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Congress on Nursing Practice and Economics

Sunday September 30 and Monday October 1, 2007 SUMMARY

Congress Members Present: Chairperson, Kathleen M. White, PhD, RN, CNAA, BC; Vice-Chairperson Karen Ballard, MA, RN (Day 2); Esther Acree, RN, MSN, SpCl.NSG, BC-FNP; Carolyn Baird, MBA, M.Ed, RNC (INSA); Mary L. Behrens, RN, MSW, FNP-C; Carola M. Bruflat, RNC, MSN, WHNP/FNP (AWHONN); Virginia Burggraf, DNS, RN, FAAN; Myra C. Carmon, EdD, CPNP,RN; Thomas Ray Coe, RN, MS, CNAA, FACHE; Stephanie Davis Burnett, MSN, RN, FNP, CRRN (ARN); Sally Burrows-Hudson, MS RN CNN (ANNA (Day 1-via phone); John F. Dixon, MSN, RN, CAN, B (AACN-West); Emma L. Doherty, MA, RN; William R. Donovan, MA, RN; Bette M. Ferree, MSN, RN, APRN, BC; Susan Foster, MSN, APRN; Irmatrude Grant, MS, RN (Day 2); Janet Y. Harris, RN, MSN, CNAA , BC (Day 1); Debra Hobbins, MSN, APRN; Patricia Leo Holloman, BSN, RN (Day 2), CNOR; Patricia Kunz Howard, PhD, RN, CEN (ENA) (Day 1); Bette K. Idemoto, PhD, RN, CCRN, CS; Sandra Gracia Jones, PhD, ARNP, CS, FAAN; David M. Keepnews, PhD, JD, RN, FAAN (Day 2-via phone); Patrick E. Kenny, EdD, RN, ACRN, CAN, BC, C; Jane Kirschling, DNS (AACN-East); Kathleen G. Lawrence, MSN, RN, CWOCN; Carla A. B. Lee, PhD, ARNP, BC, FAAN; Lori Lioce, MSN, FNP-C; Jennifer H. Matthews, PhD, APRN , BC; Peter T Mitchell, MSN, RN, CNP, APRN-BC; Pamela Sue Neal, MSN-NA, RN, C-FNP; Catherine E. Neuman, MSH, RN, CNAP; Anne Mabe Newman, DSN, APRN, BC; Ann M. O'Sullivan, RN, MSN, CAN; Jackie R. Pfeifer, RN, BSN, CCRN-CSC; Theresa Ann Posani, MS, RN, CNS; Elizabeth Poster, PhD, RN, FAAN; Robin R. Potter-Kimball, RN, MS, CNS,BC; Cheryl-Ann Resha, MSN, EdD, RN; Linda Riazi-Kermani, BSN, RN, CEN; Pauline F. Robitaille, RN, MSN, CNOR (AORN); Patricia Schlosser, RN; Cheryl K. Schmidt, PhD, RN (Day 2); Sue Sendelbach, PhD, RN, CCNS (NACNS); Nancy Shirley, PhD, RN; Joanne Sikkema, MSN, ARNP; Jeanne Surdo, RN, BSN, MA; Sandra K. Tunajek, CRNA, MSN, DNP (Day 2-via phone); Mary Mason Wyckoff, MSN, APRN, BC , CCNS

Congress Members Absent: Susan A. Albrecht, PhD, RN, FAAN; Karen Ballard, MA, RN (Day 1); Sally Burrows-Hudson, MS RN CNN (ANNA (Day 1); Irmatrude Grant, MS, RN (Day 1); Janet Y. Harris, RN, MSN, CNAA , BC (Day 2); Kimberly A. Hickey, MSN, APRN, BC; Patricia Leo Holloman, BSN, RN (Day 1), Patricia Kunz Howard, PhD, RN, CEN (ENA) (Day 2); Beverly Jorgenson, RNC, MSN, NNP; David M. Keepnews, PhD, JD, RN, FAAN (Day 1); Patricia L. Keller, MSN, RN,BC; Pamela A. Kulbok, DNSc, APRN, BC; Karen Leone-Natale, BSN, RN; Cheryl K. Schmidt, PhD, RN (Day 1) Karen J. Stanley, RN, MSN, AOCN, FAAN (ONS); Sandra K. Tunajek, CRNA, MSN, DNP (Day 1); LaTonia Denise Wright, JD, RN;

