Nursing practice is regulated through state and fed-eral legislative and administrative laws and agencies.
The state and federal legislatures develop and pass laws. Federal administrative agencies, such as the Veterans Administration, oversee compliance with regulations by their agencies. Some examples of fed-eral administrative regulatory agencies include the Centers for Medicare and Medicaid Services (CMS), the Occupational Safety and Health Administration (OSHA), and the Centers for Disease Control and Prevention (CDC). State administrative agencies, such as state boards of nursing, create regulations to accompany, detail, and implement state laws.
CENTERS FOR MEDICARE
AND MEDICAID SERVICES (CMS)
The CMS administers the Medicare program and collaborate with states to administer Medicaid, the 86 Understanding Organizations
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State Children’s Insurance Health Care Program, and HIPAA. CMS is specifically responsible for sim-plification of standards for implementation of and HIPAA and maintenance of quality standards for health care through its surveys and certification functions (CMS, 2004).
HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
CMS oversees implementation of HIPAA standards and regulations. Title I of HIPAA is designed to pro-tect health insurance coverage for workers and their families when they change or lose their jobs.
Title II of HIPAA, The Administrative Simplifica-tion provisions, “requires strict security measures to protect the electronic health data of patients”
(Follansbee, 2002, p. 42). Consequently, nursing policies and procedures associated with the man-agement of health-care information have changed dramatically (Follansbee, 2002).
Requirements under HIPAA require nursing service to comply with privacy standards by (1) developing appropriate policies and procedures, (2) providing notice of privacy practices and other forms, (3) implementing measures to secure pri-vacy, (4) contracting with business associates to secure privacy, and (5) training all nursing staff involved in patient care (Lucas, Adams, & Wachs, 2004). According to these authors (pp. 178–179):
“HIPAA’s privacy regulations are considered ‘the floor’ or minimum standard for the protection of PHI [protected health information]. As such, it is likely that these privacy regulations will become the
‘industry standard’ to which all health care profes-sionals will be held.”
Research in Long-Term Care:
Issues, Dilemmas, and Challenges
Scott and Elstein (2004) reported that as the American population ages, already sizable long-term care expenditures are likely to increase. The CMS, as the largest purchaser of health care for the aging population, is continuously working to improve the standard of long-term patient care through (1) quality monitoring and enforcing of patient care standards, (2) providing information to beneficiaries about the standard of patient care, and (3) enhancing resources to improve standardized patient care.
Medicare and Medicaid also establish program requirements in long-term care facilities. For exam-ple, according to regulations created by CMS (CMS, 2003, September), long-term care facilities may, in specific circumstances, utilize paid feeding assis-tants to supplement the services of certified nurse aides. The training and certification of the feeding assistants must have occurred under standardized guidelines, established by CMS.
OCCUPATIONAL SAFETY
AND HEALTH ADMINISTRATION
The Occupational Safety and Health Administration (OSHA, 2004) is a federal agency whose mission is designed to: “assure the safety and health of America’s workers by setting and enforcing stan-dards; providing training, outreach, and education;
establishing partnerships; and encouraging contin-ual improvement in workplace safety and health.”
OSHA provides a foundation for understanding workplace health and safety by producing publica-tions, pamphlets, audiovisual programs, computer access programs, and other documents designed to promote compliance with safety standards (Nester, 1996). OSHA works to build partnerships between occupational safety and health-care administration, according to Nester (1996). For example, the Office of Occupational Health Nursing within OSHA is an active advocate for health-care workers, such as nurses, assisting with the establishment of stan-dards that protect and provide for the safety of patients and all health-care providers.
The OSHA Pathogens Standard
In 1991 the OSHA standard designed to protect health-care providers from exposure to blood and other potentially infectious materials became mandatory. According to Goldstein and Johnson (1991), health-care employers were required to institute an infection control plan based upon this OSHA standard, which included universal precau-tions, engineering and work practice controls, per-sonal protective equipment, and housekeeping.
Occupational health nurses (1) coordinated the development, maintenance, and revision of this infection control program, in compliance with the OSHA regulations, (2) educated management about the hazards of blood-borne pathogens, and (3) pro-vided assistance to ensure compliance with the
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OSHA standard, resulting in a safe and healthy work environment for the health-care provider.
Nursing plays an active role in OSHA’s func-tions. Nurses are not only regulated/protected by OSHA standards but also play an important role in their implementation to meet standards for patient safety.
CENTERS FOR DISEASE CONTROL (CDC) The Centers for Disease Control and Prevention (CDC, 2004) is the leading federal agency for pro-tecting the patient’s health and safety both at home and abroad. The CDC is responsible for (1) devel-oping and applying disease prevention and control, (2) maintaining environmental health, and (3) pro-moting health and education activities designed to improve the well-being of the people of the United States. But research has demonstrated that more nursing expertise is needed in the area of disease control, as this environmental concern is a “front line” patient care safety issue in nursing practice.
