Roadmap to HIPAA: keeping occupational health nurses on track.

So what does HIPAA require most covered entities to do? At this point, the Privacy Rule compliance date has already passed for all covered entities except small health plans. Most of the requirements under the Privacy Rule dictate the development of appropriate policies and procedures, a notice of privacy practices and other forms, implementation of measures to secure the privacy of PHI, contracting with Business Associates, and training of all involved. For covered entities, testing of the electronic standard transactions to exchange data between participating parties should have begun by April 16, 2003. Although full implementation of the electronic transactions should have taken place by October 16, 2003, the government has allowed covered entities that are still actively working toward compliance to operate under contingency plans. It remains unclear when the use of such plans will be disallowed. After standards are published for claim attachments and first report of injury, these electronic standard transactions will be incorporated by the designated compliance date. Appropriate use of national identifiers will be implemented after final rules and standards are published. For the occupational health nurse who is not a covered entity, the most critical implementation factor is a HIPAA compliant authorization form so the occupational health nurse can continue to obtain necessary PHI. This is essential when attempting to obtain medical information, even for workers' compensation or disability case management. Although these plans are not considered health plans under HIPAA and, therefore, would not require the designation of covered entity, the occupational health nurse frequently needs to obtain PHI to manage these cases. Most providers in the health care community will be covered entities under HIPAA and will not be able to release PHI without a signed HIPAA compliant authorization form. In addition, providers will want a HIPAA compliant authorization form signed when requesting health information from the occupational health nurse. The HIPAA's privacy regulations are considered "the floor" or minimum standard for the protection of PHI. As such, it is likely that these privacy regulations will become the "industry standard" to which all health care professionals will be held. Even though the occupational health nurse may not be a covered entity, implementing appropriate HIPAA procedures is recommended. Knowing that most of HIPAA's privacy rule contains requirements already in place and in practice for most occupational health nurses can take some of the worry out of this complex regulation. Additionally, the nurse interacts with the health care system in a variety of roles. As a health care consumer, occupational health nurses can assert their own patient rights when interacting with covered entities. As the trusted advisor and consultant to many employees, the occupational health nurse can play a vital role in educating employees about HIPAA and assisting employees with navigating an ever-complex health care system. As a health care professional, the occupational health nurse continues to protect and safeguard all PHI while respecting employees' rights and delivering quality care. Staying knowledgeable and up-to-date on the HIPAA regulations as they continue to evolve and change allows occupational health nurses to stay on the right course while mapping their way toward regulatory compliance (see Sidebar for recommended resources).     

Making chicken pox prevention a priority

School nurses are the IDEAL professionals to catch those kids without a history of chicken pox (varicella illness) who have not been immunized, thereby falling into the susceptible range. We handle charts daily. We have both illness history (if it was provided) and immunization dates. We can call parents. We can talk to kids. Wouldn't it be easy if we could do that and then call (or email) the primary care provider? But there is no longer an "easy" way to communicate health information. Doing things the easy way could be perceived by some as "tattling" and by others as "reporting without permission." Instead, the school nurse must take the time-consuming (and better long range) path of education ... of the student, and the parent. And the priority can slip down below other school nurse requirements such as getting kids their required immunizations, first aid and illness care, individualized health care plans for students with medical problems, parent and teacher phone calls, and endless conversations. It takes a village to raise a child though, and the school nurse is a village resident. The following information is vital to the knowledge base of today's school nurse. Please read it, store it and consider it when planning and intervening with your students in the day-to-day interaction that promotes optimal health and wellness.     

Activities of home-based heart failure nurse specialists: a modified narrative analysis.

BACKGROUND: Heart failure nurse specialists strive to optimize patients' outcomes in home-based settings. OBJECTIVE: To document the activities of home-based heart failure nurse specialists. METHOD: A modified narrative analysis of clinical notes of home-based heart failure nurse specialists during a 12-month period was used. RESULTS: Data analysis revealed 7 key activities of home-based heart failure nurse specialists: (1) monitoring signs and symptoms and reinforcing patients' self-management: identifying trends and appropriate action; (2) organization, liaison, and consultation with other health professionals to deal with changes in clinical status; (3) clarifying and reinforcing patients' self-care strategies; (4) assisting patients in their desire to avoid institutionalized care; (5) identifying patients' psychosocial issues: dealing with social isolation; (6) providing support: journeying with patients and patients' families; and (7) helping patients and patients' families deal with death and dying. CONCLUSIONS: A major proportion of the activities of home-based heart failure nurse specialists are related to facilitating communication between health professionals and providing information and support to patients and patients' families.     

Improving family communications at the end of life: implications for length of stay in the intensive care unit and resource use.

