Reflection Chap 87 And 87

Complete this week’s assigned readings, chapters 86 & 87 of your book After completing the readings, post a reflection discussing your thoughts and opinions about one or several of the specific topics covered in the textbook readings. pertaining to politics in associations and interest groups. Identify which one MSN Essential most relates to your selected topic in your discussion.

As a reminder, no scholarly sources are required only your text book :

Mason, D. J., Leavitt, J.K., Chaffee, M.W. (2016). Policy and Politics: In Nursing and Health Care. (7th• Ed) St. Louis, Missouri: Elsevier, Saunders. ISBN-13: 9780323299886

Policy & Politics in Nursing and Health Care Seventh Edition

Diana J. Mason, PhD, RN, FAAN

Rudin Professor of Nursing

Co-Director of the Center for Health, Media, and Policy

School of Nursing

Hunter College

City University of New York

New York, New York

Deborah B. Gardner, PhD, RN, FAAN, FNAP

Health Policy and Leadership Consultant, LLC

Honolulu, Hawaii

Freida Hopkins Outlaw, PhD, RN, FAAN

Adjunct Professor

Peabody College of Education

Vanderbilt University




Nashville, Tennessee

Eileen T. O’Grady, PhD, NP, RN

Nurse Practitioner and Wellness Coach

McLean, Virginia




Table of Contents

Cover image

Title page


About the Editors





What’s New in the Seventh Edition?

Using the Seventh Edition

Acknowledgments Unit 1 Introduction to Policy and Politics in




Nursing and Health Care

Chapter 1 Frameworks for Action in Policy and Politics

Upstream Factors

Nursing and Health Policy

Reforming Health Care

Nurses as Leaders in Health Care Reform

Policy and the Policy Process

Forces That Shape Health Policy

The Framework for Action

Spheres of Influence


Health and Social Policy

Health Systems and Social Determinants of Health

Nursing Essentials

Policy and Political Competence

Discussion Questions


Online Resources

Chapter 2 An Historical Perspective on Policy, Politics, and Nursing

“Not Enough to be a Messenger”

Bringing Together the Past for the Present: What We Learned From History





Discussion Questions


Online Resources

Chapter 3 Advocacy in Nursing and Health Care

The Definition of Advocacy

The Nurse as Patient Advocate

Consumerism, Feminism, and Professionalization of Nursing: the Emergence of Patients’ Rights Advocacy

Philosophical Models of Nursing Advocacy

Advocacy Outside the Clinical Setting

Barriers to Successful Advocacy


Discussion Questions


Online Resources

Chapter 4 Learning the Ropes of Policy and Politics

Political Consciousness-Raising and Awareness: the “Aha” Moment

Getting Started

The Role of Mentoring

Educational Opportunities

Applying Your Political, Policy, Advocacy, and Activism Skills

Political Competencies

Changing Policy at the Workplace Through Shared Governance




Discussion Questions


Online Resources

Chapter 5 Taking Action: How I Learned the Ropes of Policy and Politics

Mentors, Passion, and Curiosity

Chapter 6 A Primer on Political Philosophy

Political Philosophy

The State

Gender and Race in Political Philosophy

The Welfare State

Political Philosophy and the Welfare State: Implications for Nurses

Discussion Questions


Online Resources

Chapter 7 The Policy Process

Health Policy and Politics

Unique Aspects of U.S. Policymaking

Conceptual Basis for Policymaking

Bringing Nursing Competence Into the Policymaking Process


Discussion Questions





Online Resources

Chapter 8 Health Policy Brief: Improving Care Transitions

Improving Care Transitions: Better Coordination of Patient Transfers among Care Sites and the Community Could Save Money and Improve the Quality of Care1


Online Resources

Chapter 9 Political Analysis and Strategies

What is Political Analysis?

Political Strategies

Discussion Questions


Online Resources

Chapter 10 Communication and Conflict Management in Health Policy

Understanding Conflict

The Process of Conversations

Listening, Asserting, and Inquiring Skills


Discussion Questions


Online Resources

Chapter 11 Research as a Political and Policy Tool




So What is Policy?

What is Research When It Comes to Policy?

The Chemistry between Research and Policymaking

Using Research to Create, Inform, and Shape Policy

Research and Political Will

Research: Not Just for Journals

Discussion Questions


Online Resources

Chapter 12 Health Services Research: Translating Research into Policy

Defining Health Services Research

HSR Methods

Quantitative Methods and Data Sets

Qualitative Methods

Professional Training in Health Services Research


Fellowships and Training Grants

Loan Repayment Programs

Dissemination and Translation of Research Into Policy

Discussion Questions


Online Resources




Chapter 13 Using Research to Advance Health and Social Policies for Children

Research on Early Brain Development

Research on Social Determinants of Health and Health Disparities

Advancing Children’s Mental Health Using Research to Inform Policy

Research on Child Well-Being Indicators

Research on “Framing the Problem”

Gaps in Linking Research and Social Policies for Children

Nursing Advocacy

Discussion Questions


Online Resources

Chapter 14 Using the Power of Media to Influence Health Policy and Politics

Seismic Shift in Media: One-to-Many and Many-to-Many

The Power of Media

Who Controls the Media?

Getting on the Public’s Agenda

Media as a Health Promotion Tool

Focus on Reporting

Effective Use of Media

Analyzing Media

Responding to the Media





Discussion Questions


Online Resources

Chapter 15 Health Policy, Politics, and Professional Ethics

The Ethics of Influencing Policy

Reflective Practice: Pants on Fire

Discussion Questions

Professional Ethics

Reflective Practice: Foundational Nursing Documents

Personal Questions

Reflective Practice: Negotiating Conflicts between Personal Integrity and Professional Responsibilities

Personal Question

U.S. Health Care Reform

Reflective Practice: Accepting the Challenge

Personal Question

Reflective Practice: the Medicaid 5% Commitment—an Appeal to Professionalism

Discussion Question

Reflective Practice: Your State Turned Down Medicaid Expansion

Personal Question

Reflective Practice: Barriers to the Treatment of Mental Illness

Personal Question

Ethics and Work Environment Policies




Mandatory Flu Vaccination: the Good of the Patient Versus Personal Choice


Discussion Questions


Online Resources

Unit 2 Health Care Delivery and Financing

Chapter 16 The Changing United States Health Care System

Overview of the U.S. Health Care System

Public Health

Transforming Health Care Through Technology

Health Status and Trends

Challenges for the U.S. Health Care System

Health Care Reform

Opportunities and Challenges for Nursing

Discussion Questions


Online Resources

Chapter 17 A Primer on Health Economics of Nursing and Health Policy

Cost-Effectiveness of Nursing Services

Impact of Health Reform on Nursing Economics

Discussion Questions





Chapter 18 Financing Health Care in the United States

Historical Perspectives on Health Care Financing

Government Programs

The Private Health Insurance and Delivery Systems

The Problem of Continually Rising Health Care Costs

The ACA and Health Care Costs

Discussion Questions


Online Resources

Chapter 19 The Affordable Care Act: Historical Context and an Introduction to the State of Health Care in the United States

Historical, Political, and Legal Context

Content of the Affordable Care Act

Impact on Nursing Profession: Direct and Indirect

Overall Cost of the Aca

Political and Implementation Challenges


Discussion Questions


Online Resources

Chapter 20 Health Insurance Exchanges: Expanding Access to Health Care




What is a Health Insurance Exchange?

Exchange Purchasers

Other Health Insurance Options

Federal or State Exchanges


Development of the Exchanges

Establishing State Exchanges

The Federal Exchange Rollout: ACA Setback

New York’s Success Story

The Oregon Story

Exchange Features

Marketplace Insurance Categories

Role of Medicaid

Nurses’ Roles with Exchanges

Consumer Education

State Requirements Include Aprns in Exchange Plans

Assessing the Impact of the Exchanges and Future Projections


Discussion Questions


Online Resources

Chapter 21 Patient Engagement and Public Policy: Emerging New Paradigms and Roles

Patient Engagement Within Nursing




Patient Engagement and Federal Initiatives

The VA System: an Exemplar of Patient-Centered Care

From Patient Engagement to Citizen Health


Discussion Questions


Online Resources

Chapter 22 The Marinated Mind: Why Overuse Is an Epidemic and How to Reduce It

Commonly Overused Interventions

Reasons for Overuse

Financial Incentives as the Major Cause of Overuse

The Marinated Mind

Physician and Nurse Acknowledgment of Overuse

Public Reporting to Reduce Overuse

Journalists Advocate for More Transparency About Overuse

Discussion Questions


Online Resources

Chapter 23 Policy Approaches to Address Health Disparities

Health Equity and Access

Policy Approaches to Address Health Disparities

Evaluating Patient-Centered Care





Discussion Questions


Online Resources

Chapter 24 Achieving Mental Health Parity

Historical Struggle to Achieve Mental Health Parity

Implications for Nursing: Mental Health Related Issues and Strategies

Discussion Questions


Online Resources

Chapter 25 Breaking the Social Security Glass Ceiling: A Proposal to Modernize Women’s Benefits1

Benefits for Women

Strengthening the Program

Changes We Oppose

Strengthening Financing

Discussion Questions


Online Resources

Chapter 26 The Politics of the Pharmaceutical Industry

Globalization Concerns

Values Conflict

Direct to Consumer Marketing




Conflict of Interest





Discussion Questions


Online Resources

Chapter 27 Women’s Reproductive Health Policy

When Women’s Reproductive Health Needs are Not Met

Why Do We Need Policy Specifically Directed at Women?

Women’s Health and U.S. Policy

Discussion Questions


Online Resources

Chapter 28 Public Health: Promoting the Health of Populations and Communities

The State of Public Health and the Public’s Health

Impact of Social Determinants and Disparities on Health

Major Threats to Public Health

Challenges Faced by Governmental Public Health

Charting a Bright Future for Public Health

Discussion Questions





Online Resources

Chapter 29 Taking Action: Blazing a Trail…and the Bumps Along the Way—A Public Health Nurse as a Health Officer

Getting the Job: More Difficult Than You Might Think

Creating Access to Public Health Care in West New York

On-the-Job Training

Political Challenges

Safe Kid Day Arrives

Nurses Shaping Policy in Local Government

Successes and Challenges


Chapter 30 The Politics and Policy of Disaster Response and Public Health Emergency Preparedness

Purpose Statement

Background and Significance

Presidential Declarations of Disaster and the Stafford Act

Policy Change After September 11

The Politics Underlying Disaster and Public Health Emergency Policy

The Homeland Security Act

Project Bioshield 2004

Pkemra 2006 and Disaster Case Management

National Commission on Children and Disasters 2009

Threat Level System of the U.S. Department of Homeland Security





Discussion Questions


Online Resources

Chapter 31 Chronic Care Policy: Medical Homes and Primary Care

The Experience of Chronic Care in the United States

Medical Homes

The Role of Nursing in Medical Homes

Patient-Centered Medical Homes: the Future

Discussion Questions


Online Resources

Chapter 32 Family Caregiving and Social Policy

Who are the Family Caregivers?

Unpaid Value of Family Caregiving

Caregiving as a Stressful Business

Supporting Family Caregivers

Discussion Questions


Online Resources

Chapter 33 Community Health Centers: Successful Advocacy for Expanding Health Care Access

Community Health Centers Demonstrate the Advocacy Process for





The Creation of the Neighborhood Health Center Program

Program Survival and Institutionalization

Continuing Policy Advocacy

The Expansion of Community Health Centers Under a Conservative President

Community Health Centers in the Era of Obamacare

Discussion Questions


Online Resources

Chapter 34 Filling the Gaps: Retail Health Care Clinics and Nurse- Managed Health Centers

Retail Health Clinics

Access and Quality in Retail Clinics

Retail Clinics and Cost

Challenges and Reactions to the Model

Nurse-Managed Health Clinics

Future Directions for Retail Clinics and NMHCs

Discussion Questions


Online Resources

Chapter 35 Developing Families

The Need for Improvement

Social Determinants and Life Course Model




Innovative Models of Care

Health Care Reform

Barriers to Sustaining, Spreading, and Scaling-Up Models


Discussion Questions


Online Resources

Chapter 36 Dual Eligibles: Issues and Innovations

Who are the Duals?

What are the Challenges?

Health Care Delivery Reforms That Hold Promise

Implication for Nurses

Policy Implications

Discussion Questions


Online Resources

Chapter 37 Home Care and Hospice: Evolving Policy

Defining the Home Care Industry

Home Health


Home Medical Equipment

Home Infusion Pharmacy

Private Duty




Reimbursement and Reimbursement Reform

Hospital Use and Readmissions and the Focus on Care Transitions

Quality and Outcome Management

The Impact of Technology on Home Care

Championing Home Care and Hospice and the Role of Nurses

Discussion Questions


Online Resources

Chapter 38 Long-Term Services and Supports Policy Issues

Poor Quality of Care

Weak Enforcement

Inadequate Staffing Levels

Corporate Ownership

Financial Accountability

Other Issues

Home and Community-Based Services

Public Financing


Discussion Questions


Online Resources

Chapter 39 The United States Military and Veterans Administration Health Systems: Contemporary Overview and Policy Challenges




The MHS and VHA Budgets

Advanced Nursing Education and Career Progression

Contemporary Policy Issues Involving MHS and VHA Nurses

Post-Deployment Health-Related Needs


Seamless Transition


Discussion Questions


Online Resources

Unit 3 Policy and Politics in the Government

Chapter 40 Contemporary Issues in Government

Contemporary Issues in Government

The Central Budget Story

Fiscal Policy and Political Extremism

How Will the Nation’s Economic Health be Addressed?

The Impact of Political Dysfunction


Loss of Congressional Moderates


Congressional Gridlock: Where is the President’s Power?

Beleaguered Health Care Reform

Implementation Challenges




Increasing Access

Affordable Care Act Costs and Savings

Legal Challenges to the ACA

Immigration Reform: Will Health Care be Included?

Current Health Care Access

The Ethics and Economics of Access

Immigration Health Care Reform Options

Rising Economic Inequality

Measuring Wealth

The Great Recession Reshaped the Economy

Costs of Economic Inequality

Impact of Economic Inequality on Health Equity

Effectively Addressing Economic Inequality

Proposed Policy Strategies

Climate Change: Impacting Global Health

Climate Change: It’s Happening

Mitigation Versus Adaptation

International Progress

Adaptation is Local

Examples of Health in All Policies

Nursing Action Oriented Leadership


Discussion Questions





Chapter 41 How Government Works: What You Need to Know to Influence the Process

Federalism: Multiple Levels of Responsibility

The Federal Government

State Governments

Local Government

Target the Appropriate Level of Government

Pulling It All Together: Covering Long-Term Care

Discussion Questions


Online Resources

Chapter 42 Is There a Nurse in the House? The Nurses in the U.S. Congress

The Nurses in Congress

Evaluating the Work of the Nurses Serving in Congress

Political Perspective

Interest Group Ratings

Campaign Financing

Sources of Campaign Funds


Online Resources

Chapter 43 An Overview of Legislation and Regulation

Influencing the Legislative Process




Regulatory Process

Discussion Questions


Online Resources

Chapter 44 Lobbying Policymakers: Individual and Collective Strategies

Lobbyists, Advocates, and the Policymaking Process

Lobbyist or Advocate?

Why Lobby?

Steps in Effective Lobbying

How Should You Lobby?

Collective Strategies

Discussion Questions


Online Resources

Chapter 45 Taking Action: An Insider’s View of Lobbying

Getting Started

Winds of Change Coming in State Legislatures

Political Strategies

There Really is a Need for Lobbyists

Chapter 46 The American Voter and the Electoral Process

Voting Law: Getting the Voters to the Polls

Calls for Reform




Voting Behavior

Answering to the Constituency

Congressional Districts

Involvement in Campaigns

Campaign Finance Law

Types of Elections

The Morning After: Keeping Connected to Politicians

Discussion Questions


Online Resources

Chapter 47 Political Activity: Different Rules for Government- Employed Nurses

Why Was the Hatch Act Necessary?

Hatch Act Enforcement

Penalties for Hatch Act Violations

U.S. Department of Defense Regulations on Political Activity

Internet and Social Media Influence


Discussion Questions


Online Resources

Chapter 48 Taking Action: Anatomy of a Political Campaign

Why People Work on Campaigns




Why People Stop Working on Campaigns

The Internet and the 2012 Election Campaign

Campaign Activities

Discussion Questions


Online Resources

Chapter 49 Taking Action: Truth or Dare: One Nurse’s Political Campaign

Stepping Into Politics

Ethical Leadership

Making a Difference

Lessons Learned

Chapter 50 Political Appointments

What Does It Take to be a Political Appointee?

Getting Ready

Identify Opportunities

Making a Decision to Seek an Appointment

Plan Your Strategy

Confirmation or Interview?


After the Appointment

Experiences of Nurse Appointees





Discussion Questions


Online Resources

Chapter 51 Taking Action: Influencing Policy Through an Appointment to the San Francisco Health Commission

Democracy and Service to the Health Commission

Checks and Balances of Health Commission Activities

Scope of Work of the Health Commission

Infrastructure of the Health Commission

Balancing Health Commission Service with Academia

Introspection: Re-Experiencing Decision Making on the Health Commission


Chapter 52 Taking Action: A Nurse in the Boardroom

My Political Career

My Campaign

Campaign Preparation

Launching the Campaign

Lessons Learned

The Future


Chapter 53 Nursing and the Courts

The Judicial System




Judicial Review


The Role of Precedent

the Constitution and Branches of Government

Impact Litigation

Expanding Legal Rights


Enforcing Legal and Regulatory Requirements

Antitrust Laws and Anticompetitive Practices

Criminal Courts

Influencing and Responding to Court Decisions

Nursing’s Policy Agenda

Discussion Questions


Online Resources

Chapter 54 Nursing Licensure and Regulation

Historical Perspective

The Purpose of Professional Regulation

Sources of Regulation

Licensure Board Responsibilities

Licensure Requirements

The Source of Licensing Board Authority

Disciplinary Offenses




Regulation’s Shortcomings


Discussion Questions


Online Resources

Chapter 55 Taking Action: Nurse, Educator, and Legislator: My Journey to the Delaware General Assembly

My Political Roots

Volunteering and Campaigning

There’s a Reason It is Called “Running” for Office

A Day in the Life of a Nurse-Legislator

What I’ve Been Able to Accomplish as a Nurse-Legislator

Tips for Influencing Elected Officials’ Health Policy Decisions

Is It Worth It?


Unit 4 Policy and Politics in the Workplace and Workforce

Chapter 56 Policy and Politics in Health Care Organizations

Financial Pressures From Changing Payment Models

The Broadening Influence of Outcome Accountability

A Door Opens—Policy to Support the Role of the Nurse Practitioner


Discussion Questions





Online Resources

Chapter 57 Taking Action: Nurse Leaders in the Boardroom

Getting Started

Are You Ready?

Discussion Questions


Online Resources

Chapter 58 Quality and Safety in Health Care: Policy Issues

The Environmental Context

The Policy Context: Value-Driven Health Care

Value-Based Payment and Delivery Models

Impact of Value-Driven Health Care on Nursing


Discussion Questions


Online Resources

Chapter 59 Politics and Evidence-Based Practice and Policy

The Players and Their Stakes

The Role of Politics in Generating Evidence

The Politics of Research Application in Clinical Practice

The Politics of Research Applied to Policy Formulation




Discussion Questions


Online Resources

Chapter 60 The Nursing Workforce

Characteristics of the Workforce

Expanding the Workforce

Increasing Diversity

Retaining Workers

Addressing the Nursing Workforce Issues


Discussion Questions


Online Resources

Chapter 61 Rural Health Care: Workforce Challenges and Opportunities

What Makes Rural Health Care Different?

Defining Rural

Rural Policy, Rural Politics

The Opportunities and Challenges of Rural Health

Discussion Questions


Online Resources

Chapter 62 Nurse Staffing Ratios: Policy Options




The Establishment of California’s Regulations

What Has Happened as a Result of the Ratios?

What Next?

Discussion Questions


Online Resources

Chapter 63 The Contemporary Work Environment of Nursing

Primary Factors

Secondary Factors

American Hospital Association (AHA) Report

Crucial Communication

Discussion Questions


Online Resources

Chapter 64 Collective Strategies for Change in the Workplace

Building a Culture of Change

Workplace Cultures Differ

Implementing the Change Decision

Examples of Change Decisions


Discussion Questions


Online Resources




Chapter 65 Taking Action: Advocating for Nurses Injured in the Workplace

Life Lessons

Becoming a Voice for Back-Injured Nurses

Establishing the Work Injured Nurses Group USA (WING USA)

Legislative Efforts to Advance Safe Patient Handling

The Future


Chapter 66 The Politics of Advanced Practice Nursing

Political Context of Advanced Practice Nursing

The Political Issues

Toward New APN Politics: Overcoming Appeasement and Apathy

Discussion Questions


Chapter 67 Taking Action: Reimbursement Issues for Nurse Anesthetists: A Continuing Challenge

Nurse Anesthesia Practice

Nurse Anesthesia Reimbursement

Advocacy Issues in Anesthesia Reimbursement

TEFRA: Defining Medical Direction

Physician Supervision of CRNAs: Medicare Conditions of Participation

Medicare Coverage of Chronic Pain Management Services






Chapter 68 Taking Action: Overcoming Barriers to Full APRN Practice: The Idaho Story


Nurturing the Passion to Achieve Statutory Change

Building Broad Coalitions and Relationships

Sustaining the Effort and the Vision

Removing Barriers to Autonomous APRN Practice

The Stars Align

The 2012 NPA Revision


Chapter 69 Taking Action: A Nurse Practitioner’s Activist Efforts in Nevada

Being a Leader

Activism Means Leaving Your Comfort Zone

Honing Your Verbal and Nonverbal Messages

Activism Requires Funding Knowledge

Developing Activist Skills Through Experience


Chapter 70 Nursing Education Policy: The Unending Debate over Entry into Practice and the Continuing Debate over Doctoral Degrees

The Entry Into Practice Debate

The Entry Into Advanced Practice Debate





Discussion Questions


Online Resources

Chapter 71 The Intersection of Technology and Health Care: Policy and Practice Implications

Public Policy Support for HIT


Discussion Questions


Online Resources

Unit 5 Policy and Politics in Associations and Interest Groups

Chapter 72 Interest Groups in Health Care Policy and Politics

Development of Interest Groups

Functions and Methods of Influence

Landscape of Contemporary Health Care Interest Groups

Assessing Value and Considering Involvement


Discussion Questions


Online Resources




Chapter 73 Current Issues in Nursing Associations

Nursing’s Professional Organizations

Organizational Life Cycle

Current Issues for Nursing Organizations


Discussion Questions


Online Resources

Chapter 74 Professional Nursing Associations: Operationalizing Nursing Values

The Significance of Nursing Organizations

Evolution of Organizations

Today’s Nurse

Organizational Purpose

Associations and Their Members

Leadership Development

Opportunities to Shape Policy

Influencing the Organization


Discussion Questions


Online Resources

Chapter 75 Coalitions: A Powerful Political Strategy




Birth and Life Cycle of Coalitions

Building and Maintaining a Coalition: the Primer

Pitfalls and Challenges

Political Work of Coalitions

Evaluating Coalition Effectiveness

Discussion Question


Online Resources

Chapter 76 Taking Action: The Nursing Community Builds a Unified Voice

The Necessity of Coalitions

Coalition Formation

Defining a Coalition’s Success: the Importance of Leadership and Goal Setting

A Perspective on Nursing’s Unified Voice

Nursing Unites: the Nursing Community



Chapter 77 Taking Action: The Nursing Kitchen Cabinet: Policy and Politics in Action

The Context

Discussion Questions





Chapter 78 Taking Action: Improving LGBTQ Health: Nursing Policy Can Make a Difference

LGBTQ Rights in the United States

Nursing and LGBTQ Advocacy

Taking Action



Online Resources

Chapter 79 Taking Action: Campaign for Action

The Future of Nursing Report

A Vision for Implementing the Future of Nursing Report

Success at the National Level

Success at the State Level



Online Resources

Chapter 80 Taking Action: The Nightingales Take on Big Tobacco

Tobacco Kills

Ruth’s Story

The Personal Becomes Political

Compelling Voices

Strategic Planning

Kelly’s Story




Policy Advocacy

Shareholder Advocacy: “the NURSES are Coming…”

Extending the Message

What NURSES Can Do

Nursing is Political

Lessons Learned: Nursing Activism

Discussion Questions


Online Resources

Unit 6 Policy and Politics in the Community

Chapter 81 Where Policy Hits the Pavement: Contemporary Issues in Communities

What is a Community?

Healthy Communities

Partnership for Improving Community Health

Determinants of Health

Discussion Questions


Online Resources

Chapter 82 An Introduction to Community Activism

Key Concepts

Taking Action to Effect Change: Characteristics of Community Activists and Activism




Challenges and Opportunities in Community Activism

Nurses as Community Activists

Discussion Questions


Online Resources

Chapter 83 Taking Action: The Canary Coalition for Clean Air in North Carolina’s Smoky Mountains and Beyond

Lessons in Communicating

Persuasion: the Integrated Resource Plan Example

Speaking to Power

Clean Air: a Mixed Blessing

The Crucible of Financial Challenge

Efficient and Affordable Energy Rates Bill

Nurses’ Role in Environmental Stewardship


Chapter 84 How Community-Based Organizations Are Addressing Nursing’s Role in Transforming Health Care

Community as Partner and the Community Anchor

Accountable Care Community

Superstorm Sandy

the Population Care Coordinator

Hospital Partnerships and Transitional Care

Vulnerable Patient Study





Discussion Questions


Online Resources

Chapter 85 Taking Action: From Sewage Problems to the Statehouse: Serving Communities

Sewage Changed My Life

My Campaigns

The Value of Political Activity in Your Community

Leadership in the International Community

Mentoring Other Nurses for Political Advocacy

Recommendations for Becoming Involved in Politics

Chapter 86 Family and Sexual Violence: Nursing and U.S. Policy

Intimate Partner and Sexual Violence Against Women

State Laws Regarding Intimate Partner and Sexual Violence

Federal Laws Related to Intimate Partner and Sexual Violence

Health Policies Related to Intimate Partner and Sexual Violence

Child Maltreatment

State and Federal Policies Related to Child Maltreatment

Health Policies Related to Child Maltreatment

Older Adult Maltreatment

State and Federal Legislation Related to Older Adult Maltreatment

Health Care Policies Related to Older Adult Maltreatment

Opportunity for Nursing




Discussion Questions


Online Resources

Chapter 87 Human Trafficking: The Need for Nursing Advocacy

Encountering the Victims of Human Trafficking

Advancing Policy in the Workplace

Role of Professional Nursing Associations

Advocating for State Legislation and Policy on Human Trafficking

Advancing Policy Through Media and Technology

Trafficking as a Global Public Health Issue

The World of the Victims

International Policy

U.S. Response to Human Trafficking


Discussion Questions


Online Resources

Chapter 88 Taking Action: A Champion of Change: For Want of a Hug

What Happened?

The Struggle to Find Help

We Got Help, but What About Others?

Commitment in My Community




Meeting Basic Needs

Gang Violence Prevention

It Takes a Village


Chapter 89 Lactivism: Breastfeeding Advocacy in the United States

Why Advocate for Breastfeeding?

The Historic Decline in Breastfeeding in the United States

Culture of Breastfeeding

Action to Support Breastfeeding

The Need for Breastfeeding Advocacy Education

Discussion Questions


Online Resources

Chapter 90 Taking Action: Reefer Madness: The Clash of Science, Politics, and Medical Marijuana

A Plant with an Image Problem

Once upon a Time, Cannabis Was Legal

How and Why Did the Marijuana Prohibition Begin?

My Introduction to the Problem of Medical Cannabis Use

An Opportunity for Education

Barriers and Strategies

Patients Out of Time

The Tide is Shifting




Looking Ahead at a Paradigm Shift


Chapter 91 International Health and Nursing Policy and Politics Today: A Snapshot



Global Health

The Policy Role of the World Health Organization

The Millennium Development Goals

Beyond the Millennium Development Goals

Human Resources for Health

Advanced Nursing Practice

The World Health Organization and Nursing

Nursing’s Policy Voice

Getting Involved

Discussion Questions


Chapter 92 Infectious Disease: A Global Perspective


Determinants of Infectious Disease Introduction and Transmission

Ebola Virus Disease Outbreak: West Africa, 2014

Surveillance and Reporting





Discussion Questions


Online Resources






3251 Riverport Lane St. Louis, Missouri 63043 POLICY & POLITICS IN NURSING AND HEALTH CARE ISBN: 978-0-323-24144-1

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Library of Congress Cataloging-in-Publication Data Policy & politics in nursing and health care / [edited by] Diana J. Mason, Deborah B. Gardner, Freida Hopkins Outlaw, Eileen T. O’Grady.—Seventh edition. p.; cm. Policy and politics in nursing and health care Includes bibliographical references and index. ISBN 978-0-323-24144-1 (pbk. : alk. paper) I. Mason, Diana J., 1948-, editor. II. Gardner, Deborah B., editor. III. Outlaw, Freida Hopkins, editor. IV. O’Grady, Eileen T.,




1963-, editor. V. Title: Policy and politics in nursing and health care. [DNLM: 1. Nursing–United States. 2. Delivery of Health Care– United States. 3. Politics–United States. 4. Public Policy–United States. WY 16 AA1] RT86.5 362.17′3–dc23 2015008880 Senior Content Strategist: Sandra Clark Content Development Manager: Laurie Gower Senior Content Development Specialist: Karen Turner Content Development Specialist: Jennifer Wade Publishing Services Manager: Jeff Patterson Senior Project Manager: Clay S. Broeker Design Direction: Ashley Miner Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1




About the Editors

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.

Dr. Mason was editor-in-chief of the American Journal of Nursing for over a decade. Under her leadership, the journal received numerous awards for editorial excellence and dissemination, culminating in the journal being selected by the Specialized Libraries Association in 2009 as one of the 100 most influential Journals of the Century in Biology and Medicine—the only nursing journal to be selected for this distinction.

As a journalist, she has produced and moderated a weekly radio program on health and health policy (Healthstyles) for 30 years. She blogs for HealthCetera ( and for the JAMA News Forum. In 2009, she was appointed to the National Advisory Committee for Kaiser Health News—the only nurse and health professional on the Committee.

She is the lead co-editor of The Nursing Profession: Development, Challenges, and Opportunities, part of the Robert Wood Johnson Foundation Health Policy Book Series. She has been the lead co-




editor of all seven editions of Policy & Politics in Nursing and Health Care.

She is the recipient of numerous honors, including Honorary Doctorates from Long Island University and West Virginia University; fellowship in the New York Academy of Medicine; and the Pioneering Spirit Award from the American Association of Critical Care Nurses.

DEBORAH B. GARDNER, PhD, RN, FAAN, FNAP, is a health policy and leadership consultant. She has more than 35 years of health care experience as a clinician, manager, trainer, and consultant delivering care across diverse institutional and community settings. Dr. Gardner practiced as a psychiatric mental health clinical nurse specialist for 15 years. She received a PhD in Nursing Administration and Health Policy from George Mason University.

At the National Institutes of Health (NIH) Clinical Center she established and held the position as the Director of Organizational Planning and Workforce Development for 10 years. She served at the Bureau of Health Professionals, Health Resources and Services Administration (HRSA) as a senior consultant collaborating on the implementation of the Affordable Care Act (ACA) (2010-2012). As the Director of the Hawaii State Center for Nursing, she led the State’s Campaign for Action Coalition, a Robert Wood Johnson Foundation Initiative to support the Institute of Medicine’s Future of Nursing report.

In 2012 she served as a member of the Hawaii Governor’s Healthcare Transformation Steering Committee to assess and refocus Hawaii’s health care delivery system for alignment to the ACA goals.

A Fellow in the American Academy of Nursing and in the National Academy of Practice, she was instrumental in establishing the National Center for Interprofessional Practice and Education in Minneapolis, Minnesota. She has received numerous awards, including the HRSA Administrator’s Special Citation for National Leadership in Interprofessional Education and Collaborative Practice, an International Coaching Federation Award for




Excellence in the Establishment of an Outstanding Executive Coaching Program, the NIH Director’s Award for Outstanding Mentoring and Innovation in Organizational Development Strategies, and the “Profiles in Excellence” alumni honors award from Oklahoma Baptist University.

Dr. Gardner has written numerous book chapters and articles. She serves on the Editorial Board for Nursing Economic$ and writes the Policy and Politics column. She is a professional speaker on interprofessional practice and education teams, advanced practice nursing, and health policy issues.

FREIDA HOPKINS OUTLAW, PhD, RN, FAAN, is an adjunct professor in the Peabody College of Education, Vanderbilt University, Nashville, Tennessee. She served as the Assistant Commissioner, Division of Special Populations, Tennessee Department of Mental Health and Substance Abuse Services. In this role, she helped to develop policies and initiatives that improved treatment for children with mental health and substance abuse issues. She provided leadership in securing $32 million of federal funding to support transforming the mental health system for children and their families and was part of the leadership instrumental in passing legislation to create the Children’s Mental Health Council, which developed a plan for a statewide system of care implementation, which continues today.

She participated in the American Nurses Association Minority Fellowship Legislative Internship Program. Her passion was further ignited when state and national policies impacted delivery of mental health services to children and their families to which she provided mental health services at the University of Pennsylvania nurse-managed health center. Dr. Outlaw received a Department of Health and Human Services Policy Academy Grant to lead a team of child-serving agencies, community stakeholders, families, and youth to work on transforming mental health care for children and families through planning, policy, and practice. Dr. Outlaw a member of the Robert Wood Johnson Foundation (RWJF) Collaborative National Advisory Committee, whose function is to advise the faculty of the RWJF Nursing and Health Policy Collaborative, University of New Mexico, College of Nursing. She




is a Fellow in the American Academy of Nursing and is an active member of the Psychiatric Mental Health and Substance Abuse Expert Panel.

She has written frequently on the areas of depression, impact of racism, and stress on the health of African Americans; management of aggression; seclusion and restraint; religion, spirituality, and the meaning of prayer for people with cancer; and children’s mental health. She has received recognition for her excellence in clinical practice and for her work to improve the mental health of children and their families.

EILEEN T. O’GRADY, PhD, NP, RN, is a certified Nurse Practitioner and Wellness Coach who uses an evidence-based approach with people to reverse or prevent disease. She believes deeply that more attention must be paid to getting us unstuck from lifestyles that do not support wellness.

She speaks professionally at universities, associations, corporations, schools, and communities on the importance of thoughtful self-care, patient engagement, and how to identify and remedy a life that is out of balance. She is currently adjunct faculty in the Graduate Schools of Nursing at Pace University, Georgetown University, Duke University, and George Washington University, where she was given an Outstanding Teacher Award.

She has held a number of leadership positions with professional nursing associations, most notably as a founder and vice chair of the American College of Nurse Practitioners (now the American Association of Nurse Practitioners). She was a 1999 Policy Fellow in the U.S. Public Health Service Primary Care Policy Fellowship and in 2003 was given the American College of Nurse Practitioners Legislative Advocacy Award for her leadership on nurse practitioner policy issues. She is the 2013 recipient of the Loretta Ford Lifetime Achievement Award and the Virginia Council of Nurse Practitioners Advocate of the Year Award.

She is a co-editor and author of Advanced Practice Nursing: An Integrative Approach, 5th edition (Elsevier, 2013) and has authored numerous articles and book chapters as well as a monthly column on advanced practice nursing and health policy for 10 years in




Nurse Practitioner World News.

She has taught nurses and physicians both nationally and internationally with the U.S. Peace Corps. Dr. O’Grady has practiced as a primary care provider for 15 years and is now certified as a life coach through the International Coaching Federation and as an Adult Nurse Practitioner through the American Nurses Credentialing Center. Dr. O’Grady holds three graduate degrees: a Master of Public Health from George Washington University, a Master of Science in Nursing, and a Doctor of Philosophy in Nursing/Health Policy from George Mason University. She has dual citizenship in Ireland and the United States.





Greg Abell Principal Sound Options Group, LLC Bainbridge Island, Washington

Charles R. Alexandre PhD, RN Director Quality and Regulation Butler Hospital Providence, Rhode Island

Carmen Alvarez PhD, C-NP, CNM Julio Bellber Post-Doctoral Fellow Department of Health Policy George Washington University Washington, DC

Angela Frederick Amar PhD, RN, FAAN Assistant Dean for BSN Education and Associate Professor Nell Hodgson Woodruff School of Nursing Emory University Atlanta, Georgia

Coral T. Andrews MBA, RN, FACHE Founding Executive Director Hawaii Health Connector Honolulu, Hawaii




Susan Apold PhD, RN, ANP-BC, FAAN, FAANP Robert Wood Johnson Foundation Executive Nurse Fellow Clinical Professor of Nursing New York University New York, New York

Kenya V. Beard EdD, GNP-BC, NP-C, ACNP-BC, CNE

Associate Vice President for Curriculum and Instruction Director Center Multicultural Education and Health Disparities Jersey College Teterboro, New Jersey

Mary L. Behrens MS, FNP-BC, FAANP Family Nurse Practitioner Westside Woman’s Clinic Casper, Wyoming

Susan I. Belanger PhD, MA, RN, NEA-BC Director Education, Training, and Research Sibley Memorial Hospital/Johns Hopkins Medicine Assistant Professor School of Nursing and Health Studies Georgetown University Washington, DC

Katherine N. Bent RN, PhD, CNS Assistant Commissioner, Compliance Policy U.S. Food and Drug Administration Silver Spring, Maryland

Jonathan Bentley BS, RN RN Care Coordinator Harris Regional Hospital Sylva, North Carolina

Carmina Bernardo MA, MPH




Doctor of Public Health Student Health Policy and Management Track Graduate Center City University of New York New York, New York

Virginia Trotter Betts MSN, JD, RN, FAAN President and Chief Executive Officer HealthFutures, Inc. Nashville, Tennessee

Linda Burnes Bolton DrPH, RN, FAAN Vice President, Nursing and Chief Nursing Officer Cedars-Sinai Medical Center Los Angeles, California

Marilyn Waugh Bouldin MSN, RN, PNP Member Board of Directors Heart of the Rockies Regional Medical Center Retired Director Chaffee County Public Health Salida, Colorado

Rebecca (Rice) Bowers-Lanier EdD, MSN, MPH, RN President B2L Consulting Richmond, Virginia

Patricia K. Bradley PhD, RN, FAAN Associate Professor College of Nursing Villanova University Villanova, Pennsylvania

Edie Brous MS, MPH, JD, RN Nurse Attorney

New York, New York




Mary Lou Brunell MSN, RN Executive Director Florida Center for Nursing Co-Lead Florida Action Coalition Orlando, Florida

Kelly Buettner-Schmidt PhD, RN Associate Professor of Nursing North Dakota State University Fargo, North Dakota

Josepha E. Burnley DNP, FNP-C Nurse Consultant Health Resources and Services Administration Rockville, Maryland

Rachel Burton Research Associate Health Policy Center Urban Institute Washington, DC

Ann Campbell MPH, MSN, AGPCNP-BC, RN Primary and Palliative Care Nurse Practitioner

Mary Manning Walsh Home

Integrative Health Nurse Practitioner

The Original Bloom

New York, New York

Demetrius Chapman PhD(c), MPH, MSN(R), APRN, PHCNS-BC Associate Director New Mexico Board of Nursing Albuquerque, New Mexico




Peggy L. Chinn PhD, RN, FAAN Professor Emerita University of Connecticut Editor Advances in Nursing Science Oakland, California

Yoon Jeong Choi MSN, MPhil, RN PhD Candidate School of Nursing Columbia University New York, New York

Glenda Christiaens PhD, RN, AHN-BC Former President American Holistic Nurses Association Salt Lake City, Utah

Mary Ann Christopher MSN, RN, FAAN Consultant Avon, New Jersey

Angela K. Clark MSN, PhD(c), RN Graduate Student College of Nursing University of Cincinnati Cincinnati, Ohio

Sean P. Clarke PhD, RN, FAAN Professor and Associate Dean Undergraduate Programs William F. Connell School of Nursing Boston College Chestnut Hill, Massachusetts

Sally S. Cohen PhD, RN, FAAN IOM/AAN/ANA/ANF Distinguished Nurse Scholar-in-Residence (2014-2015) Virginia P. Crenshaw Endowed Chair




Director Robert Wood Johnson Foundation Nursing and Health Policy Collaborative College of Nursing University of New Mexico Albuquerque, New Mexico

Judith B. Collins RNC, MS, WHNP, FAAN Faculty Emerita Schools of Nursing and Medicine Founding Director Health Policy Office and Women’s Health Center Virginia Commonwealth University Richmond, Virginia

Karen S. Cox PhD, FACHE, RN, FAAN Executive Vice President and Co-Chief Operating Officer Children’s Mercy Kansas City Kansas City, Missouri

Barbara I.H. Damron PhD, RN, FAAN Secretary New Mexico Higher Education Department Santa Fe, New Mexico

Patricia D’Antonio PhD, RN, FAAN Killebrew-Censtis Term Professor in Undergraduate Nursing Education Senior Fellow Leonard Davis Institute of Health Economics School of Nursing University of Pennsylvania

Philadelphia, Pennsylvania

C. Christine Delnat MSN, RN Assistant Professor Department of Nursing St. Mary-of-the-Woods College




Terre Haute, Indiana

Erin M. Denholm MSN, RN, RWJENF SVP Clinical Transformation Centura Health Denver, Colorado

Catherine M. Dentinger FNP, MPH Career Epidemiology Field Officer New York City Department of Health and Mental Hygiene Centers for Disease Control and Prevention New York, New York

Betty R. Dickson BS Retired Contract Lobbyist

Barnardsville, North Carolina

Michele J. Eliason PhD Associate Professor Department of Health Education San Francisco State University San Francisco, California

Jeanette Ives Erickson RN, DNP, FAAN, NEA-BC Chief Nurse and Senior Vice President for Patient Care Massachusetts General Hospital Boston, Massachusetts

Carroll L. Estes PhD Professor of Sociology

Founding Director Institute for Health and Aging University of California, San Francisco San Francisco, California

Robin Dawson Estrada PhD, PNP-BC, RN Assistant Professor




College of Nursing University of South Carolina Columbia, South Carolina

Sandra Evans MAEd, RN Executive Director Idaho Board of Nursing Boise, Idaho

Julie Fairman PhD, RN, FAAN Nightingale Professor in Nursing Director Barbara Bates Center for the Study of the History of Nursing Co-Director Robert Wood Johnson Foundation Future of Nursing Scholars Program School of Nursing University of Pennsylvania Philadelphia, Pennsylvania

Lola M. Fehr MS, CAE, PRP, RN, FAAN President Fehr Consulting Resources Greeley, Colorado

Loretta C. Ford PNP, EdD, RN, FAAN, FAANP Professor and Dean Emerita School of Nursing University of Rochester, New York

Elizabeth B. Froh PhD, RN Clinical Supervisor Lactation Team and Human Milk Management Center Children’s Hospital of Philadelphia Philadelphia, Pennsylvania

Beth Gharrity Gardner MA, PhD(c) PhD Candidate Department of Sociology




University of California, Irvine Irvine, California

Catherine Alicia Georges EdD, RN, FAAN Professor and Chairperson Department of Nursing Lehman College Bronx, New York

Rosemary Gibson MSc Senior Advisor The Hastings Center Garrison, New York

Greer Glazer PhD, RN, CNP, FAAN Dean University of Cincinnati College of Nursing Schmidlapp Professor of Nursing Cincinnati, Ohio

Barbara Glickstein MPH, MS, RN Co-Director Center for Health, Media and Policy Hunter College City University of New York New York, New York

Bethany Hall-Long PhD, RNC, FAAN State Senator State of Delaware 10th District Professor of Nursing University of Delaware Newark, Delaware

Mary Mincer Hansen PhD, RN Adjunct Associate Professor MPH Program and Global Health Department Des Moines University Des Moines, Iowa




Tine Hansen-Turton MGA, JD, FCPP, FAAN Chief Executive Officer National Nursing Centers Consortium Chief Strategy Officer Public Health Management Corporation Philadelphia, Pennsylvania

Charlene Harrington PhD, RN Professor Emeritus of Nursing and Sociology School of Nursing University of California San Francisco, California

Mary Ann Hart MSN, RN Program Director Graduate Program in Health Administration Assistant Professor of Nursing and Health Administration School of Nursing, Science, and Health Professions Regis College Weston, Massachusetts

Heidi Hartmann PhD President Institute for Women’s Policy Research Research Professor George Washington University Washington, DC

Susan B. Hassmiller PhD, RN, FAAN Senior Adviser for Nursing Director Future of Nursing: Campaign for Action Robert Wood Johnson Foundation Princeton, New Jersey

Barbara Hatfield RN Former Delegate West Virginia House Charleston, West Virginia




Pamela J. Haylock PhD, RN, FAAN Oncology Care Consultant Medina, Texas Adjunct Instructor Schreiner University Kerrville, Texas

Margaret Wainwright Henbest MSN, RN Executive Director Nurse Leaders of Idaho Boise, Idaho

Karrie Cummings Hendrickson PhD, MSN, RN Finance Clinical Coordinator Department of Analytic Strategy Yale New Haven Health System New Haven, Connecticut

