In this statement of standards, therefore, the American Nurses Association enunciates its policies for nursing care in nursing homes. In so doing, the American Nurses Association accepts the responsibility of the profession to formulate the standards for nursing care for the patients. The statement is made with the knowledge of the characteristics of the patients in these homes as indications of the nursing services and facilities required. The statement is made with the understanding that the major function of a nursing home is to provide nursing care. The American Nurses Association accepts the definition adopted by the U.S. Department of Health, Education, and Welfare for purposes of developing its standards guide for nursing homes: "The term 'nursing home' means a facility or unit which is designated, staffed, and equipped for the accommodation of individuals who are not in need of hospital care but who are in need of nursing care and related medical services which are prescribed by or performed under the direction of persons licensed to provide such care or services in accordance with the laws of the State in which the facility is located." The American Nurses Association, furthermore, believes that nursing homes should be licensed, and periodically evaluated by an official State agency in which the professional knowledge of medical and nursing personnel is available. A qualified registered professional nurse should be assigned by this State agency for the purpose of evaluating the nursing care in the nursing homes. The quality and quantity of nursing care available to the patients are dependent upon the ability to recruit and retain qualified nursing personnel. A general improvement of employment conditions is essential to improvement of patient care in nursing homes. The American Nurses Association recommends that in all instances a registered professional nurse carry the responsibility for nursing care in the nursing home. In many instances in the nursing home, the patient's physician does not provide the degree of medical supervision that would be provided for the patient in this hospital. The registered professional nurse discharges her responsibilities in partnership with the physician. In this respect, the American Nurses Association agrees with certain statements made in 1958 by the American Hospital Association listing requirements for inpatient care instiutions other than hospitals, as follows: "There shall be a duly licensed physician or physicians who shall advise on medical administrative problems, review the institution's plan for patient care, and handle emergencies if the patient's personal physician is unavailable. "Each patient shall be under the care of a duly licensed physician, and shall be seen by a physician as the need indicates. "There shall be a medical record maintained for each patient, which shall include at least (a) the medical history, (b) report of physical examination, (c) diagnosis, (d) physician's orders, (e) progress note (medical and nursing), (f) medications and treatments given." STANDARDS OF NURSING CARE IN NURSING HOMES 1. Skilled nursing care (including its preventive, curative, and rehabilitative aspects) is a necessity in a nursing home. Therefore, the nursing home should provide direct (preferably on the premises 24 hours a day) supervision of nursing care by a registered professional nurse. 2. The registered professional nurse in charge should preferably have had training beyond her basic nursing education in care of the aged and chronically ill. in patient rehabilitation, and in management and leadership. 3. There should be a registered professional nurse or a licensed practical nurse on duty at all times. The number and type of nursing personnel on duty should depend upon the number and condition of the patient population. 4. The registered professional nurse, who is responsible for the kind and quality of nursing care, has an obligation to protect the public by not delegating to a person less qualified any service which requires the professional competence of a nurse. However, certain aspects of the daily patient care may involve or be delegated to other personnel. 5. The registered professional nurse in charge should participate in the planning and budgeting for nursing personnel, equipment, and facilities. 6. The registered professional nurse in charge should have responsibility for the selection, orientation, supervision, evaluation, and employee development of professional and allied nursing personnel; this responsibility to be discharged in conformity with the functions, standards, and qualifications for practice as established by the American Nurses Association. 7. The registered professional nurse in charge should coordinate and conduct the total nursing program. This would involve interpretation of medical orders and provision for restoration of the patient to his optimum physical, mental and emotional, and social potential. 8. The registered professional nurse in charge should participate in the screening of prospective patients in terms of kinds of care available in the institution. 9. There should be a nursing care plan established for each patient. In the development of the nursing care plan it is necessary to have a written statement by the physician regarding the nature of the illness, the condition of the patient, and the treatment prescribed. 10. There should be a nursing record for each patient. The registered professional nurse should be responsible for the accuracy of the reporting and recording of the patient's symptoms, reactions, and progress. 11. The registered professional nurse in charge should make rounds with the physician and confer with him concerning the patient's nursing needs. 12. The policies relating to the control of prescribed medicines and treatments should be in writing, defining frequency of medical review, and the recording and renewal of orders. These policies should have the approval of the consulting physician or responsible medical group. 