Position statements are used to clearly delineate AASCIN's stand on a particular health policy or professional practice issue. The following position statements have been endorsed or written by AASCIN.

PS/E 1. The Role of the Registered Nurse in the Management of Patients Receiving IV Conscious Sedation For Short-Term Therapeutic, Diagnostic, or Surgical Procedures (Endorsed) 1991

PS/E 2. Rescinded due to Board Action 9/96

PS 1. Access to Health Care (AASCIN) 1991

PS 2. Nursing Education and Research (AASCIN) 1991

PS 3. Prevention of Transmission of Blood Borne Pathogens (AASCIN) 1991

PS 4. Health Care Reform (AASCIN) 1993

PS 5. Advanced Practice Nurses (AASCIN) 1993

PS/E 3. Tuberculosis Prevention and Control (Endorsed) 1992

PS/E 4. Medical Rehabilitation Insurance Benefits (Endorsed) 1993

PS 6. Registered Nurse Utilization of Unlicensed Assistive Personnel (AASCIN) 1995

PS 7. Violence as a Leading Cause of Spinal Cord Injury (AASCIN) 1996

PS/E5. The Use of Placebos for Pain Management in Patients with Cancer (Endorsed) 1996

PS/E 6. Resolution in Support of a National Child Safety Lock Law (Endorsed) 1997

PS/E 7. Unlicensed Assistive Personnel in Home Care Settings (Endorsed) 1998

PS 8. Access to Home Care Services

PS 9. Position Statement on Multi-State Licensure

PS/E 8. The Perianesthesia Patient with a Do-Not-Resuscitate Advance Directive (Endorsed) 1998

PS/E 9. The Nurse's Role in Laser Procedures (Endorsed) 1999

PS/E 10. Protection and Early Detection of Skin Cancer (Endorsed) 1999

PS/E 11. Political Awareness for the Registered Nurse (Endorsed) 1999

PS/E 12. General Health and Wellness (Endorsed) 1999

PS/E 13. Identification of the Registered Nurse in the Workplace (Endorsed) 1999

PS/E 14. Unlicensed Assistive Personnel (UAP) (Endorsed) 2000

Access to Health Care

BACKGROUND
The U.S. Health Care System is in crisis. More than 60 million Americans are either uninsured or underinsured. The system is very costly, its quality inconsistent, and its benefits unequally distributed. Although the system provides highly sophisticated care to many, millions of Americans must overcome enormous obstacles to get even the most basic services.

POSITION
AASCIN endorses Nursing's Agenda for Health Care Reform and its "core of care" components. These components include:

• Ensuring access for all Americans to services by delivering primary health care in community based settings.

• Fostering consumer responsibility for personal health, self care, and informed decision making in selecting health care services.

• Facilitating utilization of the most cost effective providers and therapeutic options in the most appropriate settings.

As the largest group of health care practitioners in America, nurses are uniquely positioned to provide insight and suggestions for health care reform.

REFERENCES
American Nurses Association (1991). Nursing's Agenda for Health Care Reform. Kansas City: ANA

(adopted 9/91)

Nursing Education and Research (AASCIN)

1991Although enrollment in nursing schools is increasing and financial and workplace incentives have attracted more nurses to the profession, the demand for registered nurses continues to exceed the supply. Federal estimates project more than 600,000 new jobs for RN's will be created by the year 2000 to meet the escalating demands in all health care settings. To meet this need, the current supply of all nurses must increase by nearly 45%.

The Nurse Education Act (NEA) provides funding for several areas including advanced nursing education, nurse practitioners, certified nurse midwives, disadvantaged students direct support, traineeships for graduate students and nurse anesthetist students, a loan repayment program, and an undergraduate scholarship program.

The National Center for Nursing Research (NCNR) provides grant opportunities to expand the scientific knowledge base of professional nursing.

POSITION
AASCIN supports the highest level of authorization and appropriations for the NEA and NCNR.

