Discuss 2 Please don’t combine everything. Answer each question separately for clarity
1A:Identify a current healthcare policy in your current role that you would like to see revised. Why? What would be the projected outcomes?
1B: discuss both the obvious and the non-obvious stakeholders?
1C: Which stakeholders to you have the potential to influence?
1D: What barriers do you face with reaching stakeholders and allowing them to buy in?
1F Take the identified healthcare policy and. Identify both obvious and non-obvious stakeholders.
1G:Also identify stakeholders that you have the potential to influence.
1H:Determine the effect of healthcare politics on the healthcare stakeholders, state and federal government, and the nursing profession (
1J: Analyze legislative process and the impact of special interest lobbies
2A: How have you seen the diverse interests of healthcare stakeholders impact patient care in your nursing practice or in the practice of other nurses?
2B: In general, do you think political action committees (PACs) and special interest groups (SIGs) contribute to or detract from improvements in patient healthcare? Provide an example to illustrate your thoughts.
2C: What role should politics play in healthcare reform? What role should the DNP-prepared nurse play in the political process that impacts healthcare reform?
EVERYTHING YOU NEED IS IN THE ARTICLE
Nurse Staffing Ratios
“The problems of the world cannot possibly be solved by skeptics or cynics whose horizons are limited by the obvious realities.”
John F. Kennedy
The importance of nursing to the delivery of high-quality health care has been recognized since the inception of the practice of nursing. Various factors contribute to the quality of nursing care including the expertise of nursing staff, availability of supportive personnel and other health professionals, good communication among the care team, and the nurse/patient ratio. It was not until the early 2000s that high-quality empirical research found consistent relationships between licensed nurse staffing and the quality of patient care (Lang et al., 2004; Kane et al., 2007).
Concerns about the effects of changes in nurse staffing levels in the 1990s, combined with the increasing influence of nursing unions, resulted in the passage of California Assembly Bill (AB) 394 in 1999, the first comprehensive legislation in the United States to establish minimum staffing levels for registered nurses (RNs) and licensed vocational nurses (LVNs) in hospitals. This bill required that the California Department of Health Services (DHS) establish specific staffing ratios. These were announced in 2002 and implemented beginning in 2004. Since then, other states and the federal government have considered developing regulations for nurse staffing in hospitals. In 2014, for example, Massachusetts passed legislation mandating a ratio of one or two patients per nurse in intensive care units (Associated Press, 2014).
The Establishment of California’s Regulations
Throughout the late 1990s and early 2000s, there was substantial debate about the changes in hospital staffing that had occurred in the 1990s and the effects of such changes on the quality of care (Aiken, Sochalski, & Anderson, 1996; Spetz, 1998; Unruh & Fottler, 2006; Wunderlich, Sloan, & Davis, 1996). In some states, legislators and regulatory agencies considered staffing requirements with an aim to increase the numbers of nurses and other health care personnel working in hospitals and other settings. As the 1990s ended, a shortage of RNs emerged, and concern about poor staffing in hospitals continued (Kilborn, 1999). It was in this environment that AB 394 was passed by the California legislature. Previous Republican governors had vetoed similar legislation, but union-friendly Democratic Governor Gray Davis signed AB 394, satisfying union efforts to pass minimum-ratio legislation. AB 394 charged the California DHS with determining specific unit-by-unit nurse/patient ratios.
The DHS began an extensive effort to determine the new minimum nurse staffing ratios, with little research to guide them (Kravitz et al., 2002; Lang et al., 2004; Spetz et al., 2000). To help develop the proposed ratios, the DHS commissioned a study by researchers at the University of California, Davis (Kravitz et al., 2002). It also received recommendations about the ratios from stakeholders, ranging from the California Hospital Association (CHA) proposal of a ratio of 1 licensed nurse per 10 patients in medical-surgical units and the California Nurses Association recommendation of 1 517licensed nurse per 3 patients in medical-surgical units. The ratios established by DHS were between those recommended by the CHA and the unions, with a 1 : 6 ratio in medical-surgical units starting January 1, 2004, and a 1 : 5 ratio in medical-surgical units commencing in January 2005. Other units have higher minimum-ratio requirements. The minimum ratios do not replace the requirement that hospitals staff according to a patient classification system (PCS); if a hospital’s PCS indicates that higher staffing is needed, the hospital should staff accordingly.
What Has Happened as a Result of the Ratios?
The implementation of California’s minimum nurse staffing ratio legislation led to legal challenges and state government efforts to expand RN education. It also drove increases in hospital nurse staffing and wages in California. Several studies have found that the ratios are linked to higher nurse satisfaction, but there is little evidence that the regulations improved patient outcomes. Some research has found that there may have been negative impacts on hospitals’ finances and ability to provide charity care.
Two days before the ratios went into effect, the CHA filed a lawsuit arguing that the staffing ratios should not apply if a nurse takes a scheduled break or unscheduled restroom visit. The DHS contended that if the ratios were to have any meaning, they must be effective at all times. The judge hearing the case agreed with the DHS in a May 2004 ruling (Berestein, 2004). The second major legal challenge to the ratio regulations came from Governor Arnold Schwarzenegger, who sought to delay the implementation of the stricter ratio of one licensed nurse to five patients scheduled for January 2005 due to the severe shortage of licensed nurses (Rapaport, 2004). The CHA filed suit against the DHS in December 2004 alleging that the emergency order had illegally bypassed the legislature (LaMar, 2005). In early March, a Superior Court judge tentatively ruled that the DHS had indeed not followed the law when issuing the emergency regulation (Salladay & Chong, 2005), and the judge’s decision was finalized in May 2005 (Benson, 2005a, 2005b; Gledhill, 2005).
Expansion of Nursing Education
To assist hospitals in meeting the staffing ratio rules, both former Governor Davis and Governor Schwarzenegger dedicated funds to expanding nursing education and reducing attrition from nursing programs. Between 2004 to 2005 and 2009 to 2010, nursing graduations in California increased by 72%, reaching over 11,500 new RN graduates per year (Spetz, 2013).
Are Hospitals Meeting the Ratios?
The inspection and enforcement mechanisms of the DHS are relatively weak. The DHS does not have the authority to impose fines or monetary penalties on hospitals that are found to violate the ratios, but instead requests and monitors plans submitted by hospitals to remedy the problem. However, other mechanisms do exist to ensure that hospitals adhere to the ratios. First, government payers such as Medicare and Medi-Cal (the state Medicaid program) require that hospitals meet all state and federal regulations and can deny payment to violators. Second, California’s cap on malpractice awards does not apply in cases of negligence, and a hospital could be deemed negligent if it consistently did not adhere to minimum nurse staffing regulations (Robertson, 2004). Third, unions draw public attention to hospitals that do not meet the staffing requirements, resulting in negative publicity for hospitals and increased scrutiny from DHS inspectors. Fourth, labor organizations that represent nurses have sought to incorporate staffing standards in their contract negotiations, with some success (Gordon, 2005; Osterman, 2005).
Several studies of all California hospitals have found that annual average numbers of RN productive hours and nurse staffing ratios in medical-surgical units increased markedly between 2001 and 2006 (Conway et al., 2008; Cook et al., 2012; Mark et al., 2012; Munnich, 2013; Spetz et al., 2009; Spetz et al., 2013). Spetz and colleagues (2009) found that statewide average RN hours per patient day increased 16.2% from 1999 through 2006, to an average of 6.9 hours per patient day. Interviews 518conducted with hospital leaders by a research team at the University of California, San Francisco (UCSF) revealed that many chief nursing officers and other managers said they had hired nurses to meet the ratios, and most noted that it is challenging to adhere to the ratios at all times, including during scheduled breaks (Chapman et al., 2009).
Aiken and colleagues (2010) surveyed nearly 80,000 RNs in California, New Jersey, and Pennsylvania to learn their experiences with staffing, the work environment, and patient care. They found that nurse workloads, measured according to the average number of patients per shift, were lower in California than in New Jersey and Pennsylvania and that over 80% of California nurses reported that their assigned workloads were in compliance with the state’s regulation.
Has the Mix of Staff Changed?
There have been concerns that hospitals may have eliminated support staff positions because of the minimum licensed nurse staffing requirements (Spetz, 2001). Analyses of staffing data collected by the Collaborative Alliance for Nursing Outcomes (CALNOC) suggest that the substitution of licensed nurses for unlicensed staff may be widespread as the increase in RN staffing was much larger than the overall staffing increase among their hospitals (Bolton et al., 2007; Donaldson et al., 2005). In a series of qualitative interviews, some hospital leaders reported that they had laid off ancillary staff to use budgets to hire more RNs (Chapman et al., 2009), and the survey conducted by Aiken and colleagues found that nurses perceived reductions in LVN and aide use (Aiken et al., 2010). However, more recent analyses have measured only a slight decline in LVN staffing (Cook et al., 2012; Spetz et al., 2009; Spetz et al., 2013) and aide staffing (Cook et al., 2012; Spetz et al., 2009).
Have Hospitals Reduced Services and Charity Care?
The California Hospital Association warned that strict minimum nurse/patient ratio requirements would force hospitals to reduce their services. To maintain the minimum ratios, hospitals might reschedule procedures, close selected units and beds, or shut their doors entirely. However, there have been few verified reports of the minimum nurse/patient ratios causing permanent closures of inpatient hospital units or beds. There is some indication that there was lower growth in the provision of uncompensated care services among hospitals on which the regulations had the greatest impact on staffing levels (Reiter et al., 2011).
Have Hospitals Suffered Financial Losses?
Since 1999, California hospitals have been financially buffeted by numerous factors, including changes in Medicare and Medicaid payment policy and requirements that hospital facilities meet seismic standards through retrofitting or new construction (Spetz et al., 2009). Thus, it is difficult to determine whether the staffing regulations had any discernable effect on hospital finances. Qualitative evidence reported that hospital CEOs absorbed the costs of the ratios by reducing other budget areas, and some hospitals were able to obtain higher insurance reimbursement rates to cover additional staff expenses (Spetz et al., 2009). However, one analysis found that hospital prices rose even more between 1999 and 2005 than could be explained by labor cost increases that resulted from the nurse staffing ratios alone (Antwi, Gaynor, & Vogt, 2009).
In an analysis of hospital financial data, Cook (2009) found no significant change in total annual labor costs for licensed nurses, total annual hospital costs, or hospital prices. Reiter and colleagues (2012) used data from Medicare cost reports to explore whether changes in financial status differed between California hospitals that had higher versus lower preregulation staffing levels, and between California and other states. They found that relative to hospitals outside California, operating margins for California hospitals with lower preregulation staffing levels declined, and operating expenses increased significantly.
Did Wages for Nurses Increase?
In theory, when the demand for workers rises more rapidly than the supply, wages should rise. Two studies have examined whether growth in the hiring of RNs caused by the staffing regulations is linked 519to more rapid growth in RN wages. One study found that wage growth among urban RNs in California was as much as 12% higher than in other states (Mark, Harless, & Spetz, 2009). A more recent analysis measured a 4.9% increase in RN wages between 2000 and 2007 with one dataset, and no increase at all with a different dataset (Munnich, 2013).
Are Nurses More Satisfied?
Advocates of staffing ratio regulations link improved staffing to nurse satisfaction and argue that greater nurse satisfaction will reduce nurse turnover and lead to better patient outcomes (California Nurses Association, 2009; Public Policy Associates, 2004). An analysis of statewide nurse survey data found that there were significant improvements in overall job satisfaction among hospital-employed RNs between 2004 and 2006 (Spetz, 2008). Nurse satisfaction also increased with respect to the adequacy of RN staff, time for patient education, benefits, and clerical support.
Aiken and colleagues (2010) also found in their survey of nurses in three states that RNs in California were more satisfied with their working conditions. Nurses in California were significantly more likely to report that their workload was reasonable and allowed them to spend adequate time with patients and that they were able to take breaks during the workday. Nurses with lower workloads were significantly less likely to report that they received complaints from families, faced verbal abuse, were burned out, were dissatisfied, felt quality of care was poor, or were looking for new jobs.
Did the Ratios Improve the Quality of Care?
One of the main purposes of California’s minimum staffing legislation was to improve the quality of patient care. However, to date there is no convincing evidence that patient safety or the quality of care has improved. In the first paper published on this subject, rates of patient falls and hospital-acquired pressure ulcers reported to CALNOC between 2002 and 2004 were analyzed for 68 hospitals, and it was found that there was no statistically significant change that could be attributed to the ratios (Donaldson et al., 2005). A follow-up study of data through 2006 confirmed these results (Bolton et al., 2007). These analyses had two main shortcomings: They included only a subset of California’s hospitals and the two outcomes examined might not be very sensitive to changes in licensed nurse staffing. Studies that examine whether licensed nurse staffing affects rates of hospital-acquired pressure ulcers and postoperative hip fractures from a patient fall have produced mixed findings (Agency for Healthcare Research and Quality, 2005).
Aiken and colleagues linked their survey data to secondary data on patient outcomes collected by state government agencies (Aiken et al., 2010) and found that in all three states studied, higher nurse staffing levels were associated with lower rates of 30-day inpatient mortality and failure-to-rescue. These relationships were stronger in California than in other states. However, this analysis cannot confirm that the staffing regulations directly caused changes in patient outcomes. Research based on a single year of data does not measure the effect of changes in policy or practice on changes in patient outcomes. Although the responses of nurses regarding the patient safety environment suggest that the lower workloads in California are associated with more positive nurse perceptions of patient safety, these perceptions may not lead to actual improvements in patient outcomes. It’s important to note that the analysis of patient outcomes in this study was limited to two outcomes.
Several newer studies have used multiple years of statewide data and examined a wider variety of outcomes. For example, Spetz and colleagues examined OSHPD patient discharge data for all nonfederal, general acute care California hospitals from 1999 through 2006 but could not associate improvements in outcomes to the implementation of the ratios (Spetz et al., 2009). In a more rigorous analysis of OSHPD data from 2001 to 2006, Cook and colleagues (2012)found no association between changes in nurse staffing and changes in pressure ulcer rates or failure-to-rescue a patient after a 520complication. Using similar methods, Spetz and colleagues (2013) examined six patient safety indicators using OSHPD data from 2000 to 2006 and found that growth in registered nurse staffing was associated with an improvement for only one outcome, mortality following a complication. They also analyzed whether the average length of stay declined among patients who experienced adverse events to explore the possibility that improved surveillance in better-staffed hospitals might reduce the severity of any complications. They found growth in staffing was significantly associated with reduced length of stay for only one patient safety indicator: select infections due to medical care.
The most comprehensive analysis of the impact of California’s regulations on patient outcomes was published by Mark and colleagues (2012). Using patient discharge data from California and 12 comparison states they examined whether differences in staffing changes between California and other states were associated with different patient outcome trajectories. Their analysis also considered differences between hospitals with high preregulation staffing as compared with low preregulation staffing. They found that failure-to-rescue following a complication decreased significantly in some California hospitals, and infections caused by medical care increased significantly in some California hospitals as compared with comparable hospitals in other states. There were no statistically significant changes in either respiratory failure or postoperative sepsis.
Together, this research indicates that California’s regulations did not systematically improve the quality of patient care, although there remains a need for more research on this topic. The outcomes examined thus far have been relatively limited, and it is possible that patient care improvements will be found in other areas such as medication safety. It also is possible that changes in patient outcomes caused by the staffing ratios occur over a longer period of time. However, examining and interpreting data over a longer period of time will be complicated by the fact that many health systems and hospitals have established quality improvement programs in response to increased public attention to medical errors and patient outcomes.