BACKGROUND: Inadequate communication persists between healthcare professionals and patients and patients' families in intensive care units. Unwanted or ineffective treatments can occur when patients' goals of care are unknown or not honored, increasing costs and care. Having the primary physician provide medical information and then having a physician and clinical nurse specialist team improve opportunities for patients and their families to process that information could improve the situation. This model has not been tested for its effect on patients' outcomes and resource utilization. OBJECTIVES: To evaluate the effect of a communication team that included a physician and a clinical nurse specialist on length of stay and costs for patients near the end of life in the intensive care unit. METHODS: During a 1-year period, patients judged to be at high risk for death (N = 151) were divided into 2 groups: 43 patients who were cared for by the medical director teamed with a clinical nurse specialist and 108 patients who received standard care, provided by an attending physician. RESULTS: Compared with the control group, patients in the intervention group had significantly shorter stays in both the intensive care unit (6.1 vs 9.5 days) and the hospital (11.3 vs 16.4 days) and had lower fixed ($15,559 vs $24,080) and variable ($5087 vs $8035) costs. CONCLUSIONS: Use of a physician and a clinical nurse specialist focused on improving communication with patients and patients' families reduced lengths of stay and resource utilization.     

Documenting patients' end-of-life decisions

The anguish families experience when they are asked to make health care decisions for incompetent members has stimulated the search for an adequate procedure to document patients' end-of-life decisions. This study explores a method of recording competent patients' wishes via a "value history," a questionnaire that can guide families and the health care team during an incompetent person's terminal illness. Questions addressed were these: Can a primary care physician gather information from competent patients about their care before they become incompetent? Can a nurse practitioner gather the information as efficiently as a physician? Do patients want this information recorded in their charts? and, Is the primary care office as well as the patient's home an appropriate location to obtain a value history? Four hundred patients were invited to record their wishes for future care. Patients expressed that they wanted to be told the truth about their health and their health care, and they wanted to participate in decision-making, even while dying. The majority did not want to be maintained indefinitely on life-support systems. Patient responses were similar regardless of whether the NP or physician conducted the interview. A primary care office or patient's home are both suitable for filling out the value history. Because of the enthusiastic patient responses, the authors recommend that value histories become a routine part of a patient's medical record.     

Privacy and confidentiality: the Health Insurance Portability and Accountability Act in critical care nursing

Nurses are responsible to protect the confidentiality and security of patients' health information. In the critical care setting, these privacy and confidentiality issues may be even more poignant. If able to carry on with their normal lives after discharge, many of the patients that nurses treat will have some sequelae from their illnesses that could affect their careers, finances, and personal lives. This article reviews the current literature, presents a discussion of confidentiality and security as it applies to uniquely identifiable health information, and offers some "best practices" that can be used in daily practice. Furthermore, the author discusses the Health Insurance Portability and Accountability Act of 1996 and details some reasons why the act is not fully implemented a full 6 years after it was signed into law.     

The invisible culture of the multiracial, multiethnic individual: a transcultural imperative

The main purpose of this introductory article is to evoke professional awareness, spark interest, stimulate thought, and disseminate information concerning multiracial, multiethnic (multiple heritage) individuals within the United States. General background information, terms, definitions, ethno-historical influences, practice implications, and current issues will be highlighted. Areas for further exploration will be proposed. Transcultural imperatives urge all nurses and other health care professionals to become active participants in the new cultural evolution of a different, broader worldview that uncovers the "invisible" culture of multiple heritage individuals. The new vision challenges nurse and other health care professionals to embark upon a new journey in the quest for cultural congruent care for all individuals.     

Palliative care in non-malignant disease: a pragmatic response

With increasing requests for palliative care provision for all patients regardless of diagnosis, professionals within specialist palliative care services and palliative care nurse specialists need to consider how they will respond. Current palliative care is considered inequitable as the majority of palliative care services do not include those with non-malignant disease. This article examines a number of issues concerning the extension of palliative care to this patient population. It considers the needs of non-cancer patients, palliative care responsibilities, resource implications, professional knowledge and responsibilities, and possible action. Recommendations include the need for further research to explore these patients' needs and the role of specialist palliative care services. Suggestions regarding how Macmillan nurses could respond to the increased demand for palliative care services are offered. Within the current financial climate, the only realistic response for the Macmillan nurse is to act as a consultant working in collaboration with other health professionals outside the palliative care specialty.     