Congress Liaisons Present: Sara A. McCumber, APRN,BC, (American Nurses Credentialing Center [ANCC]); Maureen Ann Nalle, PhD, RN; (Center for American Nurses [CAN]); Carolyn Hietamaki, RN, (United American Nurses [UAN])

ANA/ANCC/CAN Staff: Linda J. Stierle, MSN, RN, CNAA,BC; Rose Gonzalez, PhD, RN; Nancy Hughes, RN, BSN; Mary Jean Schumann MSN, RN, MBA, CPNP; Vernell P. DeWitty, RN, MSN, MBA; Isis Montalvo, RN, MBA, MS; David Paulson, PhD; Rita Munley Gallagher, PhD, RN; Cynthia Haney, Esq.; Cheryl Peterson, MSN, RN; Patricia Rowell, PhD, RN; Janet Haebler, MSN, Yvonne Humes, Vernice Woodland


Item Discussion Action

Call to Order The meeting was called to order at 9:31am by Kathleen M. White, PhD, RN, CNAA,BC, Chairperson, Congress on Nursing Practice & Economics. White noted the absence for personal reasons of a number of CNPE members. Also absent are the members from New York who are closing their convention today. The NDNQI conference is coming up quickly. The Disaster conference was a great success. The website has been revised. The CEO report was highlighted. The

membership initiative is focusing on new options for involvement in the association.

Welcome –

President’s Update

Rebecca M. Patton, MSN, RN, CNOR, President, American Nurses Association noted her appreciation for what the members of CNPE are accomplishing. NDNQI continues to be a stellar program for ANA. The NDNQI conference last January continues to be talked about and ANA is looking forward to the next conference. Nursing Care in Life, Death and Disaster also continues to be talked about. President Patton called attention to for information

regarding documentation for all the activities of the association. The ANA BOD has committed major resources to finance initiatives around creating the preferred future of the ANA. This is a very exciting effort focused on membership and partnering with other organization. CNPE member Mary Behrens has been reappointed as the Chair of the ANA-PAC. In the last election cycle, 89% of the candidates endorsed by the ANA-PAC were elected in the federal election cycle. Discussion centered on:

• Pennsylvania and Maryland are considering working together to develop a regional Congress on Nursing Practice and Economics. The issue that they are united on is the school nurse ratio.

• In general, the national nursing organizations are more coordinated and speaking with one voice.

• The Florida Nurses Association is really concerned about membership. FNA is starting a project to develop a preferred future.

• There is a need to highlight the work of the CNPE.

Welcome – CEO’s Update

The association is engaging in a major rebranding and membership campaign. There has been significant change in the members-only section of Discussion centered on:

• North Carolina is celebrating its 100th Anniversary.

• Members of the Florida Nurses Association voted in a dues increase and are interested in membership options. Virginia Nurses Association celebrated 107 years last night.

Discussion of Standards and Guidelines Report

Approval of the Operating Guidelines ~ Carol Bickford, PhD, RN provided an overview of the changes to operating guidelines. They included deletion of content about

oversight of specialty scopes of standards and added to non-voting members to the Committee. Approval of the group’s Strategic Plan was sought. The Scope and Standards for Nursing Informatics was presented for acknowledgement/approval.

Motion I: Approve report and recommendation Standards and Guidelines Committee

M: P. Mitchell Unanimous


Item Discussion Action

approval of the Strategic Plan of the Congress on nursing Practice and Economics’ Committee on Standards and Guidelines.

M: P. Kenny Unanimous

Motion III: Move to approve the Scope and Standards for Nursing Informatics

M: Behrens Unanimous

Discussion of revision of Nursing’s Social Policy Statement, Second Edition took place. There is a need to review in consideration of the five year review/revise rule. It was suggested that the document could be incorporated into one document. A workgroup will be empanelled.

Procedural Sedation-

Isis Montalvo, RN, MBA, MS noted that the Emergency Nurses Association convened a stakeholders meeting to develop a consensus statement on Procedural Sedation and Rapid Sequence Intubation in the Emergency and Critical Care Settings. Stakeholders included: American Nurses Association, Emergency Nurses Association, American Association of Critical Care Nurses, Agency for Healthcare Research and Quality, Air & Surface Transport Nurses Association,

American Academy of Emergency Medicine, American Association of Nurse Anesthetists, American College of Emergency Physicians, American Organization of Nurse Executives, American Radiological Nurses Association,

American Society for Pain Management, National Association of Children’s Hospitals and Related Institutions, National Council of State Boards of Nursing, and the Society of Critical Care Medicine. The draft consensus statement was reviewed by the CNPE and feedback was provided on the document. Further feedback may be provided to ANA staff member, Isis Montalvo until October 12, 2007. The feedback will then be communicated to ENA.

