Stricter control needed over private nursing homes

Care of the aged is costly and getting costlier. Over the past few years, increasing demand for hospital beds and the high costs involved have led the NHS to off-load the responsibility for the long-term care of old people on to the private nursing home sector.

Regulation of advanced nursing practice: one state's approach

The concept of advanced nursing practice varies widely in interpretation and regulation. The economic, societal, and political forces affecting change in the U.S. health care delivery system have heightened the public's interest in alternative approaches to health care. Traditional acts of medicine increasingly overlap with those of other providers, such as nurse practitioners, nurse midwives, nurse anesthetists, and clinical nurse specialists. Crucial challenges face state Boards of Nursing as they balance their public protection responsibilities with their support of the evolution of nursing practice. This article provides information regarding the national approach to the regulation of advanced practice nursing, followed by an overview of one state's approach to this issue.

State regulation of hospital water temperature

OBJECTIVE

The purpose of this study was to determine current regulations and policies in the United States concerning maximal water temperatures in acute care hospitals.

DESIGN

A standardized questionnaire administered by telephone to health department officials from 50 states and the District of Columbia.

SETTING

State Health Departments in the 50 states and the District of Columbia.

RESULTS

All states responded to the survey. Respondents from 39 states (77%) reported regulating maximum allowable hospital water temperature at a mean of 116 degrees F (median, 120 degrees F; mode 110 degrees F; range, 110 degrees F to 129 degrees F). Twelve states (23%) have no regulations for maximum water temperature. Of the 39 states regulating maximum water temperature, 30 (77%) routinely monitor hospital compliance. Nine states (23%) conduct inspections only in response to a complaint or incident.

CONCLUSIONS

There is great variation among the states with respect to the existence, enforcement, and specific regulations controlling hospital water temperature. Risk-benefit and cost-effectiveness analyses would help to assess the risk of scald injuries at water temperatures that will inhibit microbial contamination.

Learning to pay attention. An ethics study group refocuses on issues affecting long-term care residents' daily lives

In 1991 the Sisters of Charity Healthcare Systems (SCHCS), Cincinnati, established an ethics study group for its long-term care facilities. The group was originally organized to address end-of-life treatment decisions, but it soon found that the daily lives of people by and for whom such decisions would be made were worthy of attention in their own right. Autonomy had been a topic of group discussions early on. Once reinterpreted in the context of long-term care, it became the pivotal value for the group. One key to the group's progress was identifying intrinsic and extrinsic factors that distract care givers' attention from issues of concern to residents. Members found that state and federal regulations, as well as constraints on medical treatment by payers such as Medicare and Medicaid, often ignore the human dimension in terms of which the elderly's needs and preferences can be framed. Rigidly defined roles and routines also blunt care givers' sensitivity to residents' concerns. The group is currently developing a program of in-service ethics education and training. Designed in four modules, the program will focus on the following topics: protecting and enhancing resident rights, staff issues and professionalism, talking about death and dying, and staff-physician issues.

Regulation of prehospital nursing practice: a national survey

INTRODUCTION

In 1988, the National Flight Nurses Association and ENA published a revised joint position statement advocating that registered nurses (RNs) "should not be required to certify as Emergency Medical Technicians (EMTs) at any level before assuming a nursing role in the prehospital environment." The position endorsed a collaborative role with emergency medical services agencies, regulation of prehospital nursing by state nursing agencies, and additional educational requirements in areas unique to prehospital emergency care. This study examines the existing state of affairs in the regulation of prehospital practice of RNs throughout the United States.

METHODS

Data were obtained by review of written state rules and regulations pertaining to certification of prehospital care providers and by telephone survey of state emergency medical services agencies nationwide.

RESULTS

All 50 (100%) of the states were contacted. In 44 of the 50 states (88%), no certification in prehospital nursing exists. As a result, most states require that RNs become EMTs at some level as a prerequisite for prehospital practice. Of these states, 36% (16/44) allow RN substitution to meet ambulance staffing requirements without additional certification requirements. Of these states, 61% (27/44) require RNs to complete the entire EMT curriculum to obtain certification, whereas 39% (17/44) allow challenge examinations in combination with varying other educational requirements. Nursing "certification" for prehospital practice exists in 12% (6/50) of states.

DISCUSSION

As a nation, we are far from actualizing the recommendations stated in the ENA and National Flight Nurses Association position.

Ethical and legal concerns: reproductive technologies 1990-1993

After the rapid increase in reports, bills, and regulations on assisted reproductive technologies (ART) in the 1980s, the first 3 years of the 1990s reveal a continuation of this trend notably in three major aspects. First, a certain consistency has developed in terms of the conditions of accessibility to ART, the definition of infertility, the terms of donation, and the primacy of social filiation, so that anonymity remains controversial. Second, the importance of protection of genetic material has been reaffirmed with regard to gamete and embryo conservation, embryo research, and, in particular, the acceptability of preimplantation diagnosis. Finally, the framework of practices concerning accreditation and control, organization of national data, and management of nominative information has been increasingly refined.