Health promotion: the emerging frontier in nursing

Health promotion is gaining recognition as a health care strategy The major premise of this paper is that the nature of health promotion is emerging Rising into view, health promotion offers many challenges and opportunities to all health care professionals Many of the influences that health promotion will have on nursing have not yet been fully explored What is health promotion? What concepts are inherent in health promotion? Are there models of health promotion that are specific to nursing7 What will be nursing's role in health promotion? What changes are required by the nursing profession to enable nurses to emerge within this new frontier? These are central questions for nurses as health promotion professionals to ponder, and attempts are made in this paper to answer these questions     

Privacy and confidentiality issues in primary care: views of advanced practice nurses and their patients--an APRNet study [corrected

Various aspects of the concepts of privacy and confidentiality are discussed in relation to health care information in primary health care settings. In addition, findings are presented from patient and nurse practitioner focus groups held to elicit concerns that these two groups have in relation to privacy and confidentiality in their respective primary care settings. The focus groups were held prior to the implementation of the Health Insurance Portability and Accessibility Act in the USA. Implications for advanced practice registered nurses in primary care practices are provided.     

An economic model for nurse manpower planning in the Caribbean: Part II--Strategies

Figure 5 illustrates the key ingredients of manpower planning. Whatever model or framework that have or will be considered for the Region must be based on cost containment necessitated by the scarcity of resources. Since the health sector is labour intensive, health manpower is critical for its successful functioning. Approximately 65-70% of the Ministries of Health's recurrent budget is allocated for health personnel. Budgetary restrictions as a result of economic downturn have therefore impacted severely on the manpower resources resulting in a decreased supply of all categories of health workers in the health service. Even the most minimum level of services is therefore jeopardized. Most countries of the Region are at present suffering from a net loss in most of the health professional groups and some countries are without auxiliary groups. In providing quality care, certain questions need to be answered. In the light of decreasing economic resources and accompanying decreasing nurse manpower resources: 1. What degree of substitutability between categories of health manpower generally and specifically, between different categories of nurses will affect their efficient use and provide quality care? 2. What are the least cost combinations of nurse manpower that will ensure greater productivity and quality care? 3. What are the policy restrictions that may hinder substitutability? 4. What are the market forces that affect the demand and supply of nurses? In all of the above, it is necessary to understand that the basis of any nurse manpower policy and plan and the economic analysis of these is guided by the demand for health care and services as well as economics within a given country.     

Statutory disclosure in article 280 of the Turkish Penal Code

A new Turkish Penal Code came into effect on 1 June 2005. Article 280 concerns health care workers' failure to report a crime. This article removes the responsibility from health care workers to maintain confidentiality, but also removes patients' right to confidentiality. It provides for up to one year of imprisonment for a health care worker who, while on duty, finds an indication that a crime might have been committed by a patient and who does not inform the responsible authorities about it. This forces the health care worker to divulge the patient's confidential information. A patient who thinks he or she may be accused of a crime may therefore not seek medical help, which is the universal right of every person. The article is therefore contrary to medical ethics, oaths taken by physicians and nurses, and the understanding of patient confidentiality.     

Whither nursing in the 21st century?

There is no doubt that the role of the nurse in New Zealand will continue to evolve. Developments in the US where clinical nurse specialists and advanced nurse practitioners are taking on roles and responsibilities that in New Zealand are undertaken by other health professionals, mainly medical, will ultimately permeate the New Zealand health care system. Today the nurse practitioner has a greater degree of professional independence than at any time in the history of the profession, and, if the recommendations of the taskforce are accepted and nurse prescribing eventuates, the nurse will have even greater independence and autonomy. With this increased professional independence comes a greater emphasis on the responsibilities of the nurse and professional accountability. The acceptance of greater responsibility will inevitably result in a proliferation of nurse "specialists". Postgraduate programmes must be established with carefully planned curricula to accommodate the requirements of these nurse specialists. Planning, content and design of these programmes must come from nurses in consultation with the Nursing Council, the Ministries of Health and Education, and health agencies. The functioning of the human species within their environment, in both wellness and illness, can only be adequately explained or explored with a sound knowledge of biological systems. It is for this reason that the study of biological sciences must be undertaken by nursing students to prepare them for the advanced role they are likely to play in the health care system of the 21st century.     

Anticipating emotion: a qualitative study of advance care planning in the community setting

Advance care planning at the end of life is high on the political agenda across the UK. The aim is to deliver patient-centred care for all patients, whenever possible in their preferred place of care. It is widely acknowledged that discussions about the end of life are sensitive and often difficult for health professionals, particularly those in the community setting. The aim of this qualitative study was to determine the factors that assist or hinder the primary care health professionals having these discussions. The sample included one GP and one district nurse (DN) from each of three GP practices. Semi-structured interviews were conducted with the participants, and the data was analysed using a thematic approach. The findings clearly depict two of the challenges faced by the GPs and DNs in the community: emotional labour, and balancing patients' and families' expectations about care provision in the community with the limited resources available. This study contributes to the knowledge base of advance care planning by providing insight into the experiences of the GPs and DNs who care for patients at the end of life. Further research is required to more fully understand the emotional impact on the health professionals having these sensitive discussions.     