One remaining issue central to the debate about minimum nurse/patient ratios has yet to be addressed: What was the total cost of the ratio regulations?
Cost of the Ratios
Any positive impact of minimum staffing ratios should be weighed against their cost (Donaldson & Shapiro, 2011). As of 2014, these costs had not been accurately quantified. A careful accounting of the extent to which increases in nurse staffing were necessitated by the ratios, and the cost of any such increases, is necessary. Moreover, it is important to quantify the value of other investments hospitals might have made if they were not required to adhere to the staffing ratios. A hospital may have delayed implementation of a new infection-control system that would have reduced infection rates, and such opportunity costs should be included as part of the overall cost of the staffing regulations.
The only federal regulation that directly referred to nurse staffing levels in hospitals at the time of writing is the 42 Code of Federal Regulations (42CFR 482.23[b]), which requires hospitals that participate in Medicare to have “adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed” (American Nurses Association, 2009). In 2009, Sen. Barbara Boxer (D-CA) introduced S 1031, and Rep. Janice Schakowsky (D-IL) introduced H.R. 2273, both of which would have required that hospitals implement nurse-to-patient staffing plans and meet minimum RN nurse-to-patient ratios for specified patient care units. These bills did not pass, although the bills were reintroduced in 2011 and 2013.
Some states have pursued their own staffing regulations. State regulations generally take one or more of three approaches: a requirement that hospitals develop and implement nurse staffing plans with direct input from nurses, requiring 521public disclosure of staffing levels, and/or establishment of fixed minimum staffing ratios. California is the only state to have implemented a law using this third strategy, although similar legislation has been proposed in other states including Illinois, Kentucky, Maryland, New Jersey, New York, Vermont, and West Virginia.
Some states have opted to develop staffing regulations that offer hospitals more flexibility than fixed minimum staffing ratios. Connecticut, Illinois, Nevada, Ohio, Oregon, Texas, and Washington have signed into law requirements that hospitals implement and enforce a written nurse staffing policy. In most of these states, the staffing policy must be developed by a committee that includes staff nurses. Rhode Island requires that hospitals submit a “core staffing plan” to the state department of health annually, with specific staffing for each patient care unit and each shift (American Nurses Association, 2013).
The third, and least binding, approach to nurse staffing regulation is to mandate reporting of staffing ratios to the public or to a regulatory agency. In New York, for example, facilities must make available to the public information about nurse staffing and patient outcomes. Specific adverse events, such as medication errors and decubitus ulcers, are considered reportable information under this law. Other states with public reporting requirements are Illinois, New Jersey, Rhode Island, and Vermont. New Jersey’s regulation mandates that hospitals post daily staffing information for each unit and shift and provide these data to state regulators, and in 2009, New York added a similar posting requirement to its regulations.
Even without new legislation, hospitals are likely to continue to focus on nurse staffing improvements as the evidence suggests that nurse staffing is a good financial investment in quality improvement (Rothberg et al., 2005). More research is needed, however, to determine whether the lack of measured benefit from California’s regulation is caused by limitations of prior research or indicative of an actual lack of impact. If California’s regulation can one day be shown to have improved patient outcomes at an acceptable cost, it will be easier for other states to follow in California’s footsteps.
1. It is not clear from the research conducted thus far whether California’s staffing regulations have improved patient outcomes. However, several studies have found that nurse satisfaction has improved and that nurses perceive that they are providing better care. Is improving nurse satisfaction a sufficient reason to establish this type of regulation?
2. Several studies have suggested that hospitals responded to the staffing regulations by reducing staffing of non-RN personnel. What might be the benefits and consequences of reducing non-RN staffing?
3. Are regulations that require staffing committees likely to effectively address concerns about inadequate nurse staffing? What about laws that require public reporting of staffing levels?
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Frameworks for Action in Policy and Politics
Eileen T. O’Grady, Diana J. Mason, Freida Hopkins Outlaw, Deborah B. Gardner
“The most common way people give up their power is by thinking they don’t have any.”
March 31, 2013 marked an important deadline in the implementation of landmark legislation, the Affordable Care Act (ACA)1, also known as Obamacare. By that date those eligible to enroll for insurance coverage through the marketplace had to purchase a plan if they were to avoid a 2015 tax penalty of $95 or 1% of their annual income (whichever was higher). Amid a frenzy of media attention, an estimated 8 million people signed on for coverage during open enrollment—the period between October 2012 and the deadline—exceeding the revised target of 6.5 million (Kennedy, 2014). And the numbers kept increasing, as millions more enrolled in Medicaid or the Children’s Health Insurance Program (known as CHIP) (Centers for Medicare and Medicaid Services [CMS], 2014).
Nurses were essential to these enrollments. For example, Adriana Perez, PhD, ANP, RN, an assistant professor at Arizona State University College of Nursing, used her role as president of the Phoenix Chapter of the National Association of Hispanic Nurses to organize town hall meetings with Spanish-speaking state residents to explain the ACA and encourage enrollment among those with a high rate of un- or under-insurance. She also developed a training model in partnership with AARP-Arizona and used it to empower Arizona nurses to educate multicultural communities on the basic provisions of the ACA. Through many such initiatives, the United States reduced the number of uninsured people by over 10 million in 2014; the number is projected to be 20 million by 2016 (Congressional Budget Office [CBO], 2014).
However, access to coverage does not necessarily mean access to care, nor does it ensure a healthy population. Health care access means having the ability to receive the right type of care when needed at an affordable price. The U.S. health care system is grounded in expensive, high-tech acute care that does not produce the desired outcomes we ought to have and too often damages instead of heals (National Research Council, 2013). Despite spending more per person on health care than any other nation, a comparative report on health indicators by the Organisation for Economic Co-operation and Development (2013) shows that the United States performs worse than other nations on life 2expectancy at birth for both men and women, infant mortality rate, mortality rates for suicide and cardiovascular disease, the prevalence of diabetes and obesity in children, and other indicators.
In 1999, the Institute of Medicine (IOM) issued a report, To Err is Human: Building a Safer Health System, which estimated that health care errors in hospitals were the fifth leading cause of death in the U.S. (IOM, 1999). By 2011, preventable health care errors were estimated to be the third-leading cause of death (Allen, 2013; James, 2013). The ACA includes elements that can begin to create a high-performing health care system, one accountable for the provision of safe care, as well as improved clinical and financial outcomes. It aims to move the health care system in the direction of keeping people out of hospitals, in their own homes and communities, with an emphasis on wellness, health promotion, and better management of chronic illnesses.
For example, the ACA uses financial penalties to prod hospitals to reduce 30-day readmission rates. It also provides funding for demonstration projects that improve “transitional care,” services that help patients and their family caregivers to make a smoother transition from hospital or nursing home to their own homes to help reduce preventable hospital readmissions. Based, in part, on research by Mary Naylor, PhD, RN, FAAN, professor of nursing at the University of Pennsylvania School of Nursing, these demonstrations are stimulating creative methods of accountability across health care settings, with most using nurses for care coordination and transitional care providers (CMS, n.d.; Coalition for Evidence-Based Policy, n.d.; Naylor et al., 2011).
Promoting health requires more than a high-performing health care system. First and foremost, health is created where people live, work, and play. It is becoming clear that one’s health status may be more dependent on one’s zip code than on one’s genetic code (Marks, 2009). Geographic analyses of race and ethnicity, income, and health status repeatedly show that financial, racial, and ethnic disparities persist (Braveman et al., 2010). Individual health and family health are severely compromised in communities where good education, nutritious foods, safe places to exercise, and well-paying jobs are scarce (Halpin, Morales-Suárez-Varela, & Martin-Moreno, 2010). Creating a healthier nation requires that we address “upstream factors”; the broad range of issues, other than health care, that can undermine or promote health (also known as “social determinants of health” or “core determinants of health”) (World Health Organization [WHO], n.d.). Upstream factors promoting health include safe environments, adequate housing, and economically thriving communities with employment opportunities, access to affordable and healthful foods, and models for addressing conflict through dialogue rather than violence. According to Williams and colleagues (2008), the key to reducing and eliminating health disparities, which disproportionately affect racial and ethnic minorities, is to provide effective interventions that address upstream factors both in and outside of health care systems. Upstream factors have a large influence on the development and progression of illnesses (Williams et al., 2008). The core determinants of health will be used to further elucidate and make concrete the wider, more comprehensive set of upstream factors that can improve the health of the nation by reducing disparities. Figure 1-1 depicts the core determinants of health developed by the Canadian Forces Health Services Group.
FIGURE 1-1 Surgeon General’s Mental Health Strategy: Canadian Forces Health Services Group—An Evolution of Excellence. (From www.forces.gc.ca/en/about-reports-pubs-health/surg-gen-mental-health-strategy-ch-2.page.)
A focus on such factors is essential for economic and moral reasons. Even in the most affluent nations, those living in poverty have substantially shorter life expectancies and experience more illness than those who are wealthy, with high costs in human and financial terms (Wilkinson & Marmot, 2003). To date however, most of the focus on reducing disparities has been on health policy that addresses access, coverage, cost, and quality of care once the individual has entered the health care system–despite the fact that for more than a decade research has established that most health care problems begin long before people seek medical care (Williams et al., 2008). Thus, changing the paradigm requires knowledge about the political aspects of the social determinates of health and the broader 3core determinants. Political aspects of the social determinants of health appear in Box 1-1.
Political Aspects of the Social Determinants of Health
• The health of individuals and populations is determined significantly by social factors.
• The social determinants of health produce great inequities in health within and between societies.
• The poor and disadvantaged experience worse health than the rich, have less access to care, and die younger in all societies.
• The social determinants of health can be measured and described.
• The measurement of the social determinants provides evidence that can serve as the basis for political action.
• Evidence is generated and used in a continuous cycle of evidence production, policy development, implementation, and evaluation.
• Evidence of the effects of policies and programs on inequities can be measured and can provide data on the effectiveness of interventions.
• Evidence regarding the social determinants of health is insufficient to bring about change on its own; political will combined with evidence offers the most powerful strategy to address the negative effects of the social determinants.
Adapted from National Institute for Health and Clinical Excellence. (2007). The Social Determinants of Health: Developing an Evidence Base for Political Action. Final report to the World Health Organization Commission on the Social Determinants of Health. Lead authors: J. Mackenbach, M. Exworthy, J. Popay, P. Tugwell, V. Robinson, S. Simpson, T. Narayan, L. Myer, T. Houweling, L. Jadue, and F. Florenza.
The ACA begins to carve out a role for the health care system in addressing upstream factors. For example, the law requires that nonprofit hospitals demonstrate a “community benefit” to receive federal tax breaks. Hospitals must conduct a community health assessment, develop a community health improvement plan, and partner with others to implement it. This aligns with a growing emphasis on population health: the health of a group, whether defined by a common disease or health problem or by geographic or demographic characteristics (Felt-Lisk & Higgins, 2011).
Consider the 11th Street Family Health Services. Located in an underserved neighborhood in North Philadelphia, this federally qualified, nurse-managed health center (NMHC) was the brainchild of public health nurse Patricia Gerrity, PhD, RN, FAAN, a faculty member at Drexel University School of Nursing. She recognized that the leading health problems in the community were diabetes, obesity, heart failure, and depression. Working with a community advisory group, Gerrity realized that the health center had to address nutrition as an “upstream factor” that could improve the health of those living in the community. With no supermarket in the neighborhood until 2011, she invited area farmers to come to the neighborhood as part of a farmers’ market. She also created a community vegetable garden maintained by the local youth. And area residents were invited to attend nutrition classes on culturally relevant, healthful cooking. 11th Street Family Health Services is one of over 200 NMHCs in the United States that have improved clinical and financial outcomes by addressing the needs of individuals, families, and communities 4(American Academy of Nursing, n.d., b). The ACA authorizes continued support for these centers, although the law does not mandate they be funded. Congress would have to appropriate funding for NMHCs but has not done so. (See Chapter 34 for a more detailed discussion of NMHCs.)
The ACA may not go far enough in shifting attention to the health of communities and populations. One approach gaining notice is that of “health in all policies,” the idea that policymakers consider the health implications of social and economic policies that focus on other sectors, such as education, community development, tax codes, and housing (Leppo et al., 2013; Rudolph et al., 2013). As health professionals who focus on the family and community context of the patients they serve, nurses can help to raise questions about the potential health impact of public policies.
Nursing and Health Policy
Health policy affects every nurse’s daily practice. Indeed, health policy determines who gets what type of health care, when, how, from whom, and at what cost. The study of health policy is an indispensable component of professional development in nursing, whether it is undertaken to advance a healthier society, promote a safer health care system, or support nursing’s ability to care for people with equity and skill. Just as Florence Nightingale understood that health policy held the key to improving the health of poor Londoners and the British military, so are today’s nurses needed to create compelling cases and actively influence better health policies at every level of governance. With national attention focused on how to transform health care in ways that produce better outcomes and reduce health care costs, nursing has an unprecedented opportunity to provide proactive and visionary leadership. Indeed, the Institute of Medicine’s landmark report, The Future of Nursing: Leading Change, Advancing Health (2011), calls for nurses to be leaders in redesigning health care. But will nurses rise to this occasion?
Health care opinion leaders in a 2010 poll identified two reasons nurses would fall short of influencing health care reform: too many nurses do not want to lead, and with over 120 national organizations, nursing often fails to present a united front (Gallup, 2010). As the largest health care profession, nursing has great potential power. Yet, similar to many professions, it has struggled to collaborate within its ranks or with other groups on pressing issues of health policy. The IOM report has provided a rallying point for nursing organizations to work together and engage other stakeholders to advance its recommendations.
Reforming Health Care
The Triple Aim
In 2008, Don Berwick, MD, and his colleagues at the Institute for Healthcare Improvement (IHI) first described the Triple Aim of a value-based health care system (Berwick, Nolan, & Whittington, 2008): (1) improving population health, (2) improving the patient experience of care, and (3) reducing per capita costs. This framework aligns with the aims of the Affordable Care Act.
The Triple Aim represents a balanced approach: by examining a health care delivery problem from all three dimensions, health care organizations and society can identify system problems and direct resources to activities that can have the greatest impact. Looking at each of these dimensions in isolation prevents organizations from discovering how a new objective, decreasing readmission rates to improve quality and reduce costs, for instance, could negatively impact the third goal of population health, as scarce community resources are directed to acute care transitions and unintentionally shifted away from prevention activities. Solutions must also be evaluated from these three interdependent dimensions. The Triple Aim compels delivery systems and payors to broaden their focus on acute and highly specialized care toward more integrated care, including primary and preventive care (McCarthy & Klein, 2010).
The IHI (n.d.) identified these components of any approach seeking to achieve the Triple Aim:
• A focus on individuals and families
• A redesign of primary care services
• Population health management
• A cost-control platform
• System integration and execution
Note that these possess the goal of creating a high-performing health care system but do not focus on geographic communities or social determinants per se. However, these two concepts can be incorporated into the Triple Aim of improving the health of populations and reducing health care costs.
The Triple Aim is easy to understand but challenging to implement because it requires all providers, including nurses, to broaden their focus from individuals to populations. The success of the nursing profession’s continued evolution will hinge on its ability to take on new roles, more cogently and creatively engaging with patients and stepping into executive and leadership roles in every sector of heath care. But it must do so within an interprofessional context, leading efforts to break down health professions’ silos and hierarchies and keeping the patient and family at the center of care.
