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Washington Watch | Issues Update | Health & Safety

Issues Update

American Journal of Nursing - June, 2002 - Volume 102, Issue 6

Two Steps Forward, One Step Back
Bush administration action on regulations a mixed bag.

By Susan Trossman

Since George W. Bush assumed the presidency, the ANA has experienced both successes and setbacks in addressing federal regulations that impact nursing.

The Bush administration is providing nursing leaders with new opportunities to communicate their concerns about and solutions to various government regulations. Yet the administration has placed some health and safety proposals on the back burner, while moving ahead with another regulation that could harm patient care.

“We appreciate the Bush administration’s efforts to provide more avenues for nurses to express our concerns about federal regulations,” said ANA president Mary Foley, MS, RN. “However, we hope that our concerns—and our solutions—on issues like ergonomics will be translated into concrete measures that not only reduce bureaucratic red tape but also ensure the safety of nurses and patients.”

MOVING FORWARD

The ANA is lobbying against measures to increase the use of single-task workers, thereby reducing the minimum training requirements for assistive staff in long-term care facilities. (Federal law now requires certified nursing assistants in these settings to receive at least 75 hours of initial patient care training.)

Secretary of Health and Human Services Tommy Thompson recently changed Medicare and Medicaid regulations to permit single-task workers to transport patients. In addition, Centers for Medicare and Medicaid Services (CMS) administrator Thomas Scully announced plans to allow single-task workers to feed nursing home patients.

The long-term care industry wants to employ more single-task workers as a way to quickly combat staffing shortages and high turnover, but the ANA believes that staffing with single-task workers represents a slippery slope and reduces the quality of care patients receive.

“The ANA opposes the use of single-task workers, because we believe they inevitably will be used to perform more than one task and they won’t have the training to perform other tasks safely,” said Erin McKeon, ANA assistant director of governmental affairs. “Further, we don’t believe the 75-hour requirement is onerous. We really wish government regulators would look at the reasons behind high turnover in nursing homes—like low pay, dangerous working conditions, and no health care benefits.”

McKeon said the ANA is adamantly opposed to allowing workers with less training to feed long-term care patients, who often have problems with swallowing or who receive tube feedings.

FALLING BACK

In February, Foley and ANA staff met with John Henshaw, administrator of the Occupational Safety and Health Administration (OSHA), to discuss health and safety concerns including tuberculosis (TB), ergonomics, violence in the workplace, and the importance of training grants. They also reviewed the ANA’s long history of advocacy on health and safety issues and expressed their willingness to work with OSHA to address the hazards that nurses face every day.

At an AFL-CIO meeting with OSHA administrators held that same month, Cheryl Johnson, RN, pressed Henshaw for a firm date on which nurses could expect implementation of the TB standard. Johnson is a Michigan Nurses Association member and chairperson of the United American Nurses, AFL-CIO, the labor arm of the ANA. Johnson also met with Secretary of Labor Elaine Chao in late March to discuss nursing concerns.

“No matter where nurses work—at a rural clinic or in an ICU of a major hospital—they can be exposed to TB,” Johnson recently said. “We want to create safer workplaces, and the TB standard is one piece of the puzzle that will allow us to reach that goal.”

However, the Bush administration has once again delayed the final publication of an OSHA standard aimed at protecting workers in hospitals, long-term care facilities, and other high-risk employment settings from exposure to TB. OSHA officials announced in March that they were extending for another 60 days the period in which organizations can provide input on the proposed TB standard, which had been on the verge of finalization in 2001.

As originally proposed in 1997, the standard would force employers in high-risk settings to ensure that certain infection prevention and control measures are in place. One measure would require employees to use respirators when performing certain high-hazard procedures on infectious patients.

“The ANA believes that health care employers should be expected to comply with a reasonable TB standard, particularly if the public is to have any faith that these same facilities can respond competently to a bioterrorism event involving even more dangerous airborne infectious agents,” said Karen Worthington, MS, RN, COHN-S, ANA senior occupational health and safety specialist.

