Capitalizing on the theme of “Nurses Leading the Way,” representatives to the American Nurses Association’s (ANA) Membership Assembly displayed their leadership skills by electing the association’s new president and offering strategies to advance nursing and health care in three key topics.
Following her oath of office June 14, new ANA President Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, said, “This is indeed the most impressive honor in my entire career. I look forward to working to serve nurses, improve the quality and safety of care for our patients, and continue to transform our nation’s health.
“I am very pleased to work with you to continue to bring our message forward on how we’re going to lead and change health care. And I look forward to creating the next stage of ANA’s legacy, post-transformation.”
A Virginia Nurses Association member, Cipriano is a nurse consultant and the former editor-in-chief of ANA’s journal, American Nurse Today.
In practice-associated actions, some 350 representatives and observers had the opportunity to engage in dialogue forums on issues related to nurses’ full practice authority, access to palliative care and high-performing interprofessional teams. New this year, the forums differed slightly in format but were designed as a way for participants to learn more about relevant topics and advise ANA moving forward. Assembly representatives subsequently voted on specific recommendations.
Being able to practice fully
The first forum addressed “Scope of Practice — Full Practice Authority for All RNs,” a topic proposed by the South Carolina Nurses Association. Participants engaged in table discussions about legislation mandating physician supervision of advanced practice registered nurses (APRNs) over a certain period of time before APRNs could gain full practice authority; major practice barriers for RNs; and potential strategies to move past “turf” battles as new roles and categories of health care workers evolve.
They shared, for example, that current legislation in Kansas calls for a 2,000-hour transition-to-practice requirement for APRNs, and 2015 legislation planned in Colorado and Nevada would remove current requirements for a transition period to full practice authority.
In discussing practice barriers for RNs, participants commented on a lack of role clarity and no separate, visible reimbursement for RN services. They also noted that promoting interprofessional, team-based care, valuing all members of the health care team and clarifying nurses’ roles could help diminish turf battles.
Representatives formally voted on recommendations for the ANA Board of Directors’ consideration. Specifically they recommended that ANA support interprofessional education, practice and research to promote the full scope of RN practice; encourage nursing research to compare full practice authority states, transition to APRN practice states, and restricted APRN states; educate the public, policymakers and other health professionals about emerging roles and overlapping responsibilities; and support eliminating practice agreements between APRNs and physicians.
Integrating palliative care
In the second forum, guest speakers took the stage to address the “Integration of Palliative Care into Health Care Delivery Systems: Removing Barriers, Improving Access.” This topic was proposed by the Ohio Nurses Association (ONA), which voiced ONA members’ concerns about a lack of access to and payment for palliative and hospice care.
Kathryn M. Lanz, DNP, ANP, GNP, ACHPN, director of geriatric services for the University of Pittsburgh Medical Center’s Palliative and Supportive Institute, started her presentation with some troubling statistics based on a national survey of Americans. Sixty-five percent of responders reported having loved ones who died in pain, half of older Americans visited an ED in the last month of life, and 70 percent of the public worries about end-of-life issues.
That said, she noted that there are good palliative care models that take a person-directed approach to care and are value-based. She further reported that implementing those models improves patients’ symptoms, quality and length of life, as well as family satisfaction and bereavement outcomes.
Key characteristics of effective models include family and social support, goal setting in which patients’ desires match their treatment, and a flexible approach to “dosing” — that is, the appropriate type of care is given at the right time as patients’ symptoms wax and wane, according to Lanz.
Marijo Letizia, PhD, RN, APN/ANP-BC, FAANP, professor and associate dean of masters and DNP programs at Loyola University, Chicago, addressed the importance of improving the knowledge and skills of basic and advanced care nurses in the area of palliative care. She noted that both formal preparation and continuing education coursework should be implemented — for every nurse and specialty.
“We don’t have to reinvent the wheel,” said Letizia about creating palliative care content. She mentioned helpful educational resources created by the Hospice and Palliative Nurses Association (HPNA), an organizational affiliate of ANA, and the National Consensus Project for Quality Palliative Care.