The ACA and Nursing
The ACA is arguably the most significant piece of social legislation passed in the United States since the enactment of Medicare and Medicaid in 1965. Implementation continues to be a vexing process and a political flashpoint. It has defined the ideologies of U.S. political parties, and yet the public remains largely uninformed and misinformed about the legislation; 3 years after its passage, 4 out of 10 Americans were still unaware of many of its provisions and unsure that the ACA had become law (The Henry J. Kaiser Family Foundation, 2013). (Chapter 19 provides a thorough description of the ACA.) The ACA is over 2000 pages long, which reflects the complexity of creating a new health care infrastructure that addresses a wide array of issues including patient protections, health insurance industry reforms, and workforce development, to name a few. Newer systems of care are emphasized in the ACA that link patient outcomes to costs incurred in treatment and to high-value health systems. The legislation can be categorized into four main cornerstones (Figure 1-2).
FIGURE 1-2 Four cornerstones of reform. (From O’Grady, E. T., & Johnson, J. . Health policy issues in changing environments. In A. Hamric, C. Hanson, D. Way, & E. O’Grady [Eds.], Advanced practice nursing: An integrative approach [5th ed.]. St. Louis, MO: Elsevier-Saunders.)
The ACA was born out of national macroeconomic concerns. The United States spent $2.7 trillion in 2011, or $8680 per person, on health care; a rate higher than inflation that is expected to consume nearly 20% of the gross domestic product by 2020 (CMS, 2013). With businesses having to spend such large amounts on health care for employees, the United States cannot compete in the global economy. Furthermore, such high health care expenses divert funds away from addressing the upstream factors that could prevent the need for costly acute care. Although previous presidents in the past 50 years tried unsuccessfully to pass health care reform legislation, President Obama was elected at a time when many Americans agreed that the United States could no longer afford to maintain a health care system that had neither spending controls nor accountability for improving clinical outcomes. The ACA was an outgrowth, in part, to “bend the cost curve,” or reduce the rate of increase in health care spending (Cutler, 2010).
To improve the health of the public and reduce health care costs, health promotion and wellness, disease prevention, and chronic care management must be built into the foundation of the health care system (Katz, 2009; Wagner, 1998; Woolf, 2009). At 6the same time, acute care must use fewer resources, be made safer, and produce better outcomes (Conway, Mostashari, & Clancy, 2013).
Nurses are important players in shifting the focus of health care to one that prevents illnesses, promotes health, and coordinates care. Nurses have been performing in such roles without naming or measuring their activities for decades. But there are exceptions. The American Academy of Nursing’s Raise the Voice Campaign (American Academy of Nursing, n.d., a) has identified nurses who have developed innovative models of care for which there are good clinical and financial outcome data. Known as “Edge Runners,” these nurses have demonstrated that nursing’s emphasis on care coordination, health promotion, patient- and family-centeredness, and the community context of care provides evidence-based models that can help to transform the health care system.
The ACA presents many opportunities for nurses to test new models of care that have already shown promise for improving health outcomes and the experience of health care, while lowering costs. The Center for Medicare and Medicaid Innovation (CMMI) was authorized to spend $10 billion over a decade to pilot-test programs that may improve the safety and quality of care. For example, under the Bundled Payments for Care Improvement Initiative, health systems will enter into payment arrangements that include financial and performance accountability for episodes of care. Currently being studied, an episode of care includes the inpatient stay and all related services during the episode up to 90 days after hospital discharge. These models may lead to higher quality, more coordinated care at a lower cost to Medicare. If the program is successful in achieving these outcomes, they are authorized to launch the program nation-wide.
If these can be shown to achieve the Triple Aim, the ACA authorizes the Secretary of the U.S. Department of Health and Human Services to put these programs in place permanently. The CMMI provides opportunities for nurse leaders and nurse researchers to demonstrate new methods of improving care in cost-effective ways. In addition, the ACA created the Patient-Centered Outcomes Research Institute (PCORI) with $3.5 billion to support comparative-effectiveness research that examines the outcomes that matter to consumers. Nurses serve on the governing board and review panels of PCORI. It provides nurses with opportunities to compare nursing interventions, head-to-head or with medications or other treatments that have sufficient evidence.
The following examples illustrate how nursing is embedded in the four cornerstones of reform. Some of these examples address only one cornerstone; others address all four.
1. Create Value.
NMHCs are operated by advanced practice registered nurses (APRNs), primarily nurse practitioners (NPs). These clinics are often associated with a school, college, university, department of nursing, federally qualified health center, or an independent nonprofit health care agency. Managed by APRNs, NMHCs are staffed by an interprofessional team that may include physicians, social workers, public health nurses, psychiatric mental health nurses at the generic and advanced levels, and behavioral therapists. Barkauskas and colleagues (2011) found that quality measures for NMHCs compared positively with national benchmarks, particularly in chronic disease management. The founders of several NMHCs have been designated Edge Runners, including Patricia Gerrity of the 11th Street Family Health Service, as described earlier. NMHCs serve as critical access points for keeping patients out of the emergency room and hospitals, saving millions of dollars annually (Hansen-Turton et al., 2010).
2. Coordinate Care.
The patient-centered “medical home” or “health home”2 (PCMH) model was designed to satisfy patients’ needs and to improve care access (e.g., through extended office hours and increased communication between providers and patients via e-mail and telephone), 7increase care coordination, and enhance overall quality, while simultaneously reducing costs. The medical home relies on a one-stop-shopping approach by a team of providers, such as physicians, nurses, nutritionists, pharmacists, and social workers, to meet a patient’s health care needs. Peikes and colleagues (2012) found that the PCMH model’s attention to the whole person across care settings (such as from hospital to home) may improve physical and behavioral health, access to community-based social services, and management of chronic conditions. A number of NMHCs have achieved PCMH designation by the National Committee on Quality Assurance.
3. Payment Reform.
Bundling payments and paying for care coordination, including through “accountable care organizations” (ACOs), are examples of payment reform. ACOs are similar to integrated delivery systems that combine services across health care settings and focus on ways to improve care delivery and outcomes under a bundled payment plan. Bundling payments allows for reimbursement of multiple services provided during an episode of care, rather than the traditional fee-for-service payments for each service or procedure for a single illness. ACOs differ from health maintenance organizations (HMOs) in that they are not incentivized to cut services but rather to keep people healthy. Indeed, one of the major differences between HMOs in the 1990s and ACOs today is that the latter are held to a higher standard of measuring, reporting, and making transparent the process and outcome indicators of quality. Each ACO has to have a minimum of 5000 Medicare patients (population health); if the ACO demonstrates that it keeps people healthy and saves Medicare money, those savings are “shared” with the ACO. Nurses are central to preventing complications in hospitalized patients, ensuring smooth transitions to home, and coaching the patient and family caregivers in self-care and health-promoting behavioral changes. As such, they are a vital component of ACO success.
But payment reform is proving to be challenging. The CMMI, authorized under the ACA, initially funded 31 “pioneer” ACOs. By mid-2014, only 22 remained, mostly because of difficulty in managing payment to the various entities in the ACO’s network. Nonetheless, there is some consensus that the fee-for-service payment system encourages overtreatment (unnecessary and costly care) and must be replaced (Cutler, 2010; Gibson & Singh, 2012).
4. Improve Access to Coverage.
The ACA does not guarantee health insurance coverage for all, including undocumented immigrants, but, by 2017, it will cover up to 30 million of the 45 million who were uninsured when the bill was signed in 2010 (89% of the total nonolder adult population; 92% of nonolder adult American citizens) (Congressional Budget Office [CBO], 2014). It makes it illegal for insurance companies to deny coverage to people with preexisting conditions, to drop people once they acquire a costly illness, or to apply annual and lifetime caps on coverage. As the demand for health care surges, it is expected that APRNs will be positioned to provide much of the needed primary care, creating the need for APRNs to practice to the full extent of their education and training. Barriers preventing such practice include mandated physician supervision or collaboration in two thirds of states, insurers refusing to credential or impanel APRNs, Medicare requirements for physicians—rather than NPs—to order referrals to home care and hospice, and other local, state, and national policies that limit APRN practice.
Access to coverage does not ensure that people will have access to care. There is a lack of primary care physicians (PCPs) serving the poor, in both rural and urban regions; approximately 210,000 PCPs currently practice, and it has been estimated that another 52,000 will be needed by 2025 (Petterson et al., 2012). This shortfall has led to the development of the APRN role. A workforce analysis center at the Health Resources and Services Administration reported that if primary care NPs and physician assistants (PAs) are fully integrated into a health care delivery system that emphasizes team-based care, the projected shortage of PCPs would be “somewhat alleviated” by 2020 (U.S. Department of Health and Human Services, 2013).
Community-based health care centers will be expanded in areas where there are health care 8provider shortages. Expansion of the National Health Service Corps is expected to ensure that providers, including registered nurses (RNs) and APRNs, will be available to staff these centers. An emphasis on primary care will increase the demand for NPs and RNs, and the ACA authorizes additional support for primary care workforce development (loans, scholarships, new educational program development, and expansion of existing programs). (See Chapter 60 for more on the nursing workforce.)
Nurses as Leaders in Health Care Reform
Coinciding with the passage of the ACA was the timely publication of The Future of Nursing: Leading Change, Advancing Health (IOM, 2011). It makes four recommendations, one of which is “Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States” (Figure 1-3).
FIGURE 1-3 Four key messages: The IOM report. (From Institute of Medicine. . The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Retrieved from www.iom.edu/nursing.)
This presents a challenge to nurses: to identify opportunities to participate in policy decision making at all levels of society, the health care system, and health care organizations. Although nursing is well positioned to contribute to a reformed health care system, we cannot assume that those making the decisions about reform will automatically seek nurses’ input. And, if invited to policy tables, will nurses show up and participate fully? The IOM report calls for the profession to develop its leadership capacity, while encouraging policymakers and others to appreciate nurses’ perspectives on policy. Whether developing new models of care, sharing ideas for regulations with policymakers, developing demonstration projects that the new health care law seeks to test, or advocating new legislation to amend and improve upon the law (or preventing it from being dismantled), nurses must strengthen their social covenant with the public and more forcefully engage in shaping policy at all levels within government, workplaces, health-related organizations, and communities.
Policy and the Policy Process
What do we mean by policy? Policy has been defined as the authoritative decisions made in the legislative, executive, or judicial branches of government intended to influence the actions, behaviors, or decisions of citizens (Longest, 2010). But that definition limits its application to sectors outside of government. For example, health care organizations set policy that affects employees, patients, and even surrounding communities (for example, by closing a neighborhood clinic or buying property for hospital expansion). Thus, a broader definition of policy is “a relatively stable, purposive course of action or inaction followed by an actor or set of actors in dealing with a problem or matter of concern” (Anderson, 2015, p. 6).
Public policy is policy crafted by governments. When the intent of a public policy is to influence health or health care, it is a health policy. Social policies identify courses of action to deal with social problems. All are made within a dynamic environment and a complex policymaking process. Private policies are those made by nongovernmental entities, whether health care organizations, insurers, or 9others. Indeed, there is growing recognition that policies set by health care organizations and insurers, for example, can limit APRN practice even in states that have removed laws requiring physician supervision or collaboration. A hospital can limit what APRNs do as long as the organization does not call for APRNs to practice beyond the state’s scope-of-practice policy.
Policies are crafted everywhere, from small towns to Capitol Hill. States use policies to specify requirements for health professions’ licensure, to set criteria for Medicaid eligibility, and to require immunization for public university students, for example. Hospitals use policies to direct when visitors may visit patients, to manage staffing, and to respond to disasters. Public schools employ state policies to specify who may administer medications to schoolchildren and what may be sold from a school vending machine. Towns, cities, and other municipalities use policies to manage public water, to define who may run for office, and to decide if residents may keep exotic pets.
In a capitalist economy such as that of the United States, private markets can control the production and consumption of goods and services, including health care. The government often “intervenes” with policies when private markets have failed to achieve desired public objectives. But when is it necessary for the government to intercede? Broadly speaking, in the current U.S. political system, the divide between liberal and conservative political parties is a fundamental disagreement about the degree to which government can and should solve problems (Kelly, 2004) in education, national security, the environment, and nearly every other aspect of public life. The American political landscape is continuously shifting, as public mood shifts with new Representatives being elected and senior Representatives desiring to stay in office.
Longest (2010) describes two types of public policies the government develops:
• Allocative policies provide benefits to a distinct group of individuals or organizations, at the expense of others, to achieve a public objective (this is also referred to as the redistribution of wealth). The enactment of Medicare in 1965 was an allocative policy that provided health benefits to older adults using federal funds (largely from middle- and high-income taxpayers).
• Regulatory policies influence the actions, behavior, and decisions of individuals or groups to ensure that a public objective is met. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 regulates how individually identifiable health information is managed by users, as well as other aspects of health records.
Policymaking is an often unpredictable dance that requires a high degree of political competence. Our system is based on continuous policy modification—incremental change is exceedingly more likely than revolutionary change. But there are exceptions; once in a generation a large social program is passed such as Medicare and Medicaid in the 1960s and the ACA in 2010.
Forces That Shape Health Policy
Some of the most prominent forces that shape health policy appear in Figure 1-4.
FIGURE 1-4 The forces that shape policy.
Values undergird proposed and adopted policies and influence all political and policymaking activities. Public policies reflect a society’s values and also its conflicts in values. A policy reflects which values are given priority in a specific decision (Kraft & Furlong, 2010). Once framed, a policy reveals the underlying values that shaped it. Different people value different things, and when resources are finite, policy choices ultimately bring a disadvantage to some groups; some will gain something from the policy, and some will lose (Bankowski, 1996). To support or oppose a policy requires value judgments (Majone, 1989). Conflicts between values were apparent throughout the debates on the ACA; for example, despite a strong contingent of advocates for a government-run, nonprofit insurance option that would compete with private insurers, the insurance industry opposed it, as did others who saw it as an increase in government control, and it was not included in the law.
Politics is the use of relationships and power to gain ascendancy among competing stakeholders to influence policy and the allocation of scarce resources. Because inevitably there are competing interests for scarce resources, policymaking is done within a political context.
The definition of politics contains several important concepts. Influencing indicates that there are opportunities to shape the outcome of a process. Allocation means that decisions are being made about how to distribute resources. Scarce implies the limits to available resources and that all parties probably cannot have all they want. Finally, resourcesare usually considered to be financial but could also include human resources (personnel), time, or physical space such as offices (Mason, Leavitt, & Chaffee, 2012). Engaging in the political context of policymaking includes knowing the positions of key stakeholders and political parties, as well as the electoral process, public opinion, the influence of media coverage, and more (see Chapter 9 for an in-depth discussion of political analysis and strategies). Understanding politics is an invitation not to misuse power, people, or information but rather to align the health of the public with the interest of the policymaker. For example, a Congresswoman may have run her campaign focused on improving the economy. She may not have linked the rising obesity epidemic as a threat to the larger macroeconomy and American productivity. Nurses could link obesity to the economy by describing the catastrophic direct and indirect costs of the obesity epidemic and how it is making the United States less competitive in a global market. This is a way for nurses to use their power to create more urgency about the most pressing public health issues.
Policy Analysis and Analysts
Analysis is the examination of an object or a process to understand it better. Policy analysis uses various methods to assess a problem and determine possible solutions. This encourages deliberate critical thinking about the causes of problems, identifies the ways a government or other groups could respond, evaluates alternatives, and determines the most desirable policy choice. (See Chapter 7.) Policy analysts are individuals who, with professional training and experience, analyze problems and weigh potential solutions. Citizens can also use policy analysis to better understand a problem, 11alternatives, and potential implications of policy choices (Kraft & Furlong, 2010).
