVES TO INSTITUTIONAL CARE If health status is defined as the ability to function well enough to carry out normal roles and responsibilities in the community or a level > Homeostasis is that complex group of neuromuscular, cardiac, and endocrine gland reactions whereby the body maintains its basic physiological function within normal limits; such as tem- perature, pulse rate, cardiac output, respiratory rate, blood pres- sure, oxygen supply to the tissues, blood volume and composi- tion; and acts to maintain such normal values under the stress of blood loss, fever, tachycardia, acute disease, and injuries. of wellness consistent with the limitations im- posed by the aging process, nurses should reject the illness orientation they impose on the el- derly. The National Center for Health Statistics indicates that only five percent of persons over 65 are so ill or function so poorly that they must live in nursing homes, homes for the aged, mental hospitals or other institutions. Those same statistics indicate that older people have more disability days than young or middle-aged people. But they are, on the average, restricted in activity only 35 days a year and are confined to bed on only 12 of these days (/3). Nutritional Services Nutritional inadequacy is recognized as a pri- ority problem of the aged. But problems of under-nutrition and malnutrition cannot be solved independently of related problems of in- come and limited knowledge of nutrition; feel- ings of loneliness, rejection, and apathy; declin- ing health, vigor and loss of mobility; physical handicaps that make food-shopping and prepara- tion difficult; and metabolic changes that ac- company aging (/4). Transportation Without mobility, the elderly find it inconven- ient or impossible to shop for food, go to church, visit friends or relatives or receive am- bulatory health care services. For many it is their second major concern just behind inade- quate income and the high cost of health care (15). Housing Broadened public housing coverage is needed not only to provide suitable residential living, but also services for central dining facilities for the poor elderly who cannot cook their own meals. Home Health Care Services Health care services to the homebound but able to be maintained in the home have been successful in many communities. The services should encompass professional nursing care; home health aid services; homemaker services: medical services; physical, occupational, or speech therapy; and medical supplies, drugs and medications, and laboratory services. 1) ''Geriatric Day Hospital A day hospital is a facility to which patients may come, or be brought, in the morning, where they may spend several hours in therapeutic ac- tivity and then return on the same day to their home. Facilities essentially are for nursing care services, physiotherapy, and occupational ther- apy, for medical examination and usually for various other activities including speech therapy, dentistry, chiropody, and hair dressing. Day Care Centers Day care centers provide social facilities— company, a cooked meal, possibly a bath, chi- ropody, recreation but no remedial services. Social Agencies Community centers, Golden Age or senior cit- izen clubs offer group therapy to the relatively well elderly as a means of enriching the lives of old persons. Many of these non-institutionalized persons are depressed or feel bored, lonely or anxious; others resemble institutionalized per- sons but are ambulatory; capable of using public transportation, and interested in group relation- ships as a means of getting help (/6). The Significant Role for Nursing Fundamental to our deliberations about the role of PRIMEX was the assumption that they would function within the system of health care as members of health teams; health teams insur- ing a network of communications providing link- ages for services required for people at any stage of the health continuum. A primary concept is that the talents required for these services may vary from those of a specialist in medicine to a community worker trained in case finding such as a community health aide. The reference to talents does not imply a hierarchy but refers to the demands of a given situation at a point in time. It is my premise that the following charac- teristics are requisite to effective utilization of a mix of health service personnel in systems of health services delivery: 1. Assumption by or delegation to the vari- ous members of the health team for health care services based upon their level of knowledge, judgment, and clinical com- petence or distinctive area of expertise. 16 2. A system of communications and proto- cols that insure smoothly coordinated and synchronized activity and services.® Nurse practitioners have already made a signifi- cant impact on the care of the aged and chroni- cally ill in hospital out-patient services, neigh- borhood health centers, and nurse clinics in housing projects or single room occupancy buildings as well as in the home. A New York Hospital-Cornell University Pro- ject (1960-1965), under the direction of Dr. George G. Reader, was the first hospital-based experiment in the organization of welfare medi- cal care service in New York City. The study of an implementation of an extended role of the nurse was an integral part of the experiment. Initial and interrelated studies reported in 1962 focused upon the determination of nursing needs of elderly clinic patients and upon the psychosocial problems of the same interviewees to seek understanding of the deeper social and emotional problems. Doris Schwartz, R.N., As- sociate Professor of the School of Nursing, was a participant in this study. In 1968 Mrs. Mamie Wang, who had been a nurse-interviewer in the 1962 study, developed an exploratory project for expanding the role of the nurse in the general medical clinic, with the aim of reducing fragmentation of services which the earlier studies had documented. A new ap- proach to services was projected which would provide a primary health care contact for se- lected chronically ill patients, would be con- cerned with all aspects of these patients’ care and would have the flexibility in organizational relationships to accomplish these goals. Mrs. Wang became this primary health contact. She and Dr. Frederic Kirkham developed a proto- type for a complementary and collaborative role of the nurse in this setting with Mrs. Wang shar- ing increased responsibility for patient care. The Visiting Nurse Service of New York City and the New York Hospital, for the last several years, had also been experimenting with and pro- viding expanded services in health maintenance and in the provision of guidance and surveillance services of the health practices of the aged and chronically ill in single room occupancy dwell- ings and in housing projects for the elderly and handicapped. San example of a protocol developed by the Division of Am- bulatory Services of the New York Hospital and the Visiting Nurse Service of New York appears as Appendix C, ''Numerous examples appear in the professional literature of innovative practices in the utiliza- tion of PRIMEX in the care of the aged. But I shall refer to examples of our graduates. The following selected examples were described by a graduate and a member of the staff of the Visit- ing Nurse Service of New York(/ 7): One of my colleagues works in the Corona- Flushing district of Queens which has a popu- lation largely of middle and upper income level residents, and some areas of low income and poverty levels. There are many aged resi- dents. A large number of the population in Grace’s district attend clinics at alocal munici- pal hospital. She, therefore, chose to set up a relationship with a clinic at the hospital which is attuned to the needs of the elderly and de- livers comprehensive care. Grace attends Geri- atric Clinic when it meets on Wednesday mornings and in the P.M. attends seminars and planning conferences of the Extended Care Unit of the hospital. The patients of this unit may be either potential clients of Geriatric Clinic or well-known to the clinic. Grace sees some of the patients in Geriatric Clinic independently and sees others jointly with the chief of the clinic and/or his two residents. Institution and modification of the treatment plans are jointly arrived at. Written and verbal communications on all patients from Geriatric Clinic, being followed by the Visiting Nurse Service offices in Queens, are coordinated by Grace. We always have the most current information as a result of this effort. The plans for further utilization of the fam- ily nurse practitioner in routine monitoring in the home of select Geriatric Clinic patients with reasonably stable conditions are under- way. Grace and the doctors have jointly drawn up drafts of protocols which will serve as guides to monitor these patients. The next step will be to review the entire Geriatric Clinic population and select those who can best benefit from such extension of services. The advantages to the chronically ill elderly are enormous. Clinic visits frequently disrupt normal routines; are often anxiety provoking; are certainly time-consuming and exhausting, and are expensive to those on limited income and not eligible for transport services, and are costly to the institution. The Astoria district where I’m assigned is a 38 square mile area adjacent to the Corona- Flushing district. It lies directly across the river from mid-Manhattan. It is chiefly a mid- dle income area with some pockets of low in- come and poverty-level populations. It is a colorful area. We have large populations of first and second generation Greeks, Italians, Germans, and a recent influx of Spanish- speaking residents from the Latin and South American countries. Roughly 70 percent of our patient load are 65 year-olds and over. There are many chronically ill elderly in our district and a considerable number of these are not receiving adequate health services. Some of the patients that Grace sees in Ger- iatric Clinic live in the Astoria district. When their conditions warrant, they are monitored by me between clinic visits. Let me illustrate. Last February I was asked to see a Geriatric Clinic patient living in our district who had developed digitalis toxicity and was having several PC’s (premature complexes) per min- ute. His digitalis and diuretic had been discon- tinued. Hospitalization had been considered, but the patient’s condition didn’t seem to warrant this. Having him return to the emer- gency room or another clinic on Friday and the following Monday had also been consid- ered. But, this would have been a hardship for this 75 year-old man with diabetes mellitus and diabetic neuropathy besides his cardiac condition. It would have meant a 4% mile trip one way requiring one-hour travel time on a combination of buses and subways and several flights of stairs to negotiate. The patient was a soft spoken, dignified elderly gentleman who had once been a chef in some fashionable es- tablishments in the metropolitan New York City area. My job was to monitor him care- fully with respect to the PC’s and the advent of failure signs and symptoms. He was seen twice weekly by a family nurse practitioner and once a week in Geriatric Clinic. He sta- blized quickly. But, on a Tuesday after a holi- day, I visited him only to find most of the signs and symptoms of CHF (congestive heart failure). I paged the patient’s doctor from the Geriatric Clinic on the telephone. Within three to four minutes he had responded. I reported the findings. He suggested the patient report to clinic the following morning. Wasn’t there something that could be done now, I pro- tested. The patient still had some digitalis and diuretics in the home. The doctor ordered STAT doses of two digitalis tablets and one 17 ''diuretic. By the time the patient appeared in clinic the following morning, he had compen- sated. It was a good feeling. Patients living practically in the shadow of the New York Hospital-Cornell Medical Cen- ter across the river who have no easy access to health services for whatever reason are eligible under an established protocol for these serv- ices in the Health Maintenance Service of the Ambulatory Care Department of Cornell Med- ical Center. The history and physical are per- formed in the patient’s home. The pertinent data is telephoned to one of my colleagues at the clinic, an appointment is made, and a pho- tocopy of my work-up is either mailed or de- livered directly. In the case of the protocol with Health Maintenance Service, my collabo- rating physician, who is acquainted with me from the past and through the PRIMEX pro- gram, signs for whatever initial laboratory and radiology studies are indicated by the findings in my work-up. Further tests and follow-up are carried out in Health Maintenance Service. Perhaps this has given you some idea of a family nurse practitioner functioning in an a- gency such as ours—a large urban visiting nurse service. Another recent example of community serv- ices for the elderly is an agreement to establish between the New York Hospital-Cornell Medical Center and the New York City Housing Author- ity. This arrangement provides the part-time services of a nurse practitioner to the residents of an Elderly Project on East 71st Street. The Housing is a new facility. A physical facility is donated by the New York City Housing Author- ity and the New York Hospital provides the equipment and supplies necessary to furnish the facilities as well as the services of the nurse prac- titioner. The functions of the nurse include the following: 1. Complete interviews on tenants in order to identify major health problems and to determine the tenant’s customary source of medical care. Provide health counseling services. . Make any necessary referrals so that pa- tients receive appropriate medical care. 4. Administer preventive health services such as influenza injections and tuberculin test- ing, the materials of which are provided by the New York City Department of Health. wn 18 5. Provide liaison with the New York Hospi- tal. 6. Coordinate care with other health facili- ties with which the tenants might be con- nected. 7. Institute screening measures for such dis- eases as diabetes, hypertension, and so forth. 8. Provide health education to groups of pa- tients as the need arises. 9. Maintain a confidential record on every tenant who contacts the service, the re- cord of which should contain appropriate medical and health related data concern- ing the tenant. The examples cited above are limited to and illustrative of the role of our graduates in the care of the elderly in out-patient departments, neighborhood health centers, nurse clinics, in single room occupancies and in the home. They also act as liaison with a nursing home where the New York Hospital contracts for 120 beds for referral of patients requiring extended care and monitored services by the medical staff of the New York Hospital. In the instance of the nurs- ing home a nurse coordinator is provided by the hospital. CONTINUING EDUCATION—PRIMEX PROJECTS My orientation to the PRIMEX role in long- term care is that of the experimentation and evaluation of the project staff in a continuing education program for the past four years’. A concomitant educational activity has been fac- ulty involvement in curriculum modifications in the baccalaureate programs. It is universally accepted that the system of higher education which provides the basic prepa- ration for the members of a profession must also provide opportunities for practitioners to keep abreast of their fields. A phenomenon clearly evident in the evolution of nursing practice roles is that of simultaneous introduction of educa- tional opportunities for the acquisition of know- ledge, skill, and competence _ through continu- ing education, undergraduate, and graduate education programs. The rationale is self evident for there is always a need for an immediate pool 7Grant No. HS01366 Bureau of Health Services Research, Health Resources Administration. Department of Health, Edu- cation, and Welfare. ''of nurses recruited from those already in the practice setting as well as for the future practi- tioners currently enrolled or to be recruited for undergraduate and graduate programs. The current demand for adequately prepared and highly competent nurses to fill positions re- quiring specialized clinical nursing skills has reached critical dimensions. Currently employed nurses and nurses returning to the labor force require educational programs that will restore or renew their ability to practice effectively in a variety of complex specialized services in hospi- tals and in specialized, as well as generalized, services in a variety of community agencies. Continuing education programs are designed to provide educational opportunities for the acqui- sition of knowledge and the extension of the professional competency of practitioners. They do not supplant degree granting programs of higher education. Social forces are changing our educational tra- ditions in all types of educational institutions. These forces and pressures are moving us away from elitist education or mediocracy and toward equalitarianism. They are enlarging the definition of the ed- ucational process to include learning activities which have taken place along side of, and usu- ally independent from, our existing formal systems. Most of all, they are encouraging an attitude closely attuned to rapid social changes—an attitude of fostering increasing diversity of educational opportunity for our citizenry, but diversity by design rather than by accident and happenstance (/8). Continuing education programs preparing nurse practitioners are considered non-tradi- tional approaches to the education of nurses. One cannot continue to ignore the differing ca- pabilities of students for mastery of the achieve- ment of behaviors (cognitive, psychomotor, and affective) requisite to nursing practice of varying degrees of complexity. This is not an attempt in any way to imply that continuing education pro- grams are a substitute for baccalaureate or higher degree programs. But what is inferred is that the acquisition of competencies inherent in the PRIMEX role may be achieved through pro- grams of continuing education for selected prac- ticing nurses at the time the concepts and com- petencies are being incorporated into baccalaure- ate degree programs. Graduate education programs have a broader purpose. Clinical nursing and related courses in the specialized areas of nursing practice in gradu- ate programs leading to advanced degrees place emphasis upon the study of the practice of nurs- ing and the continued development of compe- tencies essential for systematic inquiry. The pur- pose is the preparation of nurse clinicians capable of improving the advancement of nurs- ing theory and practice. Clinical nursing courses in specialized and gen- eralized areas of nursing practice in continuing education programs place emphasis upon speci- fic knowledge and skills originating from the purposes and needs of the employment or prac- tice setting. The purposes of continuing educa- tion programs are derived from innovations in practice settings. These innovations may have their base in advances in medical science and technology, in experiments in the organization and delivery of health care services, or in propos- als for changing practice resulting either from the recognition of existing gaps or from a reor- dering of the priorities for these health care serv- ices. The following definition of continuing educa- tion has been endorsed by the faculty of our School of Nursing: The organized, planned presentation of ap- propriate educational experiences at a profes- sional level which are university oriented and related to the needs and purposes of employ- ment or practice settings. The education programs within the Division of Continuing Education have their origins in selected areas of clinical nursing practice. Al- though specific objectives are indicated for the various programs, the following general objec- tives serve as a guide for program planning and evaluation: e Change in attitudes and approaches to prob- lems of nursing practice e Correction of outdated knowledge e Acquisition of new knowledge in specific areas of nursing practice e Introduction to and/or mastery of specific skills and techniques e Alteration in the learning habits of the prac- titioner CONCLUSION The Standards of Geriatric Nursing Practice published in 1973 by the American Nurses’ As- sociation is based on the premise that there are 19 ''primary factors which make the nursing of older people different. Among these factors are: the chronological age and the effect of the aging process; the multiplicity of an older person’s losses; social, economic, psychologic, and biologic factors; the frequently atypical response of the aged to disease, coupled with the different forms disease entities may assume in the aged per- son; the accumulative disabling effect of mul- tiple chronic illness and/or degenerative pro- cess; cultural values associated with aging and social attitudes toward the aged(/9). It is of interest to note that the Standards begin with two statements concerning attitudes, since one of the major issues perceived in geriat- ric nursing is the attitude of practitioners provid- ing the care. I would propose that a major issue is the value practitioners in general place upon geriatric nursing as a professional commitment. The elderly and their health needs have been as ignored by nurses as by society at large. It is the author’s premise that a nurse practi- tioner prepared through a continuing education program similar to that of the PRIMEX program is essential for the care of individuals with long- term health problems with particular emphasis upon the aged. References 1. Secretary’s Committee to Study Extended Roles for Nurses, Extending the Scope of Nursing Practice. Washington, D.C., Superintendent of Documents, U.S. Government Printing Office, 1971. 