Linda Hirota Hevenor MPH, MS, RN Director of Patient Safety Department of Quality and Operational Excellence Lifespan Providence, Rhode Island

Sarah Hexem JD Law and Policy Program Manager National Nursing Centers Consortium Philadelphia, Pennsylvania

Anne Hudson RN, C, BSN Founder Work Injured Nurses Group USA Public Health Nurse Coos County Public Health Department Coos Bay, Oregon

Randall Steven Hudspeth PhD, MS, APRN-CNP/CNS, FRE, FAANP Executive Clinical Consultant




Hudspeth LLC Boise, Idaho

Lauren Inouye MPP, RN Associate Director of Government Affairs American Association of Colleges of Nursing Washington, DC

Brenda Isaac RN, BSN, MA, NCSN Lead School Nurse Kanawha County Schools Charleston, West Virginia

Jean E. Johnson PhD, RN, FAAN Professor and Founding Dean (retired) School of Nursing George Washington University Washington, DC

Jane Clare Joyner RN, MSN, JD Senior Policy Fellow American Nurses Association Silver Spring, Maryland

Louise Kahn MSN, MA, RN, CPNP Specialty Nurse Center for Development and Disability University of New Mexico Albuquerque, New Mexico

David M. Keepnews PhD, JD, RN, NEA-BC, FAAN Professor and Director of Graduate Programs Hunter-Bellevue School of Nursing Hunter College, City University of New York New York, New York

Karren Kowalski PhD, RN, NEA-BC, ANEF, FAAN President and Chief Executive Officer Colorado Center for Nursing Excellence




Denver, Colorado Professor School of Nursing Texas Tech University Health Sciences Center Lubbock, Texas

Mary Jo Kreitzer PhD, RN, FAAN Director Center for Spirituality and Healing Professor School of Nursing University of Minnesota Minneapolis, Minnesota

Bryan Krumm MSN, CNP Psychiatric Nurse Practitioner Sage Neuroscience Center Albuquerque, New Mexico

Ellen T. Kurtzman MPH, RN, FAAN Assistant Research Professor School of Nursing George Washington University Washington, DC

Susan R. Lacey RN, PhD, FAAN Leadership, Research, and Empowerment Consultant Huntsville, Alabama

Jean Larson RN, MSN Board Member Canary Coalition Leicester, North Carolina

Kathryn Laughon PhD, RN, FAAN Associate Professor School of Nursing University of Virginia Charlottesville, Virginia




Roberta P. Lavin PhD, APRN-BC Associate Dean for Academic Programs and Professor University of Missouri, St. Louis St. Louis, Missouri

Judith K. Leavitt RN, MEd, FAAN Health Policy Consultant Barnardsville, North Carolina

Sandra B. Lewenson EdD, RN, FAAN Professor Lienhard School of Nursing College of Health Professions Pace University Pleasantville, New York

Elena Lopez-Bowlan APRN, MSN, FNP-BC Examiner, Compensation and Pension Veterans Administration Sierra Nevada Health Care System Reno, Nevada

Robert J. Lucero PhD, MPH, RN Associate Professor of Nursing College of Nursing University of Florida Research Health Scientist HSR&D Center of Innovation on Disability and Rehabilitation Research North Florida/South Georgia Veterans Health System Gainesville, Florida

Beverly Malone PhD, RN, FAAN Chief Executive Officer National League for Nursing Washington, DC

Ruth E. Malone PhD, RN, FAAN Professor and Nursing Alumni/Mary Harms Endowed Chair Department of Social and Behavioral Sciences




School of Nursing University of California San Francisco, California

Mary Lynn Mathre RN, MSN, CARN President and Co-Founder Patients Out of Time President and Founding Member American Cannabis Nurses Association Howardsville, Virginia

DeAnne K. Hilfinger Messias PhD, RN, FAAN Professor College of Nursing and Women’s and Gender Studies University of South Carolina Columbia, South Carolina

Gina Miranda-Diaz DNP, MS/MPH, RN New Jersey State Licensed Health Officer Director Health Department West New York, New Jersey Assistant Professor Department of Nursing Lehman College Bronx, New York

Suzanne Miyamoto PhD, RN Senior Director of Government Affairs and Health Policy American Association of Colleges of Nursing Washington, DC

Wanda Montalvo MSN, MPhil, RN Montalvo Consulting Staten Island, New York

Alan Morgan MPA Chief Executive Officer National Rural Health Association




Washington, DC

Ellen S. Murray MS Colin Powell School for Civic and Global Leadership City College of New York City University of New York New York, New York

Colonel (Retired) John S. Murray PhD, RN, CPNP-PC, CS, FAAN Pediatric Nurse Consultant and Graduate Student Online Master of Science in Global Health Program Feinberg School of Medicine and Professional Studies Northwestern University Boston, Massachusetts

Len M. Nichols PhD Professor of Health Policy Director Center for Health Policy Research and Ethics George Mason University Fairfax, Virginia

Karen O’Connor PhD, JD Jonathan N. Helfat Distinguished Professor of Political Science American University Washington, DC

Terry O’Neill JD President National Organization of Women (NOW) President NOW Foundation New York, New York

Douglas P. Olsen PhD, RN Associate Professor College of Nursing Michigan State University East Lansing, Michigan




Katie Oppenheim BSN, RN Staff Nurse Birth Center Von Voigtlander Women’s Hospital University of Michigan Health System Ann Arbor, Michigan

Judith A. Oulton RN, BN, MEd, DSc (Hon) Partner Oulton, Oulton, and Associates Tatamagouche, Nova Scotia, Canada

Sharon Pappas PhD, RN, NEA-BC, FAAN Chief Nursing Officer Porter Adventist Hospital Chief Nurse Executive Centura Health Denver, Colorado

Lynn Price JD, MSN, MPH Professor and Chair Graduate Nursing School of Nursing Quinnipiac University Hamden, Connecticut

Chad S. Priest JD, MSN, RN Assistant Dean for Operations and Community Partnerships School of Nursing Indiana University Adjunct Assistant Professor of Emergency Medicine Co-Director Disaster Medicine Fellowship Program School of Medicine Indiana University Indianapolis, Indiana

Joyce A. Pulcini PhD, RN, PNP-BC, FAAN, FAANP Professor




Director of Community and Global Initiatives School of Nursing George Washington University Washington, DC

Frank Purcell BS Senior Director, Federal Government Affairs American Association of Nurse Anesthetists Washington, DC

Susan C. Reinhard PhD, RN, FAAN Senior Vice President AARP Public Policy Institute Chief Strategist Center to Champion Nursing in America Washington, DC

Victoria. L. Rich PhD, RN, FAAN Associate Professor Nursing Administration School of Nursing University of Pennsylvania Philadelphia, Pennsylvania

Nancy Ridenour PhD, APRN, BC, FAAN Dean and Professor College of Nursing University of New Mexico Albuquerque, New Mexico

Karen M. Robinson PhD, PMHCNS-BC, FAAN Gerontology Professor Executive Director Caregivers Program of Research School of Nursing University of Louisville Louisville, Kentucky

Beth L. Rodgers PhD, RN, FAAN




Professor College of Nursing University of New Mexico Albuquerque, New Mexico

Carol A. Romano PhD, RN, FAAN Rear Admiral (Retired) USPHS Dean and Professor Graduate School of Nursing Uniformed Services University Bethesda, Maryland

Carol F. Roye EdD, RN, CPNP, FAAN Associate Dean for Faculty Scholarship Professor Lienhard School of Nursing Pace University New York, New York

Angie Ross MEd Consultant Winter Park, Florida

Alice Sardell PhD Professor Department of Urban Studies Queens College City University of New York Faculty Doctorate of Public Health Program School of Public Health City University of New York Flushing, New York

Chelsea Savage DNP, MSHA, BA, RN, CPHRM Professional Liability Investigator Virginia Commonwealth University Medical Center Richmond, Virginia




Christine Ceccarelli Schrauf PhD, RN, MBA Associate Professor School of Nursing Elms College Chicopee, Massachusetts

James Mark Simmerman PhD, RN Asia Pacific Regional Director of Epidemiology Sanofi Pasteur Vaccines Bangkok, Thailand

Arlene M. Smaldone PhD, CPNP, CDE Associate Professor of Nursing Assistant Dean Scholarship and Research School of Nursing Columbia University New York, New York

Andréa Sonenberg PhD, WHNP, CNM-BC Associate Professor Graduate Program Lienhard School of Nursing College of Health Professions Pace University Pleasantville, New York

Diane L. Spatz PhD, RN-BC, FAAN Professor of Perinatal Nursing Helen M. Shearer Professor of Nutrition School of Nursing University of Pennsylvania Nurse Researcher and Director of the Lactation Program The Children’s Hospital of Philadelphia Philadelphia, Pennsylvania

Joanne Spetz PhD, FAAN Professor Philip R. Lee Institute for Health Policy Studies




Associate Director for Research Strategy Center for the Health Professions University of California, San Francisco San Francisco, California

Caroline Stephens PhD, MSN, APRN, BC Assistant Professor Department of Community Health Systems Associate Director Hartford Center of Gerontological Nursing Excellence School of Nursing University of California, San Francisco San Francisco, California

Elaine D. Stephens MPH, FHHC, RN Executive Vice President National Association for Home Care and Hospice Washington, DC

Patricia W. Stone PhD, RN, FAAN Centennial Professor in Health Policy Director of the Center for Health Policy School of Nursing Columbia University Visiting Professor for Faculty of Health University of Technology, Sydney Sydney, New South Wales, Australia

Lisa Summers CNM, DrPH Director of Policy and Advocacy Centering Healthcare Institute Boston, Massachusetts

Elaine Tagliareni EdD, RN, CNE, FAAN Chief Program Officer National League for Nursing Washington, DC

Carol R. Taylor PhD, MSN, RN




Professor of Nursing, Senior Clinical Scholar Kennedy Institute of Ethics Georgetown University Washington, DC

Clifton P. Thornton MSN, BS, BSN, RN, CNMT Pediatric Nurse Practitioner Research Nurse School of Nursing John Hopkins University Baltimore, Maryland

Cora Tomalinas BSN, PHN, Retired RN Commissioner FIRST 5 Santa Clara County Member Governing Board Santa Clara County Re-Entry Collaborative Member San Jose Mayor’s Gang Prevention Task Force Policy and Technical Team San Jose, California

Brian Valdez JD Policy and Development Specialist National Nursing Centers Consortium Philadelphia, Pennsylvania

Tener Goodwin Veenema PhD, MPH, MS, RN, FAAN Associate Professor School of Nursing John Hopkins University Center for Refugee and Disaster Response Johns Hopkins Bloomberg School of Public Health Baltimore, Maryland

Antonia M. Villarruel PhD, RN, FAAN Professor and Margaret Bond Simon Dean of Nursing School of Nursing




University of Pennsylvania Philadelphia, Pennsylvania

Elizabeth Waetzig JD Founding Partner Change Matrix, LLC Granger, Indiana

Laura M. Wagner PhD, RN, GNP, FAAN Assistant Professor School of Nursing University of California, San Francisco San Francisco, California

Jamie M. Ware JD Policy Director National Nursing Centers Consortium Manager of Strategic Policy Initiatives Public Health Management Corporation Philadelphia, Pennsylvania

Joanne R. Warner PhD, RN Dean and Professor School of Nursing University of Portland Portland, Oregon

Catherine M. Waters PhD, RN, FAAN Professor Department of Community Health Systems School of Nursing University of California, San Francisco San Francisco, California

Ellen-Marie Whelan PhD, CRNP, FAAN Senior Advisor Centers for Medicare and Medicaid Services Innovation Center Washington, DC




Kathleen M. White PhD, RN, NEA-BC, FAAN Associate Professor and Track Coordinator Health Systems Management and MSN/MBA Director Master’s Entry into Nursing Program Department of Acute and Chronic Care School of Nursing John Hopkins University Baltimore, Maryland

Marie Davis Williams MSW, LCSW Deputy Commissioner Tennessee Department of Mental Health and Substance Abuse Services Nashville, Tennessee

Shanita D. Williams PhD, MPH, APRN Chief Nursing Education and Practice Branch Division of Nursing and Public Health Bureau of Health Workforce Health Resources and Services Administration Rockville, Maryland

Rita Wray BC, MBA, RN, FAAN Founder and Chief Executive Officer Wray Enterprises, Inc. Jackson, Mississippi

Alixandra B. Yanus PhD Assistant Professor of Political Science High Point University High Point, North Carolina





Phyllis S. Brenner PhD, RN, NEA-BC Professor of Nursing and Nursing Administration Program Director College of Nursing and Health Madonna University Livonia, Michigan

Dian Colette Davitt PhD, RN Associate Professor Webster University St. Louis, Missouri

Michelle L. Edmonds PhD, FNP-BC, CNE Professor of Nursing School of Nursing Jacksonville University Jacksonville, Florida

Teresa Keller PhD, RN Associate Director for Undergraduate Studies School of Nursing New Mexico State University Las Cruces, New Mexico

Karen Kelly EdD, RN, NEA-BC Director Continuing Education Associate Professor




School of Nursing Primary Care and Health Systems Nursing Southern Illinois University, Edwardsville Edwardsville, Illinois

Carol A. Mannahan EdD, RN, NEA-BC Assistant Professor Kramer School of Nursing Oklahoma City University Oklahoma City, Oklahoma

Brenda B. Rowe MN, JD, RN Associate Professor Georgia Baptist College of Nursing of Mercer University Atlanta, Georgia

Melissa V. Sirola BSN, MSN, MBA, RN Adjunct Instructor Caldwell University Caldwell, New Jersey

Annette Weiss PhD, RN, CNE Assistant Professor Expressway RN Program Director Misericordia University Dallas, Pennsylvania





In 2010, the Institute of Medicine challenged the nation and the nursing profession to ensure that nurses are participating as leaders in decision making about health, health care, and health policy. The landmark report The Future of Nursing: Leading Change, Advancing Health is bringing attention to this most valuable resource for transforming health in the United States.

I’ve had the privilege of serving as Chairperson of the Strategic Advisory Committee for the Future of Nursing: Campaign for Action that is charged with overseeing the implementation of the report’s recommendations. Specifically, the report recommends the expansion of “opportunities for nurses to lead and diffuse collaborative improvement efforts,” including in health systems, and aims to “prepare and enable nurses to lead change to advance health.” For this latter recommendation, the report specifically calls




for “public, private, and governmental health care decision makers at every level [to] include representation from nursing on boards, on executive management teams, and in other key leadership positions.”

Leading—as a clinical bedside leader, executive in a health care organization, member of a state or federal health advisory body, or a legislator at the local, state, or federal level—requires knowing how private and public policies are made, exquisite political skills, and the confidence and willingness to guide the decisions and actions of individuals and groups. These are not easy skills to learn but are essential for every nurse who wants to lead.

I know the importance of learning how to lead. For more than 10 years, I was Chief of Staff for former Senate Majority Leader and presidential candidate Bob Dole of Kansas, after working as a professional staff member for the Senate Committee on Finance and, later, as Deputy Staff Director of that committee. These superb opportunities gave me a deep understanding of policymaking and of the leadership and political skills that are required to shape policy. I never questioned that nurses should do this kind of work. It was my good fortune to “learn the ropes” as President of the California Student Nurses Association and later as Program Director for the National Student Nurses Association.

Society must recognize the important perspectives that nurses can bring to decision-making tables, but nurses must be ready to fully engage in the important health-related decisions of our day. Policy & Politics in Nursing and Health Care is an invaluable resource for nurses to learn the ropes of being leaders in local, state, national, and international organizations—from the bedside to the boardroom to the backrooms of policymaking. It provides guidelines and an important framework for developing leaders. For the more sophisticated nurse leaders, it offers in-depth analyses of important policy issues within a political context.

Policy & Politics in Nursing and Health Care has been in publication for 30 years. This essential resource continues to prepare the current and future generations of nurse leaders. We must use it wisely if we’re to achieve the recommendations in The Future of Nursing. Our nation’s health depends upon nurses being leaders in transforming




health and health care in the United States and globally.

Sheila Burke MPA, RN, FAAN Faculty Research Fellow, Malcolm Weiner Center for Social Policy Adjunct Lecturer, John. F. Kennedy School of Government at Harvard University Chair, Government Relations and Public Policy, Baker, Donelson, Bearman, Caldwell & Berkowitz

On the threshold of significant change, we find ourselves at a pivotal time for health care in the United States. For far too long, Americans have been served by a fragmented health care system and one that has heavily emphasized acute care, at the expense of keeping people well. It has come with a price tag of about $2.7 trillion a year. Costs have been ticking ever upward until recently. As a result, health care services have been unaffordable and largely inaccessible to millions of Americans. For all Americans, consistent care quality could not be guaranteed.

The Affordable Care Act has been instrumental in helping the nation reset this picture. Even in the midst of heated rhetoric and misinformation, the law is moving us forward on insurance coverage for previously uninsured Americans, access to care, improved care quality, and new payment mechanisms. Addressing these things is crucial to improving health care and the health of the nation.

Nurses are already central to this law and the change that it seeks to produce. The law includes opportunities to spread models of




care that nurses were instrumental in developing, such as home visitation programs for high-risk mothers, programs for all- inclusive care of elders, nurse-managed health centers, and transitional care. The law uses provider-neutral language and improves the Medicare payment rate for nurse midwives. It also includes substantial funding to increase the primary care workforce, including nurses.

These and other elements of the law reflect engagement of various constituencies, including nursing. Policymaking is not for the timid. It requires mastery of knowledge and skills in the art and science of politics and the policy process. Though nursing organizations have long had influential leaders at national, state, and local levels, this set of competencies hasn’t been universal across members of the profession.

I know well the growth in nursing’s policymaking savvy. I have been a part of some of the important health policy discussions of our day and have watched as other nurses have sought to use their knowledge to inform laws and regulations that govern health care. Some years ago, as the director of a Center for Health Policy, Research and Ethics, I led an annual policy program on policy and political development for nurses. I also have had the privilege of serving as Chief of Staff to two U.S. Senators, serving as a member of the Institute of Medicine and the Medicare Payment Advisory Commission, and chairing the National Advisory Council for the Agency for Healthcare Research and Quality. In his first term, President Barack Obama appointed me to serve as the Administrator of the Health Resources and Services Administration, a division of the U.S. Department of Health and Human Services. In this capacity, my responsibilities included helping to lead the nation’s efforts to ensure that we have a well- prepared nursing and health care workforce that can meet the vast and varied health needs of the nation. However, we need many more nurses at the multitude of policy tables at local, state, and federal levels. There may be as many opportunities for nurses to engage in this arena as there are nurses.

The health of the nation can directly benefit when nurses have sophisticated knowledge and skill in policymaking and its political




context. We should expect no less of members of our profession— and deliver no less for our nation.

Mary Wakefield PhD, RN, FAAN Acting Deputy Secretary U.S. Department of Health and Human Services





The Affordable Care Act (ACA) had just become the law of the land as the prior edition of Policy & Politics in Nursing and Health Care (sixth edition) was going to press. Now, its implementation is benefiting many of the previously uninsured, reducing health care costs, and moving our nation on the path toward the Triple Aim: improving people’s experiences with care, improving health outcomes for the population, and reducing health care costs. And yet, it has illuminated the complexities and failures of a health care system that lags behind other nations in promoting health. Indeed, there is a growing recognition that health care’s consumption of approximately 18% of the U.S. gross domestic product is undermining efforts to promote the health of families and communities rather than treating preventable illnesses—and at a very high price in humanistic and monetary terms.

This current edition of Policy & Politics in Nursing and Health Care focuses on the changes that the ACA has brought about, its deficiencies that mandate further reform in health care, and the importance of social determinants of health, or “upstream factors,” that must be addressed if we are to have communities and a nation that thrive in terms of economic, social, and health dimensions. In concert with the Institute of Medicine’s report The Future of Nursing: Leading Health, Advancing Change, this book highlights the role that nurses and other health professionals can play in leading the transformation of health care and creating healthy communities.

The book does this with the continuing aim of appealing to all nurses, from novice to expert, as well as other health professionals,




although in this edition we have placed a stronger emphasis on the implications of the issues discussed for advanced practice nurses, including those pursuing or holding the doctorate of nursing practice (DNP). The DNP was designed to prepare nurses as clinical leaders who could develop evidence-based approaches to improving the health of specific populations. The book’s emphasis on both reforming health care and addressing upstream factors that promote health is particularly suited to nurses with DNPs. However, we maintain that every nurse has a social responsibility to shape public and private policies to promote health. As such, this edition is designed to appeal to undergraduate, master’s, DNP, and PhD students, as well as to practicing health professionals.

What’s New in the Seventh Edition? This edition continues the almost 30-year approach of prior editions that have led others to describe the book as a “classic” in nursing literature. However, classics become stagnant if not refreshed. A new team of editors has brought a fresh perspective to this edition. The order of authorship on the cover does not reflect effort; rather, the editing of this book was truly a team effort. The new team is a result of transitions in the lives of former co-editors Judith Leavitt and Mary Chaffee. Certainly, their imprint, and that of the first-co- editor, Susan Talbott, continues to manifest throughout the book, but there is much that has changed.

Central to these changes are updates on the Affordable Care Act and its implementation, its impact on nursing and the health of people, the role of politics in our health care system, and the need for further policy reforms. As noted previously, the importance of improving the health of people while reducing health care spending by addressing upstream factors or social determinants of health is a major theme.

We have also further developed the conceptual framework for the book, as described in Chapter 1. This chapter also emphasizes the competencies that nurses are expected to demonstrate at the conclusion of undergraduate and graduate programs.

Evidence-based policy is another major theme that continues in this




edition, but with more emphasis. Throughout the book, authors have provided more depth and breadth to the evidence that undergirds policy issues and potential responses, with the understanding that evidence is necessary, but often not sufficient, for policy change.

Indeed, it is the political context of policy change that must be addressed for success in many policy-related endeavors. As such, individual and community activism continue to be emphasized as ways for nurses and other health professionals to contribute to and lead policy change. New and updated vignettes (called Taking Action) provide real-life examples of such activism.

Some of the continuing chapters have new authors with fresh perspectives. Other new content includes:

• Using research to advance health and social policies • Highlights of the ACA, with implications for nurses and other

health professionals • The politics of advanced practice nursing • Ethical dimensions of policy and politics • The new health insurance exchanges • Patient engagement • Overtreatment • Social Security and women • Women’s reproductive health • Public health • Emergency preparedness • Developing families • Dual eligibles • Nurses in boardrooms • Quality and safety in health care • Nurses’ work environments • The intersection of technology and health care • Community-based organizations addressing health




Using the Seventh Edition Using the book as a course text. Faculty will find content in this book that will enhance learning experiences in policy, leadership, community activism, administration, research, health disparities, and other key issues and trends of importance to courses at every educational level. Many of the chapters will help students in clinical courses understand the dynamics of the health system. Students will find chapters that assist them in developing new skills, building a broader understanding of nursing leadership and influence, and making sense of the complex business and financial forces that drive many actions in the health system. The book presents an in-depth view of the issues that impact nurses and suggests a variety of opportunities for nurses to engage in the policy issues about which they care deeply.

Using the book in government activities. The unit on policy and politics in the government includes content that will benefit nurses considering running for elective office, seeking a political appointment, and learning to lobby elective officials about health care issues.

Using the book in the workplace. Policy problems and political issues abound in nursing workplaces. This book offers critical insights into how to effectively resolve problems and influence workplace policy as well as how to develop politically astute approaches to making changes in the workplace.

Using the book in professional organizations. Organizations use the power of numbers. The unit on associations and interest groups will help groups determine strategies for success and how to capi- talize on working with other groups through coalitions.

Using the book in community activism. With an expanded focus on community advocacy and activism, readers will find information they need to effectively influence remedies to policy problems in their local communities.





In every edition of this book, the co-editors have expressed their sincere gratitude to the many authors who have contributed their time and expertise to write a chapter out of a commitment to furthering the education of nurses and other health professionals on policy and politics. This edition is no exception. We are grateful for the thoughtful contributions of more than 100 authors and hope that readers will learn from them.

We are also grateful for the enduring contributions and imprint of the prior co-editors of this book that have made it the leading resource in its field. Susan Talbott was the co-editor on the first edition; Mary Chaffee on the fourth through sixth editions; and Judith Leavitt on the second through sixth editions. We hope that they are pleased with the continued development of the book.

We owe a huge debt of thanks to Beth Gardner, the book’s editorial manager for this edition. She tracked and managed 92 manuscripts, kept the co-editors moving along, coordinated our communications, and was simply amazingly organized. In the midst of this, she married, pursued a doctoral dissertation, and remained in good humor. Beth, we are grateful for your superb work.

We also acknowledge the continuing support of Elsevier and the editorial team that worked with Sandy Clark, including Karen Turner. We are indebted to Clay Broeker, an extraordinary pro- duction manager who has worked on the last three editions of the book. Thank you, Clay, for your continued commitment to excellence in publishing.




Each of us has some special people to acknowledge. Diana Mason

I want to acknowledge my husband, James Ware, for his continued support of my long days of work, including on this book.

My thanks, too, for the support I have received from Dean Gail McCain, Graduate Director David Keepnews, Barbara Glickstein, and my colleagues at Hunter College; the Center for Health, Media and Policy; and the City University of New York.

Deborah Gardner

Undertaking this editing experience would not have been possible without the consistent support of my husband, Dan. I also want to express my great joy in sharing this project with my daughter and colleague, Beth Gardner.

I also thank Mary Wakefield, who mentored me through my first experience in writing a policy chapter. As a co-author with her back in 1998, I learned from the best. Last but not least, Judith Leavitt, co- editor of four editions of this text, supported me as an author in other editions and believed I could take on this editing role.

Freida Outlaw

Special thanks to my husband, Lucius Outlaw, Jr., my greatest supporter; my delightful sons and the two lovely wives and one special woman in their lives; my mother, sister, and her family; my wonderful friends who have been with me from the beginning (BFF Lois Oliver); and my new friends. You are my village. I would like to express my gratitude to Martha Pride, PhD, RN, my psychiatric nursing professor at Berea College, and to Dr. Hattie Bessent and the Minority Fellowship Program for the support and guidance given to me.

Eileen O’Grady

A heartfelt thanks to Dr. Loretta Ford, founding mother of the nurse practitioner role. Writing a chapter with her is a privilege. We are so fortunate to see true leadership firsthand. She has shown us, with a sparkle in her eye, how to live courageously and be of maximal service. It is fortunate to know somebody so fearless and funny.




Thank you to all of those (including each author in this book) who stepped out of the safety of their clinical roles and took a risk to speak out on behalf of better health care in a larger venue.





Introduction to Policy and Politics in Nursing and Health Care OUTLINE

Chapter 1 Frameworks for Action in Policy and Politics Chapter 2 An Historical Perspective on Policy, Politics, and Nursing Chapter 3 Advocacy in Nursing and Health Care Chapter 4 Learning the Ropes of Policy and Politics Chapter 5 Taking Action: How I Learned the Ropes of Policy and Politics Chapter 6 A Primer on Political Philosophy Chapter 7 The Policy Process Chapter 8 Health Policy Brief: Improving Care Transitions




Chapter 9 Political Analysis and Strategies Chapter 10 Communication and Conflict Management in Health Policy Chapter 11 Research as a Political and Policy Tool Chapter 12 Health Services Research: Translating Research into Policy Chapter 13 Using Research to Advance Health and Social Policies for Children Chapter 14 Using the Power of Media to Influence Health Policy and Politics Chapter 15 Health Policy, Politics, and Professional Ethics





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.” Alice Walker

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 expectancy 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).

Upstream Factors 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


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 core determinants. Political aspects of the social determinants of health appear in Box 1-1.

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 (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. [2013]. 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 the 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), increase 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 provider 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. [2011]. The future of nursing: Leading change,

advancing health. Washington, DC: National Academies Press. Retrieved from




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 others. 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 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 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, resources are 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, alternatives, 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 Media 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 and 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 re- sponsibility. 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 access 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.




The Government 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 for 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 ( 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 Chapter 75). The Coalition for Patients’ Rights ( 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.

The Community 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.

Health 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 policies 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 Essentials 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.

TABLE 1-1 AACN’s Nursing Essentials Series: Policy Competencies for Nurses




Nursing Program

Policy Essential: All Nurses at This Level Must Have Expertise in:


BSN Policy Essential VI1 (2008)

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 (1996)

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 (2011)

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 (2010)

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 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 Sources:

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 to 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. [2013]. 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-


Deep Knowledge 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).

Political Antennae 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.

Discussion Questions 1. What are the most pressing health care problems you see in your community? How can you frame that issue in a health policy context?

2. Can you identify areas in your own political competence that requires growth? What do you need to learn to be more effective?

3. Why has nursing made policy and political competence such a strong part of the nursing curriculum and role development?

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. 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.





An Historical Perspective on Policy, Politics, and Nursing Patricia D’Antonio, Julie Fairman, Sandra B. Lewenson

“Reform can be accomplished only when attitudes are changed.” Lillian Wald

In 1893, Lillian Wald, then a young medical student, visits the sick mother of a poor and vulnerable New York City family. What she sees—a young mother struggling to recover in a ramshackle tenement, with little access to fresh air and healthy food—and what she does—leaving medical school and returning to nursing because she believed nurses could have a greater impact—changes her life (Wald, 1915). She and her nursing school colleague, Mary Brewster, establish the Henry Street Settlement House in New York City’s lower east side. Like many reformers in the late nineteenth century, Wald and Brewster believed that only by living in impoverished, immigrant communities could they effect meaningful change in the city’s housing, sanitation, nutrition, and educational policies. But Wald takes her vision one step further. She establishes the Visiting Nurse Service at the Henry Street Settlement (D’Antonio, 2010). At a time when the best in health care centered on the home, she decides that those most vulnerable would have the best in nursing care




when ill at home and they would also have the best in health promotion and disease prevention; these families would learn from visiting nurses how to keep themselves healthy in the face of the infectious diseases rampant at the time. And, these visiting nurses would respond to calls from the families in the community just as she would respond to the calls from physicians. Turing her vision into a reality took hard work and strategic partnerships with insurance companies, donors, schools, and the New York City’s Department of Health. However, she prevails—and changes the structure of the U.S. health care system. What come to be known as public health nurses remain central to developing programs addressing public health efforts to promote health and prevent disease. Wald’s skill lay in her ability to harness the support of those in power.

Recognizing the strength of coalitions to enact change Wald, along with her colleagues at the settlement house and other nurse leaders, participated in the establishment of the National Organization of Public Health Nursing in 1912, creating an organization to control the standards and practice of public health nurses. She created coalitions, such as that with the American Red Cross, when concerned about the need for access of care in rural communities (Lewenson, 2015), and she knew how to procure the financial resources from private foundations and donors to support many of her public health initiatives. Her success lay in creating coalitions that first identified problems, then found the right resources, and effected successful solutions by making the issues ones that the public “owns.”

Why should anyone care about one story about one famous nurse? Because the issues that Wald and her colleagues set out to address remain central to the current debates about how to get the best in health care to vulnerable and dispossessed individuals, families, communities, and populations. Rates of infectious diseases are again climbing in the U.S. and across the globe, adding to the increasingly recognized and growing burden of noninfectious diseases. Certainly, major policy initiatives such as the Affordable Care Act (ACA) promise to increase access to health care, improve quality, and contain costs by shifting the focus from acute care hospitals to homes, communities, and primary care sites. The ACA




privileges health promotion and disease prevention in ways unprecedented since the early 1920s. Remembering Wald’s story is a reminder that nurses have been, and will continue to be, active participants in health policy debates from the home to the national level and in turning ideas into reality.

Stories create the foundation upon which policies move forward or fail, but the reason for exploring the intersections of history and health policy transcends simply knowing stories. Examining points at these intersections allows for a richer understanding of the possibilities as well as the problems that resonate in health policy deliberations. The distance of time as one studies change over time, the core of historical methods, allows a different view of the tensions existing between public and private spheres of influence, community needs and professional prerogatives, best evidence, and political power. This chapter uses historical case studies, looking to the past to find themes, ideas, and actions that can provide tools for considering future policy deliberations and actions.

“Not Enough to be a Messenger” Buoyed by the success of public health initiatives like Wald’s, public health officials returned from rebuilding post–World War I Europe to implement a bold new vision in the United States. The turn toward health care, in addition to illness care, was one of the hallmark characteristics of the “new public health” of the 1920s. If the prewar public health agenda of reformers like Wald focused on the ill individual and environment then the postwar agenda would focus on the individual alone and how that individual could experience even greater health through the practices of personal hygiene, mental hygiene, and social hygiene. Its centerpiece was the “periodic medical examination”—now being urged for women as well as children. Public health leadership were well aware that cancer and degenerative heart disease were emerging as leading causes of death and they urged nurses to preach to patients to demand, and physicians to provide, examinations that would detect susceptibility to these diseases or identify them when there were still treatment options. They also recognized that routine prenatal examinations that identified and treated medical problems




offered the best hope of decreasing appallingly high rates of maternal mortality and launched campaigns that urged mothers and fathers to see pregnancy as akin to a disease and not as a normal phenomenon (D’Antonio, 2014). The problem lay in convincing the public.

In New York City, the focus of this section and the epicenter of both the public health and nursing worlds, public health leadership in the city turned to nurses to deliver this message. This decision seemed self-evident. Public health nurses had long considered themselves and had been considered by others as the “connecting link” between patients and physicians, between and among institutions, and between scientific knowledge and its implementation in the homes they visited. They became the centerpiece of the city’s “demonstration projects,” an envisioned mix of different types of public and private partnerships that would test ways of delivering this message that were carefully coordinated for efficiencies, cost-effectiveness, and high quality.

Public health nursing leaders in New York City believed that the turn toward health, particularly that of mothers and young children, would define their professional identity and disciplinary independence to a broader community. Health work with mothers and young children had been part of their traditional practices; and, as men were more likely to have periodic medical examinations associated with the purchase of life insurance policies and employment, women and young children seemed particularly vulnerable. In 1921, with funds from an anonymous donor, a small group of white New York City public health nurses, some also involved in the demonstration projects, launched The Citizen’s Health Protective Society in the middle-class Manhattanville section of the city. This would be a self-sustaining insurance program that promised prenatal care for mothers; attendance at a medically supervised childbirth if delivered at home, and nine visits for all mothers in the postpartum period. It also promised health supervision of babies and preschool children and bedside nursing if sick at home. Do you want, it queried in handouts to families in Manhattanville, a carefully selected white, middle-class community, a self-supporting nursing and health service for $6 per year for an individual and $16 per year for families of three or




more? Manhattanville did not. The Society moved to a more promising location at 134 Street and Amsterdam Avenue. This community remained uninterested as well. The Society closed in 1924. Families appreciated health work but they would only pay for illness care. They would not pay for nursing health care (Maternity Center Association, 1924).

Public health nurses in the city’s demonstration projects had more success. These nurses, similar to progressive urban colleagues throughout the country, went one step farther than their health education mandate. They used their experiences in the demonstration projects to move to identifying families as their practice domain. They built knowledge that bridged the biological sciences that supported their public health practices with the new social sciences that buttressed their work with families. This practice, however, brought them out of bounded disciplinary interests and into a place at the center of not only their own but also others’ agendas. Foundations, families, physicians, and other public health workers all had particular ideas about what nurses should and could do as they delivered their messages of health.

This placed the demonstration project nurses squarely in the middle of escalating tensions among New York City’s Department of Health, the private agencies who delivered home health care, and the Rockefeller Foundation and Milbank Memorial Fund who provided the financing, over who controlled the public health agenda. The private or (as they referred to themselves) voluntary agencies and philanthropies publically ceded control to the official agency that the Departments of Health represented. But privately they constantly sought ways to turn the Department of Health toward their priorities. In New York City, both the private agencies and Rockefeller Foundation and the Milbank Memorial Fund believed public health nurses were key to this process. Indeed, the involvement of the city’s public health nurses in the demonstration projects operating in the East Harlem section of the city had been a central element in the Rockefeller Foundation’s support. It could not be a true demonstration of care control, the Foundation believed, unless it involved the city’s own public health nurses who ran clean milk and infant welfare stations; and who implemented programs of case finding, case holding, and case control of




tuberculosis and other infectious diseases. And it could not be a true maternal-child nursing service without the support of the city’s school nurses who worked with those over 6 years of age. The Foundation’s policy, in the United States and abroad, was one of only working through governmental public health authorities to ensure the sustainability of its initiatives. It hoped to use a consolidated private and public health nursing system in East Harlem to ultimately do the same in New York City (D’Antonio, 2014).

But the public health nursing leaders of the city’s demonstration projects never persuaded the various heads of the New York City’s Department of Health to let its nurses join any of their projects. The Department of Health maintained that its nurses were official agents of the city with real police power that it hoped they would rarely use; it needed to maintain control of their practices. The Department of Health had its own agenda for its nurses. It wanted to position them as representatives of a new public health message clothed in tact and sympathy rather than, as in the past, the bearer of quarantine placards and sanitary citations.

More importantly, the nurses involved in the health demonstration projects had shared no investment with their supporting philanthropies in involving the city’s own public health nurses. Because, in the end, they won what they themselves wanted. By the end of the formal demonstration period in 1928, both private and public health nurses in New York City—not the physicians who had done so in the past—supervised the independent practices of other public health nurses. This was a substantive achievement. Public health nurses employed by New York City finally gained control of their own nursing practices.

At the same time, nurses in the demonstration projects thrived in their missions of service to mothers and young children and of research on the most pressing issues in public health nursing. It launched a program that continued a long-standing nursing mission to provide bedside nursing to sick residents in their own homes. It also strengthened its outreach to pregnant women, encouraging medically supervised births preferably in hospitals, and providing both prenatal and postpartum care in homes. It started new health education services for preschool children. It also




began sustained research projects about the organization of public health nursing work, particularly that situating generalized nursing as the standard for urban public health nursing. And, in 1928, in response to the needs of the discipline for more advanced clinical education, it recast itself as a postgraduate training site for public health nursing students in New York, from around the nation and from international sites of Rockefeller Foundation philanthropy (D’Antonio, 2013).

New York City’s health demonstration projects eventually established what are now the norms for primary, pregnancy, dental, and pediatric care. However, this change came almost painfully slowly through the day-to-day work of public health nurses going door to door, street to street, school to school, and neighborhood to neighborhood preaching the gospel of good health to those without access to the resources that class, race, ethnicity, and financial stability provided to others. As importantly, however, it came through the efforts of families to first incorporate and then to normalize these messages of health by removing them from stigmatizing sites of health and social welfare (in which the public health nurses were located) and placing them within the schools that the community embraced. The nurses in New York City’s health demonstration projects slowly moved from understanding their role as bringing “medicine and a message” of middle-class values to immigrant families they wished to assimilate, to conceiving it as one of being “more than just a messenger” as they sought to serve as embodiments of a new emphasis on sound mental as well as physical health. Support for public health nursing did decline in the 1930s as nurses painfully realized that it was “not enough to be a messenger.” But the decline was less about no longer serving families who needed to assimilate, as other historians have suggested. The decline was as much about families taking responsibility for their health (D’Antonio, 2014).

New York City’s public health nurses were also working in a context increasingly dominated by the rise in hospitals and their outpatient clinics where families increasingly sought health care. But the nurses in New York City’s demonstration projects paid little attention to warnings about the implications of these new clinical sites for public health practice. They steadfastly maintained the site




of their practices to that place where it could be most effectively and independently exercised: with cooperative families in their own homes, in the clinics the nurses controlled, and in the classrooms they created. Despite their commitment to maternal- child health initiatives, this narrow focus allowed them to professionally ignore one of the most pressing public health issues in the city—and indeed the United States—in the early 1930s: the newly rising rates of maternal mortality attributed by both the New York Academy of Medicine and the Maternity Center Association to poor obstetric practices in hospitals that women were increasingly choosing as sites of their infants’ births. These nurses could not see or take responsibility for solving problems that lay inside public health policies but outside their defined disciplinary purviews and sites of practice (D’Antonio, 2014).

Bringing Together the Past for the Present: What We Learned From History Generations later, a different group of constituents gathered to consider a new agenda for nursing in the twenty-first century that would situate patient care, rather than professional self-interest, at the forefront. In 2009, the Robert Wood Johnson Foundation (RWJF) in collaboration with the Institute of Medicine (IOM) commissioned a new study charged with developing recommendations for reconceptualizing nursing practice and education within a reformed health care system. The Committee appointed by the IOM was indicative of the changing health care political landscape and reflected the multiple stakeholders and thought leaders who were or would be partners with nurses to improve patient care. The Committee was very diverse in age, profession, political leanings, and race/ethnicity, and included consumer representation. The 6 nurses on the 18-member committee all came from diverse backgrounds and served as a contrast to the dominance of white women in the profession seen in the demonstration projects and public health leadership of the 1920s and 1930s. The pivotal role of foundations had changed: they now shared influence with multiple




stakeholders such as the federal government, pharmaceutical corporations, consumer groups, and the insurance industry. These groups were now critical players in shaping the scope of nursing practice. In ways unthinkable in the 1920s and 1930s, consumers of nursing care played pivotal roles.

The final report, The Future of Nursing: Leading Change, Advancing Health, and its recommendations, reflected the diversity of the committee and the stakeholders as well as the political landscape of health reform being debated as the committee deliberated (IOM, 2011). The first recommendation that nurses should practice to the fullest extent of their knowledge and skills links the story of the New York public health nurses to the nurses of the present. The conceptualization of the role of the public health nurses with families and communities as well as their aims and efforts to fully incorporate their skills and knowledge into their practice reflects historic continuities of nursing practice over the past century. This continuity resonated strongly with the public, professional organizations, and federal and state governments. Since the IOM report was issued seven states have removed practice barriers to allow nurse practitioners to practice independently and numerous other states are expanding their practice acts. At the national level, retail clinics, health care service sites in drug stores, and big box stores typically staffed with nurse practitioners are growing in number and popularity, and nurse-managed health centers are recognized by the ACA as a practice model that can provide access to high-value care for people with limited resources (Fairman et al., 2011). In general, policymakers and the public still see nurses—but now nurse practitioners rather than, as in the past, public health nurses—as a viable and valuable policy solution to the current primary care provider shortage and misdistribution.

Health policy researcher Debra Stone notes there is no strict dichotomy between reason and power, and between policy and politics (Stone, 2001, p. 377). The IOM Future of Nursing report placed nurses at the center of a perfect storm of these forces and reflected the political, economic, and social context that propelled both professional and public interests (IOM, 2011). The report recommendations were also strategically shaped to position the patient as the focus of care within a reformed health system and the




history of both public health nurses and nurse practitioners is a reminder of the importance of public need when public disciplinary interests are articulated. History is also a reminder that sometimes small, piecemeal changes or events can be the springboard for larger policy issues at the right time and place.

When thinking about the policy levers that drive our health care system, we can look to history as a way of providing perspective and for pulling apart the power dynamics that drive policymaking. Our examples demonstrate how the IOM report placed nurse practitioners, just as the Public Health Department and the Rockefeller Foundation situated the earlier public health nurses, as policy solutions for improving the health care of the nation at a particular time and place. Our histories show that polcymaking is untidy; we want it to be rational but “reasoned analysis is necessarily political. It always involves choices to include things and exclude others and to view the world in a particular way when other visions are possible” (Stone, 2001, p. 378). The public health nurses of the 1920s and 1930s were perhaps not as facile at understanding this reality or not as skilled at thriving within an environment when the political alliances were flexible and shifting. But they did adjust. These are important lessons to learn and remember. Today, as we try to reformulate our health care system to be more accessible, efficient, and inclusive, policymakers are making choices about providers and services. Nurse practitioners are part of policy solutions as seen through the ACA support of retail clinics and nurse-managed health centers. However, they need to remember that strategic alliances shift, that new stakeholders emerge, and that future policy decisions may not always be rational, but they will always be political.

There are both historical continuities and differences in the stories of public health nurses of the 1920s and 1930s and the growing appeal of nurse practitioners today to policymakers and stakeholders. The ability to build coalitions and partnerships is as critical today as it was in the 1920s and 1930s. In the early 1960s, when nurse Loretta Ford and physician Henry Silver serendipitously found they shared common interests of providing better care to rural poor families, they knew physician manpower was unavailable and that the nurse with additional skills and




knowledge could provide the needed level of care. The United States was suffering from a primary care shortage similar to the current shortage. Although they published their model early, they were not alone in coming to these conclusions. Nurse Barbara Resnick and physician Charles Lewis in Kansas City in the mid- 1960s were also situating nurses as the solution to patient dissatisfaction with the lack of continuity of care in their university outpatient clinics. Although models like these were part of larger changes occurring where physicians were in short supply or nurses initiated their own practices, individual and sporadic efforts such as these were not enough to drive changes in policy even when analytic reasoning indicated their effectiveness. Nurse practitioners lacked a unified coalition to move their interest forward—for exam- ple, to change restrictive state practice regulations and payment structures—and they lacked interested groups and partners outside of nursing to help broaden their appeal. Although individual physicians were supportive, organized medicine was not.