(adopted 9/91)

Prevention of Transmission of Blood Borne Pathogens

BACKGROUND
The transmission of blood borne pathogens (HBV, HIV) has brought to the forefront questions of testing, disclosure, and continued practice for health care workers. Many professional organizations are preparing consensus statements bearing on issues related to health care workers who are, or may be, infected by the human immunodeficiency virus. AASCIN wishes to comment on this important issue.

DEFINITIONS
HBV - Hepatitis B virus (previously called serum hepatitis)

HIV - Human Immunodeficiency virus

HCW - Any professional person providing health care

Blood Borne Pathogen - Refers to blood or other hazardous body fluids (those containing visible blood) that can transmit pathogens.

POSITION
AASCIN continues to advocate the highest quality of care for all patients and the protection of the civil and human rights of all persons with HIV/HBV infection.

AASCIN supports the Centers for Disease Control (CDC) recommendations for Prevention of HIV and HBV transmission in health care settings which emphasizes the need to treat blood and body fluids from all patients as potentially infectious. This approach is referred to as universal precautions.

Adherence to CDC guidelines on universal precautions will minimize the risk of transmission of HBV, HIV, and other blood borne pathogens.

Research data indicate that prevention of transmission of HIV/HBV infection from health care workers is best accomplished by strict adherence to infection control procedure and implementation of universal precautions. Disclosure of HIV status does not in itself prevent the transmission of blood borne infections.

(adopted 9/91)

Health Care Reform

BACKGROUND
Our nation's health is seriously compromised by inadequate health care services, inconsistent quality of care, and escalating costs. Reform of our health care system is imperative to assure quality health care that is accessible and affordable to all. As caregivers in a myriad of settings, nurses are in a prominent position to assess population health needs and advocate for health care reform.

Nursing's Agenda for Health Care Reform (ANA) calls for a "core of care" for all Americans. Components of nursing's "core of care" include:

1. a restructured health care system that improves consumer access to services and promotes consumer accountability for personal health;

2. a nationally standardized package of essential services;

3. a phasing-in of essential services including a plan for those who have had limited access to care;

4. planned change to anticipate new health needs;

5. steps to decrease health costs including assurance of direct access to a full range of providers;

6. case management for those with continuing care needs;

7. provisions for long-term care which provides a continuum of services;

8. insurance reforms to improve access to coverage; and

9. public/private sector review to determine resource allocation, approaches to reduce costs, reimbursement levels, and insurance premium levels

POSITION
AASCIN endorses "Nursing's Agenda for Health Care Reform" and supports the concept of a "core" of essential health care services for all Americans. Nursing's plan for reform proposes a shift from a system that focuses on illness and cure to one that emphasizes the promotion, restoration, and maintenance of health.

AASCIN supports the use of the most appropriate practitioner to provide care. The reformed plan should include the full utilization of advanced practice nurses.

AASCIN also encourages a productive inclusion/alignment of the current VA system into the reformed plan. The reformed plan should also address malpractice and litigation reform.

AASCIN recognizes the consumer as the focal point of the health care system and advocates increased consumer responsibility in health care decision making.

AASCIN supports a restructured health care system which ensures health services that are effective, cost efficient, and focused on consumer needs.

(Revised 9/93)

Advanced Practice Nurses

BACKGROUND
The increased number of aging residents, growth of chronic illness, demand for more complex and technologically advanced care, and the growing concerns of cost and quality are some of the challenges faced by the US health care delivery system. Nurses have always explored ways to assist in meeting the challenges and demands of health care.

The evolution of nursing practice has produced an increasing body of knowledge as well as multiple levels of nursing practice. Advanced practice nurses have obtained advanced educational degrees, achieved certification in their respective areas of practice, and mastered skills necessary to meet changing health care needs. Their education and experience is a critical factor in the high level of care they provide.