2. Feinstein, A. R. Clinical Judgment. Baltimore, Md., The Williams and Wilkins Co., 1967, pp. 24-25. 3. Ibid. 4. Berdit, M. and J. W. Williamson “Functional Limitation Scale for Measuring Health Outcomes.” In Health Status Index, ed. by Robert L. Berg. Chicago, Hospital Research and Educational Trust, 1973, p. 63. . Ibid. . Ibid., p. 64. . Skinner, D. E. and D. E. Yett “Debility Index for Long- Term Patients.” In Health Status Index, ed. by Robert L. Berg. Chicago, Hospital Research and Educational Trust, 1973, pp. 69-82. 8. Beattie, W. M. “Matching Services to Individual Needs of the Aging.” In Working with Older People. Volume III. The Aging Person: Needs and Services. Washington, D.C., U.S. Department of Health, Education, and Welfare, April 1970, p: 2: 9. Division of Health Care Services. Working with Older People. Volume II. Biological, Psychological and Sociolog- ical Aspects of Aging. Washington, D.C., U.S. Department of Health, Education, and Welfare, 1970, p. 3. 10. Ibid. 11. Ibid. ANAN 20 12. 13. 14. 153 16. 17. 18. 19. Katz, S., M.D. ‘‘Rehabilitation of Hospitalized Aged Per- sons.” In Working with Older People. Volume III. The Aging Person: Needs and Services. Op. cit p. 63. Report of the Post-Conference Board of the White House Conference on Aging, April 18, 1973. (Unpublished) Pechovita, J. ‘‘Nutrition for Older Americans.” Journal of American Dietetic Association, 71:19-20, January, 1971. U.S. Senate Report No. 91-1520, The Special Committee on Aging. “Older Americans and Transportation: A Crisis in Mobility,” December 1970. Goldfarb, A. I. “Group Therapy with the Old and Aged.” In Group Treatment of Mental IlIness—Modern Group Book V/, ed. by Harold I. Kaplan and Benjamin J. Sadock. New York, N.Y., E.P. Dutton and Co., Inc., 1972, p. 114. Schaefer, A. M. ‘‘Family Nurse Practitioner.’’ Paper pre- sented at a Conference for Graduates of Nurse Clinician Courses at the Walter Reed Army Institute of Research, Washington, D.C., June 4, 1973, Included in Selected Read- ings on the Expanded Role of the Nurse. Available from the Division of Continuing Education, Cornell University-New York Hospital School of Nursing, New York, N.Y., pp. 126-140. Commission on Non-Traditional Study. Diversity by Design. San Francisco, Calif., Jossey-Bass Publishers, 1973, p. 6. American Nurses’ Association. Congress for Nursing Prac- tice. Standards of Geriatric Nursing Practice. Kansas City, Mo., The Association, 1973. ''CHAPTER 4 Problems and Issues in Long-Term Care: For Nursing Education Implications Rozella M. Schlotfeldt, R.N., Ph.D., F.A.A.N. Work is love made visible Kahlil Gibran The Prophet One great opportunity for nurses to demon- strate their devotion and service to their fellow- men is provided by persons who require sus- tained care over prolonged time periods. It is a fact that many persons who could benefit from such care now find that it is denied to them (2,23). Nursing care over sustained time is denied to some persons who need it because care in acute care facilities may be prohibitive in cost. It is denied to others because utilization review com- mittees in those institutions properly prohibit the prolonged occupancy of beds reserved for acutely-ill patients by persons having chronic ill- nesses, or by those whose conditions are suffi- ciently stabilized to permit their being trans- ferred to extended care facilities or to skilled nursing homes. However, professional nurses in sufficient numbers are not available in those in- stitutions to provide the type of nursing care patients need—or even to supervise the care given by other than professional nursing person- nel. Persons who are aged, permanently incapaci- tated by injuries, strokes, and by incurable and debilitating diseases are frequently denied the services of knowledgeable, competent nurses simply because professionals in perceptible num- bers do not elect to fulfill their career aspira- tions in nursing homes, publically supported hospitals for chronically-ill patients, and homes for the aged. Similarly, persons who suffer from mental illnesses and from genetic failures result- ing in enforced and prolonged institutionaliza- tion, primarily in publicly-supported mental hos- pitals, rarely have the nursing care they need for restoration or for comfortable and maximally productive and optimally independent lives. Those individuals who are incarcerated in penal institutions rarely have health surveillance pro- vided by knowledgeable, competent health pro- fessionals, and rare are the nurses who make their contributions within those institutions (4). Many persons who are homebound as a con- sequence of infirmities, physical impairments, or protracted, chronic illnesses are denied the serv- ices of professional nurses. Either the cost of home health care may be prohibitive to some persons who could benefit from it, or those who are afflicted may not know about the availabil- ity of nursing through community health agen- cies, with or without the need for personally subsidizing the cost of such nursing services. Scores of persons suffer from the social ills attendant to boredom, circumstantial thwarting of personal aspirations or personal fulfillment, indolence and imagined illnesses promoted by television hypnosis, and by clever advertising. Some of them resort to illness-producing ex- cesses in eating and drinking and to the unneces- sary and harmful use of drugs. Many of them could be helped toward actively seeking healthy lives by knowledgeable nurses—if their services were known and made available. But nurses are not yet generally known as practitioners who promote health and possess the knowledge and skills to prevent such insidious, chronic, incapac- itating disabilities. Many persons who are chronically ill and under the care of physicians suffer from acute exacerbations of their diseases, or from unneces- sarily unstable states, simply because they have insufficient knowledge about their illnesses and are not actively and effectively involved in their own programs of therapy (5). Skillful nurses 21 ''about the general health status of the nation as well; but the focus of medical practice, educa- tion, and research is on discovering the existence and cause of pathologies and on eliminating, at- tenuating, or minimizing their harmful effects and consequences. Some professionals, such as physical thera- pists, are concerned with specific aspects of ther- apy. It is upon them that sick and injured people must rely for the execution of specialized skills to bring about desirable treatment outcomes. Diet therapists translate knowledge about nu- trients, nutrition, and diseases related thereto into special services through which therapies are enhanced through the proper form and use of foodstuffs. Pharmacists’ focus are on the advancement and use of knowledge and dissemination of in- formation about drugs—in the interest of pro- moting their effective, efficient, and proper use. They provide drugs and drug information serv- ices to other health professionals and to lay people, and monitor drug utilization with a view toward promoting their proper handling and use and minimizing drug misuse, overuse, and abuse. Some social workers work with health profes- sionals. Their professional focus is on promoting the optimal socialization of human beings. Inas- much as social and economic deprivations and unresolved life crises have impact upon the health of human beings, they, too, have a unique contribution to make to the health and medical care system. Regrettably, the services of all of the health professionals are denied to many persons who have need for them. Such deficits in services are particularly notable in long-term care facilities. But historians of the future will undoubtedly designate the past decade as the period when social awareness quickened relative to the need for improved medical and health care for those who are aged, infirm, debilitated, deprived, and chronically ill; and historians will credit Titles XVIII and XIX of the Social Security Act as those that prompted, however belatedly, the institution of public policies and programs to upgrade the quality of medical and health care provided under the provision of those Titles, es- pecially that provided for persons in long-term care facilities (8,9). There is little question that a comprehensive, national system of medical and health care will be instituted within the next few years. Al- though it will likely be instituted in a step-by- 22 step approach, and although its precise features cannot yet be fully discerned, reasonable con- sistency in models proposed makes it safe to pre- dict the characteristics that the system will even- tually exemplify (J0,//). First, it will assure access to care for all per- sons, undoubtedly combining a variety of public and private financing schemes. Second, it will provide the gamut of services, including periodic health assessment, health sur- veillance, dental care, emergency care, diagnostic services, in-patient care during acute illnesses, and appropriate supervision and out-patient, in- stitutional, and home care, as needed, for per- sons who are chronically ill (both physically and mentally), disabled, infirm, and senile. Third, major referral institutions will be linked with specified networks of community services in an organizational plan designed to facilitate transmittal of pertinent information about persons served and additionally, make ed- ucational opportunities for students of the health professions in the gamut of settings. Note should be taken that the provision of institu- tional and “at home” care for chronically ill and aged persons within the community network of services will bring’ the care provided for them under the surveillance of professionals that are an integral part of the entire system. Further, such coordination of services will provide on-site opportunities for faculty, students, and staff representing all of the health professions to be- come actively and collaboratively involved in practice, learning, and research in acute and long-term care institutional settings, including nursing homes, and in patients’ homes as well. Fourth, information about persons served will be freely shared between and among institutions and agencies and with persons served. Collection of uniform, aggregate data will make it possible to make assessments of the health status of com- munities, regions, and of the nation. It will be necessary for all health professionals to explicate anticipated outcomes of care and to monitor the efficacy of their practices, thereby contributing to assessment of the total health and medical care program. Such continuous assessments will, it seems, contribute to establishing the specific contribution(s) each type of health professional (and assistants) can best make to the total care system. It is to be expected that proper artic- ulation of the roles of health professionals will eventuate when goals, strategies, and outcomes of their respective practices are made explicit, ''could exercise surveillance over such patients, in- structing them initially, and effectively moni- toring their progress toward regaining optimal health and function—if sufficient numbers of professionals were available and their nurse role properly and fully executed. But conceptualiza- tion of the nurse as the health professional pri- marily responsible for the care of human beings through which they attain, mantain, and regain optimal health has not yet been fully institution- alized, undoubtedly because the nurse role as represented by professionals has not yet been uniformly demonstrated (6). It is indeed a paradox that a field of essential and consequential work that has grown and steadily developed over the centuries—a field whose essential focus and professional responsi- bility were established over a century ago has still not been so recognized. But nursing, unlike medicine and dentistry, has had an unduly diffi- cult and prolonged emergence through the stages typical of all of the health professions. It is in- structive to note the central role played by edu- cation in the emergence of practice professions from their trial and error beginnings, through apprentice and technical training, and finally to professional education and training through which to equip practitioners for work recog- nized as being truly professional in all of its characteristics. Such emergence is marked by the availability of a critical mass of well-educated, competent, self-confident professionals. Those professionals are actively engaged in practice; and some of them are also engaged in the discov- ery of knowledge and in the design and test of new practice strategies—always with a view toward ever more complete fulfillment of a so- cially valued, valuable, and clearly identifiable professional practice role. Nursing is now ready to designate its profes- sionals as those who have completed programs of professional study at undergraduate and grad- uate levels. Those nurses, upon entry into gen- eral or specialty practice, are skillful and accu- rate in assessing the general health status of human beings of all ages. They act competently and with judgment to institute nursing care de- signed to promote the optimal physical and mental health and general well-being of human beings, and then accurately evaluate the out- comes of that care. They serve human beings of all ages, whether those subjects are well, near- well, ill, injured, infirm, deprived, or dying. They serve individuals, families and communi- ties, engaging in first contact or ambulatory care, in care of persons who suffer from acute and chronic illnesses, and in care of those whose infirmities or disabilities require that they re- ceive nursing care over prolonged time periods. The nurse fulfills the health surveillance func- tion for persons in all states of wellness and ill- ness; and for those who are infirm or incapaci- tated, provides compensatory, sustaining, supportive, teaching, and guidance services de- signed to restore them to optimal function, com- fort, and well-being. Additionally, the nurse’s goal is to render persons maximally competent with regard to executing their own programs of required therapy and maximally independent with regard to seeking optimal health. There is no question that nurses are concerned with pathologies, with their prevention, with their identification and with execution of medi- cal therapies prescribed for patients. Indeed, nurses execute and manage therapeutic regimens within agreed-upon indicators and parameters, particularly for patients in critical care circum- stances and for those requiring sustained care over time, such as persons who are aged and chronically ill. Nurses also identify health prob- lems by taking health histories, making pertinent observations of signs and symptoms, performing physical assessments, and evaluating relevant so- cial data. Nurses monitor the health status, prog- ress, and decline of those they serve. The focus of nursing practice, nursing education, and nurs- ing research is on accurately assessing and skill- fully intervening to maximize the health status and to actualize the health potential of all per- sons served. Nurses, of course, should work in collaboration with other health professionals. One goal, not yet uniformly achieved, is that of articulating the roles of all health professionals with a view toward fulfilling the health and med- ical needs of persons they all serve; and to edu- cate future health professionals in ways to pro- mote attainment of that end (7). The health professionals with whom the nurse works most closely is the physician. Indeed, the physician and nurse roles, if properly executed, can be said to be truly complementary. Physicians are charged with responsibility for differential medical diagnosis and medical treat- ment of all human diseases and disabilities, with discovery of their causes, and with development and test of effective cures for diseases whose causes are known, and of means of control mechanisms of diseases whose causes remain ob- scure. There is no question about physicians’ concern about the health of their patients and 23 ''and when they are systematically evaluated. Un- doubtedly, talents and competencies of practi- tioners will then be fully and appropriately uti- lized in order to achieve the goals of having exemplary, as well as cost-effective services. Envisioning the characteristics of a coordina- ted health and medical care system points up the need for remarkable changes in