Position Statement Work Group Report

Ann Mabe Newman, DSN, APRN,BC and Rita Munley Gallagher, PhD, RN reminded the group that the CNPE Position Statement Workgroup has been charged with responsibility for oversight of position statements. The Congress on Nursing Practice and Economics (CNPE) Position Statement Workgroup reviewed current American Nurses Association (ANA) position statements (exclusive of those under the aegis of the Center for Ethics and Human Rights and/or other

workgroups) using the following criteria: a. Is the science/law current?

b. Is the position superseded by a more recent position?


d. Are similar issues addressed in another ANA position?

Following a vote by the full CNPE, a recommendation to sunset selected position statements was advanced to the ANA BOD. The workgroup asked CNPE to prioritize disposition of a number of position statements.

Quadrennial follow up, Policy paper, and on going work Personal and Professional Responsibility

ANA staff provided a report on ANA's June 2007 policy conference, Nursing Care in Life, Death and Disaster. The conference examined issues related to the standard of care provided during a major disaster and the professional, legal and ethical issues that must be considered in decision-making. Also considered at the conference, was a policy paper

developed at Columbia University's Center for Health Policy and a multi-disciplinary expert panel. Conference

participants provided significant feedback on the document for the expert's panel consideration. In addition, the document will be posted for a public comment period.

Competence The document has not, as yet been posted for public comment online. The workgroup reviewed comments and incorporated them into the document. The Workgroup will be inactive until public comments are received.

Electronic Health Record ~ The goal is improved patient safety. A series of position statements will be developed. Conference calls and electronic methods.

Elimination of Violence in Advertising ~ Complete

Health Care Reform ~ Materials will be posted on the website for review by the Workgroup. Following the ANA Task Force meeting the group will revisit its plan.

Pay 4 Performance/Value Based Purchasing ~ Conference calls will be held to obtain information from those who are engaged in the process of P4P. An educational session and forum will be held at HOD

Replacement of RNs with Nursing Assistive Personnel ~ Complete

Workgroup Reports

Continuum of Nursing Practice – predicated upon the nursing shortage – the focus will be on what nursing can/should retain and what can be given up – core roles in each category – basic nurse, advance practice nurse, research nurse should be detailed. The workgroup will be looking to ICN, nurse practice acts and NCSBN as resources. This workgroup should interact with Nursing’s Social Policy Statement workgroup and the Competency workgroup. It was noted that pharmacists are taking on roles that nurses traditionally do; EMTs say they want to do more than pick up bodies; rather than just being reactive to this, hope is to be more proactive about safeguards, education, what RNs think this should look like. What pharmacists think is “health assessment” and what RNs think is “health assessment” could be very different things. Maybe needs to be a forum of national nurse leaders; but CNPE workgroup can be a springboard/starting place for this.

Discussion centered on:

• The ANCC role delineation should be made available as a resource.

• Delineation of roles should not be confused with scope of practice; it is the RN’s professional judgment as to whether s/he is competent to do a particular thing within scope of nursing practice.


Item Discussion Action • Compartmentalization of what is nursing care and what is the role of nurses should be avoided.

• There is a need to be careful about various job titles – paramedic is not same as an EMT, for example. They are beginning to be seen in critical care depts. as well as emergency depts.

• Legal definitions (ex. “distribution” is giving a diabetic a needle with insulin to take home) should be explored.

Continuum of Nursing Practice ~ The group will be exploring the roles of all levels of nursing (nursing assistive personnel to Doctorally prepared) utilizing the work of ICN, NCSBN using electronic means.

Safe Connections ~ Complete

Transforming the Work Environment of Nurses ~ Reconceptualized

Nursing’s Social Policy Statement Revision ~ A workgroup has been empanelled

Position Statement Review ~ Specialty Nursing Organizations will be asked by the CNPE Chair for permission to review relevant position statement. In the future at the Fall meeting, position statements in need of revision in the upcoming year will be brought forward to CNPE for consideration by CNPE. The template will be reviewed and revised to include collaboration around the issue as well as consideration of fiscal implications. CNPE did affirm in the value of ANA having position statements. However, they must be germane to ANA’s desired future document and congruent with ANA policy.