The use of Advanced Practice Nurse (APN) in rural areas has steadily increased. This is due to high quality care delivered in a safe cost effective manner by APN's. (Office of Technology Assistance, 1986). APN's also do not face legislated or regulated anti-competitive barriers. In many cases, APN's are the only primary care providers in rural settings.

As Americans search for ways to fix our ailing health care system, it is clear that APN's must have a prominent role in all geographical areas and practice settings.

POSITION
AASCIN believes in the utilization of advanced practice nurses to the fullest extent of their scope of practice. In addition we strongly support these principles:

Advanced practice nursing roles include Nurse Practitioners, Clinical Nurse Specialists, Nurse Anesthetists, and Nurse Midwives. AASCIN advocates for title protection for each of these practitioners and uniform use of terminology and scope of practice definitions to improve public understanding.

The advanced practice of nursing is based on a graduate level of preparation with a major in nursing or related area. Certification in the appropriate clinical area would be achieved within two years of completion of the graduate degree.

Consumers should have access to cost effective quality care using the most appropriate provider. Barriers to accessing all providers should be eliminated. These barriers include, but are not limited to, supervision of nurses by non-nurses, prescriptive authority without interference from medical and pharmaceutical entities, anti-competitive legislation and regulations, access to clinical privileges for all advanced practice nurses.

The nursing profession should determine the scope of nursing practice. Revised 3/99

Registered Nurse Utilization of Unlicensed Assistive Personnel

BACKGROUND
The United States is perceived as being in a crisis with regard to health care: a crisis of cost and coverage. The cost of health care continues to increase making it more and more expensive for persons, insurance providers, and employers. Additionally, the number of persons uninsured and underinsured is growing in this country.

In an effort to solve these problems, the health care industry and the government are restructuring the way in which health care is delivered and paid for. As a result of restructuring, the manner in which Registered Nurses (RN) deliver health care is changing, specifically their utilization of Unlicensed Assistive Personnel (UAP). Health care providers have for decades used UAP to provide support for the RN in the delivery of professional nursing care; however, the role and accountability of UAP has not been well defined and varies greatly among institutions and health care settings. UAP who provide support to the RN should never be used as a substitute for the RN. With restructuring, UAP, in some settings, perform nursing activities for which they are not trained, educated, or licensed.

DEFINITIONS
Delegation: entrusting to another as one's representative

UAP: nursing aides, personal care attendants, family members, friends, appointees of the client

POSITION
The restructuring of health care has altered the way nursing care is delivered. Registered Nurses are being asked by health care employers to increase their delegation and use of UAP. This has resulted in concern for the safety of the patient, the quality of care, and public welfare. In virtually all health care settings, UAP are being delegated to and performing duties which are within the scope of nursing. The RN has a legal scope of practice and a legal authority to perform nursing acts; UAP do not.

AASCIN believes:

• The RN should have the protection of the National Labor Relations Act and states should assure adequate staff to maintain quality care for different health care settings, e.g., acute care, subacute care, skilled nursing facilities, and home care.

• All persons seeking health care are entitled to be seen and treated by educated competent personnel.

• The RN is responsible to practice within the state's Nurse Practice Act and therefore cannot delegate professional duties.

• Budgetary and resource considerations are not valid reasons for wrongful delegation.

• Employers and RNs who participate in wrongful delegation should be fined or sanctioned, i.e., accreditation or licensure revoked or suspended.

• The RN does not have to teach UAP who do not demonstrate the ability to learn and perform care.

• UAP who do nursing tasks should be under the direct supervision of the RN, and the RN must participate with authority in the evaluation of UAP.

• UAP should not be used as a substitute for the RN in providing nursing care.

• UAP function differently in different health settings and may not be subject to the same legal mandates in all settings. In licensed settings, UAP are subject to state license restrictions. In settings not subject to licensed regulation, where UAP are arranged for by the client or the client's agent, the UAP works as the client's UAP, and the UAP's care and supervision are the responsibility of the client or client's agent.