Disease Control: A Safety Issue in Nursing Practice
According to Larson and Butterfield (2002), clients often use nurses as their primary contact for expressing concerns about health problems related to environmental disease control. In response to this need, core competencies for nursing expertise in the field of environmental disease control were devel-oped by the Institute of Medicine, Agency for Toxic Substances and Disease Registry, and National Institute of Nursing Research. These core disease control competencies comprise a baseline of knowl-edge and awareness as well as a standard by which nurses intervene to prevent and minimize environ-mental disease. Nursing standards for disease con-trol focused on the following four competencies:
1. Basic knowledge and disease control con-cepts: “Understanding scientific principles [of] … basic mechanisms of exposure…pre-vention and control strategies … applied research, and the interdisciplinary nature of environmental health.”
2. Assessment and referral: “Completing a com-prehensive environmental exposure history and making appropriate referrals … locating
and providing appropriate scientific informa-tion for individual patients and communities.”
3. Advocacy, ethics, and risk communication:
“Understanding the role of advocacy, princi-ples of environmental justice, and risk com-munication in addressing environmental health issues.”
4. Legislation and regulation: “Understanding
… environmental health policy as well as state and national regulations” (Larson &
Butterfield, 2002, pp. 301–308; quoting Pope, Snyder, & Mood, 1995).
Establishing Safety Protocols Based Upon CDC and OSHA Recommendations
In 1987 OSHA was petitioned by the ANA and labor unions to issue an emergency infection con-trol standard, subsequent to the first documented reports of occupationally acquired human immuno-deficiency virus (HIV) in health-care providers (Miramontes, 1990). OSHA responded by enforc-ing voluntary guidelines developed by the CDC 4 years earlier. Subsequently, OSHA drafted regula-tions containing the final set of HIV safety protocols in1991.
According to Miramontes (1990), OSHA estab-lished HIV safety standards and protocols to be uti-lized by all health-care providers, addressing (1) types of protective clothing and equipment, (2) housekeeping and laundry areas, (3) infectious waste disposal, and (4) tracking employees, pre-and postexposure. In enforcing these stpre-andards, hospitals stress continued education and training in order to increase compliance. Miramontes (pp.
561–562) cited a research study that found “after a two-year training/evaluation period, physician compliance with infection control procedures increased from 20% to 80%, and nurse compliance rose from 50% to 86%.”
All Good Things…
Nursing practice is regulated on the state and fed-eral levels. On the state level, nursing is regulated via the state’s nursing practice act, which provides for licensure as a registered nurse. Subsequently, 88 Understanding Organizations
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certification acknowledges nursing competence at an advanced level of practice.
The nursing practice act establishes the standard of care and scope of practice, which are monitored by the state’s governing board, usually the board of nursing examiners. The nursing practice act also regulates advanced practice; for example, the clini-cal nurse specialist. The scope of nursing practice
has been expanded by telenursing, requiring the development of the Nurse Licensure Compact (NLC). The NLC creates standardization within nurse practice acts that vary and lack uniformity from state to state, providing more standard meth-ods of compliance, discipline, and rehabilitation.
Nursing has been developed upon the core com-petence of caring, a concept difficult to measure, document, or legislate. Other essential competen-cies, which appear to be measurable behaviors, include health promotion, supervision, interper-sonal communication, direct care, computer, and case load competencies. Competencies may be doc-umented with videotaping, orientation records, portfolios, self-assessment tools, records of manda-tory intranet training courses, and continuing education records. Advanced areas of nursing prac-tice have more specialized sets of competencies.
Specific competencies are required in nursing informatics at four levels, consisting of the begin-ning, experienced, informatics specialist, and informatics innovator nurse. Informatics may be integrated into the nursing standards.
Evidence-based nursing practice is the expected standard of care. Nursing research is the mecha-nism to provide evidence-based practice. The nurse may integrate evidence-based practice into the nurs-ing process, for example, by follownurs-ing a four-step clinical decision-making process. Policies and pro-cedures also establish the standard of care and thus regulate nursing practice.
Independent organizations, such as JCAHO, monitor a health-care provider’s compliance with state and federal laws and regulations. Accredita-tion is the process utilized by an organizaAccredita-tion, such as a school of nursing or health-care facility, to ver-ify competency of its educational or health-care pro-gram, respectively. Staffing and productivity must also be regulated under these accreditation guide-lines to meet the standard of care.
Legislative and administrative regulation of nursing occurs on the federal level; for example, through CMS. CMS oversees the administration of HIPAA, a federal law that regulates confidentiality issues related to patient care. OSHA is a federal agency that promotes standards for patient safety in the health-care environment. The CDC is the fed-eral agency that develops and promotes disease pre-vention and control.
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