Having data is important, as the public health nurses understood, but, as Stone (2001) also argued, politics may trump data. Data supporting the value and quality of nurse practitioner services began appearing in the early 1970s. A meta-analysis of 1970s-era studies of nurse practitioner effectiveness done by the Congressional Office of Technology Assessment documented their effectiveness in 1984. Although powerful in its scope and innovation, this study did not stimulate the interests of lawmakers at the state and federal level, who could have used the data to develop a reasoned policy analysis. Although professional nursing did have lobbyists working on professional issues, the organizations were more focused on workplace issues than broader policies, and not mature or flexible enough to work together as a larger, powerful group until the late 1970s. Organized medicine was indeed “organized” and had powerful lobbies and leadership that kept its message simple and consistent, and one that would be replayed for decades. The message was that physicians were the only safe providers because of their longer and more intensive education; yet, their position actually lacked data.

Another lesson learned from the public health nurse narrative that resonates today is the importance of the creation of bridges




between the community and the health system. In the late 1970s, professional nursing organizations such as the American Nurses Association (ANA) seized a strategic opportunity to reformulate their policy agenda. Building on the growing body of studies that indicated high patient satisfaction and clinical effectiveness of nurse practitioners as providers, and a growing strategic and political movement that situated the patient as the focus of professional legitimacy, the ANA built policy positions that situated nurse practitioners as normative providers for groups of patients such as older adults, children, and healthy adults. A deceptively strong and influential patient movement was also beginning to support nurse practitioner-provided care. Although patient support was unorganized and lacked a single leader, patients across the country showed their appreciation by returning for follow-up and bringing in their family and neighbors. The ANA effectively built upon the momentum patients provided to begin to form coalitions and work more effectively with the nascent nurse practitioner organizations to generate more powerful policy positions and partnerships.

We also learn from history that sometimes coalitions are not enough to move the policy levers. Even as nurses built coalitions and patients became their advocates through the 1980s and 1990s, there were pieces missing. For example, medical organizations influential in the policy arena did not offer nurses large-scale support. Physician organizations were not interested in partnerships and still held strong political capital at the state and national level. Individual physicians certainly supported nurse practitioners in their own practices, but organized medicine did not see them as independent providers or partners.

Organized medicine could situate nurses in this way because it still had enormous political power and resources. But physicians’ cultural authority has now been challenged. Fraud and payment scandals and exposes of physicians’ relationships with pharmaceutical companies generated public skepticism during a time of patient empowerment movements and civil and women’s rights movements. As historians Beatrix Hoffman and Nancy Tomes (2011) noted, patients reinvented “new terms for themselves —consumers, clients, citizens, and survivors—in their search to be heard in the health care arena” (p. 2) and exercised greater control




over their care. In their search, patients found nurse practitioners qualified and value-based providers, educated and willing to see the patient as the “source of control” as the IOM report Crossing the Quality Chasm posited (IOM, 2001).

The stories of nurse practitioners and public health nurses are also connected by the ability to thrive and continue negotiations within a slow and subtle policy process. Incremental change occurred in health policy at the turn of the twenty-first century, although this was not a naturally rational or progressive movement. One of the ways this transformation can be illustrated is by the shift in the language defining who could provide care and receive payment. Many stakeholders worked over decades to bring about these changes. These categories are politically constructed worldviews, bestowing advantages and disadvantages. The change in language signified the slowly occurring power shift and the power of professional nursing and its allies to renegotiate the boundaries of patient care. Federal legislation began to include the term “provider” instead of “physician,” or the more inclusive phrase “physicians and nurses.” Medicare recognized nurse practitioners as primary care providers, although the states still maintain their regulatory authority to allow or not allow full scope of practice.

Another lesson learned is that coalitions must be flexible and ready to change. As the power dynamics in health care started to shift, nurse practitioners gained new partners and support. Since the 1980s, the Federal Trade Commission produced advocacy letters declaring restrictive practice acts anticompetitive and against the interests of consumers. Their activity in this area accelerated in the first decade of the twenty-first century. The American Association of Retired Persons (AARP), the largest consumer group in the world, had nurses in key leadership positions to steer the organization, which developed policy positions that supported nurse practitioners. As medicine was becoming more corporatized and less patient-centric, the public began rating nurses as the most trusted health professional in Gallup polls, with the exception of 2001 when firefighters topped the list (Gallup, n.d.). Even so, nurse practitioners were not always part of the policy solutions to the primary care shortage. Building more capacity in medical




education, even when it became harder and harder to attract physicians into primary care, continued to be the traditional policy strategy although its sustainability as policy is weakening. Policymaker recognition of the high cost of physician education and the viability of nurse practitioners as a reasonable and faster option to provider supply growth was supported by reports by the Rand Health Foundation and the National Governors Association.

By the time the IOM’s Future of Nursing report was published in 2011, patient support, coalition building, and new partnerships had positioned nurse practitioners to be a consistent part of the policy process. Although the IOM report might have served as the spark, it was nested in both the policies and politics of the past century as well as the context surrounding health reform debates occurring in Congress. A litany of factors including rising health care costs, a shifting focus from specialty to primary care, and a shortage of primary care providers created a demand for new and more efficient models of care. Nurses gained willing and energetic partners in the public media and with the patients they served. A large private foundation, RWJF, leveraged its long-term interest in nursing to support the IOM report. Other new partners came forward; in particular, the Association of American Medical Colleges showed courage and strength by supporting nurse practitioners in press releases and policy statements. The nursing profession as a driver of policy change had come of age. It developed coalitions across nursing professional organizations that were focused on policy, and it developed new partnerships with powerful organizations outside of nursing that saw nursing’s value while creating new opportunities and connections with nursing to both influence policymakers and drive policy change.

Conclusion The two stories—about public health nurses shaping health outcomes of immigrant populations during the early twentieth century and about the evolving policy support (via the IOM report) for nurse practitioners—show how health care policies and politics, perhaps even more than nurses’ work, shape the delivery of care and the outcomes sought. For the public health nurses, the day-to-




day politics between and among professionals, the various private and public enterprises that offer health care options, especially to vulnerable populations, have typically looked to more traditional methods of providing care rather than seeking nursing as part of the solution to the delivery of primary health care. Yet, the value public health nurses brought to community and population health argue for nurses to participate in policymaking and to advocate their inclusion in health care solutions. For nurse practitioners, history is a reminder of how they gained policy momentum amid the shifting weights of reasoning and power, and with the growing power of consumer movements. Both stories illustrate how messy policymaking can be, how alliances can be tenuous while understanding the value of coalitions and partnerships as stabilizing agents in uncertain policy environments. History provides rich data that can help nurses advocate the role this profession can make as part of a larger solution to improve health care in the United States.

Discussion Questions 1. What types of alliances exist and what types need to be cultivated to affect change in your own areas of nursing practice?

2. What are the problems and/or the possibilities in developing cross-disciplinary as well as public and private alliances to affect change?

3. What type of historical evidence can be used to support nursing’s political advocacy in providing primary health care?

4. Explore the advocacy efforts Lillian Wald, public health nurses in urban and rural settings, and nurse practitioners used to affect change in health care.

References D’Antonio P. American nursing: A history of knowledge, authority

and the meaning of work. Johns Hopkins University Press:




Baltimore, MD; 2010. D’Antonio P. Cultivating constituencies: The story of the East

Harlem Nursing and Health Service, 19281941. American Journal of Public Health. 2013;103(6):988–996.

D’Antonio P. Lessons learned: Nursing and health demonstration projects in New York City, 1920-1935. Policy, Politics and Nursing Practice. 2014;14(3–4):133–141; 10.1177/1527154413520389.

Fairman J, Rowe J, Hassmiller S, Shalala D. Broadening the scope of nursing practice. New England Journal of Medicine. 2011;364(3):193–196.

Gallup. (n.d.). Honesty/ethics in professions. Retrieved from Professions.aspx.

Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. National Academy Press: Washington, DC; 2001.

Institute of Medicine. The future of nursing: Leading change, advancing health. The National Academies Press: Washington, DC; 2011.

Lewenson SB. Town and country nursing: Community participation and nurse recruitment. Kirchgessner J, Keeling A. Nursing rural America. Springer: New York; 2015:1–19.

Maternity Center Association, Columbia University Health Sciences Center, Box 52, Folder 2, 1924.

Stone D. Policy paradox: The art of political decision making. revised ed. Norton: New York; 2001.

Tomes N, Hoffman B. Introduction: Patients as policy actors. Hoffman B, Tomes N, Grob R, Schlesinger M. Patients as policy actors. Rutgers: New Brunswick, NJ; 2011.

Wald LD. The house on Henry Street. Henry Holt and Company: New York; 1915.

Online Resources American Association for the History of Nursing. Learning Historical Research.

155 Nursing History and Health Care.






Advocacy in Nursing and Health Care Chad S. Priest

“I come to present the strong claims of suffering humanity. I come to place before the Legislature of Massachusetts the condition of the miserable, the desolate, the outcast. I come as the advocate of helpless, forgotten, insane men and women; of beings sunk to a condition from which the unconcerned world would start with real horror.” Dorothea Dix

Nurses have a long history of advocating on behalf of and alongside patients, families, and communities to promote health, equality, and justice. Nursing is widely respected for effective pro- fessional advocacy that has expanded the professional role of the registered nurse and created safer working conditions for nurses. Florence Nightingale’s revolutionary advocacy around the environment of care and Margaret Sanger’s pursuit of reproductive freedom for women exemplify nursing advocacy.

Despite a history rooted in speaking for and working on behalf of the most vulnerable in the United States, nursing’s relationship with advocacy is complicated. Perhaps this is because the profession was for many years defined by loyalty to others— namely to physicians and hospitals—and not to patients. Echoes of this tension reverberate today, as nurses are routinely challenged as




they navigate between loyalty to physicians and hospitals and advocacy on behalf of patients, families, and communities. Complicating matters, nursing schools and institutions do not necessarily prepare students to serve as advocates. Many nurses find the idea of advocacy on behalf of patients (and even themselves) to be daunting. The nursing profession has also sent mixed signals about the value of advocacy, and there has been scant research into what exactly nursing advocacy looks like.

This chapter is about advocacy at the individual, community, and system levels—and the relationship between advocacy and policy. Because this chapter is about advocacy, this chapter is also about nursing. Although the relationship between nursing and advocacy deserves refinement, nursing practice is rooted in advocacy on behalf of and alongside those who are sick, vulnerable, and in need of care.

The Definition of Advocacy The word advocacy is derived from the Latin word advocatus, meaning to plead the cause of another (Advocate, n.d.). Although the word advocacy is most frequently associated with legal and political settings, the definition has expanded to encompass a wide range of activities undertaken in support of individuals, families, systems, communities, and issues. Nurses are widely viewed as advocates for patients and their families. Some have suggested that patient advocacy is an integral part of nursing practice (Hanks, 2010a, 2010b; Vaartio et al., 2009; Vaartio et al., 2006). In modern nursing practice, nurses serve as advocates when they ensure that patients understand the treatments they are receiving while in the hospital, or serve as a translator between the patient and members of the health care team. Many nurses work to coordinate care and help patients navigate the complexities of the health system.

In the community setting, nurses frequently work with residents and community leaders to advocate for healthier neighborhoods. Working alongside members of the community, community health nurses seek to mitigate the social determinants of illness through advocacy at the individual, system, and policy levels. As experts in the delivery of health care and the promotion of health, nurses are




also frequently engaged in issue advocacy, addressing such issues as access to care and disease prevention.

Through professional organizations such as the American Nurses Association (ANA) and the American Association of Nurse Anesthetists (AANA) (see Chapter 74 ), nurses serve as advocates for the nursing profession itself by educating and appealing to state and federal legislators and policymakers to promote safe workspaces for nurses and to safeguard the nursing scope of practice.

The Nurse as Patient Advocate Patient advocacy is a frequently described, but poorly understood, concept in nursing. It is viewed as a central tenet of nursing practice, both in the United States and around the world (Allcock, 1989; Altun & Ersoy, 2003; Bu & Jezewski, 2007; Foley, Minick, & Kee, 2000; Gale, 1989; Hanks, 2005; Jugessur & Iles, 2009; Kohnke, 1978; Mathes, 2005; McSteen & Peden-McAlpine, 2006; Morra, 2000; Vaartio et al., 2006). Despite widespread acceptance of the role of patient advocate by nurses in the published literature, there is only an emerging understanding of what nursing advocacy is, how (and whether or not) it is performed by nurses, and what results from nursing advocacy (Baldwin, 2003; Grace, 2001; Mallik, 1998). Advocacy has traditionally been associated with legal and political activity. As advocacy has evolved in nursing, it has taken on a number of meanings—from advocating for social justice (Paquin, 2011) to simply performing nursing functions adequately and safely.

Winslow (1984) identified two major metaphors—loyalty and advocacy—espoused by nursing leaders and educators from the profession’s birth through the mid-1980s. Loyalty as a metaphor for practice was rooted in the “battle against disease” and featured rigid hierarchies that were prevalent in military practice settings through the 1940s (Winslow, 1984). Instructional books from the early period of the profession characterized the nurse as a warrior in the battle against disease and illness, glamorizing a life of “toil and discipline” in which nurses pledged loyalty to their physician leaders (Winslow, 1984). The primary goal of loyalty by nurses was




to project and reinforce confidence in the health care enterprise. Nurses were explicitly taught that loyalty to the physician equated with faithfulness to the patient (Winslow, 1984).

The primacy of loyalty as a nursing ethic came under attack in 1929 in a most unusual place. In a hospital in Manila, The Philippines, a physician ordered a new graduate nurse, Lorenza Somera, to administer cocaine injections, instead of procaine injections, to a tonsillectomy patient (Winslow, 1984). Somera loyally carried out the physician’s order, resulting in the death of the patient. Although it was clear that the physician had erred in ordering the incorrect medication, he was acquitted of all charges while Somera was found guilty of manslaughter for failing to question the orders of the physician (Winslow, 1984). The Somera case sparked worldwide protests from nurses and served to push nursing toward independent practice and accountability. It was also one of many events that led to a reconceptualization of the dominant nursing metaphor from loyalty to physicians to advocacy for patients (Winslow, 1984).

Consumerism, Feminism, and Professionalization of Nursing: the Emergence of Patients’ Rights Advocacy During the 1960s and 1970s, influenced by feminist and consumer- rights ideologies, nursing advocacy became the dominant metaphor for nursing (Hewitt, 2002; Mallik, 1998; Winslow, 1984). The concept of “nurse as advocate for the patient” recognized the inherently oppressive nature of patienthood, wherein the patient is vulnerable as a result of his or her illness and unable to care for himself or herself (Bu & Jezewski, 2007). Advocacy for the patient was thus framed as rejection of loyalty to the physician, freeing nurses to develop their own professional identity. Indeed, adoption of the patient advocate role occurred simultaneously with the professionalization of nursing (Porter, 1992; Shirley, 2007). As a construct for nursing practice, advocacy had the advantage of being




seen as morally good for patients, as well as providing an opportunity for nursing to promote professional autonomy (Kosik, 1972; Winslow, 1984).

Early forms of nursing advocacy borrowed heavily from legal models of advocacy and centered on consumerism and patients’ rights. Through this lens, the nurse acted as a guardian and intervened when these rights were threatened by the medical establishment (Bramlett, Gueldner, & Sowell, 1990; Mallik, 1997a; Mallik & Rafferty, 2000; Winslow, 1984). This form of advocacy was eventually codified in the ANA Code of Ethics in 1978, which proclaimed that:

[I]n the role of client advocate, the nurse must be alert to and take appropriate action regarding any instances of incompetent, unethical, or illegal practice(s) by any member of the health care team or the health care system itself, or any action on the part of others that is prejudicial to the client’s best interests. (Bernal, 1992, p. 18.)

Some U.S. state boards of nursing have codified, and thus mandated, nursing advocacy by including language in nurse practice acts that either explicitly or implicitly defines an advocacy role. For example, the Indiana Nursing Practice Act defines Registered Nursing to include “advocating the provision of health care services through collaboration with or referral to other health professionals” (Indiana Nursing Practice Act, 2008).

Philosophical Models of Nursing Advocacy Gadow Although patients’ rights advocacy formed the basis of nursing advocacy and remains the dominant conception of nursing advocacy, nursing theorists have advanced competing conceptualizations of advocacy that seek to define a unique nursing advocacy. Sally Gadow advanced an “existential advocacy”




whereby the nurse’s role is to help patients clarify their values and the illness experience, and exercise their right to self-determination (Gadow, 1983). The premise underlying existential advocacy was that nurses are uniquely situated to advocate for patients, because they frequently spend the most time with patients and have an intimate connection with patients and their families. She also viewed advocacy as a moral imperative, with the ultimate goal being to increase patient autonomy (Hanks, 2005).

Curtin Writing during the same period as Gadow, Curtin (1979) sought to situate nursing advocacy as “human advocacy.” Curtin invited nurses to help patients identify meaning and purpose in their illnesses with the ultimate goal of enhancing patient autonomy (Curtin, 1979; Mallik, 1997a).

Kohnke Occupying something of a middle ground between patients’ rights advocacy and the philosophical advocacies of Gadow and Curtin, Kohnke developed a model of functional advocacy that called nurses to serve as brokers of information and supporters of patient decision making (Kohnke, 1978, 1980). More than any other theorist of the time, Kohnke expressly suggested that physicians persecuted patients (whom she calls victims) through their “we know best” attitude (Kohnke, 1980). An illustration appearing with her work in the American Journal of Nursing depicts the physician as a puppet- master manipulating a helpless patient, with the nurse as a “rescuer,” attacking the physician with the banner of health (Kohnke, 1980).

Although nursing advocacy has been widely internalized as a core professional value by many nurses, critics have questioned the utility of nursing advocacy as a framework for practice and have argued that few nurses are actually engaged in advocacy activities. Several critics have questioned whether or not nurses have the capacity to serve as advocates, noting that many nurses lack the institutional and personal power required to advocate for patients’ rights (Bernal, 1992; Grace, 2001; Hanks, 2007; Hewitt, 2002;




Mackereth, 1995; Martin, 1998). Hewitt (2002) points out that “for the nurse to be in a position to empower patients, it is necessary for the nurse to be first empowered” (Hewitt, 2002, p. 444).

Although it is well understood that the oppressive nature of the medical establishment impairs patient autonomy, it is less clear why nurses view themselves as well suited to act as patient advocates (Mallik, 1997b; Martin, 1998; Negarandeh et al., 2008; O’Connor & Kelly, 2005). One central theme in the nursing advocacy literature is that nurses are uniquely situated to serve as patient advocates because they spend the most time with patients and have the most influence over the patient’s experience while the patient is hospitalized or ill (Bu & Jezewski, 2007; Curtin, 1979; Hanks, 2007; Martin, 1998; Schroeter, 2002, 2007). The intimacy of nursing care has been suggested as the mechanism by which nurses are able to engage in existential advocacy behaviors (i.e., empowerment advocacy) (Curtin, 1979). In a study of nursing elite in the United Kingdom, Mallik (1998) found that nursing leaders viewed the intimate nursing relationship with suspicion. One subject in her study stated:

[T]his complete “under the skin oneness” is a piece of impertinence really. I mean somebody who has 55 years of history behind them walks through the door and suddenly you are their best friend and you know everything there is to know about them, it’s a bit beyond the pale. (Mallik, 1998, p. 1005.)

Others have argued that when nurses assume the role of advocate, they unfairly and inappropriately stake an exclusive claim to the role, alienating other health care team members that arguably engage in advocacy behaviors in the course of their professional duties (Hewitt, 2002; Mallik, 1997a).

Perhaps the most devastating critique of nursing advocacy, especially considering the high value nurses place on evidence- based practice, is that the phenomenon is poorly understood (Hewitt, 2002). Despite substantial attention to nursing advocacy since the early 1970s, there is a dearth of scientific research exploring the phenomenon. Only a handful of researchers have undertaken any scientific exploration of nursing advocacy. Most of




these are qualitative researchers who have focused on understanding the concept of nursing advocacy and how nurses internalize and enact the nursing advocacy role. Despite their inability to fully explain nursing advocacy, these studies have resulted in remarkable consistency with respect to identifying advocacy functions and personal traits and characteristics of nurses that appear to promote or inhibit advocacy behaviors.

Advocacy Outside the Clinical Setting Nursing advocacy is not limited to clinical settings. Nurses are expert health care providers who are well positioned to advocate for policies and practices that promote and encourage health. Three types of nursing advocacy influence policy, population health, and the profession of nursing: issue advocacy, community and public health advocacy, and professional advocacy.

Issue Advocacy The nursing care of patients necessarily extends beyond the hospital or clinic. Consider that symptom management for many patients requires interventions that are not purely medical. For example, mental health nurses frequently set goals with their patients to integrate patients into the community. The reality is that patients with mental illness cannot be expected to integrate into the community without the existence of health care services and programs that support such integration. Mental health nurses are frequent advocates for these programs and services. This issue advocacy directly promotes improved patient outcomes, although it does not involve advocacy on behalf of any one individual.

Importantly, issue advocacy is almost always best accomplished through the formation of coalitions. Nurses are excellent coalition partners, bringing evidence-based expertise and professional credibility to any debate. For example, Muckian (2007) describes a successful grassroots coalition of nurses, patients, families, and other advocates that organized to reverse budget cuts to a Wisconsin in-home Medicaid program for children with autism.




Community and Public Health Advocacy Although reforming the health care system is important, and nurses’ input into reform is critical, advocacy in support of health extends beyond issue advocacy. There is wide agreement among researchers, policymakers, and providers that social structures and behaviors have a significant impact on health. The quality of the environment, the nature of human relationships, the durability of the social infrastructure, and the justice inherent in the social order are all, in isolation and in combination, powerful determinants of health status. These social determinants of health and illness are complex, multifactorial, and almost entirely unresponsive to the biomedical interventions that are the core of the current health system.

Nurses, however, are well positioned to work with communities to mitigate social determinants of illness and promote health. Oftentimes this involves explicitly advocating for social justice (Paquin, 2011). Community health nurses routinely interact with community leaders to improve community conditions that impact health. For example, Longo and colleagues (2010) described a nursing-led indoor air quality assessment for persons exposed to volcanic air pollution from the ongoing eruption of the Kilauea volcano in Hawaii.

Professional Advocacy Nursing, and nurses, matter. Consider the following: • Nurses compose the largest segment of the health care workforce. • Patients are in frequent contact with nurses who deliver almost all

of the care to patients in the hospital setting (Needleman, 2008). • Research has demonstrated that the amount and quality of

nursing care that patients receive is directly related to a number of health outcomes (Needleman, 2008).

Because nurses have a direct relationship to the health of patients, advocacy on behalf of the nursing profession is a powerful form of patient advocacy. Advocacy on behalf of the profession frequently involves examining issues such as workplace safety, nurse/patient ratios, expanded scope of practice, and limitations on malpractice




liability. At the national level, organizations such as the ANA attempt to provide broad representation of nursing interests to members of congress, policymakers, and thought leaders. Advanced practice nurses (APRNs) and their representative organizations are known to be highly effective advocates at the state and federal levels. Through advocacy of advanced practice nursing, these nurses also advocate for improved access to care and the reduction of health disparities in communities.

Barriers to Successful Advocacy Similar to any political activity, advocacy is time-consuming and requires a significant commitment on the part of the nurse. Whether it is direct patient advocacy requiring the nurse to stay late after a shift to work with a family, or issue advocacy involving research around an issue and meetings with members of the legislature, some nurses are unwilling or unable to devote the time needed for successful advocacy.

For those who make the commitment of time and energy to become advocates, other barriers may exist, including lack of education and training about advocacy skills or outright fear of retribution from employers or governmental organizations as a result of advocacy activities (Galer-Unti, Tappe, & Lachenmayr, 2004). Each of these barriers is discussed in the following sections.

Education and Training One of the major barriers to successful nursing advocacy is a lack of education and training in advocacy during formal nursing education. Although some schools of nursing offer programs or units to expose students to political processes, typically limited to visits to state board of nursing meetings or legislative committees, few educational programs are designed to promote advocacy skills in nurses. Additionally, faculty may not model effective advocacy behaviors.

In one of the few examples of research into how nurses learn and engage in advocacy, Foley, Minick, and Kee (2002) discovered that some nurses reported feeling as though advocacy was “deeply




rooted in who they were” so that advocacy skills were essentially ingrained in their personhood (Foley, Minick, & Kee, 2002, p. 184). Other nurses reported learning advocacy skills by watching their colleagues or mentors engage in advocacy behaviors (Foley, Minick, & Kee, 2002). Still others reported that it wasn’t until they gained confidence as a nurse that they felt comfortable engaging in advocacy (Foley, Minick, & Kee, 2002). These findings are problematic for those interested in teaching advocacy skills, as they suggest that advocacy skills are primarily a part of individual personalities or are learned in practice, and not during formal education.

Zauderer and colleagues (2008) outlined a political-organizing educational program for nursing students that focused on empowering students to be aware of, and to participate in, the political process. This program focused on political activism and included a trip to the state capital to lobby legislators (Zauderer et al., 2008). Although this training approach is likely to be useful to build skills in advance of a specific legislative encounter and is certainly valuable, it is not clear if a political-organizing framework is sufficient to prepare students to act as advocates in their practice upon graduation.

McDermott-Levy (2009) described a unique opportunity to train students in advocacy for environmental health. During a clinical experience, one of McDermott-Levy’s students cared for a patient with laryngeal cancer (McDermott-Levy, 2009). In the course of caring for the patient, the student discovered a history of laryngeal cancer in the patient’s immediate family. Further investigation revealed that the family may have been exposed to carcinogens while living in a coal-mining community (the patient’s father worked in a coal mine as well). McDermott-Levy suggests that nurses trained in environmental health would be well positioned to advocate for patients and communities in these situations. Considering the work of Foley and colleagues (2002) described earlier in this chapter, organic clinical encounters are likely to be extraordinary opportunities to introduce students to advocacy skills. Consider that these students could have engaged in any number of advocacy activities related to the environmental exposure—all from an encounter with one patient. In their




groundbreaking study of nursing education, Benner and colleagues (2010) call for greater attention to nursing advocacy in the schooling, learning, and teaching process. They accurately point out that “[e]nthusiasm for nursing as a social good is a motivation for both students and teachers, and a ‘moral source’ against frustration and fatigue” (p. 206).

Institutional Barriers and Fear of Retribution Advocacy, whether on behalf of patients or in support or opposition to issues, is typically associated with some degree of “rocking the boat.” After all, if the status quo were effective, there would be no need for advocacy (unless, of course, you were advocating for the preservation of the status quo). Speaking up for what you believe can be a risky endeavor. Consider that many nurses avoid advocating for better workplace conditions, or for patient safety, for fear that their employers will retaliate against them. Although many health care institutions respect the contribution of nursing and promote nursing autonomy, nurses who fear retaliation for doing the right thing have plenty of examples to substantiate their concerns. And it is not just health care organizations that have retaliated against nurses who were strong advocates: governmental organizations such as state boards of nursing also send mixed signals about nursing advocacy.

Consider the interesting, and perhaps troubling, case of Ellen Finnerty, a Registered Nurse from California who was terminated from her job and had her Registered Nursing license revoked by the California Board of Registered Nursing based on her advocacy for a patient under her care. Finnerty had worked as a Registered Nurse for 20 years and was serving as a charge nurse on a medical- surgical floor when one of her patients developed respiratory problems (Finnerty v. Board of Registered Nursing, 2008). According to the court records, the patient was exhibiting labored breathing, but had stable vital signs. The treating physician ordered that the patient be intubated immediately while on the medical- surgical unit. Finnerty disagreed with the physician’s order, claiming that the patient should be taken to the intensive care unit (ICU) for the intubation because the medical-surgical unit lacked




the appropriate equipment to perform the procedure and nurses were distracted handling many patients during the change of shift. Despite Finnerty’s objection, the physician reaffirmed the order for the intubation. Finnerty then countermanded the order directly, unplugged the patient’s bed, and transferred the patient directly to the ICU where the patient arrived in stable condition and was successfully intubated.

Unfortunately, the patient experienced respiratory arrest a few minutes later and died. Although the patient’s demise was not related to any delay in intubation that may have taken place caused by the transfer to the ICU, Finnerty’s employer terminated her employment (although the termination was later changed to a resignation) as a result of her “gross negligence—failure to follow direction from [the] treating physician.” Shortly thereafter, the California Board of Registered Nursing filed a complaint against Finnerty alleging unprofessional conduct and gross negligence and incompetence and seeking the revocation or suspension of her license (Finnerty v. Board of Registered Nursing, 2008). The Board determined that Finnerty had inappropriately substituted her clinical judgment for the physician’s and that her actions violated the nurse practice act, and they issued a revocation of her license.

Finnerty appealed the decision up to the California Court of Appeals, claiming that “she was required by the Board’s standards of competent performance to act as Mr. C.’s advocate by taking him to the ICU for intubation, rather than permitting intubation to take place in an environment that was not equipped for intubation.” The case of Ellen Finnerty calls into question whether and how nurses can act as advocates for patients in the face of questionable decision making by other members of the health care team. What would happen if the nurse did not question the intubation in the medical- surgical environment and the patient had an adverse outcome?

Summary Advocacy is widely viewed as a fundamental nursing role, whether on behalf of patients, communities, or the profession, and in crafting policy solutions. Although many nurses are engaged in advocacy behaviors, there are significant barriers to advocacy by




nurses. First, whereas some boards of nursing require that nurses engage in advocacy, others appear to punish nurses who stand up for what is right. Second, there is tension between nurses’ loyalty to patients (or communities, the profession, or policies) and nurses’ obligations to institutions (e.g., hospitals). Finally, advocacy education and training is not a routine component of most formal nursing education programs, leaving nurses to rely on their colleagues to learn effective advocacy behaviors. Despite these barriers, advocacy on behalf of health can be extremely rewarding, and nurses are in a unique position to advance the cause of patients’ interests in the complex health care system.

Discussion Questions 1. What examples of advocacy do you see in your own nursing practice, or the nursing practice of others?

2. What are the barriers you have experienced to effective nursing advocacy? What are ways to mitigate those barriers?

3. How can schools of nursing more effectively prepare nurses to serve as advocates?

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Learning the Ropes of Policy and Politics Andréa Sonenberg, Judith K. Leavitt, Wanda Montalvo 1

“Were there none who were discontented with what they have, the world would never reach anything better.” Florence Nightingale

Every politically active person, from U.S. Presidents to chief executive officers, learned the political and policy skills that catapulted them into positions of power and responsibility. Nurses arrive in those positions in a similar fashion. Although one can learn about the policy process and political analysis through formal education, it is only through experience and practice that one can apply what has been learned to become effective in the position. A most important catalyst in becoming involved is to find mentors— colleagues and friends who are politically savvy—to teach us, to believe in and support us, and to celebrate our successes and help us learn from our failures.

This chapter explores how to become involved through mentoring, education, and experience. Students new to politics, as well as experienced nurses, have unlimited ways to expand their knowledge and involvement. Whatever one’s experience, engaging in the process serves to improve one’s skills. There are infinite causes and issues in health care to stimulate one’s interest if one wants to become engaged. The first step is to decide how much




energy and time one is willing to devote. Success in the world of policy and politics demands the strengths and skills that nurses possess. Working in the policy arena will open doors to opportunities where nurses can become significant participants and leaders. This book includes many of their inspirational and motivational stories.

Political Consciousness-Raising and Awareness: the “Aha” Moment How does one get started? Many find that there is a defining moment when the old ways of reacting to issues of injustice, inequality, or powerlessness no longer work. It is the moment when a person realizes that an issue or problem is caused by failures in the system. For instance, lack of support staff on an acute care unit may be related to decreased reimbursement rates rather than an uncaring hospital administration. Denial of care for a patient eligible to receive Medicaid or Medicare could be related to cuts in federal funding, rather than the patient’s need for care. Ultimately, disparity in health outcomes may be due, in part, to health care policies. Realizing that a problem may be caused by a policy failure is a critical first step toward becoming part of the policy solution. This is political consciousness-raising and an “aha” moment. It is the adrenaline rush that urges, “Something must be done—and I need to become involved.”

Until that defining moment, nurses may feel frustrated, angry, or hopeless. When the “aha” moment hits, they begin to understand that they can and must influence those who make the laws and regulations that create the inequities. Nurses then recognize the personal nature of policy issues (“the political is personal”). Advancing a solution requires skills that can be learned. When nurses accept they are not at fault for the inadequacies of the health care system and believe that nursing can shape solutions, the profession becomes political. Nurses become proactive rather than reactive. The result is individual nurses and the profession become empowered to act. Feeling empowered is essential to true advocacy (Sessler Branden, 2012).




Being politically active as a nurse is grounded in the role of advocacy, which many nurses equate with patient advocacy. In the professional realm of nursing, advocacy should be approached from a broader definition. Florence Nightingale saw nursing in all of its forms as advocacy; a “calling” that required nurses to look for, and act in, ways to be world citizens for the sake of human health (Dossey et al., 2005). Through her grounded theory research, Sessler Branden (2012) identified the following far-reaching conceptual definition of advocacy that emerged: “a dynamic process through which the nurse engages in a set of actions with broadly stated goals ultimately affecting a desired change at any level of patient care, health care systems and/or health policy.” A more extensive discussion of advocacy can be found in this text (see Chapter 3).

Getting Started Through interviews with 27 American nurses involved in health policy at the national, state, and local levels, Gebbie, Wakefield, and Kerfoot (2000) set out to discover how and why these activist nurses became involved. Their results corroborated what we knew anecdotally: • The majority of respondents had parents, most often fathers, who

were active in policy and politics and who created a mentoring, supportive environment.

• Many were raised to be independent and to believe in their capacity to accomplish what they wanted.

• High school provided a training ground in political socialization. • Nursing education provided role modeling and mentoring by

faculty, deans, and alumni as well as the opportunity to increase political awareness through courses in policy, political science, and economics.

• Clinical practice often provided strong role models and experiences in public health and community health provided opportunities for political insights.

• Graduate education opened doors for many, through such avenues as the study of law, health economics, and health policy.




• Some had their consciousness raised gradually through work experiences that exposed them to public policy and the need to understand how to influence the process.

Nurses who were interviewed confirmed that there are multiple points of entry into the policy arena. Whether this book, a course in policy and politics, or a conversation with a colleague is your first exposure, you have already started.

Political skills can be learned. Nurses bring many skills to the political arena that are learned through education and refined in clinical practice. Politics requires the kind of communication skills that nurses use to persuade an unwilling patient to get out of bed after abdominal surgery or a child to swallow an unpleasant-tasting medication. Nurses are health care experts. We speak knowledgeably about what patients and communities need because we experience it firsthand.

The Role of Mentoring The Mentor Advantage Emerging nurse leaders seeking to advance their careers and develop political skills should secure a mentoring relationship. Stewart (1996) defines mentoring in nursing as a teaching–learning process acquired through personal experience within a one-to-one, reciprocal relationship between two individuals diverse in age, personality, life cycle, professional status, and/or credentials. It is a developmental relationship where the mentor provides the protégé with career and psychosocial supports, such as counseling, friendship, acceptance, role modeling, challenging assignments, and sponsorship (Fagenson, 1989; Kram, 1983; Zey, 1984). Mentoring occurs at many levels and should be continuous, goal directed, and under the aegis of a capable person to serve the protégé as a trusted teacher and counselor (Vance & Olson, 1998). The characteristics of successful mentors include being trustworthy, an active listener, accessible, and able to support the protégé’s professional development (Cho, Ramanan, & Feldman, 2011). Good mentors are able to identify strengths and limitations in their protégé and provide critical feedback to support career and political




skill development. Compared to nonmentored individuals, productive mentoring relationships result in the protégé gaining increased visibility, self-efficacy, access to new social networks, and greater career mobility (Allen et al., 2004; Fagenson, 1989; Scandura, 1992).

As a way of learning “the ropes,” mentoring is a vehicle for developing political skill and contextual knowledge, part of a critical set of competencies used throughout a protégé’s career. The mentor-protégé transfer of knowledge occurs through observation of role-modeling, encompassing mentor behavior that can be observed and imitated by the protégé (Chopin, 2012). Political skill is composed of four underlying dimensions and requires a degree of personal learning, discernible mainly through application and not easily taught or learned (Blass, 2007). The question for the protégé is “what are the components of political skill and how do I go about developing them?” Ferris (2007) defined four distinct factors of political skill: • Social astuteness: Individuals possessing political skill are astute

observers of others and are keenly attuned to diverse social situations. They comprehend social interactions and accurately interpret their behavior; they are able to discern the situation and are self-aware.

• Interpersonal influence: Politically skilled individuals have a subtle and convincing personal style that exerts a powerful influence to persuade those around them. They are able to strategically modify their behavior to different persons in different settings.

• Networking ability: Individuals with strong political skill are adept at developing and building partnerships with diverse networks of people for beneficial alliances and coalitions.

• Apparent sincerity: Politically skilled individuals appear to others as possessing high levels of integrity, authenticity, sincerity, and genuineness. This dimension of political skill strikes at the very heart of whether or not influence attempts will be successful because it focuses on the perceived intentions. If actions are not interpreted as manipulative or coercive, individuals high in apparent sincerity inspire trust and confidence from those around them.




The protégé learns through observation of the mentor, modeling the new skill with repeated practice (May & Kahnweiler, 2000). This happens most effectively when seeing the mentor in real situations as they influence others; through body posture, use of language, and listening to their messaging. More importantly, the mentor allocates time to debrief about the observed interaction to help the protégé understand how and why the mentor acted in such a manner. The development of these skills occurs over time. The protégé must be mindful and respectful of the mentor’s time, proactively prepare and schedule meetings with the mentor, and be open to mentor feedback (Straus, 2013). Informal mentor–protégé relationships tend to gain better results as compared to formal mentoring systems because “assigned” relationships may remain superficial (Armstrong, Allinson, & Hayes, 2002). Mentors should be on the lookout for emerging nurse leaders to identify a protégé with a similar cognitive styles; this will help to facilitate a mutual understanding and effective communication and supports a positive attitude about the mentoring relationship (Armstrong, Allinson, & Hayes, 2002; Chao, 1997).

Participating in lobby days and observing skilled lobbyists negotiate with policymakers is a great way to sharpen one’s skills. At these events, nurse lobbyists and activists serve as mentor- guides and role models to nurses and students. They provide information and strategies and they model effective behaviors while lobbying policymakers on specific legislation. These activists also provide the inspiration and vision for what can be done if nurses work together toward shared goals. This is real-life learning and it is a highly effective and practical way of developing political awareness and know-how.




FIGURE 4-1 Dr. Linda Streit (second from left), Dr. Lisa Eichelberger (third from left), and Congressman John Lewis (D), Georgia (center); the rest are nursing

students attending the American Association of Colleges of Nursing Annual Student Health Policy

Summit in Washington, DC.

Finding a Mentor To find a mentor, it is important to determine what you would like to learn or in what area of politics and policy you would like to be involved. Start with self-reflection and write down your areas of strength along with areas of self-improvement. Consider the types of political skill you want to develop at either an organizational level or health policy level. Answering these questions helps you to begin thinking of the type of qualities you are searching for in a mentor. Then identify people whom you have noticed, heard, or read about who are activists in your area of interest. Leverage your networks. Good sources for finding mentors are nursing associations, schools of nursing, professional organizations, local governmental departments or offices, and local political




organizations and campaigns. You may contact the person directly, via e-mail, by phone, or with a note, or ask a colleague to help with an introduction. Make clear why you think the person would be a good mentor. Tell them what you want to learn and why you would like them to assist you. Consider connecting with someone outside of nursing. For instance, nurses can get involved in local political campaigns where they are warmly welcomed, particularly if they identify themselves as nurses. The important criteria for a mentor are knowledge and an interest in you. Remember to give the relationship time to develop and be honest about expectations and time available. Sometimes the mentor need only get you started; in other situations a mentor can become a lifelong friend and role model.

Collective Mentoring Learning politics is not a solitary activity. This means that nurses should be on the lookout for mentors who can serve as their teachers and guides as they hone political and policy skills. Every nurse should assume responsibility for actively mentoring others as they refine their repertoire of skills and deepen their involvement. Reciprocal collective mentoring is extremely effective in expanding the political power of the profession and its members. Collective mentoring can occur in schools, clinical agencies, and professional associations.

Inherent in this form of mentoring is the development of networks of persons who are active in policy and who take responsibility for expanding these networks. Nurses in these networks should develop strategies for mentoring political neophytes and for “claiming” nurses who may not be in traditional careers (Gebbie, Wakefield, & Kerfoot, 2000). For example, politically active faculty members can network with political leaders in professional associations to provide undergraduate and graduate students with lobbying and leadership opportunities. Many state nursing associations are successfully reaching out to collectively mentor hundreds of nursing students through lobby days in national and state capitols. Nursing students and practicing nurses have many opportunities to experience collective mentoring




in learning the political ropes through relationships with leaders and peers in organizations such as the National Student Nurses Association, American Nurses Association (ANA), specialty and state nursing associations, and volunteer health-related organizations. Also, local political parties, community organizations, and the offices of elected officials offer nurses opportunities to learn through mentored experiences. These organizations offer mentoring opportunities for involvement in lobbying, policy development, media contacts, fund-raising, and the political process in various venues.

Mentoring in policy development also requires connections to knowledgeable leaders. In the workplace, one can learn from health professionals who serve as leaders on influential committees. For example, if you want to work on improving staffing systems, you would need to learn about the cost of staffing, the cost of bringing in temporary staff, and the budget allocation for staffing on the unit. A clinical unit manager should have that information and can help guide your learning. In addition, one would need to know how much Medicare and Medicaid allocate to particular types of patients (outside the control of the institution) and the acuity level of patients. By working with knowledgeable staff, one can learn how to put this information together, how to influence colleagues to support a proposed policy, and how to gain access to and support from organizational leaders.

Educational Opportunities There are many ways to learn how to influence health policy; some will depend on your own learning style, where you live, and your interests. Whatever your educational and political goals, there is something for everyone; from continuing education programs to graduate programs in political science and policy, from workshops run by campaign organizations to fellowships and conferences.

Programs in Schools of Nursing Health policy is one of the “essentials” of nursing education at the baccalaureate, master’s, PhD, and DNP levels. (American




Association of Colleges of Nursing, 2006, 2008, 2010, 2011). Nursing programs offer courses, either as core requirements or electives, related to health policy or with health policy content embedded. Many of these can be taken as continuing education credits even if you are not enrolled as a part-time or full-time student. Additionally, several schools of nursing have established graduate degree programs in policy. Schools of nursing offering health policy concentrations on the graduate level can be found on the American Association of Colleges of Nursing (AACN) website.

Degree Programs and Courses in Public Health, Public Administration, and Public Policy College and university departments of public health, political science, policy science, political administration, and others are a rich source of policy content in academic programs. Programs leading to degrees that include health policy content are widely available at the baccalaureate, master’s, and doctoral levels. These are easily accessible through online catalogs.

Continuing Education Annual conferences on health policy topics are conducted by academic institutions and professional associations. Specialty nursing associations and state nursing associations often offer legislative workshops. Health policy organizations are also sources of continuing education through webinars and conferences. Check websites for the most current offerings, and monitor your state nursing association’s meeting announcements. Search the Internet using health policy meeting, health policy conference, or health care meeting as search terms.

Workshops A quick, intensive, and participatory approach to learning is to take a one- or two-day workshop in politics, campaigning, or policy from political or educational institutions. Political parties hold




campaign workshops at state and national level as do other nonpartisan groups. Do a websearch for political training and you will find options for learning.

Learning by Doing There are many ways to obtain valuable practical experience in health policy and politics, from volunteerism to internships to self- study programs.

Internships and Fellowships. Internships and fellowships provide great learning experiences. In addition to teaching nurses the ropes, these practical placements offer valuable mentoring and networking opportunities and may lead to employment options. Internships may be arranged for credit in academic programs. Summer or year-long internships are available at local, state, and federal legislative bodies and in government agencies. Professional associations can be a good resource for finding such opportunities. The ANA offers a year- long mentored experience called American Nurses Advocacy Institute ( The Nurse in Washington Internship (NIWI) sponsored by The Nursing Organizations Alliance (The Alliance) is a two and a half day experience (

Volunteer Service. A great way to learn politics is to volunteer to work on a political campaign (Figure 4-2). Volunteer time and energy are welcomed by candidates for elective office at all levels of government, local, state, and federal. First-time candidates with tight budgets are especially appreciative of volunteers. Building relationships through volunteer service is a critical part of learning the ropes and of networking. Also consider contacting political party headquarters for training and information about volunteer activities.




FIGURE 4-2 Nursing students with faculty member Dr. Connie Vance (second from right) participating in voter


Professional Association Activities. Many professional nursing associations offer opportunities for volunteer service that lead to rich educational, mentoring, and networking experiences. In addition to the ANA, many other nursing organizations offer opportunities. The American Association of Critical Care Nurses (AACN) and the Oncology Nursing Society (ONS), along with many specialty organizations, offer tool kits, training materials, legislative briefs, and mentoring around policy issues of concern to their practice. Other health professional associations, such as the American Public Health Association, the American Cancer Society, and the American Heart Association, have strong advocacy and legislative programs. Check their websites for volunteer opportunities.