Advocacy and Activism
Advocacy of one patient at a time has long been a central role for nurses. But nurses can be advocates on a larger scale by working in policy and politics, which is endorsed in “nursing’s social policy statement” (American Nurses Association [ANA], 2003), a document that defines nursing and its social context. Political activism may be associated with protests but has grown to include additional diverse and effective strategies such as blogging, using evidence to support policy choices, and garnering media attention in sophisticated ways.
Interest Groups and Lobbyists
Interest groups advocate for policies that are advantageous to their membership. Groups often employ lobbyists to advocate on their behalf and their power cannot be underestimated. In 2009, 1814 U.S. businesses and organizations spent $554,566,269 on lobbying and employed 3527 lobbyists to advocate for their interests in the health care reform debate and other issues (Center for Responsive Politics, n.d., a). This was a peak year that coincided with interest groups’ attempts to influence the ACA. In 2013, 1299 organizations spent $483,078,712 on lobbying and used 2918 lobbyists to advance their interests, including over $1.6 million by the ANA and $940,000 by the American Association of Nurse Anesthetists (Center for Responsive Politics, n.d., b).
The power of media is demonstrated in political and issue campaigns, whether through paid political advertisements or the “talking heads” on “news” programs that present polarized views. The aim is to deliver messages that resonate with the values and emotions of a target audience to support or oppose a candidate or proposed policy. The strategic use of media is imperative in today’s cacophony of information. Gaining the attention of a target audience is power. Persuading that audience to behave the way you want is ultimate power.
In this information age, nurses must proactively use media to influence policy and make themselves available to speak with journalists about policy matters. However, nurses have not always been eager to enter the media spotlight (see Chapter 14 on using media as a policy and political tool), particularly when it comes to talking with journalists. Social media is a tool for influencing policymakers (Grande et al., 2014) and provides nurses with an opportunity to control their message. Nurse bloggers such as Barbara Glickstein are getting visibility as “media makers.” Theresa Brown writes for the Opinionator column for The New York Times. Both are bringing nursing perspectives on policy matters to the public’s attention.
Science and Research
The information age has created an emphasis on evidence-based practice and policies. Scientific findings play a powerful role in the first step of the policy process: getting attention to particular problems and moving them to the policy agenda. Research can also be valuable in defining the size and scope of a problem and substantiating policy recommendations. This can help to obtain support for a proposed policy and in lobbying for support of it. Evidence should be used to inform policy debates and shape policy choices to help ensure that the solution will be effective. That said, evidence is essential but may not be sufficient to advance policies. Values and politics can trump evidence, as has been apparent in recent debates over two issues: climate change and decreasing rates of vaccinations. Despite the evidence showing that humans are contributing to potentially devastating changes in the earth’s climate or that childhood vaccinations do not cause autism, debates about these issues continue and affect whether policies are or are not adopted to address the problems.
The Power of Presidents and Other Leaders
The president embodies the power of the executive branch of government and is the only person elected to represent the entire nation. As the most visible government official, the president is able to propel issues to the top of the nation’s policy agenda. Although the president cannot introduce legislation, he or she can provide draft legislation 12and legislative guidance. The president can also issue executive orders when he or she cannot get support for policy change from Congress. President Obama has done so in the face of a paralyzed Congress, as did his Republican and Democratic predecessors. This force also applies to the leaders of many public and private entities. Never underestimate the power of the official leader or of those who seek to remove or thwart the leader.
The Framework for Action
Nursing has a covenant with the public. The profession’s practice laws, standards, and ethics have roots in its history of activism for social justice. A social contract with society demands professional responsibility. Thus, every nurse must continuously consider the policy context of daily practice in any setting. The solutions to today’s most intractable health care problems, including perverse payment mechanisms, deeply disturbing social injustice, and shocking ethnic and racial disparities, are not simple to solve. But, according to the annual Gallup poll (Gallup, 2013), the public regards nurses’ “honesty and ethical standards” more highly than those of any other profession. This public trust places a moral imperative on nurses to vigorously engage in influencing policy. Nurses see close up how policies get played out in patient care and can report on unintended consequences. This imperative requires nurses to expand their involvement in policy decisions at the institutional, community, state, federal, or international realm and need not be restricted to any one setting.
The Framework for Action (Figure 1-5) illustrates that nurses operate in four spheres: government, workplace, interest groups (including professional organizations), and community to influence policies that affect health and health care and core/social determinants of health.
FIGURE 1-5 A framework: Spheres of influence for action. Nurses need to work in multiple spheres of influence to shape health and social policy. Policies are designed to remedy problems in the health system and to address social determinants of health; both of which aim to improve health.
Spheres of Influence
The four spheres of influence provide a visual medium for understanding the policy arena. These spheres are not discrete silos. Policy can be shaped in more than one sphere at a time, and action in one sphere can influence others. To achieve greater 13access to care for the uninsured, for example, nurses may work in their own organization to alter policy to increase access to services. They may also use political strategies in the media, such as blogging or being interviewed on television, to express their support for better access to care. They may work with a professional association or an interest group to communicate their views to policymakers. Additional context (the who, what, where, when, and why of nursing’s policy influence) is provided in Figure 1-6.
FIGURE 1-6 The who, what, where, when, and why of nursing’s policy influence.
Government action and policy affect lives from birth until death. It funds prenatal care, inspects food, controls the safety of toys and cars, operates schools, builds highways, and regulates what is transmitted on airwaves. It provides for the common defense; supplies fire and police protection; and gives financial assistance to the poor, aged, and others who cannot maintain a minimal standard of living. The government responds to disaster, subsidizes agriculture, and licenses funeral homes.
Although most U.S. health care is provided in the private sector, much is paid for and regulated by the government. So, how the government crafts health policy is extremely important (Weissert & Weissert, 2012). Government plays a significant role in influencing nursing and nursing practice. States determine the scope of professional activities considered to be nursing, with notable exceptions of the military, veterans’ administration, and Indian health service. Federal and state governments determine who is eligible for care under specific benefit programs and who can be reimbursed 14for providing care. Sometimes government provides leadership in defining problems for both the public and private sectors to address. There are more than a dozen House and Senate committees and subcommittees that shape policy on health, and many more committees address social problems that affect health. In the House of Representatives, the Congressional Nursing Caucus, an informal, bipartisan group of legislators who have declared their interest in helping nurses, lobbies for federal funding for nursing education (Walker, 2009).
Abraham Lincoln’s description of a “government of the people, by the people, for the people” (Lincoln, 1863) captures the intricate nature of the relationship of government and its people. There are many ways nurses can influence policymaking in the government sphere, at local, state, and federal levels of government. Examples include:
• Obtaining appointment to influential government positions
• Serving in federal, state, and local agencies
• Serving as elected officials
• Working as paid lobbyists
• Communicating positions to policymakers
• Providing testimony at government hearings
• Participating in grassroots efforts, such as rallies, to draw attention to problems
The Workforce and Workplace
Nurses work in a variety of settings: hospitals, clinics, schools, private sector firms, government agencies, military services, research centers, nursing homes, and home health agencies. All of these environments are political ones; resources are finite, and nurses must work in each to influence the allocation of organizational resources. Policies guide many activities in the health care workplaces where nurses are employed. Many that affect nursing and patient care are internal organizational policies such as staffing policies, clinical procedures, and patient care guidelines. External policies are operative in the health care workplace also; for example, state laws regulating nursing licensure. Federal laws and regulations are evident in the nursing workplace such as Occupational Health and Safety Administration regulations regarding worker protection from bloodborne pathogens.
Policy influences the size and composition of the nursing workforce. The ACA authorizes increased funding for scholarships and loans for nursing education, potentially augmenting existing workforce programs funded under Title VII and Title VIII of the Public Health Service Act. The nongovernmental Commission on Graduates of Foreign Nursing Schools is authorized by the federal government to protect the public by ensuring that nurses and other health care professionals educated outside the United States are eligible and qualified to meet U.S. licensure, immigration, and other practice requirements (Commission on Graduates of Foreign Nursing Schools, 2009). The National Council of State Boards of Nursing is a not-for-profit organization that brings together state boards of nursing to act on matters of common interest affecting the public’s health, safety, and welfare, including the development of licensing examinations in nursing (National Council of State Boards of Nursing, 2009). These are just a few examples of the external forces that shape workforce and workplace policy.
Associations and Interest Groups
Professional nursing associations have played a significant role in influencing practice. Many associations have legislative or policy committees that advocate policies supporting their members’ practice and advance the interests of their patient populations. Working with a group increases the effectiveness of advocacy, provides for the sharing of resources, and enhances networking and learning. In fact, these associations can be excellent training grounds for novice nurses to learn about policy and political action (see Chapter 4). Nurses can be effective in association policy activities by serving on public policy or legislative work groups, providing testimony, and preparing position statements.
When nursing organizations join forces through coalitions, their influence can be multiplied. For example, The Nursing Community (www.thenursingcommunity.org) is an informal coalition of national nursing organizations that formed to speak with one voice on matters important to national policy and political appointments (see 15Chapter 75). The Coalition for Patients’ Rights (www.patientsrightscoalition.org) is a group of more than 35 national organizations representing health care professionals that is working to fight the American Medical Association’s attempts to limit patients’ access to nonphysician providers. Twenty members are nursing organizations.
Nurses can be influential, not just in nursing associations, but by working with other interest groups such as the American Public Health Association or the Sierra Club. Some interest groups have a broad portfolio of policy interests, whereas others focus on one disease (e.g., National Breast Cancer Coalition) or one issue (e.g., driving while intoxicated, the primary focus of Mothers Against Drunk Driving). Interest groups have become powerful players in policy debates; those with large funding streams are able to shape public opinion with media advertisements.
A limited number of nurses will have the opportunity to influence policy at the highest levels of government, but extensive opportunities exist for nurses to influence health and social policy in communities. Nursing has a rich history of community activism with remarkable examples provided by leaders such as Lillian Wald, Harriet Tubman, and Ruth Lubic. This legacy continues today with the community advocacy efforts of nurses such as Cora Tomalinas, Mary Behrens, Ellie Lopez-Bowlan, the Nightingales who took on Big Tobacco, and the nurses who are a part of the Canary Coalition for Clean Air (their stories appear in this book).
A community is a group of people who share something in common and interact with one another, who may exhibit a commitment to one another or share a geographic boundary (Lundy & Janes, 2001). A community may be a neighborhood, a city, an online group with a common interest, or a faith-based network. Nurses can be influential in communities by identifying problems, strategizing with others, mobilizing support, and advocating change. In residential communities (such as towns, villages, and urban districts), there are opportunities to serve in positions that influence policy. Many groups, such as planning boards, civic organizations, and parent-teacher associations, offer opportunities for involvement.
The Framework for Action includes health as an element of the model to represent that optimal health is viewed as the goal of nursing’s policy efforts. Optimal health (whether for the individual patient, family, a population, or community) is the central focus of the political and policy activity described in this book. This focus makes it clear that the ultimate goal for advancing nursing’s interests must be to promote the public’s health.
Nursing embraces a broad definition of health that aligns with the World Health Organization (1948): “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” It incorporates the concept of positive health, not just ill health (Greene et al., 2014). This definition requires a focus on creating communities that thrive economically, have safe environments, and use resources to ensure that their members have access to good nutrition and other elements that can promote health.
Health and Social Policy
This definition of health leads to the focus on health and social policy as key elements in the Framework for Action. Many factors that affect health are social ones, such as income, education, and housing. Although nurses involved in policy often focus on health policies, the emphasis on upstream factors requires a broader focus on the socioeconomic factors that affect health, including labor policy, laws that can stimulate job creation, or local ordinances on smoking bans.
Health Systems and Social Determinants of Health
The health care system is the focus of most discussions of health policy to date. Much of this book focuses on understanding the complex and sometimes chaotic U.S. health care system, the ACA’s role in augmenting the system’s performance, and other 16policies needed to achieve the Triple Aim. It also addresses the powerful impact that upstream factors have on the health of populations. A singular focus on the health care system is limited in the extent to which it can lead to higher levels of health for individuals, families, and communities.
Nursing has also developed a competency-based educational curriculum supporting future nurses’ involvement in policy. The American Association of Colleges of Nursing (AACN) publishes the necessary curriculum content and expected competencies of all nursing school graduates from baccalaureate, master’s, doctor of nursing practice, and research doctorate (PhD) programs. These documents serve as a framework for twenty-first-century nursing and ground the profession in the direct and indirect care of individuals, families, communities, and populations. The content builds on nursing knowledge, theory, and research and derives knowledge from a wide array of fields and professions.
A study by Byrd and colleagues (2012) found that undergraduate nursing students for the most part are largely unaware of the importance of political activity for nurses. After participating in a robust and active public policy learning activity, students measured high on a political astuteness scale. This study suggests that political skills can be learned when presented with relevance to nursing and used to hone skills such as inquiry, critical thinking, and complex problem solving. These results highlight the importance of increasing students’ awareness of how to participate in the political process, as well as encouraging their participation in student and professional organizations.
For each level of nursing education—BSN, MSN, DNP, and PhD—there is a clear expectation that graduates will have policy competency, with increasing emphasis on policy leadership as nursing students progress academically, although this is less well defined for PhD graduates (AACN, 2006; AACN Task Force, n.d.). These essentials make it clear that health policy directly influences nursing practice and every aspect of the health care system. It is understood that patient safety and quality cannot be addressed outside of the context of policy. The broader policy context is emphasized throughout nursing degree programs. It is expected that DNP graduates are able to design, implement, and advocate health policies that improve the health of populations. The powerful practice experiences of nurses can become potent influencers in policy formation. Additionally, a DNP graduate integrates these practice experiences with two additional skill sets: the ability to analyze the policy process and the ability to engage in politically competent action (AACN, 2006). See Table 1-1 for a summary of the policy competencies in successive nursing education programs.
AACN’s Nursing Essentials Series: Policy Competencies for Nurses
Policy Essential: All Nurses at This Level Must Have Expertise in:
BSN Policy Essential VI1
Health care policy, finance, and regulatory environments
Health care policies, including financial and regulatory, directly and indirectly influence the nature and functioning of the health care system and thereby are important considerations in professional nursing practice.
MSN Policy Essential VI1
Health policy and advocacy
Recognizes that the master’s-prepared nurse is able to intervene at the system level through the policy development process and to employ advocacy strategies to influence health and health care.
DNP Policy Essential V1
Health care policy for advocacy in health care
The DNP graduate has the capacity to engage proactively in the development and implementation of health policy at all levels, including institutional, local, state, regional, federal, and international levels.
DNP graduates, as leaders in the practice arena, provide a critical interface among practice, research, and policy.
Preparing graduates with the essential competencies to assume a leadership role in the development of health policy requires that students have opportunities to contrast the major contextual factors and policy triggers that influence health policymaking at various levels.
Research-Focused Doctorate in Nursing (PhD)2
Curricular elements include:
Communicate research findings to lay and professional audiences and identify implications for policy, nursing practice, and the profession
Strategies to influence health policy.
Leadership related to health policy and professional issues.
1The American Association of Colleges of Nursing. Essentials Series. Baccalaureate (2008); Masters (1996); DNP (2011). Retrieved from www.aacn.nche.edu/education-resources/essential-series.
2The American Association of Colleges of Nursing. (2010). The Research-Focused Doctoral Program in Nursing: Pathways to excellence. Report from the AACN Task Force on the Research-Focused Doctorate in Nursing. Retrieved from www.aacn.nche.edu/education-resources/phdposition.pdf.