Establishing a nurse-managed health center: interacting with regulatory, professional, and fiscal environments

In establishing a nurse-managed health center, one must be cognizant of legal and regulatory issues that could impact on the practice. The ability to negotiate outside services, such as laboratory and medical consultation, is important. Additionally, as an integral component of financial viability, attainment of third-party reimbursement should be considered.

The validation event: a critical appraisal?

Apart from the perennial concern with finance, questions of 'quality' and 'accountability' will be the principle themes in the higher education debate in the 1990s. The whole issue of 'quality' and 'accountability' has become critically important to the success or otherwise of colleges of nursing and midwifery in convincing their multiple stakeholders (clients, patients, students and purchasers) that they should have a place in the marketing of nursing and midwifery education. The validation process is an important component of the formalized quality assurance mechanism of a course. There have, however, been little or no empirical data relating to the effect of validation processes on quality of courses and, more important, in the long term, quality of care. The following issues are explored in the paper. How are 'quality' and 'accountability' defined within the context of a market orientated system? How is 'peer review' to be interpreted within a purchaser led system? Are practice outcomes prioritised within educationally led, practice-based courses? Is there a part to play for continuing external regulation? We suggest that recent developments in nursing and midwifery education have often been undermined, during validation events, by structural processes for conformity. Such a regression to the conventional has been strengthened by the absence of new conceptions of quality deliberately designed to match these innovatory courses. Conceptions, that is, framed in terms distinct from the traditional model in which quality in higher education tends to be regarded as largely an attribute of disciplinary knowledge. Finally, we suggest that the decisive determinant of professional skill, is the personal standards, the professionalism and the self-respect of the individual teacher.

Can resident-centred inspection of nursing homes work with very sick residents?

This paper seeks to address the issue of whether a resident-centred inspection process can be effective in a nursing home environment dominated by residents who require high levels of care. Two fundamental criticisms of the current Australian monitoring process are its reliance on standards that are subjective resident-centred standards and its reliance on the views of residents concerning the quality of care provided in the home. These criticisms are becoming all the more important as survival rates for the aged increase and the average level of disability of nursing home residents continues to worsen. Our data suggest that the resident-centred process, despite some difficulties, is both reliable and practical, regardless of the care needs of residents in the home. Data collected from inspection teams show that inspectors use a variety of sources to validate information, with residents being one component. These sources vary little in importance between homes with different levels of care needs or behavioural problems. Perhaps of more importance is the finding that a home's overall performance across 31 resident-centred standards is not affected by either the home's average level of total care needs or the number of residents with severe behavioural problems. There are some significant effects (in both directions) of resident disability on compliance with particular standards. Most notable is the finding that the standard requiring appropriate use of restraint is less likely to be met when there are large numbers of residents with high levels of disability or behavioural problems.

Medicare and Medicaid programs; quarterly listing of program issuances and coverage decisions--HCFA. Notice

This notice lists HCFA manual instructions, substantive and interpretive regulations and other Federal Register notices, and statements of policy that were published during October, November, and December of 1992 that relate to the Medicare and Medicaid programs. Section 1871(c) of the Social Security Act requires that we publish a list of Medicare issuances in the Federal Register at least every 3 months. Although we are not mandated to do so by statute, for the sake of completeness of the listing, we are including all Medicaid issuances and Medicare and Medicaid substantive and interpretive regulations (proposed and final) published during this timeframe. We also are providing the content of revisions to the Medicare Coverage Issues Manual published between October 1 and December 31, 1992. On August 21, 1989 (54 FR 34555), we published the content of the Manual and indicated that we will publish quarterly any updates. Adding to this listing the complete text of the changes to the Medicare Coverage Issues Manual allows us to fulfill this requirement in a manner that facilitates identification of coverage and other changes in our manuals.

The effect of the Medicare regulations on hospice practice: enhancing staff performance

The purpose of this paper is to examine the federal hospice regulations (42 CFR 418.50-.100) and identify from these standards key characteristics that help define important aspects of palliative hospice care. The other purpose will be to examine these requirements to determine what these standards say or imply about the functioning of the hospice staff within the certified program. We assert that in order for a certified program to function in the capacity outlined in the federal hospice requirements, both the administration and staff need to understand, and then practice, the complex role delineated within the Congressional Law and ensuing regulations. The Medicare hospice regulations are a recognized program standard throughout the nation. These requirements, finalized in 1983, were developed by the Health Care Financing Administration (HCFA) as a result of the Congressional Tax Equity and Fiscal Responsibility Act (TEFRA, 1982). Since the promulgation of these regulations, hospices wishing to gain certification have had to adapt and mold their program focus and clinical procedures to meet this legislative mandate. Although some hospice administrators may perceive the Medicare requirements simply as hoops to be jumped through in order to gain funding, in truth, these regulations stand as a benchmark in the history of American hospice care. In their totality, the rules set forth a system of health care that is singular in program design.