• At the request of the client or client's agent, the RN may teach the client's care to UAP. The client or client's agent then accepts responsibility for the UAP's supervision and the type and quality of care the UAP provides. The exception to this would be when the UAP are supplied through an agency; in this situation the UAP would be subject to the regulations of the agency and state. Ideally, the RN teaches the client who then teaches and delegates his/her care to their UAP.

REFERENCES
American Nurses Association. Position Statement on Registered Nurse Utilization of Unlicensed Assistive Personnel, Washington DC. 1992.

Emergency Nurses Association. Position Statement on the Use of Non-Registered Nurse Caregivers in Emergency Care, Chicago IL. 1993.

Association of Rehabilitation Nurses. Position Statement on the Registered Nurse Utilization of Unlicensed Assistive Personnel, Skokie IL. 1994.

(approved 9/95)

Violence as a Leading Cause of Spinal Cord Injury

BACKGROUND
The AASCIN recognizes that violence has reached epidemic proportions in our country. Assaultive injuries by gunshot wounds and stab wounds have become a leading cause of spinal cord injury (SCI) in many large urban areas of our country. The Center for Disease Control in Atlanta stated in a recent article in the New England Journal of Medicine that the time has come for us to address this problem in the manner in which we have addressed and dealt successfully with other threats to public health. Firearms, especially hand guns, are a leading instrument of violent injury, including SCI. Violence has permeated our culture so persistently and pervasively that we are constantly threatened by its presence. Persons with SCI are potentially even more vulnerable to subsequent threats of interpersonal violence.

DEFINITION
Violence is defined as physical force or other means used by one person with the intent of causing harm, injury or death to another. Interpersonal violence in the United States has been defined by the Public Health Services as a national critical health care problem.

POSITION
The recognition of violence as a health care issue and a leading cause of SCI has impacted SCI nursing in many ways. SCI nurses care for victims with SCI and perpetrators of violence, recognizing that these are preventable injuries. This recognition has resulted in concern by SCI nurses for the potential of more SCI's occurring due to the epidemic of violence in our society.

The AASCIN believes violence is epidemic in the United States. The AASCIN believes in educating nurses across the country about the epidemic of violence in our society.

The AASCIN believes it is in a unique position to act as a community resource with regard to prevention of violent SCI.

The AASCIN believes the education and practice of professional nursing and allied health care disciplines should emphasize assessment, intervention, and teaching concerning violence as a public health problem.

The AASCIN supports collaboration with other nursing and health care organizations in an effort to address the epidemic of violence as a public health and safety issue.

The AASCIN supports legislation and education to keep guns out of the hands of children. The AASCIN supports legislation requiring gun owners to obtain education and certification in the safe use of guns.

REFERENCES
American Academy of Pediatrics Position Statement on Firearms and

Adolescents (1992) (RE9233) Pediatrics 89 (4) : 784-787.

American Nurses Association 1994 Position Statement on Curbing the Public Health Epidemic of Handgun Violence in America.

Florida Nurses Association 1994 Position Statement on Curbing the Public Health Epidemic of Handgun Violence in Florida.

"Gun Ownership as a Risk Factor for Homicide in the Home." (1993) New England Journal of Medicine 329 (15) : 1117-1118.

State of Florida Brain and Spinal Cord Injury Program End of the Year Report. July 1, 1993 to June 30, 1994.

(approved 9/96)

The Balanced Budget Act of 1997 allowed states to control how funds were used within their state. The rational was that the state was closer to its citizens and could, by controlling the funds, increase the efficiency of services. The result has been substantial changes in the availability of home care services.

Some states have capped the amount of money they pay for support services to the amount of the cost of care in a Skilled Nursing Facility (SNF). This has forced many quadriplegics, who would otherwise be living in the community, to enter SNF's. These same states have made exceptions to this rule for children and ventilator supported persons because a SNF does not have an adequate environment to support these persons. No exemption exists for the spinal cord injured person.