Internet Discussion Boards and Other Resources. There are numerous sites where one can become involved in discussions on various policy topics. Not only is this a learning experience, but it is also a valuable networking opportunity. One strategy to find discussions is to join a professional networking site, such as LinkedIn, and find various relevant groups through it. Be




broadminded about what groups discuss health policy; they range from policy and nursing to public and global health groups. Individual professional organizations are also creating their own professional networks with discussion boards. Professional organization webpages may also link to political action or government affairs webpages. Current legislative agendas are often listed, with user-friendly links to generate letters to one’s legislators by simply inputting one’s zip code. Although the letters can be sent as written, it is always beneficial to include personal anecdotes related to the issue being addressed.

Self-Study The value of reading and self-directed learning cannot be underestimated in learning about policy and politics. Many types of literature exist covering diverse interests:

Professional Journals. Many professional nursing, health care, and social sciences journals include updates on current political issues. Some are wholly focused on policy and politics (e.g., Policy, Politics, & Nursing Practice; Health Affairs); others publish regular political and policy content (e.g. American Journal of Nursing, Nursing Outlook, Nursing Economics, Journal of the American Medical Association [JAMA]).

Organizational Newsletters. Some organizational newsletters, both professional and interest group, feature health policy related columns. One that is particularly committed to disseminating health policy information to its members is the American Association of Retired Persons (AARP).

Books. Browse through the political science, government, or current events sections of your favorite bookstore and you are likely to find a goldmine. You can also browse online booksellers. Search for the words politics, policy, or health policy, and see what piques your





Newspapers. Major metropolitan newspapers offer political analysis of national, regional, and local politics. Those recognized for in-depth political reporting on health issues include the Washington Post (, the New York Times (, the Los Angeles Times (, and the Wall Street Journal (

Television. Network and cable news programs and television news-magazines address political issues and government activities. The ultimate viewing experience for politicos is C-SPAN. This channel is available as a public service created by the U.S. cable television industry to provide access to the live gavel-to-gavel proceedings of the U.S. House of Representatives and the U.S. Senate and to other forums in which public policy is discussed, debated, and decided. C-SPAN provides a wealth of information about the democratic process, without editing, commentary, or analysis. Television programs have become interactive by integrating social media, such as Twitter, so viewers can participate in televised stories and discussions.

Radio. Radio continues to be a rich source of political information and debate on AM, FM, and satellite radio stations. Policy-focused stations include the following: • National Public Radio (NPR) via public radio stations and the

Internet ( NPR provides carefully researched in- depth reporting.

• C-SPAN Radio offers public affairs commercial-free programming 24 hours a day, accessed through the radio or the Internet. The broadcast schedule is available at

• Liberal and conservative political talkfests. Many political “talking heads” have radio programs that serve as forums to debate hot political topics. Check your local radio program




website for air time and station.

Internet. An all-you-can-eat political buffet exists on the Internet. All major news organizations, activism groups, political parties, issue advocates, and many others have a presence on the Internet. A diverse universe of political discussion exists, from well- substantiated journalism to blogs with absolutely no quality control. Through social networking sites, both personal and professional, one can participate in discussions, become informed, and have the added benefit of networking.

Applying Your Political, Policy, Advocacy, and Activism Skills The purpose of learning the ropes of policy, politics, and advocacy is to influence health policy. The only way to become an effective political leader, advocate, or activist is through experience and practice, so that one can apply strategies and skills learned to influencing decisions made by governments, communities, organizations, institutions, and associations. Much political activity occurs in the sphere of government. The U.S. government is a complicated system that determines the direction of a complex nation. Activism has made a difference in many communities and has been recognized as a powerful force in promoting equity in access to quality, culturally competent, preventive health and mental health services, and community resources (Buresh & Gordon, 2013; Jansson, 2011). For example, in May 2012 New York City passed the “Soda Ban,” which limited the public sale of sugary drinks to 16 oz. Mayor Bloomberg had introduced the legislation as a public health initiative to mitigate one of the risk factors of obesity, a national epidemic (Peltz, 2013; Weissner, 2013). There was a public and corporate outcry about government involvement in personal decision making and purchasing power. A grassroots effort by concerned soda-loving citizens, local and national businesses, and corporations, such as Pepsi, Coca-Cola, and Snapple, successfully fought to overturn the ruling by filing a




lawsuit against the city (Peltz, 2013). In March 2013, on the eve of the implementation of the ban, a State Court ruled the ban to be illegal and the law was overturned. Mayor Bloomberg continues in his efforts by filing an appeal with the state’s highest court, the New York State Court of Appeals, which has agreed to hear the case (Weissner, 2013). Advocates of the law hold that the public health campaign is not over. Dr Ludwig, professor of pediatrics and nutrition at Boston Children’s Hospital, points out that “the individual liberty argument would have more weight if the health effects weren’t spilling over into society in the form of higher insurance premiums and a greater share of public dollars going to Medicare and Medicaid” (Tavernise, 2013). This case is an example of how political efforts on both sides of an initiative can be effective, and that arguments must be based on both the evidence and the precedence.

Political Competencies The Spectrum of Political Competencies (Figure 4-3) portrays the range of activities from which nurses can draw to influence health and health care. It demonstrates the breadth and variety of competencies ranging from novice to more sophisticated levels, including running for elective office. These skills can be learned and applied in a wide variety of activities aimed at improving health and health care. Some nurses have their initial experience of activism and advocacy in school. For example, students in the RN- to-BSN program at Valdosta State University in Georgia learned to address community health problems through political strategies aimed at fluoridating a community water system (Wold et al., 2008). Senior nursing students at New York Institute of Technology attended New York State Nurses Association’s Lobby Day to develop skills in civic engagement (Zauderer et al., 2008–2009). In the community, nurses can participate in a variety of activities aimed at influencing decisions, including writing letters to the editors of newspapers, writing letters to legislators, calling in to radio talk-shows, commenting on health policy blogs, participating in professional social-network group discussions, working on campaigns, serving in volunteer positions, speaking at hearings,




and participating in rallies (Figure 4-4).

FIGURE 4-3 The spectrum of political competencies and examples of activities.




FIGURE 4-4 Wanda Montalvo, RN, leads a press conference asking the NYC Council to support the

Childhood Obesity Initiative.

More sophisticated political skills are required for effective organizational leadership, obtaining political appointments, and seeking elective office. Many skills that nurses develop in clinical roles are directly transferrable to influential policy roles and paid political positions. Ohio State Senator Sue Morano, RN, identified skills that nurses can bring to elective office that help them become effective advocates. These include setting priorities, leadership, conflict resolution, collaboration, communication, and having conversations about difficult issues (Iacono, 2008). There are limitless opportunities for nurses from all educational levels and experience to learn new skills and use them to improve health for individuals and populations.

Changing Policy at the Workplace




Through Shared Governance Janet Harris, RN, Dns Infrastructures and processes within institutions offer great opportunities for nurses to get involved in policy change as well as learn internal political processes. One such example is actions by a group of nurses from a Bone Marrow Transplant Unit at a medical center in Mississippi that had rolled out Relationship-Based Care as a practice model. This model was one vehicle used in the implementation of a shared governance model.

In this model the front line staff members were engaged and empowered through Unit-Based Practice Councils. This particular council was concerned that outpatients coming to their area for chemotherapy were sitting in the admissions office for 4 to 6 hours awaiting registration and lab results. Often, not feeling well and after a long wait, patients were sent home because their counts were too low for chemotherapy administration on that day. The council decided to work to improve the process. Their initial collaborative discussions with physicians were disheartening, but the council persisted and proposed a pilot project.

Imitating the example of communication savvy demonstrated by their manager, the practice council representatives worked with various multidisciplinary groups across the organization to garner support for the project. The pilot included process redesign of laboratory specimen collection at the local doctor’s office or clinic prior to the patient’s travel to the infusion center. Blood counts were assessed locally and unnecessary trips to the center were avoided. Upon arrival at the center, a streamlined admissions process expedited the patient transfer to the chemotherapy infusion area. The resultant patient waiting time was less than 30 minutes. Not only were the patients delighted with the change, the nursing staff members were proud of their ability to successfully navigate the complex academic system, and to develop a new policy that provided better quality care for patients.

This front line group used several “learning the ropes” strategies. First, elected council members all attended training workshops on effective teamwork within the council as well as teamwork across the organization. Crucial conversation content was offered through




“Lunch and Learn” activities; staff learned how to communicate when stakes were high and opinions varied. They discussed their plans at length by evaluating the pros and cons of each step in the proposed process. The unit manager, who was one of the most senior and experienced staff members in the organization, served as a mentor to the group; a unit practice council advisor also assisted in the mentorship and advocacy role. Lastly the council learned by doing. They researched their topic using the Internet and an online reference center. They combined the evidence with the skills used in continuous quality improvement throughout the organization. The results demonstrated the organization’s front line nurses’ influence and political savvy to drive improved care for a specific patient population.

Discussion Questions 1. Create a one-page plan for your own learning about policy and politics.

2. Give examples of four opportunities for learning-by-doing.

3. List three places you can look for a mentor.

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. 1We’d like to acknowledge Janet Y. Harris, DNP, RN, NEA-BC; Mary W. Chaffee, RN, PhD, FAAN; and Connie Vance, RN, EdD, FAAN for their work on the previous editions of this chapter.





Taking Action

How I Learned the Ropes of Policy and Politics

Chelsea Savage

“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 ( 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 Legislative 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 that 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 (, 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.





A Primer on Political Philosophy Sally S. Cohen, Beth L. Rodgers

“If I were to attempt to put my political philosophy tonight into a single phrase, it would be this: Trust the people.” Adlai Stevenson

In this chapter, we present major concepts from political philosophy so that nurses will be mindful of the ideological, philosophical, and political themes that structure contemporary health policy debates. Such knowledge can enhance the ability of nurses to develop strategies that take into account political and ideological perspectives, many of which are not always evident, but nonetheless often drive political deliberations and outcomes. After an introduction to political philosophy, we present an overview of the role of the state, present major political ideologies and their evolution, summarize how political philosophy relates to contemporary gender and race issues, and discuss the “welfare state.” We conclude with a discussion of the implications of political philosophy for nurses involved in health politics and policy.

Political Philosophy Political philosophy examines, analyzes, and searches for answers




to fundamental questions about the state and its moral and ethical responsibilities. It asks questions such as, “What constitutes the state?,” “What rights and privileges should the state protect?,” “What laws and regulations should be implemented?,” and “To what extent should government control people’s lives?” Political philosophy encompasses the goals, rules, or behaviors that citizens, states, and societies ought to pursue. It provides generalizations about proper conduct in political life and the legitimate uses of power (Hacker, 1960). Today’s political philosophers build on the classic works of the past and apply them to contemporary issues, including health policy. From another perspective, political philosophy addresses two issues. The first is about the distribution of material goods, rights, and liberties. The second issue pertains to the possession and determination of political power. It includes such questions as, “Why do others have rights over me?,” “Why do I have to obey laws that other people developed and with which I disagree?,” and “Why do the wealthy often have more power than the majority?” (Wolff, 1996).

Political philosophy is a normative discipline, meaning that it tries to establish how people ought to be, as expressed through rules or laws. It involves making judgments about the world, rather than simply describing or observing people and society. Political philosophers attempt to explain what is right, just, or morally correct. It is a constantly evolving discipline, prompting us to think about how the concerns and questions just described, although as ancient as society, still affect us today.

For nurses, political philosophy offers ways of analyzing and handling situations that arise in practice, policy, organizational, and community settings. For example, it helps determine how far government authorities may go in regulating nursing practice. It offers ways of understanding complex ethical situations—such as end-of-life care, the use of technology in clinical settings, and reproductive health—when there is no clear answer regarding what constitutes the rights of individuals, clinicians, government officials, or society at large. Political philosophy offers normative ways of addressing such situations by focusing on the relationships among individuals, government, and society. Finally, political philosophy enables nurses to think about their roles as members of




society, organizations, and health care delivery settings in attempting to attain important health policy goals, such as reducing the number of people without health care coverage and eliminating disparities among ethnic groups.

The State The “state” in political philosophy (and political science) does not pertain to the 50 states of the United States. Rather, it is a “particular kind of social group” (Shively, 2005, p. 13). The state arose from the notion that people cannot rule at their will. As Andrew Levine (2002) explained, “Few, if any, human groupings have persisted for very long without authority relations of some kind” (p. 6). Today’s modern state is a highly organized government entity that influences many aspects of everyday lives (Shively, 2005). It typically refers to the “governing apparatus that makes and enforces rules” (Shively, 2005, p. 56). Therefore the terms state and government may be interchangeable. It is the role of the state (or government) in health policy issues—such as licensure of health professionals and institutions, financing care, ensuring adequate environmental quality, protecting against bioterrorist attacks, and subsiding care—that affects nurses in their professional practice and personal lives. Usually people think of national governments as the modern state. However, local and state governments also assume important roles in protecting individuals, regulating trade, and ensuring individual rights and well-being. In distinguishing between a nation and a state, note that a state is a political entity “with sovereignty,” meaning it has responsibility for the conduct of its own affairs. In contrast, a nation is “a large group of people who are bound together, and recognize a similarity among themselves, because of a common culture” (Shively, 2005, p. 51).

Despite these distinctions, the terms state and nation may overlap in common parlance because government leaders often appeal to the “emotional attachment of people in their nation” in building support for the more legal entity, a state (Shively, 2005, p. 52). Furthermore, the cultural diversity of most countries makes claims of common cultural ties as the distinguishing feature of any nation




increasingly difficult to uphold. That said, few would dispute that the political culture of the United States is different from that of other countries. We pride ourselves on individualism, a laissez-faire approach to government and economics, and a strong belief in the rights of individuals. Policy analysts often point to the unique political culture as an explanation for why U.S. social policy deviates from that of other countries. An example is the difficulty in establishing any type of national health insurance program. The Affordable Care Act (ACA) can be considered progress in this regard but it still relies on a combination of private and public initiatives, while most other developed countries have strong state- sponsored health care insurance (Canada) or delivery systems (United Kingdom).

Individuals and the State Thomas Hobbes (1588-1679). Hobbes was one of the major political philosophers to describe the relationship between individuals and the state. Hobbes developed the concept of the “social contract,” which basically claims “individuals in a hypothetical state of nature would choose to organize their political affairs” (Levine, 2002, p. 18). As Shively succinctly explained, “Of their free will, by a cooperative decision, the people set up a power to dominate them for the common good” (Shively, 2005, p. 38). Hobbes’s theory was important in establishing governance and authority, without which people would live in a natural state of chaos. To avoid such situations, according to Hobbes, people living in communities voluntarily establish rules by which they abide.

Nurses can view the social contract as a rationale for government intervention in aspects of practice, public health, and delivery of care. We turn to government to protect us from situations such as unregulated care and unlicensed practice, which might cause harm to patients if professionals and administrators were left to their own devices. We voluntarily adhere to these rules to prevent danger and minimize the consequences of unmonitored care.

John Locke (1632-1704).




Locke was a British political philosopher who greatly influenced liberal thinkers, including the writers of the U.S. Constitution, by emphasizing the importance of individual rights in relationship to the state. His defense of individual rights was fundamental to liberalism (discussed later) and the development of democracies around the world. For Locke, individual rights were more important than state power. States exist to protect the “inalienable” rights afforded mankind. One of the premises of Locke’s theories is that people should be free from coercive state institutions. Moreover, the rights inherent in such freedom are different from the legal rights established by governmental authority under a Hobbesian contract. They are basic to the nature of humanity.

Jeremy Bentham (1748-1832). Bentham, heralded as the father of classic utilitarianism, rejected the natural law tradition. His utilitarianism theory basically asserted that individuals and governments strive to attain pleasure over pain. When applying this “happiness principle” to governments, “it requires us to maximize the greatest happiness of the greatest number in the community” (Shapiro, 2003, p. 19). Instead of relying on natural law, Bentham favored the establishment of legal systems “enforced by the sovereign” (Shapiro, 2003, p. 19). Bentham’s utilitarianism has become foundational to many contemporary theories in economics, political science, bioethics, and other disciplines.

The tension between individual rights and the role of the state is inherent in many health policy discussions. Consider, for example, substance abuse. On one hand, individuals have the right to smoke tobacco and drink alcohol. One might even argue that the state should protect individuals’ rights to do so. On the other hand, such freedoms may interfere with others’ rights to fresh air and freedom from harm (e.g., from second-hand smoke inhalation or from incidents related to alcohol use). In such cases, the state has a legitimate role to intervene and protect the rights of others; the greater good. The challenge lies in finding the right balance between the rights of individuals on both sides of the issue and balancing them with the rights of the state.




Political Ideologies A political ideology is a “set of ideas about politics, all of which are related to one another and that modify and support each other” (Shively, 2005, p. 19). Political ideologies are characterized by distinctive views on the organization and functioning of the state. Ideologies give people a way of analyzing and making decisions about complex issues on the political agenda. They also provide a way for policymakers to convince others that their position on an issue will advance the public good. Three major political ideologies, liberalism, socialism, and conservatism, originated with 18th- and 19th-century European philosophers and are the basis of political deliberations and policies throughout the world (Shively, 2005). The terms and definitions of liberalism and conservatism as they have evolved over time are not necessarily consistent with these two ideologies as they exist today. Nevertheless, without appreciating their origins, the nuances in their rhetoric and their role in health policy cannot be fully understood.

Liberalism American political thought was greatly influenced by 18th-century European liberalism and the political thinking of Hobbes, Locke, and others. This 18th-century liberalism meshed well with political, economic, scientific, and cultural trends of the time, all of which sought to free people from confining and parochial values. Liberalism relies on the notion that members of a society should be able to “develop their individual capacities to the fullest extent” (Shively, 2005, p. 24). People also must be responsible for their actions and must not be dependent on others.

John Stuart Mill (1806-1873). Mill, a British political philosopher, is considered a major force behind contemporary liberalism. His essay “On Liberty” (1859) is foundational to modern liberal thinking. Mill was committed to individual rights and freedom of thought and expression, but not unconditionally. He based his work on Locke’s philosophies, tempered by Bentham’s utilitarian philosophy.




Mill contended that individuals were sovereign over their own bodies and minds but could not exert such sovereignty if it harmed others. He provides a way of reconciling Locke’s emphasis on individual rights with Hobbes’s focus on the importance of an authoritarian state. A leading contemporary political philosopher and political scientist, Ian Shapiro, applied Mill’s balancing of individual rights with his “harm principle” as follows:

… although sanitary regulations, workplace safety rules, and the prevention of fraud coerce people and interfere with their liberty, such policies are acceptable because the legitimacy of the ends they serve is “undeniable.” (Shapiro, 2003, p. 60)

The best form of government under liberal ideology is a democracy, in which individuals participate in political decision making and express their views freely. The right to vote confers an important privilege to members of a democracy in that it is a form of political expression free from domination by others.

In sum, liberal ideology is based on the importance of democracy; intellectual freedom (e.g., freedom of speech and religion); limited government involvement in economic activities and personal life; government protections against abuse of power by one person or group; and placing as many choices as possible in the private realm (Shively, 2005). In many ways, liberalism lies at the center of American political thought.

Conservatism In response to liberals’ calls for changing the existing social and political order, conservatives countered with a preference for stability and structure. They preferred patterns of domination and power that had the benefit of being predictable and gave people familiar political terrain. Under conservative thought, those in power had the “awesome responsibility” to “help the weak.” In contrast, liberals preferred to give such individuals “responsibility for their own affairs” (Shively, 2005, p. 26). Liberals wanted people to be free of government intrusion in their lives; conservatives favored a strong government role in helping those in need of




assistance. Guided by the notion that government had a responsibility to

provide structured assistance to others, 19th-century European conservatives, especially in Great Britain and Germany, developed many programs that featured government support to the disadvantaged (e.g., unemployment assistance and income subsidies). They accepted welfare policies (discussed later) that were foundational to the revival of Europe after World War II. They have been major players in contemporary European politics, especially in Great Britain, offering a synergy with American conservatism.

Socialism Socialism grew out of dissatisfaction with liberalism from many in the working class. Unable to prosper under liberalism, which relied on individual capacities, socialists looked to the state for policies to protect workers from sickness, unemployment, unsafe working conditions, and other situations.

Karl Marx (1818-1883). Marx, a German philosopher, is widely considered the father of socialism. For Marx, individuals could improve their situation only by identifying with their economic class. The 19th-century Industrial Revolution had created the working class, which, according to Marx, was oppressed by capitalists who used workers for their profits. According to Marx, only revolution could relieve workers of their oppression.

As a political ideology, socialism encompasses many ideas. Among them are equality, regardless of professional or private roles; the importance of a classless society; an economy that contributes equally to the welfare of a majority of citizens; the concept of a common good; lack of individual ownership; and lack of any type of privatization. Therefore socialism is also an economic concept under which “the production and distribution of goods is owned collectively or by a centralized government that often plans and controls the economy” (Socialism, 2005). The collective nature of socialism is in contrast to the primacy of private property that




characterizes capitalism. Socialism originated and proliferated in Europe toward the end

of the 19th and into the early 20th centuries. Then it split into two ideologies, communist and democratic socialist. In 1917, communists, under the leadership of V. I. Lenin, took over the Russian Empire and formed a socialist state, the Union of Soviet Socialist Republics (USSR). Lenin and his communist followers believed in revolution as the only way to advance socialism and achieve total improvement in workers’ conditions. Democratic socialists, in contrast, were more willing to work with government institutions, participate in democracies, and “settle for partial improvements for workers, rather than holding out for total change” (Shively, 2005, p. 33). Between 1989 and 1991, communist regimes in Eastern Germany, the USSR, and throughout Eastern Europe collapsed. In their quest for economic and political change, the new Eastern European governments have turned to democracy, democratic socialism, capitalism, and other economic and political models.

Today, only a handful of countries (e.g., Cuba, China, North Korea, Vietnam) are under communist rule. Socialists, especially democratic socialists, have prevailed in Scandinavia and Western Europe. They have been instrumental in advancing the modern welfare state in those countries and elsewhere around the world (Shively, 2005).

Contemporary Conservatism and Liberalism Contemporary political conservatism, which grew in popularity in the late 20th century, is similar to classic conservatism (described previously) but differs from it in several ways. In particular, conservatives oppose a strong government role in assisting the disadvantaged. Recall that the conservative political philosophers of the 18th and 19th centuries supported the state’s role in helping individuals through social policies. Now, liberals are the ones who generally favor a strong government role in social policies, such as health, welfare, education, and labor, whereas conservatives prefer minimal government intervention and reliance on privatization and individual choice.




Contemporary conservatives oppose rapid and fundamental change, as did proponents of earlier models of conservatism. They call for devolution of federal responsibility for health and other social issues to state governments, a diminished presence of government in all aspects of policy, a reduced tax burden, and the importance of traditional social values. Many political observers point to the 1980 election of President Ronald Reagan as a turning point for the rise of American conservatism.

In contrast to conservatives’ calls for a decreased federal presence in health care policy, liberals today support an expanded government role to help people who need income support, health care coverage, child care assistance, vocational guidance, tuition, and other aspects of social policy. The Great Society programs of President John F. Kennedy and Lyndon B. Johnson in the 1960s and early 1970s boosted American liberal policies. Among the highlights of the Great Society initiatives were the enactment of Medicare, Medicaid, and Head Start. These federal government initiatives are founded on the importance of the state helping the disadvantaged through government-sponsored programs. They are in line with traditional liberal philosophies, described previously, which support the notion that individuals should be given equal opportunities to pursue their inalienable rights. Such rights include their health and welfare, broadly defined, even though the right to health care is not a legal one under the U.S. Constitution.

Since the mid-1990s, conservatives and liberals have found themselves in a somewhat ironic situation. Conservatives have deviated from their preference for the status quo by favoring rampant changes in certain aspects of social policy, among which are privatizing Social Security and inserting the federal government into the public education domain under the No Child Left Behind (NCLB) law. Liberals, on the other hand, often find themselves as the defenders of the status quo as they fight to sustain public programs, such as Medicaid. Each of these stances also reflects ideologies of their respective camps.

George Lakoff, a well-known linguist and political scientist, has developed an interesting way of explaining the differences between contemporary liberals and conservatives by designating each as a particular type of parent. For Lakoff, conservatism revolves around




the so-called “Strict Father” model, an authoritative structure that emphasizes the traditional nuclear family (Lakoff, 2002).

According to Lakoff, liberalism favors an entirely different approach to family life, the so-called “Nurturant Parent.” In this approach, “children become responsible and self-reliant through being cared for, respected, and caring for others, both in their family and in their community” (Lakoff, 2002, p. 34). Liberals focus on investing in social programs as a form of social support. Conservatives oppose this approach because they think it fails to sustain self-discipline and reinforces moral weakness.

Lakoff’s typology places liberals and conservatives at two extremes of an ideological continuum. Most people’s views, however, lie between these two extremes. Moreover, many organizations take policy positions on health care and other issues that are in concert with a certain ideological perspective (Table 6-1). However, similar to elected officials, they may deviate from these positions on any given issue. Nursing organizations welcome members of all political persuasions and strive to foster tolerance among different ideological and partisan points of view.

TABLE 6-1 Organizations and Think Tanks That Are Aligned with a Political Ideology on Health Policy Issues

Organization Website Conservative American Enterprise Institute Concerned Women for America Family Research Council Heritage Foundation National Center for Public Policy Research Liberal Americans for Democratic Action Center for Law and Social Policy Center for American Progress Families USA People for the American Way

Gender and Race in Political Philosophy




In the postmodern era in philosophy, which started in the mid-20th century, scholars noted that the traditional philosophy failed to represent the voices of numerous groups. Two perspectives that were particularly absent were those based on gender and race.

Critical to feminist political philosophy is the idea of politics as a social contract and rejection of the contract as being necessarily male centered. Pateman (1988) notes that the social contract fails to recognize the unique needs of women and, instead, tends to subjugate them to the concerns of the males who formulated the earlier ideas of political philosophy.

Several other positions linked with feminist philosophy include, first, the idea that the views most widely espoused with regard to philosophy and politics are those of men, resulting in a patriarchal and androcentric bias reflected in social and cultural traditions. Second, there is the notion that a woman-centered view can counter this androcentric bias and provide a balanced perspective. A third viewpoint argues specifically for philosophy to advance the status of women.

Feminism, as a political philosophy, ranges from a call for consideration of women’s perspectives to radical feminism and may be extended to rejection of the heterosexual norm (MacKinnon, 1989). Democratic feminism, a variant of democratic theory, argues for an egalitarian foundation in which there are “norms of equality and symmetry” and “open debate” is possible (Benhabib, 1996, p. 70). This theory in political philosophy is related to “deliberative democratic theory,” which focuses on deliberation in the process of decision making. Democratic feminists would argue that deliberation must include diverse perspectives, including those of women, to be effective.

One drawback to feminist political philosophy is that it can divide people based on gender. Someone’s identity is not merely female or male, but is likely connected with ethnicity, socioeconomic status, work role, and other influences. Consequently, a focus on gender as a key point in political philosophy may fail to recognize the intricate interplay of the various facets that constitute identity.

In the 1990s, and building on Carol Pateman’s Sexual contract, Charles W. Mills identified the “Racial Contract” as another




example of how traditional approaches to political philosophy overlooked the realities of most of the world’s population; nonwhites or people of color, which includes Black people, Native Americans, people of Asian origin, and millions of others who are nonwhite in ancestry.

Mills (1997) explained that the “social contract tradition,” which is essential for much of “Western political theory,” did not extend to all people. Instead, it was a contract that white men wrote and intended only to apply to themselves (p. 3). Nonwhite people did not have the same relationship with the state or government as white people. They were considered objects of government or property. Because the traditional social contract is only among the people of one race, Mills refers to it as a Racial Contract.

Mills (1997) claimed that the narrow scope of contracts that were based on mainstream political philosophy was not intentional. It reflected the reality of the “the power structure of formal or informal rule, socioeconomic privilege, and norms for the differential distribution of material wealth and opportunities, benefits and burdens, rights and duties” (p. 3).

Mills (1997) provided examples of how racial oppression existed globally and was not limited to whites over nonwhites, even though that’s the scenario with which those of us in the western world are most familiar. He also discussed how the Racial Contract and “the reality of systematic racial exclusion, are obfuscated in seemingly abstract and general categories that originally were restricted to whites” (p. 118). For example, Mills pointed to the Japanese occupation of China in the 1930s as a different version of a Racial Contract, in this case a “Yellow Racial Contract,” which referred to longstanding disputes over power and supremacy between different people of Asian origin (p. 128).

In contrast to ideal contracts embedded in mainstream political philosophy, which one might use as guides for living a good or moral life, Mills (1997) contended that “nonideal contracts” are to be “demystified and condemned” for overlooking race and racial oppression by whites all over the world (p. 5). Analyzing the “nonideal contract” enables one to understand how its “values and concepts have functioned to rationalize oppression, so as to reform them” (p. 6). Thus, the “Racial Contract,” with all its flaws, can




provide a path to reform by identifying normative aspects of a revised contract that might “establish…what a just ‘basic structure’ would be, with a schedule of rights, duties and liberties that shapes citizens’ moral psychology, conceptions of the right, notions of self- respect, etc.” (p. 10).

The Welfare State The welfare state refers to the “share of the economy devoted to government social expenditures” (Hacker, 2002, pp. 12-13). Health policy analysts often compare aspects of the welfare state among developed countries. In such comparisons, the United States typically ranks lowest for public social expenditure as a percentage of the gross domestic product (GDP). However, if one adjusts for tax burdens, such as income taxes, and other public subsidies, then the United States ranks closer to the middle (Hacker, 2002). A unique aspect of the American welfare state is that most health care spending comes from the private sector.

The origins for much of the modern welfare state in Europe and the United States can be traced to the post-World War II period, when government leaders wanted to provide health and other social services to rebuild their national economies after the war’s devastation. One of the best examples of such activities was the establishment of the British National Health Service (NHS), a government-administered and government-financed health insurance and delivery system to which all United Kingdom residents are entitled. The cornerstone of the U.S. welfare system is the 1935 U.S. Social Security Act, which established the Social Security program, welfare, federal maternal and child health programs, and other important initiatives to ameliorate the devastation of the Great Depression.

Since the 1980s, the welfare state has been in a state of flux in the United States and across Europe. One response to the constraints on the welfare state in countries such as the United States and Canada, the United Kingdom, and Germany has been the infusion of competition, accountability, and requirements for increasing private sector responsibility in the provision of health care. The growth of managed care in the United States, the increased




accountability of physicians, the infusion of market-oriented practices in the United Kingdom, and tightening of rules regarding physician income in Canada exemplifies this. Shifts in political mood, as with the 2008 election of President Barack Obama, demonstrate how the ideological pendulum can swing from one side to another in a relatively short time.

Types of Welfare States There are many different types of welfare states, based on the division of responsibilities for social services between public and private sectors and the role of a central government authority. The most well known categorization is Esping-Andersen’s (1990) description of three types of welfare state: social-democratic, corporatist, and liberal. Remember that this categorization encompasses all aspects of social policy.

Social-democratic welfare states refer to the Scandinavian countries, where most social programs are publicly administered and relatively few privately sponsored social benefits are offered. These countries have “pursued a welfare state that would promote an equality of the highest standards” (Esping-Andersen, 1990, p. 27).

Corporatist welfare states are typically the Western European nations (e.g., France, Italy, and Germany), where social rights and status differentials have endured and affected social policies. These countries grant social rights to many, but primarily provide state interventions when family capacities fail.

Liberal welfare states include the United States, Canada, and Australia, where privately sponsored benefits dominate. Among liberal welfare states, the United States is distinctive for its large percentage of social spending in the form of privately sponsored benefits (Hacker, 2002). In liberal welfare states, welfare and other social benefits are highly stigmatized, and the state encourages market involvement as much as possible (Esping-Andersen, 1990).

Political Philosophy and the Welfare State: Implications for Nurses




How might nurses apply these concepts of political philosophy to their involvement in health politics and policy? Rather than sitting on the sidelines, nurses, regardless of partisan preference, can participate in the ideological and political debates that shape health policies. Each of us has perspectives on the role of government and the rights of individuals with regard to certain health policies. They form our own ideology and political positions. Determine where you stand on an issue and the underlying ideology that informs your views. Then use that knowledge as the basis for advocating for policies that have the potential to improve health policy and patient outcomes. In so doing, be mindful of the philosophical traditions that shape your views.

When engaging in political deliberations, listen to the rhetoric that others use and identify the underlying political and philosophical threads. Use similar language, as long as it is based on sound knowledge, when you meet with policymakers, or use written texts to advance your positions. The following two cases, covering the uninsured and motorcycle helmet use, clarify these points.

First, consider the issue of reducing the number of uninsured Americans. If one believes that the government’s role should be minimal and individuals should largely be accountable for health care purchasing and costs, then tax credits and other types of individual health care accounts would be the policy of choice. If, on the other hand, one believes that the state is largely responsible for ensuring a basic minimum level of health care, then one would prefer the expansion of government-sponsored programs, such as Medicare, Medicaid, and CHIP, to cover those presently lacking insurance.

Similar issues arise when considering issues of public health, such as motorcyclists’ use of helmets. For example, one view, taken predominantly by traditional liberals, might be that motorcyclists have the right to decide for themselves whether or not they wear helmets. Others, using a Hobbesian or social contract framework, might argue that it is in the best interest of society at large for riders to wear helmets and abide by laws requiring them to do so. This is partly because of the cost to society, but mostly because the state has a responsibility to protect individuals, which in turn promotes a




peaceful and orderly society. Individuals, in turn, have a responsibility to yield to the state in its attempts to maintain order. There are some cases in which the state may need to limit individual freedoms to protect the state at large. Variations among the American states in helmet laws depict the different approaches to the balance of power among individuals, the state, and the community at large.

The relationship between nursing and the state has yet to be carefully explored. Connolly (2004) states, “Undertaking political history requires an understanding of how government works, in both theory and practice” (p. 16). Yet, there are many aspects of nursing’s political history that remain untapped and that warrant a close examination of how the profession has interacted with state structures in the policy process.

Whether working with public officials, strategizing to create links between policy and practice, or studying the role of the state in public policies that pertain to nursing, political philosophy is the foundation of thought and action. It can be a lively aspect of nurses’ strategic thinking in linking policy, politics, and practice.

Discussion Questions 1. If you were meeting a delegation of nurses from ten different countries, how might you use political philosophy to explain the U.S. health care system (access, quality, and financing), the role of the U.S. welfare state, and the position of certain national nursing organizations on related issues?

2. In thinking about certain groups that have been excluded from mainstream political philosophy, what do you see as nursing’s role (individually and collectively) in ensuring that they receive the same benefits and privileges as people from other groups?

References Benhabib S. Democracy and difference: Contesting the boundaries

of the political. Princeton University Press: Princeton, NJ;




1996. Connolly CA. Beyond social history: New approaches to

understanding the state of and the state in nursing history. Nursing History Review. 2004;12:5–24.

Esping-Andersen G. The three worlds of welfare capitalism. Princeton University Press: Princeton, N.J.; 1990.

Hacker A. Political theory: Philosophy, ideology, science. MacMillan: New York; 1960.

Hacker JS. The divided welfare state: The battle over public and private social benefits in the United States. Cambridge University Press: New York; 2002.

Lakoff G. Moral politics: How liberals and conservatives think. University of Chicago Press: Chicago; 2002.

Levine A. Engaging political philosophy from Hobbes to Rawls. Blackwell Publishers: Malden, Mass.; 2002.

MacKinnon CA. Toward a feminist theory of the state. Harvard University Press: Cambridge, Mass.; 1989.

Mills CW. The racial contract. Cornell University Press: Ithaca, NY; 1997.

Pateman C. The sexual contract. Stanford University Press: Stanford, CA; 1988.

Shapiro I. The moral foundations of politics. Yale University Press: New Haven; 2003.

Shively WP. Power and choice: An introduction to political science. 9th ed. McGraw-Hill: Boston; 2005.

Socialism. [ Retrieved from]; 2005.

Wolff J. An introduction to political philosophy. Oxford University Press: Oxford, UK; 1996.

Online Resources Open courses on political philosophy, such as this one offered

by Professor Stephen B. Smith at Yale University, including short lectures on YouTube. Internet Encyclopedia of Philosophy.









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.

Box 7-1 Policy Definitions

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 consistently 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

Identifying and framing a problem is the first step, but it is also necessary to identify potential solutions. For example, concerns were raised in Washington state about the ability of insured workers to access health care in rural areas. This resulted in a delay in workers returning to work as well as insufficient reporting of injuries. Because nurse practitioners had been restricted in performing some of the functions related to certifying worker disability compensation, worker access to these providers was underused. As a result, the Washington State legislature enacted a pilot program to allow nurse practitioners (NPs) to expand their scope of practice to include serving as attending providers for injured workers. Despite some stakeholder concerns, the evidence concerning NP competency in undertaking this service was positive and subsequent analysis of the pilot program established that it was not only effective, it was also efficient in terms of use of resources (Sears & Hogg-Johnson, 2009). A policy intervention that will solve




the problem is dependent on a thorough understanding of the problem itself as well as viable, evidence-based policy options.

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 the 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. [2010]. 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 time 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 (, 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 (, 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 stream, 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).

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?




Recommended reading: Buerhaus, P. (2009) Avoiding mandatory hospital nurse staffing ratios: An economic commentary. Nursing Outlook, 57(2), 107-112. (Also see Chapters 53 and 61.)

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 appropriately 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).

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).




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

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 developed before one can move ahead with a policy recommendation that may include evidence informed by input from community stakeholders.

Policy-Relevant Research 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).

Conclusion 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.

Discussion Questions 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?

References Agency for Healthcare Research and Quality [AHRQ]. An

organizational guide to building research capacity. [Retrieved from] grants/hsrguide/hsrguide.html; 2013.

Agency for Healthcare Research and Quality [AHRQ]. Effective Health Care Program: What is comparative effectiveness research?. [Retrieved from]




comparative-effectiveness-research1/; 2013. Aiken L. Supplemental nurse staffing in hospitals and quality

of care. Journal of Nursing Administration. 2007;37:335–342. Aiken L, Clarke S, Sloane D, Sochalski J, Silber J. Hospital

nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987–1993.

Buerhaus P. Avoiding mandatory hospital nurse staffing ratios: An economic commentary. Nursing Outlook. 2009;57(2):107–112.

Center to Champion Nursing in America. Access to care and advanced practice nurses: A review of Southern U.S. practice laws. [AARP Public Policy Institute. Retrieved from] 2010.

Dorfman L, Wallack L, Woodruff K. More than a message: Framing public health advocacy to change corporate practices. Health Education & Behavior. 2005;32(3):320–336 [Retrieved from]

Dye R. Understanding public policy. 7th ed. Prentice Hall: Englewood Cliffs, NJ; 1992.

Fawcett J, Russell G. A conceptual model of nursing and health policy. Policy, Politics, & Nursing Practice. 2001;2(2):108–116.

Fukuyama F. Why are we still fighting over Obamacare? Because America was designed for a stalemate. The Washington Post. 2013, October 6 [Retrieved from] 04/opinions/42696476_1_affordable-care-act-majority- obamacare.

Gawande A. The cost conundrum. The New Yorker. 2009;36–44 [June 1, 2009].

Glasby J, Beresford P. Who knows best? Evidence-based practice and the service user contribution. Critical Social Policy. 2006;26(1):268–284.

Hewison A. Evidence-based policy: Implications for nursing and policy involvement. Policy, Politics & Nursing Practice. 2008;9(4):288–298.

Kingdon JW. Agendas, alternatives, and public policies. Little,




Brown: Boston; 1995. Lindblom C. Still muddling, not yet through. Public

Administration Review. 1979;39(6):517–526. Longest B. Health policymaking in the United States. 5th ed.

Health Administration Press: Chicago; 2010. Mahlin M. Individual patient advocacy, collective

responsibility and activism within professional nursing associations. Nursing Ethics. 2010;17(2):247–254.

Mundinger M, Kane R, Lenz E, Totten A, Tsai W, Cleary P, et al. Primary care outcomes in patients treated by nurse practitioners or physicians: A randomized trial. JAMA. 2000;283:59–68.

National Association of Pediatric Nurse Practitioners [NAPNAP]. Childhood obesity special interest group. [Retrieved from] 2013.

Naylor M, Brooten D, Campbell R, Maislin G, McCauley K, Schwartz J. Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatric Society. 2004;52(7):675–684.

O’Connor M, Jackson W. Analysis: U.S. Supreme Court upholds the affordable care act: Roberts rules? The National Law Review. 2012 [Retrieved from] court-upholds-affordable-care-act-roberts-rules. eRulemaking Program [website to enable citizens to search, view and comment on regulations issued by the US Government]. [Retrieved from]!aboutProgram; 2013.

Robert S, Booske B. U.S. opinions on health determinants and social policy and health policy. American Journal of Public Health. 2011;101(9):1655–2663.

Safriet B. Health care dollars and regulatory sense: The role of advanced practice nursing. Yale Journal on Regulations. 1992;417:442–445.

Sears J, Hogg-Johnson S. Enhancing the policy impact of evaluation research: A case study of nurse practitioner role




expansion in a state workers’ compensation system. Nursing Outlook. 2009;57(2):99–106.

Stimpson M, Hanley B. Nurse policy analyst. Advanced practice role. Nursing and Health Care. 1991;12(1):10–15.

Taft SH, Nanna KM. What are the sources of health policy that influence nursing practice? Policy, Politics, & Nursing Practice. 2008;9(4):274–287.

Weiss A, Woodhouse E. Reframing incrementalism: A constructive response to the critics. Policy Sciences. 1992;25:255–273.

Online Resources American Association of State Colleges and Universities: The

American Democracy Project. Campaign to Promote Civic Education. The Commonwealth Fund. Health Affairs. Kaiser Family Foundation.






Health Policy Brief

Improving Care Transitions

Rachel Burton

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: 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 readmissions, costing an estimated $12 billion a year, are considered potentially preventable, especially with improved care transitions.

Root Causes. 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 information 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:

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, more than 2200 hospitals will forfeit about $280 million in Medicare payments over the next year because of these readmissions penalties.

Medical Homes. 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:

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 eligible 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:

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 ( 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.

Mixed Messages. 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 ( 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.

What’s Next? 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.

References Bubolz T, Emerson C, Skinner J. State spending on dual

eligibles under age 65 shows variations, evidence of cost shifting from Medicaid to Medicare. Health Affairs. 2012;31(5):939–947.

Coleman EA. Falling through the cracks: Challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society. 2003;51(4):549–555.

Hackbarth G. Report to the Congress: Promoting greater efficiency in Medicare. Medicare Payment Advisory Commission: Washington, DC; 2007, June.

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physicians. JAMA. 2007;297(8):831–841. Kronick R, Gilmer TP. Medicare and Medicaid spending

variations are strongly linked within hospital regions but not at overall state level. Health Affairs. 2012;31(5):948–955.

Naylor MD, Aiken LH, Kurtzman E, Olds DM, Hirschman KB. The importance of transitional care in achieving health reform. Health Affairs. 2011;30(4):746–754.

Pham HH, Grossman JM, Cohen G, Bodenheimer T. Hospitalists and care transitions: The divorce of inpatient and outpatient care. Health Affairs. 2008;27(5):1315–1327.

Tilson S, Hoffman GJ. Addressing Medicare hospital readmissions. Congressional Research Service: Washington, DC; 2012.

Online Resources The Women’s and Children’s Health Policy Center.

and-childrens-health-policy- center/de/policy_brief/index.html.

. 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.





Political Analysis and Strategies Kathleen M. White 1

“The difficult can be done immediately, the impossible takes a little longer.” Unknown author, Army Corps of Engineers motto, World War II

The knowledge and expertise of nurses regarding health and health care are critical to the political process and the development of health policy. However, the word politics often evokes negative emotions and many nurses may not feel inclined to get involved. Nonetheless, nurses have the skills to be active participants in the political arena for a number of reasons. First, nurses are skilled at assessment, and being engaged in the political process involves analysis of the relevant issues and their background and importance. Second, nurses understand people and, in order to understand an issue, it is critical to know who is affected and who is involved in trying to solve the problem. Finally, nurses are relationship builders and the political process involves the development of partnerships and networks to solve problems. As skilled communicators, nurses have the ability to work with other professionals, patients, families, and their communities to solve health care problems that affect their patients and the health care system. Nurses have much to offer in the political process and need to develop skills in political analysis and strategy to truly make a





What is Political Analysis? Political analysis is the process of examining an issue and understanding the key factors and people that might potentially influence a policy goal. It involves the analysis of government and organizations, both public and private; people and their behavior; and the social, political, historical, and economic factors surrounding the policy. It also includes the identification and development of strategies to attain or defeat a policy goal. Political analysis involves nine components.

Identification of the Issue The first step in conducting a political analysis is to identify and describe the issue or problem. Identifying and framing the issue involves asking who, what, when, where, and how questions to gather sufficient information to lay the groundwork for developing an appropriate response to the issue. Start with what you know about the issue: • What is the issue? • Is it my issue and can I solve it? • When did the issue first occur, is it a new or old problem? • Is this the real issue, or merely a symptom of a larger one? • Does it need an immediate solution, or can it wait? • Is it likely to go away by itself? • Can I risk ignoring it?

Beware of issue rhetoric (Bardach, 2012) that is either too narrowly defining an issue in a technical way, or defining the issue too broadly in a societal way. Decide what is missing from what you know about the issue and gather additional information: • Why does the problem exist? • Who is causing the problem? • Who is affected by the issue? • How significant is the issue?