Policy and Political Competence
Competence is being adequately prepared or qualified to perform a specific role. It encompasses a combination of knowledge, skills, and behaviors that improve performance. Nurses are often reluctant to become involved in policy because of the “politics.” Political skill has a bad reputation; for some, it conjures up thoughts of manipulation, self-interested behavior, and favoritism (Ferris, Davidson, & Perrewe, 2005). “She plays politics” is not generally considered to be a compliment, but true political skill is critical in health care leadership, advocating for others, and shaping policy. It is simply not possible to succeed in any decision-making arena by ignoring the political realm. Ferris, Davidson, and Perrewe (2005) consider political skill to be the ability to understand others and to use that knowledge to influence others to act in a way that supports one’s objectives. They identify political skill in four components:
1. Social astuteness: Skill at being attuned to others and social situations; ability to interpret one’s own behaviors and the behavior of others.
2. Interpersonal influence: Convincing personal style that influences others featuring the ability to adapt behavior to situations and be pleasant and productive to work with.
3. Networking ability: The ability to develop and use diverse networks of people, and the ability 17to position oneself to create and take advantage of opportunities.
4. Apparent sincerity: The display of high levels of integrity, authenticity, sincerity, and genuineness (pp. 9-12).
In most cases, policymakers are generalists who make decisions on a broad range of issues. Nurses can have a profound impact on policymaking by using their knowledge to frame and define health policy alternatives. Influencing policy at all levels requires a strong set of interpersonal skills, integrity, and knowledge. According to O’Grady and Johnson (2013), political competency, at either the individual or the organizational level, can be defined by three main elements: deep knowledge, political antennae, and power (Figure 1-7).
FIGURE 1-7 Political competencies. (From O’Grady, E. T., & Johnson, J. . Health policy issues in changing environments. In A. Hamric, C. Hanson, D. Way, & E. O’Grady [Eds.], Advanced practice nursing: An integrative approach [5th ed.]. St. Louis, MO: Elsevier-Saunders.)
Deep knowledge requires freely sharing expertise and gaining the knowledge you need from others. Subject-matter expertise without knowledge of policy and its processes is a doomed strategy. Deep knowledge involves knowing the viewpoints of others, including the opposition, and having a clear message and data at the ready to support your position and neutralize opposition. For example, many physicians’ organizations oppose expansion of practice for APRNs, citing patient safety as a primary concern. Politically competent nurses can arm themselves with a summary of decades of evidence citing no such concerns (Newhouse et al., 2011; O’Grady, 2008).
Developing political competence requires a continuous scanning of the environment, and it is critical that nurses offer solutions to policy problems that are not solely nursing focused but also address the Triple Aim. Agendas cannot be advanced without the formation of coalitions and networks. Influencers of policy must consider alternative scenario development to use if opposition develops. For example, the 2008 recession had an impact on the nursing shortage: many nurses chose not to retire during that uncertain economic period. The nursing community was able to maintain nursing education funding despite the lessening of the nursing shortage using scenario development. For example, during the economic downturn and slashing of many federal programs, nurses were able to create a scenario in which the aging population explodes, the nursing workforce nears retirement age, and there is a dire nursing faculty shortage. Projections were made predicting catastrophic hospital vacancy rates and unmet health care needs. This scenario was highly effective in preventing cuts in federal funding to nursing education.
Having political antennae requires active listening with policymakers to understand their motives and to develop strategies that fit their political objectives. So if policymakers promised constituents they would not raise taxes, the politically competent nurse would work in a coalition to help find a budget-neutral solution.
Finally, having political antennae requires the avoidance of bridge-burning. Ruptured relationships can cause lasting damage, not only to the nurse involved but also to the profession. Many wounds can develop during policymaking, and it may be crucial that one exercises restraint. Political and policy disagreements require a response of genuine warmth, a quality that can go a long way in building trust. Learning how to navigate differences and agreeing to disagree without being disagreeable are important political skills.
Use of Power
Power is the ability to act so as to achieve a goal. In the policy process, power is knowing who has it, who is on what committee, and who are the thought leaders in the community. A coalition is one important way nurses can augment their policymaking power. But an individual nurse can claim it by being articulate and having an elevator speech that can spark interest.
Application of power requires raising one’s awareness about what is true and what is false. Being grounded in truth, such as knowing the value of human caring and the role that nursing can have on individuals and populations, is a form of personal integrity that leads to power. Using power is a choice that requires a noncondemnatory and helpful attitude. By freely giving expertise away and approaching “difficult” people with a benign attitude (they are doing the best they can), we hold onto our integrity, build trust, and keep emotions in check. To be effective in the policy arena, nurses must have a sharp focus on the evidence, not emotion. Advancing nursing’s policy agenda through such a use of power demands that we drop narcissism and nursing parochialism and focus on problem solving. Nursing narcissism is when a nurse shows an inordinate fascination with oneself, self-centeredness, and a high degree of smugness. This can include taking sole responsibility for some action or project in which a team was responsible. Nursing parochialism is when a nurse is in a problem-solving context (policy meeting) and only offers up the solution of “nurses” as the remedy to every problem. Parochialism is an approach that narrows options and interests and appears self-serving. Both of these destructive approaches do not deploy the cost-quality-access triad framework to problem solving and therefore severely constricts nursing power. They are to be avoided at all costs and nurses exhibiting these attitudes must be removed from decision-making tables. Effective use of power avoids polarization, egotism, and self-serving postures at all costs. Bringing nurses’ stories to the policy arena is, however, a powerful way to pair the human story to the scientific evidence.
Corralling the political power of the 3.1 million registered nurses in the U.S. can only occur if individual nurses join, support, and fully engage with professional nursing organizations. More than any other effort to date, The Future of Nursing: Leading Change, Advancing Health (IOM, 2011) has brought disparate nurses together to engage across associations and educational institutions, and with new community partners, to change policy. Many of the recommendations direct policy changes resonant with nurses. This effort is increasing nursing’s political competence, but more could be done: printed op-eds, blog posts, and interviews with nurses in major media outlets could capitalize on the high regard the public has for nursing.
Nurses who effectively use power are a sought-after and a valued asset. They get invited to the table, but they are asked back and often invited to more tables with ever-expanding influence. This requires a great degree of knowledge, along with humility, a problem-solving attitude, and a patient-centered lens. Such activities and attitudes strengthen an individual’s interpersonal power and integrity, which can inspire others.
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Institute of Medicine: The Future of Nursing: Leading Change, Advancing Health.
The Future of Nursing: Campaign for Action (current efforts to implement the IOM recommendations).
The Affordable Care Act.
1The Affordable Care Act (ACA) is the label used to refer to two laws passed by the House of Representatives and the Senate in 2010: the Patient Protection and Affordable Care Act and the Health Care and Education Affordability Reconciliation Act. We use the ACA terminology in this book.
2The ACA refers to refers to both “medical” and “health” homes. Reference to “health homes” is specific to Medicaid provisions in the law. In practice, facilities are designated as “medical homes” if they meet criteria set by the National Committee on Quality Assurance. This book will use that language, while recognizing that “health home” is more consistent with a health-promotion model.
How I Learned the Ropes of Policy and Politics
“This is the true joy in life, the being used for a purpose recognized by yourself as a mighty one; the being thoroughly worn out before you are thrown on the scrap heap; the being a force of Nature instead of a feverish selfish little clod of ailments and grievances complaining that the world will not devote itself to making you happy.”
George Bernard Shaw
I began my career at the bedside. But being at the bedside wasn’t enough to stoke my commitment to social justice and making change in the world. This story of “Taking Action” describes my journey so far, including the successes and challenges along the way, and my own assessment of how passion, combined with mentoring, can produce change in policy. I began my commitment to social justice in 2007 as a Fellow in Richmond, Virginia, for “Hope in the Cities,” a program sponsored by Initiatives of Change, USA, that focuses on building trust through honest conversations on race, reconciliation, and responsibility (www.us.iofc.org). From the rich discussions I had with diverse individuals and groups, I developed an ability to look for and understand the story of the “other” and to use this in conversations to facilitate peace and understanding. This has served me well in the political arena where differences can collide or lead to more creative policy solutions to today’s problems.
I was able to connect that commitment to social justice with my passion for nursing and health care advocacy as Chair of the Legislative Committee for the Virginia Organization of Nurse Executives in 2007. That chairmanship led to a 2-year term as Chair of the Legislative Coalition of Virginia Nurses. In 2009, I became a Fellow of the American Nurses Advocacy Institute, an initiative of the American Nurses Association to develop and mentor nurses into political leaders. A year later, I was selected to participate in the University of Virginia (UVA) Sorensen Institute Political Leaders Program. This program is designed for Virginians who want to learn the political ropes and become more active in public service. I am active in the Virginia Nurses Association (VNA), serving as Secretary and Assistant Commissioner of Government Affairs. However, I had no clue that I ever was going to do any of those things; they weren’t even in my realm of possibilities. So how did all of this happen?
FIGURE 5-1 Author Chelsea Savage participated in a protest against state legislation that would have mandated transvaginal ultrasounds prior to abortions in Virginia.
Mentors, Passion, and Curiosity
Three things created these opportunities. The first was my passion for social justice, the second was my mentors, and the third was an insatiable curiosity that propelled me to venture into uncharted territories. I was finishing a fellowship in Health Law when Shirley Gibson, a mentor and president of the Virginia Organization of Nurse Executives at that time, asked “Chelsea, will you chair the Legislative Committee for the Virginia Organization of Nurse Executives?” I said yes and within a couple of weeks I was networking with leaders in the state, leading advocacy on health care and nursing issues. I was one of the representatives of several diverse nursing organizations that comprised the 50Legislative Coalition of Virginia Nurses (LCVN), founded in part by one of my mentors, Becky Bowers-Lanier. Becky, a well-regarded nursing leader in health policy, and Sallie Eissler, a pediatric nurse practitioner, decided nursing needed a succession plan and I was supposed to help with that. So I was elected Chair of LCVN. Highlights of my time included meeting with policymakers and campaign managers for the governor’s race, creating legislative platforms that outlined succinctly our legislative priorities, and assisting with the passage of the Virginia Indoor Clean Air Act that banned smoking in restaurants and certain other public places.
Sallie Eissler was also head of the Political Action Committee for the VNA and a political junkie. She suggested that I learn about politics in Virginia by applying to the Sorensen Institute Political Leaders Program (PLP) through the UVA. PLP had nothing to do with nursing and everything to do with building political networks and learning to function in the system. Because of my connections though PLP, I was tapped to be Co-Chair for Nurses for Obama in Virginia. Our mission was to educate the public on the Affordable Care Act (ACA). Radio interviews and newspaper articles followed.
I was aware that, if you are not careful, working publicly on behalf of candidates in an election year can create problems with your employer and nonpartisan nursing professional organizations. A colleague advised me that nurses are certainly able to wear more than one hat. I could be a supporter of the ACA and even President Obama as an individual nurse, but it was up to me to make it clear I was not representing the views of my employer or my professional association.
I am lucky to have several mentors in my life, such as Becky and Sallie. I didn’t choose them, but for some reason they chose me, perhaps because I was an enthusiastic, “can do,” productive individual with a passion for creating a healthy society. Through their example, I look for opportunities to mentor. I look for passion in nurses. If a tree falls in the woods and no one is around to hear it, does it make a sound? Replace tree with “nurse” and falls in the woods with “has a passion for the health of their patients and profession” and ask: “Does quiet passion really count for anything?”
Let’s go back to professional organizations because this is how “it makes a sound.” Strength is in numbers and in nurses wanting to be heard. Bring this back to the bedside. I was a nurse manager of a 27-bed medical-telemetry unit when I started on my journey in health policy and politics. We had a significant number of full-time employment (FTE) positions that were unfilled; there just weren’t any applicants. The nursing shortage had reduced me to spending half of my time calling overworked nurses to ask them to do overtime. I was working with three professional nursing organizations at the time, and the consensus was that the shortage was linked to a shortage of nursing faculty, resulting in hundreds of qualified applicants to Virginia’s schools of nursing being turned away. Testifying before Virginia state legislators on behalf of those nursing professional associations, I verified the need to raise nursing faculty salaries. Two things happened that made that a success. The first was 51that my passion found a voice; the second was that the voice was backed by numbers of constituents who vote. There are over 100,000 nurses in the Commonwealth of Virginia. Together with our numbers and the respect the public has for our profession, we create a voice that gets attention and that is successful in creating change.
Where does passion and a commitment to become an agent for change in our society come from? Different places, but for me a good part of it came from adversity. I grew up in a strict religious sect and was not allowed to go to school after the 6th grade. I was supplied with books, and my passion led me to teach myself and obtain my GED when I was 15 years old. Education became my passion, and what I experienced created in me a commitment to social justice, advocacy for nursing, and better health care for Virginians.
Consider another example. I have a dynamic friend who was diagnosed with ovarian cancer; she immediately founded CancerDancer (www.ocancerdancer.org), an organization with almost 10,000 members, to spread the word on ovarian cancer signs and symptoms. A special characteristic of us humans is that what should discourage us often makes us a powerful catalyst for change. We are so resilient. Find your passion, then find your voice; and go out and change the world.
The Policy Process
Eileen T. O’Grady
“A problem clearly stated is a problem half solved.”
Dorothea Brande (1893-1948)
The purpose of this chapter is to provide a conceptual framework for understanding policymaking. When provided with a clear understanding of the policymaking process, nurses can more strategically and effectively influence policy. By using conceptual models, complex ideas may be depicted in a simplified form to help organize and interpret information, and to this end, political scientists have established a number of conceptual models to explain the highly dynamic process of policymaking (Dye, 1992). This chapter reviews two of these conceptual models.
Health Policy and Politics
Health policy is significantly broader than nursing care policy alone. Health policy encompasses the political, economic, social, cultural and social determinants of individuals and populations and attempts to address the broader issues in health care (see Box 7-1 for policy definitions). This distinction is important because nurses need to be aware of the relevancy and significance of health policy in any position they hold. To influence the process, a clear understanding of the points of influence is essential and this includes correct framing of the health care problem itself. For example, if a nurse working in a nurse managed clinic is troubled by the staff shortages or long patient waits, they may be inclined to see themselves as the solution by working longer hours and seeing more patients. Defining and framing the problem in a broader policy context involves assessing the history, patterns of impact, resource allocation, and community needs as a first step in the policy process. Broadening and framing the problem to influence or educate stakeholders at the community, city, state, or federal level could include advocating for better access or funding for nursing workforce development. The next step is to bring the problem to the attention of those who have the power to implement a solution. Other key factors to consider include the generation of public interest, availability of viable policy solutions, the likelihood that the policy will serve most of the people at risk in a fair and equitable fashion, and consideration of the organizational, community, societal, and political viability of the policy solution.
Policy is authoritative decision making (Stimpson & Hanley, 1991) related to choices about goals and priorities of the policymaking body. Generally, policies are constructed as a set of regulations (public policy), practice standards (workplace), governance mandates (organizations), ethical behavior (research), and ordinances (communities) that direct individuals, groups, organizations, and systems toward the desired behaviors and goals.
Health Policy is the authoritative decisions made in the legislative, judicial, or executive branches of government that are intended to direct or influence the actions, behaviors, and decisions of others (Longest, 2010, p.5).
Health Determinants include the physical environment in which people live and work, people’s behaviors, people’s biology, social factors, and health services (Longest, 2010 p. 2).
Policy analysis is the investigation of an issue including the background, purpose, content, and effects of various options within a policy context and their relevant social, economic, and political factors (Dye, 1992).
Stakeholders are those directly impacted by specific policy decisions and who may be involved in the policymaking process.
Advocacy is a role, often performed by nurses, that works to promote or protect rights, values, access, interests, and equality in health care. Much of the policy process involves advocating for policy on behalf of patients and public health.
