FEBRUARY 1984, VOL 39, NO 2 AORN J O U R N A L

Education

The social policy statement offers a direction for the ’80s

t hasn’t been easy for nursing to focus on a common course for its future development. I After all, we’re aware that our profession is

filled with diversities-diversities, for example, of educational preparation, practice settings, specialization, and credentialing. Is there any wonder we have inconsistencies in purposes and value systems?

The American Nurses’ Association ( M A ) published a position statement in 1980 to provide a foundation for a common approach to the fu- ture development of our profession. The title of this publication is Nursing: A Social Policy Statement. There is much contained in this statement that should be considered by perioper- ative nurses. The presentation of concepts and ideas directs the reader to nursing in the 1980% which is being called “the decade of decision for nursing.” I will explore some of the thoughts that were expressed by the ANA-appointed task force and share some questions that came up as I read through the statement.

The Social Context of Nursing

ow do nursing and society interrelate, and why is this relationship important? H This question is succinctly answered in

the first section of the statement. A profession comes from society; for society, not the profes- sion, determines the need for the skills and knowledge of the professional. Society and the profession coexist in a mutually beneficial rela- tionship. When one changes it cannot help but

affect the other. Health care in our society has experienced

great changes in recent decades. During the 1960s, our government expended many dollars into our country’s health care system. But during the 1970s, rapidly increasing costs began to threaten the availability of health care for many persons, and health care regulation began. The 1980s are bringing even more social and political changes for the health care system. Many nurs- ing leaders view this period as critical to the future direction of nursing.

Consider the impact of one of the recently legislated changes in the health care system- diagnosis related groupings (DRGs). DRGs are the federal government’s new payment system for Medicare patients. Hospitals are reimbursed with a set sum based on the patient’s diagnosis. The system will be phased into 80% of the hospi- tals in the United States within the next year. There is general agreement that this program will result in decreasing hospitalization time for sur- gical as well as other patients. Nurses are em- phasizing patient teaching to facilitate earlier re- covery and discharge. Many hospitals are de- veloping home care services for patients dis- charged early. Another anticipated change is in nurse staffing patterns. The ANA warns that nursing staffs could be reduced to cut costs if documentation of nursing care does not accurately reflect the amount of nursing care required in relation to a DRG.’ The development of ambulatory surgical centers emphasizes that the patient population seen in acute care settings will be changing.

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A O R N J O U R N A L FEBRUARY 1984, VOL 39, NO 2

The Nature and Scope of Nursing Practice

he social policy statement provides a def- inition of nursing that is standing the test T of time. The definition reads “Nursing is

the diagnosis and treatment of human responses to actual or potential health problems. ”

Phenomena, theory application, nursing ac- tion, and evaluation of effects of action in rela- tion to phenomena are identified as the charac- teristics of nursing.Z

Phenomena are human responses to actual or potential health problems. These phenomena may consist of responses by individuals or groups toward which nurses direct health restor- ing and health supporting activities. In contrast to the past when nursing interventions were based only on the patient’s or group’s medical diagnoses, we now individualize patient prob- lems and formalize nursing diagnoses based on data gathered during the assessment phase of the nursing process.

The second characteristic of our practice is theory application. It is agreed that nursing is not a pure science, such as mathematics, because we have borrowed from others (physics, psychol- ogy, physiology) to help establish the foundation for our practice. Our theoretical base is also self-generated. Research, which is essential for the development of any profession, is dependent upon the availability of prepared researchers. The ability to describe and predict provides us with an understanding that “serves as a basis for determining the best nursing actions to be taken.”3 The recent grass roots support of peri- operative research by much of A0R”s mem- bership shows a recognized need to study and develop our nursing practice.

Actions are the third characteristic of our prac- tice. Nursing actions are both independent and dependent in nature. Independent nursing actions result from nursing diagnoses that are identified through the assessment process. These are nursing interventions for which we are licensed to practice under each state’s Nurse Practice Act. Dependent nursing actions, which are also controlled by licensure, depend on

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physician ‘s directives, Recent technological ad- vances in health care have required an increase in the independent level of functioning by nurses, which is requiring the reexamination of many Nurse Practice Acts.