For example, HPNA and ANA have worked collaboratively on many initiatives, including developing Palliative Nursing: Scope and Standards of Practice, and HPNA has several position statements focusing on the value of nursing in hospital and palliative care.
Assembly participants also shared their own resources; called for additional education for both patients and health care professionals; spoke about improving the diversity of nurses providing hospice and palliative care; and urged the breaking down of barriers so nurses can write needed prescriptions.
After a formal vote, Assembly representatives recommended asking ANA to promote and support payment models to improve access to palliative and hospice care, including nursing care provided by both RNs and APRNs; advocate for comprehensive integration of palliative and hospice care education at all levels of nursing educational programs and professional development programs; and support developing and expanding models of nursing care that include advanced care planning for early identification and support of patients’ preferences for palliative and hospice services.
Looking at high-performing, interprofessional teams
The final forum explored high-performing, interprofessional teams, and featured presentations by Kathryn Rugen, PhD, FNP-BC, from the VA Centers of Excellence in Primary Care Education, and Tara Cortes, PhD, RN, FAAN, executive director of the Hartford Institute for Geriatric Nursing.
Cortes first addressed the history of team-based care, noting that the Institute of Medicine has been talking about interprofessional education and practice since 1970. She then suggested several strategies to advance high-performing, interprofessional practice, including writing it into organizational policies and procedures and performance indicators; breaking down the silos that exist between academia and practice; and developing and implementing new integrated models of care.
Rugen spoke specifically about the ongoing efforts at the Department of Veterans Affairs Centers of Excellence in Primary Care Education.
She noted that physician residents and nurse practitioner (NP) trainees, along with core clinic members, “learn to work in — and lead — team-based, patient-centered care that they can use in their future practice.”
The centers also focus on developing and testing innovative curriculum models, and curricula and learning activities are geared to promote shared decision-making, sustained relationships, interprofessional collaboration and performance improvement, according to Rugen.
Forum participants then had the opportunity to weigh in with their comments. For example, they reported a range of barriers to the successful implementation of high-performing, interprofessional teams — from turf wars and egos to a lack of education about individual roles and responsibilities to an absence of time and resources. In response to a question about ways ANA can support nurses to further engage and assume roles to advance high-performing interprofessional teams across care settings, participants suggested engaging hospice and mental health professionals, because they have been using this model for 20 to 30 years. They also suggested supporting multiday training for faculty and developing innovative resources that incorporate interprofessional simulation and social interaction opportunities for acculturation, among others.
When it came to voting on recommendations for ANA, Assembly representatives asked that ANA consider educating nurses about the application and impact of evolving patient-centered, team-based care models on patient outcomes, and identify metrics that evaluate the impact of high-performing, interdisciplinary health care teams on patient outcomes.
Cross-border practice update
ANA Executive Director Debbie Hatmaker, PhD, RN, FAAN, updated the Assembly on work done around a 2013 reference proposal on cross-border nursing practice. This topic is particularly important, as nurses increasingly are practicing beyond traditional geographic boundaries and may provide services to patients in many states in the course of their work as a telehealth provider.
Hatmaker noted that ANA’s 1999 policy views the state of practice as being where the nurse is located; however, that view is not widely accepted and has led to confusion.
The ANA board subsequently chartered a task force with representation from the ANA board, constituent and state nurses association leaders, regulators and other nursing thought leaders. The task force ultimately agreed to involve key stakeholders: nurses, consumers, the states, nursing regulators and insurers in the pursuit of next steps. They are to seek uniform licensure requirements, particularly as they pertain to criminal background checks and impaired practice; identify a regulatory model that could address new, emerging practices; and develop a standardized decision tree for determining scope of practice.
Concurrently nursing leaders from the Tri-Council (ANA, American Association of Colleges of Nursing, American Organization of Nurse Executives and National League for Nursing) and the National Council of State Boards of Nursing met and agreed to develop a paper that would serve as a blueprint for further action and incorporate several key principles, including that the primary goal is protecting patients and ensuring they receive safe, quality care.
To check out scenes from the 2014 ANA Membership Assembly as reported by Susan Trossman for The American Nurse, go to http://nursingworld.org/MA-slideshow.