The process of giving information to families of critically ill patients: a field of tension

We conducted research to study nurses' views on factors that influence their relationship with patients' relatives in intensive care units in three hospitals in Mallorca (Balearic Islands, Spain). This article focuses on the findings related to the process of giving information to the family. We used a post-structuralist theoretical framework and data were collected through observations and interviews. The analysis revealed that nurses thought information eases relatives' worries, but they felt that in order to avoid conflicts with physicians they should restrain themselves from providing it. We propose that the existing power relationships in intensive care units should be challenged if we expect health care professionals to offer patients' relatives a planned information process.     

The new millennium brings nursing informatics into the OR

Will the perioperative arena step out of the dark ages and into the new millennium with informatics? A paradigm shift must occur in both the perioperative arena and health care organizations. Health care organizations must realize the value of informatics and the importance of integrating the informatics nurse into the organizational information system's team. This article discusses how the informatics nurse can accelerate the paradigm shift in the perioperative arena if given the opportunity. The informatics nurse's proactive involvement in the perioperative environment will ensure that information handling technologies benefit the perioperative specialty and, ultimately, enhance patient care.     

Management of patients in the intensive care unit: comparison via work sampling analysis of an acute care nurse practitioner and physicians in training.

BACKGROUND: Little is known about aspects of practice that differ between acute care nurse practitioners and physicians that might affect patients' outcomes. OBJECTIVE: To determine if time spent in work activities differs between an acute care nurse practitioner and physicians in training (pulmonary/critical care fellows) managing patients' care in a step-down medical intensive care unit. METHODS: Work sampling techniques were used to collect data when the nurse practitioner had 6 months' or less experience in the role (T1), after the nurse practitioner had 12 months' experience in the role (T2), and when physicians in training provided care on a rotational schedule (nurse practitioner not present, T3). These data were used to estimate the time spent in direct management of patients, coordination of care, and nonunit activities. RESULTS: Results for T1 and T2 were similar. When T2 and T3 were compared, the nurse practitioner and the physicians in training spent approximately half their time in activities directly related to management of patients (40% vs 44%, not significantly different). The nurse practitioner spent more time in activities related to coordination of care (45% vs 18%; P < .001) and less time in nonunit activities (15% vs 37%; P < .001). CONCLUSION: The nurse practitioner and the physicians in training spent a similar proportion of time performing required tasks. Because of training requirements, physicians spent more time than the nurse practitioner in nonunit activities. Conversely, the nurse practitioner spent more time interacting with patients and patients' families and collaborating with health team members.     

Confidentiality of employee health records: ethical and legal dilemmas for occupational health nurses.

Health professionals must be familiar with regulations and statutes addressing privacy and confidentiality issues. The occupational health nurse must also be aware of specific limitations and exceptions to confidentiality. Occupational health nurses must become proactive in governmental affairs to lobby for changes to include workplace health records in future legislation. To ensure employee trust, occupational health nurses must maintain their ethical and legal responsibility to act morally when making decisions related to confidentiality. The AAOHN Code of Ethics and Interpretive Statements and the AAOHN Position Statement on Confidentiality of Health Information can be used as frameworks to guide occupational health nursing practice.     

Are nurse practitioners prepared for the AIDS epidemic?

Treatment of HIV-infected individuals will become a regular part of mainstream medical practice because of the increasing numbers of infected persons, the geographical dispersion of the disease, and the routine nature of much of the care required by seropositive patients. Nurse practitioners, like other health care professionals, need to be willing and able to provide such primary care. One hundred sixty-five NPs constituted an opportunity sample that was surveyed using an instrument that had been adapted from one used successfully in studies of other health professionals. The instrument consisted of 80 forced-answer and six open-ended questions. The response rate was 63 percent. It was found that nurse practitioners believed there was moderate risk of occupational contraction of HIV. NPs were more likely to agree on activities they believed to be of low risk than about the danger of perceived higher-risk activities. The respondents judged themselves as fairly competent in their ability to provide counseling and information to patients about HIV and risk-reduction. Half believed that their lack of knowledge was the biggest barrier to providing care to HIV-infected persons. Eighty-five percent thought courses on the medical aspects of AIDS were necessary, and 78 percent wanted courses in the social, ethical and legal implications of the disease. This study shows that there is a widely perceived need for continuing education on both medical and social aspects of AIDS in order to enable nurse practitioners to play a greater role in primary care provision for persons with AIDS.