Right to Accept or Reject an Assignment ~ The position statement is being rewritten with the intention of advancing it to the BOD late next year. The workgroup will have draft to ask for input before Feb meeting. Post for public comment in April/May

Use of Credentials ~ Working with NCSBN to explore the issue of requirements around the country. The workgroup will be working electronically. The workgroup intends to post a report for Congress review before the February CNPE


Disaster Preparedness – The workgroup still has not coalesced. Staffing for the workgroup remains a problem A report is anticipated in February.

Retail Clinics ~ Will be working with relevant organizations with a goal of bringing information to the February meeting

Value Based Purchasing Discussion

Pay for Performance (P4P) and Value Based Purchasing (VPB) are terms used to identify various methods linking payments to some measure of individual, group or organizational performance. An increasing number of

purchasers/payers of health care services, including the Centers for Medicare and Medicaid Services (CMS) are embracing P4P/VPB strategies in an effort to improve the quality and cost effectiveness of care while achieving high value for their health care dollars. The move toward greater use of P4P/VPB systems in the current health care environment presents a unique set of opportunities and challenges for health care providers including registered nurses. Registered nurses,

individually and collectively, confront the complex issues related to value based purchasing. ANA is currently working to gather additional information about P4P/VBP programs and the projected implications for nursing. This information is intended to guide future ANA action related to policy development and to inform registered nurses regarding implications for nursing practice, reimbursement, and professional integrity. Ellen Kurtzman, MPH, RN of the RWJF-funded


Research Project at George Washington University noted that George Washington University, Dept of Nursing Education received 2-year, funding for the project which is seeking collaboration with AAN, ANA, AONE and others. The project directly responds in needed areas:

– Assess the current state of interest in rewarding high quality nursing care

– Drive a coordinated response to the challenges and opportunities of creating pay-for-performance programs that recognize nursing’s contribution

– Strategically engage nurses in performance measurement, public reporting, and value-based purchasing The project is convening a National Advisory Panel (Mary Wakefield and Dennis O’Leary will Co-Chair) ANA’s Chief Programs Officer, Betty Nelson will serve on the Committee.

Recess The meeting recessed at 5:31pm

Monday October 1, 2007

Item Discussion Action

Reconvening The Chairperson reconvened the meeting at 9:11am

Discussion of Social Networking

Camille Soleil, Director, Special Projects provided an overview which allows for social

networking. Discussion ensued regarding the use of the code by students. Concerns regarding security were expressed. Legal issues were discussed. Early adopters will be included this week. Following Constituent Assembly the site will be fully launched.

Demonstration of Chat rooms for CNPE Workgroups

Patrice Franklin provided an overview of the process.

Nurse Competence in Aging ~ Mary Jean Schumann MSN, RN, MBA, CPNP ~ Discussion of the geronurseonline migration took place. ANA will be maintaining the site. NYU has notified users of the change, indicating their ownership of selected components of the intellectual property contained therein. ANA is looking for those with expertise to develop additional content.

Center for Environmental and Occupational Health ~ Nancy L. Hughes, MS, RN, Director ~ Discussion regarding suggestions for vaccination took place. The Principles of Environmental Health for Nursing Practice with

Implementation Strategies published. The Health Care Without Harm Coalition is analyzing the data from the recent survey on chemical center. The results will be published online. There were 1500 respondents representing every state in the nation.

Center for American Nurses ~ Wylecia Harris, MBA, CAE, Executive Director ~ NO discussion

Questions and Answers on

Department/Entity Reports


Item Discussion Action

Nelson will be representing ANA on that advisory group. The database is growing. Development of a published research agenda was suggested. A reliability and validity study is in the works. Speakers for the upcoming January 31/February 1, 2008 NDNQI conference which include CMS’ Barry Straube were announced. An award is being

developed to recognize a hospital which has done an outstanding job. A pre-conference will be held January 30th for site coordinators to increase their skills. Registration will be available in the very near future

Government Affairs ~ Rose Gonzalez, PhD(c), RN, Director ~ An update on the Presidential endorsement process was provided. All candidates have been sent letters requesting appointments for interviews. There is a tentative appointment with Bill Richardson on Thursday. Online resources are being developed and will hopefully go live the end of the year. Once again, there will be the opportunity for members to select their preferred candidate online. The Task Force is meeting regularly. Venues are being sought at both Democratic and Republic convention sites. ANA has been very supportive of cultural competence training. A question was asked as to the background of the culturally and

linguistically appropriate standards published by Office of Minority Health.. Discussion ensued as to the federal appointment process.