Public interest is a fascinating dynamic relevant to the development of public policy and is particularly important to influencing policy agendas at the community and broader policy levels. Taft and Nana (2008) have classified the sources of health policy within three domains. The first is professional, such as the need for standards and guidelines for practice. The second is organizational, which should be consistent with the needs of health care purchasers (employers), payers (insurers), and suppliers (health systems and providers). The third relates to the community stakeholders (patients and consumers) and public sources, including special interest groups and government entities.
Whatever the source, public awareness is often necessary for political action to take place and for the policy process to be initiated. For example, trends associated with health behaviors, such as the increased rates of childhood obesity, drunk driving, smoking, or gun violence, either gradual or resulting from a crisis situation, can all shift public perception and open the policy debate. Research 62consistently shows that a wide range of social and economic factors affect health although this broader causality is not well understood by the public. An opinion survey probing public opinion determined that most respondents think access to care and behaviors are most important. Far fewer respondents considered broader social determinants such as income, safe housing, race, and ethnicity to be important factors impacting a person’s health status (Robert & Booske, 2011). This gap in public understanding adds to the confusion and politicization of health policy in developing solutions that fundamentally impact a person’s health status. As public knowledge increases, however, trends become increasingly objectionable to some members of society, which propels them to seek solutions. The rate of deaths caused by drunk driving, for example, resulted in strict nationwide drunk driving laws, and research on the impact of second-hand smoking led to the near universal ban on smoking in shared open spaces.
When people have a strong sense that the status quo is unacceptable, they begin to organize in a predicable fashion, leading to actions such as coalition forming or the establishment of a nonprofit organization. To move policy agendas forward, organizations must mature and build the resources needed to be effective in the policy realm.
Interest groups can stimulate a shift from interest in a policy solution to action wherein people work collectively to find solutions. Unions, trade associations, and political action committees are such examples. Professional nursing organizations serve as an interest group for nurses, not only to explore issues about the advancement of nursing but also to focus on societal issues such as the need for health reform, informing the public of emerging diseases and health threats, and the consequences of health disparities
Fairness and equity is a primary value driver that inspires nurses to participate in the policy process. Fawcett and Russell (2001) consider the equity of a policy as the extent to which it allows the benefits and burdens of nursing practice to be equally distributed to all; in particular, equal access to health services. For many nurses, advocating for fairness and equity is an application of patient advocacy, especially when human rights and health disparities are at stake. As noted in Chapter 1, social determinants of health illustrate that, in addition to individual choices, there are important environmental factors beyond the control of the individual that require collective action if health and health care are to be accessible for all (Dorfman, Wallack, & Woodruff, 2005).
Political viability is a further issue that must be considered. Policy that is considered desirable to both politicians and stakeholders will have the best chance of passage by a policymaking body. For example, public concerns about health effects from exposure to second-hand smoke have been communicated to policymakers many times. Although policymakers may want to take action to protect the public from tobacco smoke in public places, the pressure from tobacco companies for policymakers not to act has been equally powerful. As a result, public policy related to second-hand smoking languished for years in many states. However, when local communities in these states changed their ordinances to restrict smoking in public, there was increased pressure on state legislators to take action.
Unique Aspects of U.S. Policymaking
Cost, quality, access, patient safety, and racial disparity problems persist across U.S. health delivery systems. Although the causes of these problems are multiple, the U.S. stands out from its peers across the globe for having one of the most complicated health care delivery and health care finance systems in the world. It has a highly decentralized system of government with a health care finance system that includes a mix of public and private payers. What is most unique about the United States is that no single entity, authority, or government agency is ultimately responsible for health care. All of these facts lead to a complex patchwork of decision making, causing health care policy in the United States to be a highly complex and politically polarizing process. The current health care structure reflects policy decisions from the values of current society, together with residual policies from the colonial era. The U.S. Constitution does not specifically mention health care but the preamble indicates that the federal government should “promote the general welfare.” This lies at the heart of the current political debate between the Democrat and Republican Parties regarding the role of the federal government in health care.
Federalism is the system of government in which power is divided between a central authority (federal) and constituent political units (state governments).This division of power and authority, while purposely designed by the founding fathers, is the source of much tension, acrimony, and complexity in U.S. policymaking. The locus of tension between the states and federal government is very relevant to health care policy. Medicare, Medicaid, and CHIP are examples of federally driven policies that create a partnership with states to administer health care under federal guidance. Meanwhile, regulation of health professionals, private health insurance coverage and long-term care policies have long been the domain of the individual states. This complexity between the state and federal spheres illuminates the fragmented and seemingly chaotic approach to solving health care problems in the United States.
Many aspects of the Affordable Care Act (ACA) protect states’ rights to choose the degree to which they carry out some of its most important provisions, such as creating health exchanges to expand access to care. This built-in flexibility allows states to experiment with local solutions because, for example, what works in Minnesota may not work in Manhattan. The ACA escalated tensions between federal mandates and states’ rights as evidenced by the United States Supreme Court’s role in settling 64the dispute resulting from the multistate lawsuit challenging the constitutionality of the ACA’s mandate that every citizen purchase health insurance. Although the Supreme Court upheld the individual mandate as a federal law that states must accept, the court also ruled expansion of the Medicaid program constitutional, but protected the right of states by ruling that states cannot be penalized if they choose not to participate in the expansion (O’Connor & Jackson, 2012).
The trend to allow states increased flexibility in recent decades adds complexity to health policymaking and amplifies the need for nurses to understand the policymaking process. Nurses must be knowledgeable regarding the appropriate authorities so that decision-making bodies are targeted appropriately. For example, there have been incidences of nurses who have approached federal legislators to persuade them to increase funding for school nursing, unaware that the issue was a state issue and funded at the state level.
The U.S. Constitution gives the federal government the power to block state laws when it chooses to do so. As noted earlier, state governments have authority to regulate health professionals as part of their charge to protect the public; although this is not in the Constitution, it has been the case since the formation of the United States (Safriet, 1992). This status quo is no longer appropriate as new forms of remote care delivery can render geographic boundaries irrelevant. Federalism is intended to create and sustain a highly decentralized locus of authority and is one of the most important dynamics in U.S. policymaking. This dynamic also, however, makes health care delivery systems complicated and difficult to reform.
Just as the federalist power structure creates tension between state and federal government policymaking, another outcome has been incremental policymaking. Historically, the most politically viable model, incrementalism, is used to describe policymaking which proceeds slowly by degrees. It represents a conservative approach to decision making and is viewed as a way to improve current policy. Within the U.S. Constitution, the three branches of government are designed deliberately to prevent one person or group from obtaining dictatorial powers. The disadvantage of this checks and balances structure is that it is very difficult for far-reaching policy reforms to succeed.
Once in a generation there is a major reform in U.S. health policy. The 1930s saw the implementation of Social Security, and 1965 saw the passage of Medicare and Medicaid. CHIP in the 1990s and the 2010 passage of the ACA are also examples. However, most health policy reform in the United States has been incremental. Fukuyama (2013) has described the U.S. system as a vetocracy which empowers political players who represent a minority viewpoint to block the actions of the majority resulting in paralysis. This vetocracy was illustrated in 2013, 3 years after the ACA was signed into law, when members of the House of Representatives shut down the government for 16 days (at an estimated cost of $24 billion) in an attempt to defund some of the provisions in the ACA.
Policies in the United States are far easier to stop and obstruct than pass and implement. Policymaking is largely a process of continuous fine-tuning of what already exists. A good example of incrementalism is the policy toward gays in the military. In the early 1990s it was highly controversial to implement the don’t ask, don’t tell mandate that allowed gays to serve. By the early 2000s, public opinion on homosexuality shifted dramatically and the military now accepts individuals with this sexual orientation.
Lindblom (1979) first described the concept of incrementalism in the early 1950s. When policymakers face a highly complex, theoretical, or resource-intensive decision and lack the time, capacity, or understanding to analyze all of the various policy options, they may limit themselves to a set of particular strategies instead of tackling the problem holistically. Policy solutions may be restricted to a set of familiar policy options that align with the status quo and lack a thorough evidence base (Lindblom, 1979). Therefore, incrementalism, although effective in limiting the power of any one person, group, or branch of government, also creates a process that is neither proactive, goal-oriented, nor ambitious; it ossifies timely policy, and limits innovation (Weiss & Woodhouse, 1992).
Conceptual Basis for Policymaking
The policy process consists of a series of actions, each critical to resolving a problem through analysis and formulation of solutions and can involve many organizations and individuals as well as requiring multiple steps. Two models from political scientists are relevant to nurses’ understanding of the policy process. The purpose of reviewing these models is to provide two different yet complementary approaches for readers to see how the seemingly chaotic policymaking process has a form, rhythm, and predictability.
Longest’s Policy Cycle Model
Health policy is a cyclical process. Longest (2010) mapped out an interrelated model to capture how U.S. policymaking works. It is a continuous, highly dynamic cycle that captures the incrementalism inherent in U.S. governmental decision making (Figure 7-1). In its simplest form, there are three phases to the policy process: a policy formulation phase, an implementation phase, and a policy modification phase. Each phase contains a set of actions and activities that produce outcomes or products that influence the next stage. Although simple in design, this model is deceptively complex. Defining the policy problem with adequate clarity so that it gains the attention of policymakers and stakeholders is challenging; each policy problem has many solutions and competitors seeking a place on the policy agenda. Although policymaking is dependent on good data and evidence about what works, data and evidence may not be enough to outweigh the influence of the political environment.
FIGURE 7-1 Longest’s Policy Framework. (Redrawn from Longest, B. . Health policymaking in the United States [5th ed.]. Chicago: Health Administration Press.)
Policy formulation includes all of the activities that are involved in policy design, including those activities which inform the legislators. It is in this phase that nurses can serve as a knowledge source to legislators in helping frame the problem and bringing nursing stories and patient narratives to illustrate how health problems play out with individual constituents/populations. The most effective 66time to influence legislation is before it is drafted, so that nurses can help frame the issues to align with their desire for policy outcomes that are patient-centered.
Policy implementation comprises the rule-making phase of policy development. The legislative branch passes the law to the executive branch which is charged with implementation. This includes adding specificity to the law and may also include, for example, defining the provider to include advanced practice nurses. The writing of rules after legislation is passed is a crucial and often overlooked aspect of policymaking. At this juncture, nurses with appropriate expertise can monitor and influence how the rules are written. Once written, federal regulations are published in the daily Federal Register for 60 days to receive public comment. States also have regulation processes that provide designated times for public input.
Stakeholder groups can exert enormous influence during the implementation phase (Regulations.gov, 2013). When strong letter-writing campaigns are employed, the rulemaking agency may be forced to publish those comments and make adjustments according to their volume and scientific rigor. It is not unusual for the intent of a policy to get lost in the translation to program development. This rule-making phase is an important leverage point for nurses to closely monitor and respond to regulations through grassroots campaigns.
Two important aspects of American democracy are at play during the public comment phase: (1) informed citizenry: the democratic process only works if its citizenry is informed; and (2) government is not all-knowing: the government acknowledges it does not hold all of the expertise, it must solicit that expertise from the public (Regulations.gov, 2013). An example of rule making that limited nursing occurred when the Georgia legislature revised its scope of practice law for nurses. The law had many benefits for APNs, but the executive branch of the Georgia state government made the rules and regulations more restrictive than they were before the legislation was passed. The restrictions caused many APNs to avoid practicing under the new scope of practice but to continue to work under the old scope of practice that is still in effect as it is less restrictive (Center to Champion Nursing in America, 2010).
Policy modification allows all previous decisions to be revisited and modified. Polices that are wholly pertinent at one time may, over time, become inappropriate. Almost all policies have unintended consequences which is why many stakeholders seek to modify policies continuously.
Kingdon’s Policy Streams Model
Kingdon (1995) proposed a policy streams model to reflect the issue of policy looking for a problem. He described three streams of policy activity: the problem stream, the policy stream, and the political stream. These three conditions must stream through the open policy window at the same time (also referred to as the Garbage Can Model because the three streams must make their way through a minefield of debris). The problem must come to the attention of the policymaker, it must have a menu of viable policy solution options, and it must occur in the right political circumstances.
The problem stream describes the complexities in focusing policymakers on one specific problem out of many. For example, early in the process of developing the language for health reform legislation, policymakers engaged in a long process to define exactly which problems associated with the U.S health care system should be included in a legislative package (addressed by the government vs. private markets). Driving the problem stream are values, so access could be framed as a free market versus social justice issue. Values tend to have a stronger emotional component attached to them so that part of the challenge is the lack of agreement about which problems are the most urgent and require legislation. Some believe that cost is the biggest problem, others want to limit health reform to tort reform, and some want to improve access or quality. Until the problem is adequately defined, appropriate policy solutions cannot be identified.
The policy stream describes policy goals and the ideas of those in policy subsystems, such as researchers, congressional committee members and staff, agency officials, and interest groups. Ideas in the policy stream disseminate through policy circles in search of problems. The third stream, the political 67stream, describes factors in the political environment that influence the policy agenda, such as an economic recession, special interest media, or pivotal political power shifts.
The political circumstances that push problems to the top of the policy agenda need a high degree of public importance and a low degree of stakeholder conflict around the proposed solutions. A great deal of stakeholder conflict weakens the possibility that the policy window will open. If these three conditions occur at the same time, a policy window opens and progress can be made on the issue. Kingdon (1995) sees these streams as moving constantly and waiting for a window of opportunity to open through couplings of any two streams (particularly the political stream), creating new opportunities for policy change. However, such opportunities are time-limited: if change does not occur while the window is open, the problems and options will not be addressed.
For example, although health reform was a high priority for newly elected President Obama in 2009, the economic crisis and recession became a powerful political stream bringing to bear a major debate about how escalating health care costs were making the United States less competitive in the global marketplace. The movement of U.S. jobs overseas and the recession were linked to out-of-control health care costs and the need to reform health care, thus, a policy window was opened.
Bringing Nursing Competence Into the Policymaking Process
There are many ways to think about stakeholders and interest groups. For example, some interests may be considered public interest rather than self-interest. All people affected by health policy want to know how it will affect the people and things they care about and how they can influence those policies. To effectively influence the policymaking process, nurses must successfully analyze the process and influence it with a high degree of political competence. Policy development that is dominated by public interest generally follows a course of action that is based on data, information, and community values and addresses a solution to an actual or potential problem. It tends to be practical decision making. Policy generated by self-interest often follows a course of action with a predominantly special interest focus connected to the concerns of individuals or group interests over public interest.
Organizations that are provider-focused tend to focus on access, cost, and revenue. There is a focus on the structure of the health delivery system and points of access to their services. Stakeholder organizations that are not solely of a single provider type tend to have a broader agenda, including educational programs that develop the health workforce, insurers, pharmaceutical industry, hospitals, and medical supply companies. Although these other stakeholder organizations each have agendas of their own, it is easy to see where coalitions or policy networks can form around issues (Longest, 2010). For example, hospitals and educational programs can form coalitions around health workforce development. These stakeholder coalitions exert enormous influence in shaping health policy.
An example of a provider interest group is the National Association of Pediatric Nurse Practitioners (NAPNAP) which identified childhood obesity as a organizational priority and, as a result, created a childhood obesity special interest group which participated in a wide range of governmental committees, interviews on news media, and development of clinical practice guidelines, as well as creating culturally appropriate resources for parents. Pediatric NPs have effectively participated in a range of policy and clinical endeavors to address the alarming childhood obesity epidemic (NAPNAP, 2013) (See Box 7-2).