• What additional information is needed? • What are the gaps in existing data?

Don’t cut corners or overlook the importance of this step in the political analysis, as a well-defined issue is important to the whole process, as is identifying and defining the right issue. The way a problem is defined has considerable impact on the number and type of proposed solutions (Fairclough, 2013). The challenge for those seeking to get policymakers to address particular issues (e.g., poverty, the underinsured, or unacceptable working conditions) is to define the issue in ways that will prompt decision makers to take action. This requires careful crafting of messages so that calls for solutions are clearly justified. This is known as framing the issue. In the workplace, framing may entail linking the problem to one of the institution’s priorities or to a potential threat to its reputation, public safety, or financial standing. For example, inadequate nurse staffing could be linked to increases in rates of morbidity and mortality, outcomes that can increase costs and jeopardize an institution’s reputation and future business.

It is important not to confuse symptoms, causes, or solutions with issues. Sometimes what appears to be an issue is not. For example, proposed mandatory continuing-education for nurses is not an issue; rather, it is a possible solution to the challenge of ensuring the competency of nurses. After an analysis of the issue of clinician competence, one might establish a goal that includes legislating mandatory continuing-education. The danger of framing issues as solutions is that it can limit creative thinking about the underlying issue and leave the best solutions uncovered.

Context of the Issue The second part in the political analysis process is to do a situational analysis by examining the context of the problem. This analysis should include, at a minimum, an examination of the social, cultural, ethical, political, historical, and economic contexts of the problem. Several questions can guide you in analyzing the background of the issue: • What are the social, cultural, ethical, political, historical, and

economic factors that are creating or contributing to this problem?




• What are the background and root causes of each of these factors? • Are these factors constraining or facilitating a solution to the

problem? • Are there other environmental obstacles affecting this issue?

It is important to be as thorough as possible at this stage and to consider whether the source of the information is verifiable and impartial. It is also important to understand any opposing views.

When assessing the political context, nurses need to clarify which level of government (federal, state, or local) or organization is responsible for a particular issue. Scope of practice is a good example. Although typically defined by the states, there are examples where the federal government has superseded the state’s authority, such as in the Veteran’s Administration and the Indian Health Service. Nurses also need to know which branch of government (legislative, executive, or judicial) has primary jurisdiction over the issue at a given time. Although there is often overlap among these branches, nurses will find that a particular issue falls predominantly within one branch.

Knowledge of past history of an issue can provide insight into the positions of key public officials so that communications with those individuals and strategies for advancing an issue can be developed accordingly. For example, if it is known that a particular legislator has always questioned the ability of advanced practice registered nurses (APRNs) to practice independently, then that individual may need stronger emphasis on the evidence about the quality and value of APRNs to support legislation allowing direct billing of APRNs under Medicare.

This type of context analysis is also applicable to the workplace or community organization. Regardless of the setting, assessing the history of the issue would include identifying who has responsibility for decision making for a particular issue; which committees, boards, or panels have addressed the issue in the past; the organizational structure; and the chain of command.

At an institutional level, once the relevant political forces in play have been identified, the formal and informal structures and the functioning of those structures need to be analyzed. The formal dimensions of the entity can often be assessed through documents related to the organization’s mission, goals, objectives,




organizational structure, bylaws, annual reports (including financial statement), long-range plans, governing body, committees, and individuals with jurisdiction. The informal dimensions of the organization, such as personal relationships and personal communication networks that could be positive or negative, are more difficult to analyze but need to be understood to get a full picture of the context of the issue.

One final example in the analysis of the context of the issue is worth mentioning. Does the entity use parliamentary procedure? Parliamentary procedure provides a democratic process that carefully balances the rights of individuals, subgroups within an organization, and the membership of an assembly. The basic rules are outlined in Robert’s Rules of Order ( Whether in a legislative session or the policymaking body of large organizations, one must know parliamentary procedure to develop a political strategy to get an issue passed or rejected. There have been many issues that have failed or passed because of insufficient knowledge of rule-making.

Political Feasibility The third part of a political analysis is to analyze the political feasibility of solving an issue. There are several ways to conduct a political feasibility analysis. A simple analysis is conducting a force field analysis (Lewin, 1951) to identify the barriers and facilitators to making change to solve the issue. The force field analysis asks you to think critically about the issue and the forces affecting it by creating a two-column chart. One column lists the restraining forces, or all of the reasons that preserve the status quo and any reasons why the issue should stay the same. The second column lists the driving forces, or forces that are pushing the issue to change. This exercise requires that the whole picture is considered and provides a list of the important factors that surround the issue.

A second option is to use John Kingdon’s (2010) model of public policymaking (see Chapter 7). Kingdon proposes three streams or processes that affect whether an issue gets on the political agenda; the problem stream is where people agree on an issue or problem, collect data about the issue, and share the definition of problem; the




policy stream is characterized by discussion and proposal of policy solutions for the issue; and the political stream is when public mood and political will exists to want to address the issue. Kingdon’s model explains that an issue gets on the political agenda only when the three streams couple or converge and a window of opportunity is thereby created. This analysis provides consideration of what needs to happen for the issue to advance to the public policy agenda, including an analysis of the policy and political factors.

The Stakeholders Stakeholders are those parties who have influence over the issue, are directly influenced by it, or could be mobilized to care about it. In some cases, the stakeholders are obvious. For example, nurses are stakeholders on issues such as staffing ratios. In other situations, one can develop potential stakeholders by helping them to see the connections between the issue and their interests. Other individuals and organizations can be stakeholders when it comes to staffing ratios. Among them are employers (i.e., hospitals, nursing homes), payers (i.e., insurance companies), legislators, other health care professionals, and consumers.

The role of consumers cannot be underestimated. In the political arena, these are the constituents and therefore the voters, and they can wield tremendous power over an issue and its solution. In many cases, nurses are advocates and work on behalf of stakeholders such as the patients who are affected by the care they receive. Nursing has increasingly realized the potential of consumer power in moving forward nursing and health care issues. For example, a consumer advocacy organization such as AARP possesses significant lobbying power. When nurses wanted to advance the idea of a Medicare Graduate Nursing Education (GNE) benefit, similar to the Medicare Graduate Medical Education funding to hospitals for the clinical training of interns and residents, AARP championed the proposal because it views the nursing shortage as a threat to its members’ ability to access health care. GNE was included in the ACA as a pilot project.

In commencing a stakeholder analysis it is important to evaluate




the relationships you, or others in your group, have with key stakeholders. Look at the connections with possible stakeholders throughout your organization, community, places of worship, or businesses. Consider the following when doing a stakeholder analysis: • Who are the stakeholders on this issue? • Which of these stakeholders are potential supporters or

opponents? • Can any of the opponents be converted to supporters? • What are the values, priorities, and concerns of the stakeholders? • How can these be tapped in planning political strategy? • Do the supportive stakeholders reflect the constituency that will

be affected by the issue? For example, as states expand coverage of health services

through the state’s Medicaid program, it is vital to have those who now qualify let their policymakers know how important the issue is for them and to share their personal stories of how this insurance coverage has made a difference. Yet stakeholders who are recipients of the services are too often not identified as vital for moving an issue forward. Nurses, as direct caregivers, have an important role in ensuring that recipients of services are included as stakeholders; especially when bringing issues to elected officials.

Economics and Resources An effective political strategy must take into account the resources that will be needed to address an issue successfully. Resources include money, time, connections, and intangible resources, such as creative solutions. The most obvious resource is money, which must be considered when defining the issue and getting it recognized or on the public agenda. Thus, before launching an initiative to champion an issue, it is necessary to determine the resources that will be necessary, how much it will cost, who will bear those costs, the source of the money, and what value will be achieved from the outlay of the resources. It is critical to fully examine, despite the initial financial outlay, the potential for cost savings it may produce. It could be helpful to know how budgets




are formulated for a given organization, professional group, or government agency. What is the budget process? How much money is allocated to a particular cost center or budget line? Who decides how the funds will be used? How is the use of funds evaluated? How might an individual or group influence the budget process?

Money is not the only resource to evaluate. Sharing available resources, such as space, people, expertise, and in-kind services, may be best accomplished through a coalition. It may require a mechanism for each entity to contribute a specific amount or to tally their in-kind contributions such as office space for meetings; use of a photocopier, telephone or other equipment; and use of staff to assist with production of brochures and other communications. Other cost considerations include publicity efforts such as printing materials, paying for postage, and accessing electronic communications.

Values Assessment Every political issue should prompt discussions about values. Values underlie the responsibility of public policymakers to be involved in the regulation of health care. In particular, calls for extending the reach of government in the regulation of health care facilities imply that one accepts this as a proper role for public officials, rather than as a role of market forces and the private sector. Thus, electoral politics affect the policies that may be implemented. An analysis that acknowledges how congruent nurses’ values are with those of individuals in power can affect the success of advancing an issue. There are issues that would be considered morality issues−those that primarily revolve around ideology and values, rather than costs and distribution of resources. Among well-publicized morality issues are abortion, stem cell research, and immigration. However, most issues that are not classified as morality issues still require an assessment of the values of supporters and their opponents.

Any call for government support of health care programs implies a certain prioritization of values: Is health more important than education, or jobs, or military action in the Middle East? Elected




officials must always make choices among competing demands. And their choices reflect their values, the needs and interests of their constituents, and their financial supporters such as large corporations. Similarly, nurses’ choice of issues on the political agenda reflects the profession’s values, political priorities, and ways to improve health care.

Although nurses may value a range of health and social programs, legislators review issues within the context of demands from all of their constituencies. When an issue is discussed, it is critical to link the issue to the problem it may solve. It is also important to make sure issues are framed to show how they will help the public at large and not just the nursing profession. For example, when a request for increased funding for nursing education is made, linking this request to the need to alleviate the nursing shortage or to increase the number of nurses necessary for successful implementation of health care reform would be important.

Networks and/or Coalitions Although individuals develop political skill and expertise, it is the influence of networks and coalitions, or like-minded groups that wield power most effectively. It is critical to the political analysis process to evaluate what networks or coalitions exist that are involved with the issue.

Too often nurses become concerned about a particular issue and try to change it without help from others. In the public arena particularly, an individual is rarely able to exert adequate influence to create long-term policy change. For instance, many advanced practice registered nurses (APRNs) have tried to change state Nurse Practice Acts to expand their authority. As well intentioned as the policy solutions may be, they will likely fail unless nurses can garner the support of other powerful stakeholders such as members of the state board of nursing, the state nurses association, physicians, and consumer advocacy groups. Such stakeholders often hold the power to either support or oppose the policy change. (See Chapter 75 for a discussion of building coalitions.)




Power Effective political strategy requires an analysis of the power of proponents and opponents of a particular solution. Power is one of the most complex political and sociological concepts to define and measure. It is critical to be aware of the sources of power, regardless of setting or issue, to understand how influence happens and to build your own sources of power for leadership in the political process.

Power can be a means to an end, or an end in itself. Power also can be actual or potential. Many in political circles depict the nursing profession as a potential political force considering the millions of nurses in this country and the power they could wield if more nurses participated in politics and policy formation. Any discussion of power and nursing must acknowledge the inherent issues of hierarchy and power imbalance that arise from the long- standing relationships between nurses and physicians. Some of nurses’ discomfort with the concept of power may also arise from the inherent nature of “gender politics” within the profession. Male or female, gender affects every political scenario that involves nurses. Working in a predominantly female profession means that nurses are accustomed to certain norms of social interactions (Tanner, 2001). In contrast to nursing, the power and politics of public policymaking typically are male dominated, although women are steadily increasing their ranks as elected and appointed government officials. Moreover, many male and female public officials have stereotypic images of nurses as women who lack political savvy. This may limit officials’ ability to view nurses as potential political partners. Therefore nurses need to be sensitive to gender issues that may affect, but certainly not prevent, their political success.

Any power analysis must include reflection on one’s own power base. Power can be obtained through a variety of sources such as those listed in Box 9-1(French & Raven, 1959; Benner, 1984). An analysis of the extent of one’s power using these sources can provide direction on how to enhance that power. Although the individual may hold expert power, it will be limited if one attempts to go it alone. An individual nurse may not have sufficient power to champion an issue through the legislative or regulatory process, but




a network, coalition, or alliance of nurses or nursing organizations can wield significant power to move an issue to the public agenda and to successfully solve it.

Box 9-1 Sources of Power

1. Legitimate (or positional) power is derived from a belief that one has the right to power, to make decisions and to expect others to follow them. It is power obtained by virtue of an organizational position rather than personal qualities, whether from a person’s role as the chief nurse officer or the state’s governor.

2. Reward power is based on the ability to compensate another and is the perception of the potential for rewards or favors as a result of honoring the wishes of a powerful person. A clear example is the supervisor who has the power to determine promotions and pay increases.

3. Expert power is based on knowledge, skills, or special abilities, in contrast to positional power. Benner (1984) argues that nurses can tap this power source as they move from novice to expert practitioner. It is a power source that nurses must recognize is available to them. Policymakers are seldom experts in health care; nurses are.

4. Referent power is based in identification or association with a leader or someone in a position of power who is able to influence others and commands a high level of respect and admiration. Referent power is used when a nurse selects a mentor who is a powerful person, such as the chief nurse officer of the organization or the head of the state’s dominant political party. It can also emerge when a nursing organization enlists a highly regarded public personality as an advocate for an issue it is championing.

5. Coercive power is based on the ability to punish others and is rooted in real or perceived fear of one person by another. For




example, the supervisor who threatens to fire those nurses who speak out is relying on coercive power, as is a state commissioner of health who threatens to develop regulations requiring physician supervision of nurse practitioners.

6. Information power results when one individual has (or is perceived to have) special information that another individual needs or desires. For example, this source of power can come from having access to data or other information that would be necessary to push a political agenda forward. This power source underscores the need for nurses to stay abreast of information on a variety of levels: in one’s personal and professional networks, immediate work situation, community, and the public sector, as well as in society. Use of information power requires strategic consideration of how and with whom to share the information.

7. Connection power is granted to those perceived to have important and sometimes extensive connections with individuals or organizations that can be mobilized. For example, the nurse who attends the same church or synagogue as the president of the home health care agency, knows the appointments secretary for the mayor, or is a member of the hospital credentialing committee will be accorded power by those who want access to these individuals or groups.

8. Persuasion power is based in the ability to influence or convince others to agree with your opinion or agenda. It involves leading others to your viewpoint with data, facts, and presentation skills. For example, a nurse is able to persuade the nursing organization to sponsor legislation or regulation that would benefit the health care needs of her specialty population. It may be the right thing to do, but the nurse uses her skills of persuasion for her own personal or professional agenda.

9. Empowerment arises from any or all of these types of power, shared among the group. Nurses need to share power and recognize that they can build the power of colleagues or others by sharing authority and decision making. Empowerment can happen when the nurse manager on a unit uses consensus




building when possible instead of issuing authoritative directives to staff, or when a coalition is formed and adopts consensus building and shared decision making to guide its process.

Consider the nursing organization that is seeking to secure legislative support for a key piece of legislation. It can develop a strategy to enhance its power by finding a highly regarded, high- profile individual to be its spokesperson with the media (referent power), by making it known to legislators that their vote on this issue will be a major consideration in the next election’s endorsement decisions (reward or coercive power), or by having nurses tell the media stories that highlight the problem the legislation addresses (expert power). A longer-range power- building strategy would be for the nursing organizations to extend their connections with other organizations by signing onto coalitions that address broader health care issues and expanding connections with policymakers by attending fundraisers for key legislators (connection power); getting nurses into policymaking positions (legitimate power); hiring a government affairs director to help inform the group about the nuances of the legislature (information power); using consensus building within the organization to enhance nurses’ participation and activities (empowerment), or, finally, by identifying a legislative champion for the issue who could garner the use of several power bases at once.

Goals and Proposed Solutions Typically, there is more than one solution to an issue and each option differs with regard to cost, practicality, and duration. These are the policy options. The political analysis of the issue involves the context of the issue, stakeholders, values, power, and what is politically feasible. By identifying the goal, and developing and analyzing possible solutions, nurses will acquire further understanding of the issue and what is possible for an organization, workplace, government agency, or professional organization to undertake. There needs to be a full understanding of the big picture and where the issue fits into that vision. For example, if nurses




want the federal government to provide substantial support for nursing education, they need to understand the constraints of federal budgets and the demands to invest in other programs, including programs that benefit nurses and other health care professionals. Moreover, support for nursing education can take the form of scholarships, loans, tax credits, aid to nursing schools, or incentives for building partnerships between nursing schools and health care delivery systems. Each option presents different types of support, and nurses would need to understand the implications of the alternatives before asking for federal intervention.

The amount of money and time needed to address a particular issue also needs to be taken into account. Are there short-term and long-term alternatives that nurses want to pursue simultaneously? Is there a way to start off with a pilot or demonstration program with clear paths to expansion? How might one prioritize various solutions? What are the tradeoffs that nurses are willing to make to obtain the stated political goals?

Such questions need to be considered in developing a political strategy.

Political Strategies Once a political analysis is completed, it is necessary to develop a plan that identifies activities and strategies to achieve the policy goals. The development and implementation of a political strategy to solve an issue requires that there is a tightly framed message, an aligned common purpose or goal, and a well-defined target audience. Messaging is critical to the development of a political strategy. Nurses need to be able to communicate with policymakers, other health care leaders, and the public, and may sometimes use social media for messaging to advise on institutional and public policy.

Look at the Big Picture It is human nature to view the world from a personal standpoint, focusing on the people and events that influence one’s daily life. However, developing a political strategy requires looking at the




larger environment. This can provide a more objective perspective and increase nurses’ credibility as broad-minded visionaries, looking beyond personal needs.

In the heat of legislative battles and negotiations, it is easy to get distracted. However, the successful advocate is the one who does not lose sight of the big picture and is willing to compromise for the larger goal. It is critical for nurses to frame their policy work in terms of improving the health of patients and the broader health delivery system, rather than a singular focus on the profession.

Do Your Homework We can never have all the information about an issue, but we need to be sufficiently prepared before we advocate. Usually it is unlikely to know beforehand when a particular policy will be acted on; nonetheless, it is not sufficient to claim ignorance when confronted with questions that should be answered. However, if one has done everything possible to prepare and is asked to supply information that is not anticipated, it is reasonable and preferable to indicate that one does not know the answer. The information should then be obtained as soon as possible and distributed to the policymaker who requested it. Remember not to let perfection be the enemy of good; gather the requested information, and present it as clearly and simply as possible.

Some of the ways to be adequately prepared are provided in Box 9-2.

Box 9-2 Being Prepared for Political Advocacy Here are some ways to ensure that you’re prepared for advocacy around a specific issue. Conducting a full political analysis will inform your preparation strategy.

• Clarify your position on the problem, your goal in pursuing the issue, and possible solutions.

• Gather information and data, and search the clinical and policy literature.




• Prepare documents to describe and support the issue.

• Assess the power dynamics of the stakeholders.

• Assess your own power base and ability to maneuver in the political arena.

• Plan a strategy, and assess its strengths and weaknesses.

• Prepare for the opposition.

• Line up support.

Read between the Lines It is as important to be aware of the way one conveys information as it is to provide the facts. When legislators say they think your issue is important, it does not necessarily mean that they will vote to support it. A direct question such as, Will you vote in support of our bill? needs to be asked of policymakers to know their position. Communication theory notes that the overt message is not always the real message (Gerston, 2010). Some people say a lot by what they choose not to disclose. What is not being said? Are there hidden agendas that the stakeholders are concerned about? When framing the issue, know the hidden agendas and covert messages. Be careful to make the issue as clear as possible and test it on others to be certain that reading between the lines conveys the same message as the overt rhetoric.

In God We Trust, All Others Bring Data This quote is attributed to W. Edwards Deming (Hastie, Tibshirani, & Friedman, 2011) who developed principles for managers to transform business effectiveness through the application of statistical methods. He suggested that by presenting data to workers, they can see the outcomes or intended results of their work and make improvements to meet goals. This quote resonates in today’s current heath care environment in that it requires measurement and data reporting by most health care organizations,




by many health care professionals, and at all levels of practice, including the institutional, local, state and national. Data are important to the political analysis process and again during strategy development to move an issue through the policy process. Decision makers are often dissatisfied with their ability to get or understand the data needed to make good policy decisions. They need an interpretation of the data in a form that is understandable and useable for their purposes. Nurses are skilled are interpreting and reporting data in the clinical setting and as researchers and consumers of clinical research. A nurse can make himself or herself valuable to a policymaker by preparing a report of the important points on an issue under consideration that translates data into concise information.

Money Talks Follow the money and understand the flow of funds within a private health care organization/system or the public sector. Money is important in both the public and private sectors, and the more money you have, the more powerful you appear to others, whether the money is revenue, profits, or donations. In the political arena, special interest groups, such as professional organizations (for example, the American Nurses Association), solicit money from their members and spend it to maintain a presence in Washington, DC, and 50 state capitals through political action committees (PACs). Other organizations, such as labor unions, trade associations, and some large corporations, also make donations to influence the agenda in Washington and the state capitals. One other type of influential group is the “527 committees” that get their name from the IRS code section that governs their existence. These 527 committees are advocacy issue groups that are outside the mainstream of special interest groups and corporate America. They may have ties to some of the other groups, but they have less stringent rules to follow on the use of money and how it influences the political process.

These advocacy groups hire professional advocates or lobbyists to monitor the policy and political environments and influence elected and appointed officials on issues of importance to their




special interest group. Even though money is important to have and can be very influential, the problem with money in politics is who is spending the money, what they are asking for in return, and how that affects the allocation of public resources.

Communication is 20% What You Say and 80% How You Say It and to Whom Using the power that results from personal connections can be an important strategy in moving a critical issue forward. In the example of APRN reimbursement, the original legislation that gave some APRNs Medicare reimbursement was greatly facilitated by the fact that the chief of staff for the Senate Majority Leader was a nurse. Or consider the nurse who is the neighbor and friend of the secretary to the chief executive officer (CEO) in the medical center. This nurse is more likely to gain access to the CEO than will someone who is unknown to either the secretary or the CEO. Building relationships and partnerships and networking are important long-term strategies for increasing influence but can also be short-term strategies.

Equally important is the way the message is framed and conveyed to stakeholders. We have often been told, it’s not what you say but how you say it. When delivering the message, learn to use strong, affirmative language to describe nursing practice. Use the rhetoric that incorporates lawmakers’ lingo and the buzz words of key proponents. This requires having a sense of the values of the target audiences, whether they are legislators, regulators, hospital administrators, community leaders, or the consumer public. Stakeholders appreciate a succinct and framed message that is responsive to the values and concerns of your supporters or opponents. For example, during health reform discussions, APRNs framed their issue in terms of quality of care and cost savings. Since the nation continues to be concerned about the amount of money spent on health care, the message of reducing costs without compromising quality resonated with the Administration, Members of Congress, insurers, employers, and the public alike. How you convey your message involves developing rhetoric or catchy phrases that the media might pick up on and perpetuate. Nurses




need to develop their effectiveness in accessing and using the media, an essential component of getting the issue on the public’s agenda.

Learn and use good communication techniques; in particular, the use of a persuasive and assertive communication style that focuses on the facts and the data, and limits any emotional appeals to stories that illustrate the human impact of the problem. As discussed above, it is important to develop a message that is important to your target audience.

And finally, don’t be afraid to toot your own horn. Don’t assume that your good work will be recognized or valued by others. If nursing is leading an initiative or has generated the research evidence to support the issue, present the evidence to the policymakers and let them know what has been studied or found to be effective and inform them that nurses led the work.

You Scratch My Back and I’ll Scratch Yours Developing networks involves keeping track of what you have done for others and not being afraid to ask a favor in return. Often known as quid pro quo (literally, something for something), it is the way political arenas work in both public and private sectors. Leaders expect to be asked for help and know the favor will be returned. Because nurses interface with the public all the time, they are in excellent positions to assist, facilitate, or otherwise do favors for people. Too often, nurses forget to ask for help from those whom they have helped and who would be more than willing to return a favor. Consider the lobbyist for a state nurses’ association who knew that the chair of the Senate public health and welfare committee had a grandson who was critically injured in a car accident. She visited the child several times in the hospital, spoke with the nurses on the unit, and kept the legislator informed about his grandson’s progress and assured him that the boy was well cared for. When the boy recovered, the legislator was grateful and asked the lobbyist what he could do to move her issue. Interchanges like this occur every day and create the basis for quid pro quo.




Strike While the Iron is Hot The timing of an issue will often make a difference in terms of a successful outcome. A well-planned strategy may fail because the timing is not good. An issue may languish for some period because of a mismatch in values, concerns, or resources but then something may change to make an issue ripe for consideration. The passage of the ACA is a good example. President Obama knew from studying the history of legislation in this country that the best chance of passing sweeping legislation was in the early years of a presidential term. Once elected, with both the U.S. House of Representatives and the U.S. Senate under the control of the Democratic Party, the President knew that the only hope of passing comprehensive health care reform would be if it became his priority within his first year.

United We Stand, Divided We Fall The achievement of policy goals can be accomplished only if supporters demonstrate a united front. Collective action is almost always more effective than individual action. Collaboration through networking, alliances, and coalition building can demonstrate broad support for an issue.

A 2010 Gallup poll of health care leaders found that the lack of a united front by national nursing organizations was viewed as a major reason why nursing’s influence on health care reform would not be significant. To maximize nursing’s political potential, we must look for opportunities to reach consensus or remain silent in the public arena on an issue that is not of paramount concern.

Sometimes diverse groups can work together on an issue of mutual interest, even though they are opponents on other issues. Public and private interest groups that identify with nursing’s issues can be invaluable resources for nurses. They often have influential supporters or may have research information that can help nurses move an issue forward.

The Best Defense is a Good Offense A successful political strategy is one that tries to accommodate the concerns of the opposition. It requires disassociating from the




emotional context of working with opponents and is the first step in principled negotiating. A person who is skillful at managing conflict will be successful in politics. The saying that politics makes strange bedfellows arose out of the recognition that long-standing opponents can sometimes come together around issues of mutual concern, but it often requires creative thinking and a commitment to fairness to develop an acceptable approach to resolving an issue.

It is also important to anticipate problems and areas for disagreement and be prepared to counter them. When the opposition is gaining momentum and support, it can be helpful to develop a strategy that can distract attention from the opposition’s issue or that can delay action. For example, one state nurses’ association continually battles the state medical society’s efforts to amend the Nurse Practice Act in ways that would restrict nurses’ practice and provide for physician supervision. Nurses have become concerned about the possibility of passage during a year when the medical society’s influence with the legislature was high. A key strategy to deal with this specific example is to develop coalitions and alliances to work with other health provider organizations engaged in similar battles with the physicians (e.g., optometrists, pharmacists) to monitor the current environment and be vigilant if changes arise. With this type of strategy in place, the physician groups will know that there would be a large coalition to deal with if any changes are proposed.

In developing a good defense, arm yourself with data and information about the issue. Be sure to understand how the issue fits in to either the organization’s current priorities or other important public agenda items. Know the supporters and opponents of the issue. Many groups maintain voting records of legislators on their key legislative agenda priorities. Finally, learning as much as you can about current public agenda items and organizational priorities is critical to being an informed health care professional. Visit your professional organization websites, including, the online home of the American Nurses Association. Also, the websites of specialty nursing organizations can provide valuable up-to-date information on the key issues facing the profession and health care in general.




Don’t Make Enemies and Don’t Burn Bridges To burn one’s bridges is to cut off any potential future support or collaboration with a person or organization. Because nursing or even health care is such a small world, it is critically important not to burn bridges, no matter how tempted you might be! Building bridges rather than burning them is a much smarter option for the future. It is critical to handle tricky political maneuvers with care and finesse. Everyone has experienced a sound defeat at some stage and the person who can congratulate the winner and move on to learn from the experience will thrive.

Rome Was Not Built in a Day It is important to remember that it takes a long time to do important work, to create something long lasting and sustainable. This is very true when referring to influence in the political process, whether it is governmental or organizational. It is often reported that it feels like the arguments have been going on for years, but policy successes will not happen immediately. It will take the involvement of many workers or volunteers and countless meetings, going through the political analysis of an issue and pursuing a political strategy to find a policy solution. It is critical not to overestimate the importance of that building process nor underestimate the importance of adding another brick.

Discussion Questions 1. When you are attempting to undertake a political analysis of an issue, one of the key questions to continually ask during the process is: “In this political [or social or economic] climate, can we get this done?” How would you evaluate the barriers that arise from climate or context or timing on a specific issue of interest?

2. For the same issue, who are the stakeholders and how could they be used in a political analysis that might be different from their use in political advocacy?




3. What are the political strategies that could leverage facilitators and constraints into political momentum to move the issue forward?

References Bardach E. A practical guide for policy analysis. 4th ed. CQ Press:

Washington, DC; 2012. Benner P. From novice to expert. Addison-Wesley: Menlo Park,

CA; 1984. Fairclough N. Critical discourse analysis: The critical study of

language. Routledge Press: New York; 2013. French J, Raven B. The basis of social power. Cartwright D.

Studies in social power. University of Michigan Press: Ann Arbor, MI; 1959:150–167.

Gallup. Nursing leadership from bedside to boardroom: Opinion leaders’ perception. [Retrieved from] attachments/Top%20Line%20Report.pdf; 2010.

Gerston LN. Public policy making: Process and principles. M.E. Sharpe: Armonk, NY; 2010.

Hastie T, Tibshirani R, Friedman J. The elements of statistical learning. 2nd ed. Springer: New York; 2011.

Kingdon J. Agendas, alternatives and public policies. 2nd ed. Pearson: New York; 2010 [(Longman Classics in Political Science)].

Lewin K. Field theory in social science. Harper and Row: New York; 1951.

Tanner D. Talking from 9 to 5: Women and men at work. [(reprint ed.)] William Morrow Paperbacks: New York; 2001.

Online Resources American Nurses Association’s Take Action.

pagename=nstat_take_action_home. American Association of Colleges of Nursing.




affairs/AACNPolicyHandbook_2010.pdf. National League for Nursing. American Organization of Nurse Executives.

. 1This chapter is an updated adaptation of the chapter developed in prior editions by Susan Talbott, Diana Mason, Judy Leavitt, Sally Cohen, and Ellen-Marie Whelan.





Communication and Conflict Management in Health Policy Elizabeth Waetzig, Greg Abell

“In great teams, conflict becomes productive. The free flow of conflicting ideas is critical for creative thinking, for discovering new solutions no one individual would have come to on his own.” Peter Senge

Nurses engage in conflict every day. They are trained to listen to, and advocate for, their patients and are, at times, called to resolve conflict among family members, providers, and others. Participating in health policymaking requires using these familiar skills, but also requires some very specific communication and conflict engagement skills. As Phyllis Kritek (1994), a nurse leader and educator, suggested in Negotiating at an Uneven Table, the frustration over having been excluded from the decision-making table for years sometimes has led nurses to a stubbornness of an intensity that might be a barrier to effective participation. To increase the capacity of nurses to engage effectively in politics and policymaking aimed at influencing health reform, and to be thought leaders in many other policy and political venues, this chapter will explore the following: (1) a definition of conflict; (2) a




process to engage in complex and challenging conversations; (3) skills to preserve opportunities available in these conversations; and (4) methods for effective engagement of conflict.

Understanding Conflict Senge (1990) in the opening quote identifies conflict as a place of possibility where we will find opportunities for creativity and innovation. If this is true, then, why do many people demonstrate a significant aversion to conflict? The answer may lie in some key characteristics of conflict: • The issues are considered significant to at least one of the parties. • Around these issues there is a perception of an incompatible

difference or threat. • When experiencing threat, we move to defend ideas, perspectives,

and plans of action. • We believe “the best defense is a good offense” and attacking the

other person and their ideas increases the level of threat. What might this look like in real time:

• When we are experiencing strongly held differences of opinion, we believe there is obviously a right and a wrong answer.

• From our perspective, it is obvious that we are right. • Given that we cannot both be right, then the other person is

obviously wrong. • Therefore it is my job to fix this by convincing you that “I am right

and you are wrong.” This paradigm compromises effectiveness in engaging conflict.

People pursue polarized positions and thinking, and behavior becomes focused on defending these positions. Little effort is directed to understanding the other person’s thinking because they are now often seen as an adversary. Effective strategies for conflict engagement must challenge this paradigm. The value in conflict is not found in fixing it but in acknowledging and understanding differences. While we say we respect diversity of opinion, this respect is often absent from our most challenging conversations.




Types of Conflict and Ramifications to Challenge Conflict is experienced daily that is quickly resolved or effectively ignored. Conflict can also cause us to lose sleep and dominate our waking thoughts. Bernard Mayer (2009) describes the six faces of conflict as follows: • Low impact: A decision needs to be made and although there is a

potential for differences of opinion, the issue is not particularly significant or critical. Where do you want to have lunch? On what color of paper should we print the agenda for the meeting?

• Latent: There are issues about which we know there is potential for conflict. We know strongly held differences of opinion exist. The conflict remains latent until something exposes it. Topics of religion and politics at social gatherings can expose latent conflict.

• Transient: Some conflicts occur within a time frame. For example, filing a workplace grievance or labor dispute often places the conflict into a context in which there are rules defining a time frame for engagement and resolution of the dispute.

• Representative: Almost all conflict is, to some extent, representative and not about what we think it is about. For example, the filing of a contract grievance is often representative of a deeper breakdown in a relationship between a supervisor and a direct report.

• Stubborn: Conflict has become complex, challenging, and resistant to resolution. The stakes feel high and there may be significant emotion attached to the issues and to the ways they are being addressed. However, when handled well, resolution may be reached.

• Enduring: Enduring conflict is deeply rooted in structures, systems, identity, and values. Ongoing engagement is required, and there may not be a final resolution. Engagement is to reach agreements that allow for forward movement. One way to engage enduring conflict and stay with it even when it is not resolvable is to agree to policies and procedures that clarify individual and organizational expectations and that increase the ability to function effectively together.




The Process of Conversations Complex conversations require a process that provides time for thought, reflection, and structure that is inclusive, productive, and innovative. The four stages include:

1. Preparing to participate

2. Entering or initiating the conversation

3. Increasing mutual understanding

4. Moving from inquiry and advocacy to action (This is a process that the authors developed while teaching Leading Through Conflict, an original work.)

Phase I: Preparing to Participate Who do you choose to be? To effectively prepare for a complex conversation, there are three objectives to consider:

1. Decide who you are committed to being in this process.

2. Align what you are doing with who you are committed to being.

3. Support others to prepare to engage effectively.

Preparation must be comprehensive, built on a lifelong process of reflection and a desire to stay grounded in the midst of surprise, disappointment, conflict, and change. We suggest the following questions in support of this level of preparation.

Who is the conversation calling me to be? Know what motivates you to participate and influences your choices at the table. Motivations for advocacy may include exposing problems, revenge, or assuaging ego. More positive motivators are beliefs that the thing advocated for would benefit the profession, the organization, and/or the entire population.

Why am I being invited to participate? You may bring experience and/or expertise that is essential. You may represent a group whose buy-in is necessary for implementation of a new policy. There may




be a need for a person of a certain gender, ethnicity, or profession to increase the credibility of the process. If you know the reason, is it one that aligns with your values? Can you participate with authenticity and support the outcome?

Who am I representing? Are you representing the interests of a larger group? It could be the organization or agency that employs you, the nursing profession, the health of the population served, or all of the above. Be clear about your representation and ensure that you can authentically represent those voices. This may sometimes require you to represent perspectives with which you do not entirely agree.

What are my own personal positions, philosophies, aims, intents, limits, and interests related to the issues? There are times when the values and interests of those who invited you or those you represent are such that remaining in the conversation would not serve you, those you represent, or the individuals in the conversation.

What biases, blind spots, or vulnerabilities might get in the way? How have diverse experiences, ideas, knowledge, and strengths shaped your current thinking?

Can you commit to self-reflection, awareness, and honesty even if it means potential isolation? It takes courage to stand alone when something does not feel right.

What is the situation calling you to do? When promoting change, you may agitate. When creating new policy, you are called to collaborate. You may also need to be the voice of dissent.

Are you comfortable with the role you are taking? Discomfort can show up as defensiveness and limit your ability to listen and contribute productively.

What will be most challenging? Anticipating challenges such as the issue(s), a person, or process will allow you to recognize them when they arise and to address them appropriately.

What kind of conversation do you want to have? If the group is shifting from one conversational structure to another, stop, evaluate the reason for the shift, and decide to continue as is or make a mid- course correction. Examples of conversational structures include: • A persuasive conversation is used to influence in a way that is

honest and compelling. • A distributive conversation is used to divide up a fixed resource.




• A dialectic conversation is a discussion used to investigate the truth of a theory or opinion.

• An integrative conversation is used to put the parts together into a whole.

• A generative conversation is used to create entirely new possibilities. (Isaacs, 1999, p. 38)

After preparing psychologically, focus on preparing substantively. The following questions are useful in preparing for a conversation around policy.

What is prompting this conversation? Why are we engaging at this time? Who is asking for this conversation? Is this one in a series of conversations, the subsequent ones contingent on the outcome of this one? Some reasons may be undisclosed.

What is/are the issue(s)? Does the group share a definition of the issues?

What information needs to be gathered, shared, or reviewed before and during this conversation? What data, process, and political information may be valuable?

How likely is conflict to arise in the conversation? If you can anticipate conflict, the better able you are to identify and effectively engage it when it surfaces.

What options do I have for engaging in and resolving conflict? Options include disengaging, asking for facilitative help, and identifying shared interests that may keep others at the table.

Our third focus is on procedural preparation. If the process feels fair and inclusive, then the outcome is more acceptable. The interpretation of a fair process is dependent on a number of factors: • What is your relationship to this issue? How important is the topic or

issue to you, your organization, your patients, your profession, or your community?

• What authority do you bring? Can you commit the organization you represent? To what extent is it important to clarify your authority?

• What is your level of responsibility and/or accountability? Colleagues, peers, and leaders will want to hear about the progress or outcome. Knowing your level of responsibility and to whom you are accountable gives clarity to emotional elements of a conversation.




• How will you organize to complete the work? If people are not given information about the time, location, participants, or premeeting information, the conversation may feel unorganized and trust is compromised.

• What is the structure of your work? Having everyone engage all issues at all times may be inefficient and frustrating. Instead, convene a conceptual meeting where the principles of the work are agreed upon and then a design team can provide details for the whole group to react to.

Phase I prepares participants to think through psychological, substantive, and procedural issues and clarify what they mean for their participation. Participants in this phase have prepared those being represented and those with whom they are meeting by building shared expectations.

Phase II: Entering Into the Conversation In Phase II, a foundation is laid for the group as they begin to engage. The objectives include:

1. Creating a safe space

2. Increasing trust in the process and the people

3. Including all of the voices

As you prepare, think about your needs regarding safety, trust, and your role. You must consider your relationships to those in the conversation and those external to it, the issues, and your own capacity to remain honest and compassionate in the face of diversity. As you convene the conversation, be intentional about the environment and the process.

Determine whether the process is confidential. If the conversation or process is to be confidential, what does that mean to the group? If it is not to be kept confidential, who will be informed and how will they be informed? Will the group create a unified message?

Identify and clarify potential parameters such as time and expected outcome. In most complex conversations, there are external factors that should be named and acknowledged by the group. Who




convened the process and why? What is the sense of urgency? Is there a deadline? Is it firm? Is there funding attached to the process?

Define the principles to guide the conversation. Sometimes called ground rules or group norms, these are the shared expectations about participation (attendance and level of engagement), behaviors (checking e-mail/text/Facebook and taking phone calls), logistics (how often you meet and where), and communication (disclosing helpful information).

Clarify the purpose of the conversation. Are you gathering information to better understand the problem, various points of view, and possible direction? Making decisions? Debating alternatives? Creating something new? Do you have the authority and ability to innovate?

Manage your tone. You can model the conversational structure. If you enter the conversation to tell rather than learn, others will probably do the same. If you engage in dialogue that leads to innovation rather than persuade others to take your path, you promote that conversational structure. If you work to include all of the voices with respect, others are likely to follow.

How will decisions be made? Most individuals have their own assumptions about how decisions will be made in a group. They do not prepare for the situation where a decision is needed and the group is not in agreement. Have this conversation before disagreements arise.

If you choose how to have a conversation thoughtfully, you set patterns and group norms that will serve the group well when challenging topics are addressed and divergence occurs. Knowing what to expect creates safety, increases trust, and promotes participation by everyone.

Phase III: Increasing Mutual Understanding Even when advocating or persuading, it is important to increase mutual understanding. Everyone has to be willing to share their information, ideas, knowledge, and narrative, as well as understand the same from others. The objectives of increasing mutual understanding are to:




1. Support group dialogue to create deeper shared understanding of the challenge.

2. Create a shared understanding of issues and desired outcomes.

3. Clarify outcomes with sufficient detail to prepare for implementation.

To increase mutual understanding the following is suggested: • Balance inquiry and advocacy. To inquire is to keep an open mind

and a willingness to explore other perspectives. To advocate is to promote a point of view or position. When you think that you have less power in the conversation, you are likely to advocate. Inquiry is a way to gain and build trust. To create mutual understanding, you must find a balance of exploring what is important to others as well as explaining what is important to you and those you represent.

• Be familiar with typical decision-making patterns and possibilities. Individuals tend to believe (or hope) that they move in similar directions at the same pace as they move to decisions. However, people do not think in straight lines, but tend to go off on tangents and lose track of central themes. Usually individuals start in a familiar place and, if allowed, stray to a point where they find the unfamiliar, feel uncomfortable, and stall. Can you stay with uncertainty and discomfort or do you retreat to safe and obvious solutions (or remain stuck in conflict)? Sometimes people choose to stay stuck in conflict because the adversarial relationship is frequently a most familiar place for many people. If you can consider a broader range of possibilities in the unfamiliar, creative and more innovative options may emerge.

• Build trust and increase mutual understanding. The questions we ask and the way in which we ask them either invite or discourage responses. Good questions are intentional and purposeful, come from curiosity, and cause the inquirer and the respondent to ponder.

When you gain mutual understanding through inquiry, advocacy, persistence, and compassion, you increase opportunities to create, innovate, decide, and move forward in an informed and




productive way. And if divergence shows up, you are ready to explore it rather than let it shut you down. At some point, though, the conversation must lead to action.

Phase IV: From Inquiry to Action; Moving Forward It is difficult to know when to stop talking and start doing. The shift can be intentional and structured to provide a measure of safety and consensus while implementing and evaluating an action. Here are some guiding questions for moving to action: • To what extent are we on the same page? Have you reached mutual

understanding and are you ready to move toward action? If you think that action is possible, test it out. Summarize the learning and assess the level of consensus. If you have reached agreement in principle, move to identifying and clarifying the details for action and implementation.

• Are you stuck? If you are stuck, there are still decisions to make about how to move forward. Is it okay to remain stuck? Remaining stuck for a defined amount of time may allow for creative solutions to emerge. If you remain stuck, decide when to reconvene and create expectations for what should happen in the short term.

• Has the proposed solution been reality tested? Talk about the impact and possible reactions to a proposed course of action or decision, especially if the action will require change.

• What are the details? Provide details about who will do what, by when. Leaving these details undefined can lead to unmet expectations, conflict, and distrust.

• Is there a plan for accountability? How will we know if our action is having the desired effect? Indicators of success help in making decisions to stay the course or to make corrections.

• When do you opt out? In Getting to Yes, Fisher and Ury (1983) describe a concept called your Best Alternative to a Negotiated Agreement (BATNA). If what you could accomplish on your own is better than the proposed outcome of the conversation, then you are better off proceeding with your BATNA. If not, then stay with




the process. Be aware that there are consequences for relationships when you opt to proceed with your BATNA (Fisher and Ury, 1983).

Complex and challenging conversations often lead to creative and innovative policies that are often accompanied by political relationships and structures. It is helpful to know and be able to apply a process that includes preparing for the conversation, establishing safety, trust, and space for multiple voices, increasing mutual understanding, and moving to action and implementation.

Listening, Asserting, and Inquiring Skills Complex and challenging conversations including ones that generate some conflict will require interpersonal interaction. Effective engagement is dependent on critical communication skills. While the topics we choose to talk about are critical, how we talk about them is equally important. We will unpack the skills of listening, asserting, and inquiring as they relate to the challenge of conflict.

Listening for Shared Understanding Many in the helping professions have undergone training on effective listening. Effective listening is built on the ability to recognize and balance two critical elements: It is about both doing AND being when listening.

When introducing the skill of active listening, a participant will occasionally raise their hand and state something like, “Oh yeah I know what that is. I hate it when people do that to me.” When asked to explain, they describe someone who has learned to do active listening while not really understanding what it means to be an active listener. They are experiencing someone as disingenuous in the conversation. The impact words have shift when delivered by one who is truly engaged in being an active listener. This level of listening and responding is driven by a deep commitment to understanding and learning. They are listening from a place of




mutual respect, curiosity, and a desire to learn. It is this shift in orientation that is essential to move from simply doing active listening to truly being an active listener.

The way we listen must be in integrity with our commitment to collaboration, mutual purpose, and shared learning. In fact, many identify respect for diversity of opinion as a core shared value for collaboration. However, basic civility too often disappears with the arrival of diverse opinions about high stakes, complex, and often emotional issues.