13. All medical orders should be in writing and signed by the physician. 14. There should be written nursing policy and procedure manuals which are kept in line with currently approved nursing practices. 15. There should be written personnel policies, job descriptions, plans for orientation for new staff, and provision of inservice education. Employment standards should be consistent with those recommended by the State nurses associations. 16. The nursing staff should be provided opportunity to attend professional organization and other educational meetings. 17. The registered professional nurse in charge should be responsible for defining the activities of volunteer workers as related to patient care and in guiding the volunteers in carrying out their activities. RELATED STATEMENTS ANA statements of functions, standards, and qualifications for practice. ANA code for professional nurses. Nursing care in all instances should be under the supervision of a registered professional nurse, under the direction of a physician. Therefore, we recommend amending the language of section 1603 (b) (1) to read: Nursing care provided by or under the supervision of a registered professional nurse or provided by a licensed practical nurse. We recognize that in many instances undesirable practices are being carried on and that in some so-called nursing homes there is little medical supervision and no skilled nursing care. We recommend that any payments from the social security fund be limited to only those facilities which provide at least the minimum of professional services. This point I would like to emphasize. In section 1606 (b) (2), page 15, lines 17 through 22, under the definition of a skilled nursing facility, the bill states has medical policies, which are established by a group of professional personnel including one or more physicians, to govern the skilled nursing care and related medical or other services it provides and which include a requirement that every patient must be under the care of a physician. We recommend that the size of the group be stated, since "group" can mean an indeterminate number; and that "at least one licensed professional nurse" be included in the "group of professional per sonnel." We firmly believe that each facility should have medical policies and medical supervision, but that there are nursing care functions which are independently determined and executed. The language of section 1606 (b) (3), page 15, lines 23 through 25, should be amended. It now reads: (3) is under the supervision of a physician, or a registered professional nurse, who is responsible for the execution of medical policies. We question the propriety of placing the supervision of a skilled nursing facility under the supervision of a physician "or" a registered professional nurse. Each profession has distinct responsibilities, and their functions are not interchangeable. The registered nurse carries out the physician's orders and develops the plan for nursing care. Therefore, it is recommended that "or" be changed to "and." Section 1606 (b) (5), page 16, lines 2 through 5, should be amended to read continuously provides 24-hour nursing service rendered or supervised by registered professional nurses or rendered by licensed practical nurses— omitting the words "or supervised by" in line 6. The same reasons apply as are stated in our testimony from page 3, line 69, to page 4, line 82, which states those persons are not interchangeable either. Section 1606 (c)(3), page 17, lines 6 through 9, under the caption "Home Health Agency," also needs to be amended, in our opinion. The bill states: (3) has medical policies, established by a group of professional personnel including one or more physicians, to govern the services (referred to in par. (2)) which it provides. We recommend that the item be amended to read: (3) has medical policies, established by a group of professional personnel including one or more physicians, and at least one professional nurse, to govern the services (referred to in par. (2)) which it provides. This amendment is recommended for the same reason cited before. Except for these recommendations for improving the bill, we believe that the provisions contained herein will contribute substantially to improving the prepaid health services available to our retired citizens. These benefits would be earned by the contributions paid during an individual's working years. Section 1609 very clearly establishes safeguards to prevent overutilization and abuse of the facilities described in the proposal. Persons cannot enter a facility or receive home nursing care unless it is so ordered by a physician. The length of hospital and nursing home stay is the attending physician's responsibility. If it appears desirable to continue a patient's stay beyond the time which will be paid for under policies established in the legislation, a utilization committee must review and approve the extended stay. This committee is composed of one or more physicians. We believe these to be important safeguards. The Kerr-Mills Act passed in 1960 will help to a limited degree to meet the needs of persons in need of medical care who have limited means. A report, "State Action To Implement Medical Programs for the Aged," issued by the Special Senate Committee on Aging, on June 8, 1961, reveals how uneven and inadequate this act has proven to be. State nurses' associations have supported enabling legislation introduced in the States, and have worked with the agencies involved to help to develop a sound program. But they are acutely aware that this statute leaves a large gap in meeting the problem of providing health services to our retired population. The fund built up by payroll tax on employers and employees under the social security system will provide