While OSHA is considering moving ahead on revisions to its current emergency preparedness standard, the ANA wants the agency to focus on the prevention of more conventional threats to nurses in the workplace, such as musculoskeletal disorders. To that end, the ANA is continuing its fight to get an ergonomics standard implemented. Although the administration announced its comprehensive plan to address occupationally induced musculoskeletal disorders, such as back injuries, all of the provisions are voluntary, doing little to ensure that the sorely needed prevention measures are actually implemented in health care workplaces.

According to Worthington, the ANA also is working to prevent an administration plan to cut about $8 million in OSHA training grants that are used to help identify and address health and safety hazards in the workplace. (For more on ergonomics, see Health & Safety, page 112.)

ADVANCING PRACTICE

One regulation that morphed under the Bush administration affects certified nurse anesthetists. In January 2001, the CMS issued a new ruling that overturned a federal regulation requiring physician supervision of nurse anesthetists who care for Medicare patients. Later that year, the CMS reinstated the physician supervision requirement. States, however, can opt out of the requirement if the governor and the boards of medicine and nursing agree that removing the requirement is in the best interests of their citizens and is consistent with state law. Iowa, Nebraska, and Idaho have taken advantage of this option, and more states are expected to follow.

In its 2002 Physician Fee Schedule, Ìhe CMS gives advanced practice registered nurses greater freedom when caring for Medicare patients. One major change allows Medicare to reimburse nurse practitioners (NPs) and clinical nurse specialists (CNSs) when they perform screen¡ng flexible sigmoidoscopies. Another change gives NPs and CNSs working as independent contractors greater flexibility when billing Medicare for their services.

THE LINES ARE OPEN

The Bush administration has created new opportunities for nurses to provide their input into regulatory decisions, from “open door” forums to advisory panels. The ANA is making sure nurses are well represented when these meetings occur.

The ANA pushed for the appointment of Mississippi Nurses Association member Karen Utterback, MSN, RN, CHCE, to Secretary Thompson’s Advisory Committee on Regulatory Reform. That committee, which first met in January, must develop recommendations to red˜ce the regulatory burdens that providers and consumers face. Utterback also is serving on its Regulatory Flexibility Subcommittee, which is looking at improving the rule-making process.

Utterback is pleased that she and two other nurses were appointed to the 27-member committee and that nursing has an opportunity to influence regulatory reform.

“I believe nursing has one of the best vantage points when it comes to understanding the impact of regulation,” she said. “While health care institutions put policies and procedures in place, it’s nurses who carry out the tasks that ensure regulatory compliance. Secondly, because nurses usually do not stand to gain financially from new or changing regulations, our perspective about needed regulatory change is more cleanly focused on assuring quality patient care.”

Committee members already have looked at regulations that deal with the application of physical restraints, access to emergency care, and cost-reporting documentation, Utterback said.

The ANA submitted comments to the committee largely focused on reducing the cumbersome and redundant paperwork required to get Medicare reimbursement in acute care, home care, and long-term care settings, said Sheila Abood, MS, RN, ANA assistant director of governmental affairs.

The ANA also is participating in the CMS’s monthly “open door” policy meetings, in which providers and beneficiary groups can suggest ways to improve regulatory programs within the agency. The ANA is represented on the Nurses and Allied Healthcare Professionals Committee and is also part of another group of health care provider organizations that are meeting with CMS administrator Scully to discuss issues related to long-term care, such as the single-task worker issue.

The ANA is committed to working with the Bush administration to create new federal regulations and modify existing .ones so that they are more responsive to the needs of patients and nurses. To learn more about the ANA’s activities on the regulatory front, go to http://nursingworld.org/gova/federal/gfederal.htm#legis and scroll down to “In the Agencies” and go to http://nursingworld.org/dlwa/osh and click on “Tuberculosis” and “Ergonomics.”

Susan Trossman is the senior reporter of the American Nurse at the ANA.

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