Think Like a Policymaker
Nurse Staffing Ratios
Staffing ratios have been mandated in some states through legislative action as a solution to inadequate nurse staffing and concerns about the quality and safety of patient care. Opinions vary widely about whether the implementation of mandatory staff ratios in hospitals will have the desired effect. Some say that these mandatory ratios will remove the ability of hospitals to effectively manage their costs, resulting in higher costs for taxpayers and patients. Others argue that voluntary methods to improve safe staffing have not worked and nurses are placed in high-risk care environments. Buerhaus (2009) has proposed several nonregulatory solutions to safe staffing including improving hospital work environments, incentives to hospitals for high quality care, and focused efforts on reducing the nursing shortage. Do you think this health related issue is amenable to a public policy solution, or could safe staffing standards be managed as a policy within the workplace? As a policymaker, what information would you need to decide whether this problem would benefit from a public policy solution?
According to Longest (2010) there are best practices that leaders of advocacy organizations undertake to promote their health-related mission. Once the organization makes policy influence a priority, a governmental relations (or affairs) team is formed (or a firm is contracted) to do the work. If these teams are competent, they can transform the effectiveness of the organizations by giving the CEO (and/or board of directors) anticipatory guidance and lead-time. The ability of organizations to anticipate lead time and direct resources 68appropriately is the key function of a strong public policy team. This anticipatory approach moves maturing organizations away from reacting to policy changes and toward strategic leadership (Longest, 2010). Effective advocacy organizations are continuously analyzing the environment. This requires that politically competent organizations primarily look out (not in) at the ever-changing political landscape.
Professional nursing organizations (e.g., the American Academy of Nursing, the American Nurses Association, and many nursing specialty groups) are concerned not only with public policy that impacts the health of all people, but also with policy that impacts nurses and the practice of nursing. These organizations, individually and collectively, support policies that are in the best interest of their members.
Engaging in Policy Analysis
Issue analysis is similar to the nursing process: it is necessary to clearly identify the problem (including the context of the problem, alternatives for resolution and the consequences of each, along with specific criteria for evaluating the alternatives) and recommend the optimal solution. Issue papers provide the mechanism to do this. This is a process that identifies the underlying issue, identifies the stakeholders, and specifies alternatives along with their positive and negative consequences. Issue papers help to clarify arguments in support of a cause, to recognize the arguments of the opposition, to lay out the evidence or lack thereof to an issue, and to develop strategies to inform policy analysts and advance the issue through the policy cycle (Box 7-3).
Example of a Policy Decision Brief
Re: Health Care Fraud in the Military Health System
Issue Summary: Health care fraud burdens the Department of Defense (DOD) with enormous financial losses while threatening the quality of health care. Assuming that between 10% and 20% of paid claims are fraudulent, the annual loss to DOD is $600 million to $1.2 billion.
• The U.S. Attorney General has identified health care fraud as the second priority for law enforcement, following only violent crime.
• Because health care fraud perpetrators target DOD, Medicare, Medicaid, and private health insurers simultaneously, the Defense Criminal Investigative Service (DCIS) cooperates extensively with many federal agencies in joint health care fraud investigations.
• Federal agencies fighting health care fraud, except DOD, have received additional resources to enhance their efforts.
• The TRICARE Program Integrity Office currently has a staff of 10, and a caseload of 1000 active cases.
• The 1996 Kennedy-Kassebaum legislation provided for 80 additional U.S. attorneys to be hired specifically to prosecute health care fraud and abuse.
1. Enhance prosecution. Provide state attorneys general with an incentive to participate in the prosecution of DOD health care fraud by offering a portion of recovered funds from successfully prosecuted cases.
Advantages: Could increase the total number and speed with which DOD health care fraud cases are prosecuted.
Disadvantages: Does not address the problem of inadequate resources dedicated to detecting and investigating DOD health care fraud cases.
2. Enhance detection and investigation. Provide a portion of recovered funds (5% to a maximum of $15 million annually) to the federal agencies charged with detection and investigation of DOD health care fraud to enhance their efforts.
Advantages: The bottleneck in government efforts to control military health care fraud occurs within the first two steps: detection and investigation. Returning a portion of recovered funds would serve as an incentive for superior performance, as well as allow for increased efforts in the fight against fraud. Current budget restrictions have precluded significant deterrent efforts; additional resources would be used to develop computer applications that detect and deter health care fraud more effectively.
Disadvantages: Funds previously recovered and returned to the DOD would be returned to detection/investigation agencies.
3. Continue current efforts. No change in current detection, investigation, and prosecution efforts.
Advantages: Current efforts will uncover a certain level of health care fraud and will continue to recover a portion of fraudulent claims to the government.
Disadvantages: Fraud perpetrators will become increasingly sophisticated in their activities and will be able to stay one step ahead of overburdened government investigators.
4. Develop additional data about the problem. Direct the Government Accountability Office to conduct a study on the feasibility of the alternatives.
Recommendation: Direct the Controller General of the U.S. to undertake a study and provide a report to Senator Smith on the feasibility of the above alternatives. Because of the magnitude of federal expenditures on health care, and the loss from health care fraud, it is essential to determine the best alternative based on empirical data.
It is helpful to compare alternatives by creating a scorecard. This is a two-dimensional grid with the evaluation criteria on the vertical axis and the different alternative policies on the horizontal axis with a notation for each alternative facilitating comparison of their strengths and weaknesses.
Another mechanism for helping people to understand an issue is a policy decision brief often referred to as a one page leave-behind. This provides a summary for the policymaker to read and to gain a grasp of the issue quickly. A standard format for a policy brief includes: summary of the issue, background information, analysis of alternatives, a recommendation for action, references, and personal contact information (Box 7-4).
Example of a One-Page “Leave-Behind” Summary of a Nursing Policy Issue
Remove Barriers to Nurse Practitioners’ Ability to Practice
ACTION NEEDED: Enable NPs to practice to the full extent of their license
By amending current statutes or directing the Centers for Medicare and Medicaid Services to revise outdated rules and manuals, Congress should take action to remove obsolete limitations in federal laws and regulations that do not recognize nurse practitioners’ advanced education and clinical education to furnish the full range of services.
Background: The landmark Institute of Medicine 2011 report, The Future of Nursing: Leading Change, Advancing Health, includes recommendations for Congress and the Department of Health and Human Services to remove barriers limiting the ability of nurse practitioners and other advanced practice nurses to practice at the full extent of their license. These recommendations are supported by extensive evidence of the high quality, safety, and effectiveness of care provided by nurse practitioners. To ensure increased access to better care at lower cost in the U.S., federal health care programs must eliminate policies that prevent nurse practitioners from providing patient care at the fullest extent of their license.
In spite of their recognized scope of practice, Medicare does not permit nurse practitioners to conduct assessments to admit the patients to skilled nursing facilities even though it authorizes them to order skilled nursing care. Similarly, Medicare does not allow NPs to provide the initial certification for hospice care, although they are authorized to serve as attending providers and to recertify patients’ eligibility. The need to revise these and other Medicare policies are discussed in separate fact sheets. In addition, Congress should address the following barriers to NP practice:
• Provide coverage of nurse practitioners’ services as physician services are covered.
• Several outdated regulatory barriers to NP practice could be removed simply by correcting the interpretation of the term physician to be consistent with current Medicare payment policies that authorize Part B payment to NPs for services within their scope of practice. This simple change would enable nurse practitioners to certify Medicare beneficiaries for home health and hospice services and to conduct examinations to admit patients to skilled nursing facilities.
• Recognize NPs as primary care providers in all health care plans and programs.
• The Institute of Medicine’s definition of primary care should serve as a benchmark for any legislation to expand access to primary care services.
Request: Congress and CMS should update and revise statutes and regulations to ensure patient access to nurse practitioner services.
For additional information, please contact the AANP Federal Health Policy Office at (703) 740-2529 or [email protected].
Infusing the Evidence Base into Health Policy
The role of data and research is highly valuable in understanding a health policy issue and in developing a solution to the problem. It assumes that health policy driven by an evidence base will link the evidence, policy solution, and the significance of the situation. However, evidence may support opposing views of a policy solution. For example, will expanding access to care for the poor increase or decrease costs? There is evidence that supports both sides of this policy debate and the cost shifting currently in place for most delivery systems makes it difficult to ascertain which view is correct.
Another barrier to crafting policy is that there can be a lack of clarity about the evidence that is needed. Nurses generally understand that evidence-based practice is based on science. However, there is a hierarchy of what constitutes evidence from scientific inquiry that ranges from systematic review, randomized controlled trials, cohort studies, case control studies, cross-sectional surveys, case reports, expert opinion, and anecdotal information (Glasby & Beresford, 2006). This hierarchy can make it difficult to reach an agreement among stakeholders, policymakers, and the public about what evidence is appropriate for health policy. As noted by Hewison (2008), practitioners and consumers may be at odds over which type of evidence is the more valuable. New evidence may need to be 70developed before one can move ahead with a policy recommendation that may include evidence informed by input from community stakeholders.
Despite the debate over what constitutes evidence and which evidence is relevant for health policy, health services research (HSR) can be very effective in developing policy options. HSR is a far broader form of research than clinical research in that it is a multidisciplinary field of scientific inquiry that looks at how people gain access to health care, how much care costs, and what happens to patients as a result of this care. The main goals of HSR are to identify the most effective ways to deliver high quality cost effective safe care across systems (Agency for Healthcare Research and Quality [AHRQ], 2013a). These include issues such as the restructuring of health services, human resource use in health care settings, primary care design, patient safety and quality, and patient outcomes. For example, Linda Aiken’s work on safe staffing (Aiken, 2007; Aiken et al., 2002), Mary Naylor’s work on transitions in care for older adults (Naylor et al., 2004), and Mary Mundinger’s work on the use of nurse practitioners (Mundinger et al., 2000) are widely cited in policy literature. There has been an increase in comparative effectiveness research, which uses a design to inform decisions about Medicare. It uses a range of data sources to compare the costs and harms of various treatment decisions and is commonly used to study the cost effectiveness of drugs, medical devices, and surgical procedures (AHRQ, 2013b).
Influencing the Policy Process as Nursing Practice
Many opportunities exist for nurses to become involved in the policy process. Involvement in health policy is a natural extension of the role as advocate. Nurses who seek elective office have chosen to take on the role of policymaker as their primary practice. In this case, nurses in elected office are practicing the highest form of civil service that a professional nurse can engage in to advance the public’s health. If running for elected office is not feasible or desired, the less difficult form of civic engagement is to participate in the electoral process. This includes a large menu of activities including, at the least, being informed of candidates’ positions regarding health care, but also potentially supporting financially candidates who advocate sound health policy reforms as well as working on campaigns, hosting fundraisers, and/or serving as policy advisors to candidates.
In addition to elective office, nurses serve in policy research roles; as policy analysts within professional nursing or patient advocacy organizations and health care institutions and within state or federal agencies; and as staff to policymakers. Nursing leaders have had considerable impact on policy from their leadership positions in organizations such as the AARP, the Institute of Medicine (IOM), the Health Services and Resources Administration (HRSA), and the Centers for Disease Control and Prevention (CDC).
Atul Gawande (2009) has emphasized that it is the leaders within health care who will implement policies on health reform. Nurses should be active in all policy arenas to assure that solutions improve the health of people. Mahlin (2010)asserts that nursing organizations must do more than advocate for patients, for there are many in the United States who require care yet have inadequate or nonexistent access. This author suggests it is a worthwhile goal for nurses to engage and participate more fully in the wider health policy realm because those who are outside the system cannot adequately address systematic problems and also asserts that professional nursing associations ought to extend the reach of nurses to include significant input into the debate regarding the widespread access issues for the disenfranchised. This includes nurses getting elected to Congress, becoming involved in policymaking, and serving on influential advisory and corporate boards.
The health care policy environment is rapidly changing and incremental reforms will be undertaken continuously. All nurses must see how the policy process is core to their role as nurses, advocating for patients on an increasingly broad level. The very first step in engaging effectively in the policy process is for nurses to understand how that process works. Nurses must also be knowledgeable of the current and emerging issues that are relevant to nursing practice and must develop the political competence to effectively shape health policy.
1. Identify a problem you face regularly in your clinical setting. Next, identify how this problem could be framed as a policy issue.
2. The Longest and the Kingdon models help us interpret how policy works. Select one model and apply it to a policy issue you care about.
3. What do you think yourself and your peers can do to strengthen nursing’s influence in the policy process?
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Health Policy Brief
Improving Care Transitions
An example of a well-written policy brief is presented here. It was developed by Health Affairs and the Robert Wood Johnson Foundation. Website resource: www.healthaffairs.org/health policybriefs/brief.php?brief_id=76.
Improving Care Transitions: Better Coordination of Patient Transfers among Care Sites and the Community Could Save Money and Improve the Quality of Care1
What’s the Issue?
The term care transition describes a continuous process in which a patient’s care shifts from being provided in one setting of care to another, such as from a hospital to a patient’s home or to a skilled nursing facility and sometimes back to the hospital. Poorly managed transitions can diminish health and increase costs. Researchers have estimated that inadequate care coordination, including inadequate management of care transitions, was responsible for $25 to $45 billion in wasteful spending in 2011 through avoidable complications and unnecessary hospital readmissions.
Several new federal initiatives aim to encourage more effective care transitions. In addition, debate continues over how to restructure fee-for-service payments to motivate providers across care settings to work as a team to make transitions smoother.
This brief examines the factors contributing to poor care transitions, describes the elements of effective approaches to improving patient and family experience with transitions, and explores policy issues surrounding payment reforms designed to address the problem.
What is the Background?
For years, health policy experts have identified poor care transitions as a major contributor to poor quality and waste. The 2001 Institute of Medicine (IOM) report, Crossing the Quality Chasm, described the U.S. system as decentralized, complicated, and poorly organized, specifically noting “layers of processes and handoffs that patients and families find bewildering and clinicians view as wasteful.”
The IOM noted that, upon leaving one setting for another, patients receive little information on how to care for themselves, when to resume activities, what medication side effects to look out for, and how to get answers to questions. As a result, the conditions of many patients worsen and they may end up being readmitted to the hospital. For example, nearly one fifth of fee-for-service Medicare beneficiaries discharged from the hospital are readmitted within 30 days; three quarters of these 74readmissions, costing an estimated $12 billion a year, are considered potentially preventable, especially with improved care transitions.
There are several root causes of poor care coordination. Differences in computer systems often make it difficult to transmit medical records between hospitals and physician practices. In addition, hospitals face few consequences for failing to send medical records to patients’ outpatient physicians upon discharge. As a result, physicians often do not know when their patients have been released and need follow-up care. Finally, current payment policies create disincentives for hospitals to invest in smoother care transitions. For example, although Medicare does not allow hospitals to bill for readmissions that occur within 24 hours of discharge, it does pay full price for most readmissions that occur after that time. This means that the prevailing financial incentive for hospitals is to not expend resources on improving care transitions because a poor transition often leads to readmission, which generates additional revenue.
Moreover, some analysts believe that Medicare and Medicaid payment policies have unintentionally created incentives to unnecessarily transfer patients back and forth between hospitals and nursing homes. Their suspicion is that nursing homes, which are primarily paid by Medicaid with generally low payment rates, unnecessarily transfer patients to hospitals to qualify for more generous Medicare payment rates when their patients return to them after discharge.
Lending credence to this claim, researchers have found that states with lower rates of Medicaid spending on dual-eligible patients under age 65 (people who are eligible for both Medicaid and Medicare) have higher rates of Medicare spending on these patients, and vice versa, suggesting that providers are gaming the system.
Transition to Primary Care.