our retired citizens with insurance protection against the costs of illness without the costly mechanism to determine need. Private insurance companies do not investigate an individual's resources prior to paying benefits agreed to in their contract. Voluntary insurance plans would need to be carried prior to retirement; so the fear of cutting off the lifeblood of private insurance companies is a fallacious argument against this legislation. As the number of retired aged in our population increases, a larger and larger financial burden for their medical care will have to be borne by the public. Certainly, insurance coverage against the costs of illness which may occur after retirement, with premiums paid during the working years, would be less costly to the public than taxsupported public relief for health care-a dependency which is distasteful and degrading for citizens of this country. We urge favorable consideration of this legislation. We thank the committee for the opportunity to present our views on this important legislation. Mr. KING (presiding). Thank you, Miss Thompson. Miss Thompson, I have a question or two. First of all, I appreciate your suggesting the amendments that your organization recommends. Just offhand I think two or three of them warrant serious consideration. I think they are good. Miss Thompson, I am going to read a letter and attached circular. The letter is addressed from Seattle, Wash. The first paragraph merely indicates, approves H.R. 4222 with amendments. The final paragraph reads as follows: You should be aware of the kind of pressure being exerted on the nurses at the local level and reports from these areas indicate there are attempts to persuade individual nurses to repudiate the stand they took through their professional organization. A copy of the bulletin issued by the Washington State Medical Association to all its members is self-explanatory. In point of fact this communication was issued to doctors before the Washington State Nurses Association had issued June 30 any special memorandum to its individual members regarding the bill in this session. Now, the circular that was attached, that was referred to in the letter, is dated June 21, 1961. It is to "members of the Washington State Medical Association." It is from the central office of that association." The subject, "Nurses Letters to Congress." It reads as follows: The American Nurses Association will testify in favor of the King bill at the House Ways and Means Committee hearings in July. The Washington State Nurses Association also is officially and actively supporting the King bill. Therefore, it is of utmost importance that our Senators and Representatives receive letters from registered nurses who are against the King bill. Please encourage your nurse to write to her Congressman immediately if she is opposed to social security medicine in general and the King bill, H.R. 4222 specifically. She should sign her letters with her "R.N." identification in her signature. Thanks kindly, and it is unsigned. 76123-61-pt. 2- -9 Do you know of any other individual nurses other than in the State of Washington, Miss Thompson, who received similiar letters or visits from members of the medical profession? Miss THOMPSON. Yes, Mr. King, we have communications from 42 of our State nurses associations and 35 of them have indicated that there have been some attempts to influence the stand that the American Nurses Association has taken. Mr. KING. Has your stand personally been questioned at any time, Miss Thompson? Miss THOMPSON. Yes, primarily by the American Medical Association through its State and district societies. Mr. KING. What was the nature of their approach to you, Miss Thompson? Miss THOMPSON. There have been a variety of approaches; some through the district medical societies, some through individual physicians, some through the State medical society. Sometimes they have come to the State nurses annual meetings with resolutions asking the nurses associations to adopt them. They have asked to appear on the program without prior request. They have gone to board meetings of State nurses associations asking to present their views at the board meeting. We consider this rather an unusual procedure because the board meeting of an association is considered a closed meeting and it is usually only for the persons involved on that particular board. There have been instances where nurses have been advised not to join the American Nurses Association because of the stand that we have taken on this legislation. Mr. KING. Efforts really to injure your organization. Mr. THOMPSON. It has, we think, to some extent. This is difficult to assess but in the States where the most pressure has occurred there has been the greatest drop in membership. Mr. KING. You would classify such pressures or conduct as most unusual? Miss THOMPSON. We believe that each organization has the privilege of making its own decisions about matters and that we have a perfect right as individual citizens to attempt to influence each other, but when it comes to injecting one organization's views into the internal mechanism of the other organization we do disagree with that kind of activity. Mr. KING. Would it not be particularly unfair inasmuch as the physicians' and surgeons' rating relative to your own profession is such that the nurse hesitates to disagree or-well, it comes from a source that makes it awkward to avoid compliance? Would that be putting the rate fairly, Miss Thompson? Miss THOMPSON. I would agree with you. The close working relationship has a very direct bearing on the decision that the nurse makes. Mr. KING. The conduct of caring for the ill just makes it extremely awkward to openly disagree with men and women in superior positions as your own within an organization. Miss THOMPSON. Yes. Mr. KING. That is all. The CHAIRMAN. Any further questions of Miss Thompson? |