the services now provided, especially those for persons who are chronically ill, aged, and in need of services over prolonged time periods. Over time, those changes will inevitably occur as a consequence of social demands and of what seems to be a heightened awareness on the part of profession- als and public policy-makers concerning unmet health and medical care needs. In addition, the nursing profession is gaining in recognition as the one whose practitioners in increasing num- bers are prepared for and eager to fulfill the nurse role envisioned earlier. A critical mass of nurses are now engaged in research and scholarly practice; and others are giving creative leadership in academic health centers and in other com- munity settings with a view toward hastening that change process. The central role played by education in effecting change within the nursing profession is reminescent of the central role played by education in effecting changes within the other health professions as well. There is little question that additional changes in nursing education must be effected in order to achieve the long-range goal of having exem- plary care available to all persons whose infirmi- ties, chronic illnesses, and permanent disabilities require their having health and medical care serv- ices over sustained time periods, whether they are provided within hospitals or in other types of community settings. Those changes will be reflected in: 1) changes in inter-institutional ar- rangements, 2) changes in inter-professional planning for education of health professionals, 3) changes in undergraduate curriculums, 4) changes in opportunities for specialization in nursing, and 5) changes in nursing’s investments in research and scholarship. INTER-INSTITUTIONAL ARRANGEMENTS The position here taken is that eventually the complete network of health care services and the institutions through which they are provided must be rationally brought into relationship with educational institutions offering pre-service and advanced preparation for health profession- 24 als. Further, it is logical to expect that prepara- tion of all health professionals will eventually be the responsibility of universities, and more par- ticularly, that of universities whose health pro- fession schools are integral parts of health sci- ence centers. Whereas considerable rhetoric has been set forth concerning the need for future health pro- fessionals to learn their collaborative roles while they are in training, some medical, nursing, phar- macy, physical therapy, and social work schools continue to be operated under the aegis of higher institutions supporting education for only one type of health practitioner. Additionally, some university-supported institutions desig- nated as health science centers offer pre-service and advanced educational preparation for only one or two types of health professionals. If a goal for the future is the development of an ex- emplary medical and health care system, plans must be made now to effect not only an integra- ted network of comprehensive, high quality serv- ices, but also to effect arrangements between in- stitutions providing those services and higher education institutions offering preparation for the gamut of health professionals. The key to successfully relating educational and service agencies in the medical and health care fields lies in rationally balancing privileges and responsibilities of persons who are served by the care system with those of staff members holding appointments in service agencies and those of students and faculties in all of the health science schools. The goals to be achieved are to have assurance of high quality, needed services for consumers and high quality learning and research climates for students, faculty, and agency staff members. Responsibilities of faculties of the several health professions include: 1) providing models of exemplary, comprehensive care for persons served, 2) creating educational opportunities that stimulate maximum learning on the part of their students, and 3) promoting recognition of problems whose resolution requires knowledge not yet discovered and technologies not yet de- veloped. In order best to fulfill those responsibil- ities, all health science centers should have sub- stantial numbers of their faculties actively involved in practice and research, and each of the corporate faculties (medicine, nursing, phar- macy, and others) should take responsibility for quality control of their respective professional practices in the gamut of settings utilized for ''clinical learning opportunities for students. Moreover, if succeeding generations of practi- tioners are to fulfill the expectation of providing an adequate, coordinated, health care system, faculties from the several health profession schools must provide models of collaborative practice for their students. Those models must be exemplified not alone in medical centers lo- cated in urban settings where primarily acute, episodic care is provided for persons suffering from serious illnesses and undergoing heroic therapies, but academic health science institu- tions of the future must also provide primary, acute, and long-term care in a wide variety of settings in which faculties and students learn, practice, and conduct research in remarkably ex- tended campuses. In those settings persons served (sick and well) will be helped to recognize that their own services will be of the highest quality when they encompass health promotion, disease prevention and long-term as well as epi- sodic care. Such care will be provided by a wide variety of competent health professionals who practice, teach students, advance knowledge through research, and continue to learn. In such academic institutions inquiry will also be on- going with a view toward evaluating and contin- uously improving the health and medical care system, and making it ever more efficient. Considerable progress has been made in some settings to effect appropriate inter-agency and inter-faculty relationships through future- focused, deliberate planning designed to attain particular goals (/2,13,14). However, there seems not yet to be sufficient evidence of long- range, collaborative planning to make health sci- ence centers truly comprehensive in their offer- ings, and to relate those centers of learning and research to comprehensive medical and health care service networks. As the future is envisioned, one sees the need for contractual agreements between universities and the gamut of settings in which there is pro- vided first contact or ambulatory care, acute care, and long-term care. Those agreements should explicate the practice and research privi- leges of faculties and students, and faculties’ concomitant responsibilities to directly influ- ence and help to effect high quality services in all of the practice settings. The teaching and re- search privileges and responsibilities of agency staff members should be integral parts of those agreements. In the long-term care institutional settings, I envision remarkable changes relative to their staffing and to the responsibilities and relation- ships which will exist between and among health practitioners. The role of knowledgeable, com- petent nurses, and their assistants, should be rec- ognized as crucial to providing proper care of persons who are aged, and those who have chronic health problems. Indeed, it seems rea- sonable to predict that highly competent, spe- cialist nurses will, in the future, be those who establish admission standards and care regimens and make the decisions concerning persons who are to be admitted to several types of long-term care facilities, certainly to skilled nursing homes. Their input into admission, transfer, and dis- charge decisions made for persons served in in- termediate and resident facilities, and those eligi- ble for “at home” care will also be well established. Nurses should and will take respon- sibility for obtaining the services of physicians and other professionals when they are needed. Both nurses and physicians should engage in skillful and sustained monitoring of the health and illness status of those they serve. Certainly, pharmacists and nutritionists will provide drug information and nutritional information and be responsible for surveillance over drugs and food services in all long-term care facilities in the near future. Physical, occupational and recreational therapists, lawyers, and the clergy will also, in comprehensive service institutions, play major roles in the services provided. If public policy establishes the health and medical care system of the future to encompass complete and comprehensive services as herein envisioned, the educational opportunities pro- vided for all students of the health professions to experience and learn to .provide exemplary, long-term care will be remarkably enhanced—if proper inter-institutional relationships are devel- oped. Faculties who exercise their prerogatives to improve long-term care of the present will ac- complish that goal through their own practice and research, through serving as models for and peers of agency personnel, by helping to set standards for care, by testing new strategies for care, and by recruiting and nominating compe- tent agency personnel for leadership positions. Those faculties will also contribute to improving long-term care of the future by improving the learning and research opportunities for today’s 25 ''students who will become tomorrow’s practi- tioners. INTER-PROFESSIONAL PLANNING FOR EDUCATION OF PRACTITIONERS It is reasonable to expect that faculties in any of the health profession schools will always in- vest their primary teaching efforts in producing practitioners in their own image. Recognition is also given, however, to the responsibility held by leaders in the health professions to yield appro- priate influence in order to improve the future. That responsibility can be discharged only through inter-professional communication about the future, and by inter-professional collabora- tion in planning educational opportunities for students that will have a reasonable chance of developing, in those students, appropriate and necessary competencies, attitudes, and values. One assumption made is that students of the health professions can and will learn about effec- tive collegial relationships between and among all health professionals, and that they will be willing to invest themselves in collaborative plan- ning, practicing, and investigating endeavors. But those goals can be attained only if students see models of beautifully orchestrated role relation- ships and collaborative efforts demonstrated by their faculties. They must also see successful outcomes of such collaborative efforts in real- life practice settings, and thereby learn to appre- ciate the unique contributions made to the health care system by all who are participants in it. It is further assumed that such demonstra- tions can and will occur in ambulatory, acute, and long-term care institutions, and in a variety of other community settings, including resi- dents’ homes. There are, no doubt, many learning opportu- nities that can and will be shared by health pro- fession students in classes taught by teams of practitioner-teachers representing the several practice fields. The most vivid of such learning opportunities will, no doubt, be provided in set- tings where exemplary care is provided by teams of exquisite practitioners, with each team mem- ber making his or her unique contribution. Addi- tional, effective opportunities to promote learn- ing concerning collegial relationships designed to attain common goals will be provided by collab- orative research endeavors, especially inquiries designed to assess the strategies and outcomes of 26 particular treatment and care regimens, and the efficacy of the health and medical care system. There is need also for students of the health professions to engage in serious study of the ethics, the economics, and the politics of health and medical care. To date, little effort has been made to bring students of the several professions together to acquaint them with deficiencies in public policy relative to the health care system. Few students (and faculties) have opportunities to join colleagues in other health disciplines for critical analyses of the economics of health and sickness care, and for study of problems needing resolution. Among those problems are inadequa- cies in care of aged and infirm people, of those who are mentally deficient, of those who are chronically ill and of those who are involuntarily institutionalized. Study of the heritage of the health professions would also provide opportuni- ties for health profession students to gain new insights into current circumstances and to de- velop new perspectives for the future. It is to be hoped that henceforth faculties in the several health science schools will collabgrate in plan- ning creatively for shared learning opportunities that will motivate them to create a future in which health care is truly exemplary. If, as envisioned, the gamut of service settings are appropriately utilized in the education of students, faculties will have made deliberate, co- operative plans for such education. Students will likely also have relatively more balanced learning opportunities that are appropriately selected from long-term, community and acute care set- tings. Educational resources, including teaching personnel, space, clinical learning opportunities, equipment and supplies can be expected to be reasonably shared and properly provided for all students—if collegial relationships among. all health science faculties truly do develop. It is also highly likely that collaborative planning to meet important, shared educational goals will minimize the frequency with which ill-fated, in- effective resolutions of health care personnel “shortage” problems will henceforth be put into operation. Collaborative efforts to effect lasting resolu- tions of problems relative to long-term care are badly needed. One resolution undoubtedly will be forthcoming as a consequence of changes in nursing education—some of which already have been made in several nursing schools. '' CHANGES IN UNDERGRADUATE NURSING CURRICULA For whatever strengths and deficiencies exist in the health care system, educators who prepare practitioners must share in the credits and in taking responsibility for identified inadequacies. In large part, nursing’s strengths and shortcom- ings are also derivatives of the field’s confused system of education. That system is a conse- quence of delayed decisions concerning the types and numbers of nursing personnel that are needed to fulfill the health care needs of the Nation. In part also, nursing’s strengths and shortcomings resulted from the position of re- duced influence in which its leaders were placed solely as a circumstance attandant to their being primarily women. Nonetheless, remarkable pro- gress has been made during the last decade in regularizing nursing’s system of pre-service edu- cation and in setting definitive directions for the future. Basic to both of those developments was the quite generally accepted statement of nurs- ing’s focus and scope of responsibility, as previ- ously described. In 1965, nursing officially established a sys- tem of education that placed the responsibility for pre-service, professional education of nurses in. universities, and the responsibility for pre- service preparation of nursing technicians and nurses’ assistants in educational institutions of- fering technical and vocational training (1/5). Since that time, a steady, albeit relatively slow change, has been occurring in nursing’s educa- tional system. Hospital-based diploma programs have decreased in number while graduate, bacca- laureate, associate degree, and vocational train- ing programs have increased, as have enrollments in them (16). Moreover, collaborative work has gone steadily forward to explicate and further communicate the focus and scope of responsibil- ities to be held by nurses (17), to identify the nature of graduate study needs for specialization and research (/8), and to encourage and set forth guidelines for nurses’ pursuit of continued learning (19). Although not uniformly demonstrated, good nursing schools have developed criterion- referenced and competency-based curriculums for their undergraduate students. Faculties have set forth, in behavioral, descriptive terms, the minimal competencies students are expected to demonstrate before they can be advanced in their programs of study, and before they can be graduated and certified as eligible to take license examinations, and thus qualify for entry into practice. Such curriculum planning has forced the faculties to identify the broad and more de- finitive competencies to be developed in order to equip their graduates to engage in first con- tact or ambulatory, acute, and long-term care; the knowledge base for such practice that stu- dents are required to master; and the attitudes toward continuous learning, service, inquiry, and discovery that are essential to the work of pro- fessionals. General agreement now prevails that nursing students must learn and demonstrate proficiency in assessment of the physical, social, and emo- tional assets and deficits of those for whom they provide scientifically based, humane nursing care designed to promote each person’s optimal health status. They must learn to evaluate the efficacy of the strategies they use and the out- comes of their practices. Nursing students learn to counsel and teach patients: and to involve them in their own programs of therapy. Al- though nursing education programs vary remark- ably, it is generally expected that nursing stu- dents will learn to collaborate with other health professional students and staff members. They also are expected to learn how to analyze the work system and to give guidance and help to nurses’ assistants. Nurses’ assistants include practical or voca- tional nurses, nurses’ aides, and nursing techni- cians. All have long been involved in providing direct nursing services to people in acute and long-term care settings, in peoples’ homes, and in a wide variety of other community settings. Regrettably, those assistants too frequently have not had the supervision they need from compe- tent professionals. Instead, they have been forced to act without their having the knowl- edge and skills essential to provide programs of good nursing care. Indeed, the laws governing institutional reimbursement for care of patients in skilled nursing facilities has encouraged the availability of only minimal and highly inade- quate surveillance over such care by registered nurses. Fortunately, training centers for nurses’ assist- ants are now becoming available. In addition to augmenting competencies of those nurses’ assist- ants, they will also provide opportunities for nursing students to learn supervisory skills. 