In a conversation committed to mutual purpose, some fundamental things you need to do are: • Understand the perspective by understanding objectives, needs,

and interests around the issue held by the other person(s). • Share your perspective by understanding objectives, needs, and

interests around the issue. • Jointly clarify and understand where everyone shares interests

and separate interests, not necessarily opposed to each other. • Create options that, to the greatest extent possible, will meet both

your shared and individual interests. There are a number of reasons that listening is critical:

• Listening to the other person and sharing your understanding of what has been shared lets them know if they have been heard. People will often repeat themselves and advocate their perspective until they know they have been heard.

• Listening and responding helps to clarify if what you heard is, in fact, what was intended.

• As you listen to others and provide feedback, it facilitates the others’ ability to share what is most important to them. For example, upon hearing your feedback they might say, “Yeah, that is what I said, and it is not really what I meant. Let me try it again.”

• Effective listening can defuse emotion. People have often escalated their anger and hostility because no one is listening to them.

• Listening encourages the group to slow the conversation down. For many who struggle with a lack of time, this may seem




counterproductive. However, groups spend a lot of time generating solutions to challenges that they have not taken sufficient time to fully understand. They then wonder why their plan does not meet their objectives.

These are not simply behaviors to make it look like we are really listening. These behaviors are in service of both the speaker and listener. In service of the speaker, they convey that what is being shared is important and that you are putting all of your attention into understanding what the speaker wants to have understood. In service of the listener, these behaviors position you to be receiving and processing all that is being shared. The ideas that people share are not only conveyed by their choice of words but equally by their body language, tone of voice, facial expression, and vocal inflections.

Asserting for Shared Understanding Many who are uncomfortable with conflict are also uncomfortable requesting what they need or sharing what they think. It is assumed that by initiating a request or sharing a divergent opinion, there is a risk of upsetting others. Depending on the nature of the request it might be perceived as critical of that person and upset the relationship. The request may also be denied, the opinion ignored, thinking and ideas demeaned and berated, and subsequent conflict that may develop.

The question we often face is this: “Is this context safe, and is this a safe person with whom to share my needs, thoughts, and ideas?” We engage in a cost-benefit analysis, calculating the risks of sharing and the potential benefits of putting forth ideas. Although this may be valid, our analysis of the situation does not always provide a complete or accurate understanding of the situation. We too often focus on the risks and lose sight of the benefits. Asking the question, “Should you share?” may be appropriate. However, a more complete question is, “How do you share in a way that will make it easy for the others to hear, understand, and respond?”

There are some basic and very effective strategies that support success in this aspect of engaging in challenging and complex conversations and navigating conflict. First is to consider shifting




your overall orientation when engaging a potentially challenging conversation. Move from either/or thinking to both/and thinking. When engaged in either/or thinking you can become polarized around the notion that one of you is right and one is wrong. A defensive or adversarial posture is adopted and little time spent in joint exploration. Shifting to both/and thinking is inclusive in that it seeks to hear from and explore the multiple perspectives around what is typically a complex issue. You are sharing your perspective, not as a rebuttal to another point of view, but in service of your shared learning and understanding. It communicates a commitment to mutual purpose.

While this commitment sets the stage, it does not make the conversation easy. Significant issues and often emotions that are strong still exist. It is essential to maintain civility and respect in the conversation. A key question introduced previously asks, “How do you share in a way that will make it easy for others to hear and respond?” Both what you say and how you say it are critical. At this point you want to share your perspective in a way that it neither negates nor disrespects the other person or the ideas. You are looking to maintain a conversation that is safe and supports a full exploration of the issues.

Differentiating Fact and Interpretation How often when sharing your perspective are you sharing it as fact? How often are your “facts” your interpretation and understanding of a situation? How often do you become committed to your interpretation, unwilling to acknowledge and explore the perspective of others? Be clear to yourself and with those to whom you are sharing, when you are describing facts and when you are sharing your interpretation of these facts.

When preparing to share your perspective it may be useful to reflect on the following questions:

1. What is the current situation? What can you state with certainty? (Facts)

2. What does the situation mean to you? Individually? Collectively? (Interpretation)




3. What are you working to accomplish in this situation? Individually? Collectively? (Individual and collective purpose)

You may understand the distinction and now need to determine what to share of your perspective. The answer is all of it. The critical consideration is in the how of sharing. When sharing in the context of facts and interpretation of the facts, it is essential to share both if others are truly going to understand your perspective. Start by sharing the data and/or facts that are informing your perspective. Describe specific events or behaviors that you have observed. Delineate that which you can observe from your interpretation of it without judgment.

Next, add your interpretation of what these events or behaviors mean to you. It is at this point that the how becomes most critical as you are sharing your interpretation as a hunch. As a hunch, it has not become fixed as fact and remains open to alternate interpretations. You are open to the possibility that you may have misinterpreted a situation or that a radically different interpretation might make more sense. You remain open to learning.

Inquiring for Shared Understanding An essential skill for achieving deeper, shared understanding of an issue is the ability to ask good questions. Our questions are often focused on identifying the flaw in the other person’s thinking or looking to find an easy solution to the problem. It is not possible to generate appropriate responses to a challenge that we do not fully understand and full understanding is achieved when we can articulate both our shared and individual perspectives.

There is a decision to be made at this point in a conversation. Will we ask questions in service of divergent thinking or convergent thinking? Will the questions expand shared understanding of the issue(s) or will we look for a quick and readily accessible solution? The conversation ultimately will be determined by the questions we ask. In general, questions focused on divergent thinking are intended to increase the depth and breadth of understanding of an issue. These are questions that push the conversation beyond the known into the unknown. Questions intended to support divergent thinking focus on increasing awareness of alternatives, encourage




open discussion, are designed to gather diverse viewpoints, and facilitate unpacking the logic of a problem.

For some, this may increase discomfort and frustration. For problem solvers, the goal is to make a decision and find a plan of action as quickly as possible. As such, our questions are too often oriented to convergent thinking. The focus becomes evaluating alternatives, summarizing key points, sorting ideas into categories, and arriving as quickly as possible at a general conclusion or decision.

In many situations, this is the appropriate response. As health care professionals, nurses are educated and are prepared to respond quickly and decisively during critical incidents. The ability to individually and collectively assess the needs within a situation and quickly draw on experience and technical expertise is critical to the role.

This same strategy for responding to challenges can compromise the ability to achieve one of the key values in jointly engaging complex conversations around policy: leveraging individual thinking into shared thinking to generate new and innovative thinking in the group. Some challenges are complex and will not be solved with existing solutions; they require the adaptive work of shared learning.

Intentional Inquiry: Asking Questions in Service of a Conversation of Shared Learning Author Marilee Adams (2004), in a book entitled Change Your Questions Change Your Life, introduces a strategy she calls Question Thinking. She refers to it as a “system of tools using questions for vastly better results in almost anything you do” (Adams, 2004, p. 18). Questions make up a significant part of both your internal and external dialogue and therefore have significant impact on the way(s) in which you engage your world and others. Adams (2004) states “questions drive results” (p. 18). They virtually program how we behave and what types of outcomes are available.

Adams distinguished between two paths of engagement, referred to as the Learner Path and the Judger Path. Different types of




questions characterize the paths. For example, when choosing the Judger Path, you are inclined to ask: • What is wrong with them? • What is wrong with me? • Why are they so stupid? • How do I fix this?

In contrast, when choosing the Learner Path, you are more likely to ask questions such as: • What happened? • What is useful? • What do I want? • What can I learn? • What is the other person thinking, feeling, needing, and/or

wanting? The options of Judgers Path and Learners Path are a choice. Who

are you committed to being in the conversation? What is the nature of the challenge? Is quick decisive action called for? Would it be wise to slow down and explore the challenge more completely? What choice is most in line with your intentions? Learner questions are born out of thoughtful choices, a commitment to mutual purpose and mutual benefit.

Intentional Inquiry is a method of asking questions with purpose in mind and does not mean manipulating the conversation or to coercing a specific outcome. These questions inspire reflection and new thinking. The term “intentional” is significant. Questions in this context become tools by which you intentionally seek greater understanding of the issue. Below are some examples: • Broadening questions are nonthreatening and provide a range of

response options. Tell me more about that? What might that look like?

• Clarifying questions clarify what is unclear or potentially misunderstood. What do you mean when you say the situation is unsafe? What would better communication look like?

• Explaining questions invite a person to share their line of reasoning or thought process. What leads you to that perspective?




How did you reach that conclusion? • Exploring questions are designed to get at what is most important

about an issue. What do you most need us to understand that you do not think we currently understand? What is most important to you about this issue?

• Challenging questions explore apparent inconsistencies in what is being said. Please help me understand, on the one hand you say the policy should be flexible and yet on the other hand you want to significantly limit the response options.

• Brainstorming questions generate ideas or options. What options have you considered? Given the situation, what might we consider?

• Consequential questions focus attention on the ramifications of a potential course of action. How will this decision impact the patients? How might the night staff be affected by this policy?

Questions can move us outside our comfort zone, yet possibilities worth exploring are outside our comfort zone. It is where we will find creative and innovative responses to our biggest challenges.

Conclusion Engaging in politics and policymaking require complex and challenging conversations that often include conflict. To be effective in these conversations requires an understanding of conflict, identifying it when it emerges. Prepare by reflecting and choosing who you want to be, so that you can choose how you want to act while engaged. Enter into the conversation with confidence so that you can create a safe and trustworthy environment in which all can participate. Create mutual understanding using the communication skills of listening, asserting, and inquiring. This is the most thorough and intentional way to move forward effectively in advancing health policy and being influential in politics related to health care delivery.

Discussion Questions




1. How would you describe your current relationship to conflict? Describe a time when you were significantly challenged when confronting conflict as a health care professional at an uneven table. Describe a time you successfully engaged conflict as a health care professional.

2. What challenges related to communication and conflict are you currently experiencing as a health care professional?

3. How will you apply what you have learned in this chapter to your challenges?

References Adams M. Change your questions change your life. Berrett Kohler

Press: San Francisco, CA; 2004. Fisher R, Ury W. Getting to yes: Negotiating agreement without

giving in. Penguin Press: New York, NY; 1983. Isaacs W. Dialogue: The art of thinking together. Currency: New

York, NY; 1999. Kritek P. Negotiating at an uneven table. Jossey-Bass: San

Francisco, CA; 1994. Mayer B. Staying with conflict. Jossey-Bass: San Francisco, CA;

2009. Senge P. The fifth discipline: The art and practice of the learning

organization. Currency: New York, NY; 1990.

Online Resources Harvard Program for Health Care Negotiation and Conflict

Resolution. (although the website is focused on mediation, it

includes many books and articles on national and international collaboration and conflict engagement). Negotiation Skills for Minority Nurses.




nurses. .





Research as a Political and Policy Tool Lynn Price

“If politics is the art of the possible, research is surely the art of the soluble.” Sir Peter Medawar

That research has any nexus to politics or policy may strike one as curious, if not an outright oxymoron. Research, using any methodology, is carefully considered, designed, implemented, and interpreted. Politics is, well, messy. Policy is birthed from political process, and is therefore often complex and messy in its own right. Yet, research is a powerful lever in the world of politics and policymaking. In the past few decades, research has come to play an increasingly influential role in the crafting of both political messages and policy declarations in nursing and health generally.

So What is Policy? Policy is usually thought of as formal rules, set by Congress, state legislatures, or agencies at city, county, state, or federal levels. But it is also made by private entities. Clinics and hospitals have




infection-control policies, visitation policies, and other rules pertaining to the work. Nursing schools have policies about student conduct and grading. Insurance companies create policies about how much of the physician’s rate for services will be paid to advanced practice registered nurses (APRNs). Increasingly, policymakers in both private and public venues look to evidence to inform decisions.

In both venues, research alone is not responsible for producing policy. The rules for the use of data are the same, but as policy and political players change, so do considerations about research, how best to use findings, or even what research question to ask. One can think of this as the political ecology of policymaking; that is, the many subtle and sometimes overt influences that surround the making of any policy.

What is Research When It Comes to Policy? Research in policymaking venues involves the usual suspects in quantitative methodology, including the randomized controlled trial, although the opportunities for using this gold standard are fewer than in bench science. In recent years, systematic reviews and meta-analyses have become popular in advancing policy positions. These reviews sift, distill, and analyze quantitative data from the existing literature on a topic. The end product is a solid summary of evidence in one package; efficient for both advocates and policymakers.

Several recent systematic reviews examined the plethora of studies on nurse practitioner (NP) care, concluding that NP health outcomes compare favorably to those of physicians across a wide variety of measures (Newhouse et al., 2011; Stanik-Hutt et al., 2013). Research into NP practice, care, and outcomes is hardly novel; Walter Spitzer and colleagues published the first such study in 1973 (Spitzer et al., 1973). In the 40 years since, NPs have been extensively studied. Thus, systematic reviews of this literature, which summarize the best evidence, provide a useful reference for NPs in advocating for expanded scope of practice.




Data mining, the use of data collected from large data sets residing in large health systems and governments, offers a window into the discovery of problems and crafting of policy solutions; this marriage of data and health care policymaking also has a long history (Almasalha et al., 2013; Cheung, Moody, & Cockram, 2002; Diers, 2007; Duffield et al., 2009; Eriksen et al., 1997; Heslop et al., 2004). Using secondary data is challenging but rewarding given its immense scope in time and data points, compared with what most researchers can accomplish in traditional data collection (Smith et al., 2011).

Other sources of data also provide grist for the policymaking process. Policymakers are asked to make decisions in many different areas, and to do so most likely without personal expertise in any given area. Reports from expert panels, foundations, and government research agencies can all carry great weight, if introduced in the context of moving an issue forward. Op-ed pieces by experts and position papers generated by legislative staff or others can also be powerful. The point is that one must be wide open to sources when looking for evidence to support or oppose a policy position (Béland, 2010).

In presenting data to policymakers, it behooves the advocate to be short and to the point. Policymakers deal with a tremendous number of issues across economic, health, and social terrains. Keeping the focus on one’s issue requires policy briefs that are short and specific to the problem and the policy solution (Food & Agriculture Organization of the United Nations, 2011).

Narrative, that is, the telling of a pertinent story to bring the issue to life, also has its place in the process (Epstein, Heidt, & Farina, 2012). Deborah Stone, a prominent observer of policymaking, refers to what she calls causal stories as necessary to the very genesis of a policy initiative. She notes that people have to view any particular trend, experience, or event as problematic and capable of solution (Stone, 2006); narrative data provide an effective mechanism for crafting this view.

The Chemistry between Research and Policymaking




Research can be extremely useful in casting light on a problem and nudging policymakers to action. Nursing has a distinguished lineage of nurses affecting policy through the use of data, from Nightingale’s Crimean data to American midwives who accomplished great things for their practice by persistent and consistent collection of ordinary practice data (Diers & Burst, 1983). Today, health care research examines how intricately intertwined in practice are the pieces of the health care puzzle: delivery, providers, procedures, patients, families, cultures, reimbursement, and so on. One consequence is a growing acknowledgement by non-nurse researchers of the role of nursing, and particularly advanced practice nursing in contemporary health care (Kuo et al., 2013).

Using Research to Create, Inform, and Shape Policy Research rarely exists in a vacuum, particularly health services research which ideally knits the worlds of research and policy together. Béland (2010) and Béland and Waddan (2012) argue that research design and dissemination should be used strategically and tactically. The 2011 Institute of Medicine (IOM) seminal report, The Future of Nursing: Leading Change, Advancing Health, exemplifies strategic thinking. This evidence-based report summarizes the position of nursing in the United States health system and focuses on the barriers nursing faces in implementing the full effect of the profession’s capacity to positively affect American health care. Savvy health services researchers seek to amplify that message, with studies tactically aimed at answering questions policymakers might have about the qualifications of APRNs to step into full leadership within the health care system as it evolves. In 2011, Newhouse and colleagues presented a systematic review of literature comparing APRN and physician health patient outcomes, with positive findings. In 2012, Newhouse published an article explaining the policy implications of the 2011 review. In 2013, Stanik-Hutt and colleagues published a systematic review, The Quality and Effectiveness of Care Provided by Nurse Practitioners, which provides a concise source of data on NP practice (Stanik-Hutt et al.,




2013). Since the release of The Future of Nursing in 2011, other researchers have published on NPs in the wider venue of health services research (Carruth & Carruth, 2011; Dill et al., 2013; Kuo et al., 2013; Morgan et al., 2012; Pittman & Williams, 2012; Traczynski & Udalova, 2013). Each of these articles seeks to inform the greater conversation about advancing APRN practice within the context of promoting full practice authority as recommended by the 2011 IOM report.

Research and Political Will The key to moving any issue into the public or institutional eye is transforming it into a political issue; that is, casting the issue as problematic enough to make public or private policymakers want to fix it. Effective research casts the problems it exposes as bad, even immoral, situations that must be addressed (Stone, 2006). But how will any particular issue be perceived among the numerous issues competing for attention? Sometimes political leaders themselves offer the issue as important, as has been the case with health care reform under the Obama administration. Other times, the issue comes to the fore because of particular news events, as with the increasing emphasis on human trafficking as a social and health problem. Framing the policy question at hand is essential, because it is fundamental to setting up the argument. Thus, the strategic use of research will anticipate the viewpoints of other stakeholders and seek to place the issue at hand at the top of the policy agenda.

Highlighting a problem and getting it on the agenda is not enough to advance policy in most instances. There must be enough political will to devote attention, time, and effort to solve the problem, particularly when the problem is pervasive or long- standing. Complex problems are challenging because it is difficult to capture a single framing perspective, leading to many differing opinions about what the real problem is and a subsequent dilution of political will about the issue. Health disparities have been extremely well documented, for example, and embraced by several presidential administrations as an issue that needs fixing. The ultimate measure of eliminating disparities is improved health




status, but figuring out exactly what leads to good health is enormously complex. So it is difficult to propose a straightforward solution to ending disparities and thus difficult to capture sustained political will to undertake the work of eliminating this form of discrimination (Stone, 2006).

It is this interplay of research, political will, and policymaking that frequently frustrates action-oriented people such as nurses, who want to see change happen in a timely manner. Forty years of outcomes research documenting that APRNs are safe, competent providers is now coupled with a policy environment that is trying to solve the primary care provider shortage. It seems pretty straightforward, right? Several factors intervene that make the progress to full autonomous practice nationwide slow, sometimes agonizingly so. Nursing and, in particular, advanced practice nursing is not well understood outside of the outdated (and questionable) paradigm of working under physician orders. It is surprising how many legislators, even those whose personal provider is a nurse practitioner, have no idea that nurses are diagnosing and prescribing on their own, and very safely.

There is a second reason policymakers often do not jump readily toward removing barriers to practice. Often a very powerful stakeholder (e.g., organized medicine in one form or another) sits at the table, opposing any further entry into its world by nursing or other professionals. And like it or not, this is a potent disincentive for policymakers to move off the dime on an issue. So there must be a compelling story to engage legislators in advancing full autonomous nursing practice. In the past, the theme has been access to health care in rural areas. A quick look at the states who first achieved APRN practice independent of physician involvement (e.g., Alaska, Maine, and New Mexico) reveals that they have large rural populations in need of competent providers. Lately, the theme is turning to the decreased number of physicians entering or staying in primary care practice; something known from research into health care workforce distribution.

A number of recent studies illustrate that states with full practice for APRNs appear to provide the optimal environment to maximize use of APRN providers.1 States with nurse practice acts or regulations that allow full APRN practice experience higher levels




of APRN providers and thus higher levels of patients who have an APRN primary care provider (Kuo et al., 2013). APRNs enjoy consumer confidence, particularly among those most likely to have APRNs as the only choice of primary care provider (Dill et al., 2013). Full APRN practice does not negatively affect physician wages (Pittman & Williams, 2012). Examination of practice patterns in the federal Veterans Affairs health care settings confirms that there is no significant difference in the patient populations served by APRNs, physicians, or physician assistants (Morgan et al., 2012).

So in addition to setting the scene for policy intervention by illuminating a problem, research has a vital role in creating an atmosphere conducive for policymakers to step up to the plate, especially when the issue is likely to be controversial. Ginsburg (2008) offers some valuable insights about nursing in the hospital setting and the research necessary to capture policymakers’ interest in nursing intensity and hospital payment; for instance. Moodie (2009) suggests that researchers interested in moving policy forward pay attention to what policymakers need answered, as well as the constituencies to which they have to answer, a theme also echoed by the September 2009 Briefing Paper from the Overseas Development Institute (Overseas Development Institute [ODI], 2009).

Moodie and the ODI are looking at research from a marketing viewpoint: the researcher is using data to persuade a policymaker that a certain policy answer is the one called for, based on the evidence. Moodie (2009) describes the various ecologic factors that a researcher should assess before designing any particular research with an eye toward influencing policy. The ODI paper (2009) also emphasizes Moodie’s point that research needs to be mindfully performed and presented. “Simply presenting information to policymakers and expecting them to act upon it is very unlikely to work” (ODI, 2009, p. 1). The ODI sets forth five other lessons for policy entrepreneurs who want to involve policymakers in evidence-based decisions. This advice from non-nurse policy researchers recognizes that, in addition to highlighting a problem, research can enhance, perhaps even shape the political climate in which change can occur; this is valuable advice to nursing as it continues its political and policy evolution. And along these lines,




there is one other way research is influencing the policy context, through artful dissemination in documentaries seen on television and in movie theaters.

Research: Not Just for Journals In 2005, David Satcher (former Surgeon General in the Clinton Administration), with a host of public health and academic colleagues, published a study entitled, What if we were equal? A comparison of the black-white mortality gap in 1960 and 2000 (Satcher et al., 2005). The study concluded that annually more than 83,000 excess deaths in the African-American community could be prevented if health disparities and their consequent gulag effect on access to care for minority populations were addressed.

This research, and other health disparity documentation, was picked up and studied again, journalistically, by Larry Adelman in 2008. He produced a 7-hour series called Unnatural Causes, which aired on PBS (Adelman, Stange, & Rutenbeck, 2008). During the segment entitled In Sickness and in Wealth, Dr. Adewale Troutman, Director of the Louisville, Kentucky, Metro Health Department, offers a compelling visual tour of both the physical and sociological realities of his city, vividly illustrating the interplay of poverty, social class, and health outcomes in what could be a new frontier of compelling qualitative research, which seeks to engage the public (and policymakers) directly through visual and narrative data. It is worth noting how effective such documentaries can be at getting an issue out into public discourse while bypassing special interests.

Nursing’s future rests on the clear and convincing record of research on nursing work. Moving the future forward requires that nurses and others understand nursing’s role in the complex and dynamic world of health and health care. As nursing is increasingly recognized as a vital pillar in the temple of health care, nurses must continue to document and broadcast who they are, what they do, and why it matters to patients, to policymakers, to budgets, and to the delivery of meaningful health care to all.

Discussion Questions




1. What contexts inform the crafting of policy?

2. When and how does research connect with policymaking?

3. You and your research team have concluded that the consistent use of high-energy drinks by adolescents negatively impacts memory retention. Describe your strategy for bringing this to the attention of policymakers, such as your local school board or state legislators.

References Adelman L (Producer), Stange E (Director), Rutenbeck J

(Director). Unnatural causes: Is inequality making us sick?. California Newsreel with Vital Pictures: San Francisco, CA; 2008 [Retrieved from]

Almasalha F, Xu D, Kennan GM, Khokhar A, Yao Y, Chen YC, et al. Data mining nursing care plans of end-of-life patients: A study to improve healthcare decision making. International Journal of Nursing Knowledge. 2013;24(1):15–24.

Béland D. Policy change and health care research. The Journal of Health Care Politics, Policy and Law. 2010;35(4):615–641.

Béland D, Waddan A. The politics of policy change: Welfare, Medicare, and social security reform in the United States. Georgetown University Press: Washington, DC; 2012.

Carruth PL, Carruth AK. The financial and cost accounting implications of the increased role of advanced nurse practitioners in U.S. healthcare. American Journal of Health Sciences. 2011;Fall:1–8.

Cheung RB, Moody LE, Cockram C. Data mining strategies for shaping nursing and health policy agendas. Policy, Politics, & Nursing Practice. 2002;3(3):248–260.

Diers D. Finding midwifery in administrative data systems. Journal of Midwifery and Women’s Health. 2007;52(2):98–105.

Diers D, Burst HV. Effectiveness of policy-related research: Nurse-midwifery as a case study. Image–the Journal of Nursing Scholarship. 1983;15(3):68–74.

Dill MJ, Pankow S, Erikson C, Shipman S. Survey shows




consumers open to greater role for physician assistants and nurse practitioners. Health Affairs. 2013;32(6):1135–1142.

Duffield C, Diers D, Aisbett C, Roche M. Churn: Patient turnover and case mix. Nursing Economics. 2009;27(3):185– 191.

Epstein D, Heidt JB, Farina CR. The value of words: Narrative as evidence in policymaking. Cornell eRulemaking Initiative, Cornell Law School: Ithaca, New York; 2012 [Retrieved from] SitautedKnowldge-IPA-Final.pdf.

Eriksen LR, Turley JP, Denton D, Manning S. Data mining: a strategy for knowledge development and structure in nursing practice. Studies in Health Technology and Informatics. 1997;46:383–388.

Food & Agriculture Organization of the United Nations. Food security communications toolkit. Food & Agriculture Organization of the United Nations: Rome; 2011.

Ginsburg PB. Paying hospitals on the basis of nursing intensity. Policy, Politics, & Nursing Practice. 2008;9(2):118– 120.

Heslop L, Gardner B, Diers D, Poh BC. Using clinical data for nursing research and management in health services. Contemporary Nurse. 2004;17(1–2):8–18.

Institute of Medicine. The future of nursing: Leading change, advancing health. National Academies Press: Washington, DC; 2011.

Kuo YF, Loresto FL, Rounds LR, Goodwin JS. States with the least restrictive regulations experienced the largest increase in patients seen by nurse practitioners. Health Affairs. 2013;32(7):1236–1243.

Moodie R. Where different worlds collide: Expanding the influence of research and researchers on policy. Journal of Public Health Policy. 2009;30(S1):S33–S37.

Morgan PA, Abbott DH, McNeil RB, Fisher DA. Characteristics of primary care office visits to nurse practitioners, physician assistants and physicians in United States Veterans Health Administration facilities, 2005-2010: A retrospective cross-sectional analysis. Human Resources for




Health. 2012;10:1–8. Newhouse RP, Stanik-Hutt J, White KM, Johantgen M, Bas

EB, Zangaro G, et al. Advanced practice nurse outcomes 1990-2008: A systematic review. Nursing Economics. 2011;29(5):1–21.

Overseas Development Institute [ODI]. Briefing paper 53: Helping researchers become policy entrepreneurs. Overseas Development Institute: London; 2009.

Pittman P, Williams B. Physician wages in states with expanded APRN scope of practice. Nursing Research and Practice. 2012;2012:671974.

Satcher S, Fryer GE, McCann J, Troutman A, Woolf SH, Rust G. What if we were equal? A comparison of the black-white mortality gap in 1960 and 2000. Health Affairs. 2005;24(2):459–464.

Smith AK, Ayanian JZ, Covinsky KE, Landon BE, McCarthy EP, Wee CC, et al. Conducting high-value secondary dataset analysis: An introductory guide and resources. Journal of General Internal Medicine. 2011;26(8):920–929.

Spitzer W, Kergin D, Yoshida M, Russell W, Hackett B, Goldsmith C. Nurse practitioners in primary care III: The southern Ontario randomized trial. Canadian Medical Journal. 1973;108:1005–1016.

Stanik-Hutt J, Newhouse RP, White KM, Johantgen M, Bass EB, Zangaro G, et al. The quality and effectiveness of care provided by nurse practitioners. The Journal for Nurse Practitioners. 2013;9(8):492–500.

Stone D. Reframing the racial disparities issue for state governments. Journal of Health Politics, Policy and Law. 2006;31(1):127–152.

Traczynski J, Udalova V. Nurse practitioner independence, health care utilization, and health outcomes. [Retrieved from] 2013.

Online Resources Kaiser Family Foundation. This site has a wealth of current




information about American health care and reform efforts in the states and at the federal level. World Health Organization. This site is the leading voice for

global health data and public health initiatives across the world. State Nursing and/or Advanced Practice Nursing

Organization’s websites. These sites are often the best source for information and initiatives affecting the current and future practice in nursing.

. 1Full practice means there is no mandate for physician presence such as supervision or collaborative agreement before an APRN can practice; it is not accurate to call this independent practice, as practice itself for any discipline is collaborative within the discipline and beyond.





Health Services Research

Translating Research into Policy

Patricia W. Stone, Arlene M. Smaldone, Robert J. Lucero, Yoon Jeong Choi

“Research is formalized curiosity. It is poking and prying with a purpose.” Zora Neale Hurston

The high cost of health care, large numbers of uninsured Americans, uncontrolled health care spending, and an unstable economy have led to the most recent efforts to reform health care in the United States. Most health policy experts agree that the nation must control health care costs, improve efficiency, increase access to health care, and improve the quality of care. However, it is often unclear how best to make these improvements. A strong evidence base is needed to inform decision makers on what does and does not work to improve the health care system. Research that attempts to provide this evidence is often called health services research (HSR).

Defining Health Services Research




AcademyHealth, the preeminent professional society for health services researchers, defines HSR as “the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and ultimately our health and well- being. Its research domains are individuals, families, organizations, institutions, communities, and populations” (AcademyHealth, 2008). The Agency for Healthcare Research and Quality (AHRQ) states that HSR “examines how people get access to health care, how much care costs, and what happens to patients as a result of this care. Health services research aims to identify the most effective ways to organize, manage, finance, and deliver high- quality care; reduce medical errors; and improve patient safety” (Helping the Nation with Health Services Research, 2002).

A recent focus of HSR, based on the Comparative Effectiveness Research Act of 2008, is the conduct and synthesis of research comparing the benefits and harms of various interventions. HSR also studies strategies for preventing, diagnosing, treating, and monitoring health conditions in real-world settings (Conway & Clancy, 2009). The purpose of comparative effectiveness research (CER) is to improve health outcomes by developing and disseminating evidence-based information to patients, clinicians, and other decision makers about interventions that are most effective for patients under specific circumstances (Iglehart, 2009; Volpp & Das, 2009). The U.S. Department of Health and Human Services (HHS), as part of the American Recovery and Reinvestment Act of 2009, provided $400 million of financial support for CER. In June 2009, the Institute of Medicine recommended 100 national priorities for CER (Committee on Comparative Effectiveness Research Prioritization, Institute of Medicine, 2009). Of the top 25 priorities, the following may be of particular interest to nurses: (1) Compare the effectiveness of various primary care treatment strategies and (2) compare the effectiveness of literacy-sensitive disease management programs and usual care in reducing disparities in children and adults with low literacy and chronic disease. The Affordable Care Act (ACA) authorizes CER and a number of demonstration projects that will




use HSR methods. The Patient-Centered Outcomes Research Institute (PCORI) is the

United States–based nongovernmental institute created as part of the ACA. The mission of the PCORI is to examine and evaluate relative health outcomes, clinical effectiveness, and appropriateness of different medical treatments through existing studies and conducting its own. Its board includes patients, nurses, physicians, hospitals, drug makers, device manufacturers, insurers, payers, government officials, and health experts. The PCORI is different from other international bodies such as the United Kingdom’s National Institute for Health and Clinical Excellence, which determines cost-effectiveness directly, based on quality-adjusted life year valuations. The PCORI does not have power to mandate or even endorse coverage rules or reimbursement for any particular treatment. However, the HHS may take research findings funded by the PCORI into account when deciding what procedures it will cover.

A long-standing challenge has been the capacity of the U.S. health care system to translate innovation from research into practice at a faster pace. Dougherty and Conway (2008) developed a model intended to accelerate implementation of innovations in clinical settings to address the how of health care delivery (Figure 12-1). This transformational model suggests that basic science and its translation into clinical practice is only the first step to achieve effective and safe delivery of high-quality care (translation 1 or T1). Translation 2 (T2) processes focus on the translation of clinical efficacy knowledge into clinical effectiveness, and the policy changes needed to improve outcomes is addressed in translation 3 (T3) activities. HSR and CER are the necessary population-based research activities at the T2 level and serve as the foundation for effective health policy.




FIGURE 12-1 Transforming health care across the research spectrum. (Adapted from Dougherty, D., & Conway, P. H.

[2008]. The “3T’s” road map to transform US health care: The “how” of high- quality care. Journal of the American Medical Association, 299[19], 2319-


HSR Methods HSR researchers use both quantitative and qualitative research methods, and these methods are not unique to the field. However, it is the use of these methods to generate knowledge to inform health policy development and changes that is the hallmark of HSR. Edwardson (2007) reported on the theories and conceptual frameworks used by HSR nurse researchers in studies funded by the AHRQ between 2000 and early 2005. A total of 28 different frameworks were identified in the 49 studies reviewed. The frameworks most often used were Donabedian’s Quality Paradigm (Donabedian, 1966) (i.e., structure-process-outcome), Rogers’ Diffusion of Innovation Theory (Rogers, 2003), Reason’s Theory of Human Error (Reason, 1990), and Aday and Andersen’s Model of Health Care Access (Aday & Andersen, 1974). The common theoretical underpinning among these frameworks is their conceptualization of variables at the system level rather than the individual level.




Quantitative Methods and Data Sets Using quantitative multivariate methods, HSR researchers often analyze data from administrative data sets, such as hospital discharge data, and national survey data to examine health care access and quality, regional differences in care delivery patterns, health behavior patterns, and health outcomes from a population perspective. Various types of data are available to HSR researchers through the federal agencies in the HHS including the Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS) and AHRQ. Additionally, population census and employment data are available through the U.S. Census Bureau and the Bureau of Labor Statistics.

Often researchers must combine data from multiple sources or over multiple years. The researcher must become familiar with the data set methodology report and list of variables with their respective definitions to ascertain how variables are categorized, the sampling methodology employed, and how missing data were handled. National surveys often use complex sampling frames and employ sampling weights enabling generalizability of survey findings to the population at large. To effectively use data sets that employ weighted sampling requires expertise in the use of statistical analysis software such as SAS (SAS Institute Inc., Cary, NC, USA) that allows for incorporation of sampling weights into the data analysis process. Table 12-1 provides descriptions of several publically available data sets that are available to health services researchers. What follows are examples of how these data have been used to inform policy.

TABLE 12-1 Examples of Publicly Available Data for Use in Health Services Research

Data U.S. Department of Health and Human Services (HHS) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)




Area Health Resource File (AHRF)

Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System (BRFSS)




National Health and Nutrition Examination Survey (NHANES)

National Immunization Survey (NIS)




National Survey of Ambulatory Surgery (NSAS)

National Survey of Children with Special Health Care Needs (NS-CSHCN)

National Survey of Children’s Health (NSCH)




Agency for Healthcare Research and Quality (AHRQ) Nationwide Inpatient Sample (NIS)

Kids’ Inpatient Database (KID)




Nationwide Emergency Department Sample (NEDS)

State Inpatient Databases (SID)

State Ambulatory Surgery Databases (SASD)




State Emergency Department Databases (SEDD)

Medical Expenditure Panel Survey (MEPS)

American Hospital Association (AHA) Annual Survey Database bd7f-2b3c1343660b

American Nurses Association (ANA) National Database of Nursing Quality Indicators (NDNQI) Measurement/Data-Access




All-Payer Claims Database (APCD) Council All-Payer Claims Database (APCD) (As of November 24, 2014 APCDs are currently available in 13 states: Colorado, Kansas, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, Oregon, Rhode Island, Tennessee, Utah, Vermont, and Wisconsin)

Using data from the Hospital Consumer Assessment of Healthcare Providers and Systems, Kutney-Lee and colleagues (2009) designed a cross-sectional study using multivariate regression modeling techniques to examine the relationship between nurse staffing levels and patient perceptions of their nursing care across 430 hospitals in 4 states (California, New Jersey, Pennsylvania, and Florida). Higher nurse-patient ratios and better work environments were associated with greater patient satisfaction. These findings demonstrate that appropriate staffing levels are important to patient satisfaction and support ongoing efforts to improve hospital performance.

The National Health and Nutrition Examination Survey (NHANES) data (n.d.) have been instrumental in tracking the prevalence of health problems such as obesity and diabetes over




time, and examining factors that may be associated with changes in prevalence. Using 24-hour dietary recall data from two cross- sectional NHANES surveys (NHANES III 1988-1994 and NHANES 1999-2004), researchers examined national trends in sugar- sweetened beverage consumption among adults 20 years of age or older (Bleich et al., 2009). During this study period, both the percentage of adults who consumed sugar-sweetened beverages (58% vs. 63%) and daily caloric intake from these beverages (239 vs. 294 calories) increased and accounted for a significant proportion of daily caloric intake. Based on these and other findings, the taxation of sugar-sweetened beverages has received increasing interest as a policy option to decrease obesity (Brownell & Frieden, 2009).

Another group of researchers (Mark et al., 2004) used longitudinal National Inpatient Sample data (1990-1995) combined with other national data sets to examine the effects of changes in registered nurse (RN) staffing on quality of care in a sample of 422 hospitals from 11 states. The quality of care was based on measures of inpatient mortality and three nurse-sensitive outcomes: hospital- acquired pneumonia, urinary tract infection, and pressure sores. Hospitals were stratified by level of RN staffing. The magnitude of effect of a one-unit increase in RN staffing on inpatient mortality was greater for hospitals at the 25th percentile of staffing compared with the 75th percentile of staffing, suggesting a nonlinear relationship between RN staffing and inpatient mortality. There may be a staffing threshold that dictates an optimal level of staffing to improve patient outcomes. The evidence supports administrators to develop nurse staffing plans and policymakers to advance nurse staffing legislation.

As a last example, using multiple national data sets including census and National Hospital Care Survey (NHCS) data, researchers found differences in life expectancy due to race and educational attainments (Olshansky et al., 2012). The researchers found that in 2008, adult men and women with less than a high school education had life expectancies not much better than those of all adults in the 1950s and 1960s. Furthermore, white men and women with 16 years or more of schooling had life expectancies far greater than black Americans with fewer than 12 years of education. The researchers concluded that educational




enhancements for people of all ages and races were needed to reduce the large gap in health.

Qualitative Methods Whereas quantitative research results have historically been used as evidence to support health care decision making by clinicians, hospital administrators, and policymakers, qualitative research methods can be used to address complex health care problems that require a collection of varied information. Qualitative HSR has not been used frequently in decision making to improve health services delivery (Rusinova et al., 2009). This may be in part caused by the long-held notion that the findings from qualitative research are anecdotal or subject to biases. However, the use of qualitative research methods (e.g., structured interview, focus groups, and participant observations) can produce contextual data on perceptions, beliefs, experiences, and behavior to create a rich understanding of a problem (Auerbach & Silverstein, 2003). These data can be used to create a more complete understanding of what interventions and/or strategies are necessary at the clinical, organizational, or policy level.

The use of rigorous qualitative research methods by HSR researchers has increased over the past decade. Qualitative methods may be used in mixed-methods research, in the development of survey questionnaires, and in research where the aim is to gain the perspective of stakeholders regarding a particular topic. For example, researchers (Elder et al., 2007) conducted focus groups using a sample of African-American adults housed temporarily in South Carolina hotels following Hurricane Katrina to identify why New Orleans residents decided to either remain in their homes or heed local warnings to evacuate. The use of focus groups led to the discovery of a number of themes, including misperceptions about the severity of the hurricane because of miscommunication, and evacuation barriers related to poverty and concern about neighborhood crime. Future disaster preparedness plans targeted at underserved minority communities should consider the importance of culturally sensitive approaches.




Professional Training in Health Services Research HSR has a tradition of training that emphasizes multidisciplinary education. Providing answers to complex health and health care problems requires a diverse research skill set. Traditional clinical research approaches (i.e., epidemiology, biology, chemistry) coupled with social and economic sciences use a combination of quantitative and qualitative methodologies to address health and health care problems. From randomized controlled trials to qualitative case studies, there is a strong emphasis on interdisciplinary research that addresses health service policy needs, is patient-centered, and addresses system-level problems.

Competencies Fourteen core competencies for doctoral-prepared HSR researchers have been proposed (Forrest et al., 2009). Based on these, the authors of this chapter developed core curriculum and the associated competencies for nurse HSR scientists listed in Table 12- 2. Nurse faculties may use this core curriculum to develop policy- related content in their doctoral programs. Aspiring nurse HSR scientists should review the competencies to self-assess their knowledge and expertise in these areas and strive to augment their education to gain competency in all areas.

TABLE 12-2 Nursing Health Services Research Doctoral-Level Core Competencies

Competency CURRICULAR FOCUS Analytic Theory

1. Demonstrate breadth of comparative and cost-effectiveness research theoretical and conceptual knowledge by applying alternative models from a range of relevant disciplines including clinical epidemiology, biomedical informatics, health services research, biostatistics, and health economics.

C, I, H, B, E

2. Apply in-depth nursing disciplinary knowledge and skills relevant to comparative and cost-effectiveness research related to health promotion

C, I, H, B, E, N

C, I, H, B, E, N




and/or disease prevention across the continuum of care in high-risk, underserved populations. 3. Apply knowledge of the structures, performance, quality, policy, and environmental context of health and health care to formulate value nursing solutions for health policy problems related to health promotion and/or disease prevention across the continuum of care in high-risk, underserved populations.

C, I, H, B, E


4. Pose innovative and important comparative and cost-effectiveness research questions informed by systematic reviews of the literature, stakeholder needs, and relevant theoretical and conceptual models to improve the care of high-risk, underserved populations.

C, I, H, B, E

C, I, H, B, E, N

5. Select appropriate interventional, observational, or qualitative study designs to address specific comparative and cost-effectiveness research questions to improve health promotion and/or disease prevention across the continuum of care in high-risk, underserved populations.

C, I, H, B, E


6. Know how to collect primary health outcome and health care utilization data obtained by survey, qualitative, or mixed methods.

C, I, H, B, E

7. Know how to assemble and access secondary data from existing public and private sources.

C, I, H, B, E

8. Use conceptual models and operational measures to specify study constructs for comparative and cost-effectiveness research questions and develop variables that reliably and validly measure these constructs.

C, I, H, B, E, N

9. Implement comparative and cost-effectiveness research protocols with standardized procedures that ensure reproducibility of the science.

C, I, H, B, E, N

10. Ensure the ethical and responsible conduct of research in the design, implementation, and dissemination of comparative and cost-effectiveness research related to health promotion and/or disease prevention across the continuum of care in high-risk, underserved populations.

C, I, H, B, E

N, D

11. Work collaboratively in multidisciplinary teams. C, I, H, B, E, N

12. Use appropriate analytic methods in comparative and cost- effectiveness research to clarify associations between variables and to delineate causal inferences.

C, I, H, B, E

13. Effectively communicate the findings and implications of comparative and cost-effectiveness research through multiple modalities to technical and lay audiences.


14. Understand the importance of collaborating with stakeholders, such as policymakers, organizations, and communities to plan, conduct, and translate comparative and cost-effectiveness research into policy and practice.


B, Biostatistics in comparative effectiveness research; C, clinical epidemiology; D, communication and dissemination; E, health economics; H, health services research; I, biomedical informatics; N, nursing. The authors of this chapter (Stone, P. B., Smaldone, A. M., Lucero, R. J., and Choi, Y. J.) developed core curriculum and associated competencies for nurse HSR scientists by using competencies proposed by Forrest, C. B., Martin, D. P., Holve, E., & Millman, A. (2009, June 25). Health services research doctoral core competencies. BMC Health Services Research, 9, 107.

A research doctorate (e.g., PhD) is the usual educational pathway to become a HSR researcher and develop knowledge that influences policymaking. Few schools of nursing have the capacity to train nurses to become HSR scientists; therefore, it is important to




identify a university that has a HSR training program. HSR training takes place in a number of disciplines, including nursing, public health, business, and public policy. Schools of nursing that offer HSR training often provide interdisciplinary opportunities through partnerships with other disciplines. This is key to developing the competencies of the nurse HSR scientist.

Fellowships and Training Grants Funding for training in HSR comes from a variety of sources including government-funded institutional and individual training grants. In the past, the AHRQ was the primary funder of HSR. Nurses have successfully competed for individual HSR dissertation awards (R36) and postdoctoral research training awards.

Although not the primary mission of the National Institutes of Health (NIH), increasingly it is interested in funding HSR. The National Institute of Nursing Research (NINR) provides universities competitive funds for institutional training grants. These funds are given directly to schools of nursing to provide qualified students with stipends for living expenses, funds for tuition and fees, as well as limited travel to scientific meetings. Indeed, there are training grants that prepare predoctoral and postdoctoral students to conduct comparative effectiveness research. Additionally, doctoral students who have matriculated can apply for individual National Research Service Awards (NRSA), which provides similar funding for institutional training grants. The F31 funding mechanism is designed to support individual predoctoral students. Because the F31 is a training award, major considerations in the review are applicants’ potential, their proposed research training plans, as well as institutional environment and commitment to training. The NIH RePORTER ( provides access to NIH-funded research projects. A list of NIH-funded F31 projects can be found on this website by selecting the F31 Predoctoral activity code under the project details section.