Effects, the fourth characteristic, determine whether nursing actions are effective, Successful care cannot always be equated with recovery. A responsibility of any professional organization is to establish standards for its practitioners. AORN collaborated with the ANA to develop and publish Standards of Perioperative Nursing Practice. These standards provide nurses in the operating room a means to measure the effects of their practice.

Specialization in Nursing Practice

A s the knowledge base for nursing in- creases, the focus of specialized prac- titioners narrows. This is to accommo-

date the depth of practice required to gain from the advantages of technological advances. The policy statement sees in-depth study of relevant theories and supervised clinical practice at the graduate level as necessary for specialist prepa- ration. Nurse specialists must have the ability to observe, conceptualize, diagnose, and analyze complex clinical and nonclinical problems re- lated to health.4 There are approximately 170 graduate programs in nursing in the United state^;^ only one is known to offer a major in perioperative nursing. The concern for the lack of clinical experiences by undergraduate nursing students in the operating room prompted AORN to form Project Alpha. There must be an equal future concern to promote graduate level educa- tion for perioperative nursing.

ANA’s social policy statement has identified and defined many commonalities upon which the future of all nursing is dependent. The usefulness of any statement is determined by the test of time. Published almost four years ago, this statement is still being discussed today. I en- courage each of you to read and study the state- ment for it applies to all of nursing. It does not seem that this statement is going to go away any

FEBRUARY 1984, VOL 39, NO 2 A O R N J O U R N A L

more than society’s need for nursing will be replaced. In fact, it is probably a nursing classic directing our practice beyond the decade of the ~ O S !

JANICE ALLEN, RN

Notes 1. “The DRG revolution gets rolling; hospitals al-

ready cutting back,” American Journal ofNursing 83 (November 1983) 1607.

2 . Nursing: A Social Policy Statement (American Nurses’ Association, 1980) 9.

PROGRAM SPECIALIST/ 3 . Ibid, 11. CONTINUING EDUCATION 4. Ibid, 23.

5 . NWV Nursing Data Book 1982 (New York: NLN Publication # 19- 19 15, 1983).

Implications of Nurses Declaring Brain Death Nurses are beginning to be involved in determining when a patient is dead. With this trend comes a set of liabilities and a need for awareness of a state’s laws and court action. In some states, nurses are allowed to make such determinations.

patient was dead when there was a cessation of spontaneous respiration and heart beat. That standard is no longer applicable as technology has made it possible to keep a patient alive after respiration and a heart beat have ceased. Brain death is now the most frequently used standard.

Neurosurgical Nursing explains the implications of nurses’ involvement in determining death. She said nurses should know what standard is used in their state to determine death. Also, know the facility’s guidelines and protocols when a death determination is made. Brent said, “These protocols should include but not be limited to, the need for a written, signed order before any tests are carried out; what role, if any, the family of the patient being tested for brain death will have in the procedure and ultimate decision to terminate life support systems once brain death has been established; documentation requirements; and provisions for substituted consent for the patient. ”

as of July 1982 had been adopted in 13

Traditionally, physicians determined that a

Nancy J Brent, RN, JD, in the Journal of

The Uniform Determination of Death Act

states. Other states have adopted the law through case law. It states

An individual, who has sustained either (1) irreversible cessation of circulatory and respiratory function or (2) irreversible cessation of all functions of the entire brain, is dead. A determination of death must be made in accordance with accepted medical standards.

This standard applies in Alabama, Arizona, Colorado, Idaho, Indiana, Maryland, Mississippi, Nevada, Vermont, Washington, West Virginia, Wisconsin, and Wyoming.

The Uniform Determination of Death Act can be a “‘viable argument in favor of the professional nurse for hidher actions, ” according to Brent. It is not an absolute defense though.

As nurses take on this responsibility, Brent predicts more nurses will be sued resulting in increases in rates for professional liability insurance. She said, “Nurses must continue to carry their own malpractice insurance, whatever the cost, in order to provide some protection against the cost of civil litigation. ” It is also likely that more nurses will be called to testify or be expert witnesses.

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