27 ''Although there are many strengths in nurs- ing’s system of education to prepare practition- ers, there are undoubtedly many deficiencies as well. The greatest problem lies in the wide varia- bility in competencies of faculties, in the rele- vant science base students are expected to master, in the nature and quality of clinical learning opportunities provided for them and in their acquaintance with and involvement in sci- entific inquiry. Programs vary remarkably also in the extent to which students have planned, use- ful contacts with other health professionals and in the extent to which their faculties provide models of involvement in collaborative practice and in scientific inquiry. Although a science ethic now prevails in a few nursing schools, certainly relatively few nursing students are helped to recognize the dynamic nature of their profession and to appreciate the extensive and continuously changing knowledge base that must be mastered in order to be com- petent in practice. Few are led routinely to iden- tify deficiencies in knowledge with a view toward involving them in systematic inquiry and stimulating some of them to seek to become clinical scientists. It is perhaps relatively rare for nursing students to have planned opportunities to engage in objective peer review of nursing practices with the goal of having them develop competence in, respect for, and appropriate atti- tudes toward that essential function. It is proba- bly true that few nursing students have opportu- nities to become colleagues of highly competent nursing practitioners and investigators who dem- onstrate the dynamism of their profession and the professional rewards that are inherent in it. Because of wide variance in students learning, the field now includes many nurses who are defi- cient in the competencies they should possess in order to execute the nurse role fully. Programs of short-term training to correct practitioners’ deficits have addressed particularly nurses’ devel- opment of skills in physical assessment to com- plement their other nursing skills. Hopefully, all undergraduate nursing programs will henceforth prepare professionals who possess the gamut of practitioner skills at acceptable levels upon grad- uation, and that programs of continuing educa- tion will then be available so that fully compe- tent nurses can keep current in their knowledge and skills. To date, programs of undergraduate education have undoubtedly neglected to utilize long-term practice settings to their full capacity as learning 28 and research laboratories for nursing students. Indeed, evidence exists that the nursing home industry has developed primarily as a profitable business enterprise, rather than as a setting in which exemplary nursing care is provided in a home-like environment (20). Other institutions providing long-term care are also deficient in the nature of care provided. Nurses must take con- siderable responsibility for neglecting to develop uniformly high quality programs of long-term care for persons who need them, even though recognition must also be given to the paucity of professional career opportunities that have typi- cally existed in many long-term care settings (21). Nonetheless, long-term care in patients’ homes and in a variety of institutions provides unique and needed learning and research oppor- tunities for nursing students (22,23). A concom- itant of providing nursing students with learning opportunities in the gamut of long-term and ger- iatric care settings is the opportunity to pique their interest in careers focused on specialization and research in long-term and gerontological nursing (25). Attainment of that goal will un- doubtedly be facilitated only when a critical mass of gerontological nursing specialists are available to give leadership in the field. Fortu- nately, nurses’ interest in that specialty is be- coming heightened. NURSES’ OPPORTUNITIES FOR SPECIALI- ZATION IN LONG-TERM CARE Nurse leaders have agreed that the major pur- poses of graduate study in nursing are to prepare nurse clinicians (clinical specialists) whose goal is ’ to improve nursing care through judicious use of knowledge in skillful practice, and to prepare investigators whose goal is to advance nursing knowledge through research (26). Specialization in nursing, like in all other practice fields, was an inevitable consequence of rapid advancements in knowledge, new technologic developments, and recognition of the need for additional knowl- edge and new practice strategies. Somewhat be- latedly, nursing turned its attention to develop- ing specialties in nursing practice. In the past quarter century those specialists have grown ever more natrow. For example, practitioners became specialists first in psychiatric nursing and later in child or adult psychiatric nursing; and some of them have limited their practices to develop- ment and test of particular practice strategies. ''Graduate programs for preparing nursing spe- cialists in care of adults and children having chronic disabilities have developed as a second- ary consequence of focusing nursing specialty programs on the medical model. Thus nurses be- came specialists in medical nursing, and more particularly, in caring for patients having dys- functions associated with body systems— respiratory, cardiovascular, endocrine, and the like. Although pediatric nursing was developed as one of nursing’s early specialties, gerontologic nursing has only recently captured the interest of nurses as a fascinating and needed field for specialization. Undoubtedly, the dearth of such nursing specialists, coupled with the recognized deficits in knowledgeable, competent long-term care personnel will hasten the development of graduate, specialty programs in gerontologic nursing at both master’s and doctoral levels. A concomitant interest has developed among nurses in research designed to advance the knowledge base for long-term nursing care, to develop and test new nursing strategies and ap- propriate devices to ascertain the efficacy of those strategies. NURSES’ INVESTMENTS IN SCHOLARSHIP AND RESEARCH Increases in the numbers of nursing’s basic and clinical scientists has been quite phenome- nal. Whereas prior to 1950 fewer than 50 nurses had completed doctoral study, by 1973 over 1,000 nurses had earned doctors degrees (27). During the past decade there has also been a decided shift in the nature of the research car- ried out by nurse-investigators (28). Nursing’s growing commitment to discovering knowledge about the gamut of man’s health- seeking behaviors is evidenced by continued and growing interest on the part of nursing’s investi- gators in basic research. Nurses continue to seek the traditional Ph.D., the research degree, in a wide variety of disciplines and in the profes- sion—in preparation for such inquiry. Nursing is also developing a cadre of clinical nursing scien- tists whose inquiries focus on clinical nursing problems, on the evaluation of clinical practice strategies, on outcomes of practice, and on the development of measurement devices. The goal for those investigators is to advance, verify, and structure nursing knowledge so that practition- ers will have a firm science base for their prac- tices. As the profession has moved forward in the design and conduct of educational programs that are ever more rigorous, scholars have also systematically inquired into the philosophy of science, especially nursing science (29). Nurses are manifesting considerable interest in inquiry relevant to the ethical and value prob- lems they encounter. Although nursing now has few persons prepared formally as philosophers, increasing numbers of the profession’s scholars are inquiring into philosophic issues. No doubt, the problems relative to inadequacies in long- term care will provide focus for philosophic in- quiry for some time to come. Nursing’s historians, philosophers and theo- rists, and basic and clinical scientists have grown in number and in their productivity. They are making contributions that have clarified nurs- ing’s heritage, nursing science, and the basic sci- ences; they have also made contributions to re- search methodologies. Increasingly, nursing’s investigators are involved in collaborative re- search. The fact that the nursing profession was tardy in its arrival on the academic and research scenes may account in part for the speed with which nursing’s research endeavors have recently devel-: oped. Although they have been thwarted by fi- nancial constraints now widespread, there is little doubt that nursing’s scientific movement will move steadily forward (30). It is nursing’s basic and clinical scientists that will make the greatest contributions to knowl- edge that should be useful in improving long- term care. But nursing’s philosophers will also surely address questions of values and ethics that inhere in the problems that are now being made visible by investigation of the care that is pro- vided for aged and chronically-ill citizens (1,9). The problems of long-term care are serious. In part, they can be resolved by changes in public policies; in part, they can be resolved by forth- right action on the part of health professionals. Nurses have major contributions to make to the resolution of those problems. Nursing education will responsibly address its part in the resolution of those problems by developing appropriate inter-institutional arrangements, by encouraging collaborative planning with other health profes- sionals, by making appropriate changes in pre- service and advanced programs of nursing educa- tion and by promotion research relevant for advancing nursing science and improving the care of aged and chronically ill people. 29 ''References 10. 11. 12. 13, 14. . Mendelson, M. A. Tender Loving Greed. New York, N.Y., Alfred A. Knopf, 1974. . Schwab, Sister M. ‘‘Caring for the Aged”. American Journal of Nursing, 73:2049-2053, December 1973. . Barney, J. L. Nursing Directors in Nursing Homes. Nursing Outlook, 22:436-440, July 1974. . Checker, A. and Kalinowski, R. H. ““The Medical College and Prison Health.” Journal of Medical Education, 58:831-832, July-August 1972. . Marston, M. V. “Compliance With Medical Regimens: A Re- view of the Literature.” Nursing Research, 19:312-323, July-August 1970. . Schlotfeldt, R. M. “Nursing is Health Care.” Nursing Out- look, 20:245-246, April 1972. . Institute of Medicine. Education for the Health Team. Wash- ington, D.C. National Academy of Sciences, 1972. - Social Security Amendments of 1965. Public Law 89-97, 89th Congress, H.R. 6675, July 30, 1965. Title XVIII- Health Insurance for the Aged. Title XIX—Grants to States for Medical Assistance Programs. . Long-Term Care Facility Improvement Study: Interim Re- port. Rockville, Md.: U.S. Department of Health, Education, and Welfare. Public Health Service. Office of Nursing Home Affairs. March 1975. Rutstein, D. D. Blueprint for Medical Care. Cambridge, The M. I. T. Press, 1974. White, K. L. Health and Health Care: Personal and Public Issues. Chicago, The University of Chicago Center for Health Administration Studies, 1974. Lewis, C. E. et al. “Activities, Events, and Outcomes in Am- bulatory Patient Care.” New England Journal of Medicine, 280:645-649, March 20, 1969. Bates, B. and J. E. Lynaugh “Laying the Foundations for Medical Nursing Practice.” American Journal of Nursing, 73:1375-1379, August 1973. Schlotfeldt, R. M. and J. MacPhail “Experiment in Nursing: Characteristics and Rationale.” American Journal of Nurs- ing, 69:1018-1023, May 1969. 30 IS. 16. 17. 18. 20. 21. 22; 23. 24, 25. 26. 27. 28. 29. 30. American Nurses’ Association. Committee on Education. Ed- ucational Preparation for Nurse Practitioners and Assistants to Nurses. New York, N.Y. The Association, 1965. American Nurses’ Association. Facts About Nursing, 1972-73. Kansas City, Mo., The Association, 1974. American Association of Colleges of Nursing. Functions of Professional Nurses. 1970. (Mimeographed) American Nurses’ Association. Commission on Nursing Ed- ucation. Statement on Graduate Education in Nursing. New York, N.Y., The Association, 1969. . American Nurses’ Association. Avenues for Continued Learn- ing. New York, N.Y., The Association, 1967. Mendelson, M. A. Op. cit. Randall, O. A. “Situation with Nursing Homes.” American Journal of Nursing, 65:92-97, November 1965. Katz, S. et al. The Effects of Continued Care: A Study of Chronic Illness in the Home. Department of Health, Educa- tion, and Welfare, Publication #H.S.M. -73-310. Rockville, Md., U.S. DHEW Public Health Service, 1972. Reiter, F. X. “Choosing the Setter Part.”” American Journal of Nursing, 64:65-68, 1964. Vogelberger, M. L. “Nursing Homesas Clinical Laboratories.” Nursing Forum, 9:2:177-191, 1970. Gunter, L. M. “Students Attitudes Toward Geriatric Nurs- ing.” Nursing Outlook, 19:466-469, July 1971. Commission on Nursing Education. Op. cit. American Nurses’ Foundation. Jnternational Directory of Nurses with Doctoral Degrees. 1973 Edition. New York, N.Y., The Foundation, 1973. Carnegie, M. E. “The Shifting of Research Emphasis and Investigations.” (editorial) Nursing Research, 23:195, May- June 1974. Jacox, A. “Theory Construction in Nursing: An Overview.” Nursing Research, 23:4-13, January-February 1974. Johnson, D. E. “Development of Theory: A Requisite for Nursing as a Primary Health Profession.” Nursing Research, 23:372-377, September-October 1974. ''CHAPTER 5 The Nursing Profession’s Role in PSRO Utilization Review in Long-Term Care ANA’s Certification Program Pearl H. Dunkley, Ed.D., R.N. Mounting public concern about quality and cost of health services has led to a heightened involvement of the government at all levels in regulating the quality of care purchased by pub- lic funds. In past years the public had entrusted to the professions a high degree of autonomy and self-regulation. As pointed out by Dona- bedian, there was a “social contract” between society and the professions (/). Society gave the professions the special privilege of considerable autonomy in the control of their own affairs out of respect for their expertise. In return, the pro- fessions were expected to engage in activities which would ensure services of acceptable qual- ity. Nursing, as the largest professional group within the health occupations, must be increas- ingly ready to assume a substantially larger role within the community with health professions to the end that the health needs of people can be met. The extent to which the profession will successfully achieve such a goal is dependent on how individual members of the profession as- sume full responsibility and accountability for the quality of nursing care. Effecting improve- ment in the quality and quantity of nursing care available has been the constant challenge of the nursing profession and its professional associa- tion. Since its inception in 1896, the American Nurses’ Association (ANA) has consistently demonstrated its concern for the development and implementation of professional standards through actively promoting mandatory individ- ual licensure, standards for the preparation of individuals to enter the practice of nursing, the development of a code of ethical conduct for practitioners of nursing, standards for practice, standards for the organized delivery of nursing services, and stimulation of research designed to define and enlarge the knowledge on which prac- tice of nursing is based (2). The role of ANA as standard setter in educa- tion is, perhaps, not as readily understood by ANA members and the profession at large. This basic function of a professional organization is critical in initiating changes in basic and continu- ing education within the profession. The Certificate of Incorporation in 1917 in- cluded this statement: “To promote the profes- sional and educational advancement of nurses in every proper way; to evaluate the standards of nursing education.” This responsibility of the professional association was never delegated to any other organization. The current activities of the ANA represent an intensified effort to: promote optimum health care for all people, advance the profession of nursing, and strengthen the efforts of individual practicing nurses in the pursuit of their concern as nurses. An additional effort of the ANA to promote practitioner accountability and to in- sure nursing care of an acceptable quality was the recent announcement of a program of na- tional certification in the five areas of nursing practice represented by the five divisions of practice, namely: Division of Maternal-Child Nursing, Division of Geriatric Nursing, Division of Medical-Surgical Nursing, Division of Commu- nity Health Nursing and Division of Psychiatric and Mental Health Nursing. Another major re- sponsibility of the Divisions in practice as iden- tified in 1966 Bylaws was the development of standards of practice and seeking ways to secure their implementation. The development of standards of practice and initiation of a certifica- tion program by the professional association have stimulated members of the profession to be 31 ''increasingly involved in seeking ways to main- tain competence in practice and assume account- ability for the quality of nursing practice. This paper will address itself to three basic mechanisms and their implications for the qual- ity of nursing care rendered to patients in long- term settings—Professional Standards Review Organizations (PSROs) Utilization Review (UR) and ANA’s Program of Certification. Whereas PSROs and URs are basically govern- mental regulatory mechanisms to ensure the quality, necessity and cost effectiveness of medi- cal care rendered to clients who are Medicare, Medicaid health insurance beneficiaries, ANA’s certification program is a voluntary process de- signed to recognize superior performance of in- dividual practitioners of nursing. In the imple- mentation of the PSRO mechanism, there is substantial evidence of the reliance of the Fed- eral Government on the profession of medicine and the potential for a similar level of involve- ment of other professional health care providers, to define and monitor standards of care. The potential impact of a comprehensive National Health Insurance Program which includes reim- bursement for the services of other than physi- cian health care providers, necessitates devising a system to identify those nursing care providers whose services should be reimbursed. The public has relied on licensure granted by state boards of nursing to monitor minimum standards of admission to the nursing profession. Several boards of nursing have begun to concern themselves with their appropriate roles and re- sponsibilities with regard to surveillance of con- tinuing competence to engage in the practice of nursing. In two instances the standards enuncia- ted by ANA’s Divisions of Practice are being considered for inclusion in the regulations of boards of nursing as representing minimal levels of competence. In many states, Washington and New Hampshire for instance, legislation and statutes have been enacted to define levels of nursing practice. In order to maximize the growth po- tential of the profession, it is most important that the evolution of specialties and the designa- tion of specialists be undertaken by the profes- sion rather than through legislation. The ANA certification program is national in scope, based on authoritative standards, devised by nurses for nursing and possesses all the char- acteristics of a system of identifying those nurses with specialized bodies of knowledge and skills. , 32 If legislation to fund a national system of health insurance relies