ANCC ~ David Paulson, PhD ~ The Commission on Accreditation is concerned with endorsement of products and new guidelines are likely to be forthcoming. Item writer workshops are held quarterly. They are solicited from among the ANCC database. More than 3000 individuals are participating in the Magnet Conference. The Nurse Friendly Program (which recognizes smaller hospitals) has been transferred from the Texas Nurses Association . Magnet status in long term care was discussed. It was noted that there is currently one set of parameters. Methodology for combining of the Associate Degree and BSN tests were detailed.

Set Dates for CNPE 2008 meetings

The meetings will be held on February 8th and 9th and September 21st and 22nd.

Health Care Reform Rose Gonzalez PhD(c), RN (in the absence of the chair, Betty Nelson) joined the group and provided an overview of the work of the ANA Health Reform Task Force. The Director of Communications, staff from GOVA and DNP&P and the Director of Marketing are participating. An inventory of ANA’s activities is underway. The role of CNPE in the work of the Task Force was questioned. The ANA President noted that the work will be coming together to avoid duplication of effort. An environmental scan is also taking place. The Chair of the Workgroup offered an overview of the group’s efforts which began with a review of Nursing’s Agenda. It was suggested there is a need to observe what is going on in other countries regarding national health. The American College of Physicians will be developing a report

( Health Affairs has also published much of that information in the recent past. ANA’s historical perspective on single payor was reiterated. Key elements of a healthcare plan should be identified on behalf of the association. The ethical questions of rationing were discussed. The BOD will devote time to this issue at its December meeting in which the CNPE Chair will participate. There is interest in this topic and a window of opportunity exists now. It was suggested that the workgroup explore issues related to controlling the cost of prescription drugs. President Patton noted that staff is pulling together the background. CNPE’s efforts and that of the staff workgroup will be integrated to form one initiative.


Update on HHS Lawsuit

Office of General Counsel ~ Alice Bodley ~ At issue is the CMS Condition of Participation for the Medicare Program: (b) Standard: Staffing and delivery of care. The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient. ANA’s position is that The Joint

Commission (which has deemed status from CMS) standards do not focus on RN staffing. The standard is lower than the CMS requirement. The Joint Commission’s non-prescriptive approach is too loose: There are not enough RNs to render bedside care when needed, but it doesn’t show up, or It doesn’t matter because there is no RN staffing standard. ANA met with The Joint Commission. Staff nurses helped to explain the problems to the Joint Commission. The Joint Commission representatives agreed that the standards need improvement, but will not commit to changing the RN standards. The Joint Commission agreed to focus more on staffing plans; address the role of the chief nurse executive; and develop more staffing-sensitive aspects of the tracer methodology during surveys. ANA has offered a proposed Standard (NR.4.10): The nursing service must have adequate numbers of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care to all patients as needed. There must be registered nurse

supervisors, registered nurses, and other personnel for each department and nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient.

ANA is working to identify nursing groups and leaders who may be interested in supporting ANA efforts to get the Joint Commission to create an RN staffing standard that is in conformity with the Medicare Conditions of Participation and that incorporates ANA’s Principles for Nurse Staffing.

CNPE was asked to provide “stories” regarding their experiences around short staffing. The Constituent Assembly will be addressing this issue at their upcoming meeting. Discussion centered on:

• Duties the nurse has in terms of back-up activities

• The existence of the Nursing Advisory Council and its discussion of the issue

• Involvement of the Chief Nursing Officer at the Board of trustees level is very beneficial

• A request for adoption of the Principles for Nurse Staffing was suggested

• The unrealistic nature of anticipating that staff nurses would respond to The Joint Commission surveyors

• The recommendations should include attention to the state Nurse Practice Acts

• The Organizational Affiliates were asked to direct comments to The Joint Commission

• Some organizations are foregoing accreditation by The Joint Commission and so there may be a need to continue the suit against HHS.

Old Business ANCC liaisons are asked to devote significant time to the Commissions. Two options have been offered: (1) service as a non-voting liaison through attendance but not in application review; (2) engagement in the review process with a voting seat. It was noted that the Commissions do not have enough members. Discussion ensued as to

Motion IV: Moves to accept Option B from ANCC.

M: Schlosser/2nd. Ballard


Item Discussion Action

the purpose of the liaison. There is a need for clarity of expectations. Option 2 is the preferred method at this point in time.


Adjournment The meeting was adjourned by the chair at 2:50pm.

Drafted: August 2, 2007 Revised: September 30, 2007 October 1, 2007 October 8, 2007 October 11, 2007 October 16, 2007 October 17, 2007 October 23, 2007



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