ANNA submits comments on American Nurses Association draft report Adapting Standards of Care under Altered Conditions

Cheryl A. Peterson, MSN, RN
Senior Policy Fellow
American Nurses Association
8515 Georgia Avenue
Suite 400
Silver Spring, MD 20910-3492

Re: Comments on the American Nurses Association draft report Adapting Standards of Care under Altered Conditions

Dear Ms. Peterson:

The American Nephrology Nurses' Association (ANNA) is pleased to have the opportunity to provide public comments on the American Nurses Association's (ANA) draft report Adapting Standards of Care under Altered Conditions.

We applaud ANA and the expert panel that created this report for their efforts to address a set of very important issues that directly impacts nursing practice. The collaborative process that created this draft report and the opportunity for organizations to comment publicly is greatly appreciated by ANNA.

ANNA is a professional nursing organization of more than 12,000 registered nurses practicing in nephrology. ANNA members are intimately involved in the supervision and delivery of care to adults and children with kidney disease. ANNA members work in a variety of settings including dialysis facilities, transplant centers, Chronic Kidney Disease (CKD) clinics, acute care, ambulatory clinics, and long term care.

ANNA has a long history of addressing the issue of disaster preparedness and its impact on nursing practice. In October 2001, ANNA published a set of articles in the Nephrology Nursing Journal (Volume 28, Number 5) about the issues facing the nursing practice during a variety of recent disasters.

ANNA is a leader in the efforts of the kidney community to address the special issues associated with nephrology practice during disasters. In January 2006, ANNA participated in a Disaster Summit in Washington DC that resulted in the creation of the Kidney Community Emergency Response Coalition. ANNA members participated in eight different response groups that produced a final report in July 2006. ANNA will continue to work with the nursing, kidney, and public health communities to address the issues associated with the treatment of our patients during disasters.

General Comments on the Draft Report

ANNA believes the Adapting Standards of Care under Altered Conditions report will be an important resource for the nation's nursing workforce.

We offer the following general suggestions:

  • There is a brief mention in the report regarding the role of professional associations. We encourage the panel to consider expanding this discussion to include specialty nursing associations.
  • We noticed there was no mention of nurses being part of the National Disaster Medical System (NDMS) where they can be federalized and concerns of professional liability, transportation, and resources for deployment would be minimized. We suggest that the panel consider adding this to the final report.

Comments on Specific Sections of the Report

We reviewed the draft report and found it to be extremely useful. We feel it will serve as an excellent general outline for issues surrounding emergency preparedness for nurses and other health professionals.

Introduction and Purpose

Lines 27 and 47: We suggest that the term "advanced practice nurse", "mid-level provider" or "nurse practitioner/clinical nurse specialist" be added to this section and to any other sections involving the health professional that will benefit from this report.

Definitions and Foundations

ANNA members worked with the expert panel to provide comments on earlier drafts of this report and we are encouraged to see that additional information about community settings was added to the document. We believe, however, that the report remains highly hospital based. We understand the importance of focusing on hospital settings but nephrology nurses practice in a variety of non-hospital settings that would also require a response to emergencies and disasters.

Lines 153-164 discuss the role of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). ANNA recommends that this section of the report should focus on not just hospitals but to ambulatory settings as well.

Challenges to meeting usual care expectations

ANNA feels that this section of the report is excellent and addresses critical issues for all nurses. We believe that many of the issues and recommendations will serve as topics for further education and training for our membership. We have some general comments based specifically on the nephrology nursing practice and settings.

Lines 214-221 include a list of six situational dynamics and we feel all of these apply to nephrology nursing in extreme conditions. In particular, the third point on the "shortage of workers due to transportation loss or worker family illness/injury or unwillingness to report to work," is particularly relevant to ANNA. ANNA members found that during Hurricanes Katrina and Rita there were problems related to the delivery of dialysis because nurses voluntarily evacuated the cities leaving acute contracts and out patient dialysis centers under-staffed. This raises a number of ethical questions for practicing nephrology nurses. We feel the Substantive Values chart (on page 6) addresses this issue in very general terms by stating:

Duty to provide: Health professionals will weigh their duty to provide care with obligations to their own health and that of their families.

Line 218 contains the fourth point on the list of situational dynamics, which is involvement in community triage. In many of these situations, Nephrology nurses are needed in shelters to assist with dialysis triage. This raises questions regarding liability issues when nurses perform triage as a volunteer. The protections for this delivery of care will vary from state to state. We encourage the panel to consider these concerns when evaluating this particular line item.

Line 219 the fourth point, "sudden increase in the number of patients," is an issue we are confident would occur in facilities that remain open in surge areas when others have closed. Nephrology nurses practicing in these areas may be called upon to work around the clock providing urgently needed dialysis. In these situations, standards regarding nursing history, assessment, diagnosis and provisions for continuity of care must be amended to meet the needs of the patients while preserving basic safety.

Lines 231 -235 address liability and immunity issues associated with a formal declaration of an emergency. ANNA urges the panel to address the state practice issues related to this topic. We believe this issue is addressed in the recommendations section of the report, but we feel that further discussion in this part of the document is needed.

Lines 250-274 and 307-314 discuss altered care and issues associated with triaging in circumstances requiring the application of scarce resources. ANNA realizes that in a widespread epidemic dialysis patients will likely not be triaged to receive scarce resources due their already life-threatening condition in comparison to otherwise healthy persons. We feel this is an appropriate position given the environment that would exist in such a situation. However, ANNA believes it is important that if dialysis patients are going to be triaged in these situations it be done in the most effective and appropriate manner. We urge the panel to provide additional direction and specificity in this section.


ANNA sees the possibility for it and other health professional organizations to use this report to facilitate discussions of these important topics and the opportunity to raise awareness and stimulate pre-event planning at an individual nurse level as well as at the system level.

ANNA wishes to thank ANA and the individuals involved in creating this draft report. We look forward to working with ANA, national nursing organizations, and the broader public health community to work on the disaster preparedness issues facing our health workforce.


Sandy Bodin, MA, RN, CNN
American Nephrology Nurses' Association