on the system of certifica- tion to identify those nurses whose services should be reimbursed, the concept of shared re- sponsibility between the government on behalf of the people and the profession would be sup- ported. NURSING’S INTEREST IN PROFESSIONAL STANDARDS REVIEW ORGANIZATIONS AND UTILIZATION REVIEW Standards of Practice. In 1966, the ANA (after nine years of careful study) restructured itself to reflect less attention to the occupational concerns of its members while giving more to the nature and quality of practice. Six of the 14 units which eventually emerged were charged with responsibility to develop standards of prac- tice and devise methods to seek their implemen- tation. Three other units were also charged with standard setting functions—the Commission on Nursing Service, the Commission on Nursing Ed- ucation, and the Commission on Nursing Re- search. It was conceptualized that the standards for organized nursing services, education, and re- search would take into account the Standards of Practice. Work on the standards progressed at an un- even pace and in 1972, as a result of considera- ble effort by hundreds of experts in the field, standards were developed. In 1973 and 1974, the Generic Standards and the five Division’s Standards were published in separate forms (3). In 1975 three additional sets of standards were published in three specified areas of practice in Medical/Surgical Nursing; Cardiovascular Nurs- ing, Orthopedic Nursing and Nursing in the Op- erating Room. It was not envisioned that these standards would be “‘completed” documents at the time of their publication. They are “working docu- ments” to be refined, modified, and revised on a continuing basis based on the experiences of practicing nurses and the development of nurs- ing theory and practice. The standards for nursing practice were pub- lished in 1973 while a number of activities were underway by organized medicine to determine the state of the art in evaluation of medical care and the posture which that profession would take regarding the PSRO amendments to P.L. 92-603. ''Being cognizant of the multiple approaches and activities which were concurrently occurring in nursing, the association initiated actions to devise tools to make the standards of practice more amendable to measurement and to fit the standards which were process-oriented into a conceptualization of quality assurance. Quality is used in this paper in the specific sense of “having the characteristics of excel- lence’ and is the accepted standards of care against which performance can be measured. As- surance of quality implied a commitment beyond the measurement and evaluation of the quality; it implies a commitment to take correc- tive action if care does not meet the criteria of quality. Assurance of quality begins with an inquiry into or surveillance of three aspects of the care being given: 1) the structure within which care is given, 2) the process of providing the care, and 3) evaluation of the outcomes of care. In late 1973 work was completed on a docu- ment entitled Peer Review: Guidelines for Estab- lishment of Committees (4). This document de- fined peer review as the process by which regis- tered nurses, actively engaged in the practice of nursing, appraise the quality of nursing care in a given situation in accordance with the estab- lished Standards of Nursing Practice. The pur- poses of peer review are: |) to evaluate the qual- ity and quantity of nursing care, 2) to determine the strength and weaknesses of nursing care, 3) to provide evidence to be utilized as the basis of recommendations for new or altered ways to im- prove nursing care; and 4) to identify those areas where practice patterns indicate more knowl- edge is needed. The peer review process includes two phases: The appraisal of nursing care delivered by a group of nurses in a given setting (Nursing Pro- fessional Standards Review), and the appraisal of nursing practiced by individual practitioners (Nursing Performance Review). These guidelines for forming peer review committees and identi- fying committee functions and policies were developed in accordance with the 1972 ANA House of Delegates resolution which stated that: RESOLVED, that in every health care facil- ity there be provision for nurses to partici- pate in utilization review activities related to facilities, personnel and services and other arrangements for monitoring health care practices; and be it further... (5). The ANA House of Delegates in 1974 adopted the following Resolution concerning the partici- pation of nurses in PSRO: RESOLVED, that the American Nurses’ As- sociation identify and seek legislative sup- port for the participation and contribution of nurses on behalf of their own practice in Professional Standards Review Organization Programs (6). In April 1975, a panel of experts who had been working for more than a year, completed work on a conceptual model for Quality Assur- ance in Nursing and offered the Association some 18 recommendations for action. The reader is urged to consider the entire document A Plan for Implementation of Standards of Nursing Practice for a comprehensive overview of the professional association’s plan for moni- toring of the quality of nursing care (7). The seven models developed have been appended to this paper (Appendix D) to illustrate how the mechanisms of Professional Standards Review (PSRO) and Utilization Review (UR) are viewed as specific aspects of a much larger endeavor— providing ways and means for monitoring the quality of nursing care clients receive (8). NURSING AND PSRO/UR: BASIC ISSUES It should be noted that the nursing profession, like medicine, is not unanimous in its acceptance of the fundamental concepts embodied in PSRO. As the Ad hoc Committee on the Imple- mentation of Standards observed: It should be understood from the outset that nobody really likes quality controls. Health professionals, particularly, are sensi- tive to what they perceive as an unwar- ranted, intrusion on practice. This is evident in the widely held assumption that unless standards are locally developed, they will not be locally observed. Reluctance to criti- cize peers and to accept peer criticism is advanced as an obstacle to quality assurance systems. Medical and nursing literature is re- plete with admonitions to be wary of resist- ance to other than local standards. But the accountability of professionals to them- selves, their patients, the public, their peers, their other colleagues is inherent in being a professional (9). As aresult of concern about cost of care there is emphasis on utilization controls, and review of care that center on determination as to the need 33 ''of given patients for given care at a given time in a given setting with a view to reducing length of stay in a health care facility, thereby reducing payments for the care. Quality review is too often assumed or subsumed under the utilization review. Utilization and quality reviews have ob- viously different purposes—and are sometimes at cross purposes. Other concerns being increas- ingly expressed in the nursing community relate to access and control of data gathered through PSRO and the tremendous cost of developing norms and criteria, implementing and evaluation mechanism and providing continuing education opportunities for nurses to engage in remedial learning. However, there appears to be consider- able support within the profession for the con- cept of the shared responsibility between the government and the professions, whereby sup- port is provided for the profession to further evaluate the structure and process of care, and develop standards and criteria for the outcomes of care, and establish monitoring mechanisms for the evaluation of nursing care. A rational consequence of increased govern- mental expenditure in health is increasing gov- ernmental regulations of the quality of health care which the money purchases. Any national health insurance plan which is legislated will therefore, most likely include regulatory mecha- nisms like PSRO/UR. It is therefore of some ur- gency that an appropriate role be developed and supported for nursing in each of these mecha- nisms. The basic rationale for involvement of nurses in PSRO is contained in provisions of Public Law 92-603 which states: Duties and functions of Professional Stand- ards Review Organizations Sec. 1155 (a) (1) Notwithstanding any other provision of law, but consistent with the provisions of this part, it shall (subject to the provisions of subsection (g) be the duty and function of each Professional Standards Review Or- ganization for any area to assume at the earliest date practicable, responsibility for the review of the professional activities in such area of physicians and other health care practitioners and institutional and non-institutional providers of health care services in the provision of health care serv- ices and items for which payment may be made (in whole or in part) under this Act for the purpose of determining whether: (A) such services and items are or were medically necessary , 34 (B) the quality of such services meets professionally recognized stand- ards of health care; and (C) in case such services and items are proposed to be provided in a hos- pital or other health care facility on an inpatient basis, such services and items could, consistent with the provision of appropriate medi- cal care, be effective provided on an outpatient health care facility of a different type (10). Chapter VII of the PSRO Manual further out- lines the mandatory nature of the participation of “Non-Physician” health care providers in the development of norms and intradisciplinary cri- teria and peer review of providers (//). Despite the sustained pressure of organized nursing to have a meaningful role in the imple- mentation of the PSRO law and regulations, pre- liminary reports of a survey of State Nurses’ As- sociations, revealed that nurses are involved in a minimal way and the nature of the involvement varies considerably between PSROs (/2). The recommendations included in this paper concerming the appropriate involvement of nurses in the implementation of PSROs are based on policy decisions made by the ANA’s Congress of Nursing Practice and from the ex- perience gained by staff and the Technical Ad- visory Committee in the execution of Contract 105-74-207, awarded by the Office of Profes- sional Standards Review, Bureau of Quality As- surance, Health Services Administration, Department of Health, Education, and Welfare. Through this contract, the ANA has developed and pilot tested 15 sets of screening criteria; de- veloped Guidelines for Review of Nursing Care at the Local Level and identified what it believes to be the appropriate role of nursing in the im- plementation of PSRO. In order to realize the intent of PSROs, a mechanism must be established for comprehen- sive quality assurance programs for health care. One of the major health professional groups is nursing. This is true not only by the virtue of its members now estimated at 800,000 practicing registered nurses but also of the nature and scope of its practice. Medicine and nursing are recognized as the two major functionaries in the provision of health care. In discussing Optimum Nursing Home Care in the recently published /nterim Report of the Long-Term Care Facility Improvement Study, it was stated that meeting the medical, nursing, ''psychosocial and rehabilitation needs of individ- uals in long-term care facilities should be an inte- gral part of health care. The term “health care” is not synonymous with ‘“‘medical care.”’ It is in fact broader and recognizes the need for collabo- rative efforts among health and non-health per- sonnel to make decisions and take cooperative action to meet the specific needs of patients, clients, and residents in long-term care facilities (13). The DHEW document entitled Extending the Scope of Nursing Practice: A Report of the Sec- retary’s Committee to Study Extended Roles for Nurses observed that “health care in its entirety; from the point of view of providers and consum- ers alike, is the sum total of care rendered by all disciplines (/4).”’ The plan by which the govern- ment proposes to assess the appropriate and cost effectiveness of payments made on behalf of Medicare/Medicaid patients, PSRO was designed with some attention to the self-regulating con- cept of professions. Physicians are intimately in- volved in all levels of PSRO activities and have also been given authority for all decision mak- ing. Not considered, however, is recognition of the same type of self-regulation by other health professions, including nursing. Essential to the involvement of the nurse in PSRO are the following premises: norms, crite- ria, and standards of nursing practice shall be determined by registered nurses; review of nurs- ing practice shall be conducted by peers engaged in similar practice; and registered nurses shall make decisions on all issues relating to the prac- tice of nursing. Public Law 92-603 which provides the struc- ture and authority for PSRO has failed to ad- dress appropriate involvement and decision mak- ing on the part of health professionals other than physicians. The profession believes a broader interpretation could be derived from the law regarding the composition of the National Professional Standards Review Council. Despite the present interpretation of the composition to be 11 physicians, exclusively, could not the in- tent be interpreted to be 11 physicians plus ap- propriate representation of other health care providers? It is difficult to accept that the intent of the law is to exclude non-physician care pro- fessionals from the governing body, when in fact the review process is mandated for all health care providers. In addition, the PSRO Program Manual Guidelines developed to date are unclear as to the structure for participation of providers other than physicians at either the state area or local levels. Therefore, to permit the full participation by the nursing profession in the PSRO program, it is evident that a broader interpretation of the language of the law in relation to decision mak- ing structure is needed. Such interpretation would add non-physician members to the Na- tional Professional Standards Review Council which would include representation from profes- sional nursing. In addition, nursing would be identified as an essential component of the govy- erning bodies at the State levels and local PSROs. If the language of the current law cannot be interpreted to provide such increased representa- tion, effort must be directed’ to amending P.L. 92-603 to permit increased participation by pro- fessional nurses and other health care profes- sionals affected by the law. The American Nurses’ Association proposed the following major changes in P.L. 92-603 in recent testi- mony before the Senate Subcommittee on Health: The American Nurses’ Association pro- poses that the appropriate sections of P.L. 92-603 be amended to provide for the des- ignation of registered professional nurses and other licensed health care practitioners as members of Professional Standards Re- view Organization. Thus it is suggested that in all instances where doctors of medicine and doctors of osteopathy are enumerated, the law be amended to include licensed pro- fessional nurses. The interface of care given to patients/clients by many disciplines in health care make it unwise and difficult for any one profession to review its practice wholly independent of others. Therefore, an interdisciplinary review system that pre- vents fragmentation of health care review and serves to improve all components of health care is considered the optimal struc- ture for maximum efficiency and client/ patient benefits. The adoption of such amendments would permit nurses to partici- pate in that review system. In all instances within the law where ref- erence is made to medical care this be changed to health care. The law must be consistent in recognizing that medical care, which is care given by medical doctors and doctors of osteopathy is not synonymous with health care. This is a critical concept to support the inclusion of other health care practitioners in PSRO legislation and indeed in all health legislation. 35 ''36 The association proposes that the con- cept of review in hospitals be broadened to review in all health care facilities. The nurs- ing profession believes that although it was appropriate to initiate review under PSRO in acute care settings, it is now timely to effect one system of review in all health care facilities, including acute care settings, chronic long-term settings, Health Mainte- nance Organizations, etc. Such a system would promote comparable standards, pro- vide compatible data, ensure the equitable assumption of accountability by practi- tioners regardless of location, and in the long run minimize competition and con- fusion among the multiple review systems now in effect. Consistent with the association’s position regarding the appropriate involvement of nurses and other professional practitioners in the critical points of decision making, we believe that the concept of “medical neces- sity for institutionalization” be changed to reflect participation of other health care providers in such decision making. We believe the participation of profes- sionals, other than doctors of medicine and doctors of osteopathy, particularly in long- term care settings is vital to achieving the goal of efficient utilization of institutional facilities. People are admitted to and remain in health care facilities because they have a need for continuous professional health management which cannot or is not pro- vided by family or community resources. The need may be related to medical and/or nursing management of a health problem. In some instances, such as the need for long-term care, the most valid criteria may be related to nursing care rather than medi- cal care. It follows, therefore, that the need for nursing services is one valid criterion for admission, for assigning length of stay, and for continued stay review. Professional nurses should develop nursing criteria rela- tive to admission and continued stay or where interdisciplinary review is possible, they should participate in the development of such criteria. . . Consistent with our recommendations for the inclusion of nurses at all levels of the PSRO mechanism, we propose the follow- ing changes in the membership of statewide Professional Standards Review Council. 1.One representative selected from 2 nominees representing different disci- plines designated by each PSRO. 2.Three physicians designated by the State Medical Society. 3. Three nurses, two of whom are desig- nated by the State Nurses’ Association. 