Loan Repayment Programs




Along with concurrent funding for HSR training with predoctoral and postdoctoral fellowships, there are various mechanisms of federally qualified loan repayment programs. The NIH and Health Resources and Services Administration (HRSA) provide funding to encourage health professionals to pursue careers in health-related research at colleges and universities. The NIH Loan Repayment Programs (LRPs) ( focuses on biomedical, behavioral, social, and clinical research. For at least a 1- year commitment of conducting qualified research, the NIH may repay up to $35,000 of student loan debt per year (National Institutes of Health Division of Loan Repayment, 2013). Unlike the HRSA Faculty Loan Repayment Program, the NIH LRP awards are based on a competitive peer-review process. There are two HRSA loan repayment programs (, the Faculty Loan Repayment Program (FLRP) and the NURSE Corps Loan Repayment Program (Health Resources and Services Administration, 2013). Individuals who participate in the FLRP can currently receive up to $40,000, plus a tax benefit, for 2 years of service at an accredited health professions college or university; or, if selected to participate in the NURSE Corps Loan Repayment Program, can receive up to 60% of their qualifying student loans repaid over 2 years plus the option for a third year to repay an additional 25%. More details about eligibility and service requirements can be found by visiting the websites listed above.

Dissemination and Translation of Research Into Policy There are a number of scientific journals that focus on HSR (e.g., Health Affairs, Health Services Research, Medical Care, and Policy, Politics, & Nursing Practice). As a source for scientific dissemination, AcademyHealth has become the primary interdisciplinary professional association for HSR researchers. As a component of AcademyHealth, the Interdisciplinary Research Group on Nursing Issues (IRGNI) provides a forum for researchers interested in promoting and supporting the development of HSR that focuses on nursing practice, workforce, and delivery of care. These venues




have become important mechanisms to disseminate evidence for policy development and to guide the field of HSR.

Discussion Questions 1. Based on Table 12-2, list any core competencies you have achieved. For those you have yet to achieve, develop a plan to achieve them.

2. Look up an existing data set listed in Table 12-1. Write a research question that could be answered using this data set and would be of interest to policymakers.

3. Review a current policy brief. What types of data were used in the evidence that informed the policy brief?

References AcademyHealth. What is HSR?. [Retrieved from] ItemNumber=831&navItemNumber=514; 2008.

Aday LA, Andersen R. A framework for the study of access to medical care. Health Services Research. 1974;9(3):208–220.

Auerbach CF, Silverstein LB. Qualitative data: An introduction to coding and analysis. New York University Press: New York; 2003.

Bleich SN, Wang YC, Wang Y, Gortmaker SL. Increasing consumption of sugar-sweetened beverages among US adults: 1988-1994 to 1999-2004. American Journal of Clinical Nutrition. 2009;89(1):372–381.

Brownell KD, Frieden TR. Ounces of prevention—The public policy case for taxes on sugared beverages. New England Journal of Medicine. 2009;360(18):1805–1808.

Committee on Comparative Effectiveness Research Prioritization, Institute of Medicine. Initial national priorities for comparative effectiveness research. [Retrieved from]




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Using Research to Advance Health and Social Policies for Children Louise Kahn, Freida Hopkins Outlaw, Sally S. Cohen

“There can be no keener revelation of a society’s soul than the way in which it treats its children.” Nelson Mandela

Over the past decade, policymakers involved with children’s issues have faced enormous challenges related to underperforming schools, overburdened health care systems, the increasing cost of public services, and fragmented approaches to the various problems. The importance of addressing these challenges has been recognized and they are now addressed using evidence-based research to inform both interventions and policy. New research findings have established the relationships among factors such as children’s early brain development, poverty, other social determinants of health and well-being, and traumatic events. Researchers have also confirmed the influence of these factors on unrealized human potential and poor quality of life in the form of




negative outcomes in later years (Felitti et al., 1998; Shonkoff & Phillips, 2000). Researchers and professionals who work with families with young children are noting the significance of conceptualizing child health policy more broadly, moving from individual approaches to a public health focus and encompassing the many aspects of social policy that affect children’s well-being. The purposes of this chapter are to identify the major themes pertaining to social policies for children, explain how research has enhanced such policies, describe the remaining gaps in children’s social policy and research, and explain how nurses can make meaningful contributions to the advancement of healthy social policies for children.

Research on Early Brain Development Evidence regarding infant brain development in the 1990s propelled children’s advocates and researchers to push for interventions with young children and families within the first few years of the life of the child. The groundbreaking report, From Neurons to Neighborhoods: The Science of Early Childhood Development (Shonkoff & Phillips, 2000), provided findings regarding the effects of genetics, environment, and early stress on brain architecture. In the 1990s collaborative research between the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente demonstrated strong epidemiological evidence for the relationship between childhood trauma and long-term health and social outcomes (Felitti et al., 1998). This collaborative research on adverse childhood experiences (ACE), using data from 17,000 participants, is ongoing and continues to reveal the strong health, mental health, and social impacts of childhood adversity on their lives (Felitti & Anda, 2010).

In the 2000s, using neuroimaging technology and research, scientists demonstrated the impact of neurophysiologic and neurodevelopmental stress, trauma, and neglect on children. Their findings confirmed the need for safe, predictable, and enriched environments for young children (Perry, 2010).

In 2010 the Harvard Center for the Developing Child published The Foundations of Lifelong Health are Built in Early Childhood, a report




that described how early life experiences manifest in the human body. The authors also described how significant adversity in childhood could undermine the body’s stress response systems causing deleterious effects on the brain, immune system, cardio- vascular system, and metabolism. They suggested that these effects on children could persist and lead to lifelong physical and mental health impairment (Center on the Developing Child, 2010).

Research on Social Determinants of Health and Health Disparities Many national and international organizations have published reports with similar conclusions regarding the relationship between social determinants of health and health outcomes. Among them are the World Health Organization’s (WHO, 2009) final report on health equity and social determinants of health, Healthy People 2020 (U.S. Department of Health and Human Services [HHS], 2010), and a landmark Institute of Medicine study on health disparities entitled Unequal Treatment: Confronting Ethnic and Racial Disparities in Health Care (Smedley, Stith, & Nelson, 2003). All of these reports provide scientific evidence regarding how social determinants often play a larger role in determining health outcomes than clinical interventions.

Several themes emerge from recent reports in the area of children’s health. Specifically, children of low socioeconomic status experience significant disparities in their health (Egerter et al., 2008). Economically disadvantaged and minority families in the United States have the highest rates of infant mortality. Children from poor racially segregated neighborhoods have more challenges than other children in accessing the services needed to maintain good health (Acevedo-Garcia et al., 2008).

Advancing Children’s Mental Health Using Research to Inform Policy Approximately one in five children (13%-20%) in the United Sates




has a serious mental illness that interferes with their functioning in the home, school, and community. Mental illness also harms children’s relationships with their peers (CDC, 2013). Moreover, 21% of children between 9 and 17 years old have a diagnosable mental or addictive disorder that causes some level of impairment (National Alliance on Mental Illness [NAMI], 2013). Children’s mental health needs accounted for $247 billion in health expenditures in the United States during 2007 (Miles et al., 2010).

Given the prevalence of mental health disorders in children, new approaches that integrate all child-focused systems are needed. Integrating systems in areas such as education, health, social welfare, juvenile justice, and mental health can provide a comprehensive framework for health promotion, disease prevention, and the use of evidence-based treatment when working with children, youths, and their families. These components are recognized as important aspects of a public health approach (Stiffman et al., 2010). Public health approaches to children’s mental health services acknowledge that factors not traditionally associated with health can have major health implications. Public health models focus on community-wide variables rather than intervention with only the individual children and their families.

An initiative that focuses on children’s mental health and is guided by a public health framework, supported by decades of research, is the System of Care Approach (SOC) to children’s mental health (Miles et al., 2010). The SOC movement serves children and youths with serious mental health issues. It recognizes the importance of a community-based, nonfragmented, and coordinated network of child and youth services that is family- driven, youth-guided, and culturally and linguistically competent. It also recognizes the contribution of other supports for children and youths such as community recreation centers, church groups, coaches, and other community resources (Stroul, Blau, & Sondheimer, 2008). The American Academy of Pediatrics (2014) recently advocated care coordination as an essential element of health care for children and their families which includes a family- centered and collaborative approach with professionals.

Public health approaches impact children’s mental health. At the turn of the 21st century, using a compilation of strong science-based




research, the then Surgeon General urged all Americans to view mental health as an essential component of health, and advocated taking a public health approach to the identification, prevention, and treatment of mental illnesses. This approach also included removal of the stigma associated with mental health problems (HHS, 2001).

In 2013, the CDC released a report outlining a comprehensive approach to children’s mental health. The report used research findings to inform health professionals of factors that increase children’s risk of developing mental health problems such as poverty and trauma. It identified ways of promoting and tracking the effectiveness of children’s mental health programs. The CDC (2013) advocated using systematic monitoring to increase the public’s understanding of the mental health needs of children, the use of research findings to determine risk factors and prevention strategies, monitoring of children’s early intervention and prevention programs, and the evaluation of the effectiveness of treatment programs.

Research on Child Well-Being Indicators A strategy that has been successful in forwarding policy that supports state-level progress in child health is the use of indicators of child well-being, called “childhood indicators,” such as births to teen mothers, poverty rates, educational attainment, and immunization rates. The Annie E. Casey Foundation has been a leader in providing data in these areas for each state, and analyzing the extent to which these policies meet the needs of children and their families. The annual release of the KIDS COUNT data book which includes state data for 10 leading indicators receives extensive media attention and is often a catalyst for policy change (Annie E. Casey Foundation, 2013). Other foundations and organizations publish similar compilations of child and family indicators. An emerging technology that public health and other researchers are using to document population health disparities is Geographical Information Systems (GIS) mapping. GIS mapping




can demonstrate disparities at census tract, zip code, neighborhood, and county levels, thereby identifying areas of need for community- level interventions.

Research on “Framing the Problem” Researchers and child advocates have become increasingly capable in communicating research findings and thereby advancing public policy, primarily by the use of framing theory. Framing theory suggests that people organize the world by using preexisting frames that guide their thoughts and feelings on an issue (FrameWorks Institute, 2001). Frames are strongly influenced by the media and can be very resistant to change. The FrameWorks Institute has been the leader in this area, conducting research to determine the current frames around child and family issues and designing strategic communications to change these frames to facilitate policy development. These efforts have advanced children’s policy, particularly in the area of childcare, now reframed as “early care and education” (ECE).

One of the effective frames for policies relating to children is to evaluate the economic benefits current investments will yield in the future. A RAND study (Karoly et al., 1998) provided the impetus for other analyses of how funding ECE programs could be cost- effective. These studies led economists and researchers from the Minnesota Federal Reserve Bank to endorse such policies and to form partnerships with early childhood programs (Early Childhood Research Collaborative, 2010).

Nobel Prize winning economist James Heckman (2011) has undertaken groundbreaking work with economists, developmental psychologists, sociologists, statisticians, and neuroscientists to demonstrate that the quality of early childhood development heavily influences health, economic, and social outcomes for both individuals and society. Heckman (2011) wrote that the most efficient investment of limited economic resources is in the prevention of negative social and economic outcomes by promoting equity through the provision of high-quality early childhood parenting and education to disadvantaged families. He noted that every dollar invested in high-quality early childhood education




produces a 7% to 10% return on investment per annum. Heckman (2011) recommends investing in school readiness from

birth through to the age of 5 by enriching home environments. He supports strong, high-quality, early childhood education programs and working with mothers by offering home visiting programs that seek to improve parenting skills.

One major success in linking research and policy is the Nurse Family Partnership (NFP) which partners low-income first-time mothers with nurses during pregnancy, continuing until the child’s second birthday (Nurse Family Partnership, n.d.). Evaluations of the NFP and other home visitation models convinced President Obama to initiate a multibillion dollar federal program to expand early childhood home visitation. A home visitation provision was included in the Affordable Care Act (ACA). The national NFP office encourages nurses and others to advocate for increases in federal and state funding for home visitation.

Gaps in Linking Research and Social Policies for Children Although research findings have contributed to improvements in policies and programs for children and their families in areas such health care coverage and funding for early care and education, many children’s outcomes remain unsatisfactory. For example, the reframing of childcare as early education and the expansion of prekindergarten services has not benefited infants and younger toddlers.

Large discrepancies exist between what research indicates is needed for healthy development, and what society delivers. We are unable to ensure that most children receive the quality of housing, food, and childcare that is commensurate with brain development, nor do all children have adequate health insurance coverage, even with the ACA and Medicaid expansions. Many children lack access to good, high-quality physical and mental health care.

Financial investments in programs for children are still relatively low. In 2008, only 10% of the U.S. federal budget was spent on children, compared to 38% on older adults and disabled persons




(Isaacs et al., 2009). Moreover, the percentage of federal expenditures directed toward children has actually declined over time (from 20% in 1960, to 15% in 2008). During the first 2 years of the Obama presidency (2009-2010), laws were enacted that included substantial funding increases for the Child Care and Development Block Grant, home visiting programs, and the Child Health Insurance Program Reauthorization Act. This infusion of funding was an important start to the improvement of children’s health and developmental outcomes, although current economic and political conditions put this progress at risk.

The backing of well-known economists has been tremendously valuable in garnering political support for many children’s issues. Nonetheless, advocacy remains difficult because the constituents themselves—children and parents—are not easily mobilized because of the realities of daily life. Children from families with low socioeconomic resources and from racial and ethnic minority groups are particularly disadvantaged. Also, historically, issues associated with children and families have not had priority in the policy arena.

Nursing Advocacy National and state nursing organizations have much untapped potential in terms of educating the public and policymakers by testifying on behalf of children and joining other coalitions working to influence child policy. It is important for nurses to be knowledgeable about findings from childhood research and subsequent policy implications and to keep abreast of the types of resources needed for improving the health of children. However, it is important to remember that evidence alone cannot change policies. In advancing children’s policies other factors are important, such as careful framing, supporting interdisciplinary approaches, and working with community advocates toward common goals. Nurses and others who advocate for improved health and social policies for children must emphasize children’s needs within their families and communities and the importance of coordinated care. It is important that they develop and implement strategies to widen the childhood policy community, and be




persistent in advocating for policy change informed by high-quality research.

Discussion Questions 1. Discuss the connections among child health, educational achievement, and social determinants of health.

2. Define a children’s policy problem and describe how you might frame a social policy to ameliorate that problem.

3. How might nurses promote and implement public health approaches to children’s mental health?

References Acevedo-Garcia D, Osypuk TL, McArdle N, Williams DR.

Toward a policy-relevant analysis of geographic and racial/ethnic disparities in child health. Health Affairs (Millwood). 2008;27(2):321–333.

American Academy of Pediatrics. Patient- and family- centered care coordination: A framework for integrating care for children and youth across multiple systems. Pediatrics. 2014;133(5):e1451–e1460.

Annie E. Casey Foundation. The 2013 KIDS COUNT data book. [Retrieved from] 2013.

Centers for Disease Control and Prevention. Mental health surveillance among children—United States, 2005-2011. [Retrieved from]; 2013.

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America’s health starts with healthy children: How do states compare?. Robert Wood Johnson Foundation Commission to Build a Healthier America: Princeton, N.J.; 2008 [Retrieved from] Publication=57823.

Felitti VJ, Anda RF. The relationship of adverse childhood experiences to adult health, well-being, social function, and health care. Lanius R, Vermetten E, Pain C. The effects of early life trauma on health and disease: the hidden epidemic. Cambridge University Press: London; 2010.

Felitti VJ, Anda RF, Nordenberg DF, Spitz AM, Edwards V, Koss MP, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) study. American Journal of Preventive Medicine. 1998;14(4):245–258.

FrameWorks Institute. A five minute refresher course in framing. [Retrieved from] 2001.

Heckman JJ. The economics of inequality: The value of early childhood education. American Educator. 2011;Spring:31–47.

Isaacs JB, Vericker T, Macomber J, Kent A. Kids’ share: An analysis of federal expenditures on children through 2008. Urban Institute and Brookings: Washington, DC; 2009 [Retrieved from]

Karoly LA, Greenwood PW, Everingham SS, Hoube J, Kilburn RM, Rydell CP, et al. Investing in our children: What we do and do not know about the cost and benefits of early childhood interventions. RAND: Washington, DC; 1998 [Retrieved from]

Miles J, Espiritu RC, Horen NM, Sebian J, Waetzig E. A public health approach to children’s mental health: A conceptual framework: Expanded executive summary. Georgetown




University Center for Child and Human Development, National Technical Assistance Center for Children’s Mental Health: Washington, DC; 2010.

National Alliance on Mental Illness. Facts on children’s mental health in America. [Retrieved from] State_Policy_Lion&template=/ContentMangement/ContentDisplay.cfm&ContentID=43804 2013.

Nurse Family Partnership. (n.d.). Evidence-based public policy. Retrieved from

Perry BD. Effects of traumatic events on children. The Guardian. 2010;32:2–10.

Shonkoff JP, Phillips DA. From neurons to neighborhoods: The science of early childhood development. National Academies Press: Washington, DC; 2000.

Smedley BD, Stith AY, Nelson AR. Unequal treatment: Confronting racial and ethnic disparities in health care. National Academies Press: Washington, DC; 2003 [Retrieved from]

Stiffman AR, Stelk W, Horwitz SM, Evans ME, Outlaw FH, Atkins M. A public health approach to children’s mental health services: Possible solutions to current service inadequacies. Administration Policy Mental Health. 2010;37(1– 2):120–124; 10.1007/s10488-009-0259-2.

Stroul BA, Blau GM, Sondheimer DL. Systems of care: A strategy to transform children’s mental health care. Stroul BA, Blau GM. The system of care handbook transforming mental health services for children, youth, and families. Paul H. Brookes Publishing Co., Inc: Baltimore, MD; 2008.

U.S. Department of Health and Human Services. Healthy People 2020: The road ahead. [Retrieved from]; 2010.

U. S. Department of Health and Human Services. Mental health: Culture, race and ethnicity—A supplement to mental health: A report of the Surgeon General. U. S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services: Rockville; 2001.




World Health Organization Commission on Social Determinants of Health. Final report: Closing the gap in a generation: Health equity through action on the social determinants of health. [Retrieved from] 2009.

Online Resources Adverse Childhood Events on CDC. Nurse Family Partnership. Harvard Center for Developing Child. Systems of Care.






Using the Power of Media to Influence Health Policy and Politics Beth Gharrity Gardner, Barbara Glickstein, Diana J. Mason

“Power relations … as well as the processes challenging institutionalized power relations are increasingly shaped and decided in the communication field.” Manual Castells

In the 2008 Presidential campaign, social media did for the Obama campaign what the then new media of television did for John F. Kennedy in 1960. From the onset of his campaign, then U.S. Senator Barack Obama (D-IL) enlisted the support of Chris Hughes, a founder of Facebook, and David Axelrod, a former partner in the public relations firm ASK Public Strategies. Hughes and Axelrod built a team that marshaled every tool in the social media and marketing toolbox to create and sustain the Obama campaign. The campaign was ahead of competitors in using social media to connect with a growing audience of followers on Facebook, Twitter, and blogs. In the general election, then Senator Obama had 118,107




followers on Twitter, outpacing his opponent John McCain’s 2865 followers by a factor of 40 to 1 (Lardinois, 2008). He used social media to build a grassroots movement that resulted in his historic victory (Talbot, 2008).

By the 2012 Presidential elections, the majority of social media users expected candidates to have a social media presence and stated that social media provided information that influenced their voting decisions (Steele, 2012). These trends among voters, and young voters in particular, were not lost on the Romney and Obama campaigns. By the eve of the 2012 conventions, both campaigns were regularly updating blogs on their websites and posting to Twitter, Facebook, and YouTube. As in 2008, Obama drastically outpaced all of his competitors in the volume of messages sent, the number of followers or fans, and in social media response (e.g., shares, views, and comments) (Pew Research Center’s Journalism Project Staff, 2012; Shaughnessy, 2012). Voters also played a larger role in communicating campaign messages. In 2012, the top five trending political topics on Facebook were “Barak Obama,” “Mitt Romney,” “voted,” “four more years,” and “Paul Ryan” (Groshek & Al-Rawi, 2013). Social media is now fully integrated into political campaigning and engagement (see Chapter 48).

The use of social media has not been limited to political campaigning. Launched immediately after Obama’s 2008 win, provided a website for people to share their ideas for improving legislation before it was signed into law. This sent the message that Obama had no intention of being limited by a traditional media operation as President. Rather, he was going to continue to engage people in supporting his agenda for the nation through multiple channels. When health care reform was teetering from a growing army of dissenters blocking its passage, he continued using social media to mobilize supporters to pressure Congress to act before the April 2010 recess. President Obama also took to the road and held town meetings in key communities because he knew that these meetings would garner reports on primetime television and radio and take a front-page position in newspapers. He could count on the primetime news including a sound bite and visual image of him speaking before a crowd of




enthusiastic Ohioans. The personal appearances were a way to get his message to those who were not yet social media enthusiasts and to reinforce it with those who were already his followers on Twitter and Facebook. In 2014, when the open enrollment window for signing up for health insurance drew to a close, Obama appeared on the show “Between Two Ferns,” an online parody of celebrity interviews hosted by comedian Zach Galifianakis, to urge young adults to go to to sign up for health insurance. This unlikely appearance garnered coverage across traditional and social media platforms.

New digital information and communication technologies have dramatically changed how and what we think about communicating with others, whether connecting with family or building a grassroots political movement to push policymakers to pass new laws. Even traditional media outlets are now augmenting their work with all sorts of social media to extend their reach, impact, and, in some cases, survival. Legislators are routinely launching blogs, using Facebook, and tweeting to make their voices heard and to connect with their constituents. This chapter looks at the integration of traditional and social media as powerful tools for nurses to harness in shaping health policy and politics. Throughout, we draw insights from contemporary and past cases to highlight the role of media in influencing health policy and politics.

Seismic Shift in Media: One-to-Many and Many-to-Many In the 21st century there has been a seismic shift in the way media is created and distributed. For many years, the dominant paradigm in media was a model in which one broadcaster sent a message out to a mass audience. This broadcast model is referred to as the one- to-many model. This model has been challenged by the Internet and user-generated content in which many people create media and distribute it to their individualized networks. This new model is sometimes referred to as the many-to-many model because it provides opportunities for feedback and interaction, features that have led to the ubiquitous use of the term “social media.”




We now have convergence media, or the interweaving of traditional and social media. Rather than these platforms remaining separate, traditional and networked media are working side by side. For instance, even though the New York Times in print or even as an app is mostly a one-to-many broadcasting media model, the newspaper’s blogs, videos, and comment sections reflect the digital side of the newspaper as a networked media platform. News organizations exclusive to the online environment have been created and some veteran print publications have moved entirely or mostly online, but the degree of convergence is unclear (Hindman, 2009).

Mass Media: the One-to-Many Model Traditional media in radio, television, film, and newspapers was based on the idea that one broadcaster would try to reach as many audience members as possible. However, for those interested in influencing health policy and politics through the media there were many advantages and some significant disadvantages to the one-to- many model of broadcast media (Abramson, 2003).

Radio, film, and television have all been used to communicate messages about health to consumers and policymakers alike. What all these media share is the ability to broadcast a message to a mass audience, sometimes in the millions or tens of millions. When there were few media outlets it was possible to repeatedly broadcast a consistent message to a wide audience. The use of mass media has been a major tool in health promotion campaigns because it reaches a large audience and is capable of promoting healthy social change (Institute of Medicine, 2002; Wakefield, Loken & Hornik, 2010).

There are also disadvantages to mass media communications. Large corporations own media outlets and control what goes out through their channels and the expense of buying time or space in major media outlets can be prohibitive, especially for nonprofit organizations. Mass media campaigns, by definition, are intended to reach a wide audience but are not as effective at reaching target populations. For example, a mass media campaign about HIV prevention may reach a wide audience but fail to reach the specific population that is most vulnerable to infection. However, political




operatives have developed increasingly sophisticated approaches to segmenting and targeting specific electoral districts with mass media when they want to pressure a policymaker who may hold a deciding vote on an important bill. Such organizations buy commercial time on the dominant television station in that policymaker’s district. However, what no form of mass media does very well is allow users to create and distribute their own content with the messages they find most important.

Many-to-Many: User-Generated Content and the “Prosumer” The rise of the Internet, and specifically websites that rely on users to generate content, are part of a new landscape of media creation and distribution. The early Internet featured websites that were one-way flows of information. The paradigm-shifting quality of the Internet began to emerge with the rise of Web 2.0, a term popularized by Tim O’Reilly (2005) at a conference in 2004. Web 2.0 refers to a range of Internet practices based on information-sharing, social networks, and collaborations, rather than the one-way communication style of the early era of the Internet. The key idea with the concept of Web 2.0 is that people are using the Internet to connect with other people, through their old face-to-face networks and through newly formed online social networks and communities of interest.

Prosumption is a term that some people use to describe this shift. Prosumption is the idea that producing and consuming are combined in this new many-to-many paradigm. Rather than an elite few who produce media for a mass audience to consume, now we are all both producers and consumers, or prosumers of media. The many-to-many paradigm refers not to a new form of technology but to a new way that people make use of that technology (Ritzer & Jurgenson, 2010). Social media tools may work best by enabling the development of communities of interest and social networks that successfully narrowcast, as opposed to broadcast, to like-minded individuals. Only time will tell how the many-to-many model will permeate the political communication landscape. Regardless, the collaborative, information-sharing Internet practices have broad




implications for health media, policy, and politics, but they do not mean the end of mass media.

The Power of Media A now classic example of the power of media in shaping health policy arose during the first months of William Jefferson Clinton’s presidency when he tried but failed to enact health care reform legislation despite campaigning on a policy platform that sought to guarantee comprehensive health care coverage for every American. In 1993, he proposed the Health Security Act to Congress and the public with the hope that this would become a landmark legislation. Clinton’s proposal initially had substantial public support, because many believed the country had a moral imperative to extend health care coverage to all who live in the United States. However, according to an analysis by the Annenberg Public Policy Center of the University of Pennsylvania (1995), one of the primary factors that unraveled the legislation’s progress was the Harry and Louise campaign (a series of television advertisements about two fictional characters, Harry and Louise), which was sponsored by the Health Insurance Association of America (HIAA), an ardent opponent to the President’s plan.

Actors portrayed a white, middle-class couple voicing grave concerns about the bill. They said, “Under the President’s bill, we’ll lose our right to choose our own physician,” and “What happens if the plan runs out of money?” Although the ads were not the only reason for the demise of the Clinton plan, the Harry and Louise television spots encouraged fear and negativity within the span of 60 seconds. Suddenly, it seemed as though many of the Americans who had been concerned about the growing numbers of uninsured would become more concerned about how the bill would affect their own health care options and withdraw their support from the Act. What few people realize is that even though a large segment of the population remained convinced that the health care system needed major change, the commercials convinced decision makers that public sentiment was against the reforms. This is one of the things that make the media so powerful: media discourse impacts policymaking because policymakers “assume its pervasive




influence” (Gamson, 2004, p. 243). The target audience for the Harry and Louise ads was not the public directly; rather, it was policymakers and those who could influence how the public perceived the issue, such as journalists. The ads originally aired in the country’s major media centers: Washington, DC; Los Angeles; New York City; and Atlanta. They were seen and reported on by journalists. In fact, the ads and the issue under debate got more airtime by becoming part of the journalists’ news stories (West, Heith, & Goodwin, 1996). Many people saw the ads or heard about them through viewing them on the evening news, not as a paid advertisement.

The Harry and Louise commercials are an example of the power of the media in policy and politics. It was a deliberate media strategy to reframe a public policy issue and mobilize a public constituency around it. The media saturate large numbers of people with images that directly or indirectly influence their opinions, shape their attitudes and beliefs, and transform their behavior (McLuhan, 1964). As such, understanding what is and is not shifting in the templates of message production, dissemination, and consumption is crucial for understanding media impacts.

Media campaigns such as these often rely on invoking viewer reactions through the use of misleading or extreme characterizations of legislation or opponents. Recent research suggests that such uncivil discourse is on the rise, especially in nontraditional media, such as talk radio and political blogs (Sobieraj & Berry, 2011; Jamieson, 2012). Given the traditional news values of controversy and conflict, such talk in new media channels may be especially likely to gain coverage from other media outlets. Another longstanding pathway to mass influence is through large media advertising expenditures. The amount of spending on political advertisements is often the largest segment of lobbying expenditure for sponsoring organizations. In 2014, an estimated $2.6 billion was spent on political advertising (Kantar U.S. Insights, 2014). Media advertising campaigns often conceal sponsorship with ambiguous or misleading names and may use cloaked websites to enhance the effectiveness of their deception. Cloaked websites are published by individuals or groups who conceal authorship to deliberately disguise a hidden political agenda (Daniels, 2009). The




lack of transparency of political advertising has a Machiavellian quality to it. Although advertisements for a political candidate are required to include a statement from the candidate that he or she authorized the ad, no such requirement exists for transparency of sponsorship of ads advocating policy positions.

Who Controls the Media? The traditional media industry has been owned by six major corporations that, prior to the growth of social media, controlled 90% of the news Americans read, saw, or heard (Lutz, 2012). In 2003, the Federal Communications Commission voted to ease the restrictions on cross-ownership between different news entities, permitting one corporation to own the primary television, radio, and newspaper outlets in a community. This enabled a single corporation to control messages and put forth a particular perspective. CNN founder Ted Turner objected to this consolidation of corporate media power, arguing that allowing this cross-ownership “will extend the market dominance of the media corporations that control most of what Americans read, see, or hear” and “give them more power to cut important ideas out of the public debate” (Harris, 2005, p. 83).

The gap created by the declining revenue streams and reduced newsrooms for traditional or legacy media are starting to be filled by actors building new news operations and resuscitating long- standing ones. For instance, the Kaiser Family Foundation launched its own nonprofit news organization, Kaiser Health News, in 2009. Their content is now regularly carried in traditional news outlets. Newer digital news outlets are also gaining revenue and recruiting talent from traditional media news staffs. Revenue is recently coming from entrepreneurs who are investing in the media industry; for example, founder Jeff Bezos purchased the Washington Post in 2013. Although traditional news media continue to face revenue challenges, the largest numbers of journalists producing original reporting still come from the newspaper industry (Mitchell, 2013; 2014). In this more digital and diversified media field, the pathways to getting on the public’s agenda may be more complex but many of the traditional media




still adhere to familiar lines of influence. Social media can actually drive traditional media to cover issues

that major newsrooms may not deem worthy of their limited space and time, thus advancing political advocacy. One success story is that of the YouTube video campaign, Kony 2012, launched by Invisible Children, seeking to spur international awareness of the actions of Ugandan warlord Joseph Kony and his Lord’s Resistance Army. Within a few days the video drew millions of viewers and spread to other social media such as Twitter, where it became the top story. Within weeks, the Senate introduced a bipartisan resolution condemning Kony. According to Senator Lindsey Graham (R-SC), “This is about someone who, without the Internet and YouTube, their dastardly deeds would not resonate with politicians. When you get 100 million Americans looking at something, you will get our attention” (Wong, 2012).

According to a survey conducted a week after the video’s release, the way people learned about this story varied strikingly by age cohort. Around half of young adults (aged 18 to 29) who had heard about the video first did so through social media, compared with an even mix of social and traditional news sources for those aged 30 to 49. Traditional media, especially television, informed most adults aged 50 and over (Rainie et al., 2012b).

The ownership of the Internet (e.g., online infrastructures, operating systems, and search engines) is following consolidation patterns similar to traditional media, with a few large companies such as Apple, Google, Yahoo!, Facebook, and Microsoft dominating the field (, 2014). Nonetheless, the more decentralized structure of the Web may better enable citizens to not only break news, but shape it. This bodes well for nurses who have not always been able to garner media attention for their issues. A study commissioned by Sigma Theta Tau and published in 1998 documented nursing’s invisibility in the media. The Woodhull Study on Nursing and the Media found that nurses were included in health stories in major print media (newspapers and news magazines published in September 1997) less than 4% of the time, even when they would have been germane to the story. And even more disturbing, nurses were represented in health care industry publications (such as Modern Healthcare) less than 1% of the time.




These findings may indicate a systematic journalistic bias against nursing. They also arise because nurses have not been proactive in accessing traditional media. Social media provides an opportunity for nurses to not wait for traditional media to value their perspectives. Nurses can use social media to create and distribute messages, to engage others to care about an issue, and to discuss issues from various vantage points. Given that the annual Gallup Poll continues to find that Americans rate the honesty and ethical standards of nurses higher than any other profession (e.g., in 2013, 82% for nurses, 69% for physicians, 21% for newspaper reporters, 8% for members of Congress), nurses have a unique opportunity to send persuasive messages (Gallup, 2014).

If nurses want visibility, they must become cyberactivists. Cyberactivists are people who want to create change in a variety of issues and have taken up the use of new media technologies and strategies that characterize Web 2.0 (McCaughey & Ayers, 2003), fusing the old and new media methods to allow for the widest range of engagement with the public. It has never been easier to become a cyberactivist because new digital technologies have lowered the motivational thresholds for activism, making it much easier to create, join, and coordinate groups (Shirky, 2008; Polletta et al., 2013). Nursing organizations are particularly well positioned to mount focused social media campaigns because they already have a list of people who can begin the spreading of messages. However, social networks are becoming crowded, so getting noticed requires a thoughtful strategy.

Distributed Campaigns Obama’s social media campaign strategy was a distributed campaign, a bottom-up rather than a top-down approach to political campaigns that depends on a message spreading from the grassroots rather than broadcasting and control by the campaign staff (Ozimek, 2005). These campaigns are designed to involve more than core supporters. Distributed campaigns seek to engage swing voters and to provide opportunities for core supporters to craft messages that may appeal to these swing voters more effectively than messages created by campaign staff, thereby strengthening the




commitment of core supporters to the campaign. E-mail, blogs, and other social media are used by campaign staff to initiate a dialogue that is subsequently developed by a broad community of supporters. Additionally, supporter-generated content such as more personalized Facebook groups and YouTube videos can be incorporated into the campaign.

Evidence supports the potential for distributed campaigns. In terms of shaping political communication, a 2012 Pew Internet and American Life Project survey found that 66% of social media users (estimated to be 39% of all American adults) are politically active on these sites, by posting links to political stories, encouraging others to vote, or encouraging others to take political action (Rainie et al., 2012a; Smith, 2013). In terms of consuming political information, a 2013 Pew survey indicates that approximately half of Facebook and Twitter users obtained news on those sites (Holcomb, Gottfried, & Mitchell, 2013).

Distributed campaigns provide people with tools for activism such as petitions to sign, e-mail scripts to send, or letters to sign and send to legislators. Organizations, such as Democracy in Action (, are available to help build the capacity of groups that want to develop action tools for reaching diverse audiences in distributive campaigns. Living in a media- saturated world can sometimes feel like being in a cacophony of conflicting voices. The challenge is how to use these powerful tools most effectively.

Linking in to Existing Communities Most people regularly find information online from sources that are familiar or already aligned with their views (Hindman, 2009). Similarly, popular search engines such as Yahoo! and Google structure or filter links in a way that facilitates this return to the familiar and the mainstream. One way to work both with and around these patterns may be to link into existing communities of interest and social networks rooted in friends and family. In the Kony 2012 case discussed earlier, Senator Chris Coons (D-DE) told reporters that his 12-year-old twins and his 11-year-old daughter alerted him to the issue (Wong, 2012), which they and their peers




most likely learned about through social media (Rainie et al., 2012b). Just as they have offline, the networked worlds of friendship, family, hobbies, and leisure groups may routinely overlap with political engagement and communication.

Such overlap is evident in data from the 2013 University of Southern California Annenberg School for Communication and Journalism’s national digital future survey (Center for the Digital Future, 2013). In 2013, 16.7% of Internet users identified themselves as a member of an online community, defined as “a group that shares thoughts or ideas, or works on common projects, through electronic communication only.” More than half of these groups were devoted to members’ hobbies (62%). Other groups were social (39%) or professional (33%) with only 12% described as political. However, 85% of online community members said they used the Internet to participate in communities related to social causes (this was up 10% from 2007 and 40% from 2006); and nearly three quarters said they had participated in new social causes since they joined an online community.

Friends, family, and communities of interest may convince those who might not otherwise join a cause to join because they help to either create concern about the cause or motivate the individual to shift from concern to participation (Polletta et al., 2013). As these exchanges are increasingly enabled through social media networks, traditional media avenues for getting on the public’s agenda are being restructured.

Getting on the Public’s Agenda One of the most important roles that the media plays is getting issues on the agendas of the public and policymakers. What the mainstream media do or do not cover is equally powerful in determining which issues policymakers take into consideration. But the mainstream media’s role in defining what is mainstream appears to be diminishing due to three interrelated factors: the abundance of new social media platforms, the lowered costs of producing media campaigns that can directly reach the public, and the downsizing among traditional news media outlets that may be undermining the quality of their reporting. The news-consuming




public has responded to these interrelated trends. A survey conducted by the PEW Research Center early in 2013 found that nearly a third of people abandoned a particular news source because it was no longer providing the quality information they had come to expect (Enda & Mitchell, 2013). The Digital Future Report (Center for the Digital Future, 2013) also found that 30% of Internet users stopped a subscription to a newspaper or magazine because they could get the same information online. Additionally, more people are seeking out news stories they hear about via social media, even when they weren’t looking (Mitchell, 2014). Most American adults (73%) get news from family and friends through word of mouth, but now around 15% are getting it from family and friends through social networking, and the percentage relying on social media is even higher for 18- to 29-year olds (nearly 25%) (Mitchell, 2013).

News as Entertainment: Infotainment The news media remain instrumental in getting issues onto the agenda of policymakers and generating the political campaign interest that encourages citizens to the voting booths (Groshek & Dimitrova, 2011), but non-news entertainment television programs can also mobilize public constituencies around an issue. Although the Internet has become a more important source for entertainment among Internet users, television remains the primary source for entertainment (Center for the Digital Future, 2013). This may be caused by the fact that television continues to be the dominant form of media in most people’s lives, despite the rise of other forms of media online. In 2013, the television was on around 35 hours per week in the average American household (Nielsen Reports, 2013). Teenagers still spend more time watching TV than they do online (Rideout, Foehr, & Roberts, 2010). The Internet may be where people go to find out about a health issue, but they often first become aware of the issue through television and films.

Turow (1996) points out that non-news television entertainment that often stereotypes power relationships may be more successful than the news in shaping people’s views of issues. Highly viewed TV presentations of health care hold political significance that




should be assessed alongside news. Medical and nursing dramas on broadcast and cable television, such as Grey’s Anatomy, ER, and Nurse Jackie, are often important sources of information about health and health policy for a wide audience. Researchers Turow and Gans (2002) systematically evaluated one television season of four hour-long medical dramas and found that health care policy issues appeared regularly in the programs. Evidence from a national telephone survey indicates that the percentage of regular viewers of the show ER who were aware that HPV is a sexually transmitted disease was higher (28%) one week after viewing an episode of the show about HPV than before seeing the show (9%). Even 6 weeks after viewing the episode, 16% had retained this knowledge. This capacity to quickly get a message out to millions of people through an hour-long drama is part of the reason that many health advocates work to get their particular issue included in a storyline of a major network drama.

Documentary Films Documentary films, in conjunction with online campaigns, are influencing health policy and politics while achieving mainstream commercial success. For example, two documentaries, The Invisible War (2012) and Service: When Women Come Marching Home (2011) were groundbreaking in creating public conversations about military sexual assault. Both were viewed by members of Congress and used as organizing tools nationally to get the public behind an agenda to change the military’s practices. Kirsten Gillibrand (D- NY), Senator and Chairwoman of the Personnel Subcommittee on the Armed Services Committee, cited The Invisible War as shaping her decision to draft a bill to overhaul military sexual-assault policies by removing the chain of command from prosecuting sexual assaults. Although the bill was defeated in March of 2014, her yearlong campaign drew many supporters and put the issue firmly on the political agenda.

Media as a Health Promotion Tool Media can promote health in three ways: public education, social




marketing, and media advocacy. The first two are often used to help people change their health behaviors by acquiring important information they lacked (public education) or through visual or verbal messaging that can shift a person’s attitudes and values (social marketing). Both can also be used in political campaigns and to shape public policy, but media advocacy specifically targets public policy.

Media Advocacy Media advocacy is the strategic use of media to apply pressure to advance a social or public policy initiative (Dorfman & Krasnow 2014; Wallack & Dorfman, 1996). It is a tool for policy change by mobilizing constituencies and stakeholders to support or oppose specific policy changes. It is a means of political action. It differs from social marketing and public education approaches to public health, as noted in Table 14-1. Media advocacy defines the primary problem as a power gap, as opposed to an information gap, so mobilization of stakeholders is needed to influence the development of public policies.

TABLE 14-1 Media Advocacy Versus Social Marketing and Public Education Approaches to Public Health

Media Advocacy Social Marketing and Public Education Individual as advocate Individual as audience Advances healthy public policies Develops health messages Changes the environment Changes the individual Target is person with power to make change Target is person with problem or is at risk Addresses the power gap Addresses the information gap

Adapted from Wallack, L., & Dorfman, L. (1996). Media advocacy: A strategy for advancing policy and promoting health. Health Education Quarterly, 23(3), 297. Copyright 1996 by Sage Publications. Reprinted by permission of Sage Publications.

The success of Mothers Against Drunk Driving (MADD) illustrates the power of media advocacy. MADD was formed in 1980 at a time when a drunk driver could kill a child and it would not be treated as a crime. MADD developed a policy agenda aimed at preventing drunk driving. It developed a Rating the States program to bring public attention to what state governments were




and were not doing to fight alcohol-impaired driving. Then, just after Thanksgiving (the beginning of a period of high numbers of alcohol-related traffic accidents), MADD representatives held local press conferences with their state’s officials and members of other advocacy groups to announce the state’s rating. Local and national broadcast and print press brought the story to an estimated 62.5 million people. Subsequently, lawmakers in at least eight states took action to address drunken driving (Russell et al., 1995).

Today, MADD’s website ( provides information in a number of areas: policies that people can endorse, a walk to raise funds to support the organization’s work, a link to its Twitter page, and news about drunk driving initiatives. Getting on the news media’s agenda is one of the functions of media advocacy (Dorfman & Krasnow, 2014). With numerous competing potential stories, media advocacy employs strategies to frame an issue in a way that will attract media coverage. For example, MADD often created media events by putting a wrecked car in front of a local high school a few days prior to a prom. Journalists flocked to these events and the visual impact of the wrecked car got people’s attention. The news accounts and parental outrage that resulted from these media events eventually led to wide social support for the concept of the designated driver and harsher penalties for driving under the influence.

How a message is presented is as important as getting the attention of the news media. Debates surrounding the passage and implementation of the Affordable Care Act demonstrate this point. It certainly got on the media’s agenda, but many important messages were lost in the news coverage that emphasized the controversies such as death panels and horror stories of individuals finding their insurance policies cancelled.

Framing Getting an issue on the agenda of the public and policymakers and shaping the message requires framing. Framing “defines the boundaries of public discussion about an issue” (Wallack & Dorfman, 1996, p. 299). Even more simply put, a frame is a “thought organizer” (Gamson, 2004, p. 245). Reframing involves




breaking out of the dominant perspective (or frame) on an issue to define a new way of thinking about it that can lead to very different ideas about potentially effective policy responses. Reframing requires working hard to understand the dominant frame, the values that underpin it as well as its limitations, and then exploring new frames.

Framing applies to all messaging and policy work, whether changing staffing policies in a hospital or promoting legislation that will remove soft drinks from schools. Framing for access to the media entails shaping the issue in a way that will attract media attention. It helps to attach the issue to a local concern, anniversaries, or celebrities or to make news by holding events that will attract the press, such as releasing new research at a press conference (Jernigan & Wright, 1996). Linking to issues already on the political agenda or the media’s agenda (as newsworthy) can also be advantageous to gaining access. Most importantly, it requires some element of controversy (albeit not over the accuracy of an advocate’s facts), conflict, injustice, or irony. The targeted medium or media will shape how the story is presented. For example, television requires compelling visual images. If a broad audience is to be reached, a powerful, brief message on television can provide a quick frame for an issue and influence how people will view it, but the interactive nature of social media provides the opportunity for others to continue to reframe a message, helping people to break out of a dominant frame.

Framing for content once you are in front of the media is more difficult than framing for access. A compelling individual story may gain visibility in some media, but there is no guarantee that the reporter or social media activists will focus on the public policy changes that are desired. Wallack and Dorfman (1996, p. 300) suggest that this reframing can be accomplished by the following: • Emphasizing the social dimensions of the problem and translating

an individual’s personal story into a public issue • Shifting the responsibility for the problem from the individual to

the executive or public official whose decisions can address the problem

• Presenting solutions as policy alternatives




• Making a practical appeal to support the solution • Using compelling images and symbols that resonate with the

values of the audience • Using the authentic voices of people who have experience with

the problem • Anticipating the opposition and knowing all sides of the issue

Focus on Reporting Few journalists have the time and the editorial support or the breadth and depth of knowledge about science to provide thorough reporting on health issues that have policy implications. This often results in less-than-adequate reporting on important issues, such as how communities should respond to the West Nile virus. Roche (2002) examined print media coverage of the approaches to reducing the mosquito population to reduce the incidence of, and mortality from, West Nile encephalitis. None of the newspapers or magazines examined gave any information about risk of mortality from pesticide exposure or a cost analysis of this approach. Roche concluded that the public is “operating ‘in the dark’ in evaluating the question of whether pesticides should be deployed.”