While Congress has addressed the specific rights of disabled Americans in the Americans with Disabilities Act, there remains controversy about the definition of independence and the timing of service eligibility. For example, services eligibility is being measured after services are provided and not before. Increasingly, spinal cord injured individuals, like quadriplegics who leave their homes, are denied coverage by their providers and Medicare on the grounds they are not 'confined to the home' (homebound). Without these services, without adaptive equipment in their homes, these people would not be able to leave their homes. The unfortunate part of this is it requires disabled persons with limited physical, mental, and financial resources to challenge the State in order to assert their rights.

POSITION

Home, community, family and friends are extremely important to spinal cord injured persons in terms of their quality of life, their psychological health and their future. Home care benefits represent far more than just the services provided in the home. These services are of extraordinary importance to individuals with spinal cord injury and are essential in their struggle to remain independent and healthy.

AASCIN believes an individual who uses an electronic wheel chair should be considered homebound even if he or she is able to exit their home.

AASCIN believes that want individuals should not have to limit their contribution to society in order to maintain their benefits.

AASCIN believes placing limits on the number of hours an individual can leave the home and still satisfy homebound requirement makes it more difficult for individuals struggling to remain independent and productive to be cared for outside of an institutional setting.

AASCIN believes it is the right of the individual to choose not only their provider but also the location in which their care is provided.

AASCIN believes that just as there are exceptions for the care of children and a ventilator-supported person to remain in their homes, there should be an exception for the spinal cord injured individuals.

AASCIN believes that spinal cord injured persons who need continued assistance in their homes to remain productive member of society should receive that care.

AASCIN believes it is unconscionable to uproot a quadriplegic, who is a contributing member of society, and force them into a SNF.

AASCIN believes that the federal government must resume administrative control of home health care preventing each state from administering care based on their economic condition.

AASCIN believes that every person has the right to choose where and with whom he or she lives without denial of these rights in the name of economics.

AASCIN believes that to take away the hope of an individual for a productive future in society is wrong.

References:

• National Spinal Cord Injury Association; Factsheet #2, National Spinal Cord Injury Statistics Center. Spinal Cord Injury: Facts and Figures at a Glance. Birmingham, AL: University of Alabama at Birmingham, April 1999.

• Ibid.

• Ibid.

(Adopted 9/99)

Position Statement on Multi-State Licensure

BACKGROUND
In most areas of the United States of America, access to the specialized care, education and support for the person with Spinal Cord Impairment (SCI) is not available in the local community. The Patient-Consumer must travel to a medical center that specializes in the rehabilitation of this catastrophic insult. Advancements in telecommunication technologies using: computers, telephones, interactive video and other electronic devices, make it possible to bring personalized care to the patient-consumer.

Currently, treatment for SCI is received at a rehabilitation center of specialization and excellence. The SCI Patient-Consumer is discharged home, often crossing a state line. The Registered Nurse, having provided the patient assessment, a specialized education, the implementation of care for altered functions and problem solving strategies is not legally permitted to answer SCI related questions for the patient, family, or caretakers. To be legally available to the patient with SCI, the Nurse must possess a Nursing License in the same state, in which the patient lives. State laws which were put into effect to protect the patient are in fact causing a disservice to the patient by preventing them from using currently available technological services which would increase the quality of their health care, decrease the personal cost of care and decrease the probability of complications.

Most State Laws have not been updated to reflect the advancement in health care delivery. Patient-Consumers cross State Lines to receive care. Caregivers (Nurses) should be allowed to provide on-going consultation and care for these patients.

A solution for this problem of appropriate care delivery is state adoption of a mutual recognition of Nursing Licenses; similar to a Driver's License. This allows the Nurse to follow patient care across State Lines. The AASCIN understands the concerns the States, Registered Nurses and Patients with SCI have about the model.

• The differences between the individual State's regulations.

• Will weaken the standards of some states?

• Will weaken the individual State Boards of Nursing?