4. Three persons knowledgeable in health. We further recommend that advisory groups to Statewide Professional Standards Review Organization be composed of not less than five and not more than nine mem- bers who shall be representatives of hospi- tals and other health care facilities and two consumers. No member or family member of the advisory group should have financial interest in a health facility within the state. The association proposes that National Professional Standards Review Council con- sist of fifteen members; five physicians, five registered professional nurses and five other licensed health care practitioners. We also propose the creation of a seven- member advisory committee to advise the National Professional Standards Review Council, the Secretary of DHEW and the Congress on the effectiveness of the PSRO mechanism in promoting effective, effi- cient, and economical delivery of health care to meet standards established by the health professions (15). Interim measures are needed until such time as these changes occur. An alternative which is possible, but less desirable, is the creation of a parallel structure at the national, State, and local level to assure the development, implementation and monitoring of a quality assurance program for nursing practice. Such parallel structure could be established through the ANA and its constituents. This solution is less desirable because the in- terface of care given to patients/clients by many disciplines in health care makes it unwise and difficult for any one profession to review its practice wholly independent of others. Such re- view is fragmented and can scarcely serve to im- prove care to the consumer of service. ROLE OF ANA IN FACILITATING NURSING INVOLVEMENT IN PSRO A formal plan should be developed and imple- mented to provide consultation and assistance to nurse member(s) of PSRO Advisory Committees and local units and this consultation and assist- ance be provided by recognized experts in the areas of concern. The professional nursing organization should present educational programs to prepare selected ''members of specialty organizations and expert practitioners in each of the Divisions of Practice to develop and test outcome criteria. The speci- alty organizations in nursing and the Divisions of Practice of the ANA should identify the health related issues that account for the preatest fre- quency and most significant impact of nursing interventions and develop the outcome criteria for populations that utilize this nursing care. These criteria should then be used as models for local areas in developing their criteria and by area, State and National PSROs in evaluation of the appropriateness of criteria developed at the local level. The outcome criteria for these popu- lations should be made available to nurses on any PSRO Advisory Committee or institutional review committee who are responsible for estab- lishing criteria for evaluation of nursing care and those same organizations should provide consul- tation to such nurses in situations where models have not yet been developed. ANA should develop and distribute guidelines for nurses’ participation in peer review, nursing audit and health care evaluation studies. The professional nursing organization should also work with selected members of other health pro- fessional organizations to develop, over time, guidelines for developing interdisciplinary crite- ria and interdisciplinary review process. Support should be provided to nurse researchers to iden- tify the methodological questions relative to the development and testing of patient outcome cri- teria in nursing and the setting of norms. Inasmuch as it is the objective of the Office of PSRO that PSROs be the ultimate system of re- view, Utilization Review will not be discussed as a separate system of quality assurance. More- over, the new regulations for Utilization Review are designed to improve and enhance the effec- tiveness and efficiency of the pre-PSRO Utiliza- tion Review system to institute a single review system for Medicare and Medicaid. The UR ac- tivities are compatible with the PSRO review system to ease transition to the PSRO program and developments throughout the country. When PSRO is doing the review, it will super- cede the UR requirements (/6). Under previous Medicare utilization review regulations, institutional committees were re- quired to review all cases of extended duration. They were also required to review a sample of admissions and to conduct medical care evalua- tion studies (MCES). Norms, criteria and stand- ards were not required in the review process. Review was generally retroactive in nature and generally had little impact on payment. Thus, the concepts inherent in the new regulations for URs are new to many practitioners and institu- tional providers and much confusion has re- sulted about the relationship between PSRO and UR. Hospitals and long-term facilities’ providers will be looking to PSROs for guidance in devel- oping or adopting norms, criteria, and standards and the more specific regulations relative to MCE, and new concepts for many of these facili- ties. Persons with financial interest in any skilled facility or any employee of such a facility are prohibited from participating in the review process (/ 7). The recently released report prepared by the Senate Subcommittee on Long-Term Care enti- tled Nurses in Nursing Homes: The Heavy Bur- den (The Reliance on Untrained and Unlicensed Personnel) documents that the bulk of the pre- ventive, supportive, maintenance, and rehabilita- tive care required by nursing home residents are the major responsibility of the nursing profes- sion (18). Many of the conditions of patients in long-term care facilities appear to be directly re- lated to inadequate nursing care (1/9). The sec- tion of the Long-Term Care Facility Improve- ment Study: Introductory Report that deals with patient care needs also reinforces the obser- vation that nursing is the primary health care need of patients in long-term settings (20). It is, therefore, important that the same principles of substantial involvement of nurses in PSROs be applied to the establishment and implementa- tion of Utilization Review Programs in long-term facilities. In addition, the federal regulations concerning registered nurse coverage of nursing homes must be substantially improved from the one regis- tered nurse seven days per week to at least one registered nurse on each shift, 24 hours per day. Attention must also be given to the identifica- tion of appropriate models of staffing long-term care facilities to reflect specific patient needs at specific points in time as well as the kinds of supporting personnel available. In long-term care facilities, it is most urgent that interdisciplinary patient outcome criteria be developed. Several important concepts in interdisciplinary criteria and their application need to be addressed in these facilities. Will nurses be expected to pro- vide the services of other disciplines, for exam- ple, physical therapy, occupational therapy, if these services are not available in an institution? Should there be different expectations of care in 37 ''those settings where these services are not avail- able? Should nursing not have the authority to initiate referrals to those disciplines? Outcome criteria for patients with multiple medical diag- noses will call for a different system of classifica- tion based more on symptoms and_ behaviors than medical diagnosis. There is mounting evidentiary material to in- dicate that the quality of care in many long-term care facilities is far below the minimal standards established under the conditions of participation in Medicare and Medicaid and a far cry from the standards espoused by the professions. The gov- ernment at all levels and the professions in- volved, therefore, need not wait for data from the implementation of the new regulations for Utilization Review in order to begin the almost overwhelming task of providing care that is ade- quate, humane and at a reasonable cost within long-term care facilities. At the request of Senator Moss, Chairman of the Subcommittee on Long-Term Care of the Special Committee on Aging, U.S. Senate, the ANA accepted a charge in late 1973 to examine multiple aspects of care in nursing homes. An interdisciplinary committee representing some 22 organizations was formed by the ANA. On April 24, 1975 the Report of this committee was presented to the Senate Subcommittee with statements of dozens of witnesses who pre- sented testimony in the four regional hearings which were held around the country. The entire Report, entitled Nursing and Long-Term Care: Toward Quality Care for the Aging, including the following five recommendations were in- cluded in the supporting paper #4—Nurses in Nursing Homes: The Heavy Burden (The Re- liance on Untrained and Unlicensed Personnel). In accepting the report, Senator Moss remarked that it was destined to become a landmark docu- ment in long-term care. The Senate Subcom- mittee on Long-Term Care endorsed all five of these recommendations: 1.A national policy on care of the aging should be developed, within which should be provision for care of the elderly in any kind of setting, the right to high quality care, and the right of the elderly to decision-making in regard to their own care. The national policy on care of the aging should be built on the fact that the aged are vital, dynamic persons who have made and who continue to make contributions to so- ciety. 2. Because high costs of essential health care services, coupled with the present provision 38 of fragmented, uncoordinated, and incom- plete health services stand in the way of effective delivery of health services to the aged, a plan for national health insurance should be developed to insure that health care services are provided for all citizens, guaranteeing coverage for the full range of comprehensive health services. The national health insurance plan should clearly recog- nize the distinctions between health care and medical care, and provide options in utilizations of health care services. 3.In considering options or alternatives for care, a range of health and supportive serv- ices should be made available to all elderly citizens. Thus, whether a person chooses to live in his own home and _ have services brought to him, to go to the services in a day care setting, or to move to a nursing home, he would have assurance that the needed services would be available. 4. The word “‘skilled’’ should be deleted from the phrase “‘skilled nursing care” as it cur- rently exists in the Federal standards and as the term is generally applied in actual prac- tice, because it is not measurable nor can it be defined when related to the needs of a patient. 5. Because quality health care will depend pri- marily upon the competency of the persons providing direct care, all professional per- sons and workers involved in long-term health care in any setting should have a background in the basic care of the aging. These gerontological concepts should be taught at the educational levels of the indi- viduals in the depth and detail each can understand and use. Preparation in geronto- logical nursing should be within an open ed- ucational system which promotes career mobility. The educational program of regis- tered nurses at all levels should be devel- oped and strengthened to correct specific deficiencies in the area of gerontological nursing (21 ). These recommendations will undoubtedly play a significant role in the future program of the ANA in its continuing efforts towards the end that individuals in long-term care facilities will receive nursing care of an acceptable quality. The goals of the multiple activities voluntarily undertaken by the nursing profession in the last five years to motivate its members towards full accountability for the level of care rendered may be summarized as follows: ''1. Establish criteria, standards, and norms by which organizational structure, nursing process, and patient outcomes can be eval- uated. 2. Establish a system whereby a review of nursing practice shall be conducted by peers who are engaged in similar practice. 3. Establish a review system whereby appro- priate utilization of professional nursing services is assured. 4.Improve patterns in nursing practice through correction of deficiencies in nurs- ing care identified by the review process and through continuing education and systematic study. 5. Establish mechanisms which will assure that issues related to the practice of nursing will be decided by registered nurses. 6.Promote mechanisms which will assure nursing participation in the development of policies and programs for collaborative re- view and problem-solving for the total system of health care delivery. ANA CERTIFICATION The basic principles underlying the develop- ment of expanded roles for nursing have been covered by Dr. Lambertsen in her paper on “The PRIMEX Role in Long-Term Care.” The posi- tion of the professional association is that nurses who practice in expanded roles as defined by the several guidelines issued by the ANA are engaged in the practice of nursing. They are not physi- cian extenders or physician’s assistants. They are extenders of health care services which include some traditional medical services. They have a distinct body of nursing knowledge and compe- tencies and the authority and responsibility to perform independent nursing actions and inter- dependent activities as set forth in the various nurse practice acts. According to the recently published Guide- lines for Short-Term Continuing Education Pro- grams for Geriatric Nurse Practitioners, the Geri- atric Nurse Practitioners will be prepared with increasing knowledge and skills to perform the following nursing functions (22). 1. Act as an advocate and/or significant other for patients when this is needed. 2. Sustain and support patients during diagno- sis and treatment. 3. Obtain a comprehensive health history. 4.Work collaboratively with physicians and others in identifying and meeting health needs of geriatric patients. 5. Coordinate health care and other health re- sources. 6.Teach and counsel patients and families about aging, health, and illness. 7. Make appropriate community referrals. In addition, the geriatric nurse practitioner should be prepared to: 1. Perform a physical examination. 2. Assess and manage acute and chronically ill aged patients within established parameters; this includes providing preventive aspects of care as well as direct patient care. We have no definitive statistics on the number of geriatric nurse practitioners prepared to date or the number prepared for primary care roles who are engaged in geriatric nursing practice. There are currently four programs purporting to prepare geriatric practitioners through short- term continuing education programs (Appendix F). A limited number of programs preparing clinical specialists in geriatric nursing at the mas- ter’s level have been initiated recently. To accomplish the major task of preparing sufficient nurses with the appropriate clinical knowledge and skills at the baccalaureate and graduate levels as well as through short-term continuing education programs, there will need to be massive financial support for the initiation and maintenance of programs, support of stu- dents as well as preparation of faculty. Perhaps the quickest payoff will come from the provi- sion of opportunities for baccalaureate nursing students to gain the necessary skills and clinical practice experience. The provisions included in the Nurse Training Act of 1975, have a real po- tential for stimulating the development of ap- propriate programs in gerontological nursing at all levels. In 1966, the modified bylaws of the Associa- tion created Certification Boards in the five spe- cialized areas of clinical practice represented in the structural units. The Certification process was implemented in 1974, and in January 1975 the first 99 nurses were certified by ANA for excellence in the practice of nursing. The Certifi- cation program for excellence in practice uses the Standards for Nursing Practice as the basis on which performance will be evaluated. A cur- rently licensed nurse, regardless of the basic nursing program from which she or he was grad- uated, who demonstrates currency of knowledge 39 ''and excellence in practice is eligible to apply for certification. Only clinical practitioners of nursing are eligi- ble for certification. A nurse is engaged in the clinical practice of nursing when her or his ac- tions and reflections are focused upon a particu- lar client (individual, family, group or commu- nity) and when there is personal responsibility and accountability to the client for the outcome of such actions. Consultants, researchers, admin- istrators, and educators are eligible to seek certi- fication if they are also engaged in clinical prac- tice and can meet the criteria as outlined (23). The criteria for certification in geriatric nurs- ing are based on specific eligibility requirements which include at least a year of current practice in geriatric nursing; successful achievement on a test for current knowledge in the field; substan- tial involvement in continuing education activi- ties in the field of gerontological nursing, docu- mented evidence of active practice, innovations in practice, and peer recommendations. As of July 1975, some 500 geriatric nurses had initia- ted the process to be certified. Although the long-term effects of ANA certi- fication are only speculative at present, the im- pact for the nursing profession is readily appar- ent. It is believed that ANA’s program of certification will provide positive reinforcement for nurses who participate in continuing educa- tion. It is also hoped that certification require- ments will stimulate the growth of valid continu- ing education programs. ANA certification recognizes performance which clearly reflects application of current knowledge, consideration of alternatives and strategies in nursing actions, and the derivation of new insights based on clinical data. Thus ANA certification reinforces conscious use of theory in the planning and implementing of nursing care. A certified registered nurse will ex- perience greater incentive to undertake studies that will broaden and deepen his/her compe- tence. ANA’s certification thus provides the public with a qualitative mechanism that operates on a higher level than licensure. Since a nurse must perform at a higher than minimal level to be certified, certification becomes a tool for im- proving nursing practice in that it stimulates the individual to strive for superior performance. The registered nurse stands to gain significantly from a certification program that recognizes ex- cellence in practice. A means is provided for ex- posing the excellent nurse practitioner in a fa- 40 vorable manner to employers, peers, and the public. In addition to employment opportunities that may result from such recognition, a certi- fied nurse will enjoy the self-satisfaction and pride associated with professional growth and self-accomplishment (24). It would seem that for certification to have the ultimate desired effect—the improvement of the quality of care rendered by individual nurses—many more nurses should be engaged in the process. The fact that certification is aimed at identifying and rewarding excellence perhaps discourages wide-scale participation in the proc- ess. It took medicine more than a generation to move its certification program from excellence in medical practice to certification of basic com- petence in a specialty. Events are moving much too rapidly in the health field for nursing to believe that it will have as long a period of time over which to evolve an appropriate mechanism for identifying those of its members prepared for specialized practice. It is, therefore, timely for the professional association to initiate steps to accelerate the process of directing its certifi- cation at the level of competence. In initiating this exciting national program of certification based on authoritative standards of practice, the ANA anticipates an enlarged role for nursing as a health care discipline and is tak- ing vigorous steps to ensure that the future moves individual practitioners closer to the goal of substantial improvement in the quality of nursing care. References 1. Donabedian, A., In The Nursing Audit, by M. C. Phaneuf. New York, Appleton-Century Crofts, 1972, pp. xi-xii. 2. Dunkley, P. H. “The ANA Certification Program,” Nursing Clinics of North America. 