As mentioned, one of the biggest barriers to smoother care transitions is the fact that primary care physicians often have little or no information about their patients’ hospitalizations. A review of the literature published in the Journal of the American Medical Association in 2007 found that physicians had received a hospital discharge summary about their patients, and had it on hand, in only 12% to 34% of first postdischarge visits. Even when discharge summaries are received, they often lack key information, such as test results, treatment course, discharge medications, and follow-up plans. The situation is even worse for those patients who have no usual source of care.
Patients often do not consistently receive follow-up care after leaving the hospital. Among Medicare beneficiaries readmitted to the hospital within 30 days of a discharge, half have no contact with a physician between their first hospitalization and their readmission. (Figure 8-1 shows 30-day hospital readmissions under Medicare as a percentage of admissions, by state.)
FIGURE 8-1 Medicare 30-day hospital readmissions as a percentage of admissions, 2009. (From Commonwealth Fund [2009, October]. Medicare 30-day hospital readmissions as a percent of admissions: National metrics. Washington, DC: Commonwealth Fund.)
This problem may be worsening because of an ongoing shift in practice patterns. Increasingly, outpatient primary care physicians are no longer visiting their patients when hospitalized, and hospitalized patients’ care is now being managed by hospitalists, physicians who only treat patients in the hospital. Although hospitalists are generally believed to have improved the quality and coordination of patients’ in-hospital care, their presence, and the removal of patients’ outpatient primary care physicians from the hospital, has led to an increased need for care coordination among providers that doesn’t always occur.
Care Transition Models.
Several models for improving transitions after hospitalization have been developed and rigorously tested. One of the most widely disseminated is the Care Transitions Intervention developed by Eric Coleman at the University of Colorado. This approach involves transitions coaches, primarily nurses, and social workers, who first meet patients in the hospital and then follow up through home visits and phone calls over a 4-week period.
The coaches promote development of patients’ skills in four key self-care areas: managing medications; scheduling and preparing for follow-up care; recognizing and responding to red flags that could indicate a worsening condition, such as the onset of a fever or worsening breathing problems; and taking ownership of a core set of personal health 75information by having patients brainstorm and ask their providers questions about their conditions or self-care routine. In a large integrated delivery system in Colorado, the Care Transitions Intervention reduced 30-day hospital readmissions by 30%, reduced 180-day hospital readmissions by 17%, and cut average costs per patient by nearly 20%. The intervention has been adopted by more than 700 organizations nationwide.
Another rigorously tested transitional care model, developed by Mary Naylor and her colleagues at the University of Pennsylvania, involves a longer period of intervention targeted at a high-risk, high-cost subset of older adult patients, such as those hospitalized for heart failure. In six academic and community hospitals in Philadelphia, this approach reduced readmissions by 36% and costs by 39% per patient (nearly $5000) during the 12 months following hospitalization. Under the Naylor model, an advanced practice nurse not only coaches patients and their caregivers to better manage their care but also coordinates a follow-up care plan with patients’ physicians and provides regular home visits with 7-day-a-week telephone availability.
What is in the Law?
The Affordable Care Act contains several provisions that could improve care transitions. These include both carrots (financial incentives) and sticks (financial penalties).
Among the carrot approaches, starting October 1, 2012, hospitals can receive increases to their Medicare payments if they achieve or exceed performance targets for certain quality measures, including whether they told patients about symptoms or problems to look out for postdischarge; whether they asked patients if they would have the help they needed at home; and whether they provided heart failure patients with discharge instructions. (See the Health Policy Brief published on April 15, 2011, for more information on improving quality and safety: healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_45.pdf.)
Among the stick approaches, also beginning October 1, 2012, the Centers for Medicare and Medicaid Services (CMS) can reduce payments by 1% to hospitals whose readmission rates for patients with heart failure, acute myocardial infarction, or pneumonia exceed a particular target. According to a recent analysis by the Kaiser Family Foundation, 76more than 2200 hospitals will forfeit about $280 million in Medicare payments over the next year because of these readmissions penalties.
The law also authorizes paying providers for care transition services as part of payments to primary care practices that operate as medical homes, practices that closely manage and coordinate the care of patients with chronic conditions. One demonstration project, which predates the Affordable Care Act, is the Multi-Payer Advanced Primary Care Practice Demonstration in which Medicare offers practices that have been formally recognized as medical homes in eight states up to $10 per beneficiary per month to cover the cost of medical home services, which include care transition planning.
Another demonstration, the Comprehensive Primary Care Initiative, offers monthly payments to practices that average $20 per beneficiary in the first 2 years and then transitions to $15 plus the opportunity to earn shared savings in the last 2 years. Again, a portion of these programs are intended to compensate practices for the costs of care coordination and care transitions planning.
In addition, the Federally Qualified Health Center Advanced Primary Care Practice Demonstration will pay $6 per beneficiary per month to health centers that adopt the medical home model and apply for Level 3 medical home recognition, having the most stringent requirements, from the National Committee for Quality Assurance (NCQA) by the end of the 3-year demonstration. NCQA’s medical home standards ask practices to establish processes to identify patients admitted to the hospital, share clinical information with the admitting hospital, obtain patient discharge summaries from the hospital, and contact patients for follow-up care, among many other expectations.
Medicaid and Medicare.
State Medicaid agencies can now offer providers enhanced reimbursement, such as through monthly care management payments, to cover the cost of “comprehensive transitional care” and other services if the practice qualifies as a “health home”; a practice that cares not only for Medicaid patients’ physical conditions but also helps them obtain such other services as behavioral health care and long-term care services and supports.
Also, a 5-year, $500 million Community-Based Care Transitions Program pays organizations that partner with hospitals with high readmission rates to provide care transition services for high-risk Medicare beneficiaries. All-inclusive payments cover the cost of care transition services provided to individual beneficiaries in the 180 days following an eligible discharge plus the cost of systemic changes made by partner hospitals to improve care transitions. So far 47 awardees have been announced, and applications continue to be accepted. Participating organizations initially enter into 2-year agreements, which can be extended annually through the end of 2015.
Incentives in New Payment Models.
The Medicare Shared Savings Program for accountable care organizations (ACOs) will give groups of providers an incentive to coordinate care more closely to keep patients healthy and out of the hospital because they will be eligible to share in the savings they are able to generate relative to a spending benchmark. The quality metrics that must be met by ACOs to benefit financially under the program include six that pertain to care coordination, including preventing unnecessary hospital readmissions. (See Health Policy Brief published on January 31, 2012, for more information on ACOs: healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_61.pdf.)
The Affordable Care Act also authorizes 5-year bundled payment pilots in Medicare and Medicaid to test whether making a single payment to one entity for services provided by several providers for an episode of care, such as a knee replacement, will give providers an incentive to work together to ensure that patients receive all the services they need, including hospital and follow-up care, in a more efficient manner. Managing care transitions to prevent costly hospital readmissions will be particularly important because, in the Medicare pilot, at least, the bundled payment will cover services beginning 3 days before a hospital admission for an 77eligible condition and extending 30 days after hospital discharge.
Signaling the importance of care transitions to the success of these efforts, the Medicare pilot requires bundled payments to cover the cost of transitional care services. CMS’s new Innovation Center has begun accepting applications from providers interested in piloting four bundled payment models through a separate Bundled Payments for Care Improvement initiative. The Medicaid pilot, meanwhile, requires participating hospitals to have “robust discharge planning programs.”
In addition, a new Medicare-Medicaid Coordination Office in CMS is charged with better integrating benefits for dual-eligible beneficiaries. It also works to ensure “safe and effective care transitions,” among other goals. This office has awarded contracts of up to $1 million each to 15 states to design models to coordinate primary, acute, behavioral, and long-term care for Medicare-Medicaid enrollees. CMS has also invited proposals from states to test two new payment models to better integrate care for this population and allow states to share in savings from these improvements. Twenty-six states, including the 15 states awarded demonstration design contracts, have developed proposals for this demonstration. The new payment and delivery system models are likely to focus on improving care transitions, among other strategies. (See the Health Policy Brief published on June 13, 2012, for more information on dual eligibles: healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_70.pdf.)
Physicians and Nurses.
The Affordable Care Act also requires the Department of Health and Human Services to develop and implement a plan by 2013 that would lead to reporting physician-level quality measure data on the new Physician Compare website (www.medicare.gov/physiciancompare/search.html?AspxAutoDetectCookieSupport=1), including measures of the quality of care transitions. CMS has until 2019 to decide whether to conduct a demonstration giving Medicare beneficiaries financial incentives to seek care from physicians who score highly on these measures.
The law also creates a $200 million, 4-year workforce development demonstration aimed at increasing the number of advanced practice registered nurses trained in care transition services, chronic care management, preventive care, primary care, and other services appropriate for Medicare beneficiaries.
Taken as a whole, the inclusion in the Affordable Care Act of these carrots and sticks aimed at different types of providers suggests a tension over whom to pay and how to pay them to improve care transitions. On the one hand, the payment cuts that high-readmission hospitals nationwide will soon face create an expectation that hospitals take responsibility for improving care transitions using existing resources. But the fact that another program will provide new care transitions payments to hospitals and community-based organizations suggests that they may require additional resources to provide these services.
And although physicians’ performance on care transitions quality measures will be reported on Physician Compare, no provision in the Affordable Care Act requires hospitals to alert physicians when their patients are discharged, typically the needed first step before a physician can become involved in a care transition.
Other Policy Options
If these Affordable Care Act provisions fail to improve care transitions or if CMS decides to pursue other policies, the agency’s statutory authority gives it some additional options, as follows:
• Pay physicians for care transition services. Under the Medicare physician fee schedule, CMS could create a new billing code that would enable physicians to bill for delivery of care transition services. In a proposed rule issued in July 2012, CMS would create a code to bill for care transition services delivered to Medicare beneficiaries in the 30 days following a discharge from a hospital, skilled nursing facility, or community mental health center. The code would apply to Medicare patients whose medical or psychosocial problems, or both, require moderate or high complexity medical decision making.
To qualify for the new payment, physicians would have to obtain and review a patient’s hospital discharge summary, update the patient’s medical records to reflect changes in health conditions and ongoing treatments, and establish or adjust a patient’s care plan. Physicians would be required to communicate with a beneficiary or their caregiver within 2 business days of discharge to resolve medication discrepancies and inform them about possible complications. Whether physicians will consider the payment level assigned to this billing code adequate for the effort required, however, remains unclear.
• Track whether hospitals transmit records to physicians. Another policy option would be to add a care transitions measure to Medicare’s Hospital Inpatient Quality Reporting program, a pay-for-reporting program. Adding such a measure would create a modest incentive for hospitals to better communicate with physicians about patients’ hospitalizations, especially if CMS chose to include that measure in the subset that is displayed on the Hospital Compare website (www.medicare.gov/physiciancompare/search.html?AspxAutoDetectCookieSupport=1).
If CMS wanted to further elevate hospitals’ focus on this measure, it could include it in the subset of measures it uses in the Hospital Value-Based Purchasing Program, the new pay-for-performance program for hospitals created in the Affordable Care Act and scheduled to go into effect in October 2012.
A hospital-related care transitions measure has been developed by a group of physician specialty societies and endorsed by the National Quality Forum, a nonprofit organization that works with providers, consumer groups, and governments to establish and build consensus for specific health care quality and efficiency measures. This indicator, called Timely Transmission of Transition Record (measure no. 0648), measures how often a hospital sends a transition record to a patient’s physician within 24 hours of discharge. Having this information would allow primary care physicians to identify which patients needed follow-up care.
However, hospitals may not welcome this additional reporting burden because transmittal of such records to outpatient physicians is not a billable hospital service, which means claims data cannot be used to easily calculate how often such transmittals occur. Instead, for hospitals that don’t have good electronic health record systems, labor-intensive chart reviews would be required to calculate such a measure.
If CMS were to pay hospitals to develop discharge plans, discuss them with patients, and transmit them to outpatient physicians for follow-up care, the hospitals would have a greater incentive to perform these crucial activities. CMS could also then use the hospitals’ billing records for these services to calculate quality measures assessing how often the hospitals performed these important services.
However, in the current strained federal fiscal environment, offering a new carrot to hospitals may have little appeal for policymakers. Indeed, because Medicare already gives hospitals lump-sum payments to cover all the costs associated with a hospitalization and because Medicare’s conditions of participation require hospitals to have a discharge planning process in place, policymakers may feel hospitals are already being paid for care transition services but are simply not performing them as routinely as they should be.
• Strengthen hospital do-not-pay policies. Another policy stick would be to further limit payment for hospital readmissions. For example, CMS could extend its current policy of not paying for Medicare readmissions that occur within 24 hours of a hospital discharge for the same condition to 72 hours, or even 15 or 30 days, postdischarge. Doing so would require carefully defining which readmissions would be ineligible for payments and how to account for co-occurring conditions. Already, hospitals as a group are upset about CMS’s decision to penalize them for certain planned readmissions because they do not think it adequately distinguishes between readmissions that are truly necessary compared to readmissions that are truly preventable.
Given the current budgetary environment and the fact that Medicare is estimated to spend $12 billion per year on potentially preventable hospital readmissions, interest in improving care transitions to reduce Medicare spending is likely only to grow.
Although some care transitions interventions have generated cost savings, uncertainty remains over how best to encourage providers to use these approaches. Evaluation of the changes brought about by the Affordable Care Act will begin filling gaps in our knowledge. And if the health care law’s approaches fail to make a strong enough case for providers to pay attention to care transitions, policymakers may want to explore bigger carrots and sticks.
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The Women’s and Children’s Health Policy Center.
1Health Policy Brief: Care Transitions, Health Affairs, September 13, 2012. Written by Rachel Burton, Research Associate, Urban Institute. Editorial review by Eric Coleman, Division Head Health Care Policy and Research, University of Colorado Medical Campus; Debra J. Lipson, Senior Researcher, Mathematica Policy Research; Ted Agres, Senior Editor for Special Content, Health Affairs; Anne Schwartz, Deputy Editor, Health Affairs; and Susan Dentzer, Editor-in-Chief, Health Affairs. Health Policy Briefs are produced under a partnership of Health Affairs and the Robert Wood Johnson Foundation. Reprinted with permission.
Take the identified healthcare policy from thread one. Identify both obvious and non-obvious stakeholders. Also identify stakeholders that you have the potential to influence.
In our discussion question #2, take the health care policy that you identified in thread one that needed revision. Can you discuss both the obvious and the non-obvious stakeholders? Which stakeholders to you have the potential to influence? What barriers do you face with reaching stakeholders and allowing them to buy in?
This week’s graded topics relate to the following Course Outcomes (COs).
4. Determine the effect of healthcare politics on the healthcare stakeholders, state and federal government, and the nursing profession (PO #9).
5. Analyze legislative process and the impact of special interest lobbies (PO #9
1. How have you seen the diverse interests of healthcare stakeholders impact patient care in your nursing practice or in the practice of other nurses?
2. In general, do you think political action committees (PACs) and special interest groups (SIGs) contribute to or detract from improvements in patient healthcare? Provide an example to illustrate your thoughts.
3. What role should politics play in healthcare reform? What role should the DNP-prepared nurse play in the political process that impacts healthcare reform?
Diana J. Mason, PhD, RN, FAAN
Rudin Professor of Nursing
DIANA J. MASON, PhD, RN, FAAN, is the Rudin Professor of Nursing and Co-Founder and Co-Director of the Center for Health, Media, and Policy (CHMP) at Hunter College and Professor at the City University of New York. She served as President of the American Academy of Nursing (2013-2015) and as Strategic Adviser for the Campaign for Action, an initiative to implement the recommendations from the Institute of Medicine’s Future of Nursing report, to which she contributed. From 2012 to 2015 she served as Co-President of the Hermann Biggs Society, an interdisciplinary health policy salon in New York City.