• Will States lose revenue and have to raise licenser fees?

• The ability to maintain or improve the protection of the public.

• Will a state know who is practicing within its borders?

• The possibility of dual disciplinary measures taken against a nurse by the state of licensure and/or the state of practice.

• Will there be an overwhelming inability for a nurse to defend herself in one or more states?

• Will this increase the burden of investigating complaints against nurses?

• The maintenance of a nationally centralized database.

• Will confidentiality be maintained as it pertains to a centralized database?

• How will this be funded?

• The funding of the compact administration

The States Boards of Nursing are also aware of these and other problems associated with Nursing Licensing in multiple States. Their professional organization, the National Counsel for State Boards of Nursing (NCSBN) created a task force to study telehealth and licensure. They endorsed the concept of a mutual recognition model for the regulation of interstate licensure.

In the Mutual Recognition Model the nurse is held accountable for the nursing practice laws and other regulations in the state where the nurse provides the services, while not being required to obtain a license, in states that join the compact.

The AASCIN believes each state has the right to legislate the Scope of Nursing Practice within their borders.

The AASCIN believes that the mutual recognition model does not circumvent the States rights but does in fact stimulate States to review their practice.

The AASCIN believes that technologies such as the phone, computer and interactive video should be used to supply health care information, teaching materials and specialized nursing advice.

The AASCIN believes that technologies such as the phone, computer and interactive video can be used to improve the quality of health care while reducing the cost of health care by preventing complications and unnecessary hospital admissions.

The AASCIN feels that follow-up (for continuity of care or specialty information) via telephone, computer, and video should be allowed regardless of the care giver's or patient's state of residence.

AASCIN supports multi-state licensure in order to provide persons with SCI impairments access to SCI specialty nursing they might otherwise not receive.

AASCIN supports the opportunity multi-state licensure would provide a person with SCI to obtain education and services.

The AASCIN endorses the concept of a mutual recognition model.

References
House Bill 1342 - Bill Text

"Nurse Licensure Compact", 11-06-98

www.ncsbn.org/files/mutual/compact.asp

"Nursing Regulation for the New Millennium: The Mutual Recognition Model", Carolyn Hutcherson, MS, RN and Susan H. Williamson, MPH, RN, 5-31-99,

www.nursingworld.org/ojin/topic9/topic9_2.htm

"The Regulatory Dilemma Surrounding Interstate Practice", Terri Gaffney, MPA, RN, 5-31-99, www.nursingworld.org/ojin/topic9/topic9_1.htm

"Position Statement of American Nurses Association's Board of Directors on the Nurse Licensure Compact", 2-17-99

NCSBN's FAQs, www.ncsbn.org/files/mutual/mrfaq.asp

NCBSN's "Response to ANA House of Delegates Regarding Mutual Recognition and the Interstate Compact", National Council Paper, 6-9-99

www.ncsbn.org/files/mutual/ana990609.asp

NCSBN, "Continuum of Models for Regulating Multistate Nursing Practice"

"Telepractice and Professional Licensing: A Guide for Legislators"

www.clearhq.org/teleguide.htm.

"Multistate Licensure: Premature Policy", Susan E. King, MS RN, 5-31-99,

www.nursingworld.org/ojin/topic9/topic9_3.htm

"1999 State Legislative Trends", APRN, 5-17-99

www.nursingworld.org/gova/state/hod99/aprn.htm

"ANA Response to Pew Commission Report"

www.nursingworld.org/readroom/pew.htm

"An Overview of State Laws and Approaches to Minimize Licensure Barriers", Linda Gobis, RN, FNP, JD

www.telemedtoday.com/mainpages/statelaw.htm

ANA Policy Series: "Telehealth -- Issues for Nursing", 10-09-96

www.nursingworld.org/readroom/tele2.htm

"ANA Multistate Regulation of Nurses - Backgrounder", June 24, 1998

www.nursingworld.org/gova/multibg.htm

(Approved 12/2000)