9:3:485, September 1974. 3. American Nurses’ Association. Standards of Nursing Prac- tice, Kansas City, Mo., The Association, 1974. 4. American Nurses’ Association. Guidelines for Peer Review, Kansas City, Mo., The Association, November 1973. - 5. American Nurses’ Association. Summary Proceedings ANA House of Delegates, 1972. Kansas City, Mo., The Associa- tion, 1972, p. 31. 6. American Nurses’ Association. Summary Proceedings ANA House of Delegates, 1974. Kansas City, Mo., The Associa- tion, 1975, p. 47. 7. American Nurses’ Association. A Plan for Implementation of the Standards of Nursing Practice, Kansas City, Mo., The Association, 1975. 8. [bid., pp. 15, 20-23. 9. Ibid., p. 6. 10. Public Law 92-603. 11. U.S. Department of Health, Education, and Welfare. Office of Professional Standards Review. PSRO Manual. Washing- ton, D.C., U.S. Government Printing Office, 1974, pp. 31-33. ''12. 13. 14. “15. 16. 17. American Nurses’ Association. “Participation of Nurses in PSRO”, Unpublished Survey, Kansas City, Mo., The Associa- tion, 1975. U.S. Department of Health, Education, and Welfare. Public Health Service, Office of Nursing Home Affairs, Long-Term Care Facility Improvement Study: Interim Report. Rock- ville, Md., DHEW, March 1975, p. 3. U.S. Department of Health, Education, and Welfare, Ex tend- ing the Scope of Nursing Practice, A Report of the Secre- tary’s Committee to Study Extended Roles for Nurses. Washington, D.C.; DHEW, November 1971, p. 3. American Nurses’ Association. Testimony on PSRO Pre- sented to Subcommittee on Health, Washington, D.C., The Association, September 19, 1975. U.S. Department of Health, Education, and Welfare. Social Security Administration. ‘Conditions of Participation- Hospitals and Nursing Facilities-Utilization Review.” Federal Register 29 (No. 231): 41-605-7, November 1974. Ibid., p. 41-607. 18. 19. 20. 21. 22. 23: 24. United States Senate, Subcommittee on Long-Term Care of the Special Committee on Aging. Nursing Home Care in the United States. Failure in Public Policy, Support Paper #4. Nurses in Nursing Homes: The Heavy Burden (The Reliance on Untrained and Unlicensed Personnel). Ibid., p. 369. U.S. Department of Health, Education, and Welfare, Public Health Service, Office of Nursing Home Affairs, Long-Term Care Facility Improvement Study: Introductory Report, Washington, D.C., Government Printing Office, 1975, p. 11. Op cit., United States Senate Subcommittee on Long-Term Care, p. 393. American Nurses’ Association. Guidelines for Short-Term Continuing Education Programs for Geriatric Nurse Practi- tioners. Kansas City, Mo., The Association, 1974, pp. 3-5. American Nurses’ Association. Geriatric Nursing Certifica- tion, Kansas City, Mo., The Association, 1974. Dunkley, P. H., “The ANA Certification Program,” Nursing Clinics of North America, 9:494, September 1974. 41 ''APPENDIX A Cornell University-New York Hospital School of Nursing Objectives for Nursing Practice x The following list of objectives was derived from an analysis of nursing care plans over an extended period of time, analysis of selected nursing case conferences, analysis of selected case data, review of the professional literature and critique by selected groups of practitioners and faculty members of undergraduate and grad- uate programs in nursing. The most recent cri- tique and modification was by the faculty of the Cornell University-New York Hospital School of Nursing and the faculty of the PRIMEX faculty of the Division of Continuing Education. The objectives are illustrative of the scope of nursing practice generally assumed to be repre- sentative of the practices of nurses and have pro- fessional and social acceptance through custom and usage. The behaviors of the nurse, requisite to the achievement of the objectives, are influenced by the complexity of the presenting problem and therefore by the nature of the clinical judgment required in predicting or projecting a course(s) of action. The objectives, listed below have been cate- gorized into three groups to enable practitioners to analyze the components of nursing within a nursing regimen for individuals and/or families. It is recognized that there is an interrelatedness in the actual process of care. A. Objectives related to the individual and/or families potential or actual alteration of life situation or life style. 1. To modify institutional or agency rou- tine and procedures to the individual’s needs according to his usual or preferred life style where therapeutic. *Lambertsen, Eleanor C. “‘Preparation of the Nurse Practi- tioner” CHART 68:71-74, Passim, March 1971. 42 To interpret to the individual institu- tional or agency routines and procedures. To assist the individual to formulate the meaning of experiences in daily living. To foster an environment which sets lim- its for emotional and physical safety. To assist in the socialization of the indi- vidual or group. To foster a therapeutic milieu for individ- uals and groups. . Objectives related to the individual’s and/or families’ psychosocial needs and responses to a potential or actual health problem or prob- lems. l. 9. 10. To anticipate that any change in life style or life process is potentially threatening or stressful. To facilitate questioning and interpreta- tions of explanations or instructions requisite to a therapeutic regimen. To assist the individual to meet needs for independence as well as to accept his dependency needs. To assist the individual and family cope with stress and bereavement. To assist individuals to formulate the meaning of experiences in daily living. To define the limits and boundaries of reality. To foster an environment for the emo- tional well-being of individuals and groups. To assist the individual validate his mode of thinking, feeling, and acting. To identify persistent themes and_ be- havior patterns and their significance in individuals and groups. To conserve the psychological and socio- logical resources of the individual or family. ''11. To assist the individual use a stressful ex- perience as a means of helping him to identify and modify the behavior that contributed to his disability. C. Objectives related to the individual’s physio- logical needs and responses to potential or actual health problems. Ii. To promote strategies which will aid in the promotion and maintenance of health for individuals and groups. To promote strategies which will aid in the prevention of disease and disability for individuals and groups. To identify normal physiological _re- sponses. To identify deviations from predictable physiological response of the individual to potential or actual illness or disability. To identify deviations from predictable responses to therapeutic intervention. To prevent physiological complications. To assist the individual achieve his fullest potential for self-care. To assist the individual achieve, retain and/or restore functional ability. 10. 11. 12. 13. 14. To promote the physical comfort of indi- viduals. To provide a compensatory function when individuals are unable to carry out physiological functions or life processes such as: e Respiration Elimination Nutrition Posture, position, exercise Rest, sleep, relaxation Maintenance of body temperature Personal hygiene Communication Circulation of body fluids Sexuality To assist individuals and families cope with the stress of disability and death. To provide an environment which sets limits for the physical safety of individ- uals and groups. To conserve the physiological resources of the individual and family. To adjust the institutional or agency routines and procedures to the perform- ance rate of the individual. 43 ''APPENDIX B Cornell University-New York Hospital School of Nursing Model for Identification of Scope of Practice (Definitions) 1. Populus ....... 2. Assessment ..... 4. Health Education 5. Preventative Measures ..... 6. Restorative Measures ..... 7. Curative Measures The classification of individuals, along with health-illness spectrum, requiring health maintenance and/or therapeutic services in the three domains of primary care, acute care, and long-term care services. The process of ordering phenomena through the course of identifying physio- logical and behavioral indices to determine if the organism (individual) is in an adaptive or maladaptive state. Encompasses making suggestions or recommendations to or providing guidance for individuals or groups who have expressed the need (overtly or covertly) for assistance in solving a problem or meeting a need which is perceived to affect their state of health or well-being. The counselor brings expertise to the process with the recognition that the purpose of health counseling is to assist the individ- ual or group to secure pertinent information or to assist the individual or group to evaluate the consequence of selecting courses of action. The process that bridges the gap between health information and health practice. It embraces those processes of communication and education which help each individual to learn how to achieve and maintain a reasonable level of health appropriate to his/her particular needs and interests and to follow personal and community health practices which contribute to his state of health and well- being—a positive concept going well beyond the mere absence of disease or infirmity.* In its broad sense these include first, measures which avert the occurrence of disease, and second, those which halt or retard the progression of disease into disability or death. These can be considered as primary and secondary preven- tion. Primary prevention embraces all means used in preventing the occurrence of disease, disability, or impairments. Secondary prevention aims at halting the progress of a disease from the early stage to a more severe one. The latter implies detection of disease, probably before it becomes manifest, and includes all meas- ures which lead to the discovery of disease processes even before they cause symptoms. ** Strategies employed to reinstate the functional capacity or vital life functions during or following the acute phase of illness or disability. Strategies employed to heal and restore to health; to remove or provide a rem- edy for disease or illness: *The Report of the President’s Committee on Health Education. 801 Second Ave., New York, N.Y. p. 13. **The President’s Commission on the Health Needs of the Nation, Building America’s Health—America’s Health Status, Needs and Resources - Volume 2. Washington, D.C., U.S. Government Printing Office, 1951, pp. 18-19. 44 ''Sv CORNELL UNIVERSITY— NEW YORK HOSPITAL SCHOOL OF NURSING PRIMARY CARE SERVICES Health Maintenance POPUL US* ASSESSMENT OF HEALTH STATUS HEALTH COUNSELING HEALTH EDUCATION PREVENTATIVE MEASURES RESTORATIVE MEASURES CURATIVE MEASURES WELL AND WORRIED WELL LONG TERM ILLNESS (reversible) CHRONIC ILLNESS (irreversible and progressive) COMMON AND USUALLY SIMPLE EPISODIC ILLNESS FIRST CONTACT CARE OF SERIOUS DISEASE AND TRAUMA *All age groups Encompasses Mental Health—Psychiatry Ambulatory Care Settings & Community Social Service Agencies ''ov ACUTE CARE Health Maintenance Therapeutic POPULUS* ASSESSMENT OF HEALTH HEALTH PREVENTATIVE RESTORATIVE CURATIVE HEALTH STATUS} COUNSELING EDUCATION MEASURES MEASURES MEASURES EPISODIC ILLNESS ACUTE EXACERBATION OF CHRONIC ILLNESS CRITICAL CARE “All age groups Home bound or requiring admission to a health service institution. Encompasses Mental Health—Psychiatry ''Lv LONG TERM CARE Health Maintenance POPULUS* ASSESSMENT OF HEALTH STATUS HEALTH COUNSELING HEALTH EDUCATION PREVENTATIVE MEASURES RESTORATIVE MEASURES CURATIVE MEASURES LONG TERM ILLNESS— REVERSIBLE CHRONIC ILLNESS— IRREVERSIBLE * All age groups Home bound or requiring admission to a health service institution or community social service agencies. Encompasses Mental Health—Psychiatry ''APPENDIX C The Division of Ambulatory Services at New York Hospital-Cornell Medical Center Family Nurse Practitioner Protocol A procedure for routing select Visiting Nurse Service patients referred by the Family Nurse Practitioner of Visiting Nurse Service of New York to the Division of Ambulatory at New York Hospital-Cornell Medical Center. OBJECTIVES To offer a better means of health care to a potential population in Comprehensive Health Planning (CHP) Area ‘“‘A’’ and Areas “B” and “C” which: 1. frequently has no health care facility read- ily available, and 2. cannot easily seek such facility independ- ently because of either a chronic disability and/or an acute health problem. To facilitate the delivery of health care to the above population by utilization of the Family Nurse Practitioner (FNP) in Visiting Nurse Serv- ice of New York (VNSNY). To further facilitate the delivery of such care by simple referral mechanism between the Visit- ing Nurse Service of New York Family Nurse Practitioners and the Division of Ambulatory Services at New York Hospital-Cornell Medical Center. POPULATION People referred to the Visiting Nurse Service of New York by other individuals in the com- munity, other community agencies, or people picked up through VNSNY case finding who have: l. either a chronic disability and/or acute health problems which precludes their seek- ing health care services independently. 2. attempted to solicit .the services of a local doctor without success 48 3. no source of health care services for either acute or continuing care 4. expressed the desire for health care services through the Division of Ambulatory Serv- ices at New York Hospital-Cornell Medical Center. PROCEDURE 1. The patient’s history, present illness infor- mation, and physical examination will be performed in the patient’s domicile. 2. The Visiting Nurse Service of New York Family Nurse Practitioner contacts by tele- phone the J-1 Ambulatory Services Coor- dinator, or, in her absence, J-1 General Clinic Chief Nurse to: a. request a revisit appointment as either: Priority I — to be seen within 48 hours, or Priority II — to be seen within 7-10 days. b. advise regarding recommended labora- tory test and x-rays. 3. The assigned New York Hospital Family Nurse Practitioner/M.D. will contact by telephone the VNSNY FNP to: a. confirm the revisit appointment date and time (preferrably mornings) b. receive the pertinent data from the patient’s history, present illness, and examination, and the recommended laboratory tests and x-rays. 4. The pertinent data in 3b is recorded on New York Hospital History paper by the assigned New York Hospital FNP in lieu of arrival of the written history, present illness information, and physical examination from the VNSNY FNP. 5. If the patient has transportation . needs, contact will be made with Miss Ullman, ''10. 11. MSW at New York Hospital-Cornell Med- ical Center (4472-5259) by either New York Hospital FNP or VNSNY Social Work Assistant. . The written history, present illness infor- mation and physical examination will be addressed to the assigned New York Hos- pital FNP and will arrive by mail, or with the patient, or with the VNSNY Home Health Aide accompanying the patient (when latter is indicated). A photocopy of same history, present illness information and physical examination will be entered in VNSNY record. . The J-1 Ambulatory Services Coordinator will inform the Screening Clinic Nurse of the expected arrival of the un-registered patient. . The un-registered patient will arrive in J-B Screening Clinic on the appointed day with a blue Visiting Nurse Service Referral Form from the VNSNY FNP as identification and listing the recommended laboratory tests and x-rays. The patient will also have a pink appointment slip to J-1 General Clinic. The patient will be registered and receive all requisitions for recommended laboratory tests and x-rays at that time. . The pre-registered patient (one previously registered at New York Hospital (NYH) will arrive at J-1 General Clinic with pink appointment slip and Visiting Nurse Service (VNS) Referral Form (introducing patient and listing recommended laboratory tests and x-rays) to: a. pick up requisitions for laboratory tests and x-rays, and b. go to Central Desk and Laboratory, and c. return to J-1 General Clinic for visit with assigned NYH FNP/M.D. If no laboratory tests or x-rays are ordered, the pre-registered patient may be directly routed to J-1 General Clinic. The assigned New York Hospital FNP will communicate with the VNSNY FNP the results of the workup, the recommended regimen, and the anticipated role of either the VNS FNP and/or other VNS services. TRANSPORTATION SERVICES Patients able to take a taxicab should be en- couraged to do so. Patient should: . pay the fare on the meter . request receipt from the taxicab driver for fare 3. submit the receipt to Social Service for reimbursement of the fare 4. when coming to office (Social Service) should have a statement from NYH nurse indicating patient should have refund. No— Medicaid: Ambulette may be used if patient can meet driver at the building entrance, or, if only one person is required to assist patient into ambulette. Ambulance is required if two or more attend- ants are required to assist patient into conveyance. Procedure: 1. Initial Referral At least 72 hours (3 working days) before appointment, no- tify Miss Ullman at 472-5259 and give: a. Patient’s name b. Address, apt. #, tele- phone # c. Medicaid number Subsequent Transport Arrangements Once the patient is registered at New York Hospital with initial transportation arrange- ments, patient should be encouraged to arrange his/her own transportation for subse- quent visits by calling 472-5500 (Social Serv- ice secretary in charge of transportation) at least two working days before scheduled re- visit. NO Medicaid and NO Funds Telephone call to Miss Ullman at 472-5259 for individual discussion of the case. Any need for Ambulance/Ambulette for which patient cannot pay should be carefully evaluated by the nurse. 49 ''OS * ADAPTED FROM NORMA I ANG APPENDIX D FIGURE I. MODEL FOR QUALITY ASSURANCE: IMPLEMENTATION OF STANDARDS* IDENTIFY VALUES SECURE TO DETE OF STAN MEASuREmM RMINE Deg NTS NEEDED REE oF PARDS AND CRITERIA INMENT “A MONFI FOR OLALITYV ACCHIRANCE IN NIEIRCING "4107/4 \ANTU DADTICIDATINN ''Is APPENDIX D (Con’t) Figure 2, USE OF MODEL IN AN INSTITUTION WHICH PROVIDES NURSING CARE VALUES Institution’s Philosophy IDENTIFY STANDARDS + 1. STRUCTURE Nursing Service Philosophy ANA Standards (1) + JCAH (3) Community Expectations NLN Nursing Service (2) + Medicare - Medicaid Standards (4) Nurse’s Philosophy Institution’s + Community's Client's Philosophy AHA (5) (6) AND CRITERIA + Client’s 1. STRUCTURE Others 2. PROCESS Utilization Review (9) ANA JCAH Institution’s Medicare - Medicaid Licensure Criteria (7) Community's Client's Client’s TAKE ACTION 3. OUTCOME ANA Certification (8) ANA Institution’s Institution's Medicus (10) . Community’s 2. PROCESS CHOOSE COURSE Client's Phaneuf’s Audit (11) Utilization Review Wandelt’s Qualpac (12) COURSES OF ACTION Client's Using judgments, generate alternatiy Slater’s Scales (13) tor each strength and weakness iueanniont Medicus 3. OUTCOME MAKE INTERPRETATIONS PSRO Prototype Project (14) After ordering and analyzing WRMP Project #7 (15) the data Horn’s Project (16) A. Use criteria inherent in measurement SECURE MEASUREMENTS Mayer's Care Plans (17) tool for making judgment Determined by Criteria JCAH’s Audit 1. STRUCTURE 1. AUDITS Institution's Medicare - Medicaid Structure - JCAH Client's JCAH Process - Phaneuf Audit Nurse's Licensure Outcome - PSRO Prototype Project 2. PROCESS Retrospective Review Phaneuf’s Audit WRMP Project #7, JCAH Wandelt’s Qualpac 2. OBSERVATION Slater’s Scale Structure - Medicare - Medicaid, 3. OUTCOME Licensure, Process, Medicus PSRO Prototype Project Process - Wandelt’s Qualpac, Slater's Scale, WRMP Project #7, MEDICUS (9) Peer Review (18), Risser (19), Medicus Horn’s Project Outcomes - Mayer's Care Plan, B. Make judgment using own criteria or intuition 1. STRUCTURE Other measures, institutional, client’s 2. PROCESS Other measures, Risser, institutional, client’s 3. OUTCOMES Mayer's Care Plans, client's, institutional, and other Horn’s Project, Peer Review . OTHER Self Report (Self Evaluation) Staff Evaluation Client Evaluation Physician Evaluation Community Evaluation Other Health Disciplines’ Evaluation ''cS APPENDIX D (Con’t) FIGURE 3: USE OF MODEL IN THE NURSING CARE OF A SPECIFIC CLIENT ea TAKE ACTION CHOOSE ACTION COURSE OF ACTION MAKE INTERPRETATION After ordering and analyzing the data A. Use criteria inherent in measurement tool for making judgments 1. STRUCTURE Licensure Medicare - Medicaid Medicus 2. PROCESS Phaneuf’s Audit Wandelt’s Qualpac Slater’s Scale Peer Review Medicus 3. OUTCOME PSRO Prototypes Project WRMP Project #7 Horn’s Project Peer Review B. Make judgment using other criteria or intuition 1. STRUCTURE Other measures, institution's, nurse’s, client's 2. PROCESS Other measures, institution’s, nurse’s, client's 3. OUTCOME Mayer's Care Plans, Risser, other measures, institution’s, nurse's, client’s / VALUES Own Philosophy + Client’s Philosophy + Institution’s (in which care is given) + Others 2 3 SECURE MEASURES Determined by Criteria 1. AUDITS Structure Process - Phaneuf Outcome - Prototype Study, Project #7 2. OBSERVATION Structure - Medicus ESTABLISH STANDARDS 1. STRUCTURE ANA Standards (20) Institution’s Nurse’s own Standards Client's . PROCESS ANA Institution's Nurse’s Client's . OUTCOME ANA AND CRITERIA Institution's 1. STRUCTURE Nurse’s Institution’s Client's Nurse’s Client's Medicare - Medicaid Medicus 2. PROCESS Phaneuf’s Audit Wandelt’s Qualpac Slater's Scales Nurse’s Medicus Client's 3. OUTCOME PSRO Prototype Project WRMP Project #7 Horn’s Project Mayer’s Care Plan Institution’s Nurse’s Client's Process - Wandelt’s Qualpac, Slater’s Scale, Peer Review, Risser, Medicus Outcomes - Mayer's Care Plan, Horn’s Peer Review . OTHER Self Report (Self Evaluation) (21) Staff evaluation Client’s evaluation Physician's evaluation ''es APPENDIX D (Con’t) VALUES Nurse’s or Group’s Philosophy + Community Expectations + FIGURE 4. USE OF MODEL IN PRIVATE PRACTICE Medical Community Expectations + Client's + Other se TAKE ACTION CHOOSE ACTION COURSE OF ACTION MAKE INTERPRETATIONS After ordering and analyzing the data A. Use criteria inherent in measurement tool for making judgments 1. STRUCTURE Medicus ANA Certification Medicare - Medicaid 2. PROCESS Medicus Phaneuf’s Audit Wandelt’s Qualpac Slater's Scale Peer Review 3. OUTCOME PSRO Prototypes Project WRMP Project #7 Horn’s Project Peer Review B. Make judgment using other criteria or intuition 1. STRUCTURE Client, nurse’s, other measures 2. PROCESS Client, nurse’s, other measures 3. OUTCOME Mayer's Care Plans, nurse’s, client, and other ESTABLISH STANDARDS 1. STRUCTURE ANA Standards Nurse’s own standards Medicare - Medicaid Standards Community's ANA Certification Client's 2. PROCESS ANA Nurse’s Community’s Client's 3. OUTCOME ANA Nurse’s Community’s Client’s J. SECURE MEASURES Ne ae Determined by Criteria fl 3. AUDITS Structure Process - Phaneuf Outcome - Prototype Study, Project #7 . OBSERVATION Structure - Medicus, Qualpac Process - Wandelt’s, Medicus, Slater’s Scale, Peer Review, Risser Outcome - Mayer’s Care Plans, Horn’s Project, Peer Review OTHER Self Report (Self Evaluation) Staff evaluation Client evaluation Other health discipline’s evaluation Community’s evaluation AND CRITERIA 1. STRUCTURE Medicare - Medicaid Criteria Medicus ANA Certification Criteria Nurse’s Client's 2. PROCESS Phaneuf's Audit Wandelt’s Qualpac Slater’s Scale Nurse’s Client’s Medicus 3. OUTCOME PSRO Prototype Project WRMP Project #7 Horn’s Project Mayer's Care Plans Nurse’s Client's ''vs TAKE ACTION CHOOSE COURSE POSSIBLE COURSES OF ACTION Using judgments generate alternative actions for each individual strength such as cost of implementation) and weakness (this may include variables MAKE INTERPRETATION After ordering and analyzing the data A. Use criteria inherent in measurement tool for making judgments 1. STRUCTURE NLN 2. PROCESS Phaneuf’s Audit Wandelt’s Qualpac Slater’s Scale Peer Review 3. OUTCOME PSRO Prototypes Project WRMP Project #7 Horn’s Project Peer Review B. Make judgment using other criteria or intuition 1. STRUCTURE School, other measures 2. PROCESS School's, Risser, other measures 3. OUTCOME Mayer's Care Plan, school’s, other measures APPENDIX D (Con’t) FIGURE 5: USE OF MODEL IN A SCHOOL OF NURSING VALUES School Philosophy + Teaching Philosophy + Goals of School + Philosophy of Student + Community’s Expectations 2 Others SECURE MEASURES ESTABLISH STANDARDS 1. STRUCTURE ANA Standards School's Community’s 2. PROCESS ANA School's AND CRITERIA Community's 1. STRUCTURE 3. OUTCOME NLN Accreditation (22) ANA School’s School’s 2. PROCESS Community’s A. For nursing process may use the criteria inherent in: Phaneuf’s Audit Wandelt’s Qualpac Slater’s Scale School's B. For teaching process 3. OUTCOME A. For nursing process: PSRO Prototype Project WRMP Project #7 Horn’s Project Mayer’s Nursing Care Plans School's B. For teaching process Determined by Criteria 1. AUDITS Structure Process - Phaneuf’s Audit Outcome - PSRO Prototype Project WRMP Project #7 . OBSERVATION Structure - NLN Process - Wandelt’s Qualpac Slater's Scale, Peer Review, Risser Outcome - Mayer’s Care Plans Horn’s Project, Peer Review . OTHER Self Report (Self Evaluation) Staff evaluation Client evaluation Physician evaluation Community Other health disciplines Simulation ''Ss APPENDIX D (Con’t) FIGURE 6: USE OF STANDARD V IN AN INSTITUTIONAL SE TTING— NURSING ACTIONS PROVIDE FOR CLIENT/PATIENT PARTICIPATION IN HEALTH PROMOTION, MAINTENANCE, AND RESTORATION IDENTIFY VALUES (Examples) 1. Self determination of patient and family TAKE ACTION 2. Nursing’s health orientation Policy changed to facilitate self 3. Self actualization of patient and family actualization of patient, and family and 4. Patient's right to quality care nursing contribution 5. Nursing’s contribution ne 6. Other CHOOSE COURSE OF ACTION Policy modification IDENTIFY STANDARD ANA Standard V. Nursing Action provides for client participation, etc. AND CRITERIA POSSIBLE COURSES OF ACTION 1. Provide patient and family with information 1. Patient care conference sufficient for the decision-making related 2. Consider policies (written and unwritten) to nature and extent of participation in care that affect patient, family, nurse collaboration, 2. Elicit participation e.g. visiting hours at times when 3. Use positive reinforcement of health oriented nurses are not usually available for behaviors conference with patient and family 4. Support family in positive interaction with patient 3. Program for improvement of supervisory skills 5. Support patient in positive interaction with family 6. Use negative behaviors of patient and family i f inati f th MAKE INTERPRETATIONS as occasions for re-examination of the situation 1. Function: Supervision of those Participating in care (except the physician) was poor 2. Physical, emotional, mental capacity to learn not considered SECURE MEASUREMENTS 1. Wandelt’s Qualpac (concurrent appraisal) 2. Phaneuf's Nursing Audit (audit), i.e. quality was excellent, good, incomplete, poor, unsafe overall for each of the nursing functions ''9S APPENDIX D (Con’t) FIGURE 7. USE OF STANDARD II IN A NURSING SCHOOL SETTING— —_. TAKE ACTION SELECT COURSE OF ACTION ACTIONS Nothing needs to be done. Revise criteria - not realistic. Revise curriculum. Revise learning experiences, etc. INTERPRETATIONS Ie 2. 3. Responses are in agreement with criteria Responses are not in agreement with criteria Mixed Criteria a. Tend to be supportive b. Tend not to be supportive NURSING DIAGNOSES ARE DERIVED FROM HEALTH STATUS DATA VALUES IDENTIFY STANDARDS 1. Client’s own 2. ANA Standard II 3. Nurse’s own CRITERIA FOR ANA STANDARD II . Curriculum includes nursing diagnosis content . Practice experiences for development of nursing diagnosis are provided . Student's nursing diagnosis is congruent with expert’s Expert’s nursing diagnosis . Students detail norms for client based on a corresponding population . Student's estimated degree and direction of deviation is congruent with faculty . Students identify capabilities and limits . Student's nursing diagnosis is congruent with medical diagnosis ONOTRWN= SECURE MEASURES (NOT AVAILABLE—NEED TO DEVELOP) 1. Ask questions to guide observation a. Curriculum 1) Is process of deriving nursing diagnosis taught? 2) Are students taught population norms? 3) Are students given a strategy for establishing degree and direction of deviation from norm? 4) Are practice experiences provided? . Performance 1) Is student’s nursing diagnosis congruent with expert's? 2) Does student compare client’s health status to appropriate norms? 3) Does student estimate degree and direction of deviation? 4) Does student identify capabilities and limitations? 5) Is nursing diagnosis congruent with medical diagnosis? 2. Doa content review of curriculum for a. b. Inclusion of appropriate content Inclusion of learning experiences 3. Ask students how they feel about ability to generate nursing diagnoses ''References* 1. Ww 10. 11. 12. . ‘“Management Standards for Nursing Services in Hospitals, Community Health Agencies, Nursing Homes, Industry, Schools, Ambu- latory Services, and Related Health Care Organizations. (Kansas City, Mo.: American Nurses’ Association, 1973); Generic Standards of Nursing Practice, (Kansas City, Mo.: American Nurses’ Association, 1973). . Criteria for Evaluating a Hospital Department of Nursing Service. (New York: National League for Nursing, 1965). . PEP Primer for A Quality Review Center Education Pro- gram, Joint Commission on Accreditation of Hospitals, January, 1974. . Health Insurance for the Aged, Conditions of Participation for Home Health Agencies, 0-208-731; Conditions of Partici- pation for Extended Care Facilities, 0-210-208; Conditions of Participation for Hospitals, 0-797-509, (Washington: Su- perintendent of Documents, U.S. Government Printing Office, 1966). . Quality Assurance Program for Medical Care in the Hospital, (Chicago: American Hospital Association, 1972). Review Evaluation: Nursing Service,” (Chicago, Ill.: American Hospital Association, 1972). . A State Institution Licensure Rules and Regulations. . Certification Progress Report, ANA Board of Directors Meet- ing, January, 1975. . Jacobs, N.D., “Model Utilization Review Plan for the Qual- ity Assurance Program,” Joint Commission on Accreditation of Hospitals, Chicago, Ill., 1973. Jelinek, R.C., et al., A Methodology for Monitoring Quality of Nursing Care. DHEW Publishing No. (HRA 74-25) U.S. Government Printing Office, January, 1974. Phaneuf, Maria C., The Nursing Audit: Profile for Excel- lence, (New York, N.Y.: Appleton-Century-Crofts, 1972). Wandelt, Mabel A. and Joel Ager, Quality Patient Care Scale, (New York, N.Y.: Appleton-Century-Crofts, 1974). *NOTE: These references are to materials referred to in the models which appear in Figures 1 - 7 in Appendix D. 13. 14. 15: 16. 17. 18. 19. 20. 21. 22. Slater, Doris and Mabel Wandelt, “The Slater Nursing Com- petencies Rating Scale,’ (Detroit, Mich.: Wayne State Uni- versity College of Nursing, 1975). ANA PSRO Contract: To Develop Model Sets of Criteria for Screening Quality, HSA 105-74-207. Wisconsin Regional Medical Program, ‘‘The Development of Patient Health Outcomes by Panels of Nurse Experts,” Final Report Project #7, Zimmer, Marie, Norma Lang, and Doris Miller, 1974. Development of Criterion Measures of Nursing Care, HEW Contract HF01649, University of Michigan, Ann Arbor, Barbara Horn, Principal Investigator. Mayers, Marlene, A Systematic Approach to Nursing Care Planning, (New York, N.Y. Appleton-Century-Crofts,: 1972). ANA Guidelines for Peer Review, October, 1973. Risser, N.L., ‘““Development of An Instrument To Measure Patient Satisfaction with Nurses and Nursing Care in Primary Care Settings,” Nursing Research, 24:1, 45-51, 1975. Standards of Geriatric Nursing Practice (Kansas City, Mo.: American Nurses’ Association, 1973); Standards of Psychi- atric-Mental Health Nursing Practice (Kansas City, Mo.: American Nurses’ Association, 1973); Standards of Commu- nity Health Nursing Practice (Kansas City, Mo.: American Nurses’ Association, 1973); Standards of Maternal-Child Health Nursing Practice (Kansas City, Mo.: American Nurses’ Association, 1973); Standards of Medical-Surgical Nursing Practice (Kansas City, Mo.: American Nurses’ Association, 1974). Quest for Quality: A Self-Evaluation Guide to Patient Care (New York, N.Y.: National League for Nursing, 1966). Criteria for the Evaluation of Educational Programs in Nurs- ing Leading to an Associate Degree, (New York, N.Y.: Na- tional League for Nursing, 1973); Criteria for the Appraisal of Baccalaureate and Higher Degree Programs in Nursing, (New York, N.Y.: National League for Nursing, 1969). a ''APPENDIX E Preliminary Report Survey of State Nurses’ Associations Nursing Involvement in PSRO Two of the ten states which comprise the ini- tial respondents to a questionnaire reported that they have applied for “conditional PSRO status.” Eight states of the ten reported that statewide professional standards review councils are operating or being developed in their states. The other two SNAs indicated that there were areawide PSROs operating or being developed. Of these eight states with statewide PSROs, six reported areawide professional standards review organizations were also operating or being plan- ned in their state. Of the ten SNAs reporting, two states had delegated PSROs review to hos- pitals (12). Five states reported that statewide council advisory/liaison groups have or are planning to have nurse members. Of the five, one state re- ported that 33 percent of their statewide council advisory/liaison groups were nurses, and another state reported only eight percent. The other three states did not report the percent of nurse membership of these advisory groups. Five states indicated that there were nurses on their area- wide PSRO advisory/liaison group: one state re- ported that nurses comprised 33 percent of these groups, another state reported ten percent, and three states did not report. One of the seven states reporting some kind of nurse membership on either statewide council advisory/liaison groups or areawide PSRO advisory/liaison groups, six indicated that these council or advi- sory nurses were recommended by the SNA, and only South Dakota reported that council or ad- visory nurses were also selected in part by a PSRO nominating committee (13). Three of these seven states indicated that the description of the nurse’s role as a member of the PSRO had not been formulated as of this date. Two states indicated that the nurse’s role in the PSRO was advisory only. Ohio stated that “the nurse members of the advisory council formed under that State Support System will develop 58 outcome criteria based on nursing care require- ments of patients with certain disease entities.” South Carolina states that the nurse’s role on the PSRO is ‘‘to make recommendations concerning policy matters which affect overall PSRO administration.” (14) Two states indicated that the PSRO program was involved in reviewing the quality of nursing care. Wisconsin states its PSRO would be in- volved in this process after the award of its next contract. Five states indicated that their PSROs were not involved in reviewing the quality of nursing care. Four states indicated that to the best of their knowledge nurses are serving as statewide or areawide PSRO review coordina- tors; two of these states indicated that all review coordinators were nurses, one of these states in- dicated that 80 percent of the review coordina- tors in the state were nurses, and one state did not report a percent breakdown. Three of these four states described the functions and method of appointment of review coordinators. Four states indicated that there were no nurses acting as review coordinators. One state indicated that it still is seeking funds and one state did not respond (15). Two indicated that nurses had other means of input to the PSRO programs in the state besides through the State Nurses’ Associations. Three states indicated that there were no other means for nurses to get involved in their PSRO pro- gram, three states did not know, and two states did not respond (16). The basic rationale for involvement of nurses in PSRO is contained in provisions of Public Law 92-603 which states: “Duties and Functions of Professional Stand- ards Review Organizations Sec.1155. (a) (1) Notwithstanding any other provision of law, but consistent with the provisions of this part, ''-it shall (subject to the provisions of subsec- tion (g) be the duty and function of each Pro- fessional Standards Review Organization for any area to assume, at the earliest date practi- cable, responsibility for the review of the pro- fessional activities in such area of physicians and other health care practitioners and insti- tutional and noninstitutional providers of health care services in the provision of health care services and items for which payment may be made (in whole or in part) under this ACt. aca” ao ''APPENDIX F Family/Adult/Geriatric Nurse Practitioner Programs PRIMEX — Family Nurse Practitioner Program The New York Hospital—Cornell Medical Center School of Nursing 1320 York Avenue New York, N.Y. 10021 Geriatric Nurse Practitioner Program Texas Women’s University College of Nursing 1810 Inwood Road Dallas, Tex. 75235 60 Adult/Geriatric Nurse Practitioner Program Program in Public Health Nursing School of Public Health 1315 Mayo University of Minnesota Minneapolis, Minn. 55455 Adult Health Nurse Practitioner Program University of Colorado Medical Center School of Nursing 4200 East Ninth Avenue Denver, Colo. 80020 ''‘Rec'd in Public Health Library JAN 28 1985 '' ''U.C. 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