Nurses can assist journalists and cyberactivists by both reframing health policy issues and providing the depth of detail that others may lack. For example, a journalist covering a story on the nursing shortage has focused on the faculty shortage and the need to produce more nurses. You could help the journalist to see that framing the story as purely one of a supply issue, getting more people into the pipeline, misses the important issues of retention of existing nurses. While talking with this journalist does not ensure that your frame will be incorporated into the journalist’s story, you can publicize the frame you believe is important through your blog, Facebook page, or Twitter account.

One strategy is to facilitate information exchange in the public arena by becoming news makers, aggregators, or curators of health news. Posting links to news articles and research on critical policy issues on social media sites, such as Facebook, makes the news easy to find. As searching for health information has become the third




most popular online activity for all Internet users 18 and over (Zickuhr, 2010), nurses are positioned to explain complex health policy issues by breaking them down. This can be done not just for information sharing but also for civil engagement so that people will act, whether by having a conversation with a co-worker about the issue or contacting government representatives. Facebook friends, including other nurse colleagues, can share on Facebook, which reposts these articles to their personal networks to widen the community. Social networking can generate a buzz and create conversations about an issue or policy. It is digital activism and it has enormous potential to build networks, propagate power, and frame issues.

Effective Use of Media The following recommendations provide readers with a starting point for effectively using traditional and social media.

Positioning Yourself as an Expert Health policy was once the domain of a limited field of experts setting the agenda for everyone else. The rise of user-generated content signals a radical departure from this approach. It signifies a profound transformation in what it means to be an expert and who is an expert. New media provides nurses with platforms to reach the public as media makers and aggregators of reliable health research information.

Gain Credentials. There are many types of credentials, although they are typically thought of as degrees from educational institutions, work titles, and affiliations. Some institutions require that their employees notify them of any interaction with the media, but this may be unnecessary if you don’t name the institution in your interview or other communication. For example, you could be a nurse in women’s health at a community hospital.

Become an Expert in Your Field.




Becoming the go-to person who is the expert on a topic or particular field is another way to establish yourself as an expert. You can establish this by launching your own professional website, blog, and Twitter and Facebook pages, as well as by meeting with local journalists who cover health.

Use Personal and Clinical Experience. Part of why MADD’s campaign has been compelling is their strategic use of stories from women whose children have been killed as a result of drunk driving. These bereaved mothers involved with MADD have transformed themselves into experts on the policy of driving while intoxicated and have used their experience to make this point with policymakers. Similarly, people who were infected with HIV/AIDS in the 1980s and believed that the federal government was acting too slowly to move treatment through clinical trials made themselves experts on the science of the disease and by using a variety of tactics including personal accounts of their illnesses, forced policymakers to speed up the time for drugs to reach the market. The Internet facilitates the rise of this kind of expertise.

Getting Your Message Across Getting your message to the appropriate target audience requires careful analysis and planning. For example, you might want to target a message to local homeowners, many of whom watch a particular TV station’s evening news. To get television coverage, you must have a visual story. California nurses staged a media event on a senior health issue by staging a “rock around the clock” marathon, with seniors in rocking chairs outside an insurance company. They received press coverage of the event, which elicited some supportive letters to the editor as well as some negative press from seniors who said that they were stereotyping older adults. See Box 14-1 for guidelines for getting your message across in traditional media, and Box 14-2 for ways to use social media tools to reach an audience.





Box 14-1 Guidelines for Getting Your Message Across The following guidelines will help you shape your message and get it delivered to the right media:

The Issue

• What is the nature of the issue?

• What is the context of the issue? (e.g., timing, history, and current political environment)

• Who is, or could be, interested in this issue?

The Message

• What’s the angle or the “so what”? Why should anyone care? What is news?

• Is there a sound bite that represents the issue in a catchy, memorable way?

• Can you craft rhetoric that will represent core values of the target audience?

• How can you frame nursing’s interests as the public’s interests (e.g., as consumers, mothers, fathers, women, taxpayers, and health professionals)?

The Target Audience

• Who is the target audience? Is it the public, policymakers, or journalists?

• If the public is the target audience, which segments of the public?

• What medium is appropriate for the target audience? Does this audience watch television? If so, are the members of this audience likely to watch a talk show or a news magazine show? Or do they read newspapers, listen to radio, or surf the Internet?




Or are they likely to do all of these?

Access to the Media

• What relationships do you have with reporters and producers? Have you called or written letters or thank-you notes to particular journalists? Have you requested a meeting with the editorial board of the local community newspaper to discuss your issue and what the members of the board might think about reporting on it?

• How can you get the media’s attention? Is there a hot issue you can connect your issue to? Is there a compelling human interest story? Do you have a press release that describes your issue in a succinct, compelling way? Do you have other printed materials that will attract journalists’ attention within the first 3 seconds of viewing it? Are there photographs you can take in advance and then send out with your press release? Can you digitalize the images and make them available on a website for downloading onto a newspaper?

• Whom should you contact in the medium or media of choice?

• Are you prepared? Are you news conscious? Do you watch, listen, clip, and track who covers what and how they cover it? What is the format of the program, and who is the journalist? What is the style of the program or journalist?

• Who are your spokespersons? Do they have the requisite expertise on the issue? Do they have a visual or voice presence appropriate for the medium? What is their personal connection to the issue, and do they have stories to tell? Have they been trained or rehearsed for the interview?

The Interviews

• Prepare for the interview. Obtain information on your interviewer and the program by reviewing the interviewer’s work or talking with public relations experts in your area. Select




the one, two, or three major points that you want to get across in the interview. Identify potential controversies and how you would respond to them, and rehearse the interview with a colleague.

• During the interview, listen attentively to the interviewer. Recognize opportunities to control the interview and get your primary point across more than once. What is your sound bite? Even if the interviewer asks a question that does not address your agenda, return the focus of the interview to your agenda and to your sound bite with finesse and persistence.

• Try to be an interesting guest. Come ready with rich, illustrative stories. Avoid yes or no answers to questions.

• Know that you do not have to answer all questions and should avoid providing comments that would embarrass you if they were headlines. If you don’t know the answer to a question, say so and offer to get back to the interviewer with the information.

• Avoid being disrespectful or arguing with the interviewer.

• Remember that being interviewed can be an anxiety-producing experience for many people. This is a normal reaction. Do some slow deep-breathing or relaxation exercises before the interview, but know that some nervousness can be energizing.


• Write a letter of thanks to the producer or journalist afterward.

• Provide feedback to the producer or journalist on the response that you have received to the interview or the program or coverage.

Box 14-2 Using Social Media Mobile Text Messaging




Mobile and particularly text messaging is the ideal medium for communicating with everyone equally, regardless of their age, gender, or economic status. To get started, do the following:

• Create a subscriber base with zip codes so text alerts can be targeted to subscribers; you can then ask people in a specific Congressional district to contact their representative about an important issue.

• Send alerts about a news item, an action, or a “meet-up”—the calling of a gathering of people for a shared interest.

• Send a link to a website or local news item.

• Feature a text-alert campaign on your website homepage.

Blogging Blogs are great ways for you to share your opinions and ideas on health and social topics and to bring attention to important issues. The following are some tips for blogging:

• Be creative.

• Engage your audience and invite readers to get involved.

• Tell important stories.

• Share your process (how your organization works).

• Share successes and challenges.

• Write short, action-oriented posts.

• Link to interesting local news.

• Find your niche.

• Be a subject matter expert.

• Be conversational.




• Write like you’d talk to your neighbor.

One website that provides easy tools for starting a blog is

Facebook ( Facebook provides a vehicle for building and growing a community. Lots of people are on Facebook to stay connected with friends and family. You can also create a Facebook page for your professional life, since mixing the two can be problematic if you’re a clinician.

• Create a page for your organization or specific causes or issues; updates may include a new action item and a new goal.

• Upload relevant videos, photos, and articles.

• Turn your cause into a campaign.

• Set an achievable goal, and find a creative way to engage people to invite their friends.

• Host short-term causes.

• Use the announcements feature to keep followers informed.

• Always send new info.

• Keep it short.

• If one idea doesn’t work too well, don’t be afraid to shut it down and try a new idea!

Twitter ( Twitter asks one question, “What are you doing?” Answers must be under 140 characters in length and can be sent via mobile texting, instant message, or the Internet.

Photo and Video Sharing Sites: YouTube ( and Flickr (




Photos and videos can provide important visual messages, enabling issues to get on the public’s agenda by drawing attention to a cause. YouTube has created an online video community. Flickr is a way to manage and access photos.

Blogging and Microblogging Increasingly, blogs are used as ways to communicate personal experiences and opinions. Theresa Brown is an oncology nurse living and working in Pittsburgh. Her first career was as a doctorally prepared English professor before deciding that she wanted to work more closely with people. She wrote a narrative about a dying patient that was published on the first page of the New York Times Science section, which until then had been dominated by physicians’ narratives. She was then invited to contribute to the Times’ health blog, Well. As a result, issues of concern to practicing nurses received regular visibility through her posts. Her expertise as a nurse in cancer care is clearly valued by those who post responses to her blog entries.

Twitter, an example of microblogging, is a great way for nurses to listen as well as to talk to others on a very direct level. Twitter allows users to post short, 140-character messages (called tweets). For longer conversations, people use hashtags (# symbols) to track topics. People are very creative in the way they use Twitter and it holds a great deal of potential for nurses. For example, a Twitter TweetChat is a prearranged chat that happens on Twitter through the use of Twitter posts (tweets) that include a predefined hashtag to link those tweets together in a virtual conversation. There is even a URL that provides a schedule of health-related TweetChats ( When you can’t attend a conference but know the hashtag that is being used by those in attendance, you can search for it on Twitter, read the live tweets, and join the discussion by tweeting from wherever you are. It represents both a media and a marketing tool. Each presenter’s remarks and recommendations can reach a wider audience.

You can also use Twitter to convey a position on legislation that is up for a vote on the local, state, or national level to inform public debate on how this policy will impact the health and well-being of




individuals and communities. Also, you can use Twitter and other social media to link to relevant data supporting a particular position and to see what others are saying about this policy: Is it positive? Negative? Misinformed? Journalists frequently use Twitter to find sources of information on stories they are covering or to simply uncover new stories. Following key health journalists can provide opportunities for recommending yourself or other nurses as experts on specific topics or to help them to reframe their stories.

Digital Media and Social Networking Sites (SNS) The development of Web 2.0 has meant increased participation and media attention on virtual communities, most frequently in social networking sites (SNS) such as Facebook, Twitter, LinkedIn, Pinterest, Google+, and MySpace. The impact that SNS will have on health policy is still emerging but there are some intriguing early examples of the advantage they may hold for advocacy. For instance, Facebook is emerging as an important venue for debate about health policy, and not just among people typically thought of as policymakers. The health care reform battle sparked a huge number of for- and against-themed pages, such as Ohio Against Health Care Reform (81 fans), Wyoming for Health Care Reform (247 fans), and the perennial Facebook meme, “I bet we can find 1,000,000 people who support/oppose” health care reform. Although measuring the effectiveness of such Facebook campaigns remains elusive, we will likely see more of this type of activity as health care reform is implemented.

Not everyone understands the potential of social media for shaping advocacy. Lovejoy and Saxon (2012) examined the content of tweets from the 100 largest nonprofit organizations in the United States, 24% of which were health-oriented. The authors identified three primary communication functions: information, community, and action. They found that the bulk of communications sent information (58%), 26% reinforced community via more interactive messages, and only 16% promoted some form of action such as donating, volunteering, or engaging in advocacy. Guo and Saxton




(2014) applied the same typology to investigate the tweets of 188 civil rights and advocacy organizations and had strikingly similar findings: 67% information, 20% community, and 12% action. Research on nonprofit organizations’ use of social media has also shown that the interactive features of Facebook are often underused (Waters et al., 2009). These studies suggest that nonprofit organizations are not yet as successful at reinforcing and building an online community and then mobilizing it.

Analyzing Media The first obligation that all nurses have is to be knowledgeable consumers of media. Nurses must seek out unbiased information before taking positions on policy issues and be able to critically evaluate media messages, assess who controls the media, and identify whose vested interests are being protected or promoted. Nurses should add and to their Internet favorites and evaluate their sources.

Getting to know the nature and quality of a particular journalist’s or cyberactivist’s work can help you to decide how much to trust it. Ask the following questions: • Do they frequently misrepresent issues? • Are their stories sensationalized or exaggerated? • Do they present all sides of an issue with accuracy, fairness, and

depth? • Can you substantiate wild claims through sites such as,, and

What is the Medium? The first step is to ask yourself from where you get your information and news. • What is the reputation of the television or radio station, program,

newspaper, or website? Is it known for balanced coverage of health-related issues? Is it partisan?

• Does it cover international and national, as well as state and local,




issues? • Is it a credible source of information about health issues and

policies? These questions provide a basis to judge whether or not the

information and news you are getting is credible and representative of a broad sector of public opinion. You will need a sample of various media presentations of the issue to evaluate their messages and effectiveness.

Who is Sending the Message? Part of understanding what the real message is about comes from knowing who is behind the message and why. You could interpret the real message behind the Harry and Louise commercials against President Clinton’s health care reform legislation once you knew they were sponsored by the HIAA. If the legislation had passed, the majority of insurance companies would have been locked out of the health care market.

For news media, ask the following questions: Who owns this medium? Who sponsors the website? What are the owner’s biases? In addition, more and more newspapers and online venues are using the Associated Press (AP), or other major national papers, as their source for stories. The AP does not investigate; they attend events, accept news releases, and file reports. If newspapers are using abridged stories from other papers, the news slant or bias of the other paper reflects the bias or slant of the paper you are analyzing. As newspaper and television newsroom budgets get slashed, few news outlets are able to afford investigative journalism. To preserve this important aspect of journalism, nonprofit investigative news organizations have arisen to fill the void, such as the online Kaiser Health News, founded and supported by the Kaiser Family Foundation, and ProPublica, supported by a major multiyear commitment of funding by the Sandler Foundation. While Kaiser Health News is specific to health, ProPublica is not but does cover health issues. For example, it published a series of reports on the excessive delays in the California State Board of Registered Nursing’s actions on complaints against nurses who were found guilty of drug abuse,




sexual assaults on patients, and homicides ( The reporting by Pulitzer Prize- winning journalist Charles Ornstein and Tracy Weber resulted in the governor removing several board members who were up for reappointment and the executive secretary resigning.

What is the Message, and What Rhetoric is Used? What is the ostensible message that is being delivered, and what is the real message? What rhetoric is used to get the real message across? In 2009, pollster Frank Luntz of the Luntz Research Companies leaked a 28-page memo of sound bites and rhetoric designed to stop the Washington takeover of health care to Politico. The memo, entitled “The Language of Health Care,” is reminiscent of the analysis Luntz provided to Republicans for the 2004 presidential campaign and that was used by the Republicans to win legislative battles and political campaigns in 2006. His 2009 analysis provides insight into the language used to frame health care reform by federal policymakers. For example, he proposed that the phrase that “would ‘scare people more’ about the future of American healthcare” was: “That the government will decide what treatment I can or can’t have” (Luntz, 2009, p. 24). chose “a government takeover of health care” as the 2010 Lie of the Year because it played a key role in public opinion about the ACA (Adair & Holan, 2010). Rhetoric relies on “words that work” and those that do not work based on polling results. One of the words not to say was: private health care/free market health care. Instead, the document advocated the phrase: patient-centered health care.

Every issue has spin doctors who develop believable messages based on focus groups and polling. As messages are repeated in the media, they become believable. It is essential to be attentive to the language used in media messages whether delivered directly by policymakers, pundits, or advocates, and to evaluate the credibility, bias, and intentions of these sources. What and whom should we believe?

Images also convey important messages. As Luntz’s (2005) New American Lexicon notes, “Language is your base. Symbols knock it




out of the park. The American people cannot always be expected to directly grasp the connection between your policies and your principles. Symbols bridge this gap, so use them” (Section 2, p. 2). The document promotes the obvious symbols of the American flag and Statue of Liberty. But consider the symbols used by health insurance companies to advertise to employed individuals and families. These ads use pictures of healthy active adults and bright- eyed children rather than images of obese individuals or people disabled by arthritis to attract new members to their insurance products. These are examples of targeted media messages in which images are symbols to augment carefully crafted rhetoric to sway a target audience to believe or act in a particular way.

Is the Message Effective? Does the message attract your attention? Does it appeal to your logic and to your emotions? Does it undermine the opposition’s position?

Is the Message Accurate? Who is the reporter or cyberactivist and what reputation do they have? Are they credible, with a reputation for accuracy and balanced coverage of an issue? What viewpoints are missing? Whose voice is represented in the message or article?

Responding to the Media One of the most important ways to influence public opinion is to respond to what is read, seen, or heard in the media. Letters to the editor or call-ins to talk radio programs can be powerful ways to reframe an issue or put it on the public’s agenda.

Op-eds (thought to be derived from opposite the editorial page or opinion editorial) allow a more in-depth response to current issues and provide a way to get an issue on the public’s agenda. Although they may be solicited by a newspaper or magazine, local community papers often are eager to receive op-eds that describe an important issue, include a story that illustrates the local impact




of the problem, and suggest possible solutions. Tips for successful op-eds include:

• Keep it short and within the word limit specified by the publication.

• Hook it to a national event if the publication or website has a national focus, or to a local event for local publications.

• Have a timely topic, concisely and clearly written in a conversational style, and with an unexpected or provocative slant.

• Include details or clinical examples to bring the commentary alive.

• Use data to support your argument • Define the problem, possible solutions and include a call to action.

Similarly, letters to the editor should be written immediately after the original story is published and follow the publication’s guidelines for letters. They should be concise and make a specific point relevant to the article.

Calling in to talk radio provides another opportunity for sharing your perspectives. Identify yourself as a registered nurse and stay on the line while the host or program guest responds to your point or question. You may need to correct a misunderstanding or offer additional clarifying information.

Finally, it is always a good idea to contact a journalist to thank him or her for a good story. If you have a blog, be sure to link to the story in a post. If you see a tweet you like, you can retweet it to others who follow you. If you are on Facebook and like someone’s posting, you can click on the Like icon and continue the spread of the posting.

Conclusion Nurses have not always been taught how to use the media as a health promotion tool. Harnessing the traditional and new social media will provide opportunities to shape healthy public policies and engage in political activism.




Discussion Questions 1. What are your major news sources? What are the potential biases of these sources?

2. How is framing and rhetoric shaping media discussions of a current health or social policy issue? What are the competing frames or rhetoric? How else might the issue be framed?

3. If you were to talk with a journalist about an issue of concern to you, how would you frame the issue? What language or images would you use for the frame?

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Health Policy, Politics, and Professional Ethics Carol R. Taylor, Susan I. Belanger

“To see what is right and not do it is want of courage.” Confucius

Writing in the Encyclopedia of Bioethics, Dan Callahan, one of the founders of U.S. bioethics, states that three paramount human questions lie at the heart of bioethics: • What kind of person ought I be to live a moral life and make good

ethical decisions? • What are my duties and obligations to other individuals whose

life and well-being may be affected by my actions? • What do I owe the common good or the public interest, in my life

as a member of society? The authors of this chapter believe that too few nurses take

seriously their responsibilities as citizens, in spite of being frequently reminded that the sheer numbers as the largest group of health professionals (3.1 million) and as the most trusted professionals (Gallup’s annual honesty and ethics survey), make us a formidable force (2013). Ethics may be defined as the formal study




of who we ought to be, how we should make decisions and behave. This chapter centers around what is reasonable to expect of professional nurses as citizens in regard to designing and delivering a just health system that meets the needs of all, with special concern for the most vulnerable.

Designing a system for delivering health care that adequately meets the needs of a diverse public is a complex challenge. Health care planners have always worried about access, quality, and cost. Who should get what quality of care and at what cost? What you think about health care in the United States largely depends on your past experiences. If you are well insured or independently wealthy, you can access the best health care in the world. If you lack insurance and have limited financial resources, you may die of a disease that might have been prevented or treated at an early stage if you had had access to quality care. The U.S. system has been criticized for providing too little care to some and too much of the wrong type of care to others. Many now believe that a moral society owes health care to its citizens. Health care is like clean water, sanitation, and basic education. Others, however, believe that health care is a commodity, like automobiles, to be sold and purchased in the marketplace. If you lack the funds to buy a car, that may be sad, but society has no obligation to purchase a car for you. As you read this chapter, ask yourself what you believe about health care. Is it simply unfortunate if people cannot afford the health care they and their families need?

Daily nursing practice and people’s health, wellbeing, and dying are directly affected by decisions made by governments, insurers, and health care institutions. Nursing needs a seat at these decision- making tables and nurses must be prepared and willing to take these seats. As the country’s most trusted health care professionals, the nurses in these seats must be committed to ethical decision making. Drivers for much of human enterprise are power, position, prestige, profit, and politics (Barnet, n.d.). Strikingly absent from this list are people, patients, the public, and the poor! Nursing’s challenge, as profits and politics increasingly dictate health priorities, is to keep health care strongly focused on the needs of patients, their families, and the public. Health care in the United States is a business, revenues need to be generated to make care




possible, but health care can never be only a business. First and primarily, it is a service a moral society provides for its vulnerable members. Nurses play a critical role in keeping health care centered on the people it purports to serve.

This chapter opens with a description of the ethics of influencing policy and explores the professional ethics of nurses and their advocacy and health policy responsibilities. It offers a brief analyses of how nurses can use their voice to influence policy regarding scarce resource allocations and workplace issues. Throughout, short reflective practice vignettes invite readers to reflect on the adequacy of their moral agency in select advocacy challenges.

The Ethics of Influencing Policy An ethical critique of human behavior involves paying attention to the intention of the moral agent, the nature of the act performed, the consequences of the action, and the circumstances surrounding the act. Ethics has to do with right and wrong in this world, and policy and politics has everything to do with what happens to people in this world. Moreover, both ethics and politics have to do with making life better for oneself and others. Surely both deal with power and powerlessness, with human rights and balancing claims, with justice and fairness, and with good and evil. And good and evil are not the same as right and wrong. Right and wrong pertain to adherence to principles; good and evil pertain to the intent of the doer and the impact the deed has on other people. Surely policy and politics involves justice in the distribution of social goods; fairness and equity in relationships among and between people of different races, genders, and creeds; and access to education and assistance when one is in need. Although the goodness of an action lies in the intent and integrity of the human being who performs it, the rightness or wrongness of an action is judged by the difference it makes in the world. Therefore the principles applied in ethical analysis generally derive from a consideration of the duties one person owes another by virtue of commitments made and roles assumed, and/or a consideration of the effects that a choice of action could have on one’s own life and the lives of others.

In a perfect world, legislators would all intend the good of the




public they serve and use ethical means to achieve good outcomes. In the real world, legislators and lobbyists intend many things other than the good of the public and some use unethical means to achieve dubious ends. A democracy with an increasingly heterogeneous public necessarily involves compromise. Which strategies to influence policy can nurses use without sacrificing personal and professional integrity? Each advocacy strategy involves a variation of the same question, that is, what means can be legitimately used to achieve an end that someone (or a political party or the electorate) believes to be good? The ends-and-means argument is often explained as follows. We can cut a man open (an evil means) to save his life (a good end). We can remove a perfectly healthy kidney from one person (an evil means) to transplant it to save the life and health of another (a good end). We admire the person who sacrifices his life (an evil means) to save the life of his friend (a good end). If our intention (to produce a good) can justify the means (doing an evil), then why can’t we torture one man (an evil means) to gain information that might save another person’s life or even the lives of many people (a good end)? Should we assure the passage of health care insurance reform (a good end) by strong-arm tactics (an evil means)?

It is important to note that cutting a person open, even to save his life, is not a good thing unless the person consents to it. Similarly one cannot steal one person’s kidney even to save another; rather, the consent of both donor and recipient is required. The prisoner does not choose to be tortured; although it is very tempting to justify torture to protect innocent lives, if a man can be tortured on the suspicion that he may know something subversive, who is safe from governmental oppression? The price we pay for freedom and human rights is to grant them to all people, not just a favored few. And yes, it is risky, and yes, it may reduce our “efficiency” and in some cases it may even lead to loss of life. But the alternative is that no one has rights (i.e., just claims); rights become the privilege of a favored group, while all other individuals are utterly helpless before the power of the state.

Certainly the electorate does not consent to the corruption of the legislative process, and even if a majority did approve of bending the rules of fair engagement to ensure that a particular piece of




legislation is passed, would that make it right? Would it not end up threatening the very foundations of a free society (because the foundation of a republic lies in the honesty of its processes)? What are the differences between normal legislative wrangling and abuse of power? What does it mean when political parties refuse to participate in the legislative process and/or use blatant scare tactics? What is legitimate dissent, and what is a refusal to accept democratic outcomes unless you happen to agree with them? Without civil disobedience, we would still have the Jim Crow laws. And without respect for the law, a society degenerates into either despotism or anarchy.

When people ask whether it is wrong to lie about something (e.g., the number of people affected by a particular disease) to get funding for research and/or treatment of patients with a particular disease, in a word the answer is yes. It is wrong. Why is lying wrong? It’s wrong because it undermines the foundation of any relationship: trust. In like manner, lying to further a political agenda is wrong not only because it undermines trust, but also because it fosters further dishonesty. Judging by the amount of political dishonesty reported in the media, one is led to the conclusion that there is a lot of lying going on! Adding to it, telling more lies to further our own agenda, will only make matters worse.

Reflective Practice: Pants on Fire Sarah Palin is famous for urging her supporters to oppose Democratic plans for health care using the scare tactic of death panels. She said the Democrats plan to reduce health care costs by simply refusing to pay for care:

And who will suffer the most when they ration care? The sick, the elderly, and the disabled, of course. The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s death panel so his bureaucrats can decide, based on a subjective judgment of their level of productivity in society, whether they are worthy of health care. Such a system is downright evil.




In fact there was no panel in any version of the health care bills in Congress that judges a person’s level of productivity in society to determine whether they are worthy of health care.

The truth is that the proposed health bill would have allowed Medicare, for the first time, to pay for optional doctors’ appointments for patients to discuss living wills and other end-of- life issues with their physicians. PolitiFact awarded Palin with the 2009 Lie of the Year for the death panel claim, but the political impact of her statement is hard to overstate. In 2011, the Obama administration even deleted all references to end-of-life planning in a new Medicare regulation when opponents interpreted the move as a back-door effort to allow such planning. So even, in the regulations Palin achieved her goal (Holan, 2009).

Discussion Questions 1. How do you judge Palin’s quote? Effective strategy to oppose Democrats’ plans for health care reform or unethical scaremongering?

2. Reflect on what informs your judgment: commitment to advance care planning, analysis of facts, political party loyalties?

3. Is it right for nurses to endorse health reform legislation even if the legislation is not perfect? (The answer is yes; it may indeed be the right thing to do.)

Remember, politics is about relationships, and relationships cannot prosper when one party insists that the other party must agree with them on every (or even any) issue. It is not wrong to compromise; compromise is part of the give and take of relationships, and it is part of the give and take of politics. What is critical is knowing when it is possible to compromise without sacrificing personal integrity. This prompts the question of whether it can be acceptable to distort an issue to manipulate public opinion or to win the support of a particular piece of legislation. It is usually, however, possible to frame a discussion in a manner that is more acceptable to a certain constituency without lying in this




manner. For example, in the health care arena, one can use words that appeal to known values, words such as tradition and legitimate authority (words that tend to appeal to conservatives), and words such as autonomous and experimental (words that tend to appeal to liberals). Knowing the target audience and framing the issue in words that will help them listen (or at least not harden their opposition) is smart, not unethical. Now to return to the issue of nurses’ (and others’) lobbying activities: Here compromise is in order. Any professional group has a duty imposed on it by both its social role and its code of ethics, to push forward laws and policies that protect or advance the best interests of those whom they serve. And finally, any citizen, particularly a knowledgeable one, has a civic duty to speak out for the common good.

Professional Ethics A professional ethic is built around three essential components:

1. Its purpose. All professions develop in response to a social need, one that the members of the profession promise to meet. Put in legalistic terms, this need (along with the power and privileges society grants to the profession to help the professionals meet the need) and the profession’s promised response to it constitute the profession’s contract with society.

2. The conduct expected of the professional. The ethical code developed and promulgated by the profession, its code of ethics, describes the conduct society has a right to expect from professionals as they go about the business of the profession. However, it is not a list of prescribed do’s and dont’s but rather an articulation of those values that, in fact, outline the scope of the profession’s practice and the relationships that ought to pertain between its members and the lay public, among the practitioners of this profession, between the practitioner and the profession itself, and between the professional and the community within which he or she practices.

3. The skills and outcomes expected in professional practice. Nursing’s standards of practice state with some precision the obligations of




nurses in specific areas of practice. Clearly, each of these components is dynamic, that is, subject to change and reevaluation as the profession grows, as knowledge increases, and as social mores and expectations develop. This is not to claim that there are no constants (e.g., a general imperative to respect persons), but rather to say that the meaning and application of the imperatives change.

Professional ethics is the study of how personal moral norms apply or conflict with the promises and duties of one’s profession. Society demands that professionals be held to a separate moral standard of conduct because the choices professionals make affect other people’s lives more than their own. Nursing’s foundational documents make each nurse’s advocacy and health policy responsibilities clear. Although some may think that advocacy and health policy are an ethical ideal, they are rather a nonnegotiable moral obligation embedded in the nursing role. The ANA Code of Ethics for Nurses states: “The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient” (2010). The 2015 revision of the Code of Ethics (soon to be published) places an even stronger emphasis on nursing’s advocacy responsibilities. ANA’s Social Policy Statement: The Essence of the Profession was published in 1980 and revised in 1995, 2003, and 2010. The introduction to the 2003 revision emphasizes nurses’ central role in effecting health policy.

Nursing is the pivotal health care profession, highly valued for its specialized knowledge, skill, and caring in improving the health status of the public and ensuring safe, effective, quality care. The profession mirrors the diverse population it serves and provides leadership to create positive changes in health policy and delivery systems (p. 1).

The 2003 revision also included for the first time in its list of values and assumptions of nursing’s social contract, “Public policy and the health care delivery system influence the health and well- being of society and professional nursing” (p. 4). This phrase appears again in the 2010 revision under the heading, “The elements of nursing’s social contract” (p. 6). The 2010 revision also notes as a key social concern in health care and nursing “Expansion




of health care resources and health policy” (p. 4).

Reflective Practice: Foundational Nursing Documents The American Nursing Association publishes three documents packaged as the Foundation of Nursing Package, 2010. Included in the package are the Code of Ethics for Nurses and the revised Nursing Social Policy Statement and Nursing Scope and Standards of Practice. Together these documents describe what is reasonable for the U.S. public to expect of nurses. As this text goes to press, a newly revised Code of Ethics is being studied and may be available as early as 2015.

It is the responsibility of every professional nurse to be familiar with these foundational documents and to continually assess if her/his professional practice is congruent with what is expected.

Personal Questions 1. When, if ever, did you read and reflect on these core documents?

2. In what ways do you expect your Code of Ethics to change? Do you support these changes?

3. Have you participated in discussions about how these documents pertain to your practice and what they suggest as growth opportunities for you or your colleagues?

4. What is reasonable to expect of every professional nurse in regard to advocacy and health policy?

Moral Agency and the Nurse Once professional nurses understand what is reasonable for the public to expect of them, the next step is to determine if one has the capacity to meet these expectations. In other words, one must ask, “Am I trustworthy?” Moral agency is quite simply the ability to be




what is professed: a human, a parent, a professional nurse. Moral agency in any specific situation requires more than knowing what is right to do; it also entails: • Moral character: Cultivated dispositions that allow one to act as

one believes one ought to act. • Moral valuing: Valuing in a conscious and critical way which

squares with good moral character and ethical integrity. For nurses this is a commitment to patient well-being and a degree of altruism.

• Moral sensibility: The ability to recognize the moral moment when an ethical challenge presents.

• Moral responsiveness: The ability and willingness to respond to the ethical challenge.

• Ethical reasoning and discernment: The knowledge of, and ability to use, sound theoretical and practical approaches to thinking through ethical challenges and to ultimately decide how best to respond to this particular challenge after identifying and weighing alternative courses of action; using these approaches to both inform and justify moral behavior. (See Box 15-1.)

Box 15-1 Ethics Inventory Think about a recent ethical challenge you encountered in practice.

• What signals you to an ethical challenge? Intellectual disconnect? Queasy feeling in the pit of your stomach? Discomfort or disappointment in the way you or your team are responding? Yuck factor?

• Pay attention to how you reason as you think about how you should and would respond.

• What informs your judgment? Rephrased, how do you calibrate your moral compass?

• Are there moral rules that apply?




• Do you have a responsibility to respond? Are you personally able and willing to respond? Are there institutional or other external variables making it difficult or impossible to respond?

• What counts as a good response? What criteria/principles do you use to inform, justify, and evaluate your response?

• Promotes human dignity and the common good

• Maximizes good and minimizes harm

• Justly distributes goods and harms

• Respects rights

• Responsive to vulnerabilities

• Promotes virtue

• Compatible with Code of Ethics for Nurses

• Other

• What criteria/principles do you use to critique/evaluate your response?

• We stayed out of trouble, not greatly inconvenienced.

• We made money or at the very least didn’t lose money!




• Our patient satisfaction scores will be high, or at least not negative

• Able to put my head on my pillow and fall asleep peacefully

• My/our reputation is intact.

• Transparency [Washington Post test; I could share how I/we responded with my children and feel proud.]

• Consistency

• Other

• Are there any universal (nonnegotiable) moral obligations that obligate all health care professionals?

• To whom would you turn if you were uncertain about how to proceed?

• What agency resources exist to help you think through and secure a good response? How confident are you that these resources would facilitate a good resolution of your concern?

• Can you translate your moral judgments about how best to respond into action? If you believe that institutional or other variables are making it impossible to do what you believe is the ethically right thing to do, what are your options?

• Moral accountability: The ability and willingness to accept responsibility for one’s ethical behavior and to learn from the




experiences of exercising moral agency. • Transformative moral leadership: Commitment and proven ability to

create a culture that facilitates the exercise of moral agency, a culture in which individuals are supported in doing the right thing simply because it is the right thing to do (Taylor, 2015).

Nurses who value their moral agency are familiar with the principles of bioethics which commit them, all things being equal, to: (1) respect the autonomy of individuals, (2) act so as to benefit (beneficence), (3) not harm (nonmaleficence), and (4) give individuals their due (justice). Other principles include keeping promises (fidelity) and responsiveness to vulnerability. A commitment to social justice and the common good has long characterized the profession of nursing. This commitment calls for the creation of a society in which all can flourish, not only the affluent, and the creation of a bottom floor beneath which no one can fall regarding access to basic nutrition, safe housing, education, health care, and employment.

Reflective Practice: Negotiating Conflicts between Personal Integrity and Professional Responsibilities Shortly after the Department of Health and Human Services (HHS) announced the new federal rule that required all new private plans to cover prescribed FDA-approved contraceptive methods without cost-sharing, a number of corporations sued, claiming that this new requirement violates their religious rights. These lawsuits have worked their way through the federal courts and on November 26, 2013, the Supreme Court agreed to hear two cases that involved for- profit corporations. The Court agreed to hear a case from the Tenth Circuit Court of Appeals, which ruled in favor of Hobby Lobby, an Oklahoma-based chain of craft stores owned by a Christian family who claim that the contraceptive coverage requirement violates their company’s religious freedom. The Court also agreed to hear a case from the Third Circuit Court of Appeals, which ruled against the corporation and its owners, finding that Conestoga Wood




Specialties, a cabinet manufacturer, does not have religious rights. The Supreme Court decided to take these cases to resolve the conflict between the two decisions along with other U.S. Courts of Appeals’ rulings (Sobel & Salganicoff, 2013).

Personal Question 1. You are a women’s health nurse practitioner and are asked to collaborate on filing an amicus brief to the court supporting women’s rights to free approved contraceptive methods. From your practice you know how important women’s accessibility to these methods are and have sat with many a tearful woman contemplating an unplanned pregnancy. You are Christian, however, and you support your church’s stance on not using contraceptive methods. You feel torn between maintaining your personal integrity and fulfilling your nursing obligation to aid poor women without access to basic reproductive services. How will you reconcile your conflict?

It is important to note here that effecting the right courses of action is not merely within the scope of the moral agency of the nurse. Ethics happens in the realm of the individual, the institution, and society, and each can profoundly influence the others (Glaser, 1994). A nurse with strong moral agency who is committed to health policy reform can have a profound influence on the practice of nurses working in institutions and can also influence the public’s health. Similarly, a nurse with strong moral agency who is practicing in an institution willing to sacrifice patient safety and well-being for financial profit in a society that has yet to guarantee basic health care for all may feel compromised at every turn. When a nurse knows the right course of action for a patient, family, or community and is prevented by internal or external variables from translating this knowledge into action, moral distress results, which, if unresolved over time, builds up moral residue (Epstein & Hamric, 2009; Rushton, 2006). Put yourself in the shoes of a nurse working in a busy inner city emergency room. Every day he discharges patients with instructions for follow-up treatment that he knows will never happen because of a lack of financial or




personal resources. His choices seem to be to stop caring in order not to experience frustration or distress, to show up for work like a robot and do his job, or to find meaning and purpose in working collaboratively to change the system.

U.S. Health Care Reform A just and caring society provides for the health care needs of its people. The 2010 Commonwealth Fund International comparison of the U.S. health system concluded that despite having the most costly health system in the world, the United States consistently underperforms in most dimensions of performance relative to other countries. “Compared with six other nations—Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom —the U.S. health care system ranks last or next-to-last in five dimensions of a high-performance health system: quality, access, efficiency, equity, and healthy lives” (Davis, Schoen, & Stremkis, 2010). The report was hopeful that newly enacted health reform legislation in the United States would address these problems by extending coverage to those without and helping to close gaps in coverage, leading to improved disease management, care coordination, and better outcomes over time.

A discouraging 2013 Institute of Medicine report, U.S. Health in International Perspective: Shorter Lives, Poorer Health, concluded that although the United States is among the wealthiest nations in the world, it is far from the healthiest. Despite spending far more per person on health care than any other nation, the United States has more people dying at younger ages than people in almost all other high-income countries. Among 16 peer nations, all affluent democracies, the United States is at or near the bottom in nine key areas of health: infant mortality and low birth weight, injuries and homicides, teenage pregnancies and sexually transmitted infections, prevalence of HIV and AIDs, drug-related deaths, obesity and diabetes, heart disease, chronic lung disease, and disability. Included as factors linked to the U.S. disadvantage are inadequate health care, unhealthy behaviors, and adverse economic and social conditions. “The tragedy is not that the United States is losing a contest with other countries, but that Americans are dying and




suffering from illness and injury at rates that are demonstrably unnecessary” (Woolf & Aron, 2013).

Access to Health Care Any discussion of health care access must include a review of human rights and a discussion of whether or not there is such a thing as a human right to health care services, and whether or not a just society would provide a legal right to such services. A human right is a justice claim to an essential, universal human need. The justice of the claim is affected by (1) the universality of the need, (2) the extent to which a person can meet his or her own needs, and (3) the extent to which others can help meet these needs without compromising their own fundamental needs. Some argue that health care services, or at least illness care services, are not a human right; however, a far larger number think that such needs can easily meet each of these criteria, at least under a variety of circumstances. For almost a century, Presidents and members of Congress have tried and failed to provide universal health benefits to Americans. There are a few simple facts that are important: (1) the United States is the only industrialized country in the world that does not offer some type of universal health care; (2) each year tens of thousands of Americans lose their health care coverage caused by circumstances beyond their control; and (3) the main reason that Americans file bankruptcy is outstanding medical bills. The American Nurses Association website chronicles nurses’ decades- long efforts to advocate for health care reforms that would guarantee access to high-quality health care for all.

Reflective Practice: Accepting the Challenge The Affordable Care Act (ACA) has been challenged at every turn. In the 2014 State of the Union address, President Barack Obama reported:

One last point on financial security. For decades, few things




exposed hard-working families to economic hardship more than a broken health care system. And in case you haven’t heard, we’re in the process of fixing that.

. . . Already, because of the Affordable Care Act, more than 3 million Americans under age 26 have gained coverage under their parents’ plans.

More than 9 million Americans have signed up for private health insurance or Medicaid coverage—9 million.

And here’s another number: zero. Because of this law, no American, none, zero, can ever again be dropped or denied coverage for a preexisting condition like asthma or back pain or cancer. No woman can ever be charged more just because she’s a woman. And we did all this while adding years to Medicare’s finances, keeping Medicare premiums flat and lowering prescription costs for millions of seniors.

. . . That’s why tonight I ask every American who knows someone without health insurance to help them get covered by March 31st. Help them get covered. . . . Citizenship demands a sense of common purpose; participation in the hard work of self-government; an obligation to serve to our communities (Obama, 2014).

Personal Question 1. You eagerly watched the State of the Union Address but you have mixed feelings about the ACA. You come from a family who greatly distrust big government and want the Act repealed. As a public health nurse you interact with families everyday who are complaining about difficulties enrolling in their state’s online health insurance program. You’ve read about the successes some have had




by contacting navigators in the governor’s Office of Health Reform but you know that many don’t know how to initiate this contact. Are you obligated to do all you can to get coverage for the public you serve even if this means setting aside your political commitments?

A 2013 U.S. Subcommittee on Primary Health and Aging reported that nearly 57 million people in the United States, one in five Americans, live in areas without adequate access to primary health care caused by a shortage of providers in their communities. The facts in this report are sobering: • Fifty years ago, half of the physicians in the United States

practiced primary care, but today fewer than one in three do. • As many as 45,000 people die each year because they do not have

health insurance and do not get to a physician on time. • The average primary care physician in the United States is 47

years old, and one-quarter are nearing retirement. In 2011, about 17,000 physicians graduated from American

medical schools. Despite the fact that over half of patient visits are for primary care, only 7% of the nation’s medical school graduates now choose a primary care career (Sanders, 2013).

Reflective Practice: the Medicaid 5% Commitment—an Appeal to Professionalism More than one fifth of the U.S. population is ensured through Medicaid, a number that is growing rapidly as the ACA is implemented (The Kaiser Commission on Medicaid and the Uninsured, 2014). The Congressional Budget Office predicts that nine million additional people will gain coverage through Medicaid in 2014. One key concern is whether the increased demand will be adequately met, whether there will be a sufficient number of clinicians who accept new Medicaid patients. At the present about 30% of office-based physicians do not accept new Medicaid patients. In certain specialties, the percentage is considerably




higher. The Medicaid reimbursement rates vary by state; in some cases they are so low that physicians regularly lose money on Medicaid patients.

In a recent article in the Perspective section of The New England Journal of Medicine, Lawrence Casalino proposed asking each physician to commit to providing care for enough Medicaid enrollees so that at least 5% of their practice consists of Medicaid patients (2013). Casalino concludes his short article with these words: “A 5%-commitment campaign would be a meaningful, highly visible demonstration of physician professionalism—of putting patients first.”

Discussion Question 1. Nurses have always been at the forefront in ensuring that all have access to safe, effective, and appropriate care. How likely are today’s advanced practice nurses to respond to Casalino’s challenge by ensuring that their practice commits to providing at a minimum care for enough Medicaid enrollees so that at least 5% of their practice consists of Medicaid patients? Will advanced practice nurses partnering with physicians be able to bring this issue to the practice and be skilled in effecting a positive response to Casalino’s appeal to professionalism?

Reflective Practice: Your State Turned Down Medicaid Expansion As part of the ACA’s broader effort to ensure health insurance coverage for all U.S. residents, the federal government from 2014 to 2017 has agreed to pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. States that participate in the ACA expansion must provide Medicaid coverage to all state residents below a certain income level. As of January 2014, 26 states and the District of Columbia were expanding Medicaid (The Advisory Board Company, 2014). Every state that opted out has a Republican governor. Dickman and




colleagues (2014) report that the Supreme Court’s decision to allow states to opt out of Medicaid expansion will have adverse health and financial consequences. Based on recent data from the Oregon Health Insurance Experiment, they predict that many low-income women will forego recommended breast and cervical cancer screening; diabetics will forego medications; and all low-income adults will face a greater likelihood of depression, catastrophic medical expenses, and death. Disparities in access to care based on state of residence will increase. Because the federal government will pay 100% of increased costs associated with Medicaid expansion for the first three years (and 90% thereafter), opt-out states are also turning down billions of dollars of potential revenue, which might strengthen their local economy.

Personal Question 1. You practice in a mobile van that serves poor children and families in the inner city. You have seen many media stories about families who are receiving badly needed health care for the first time in their lives because they now have coverage. You are exasperated with your state representatives who have repeatedly blocked efforts to expand Medicaid and worry about your state’s ability to pay the costs of Medicaid in the future. You have personal knowledge of corruption within your state’s current administration and are wondering if you should go public with your knowledge or feed it to the opposite party to ensure that current leaders will not be re-elected. What do you do?

Allocating Scarce Resources Health care resources are limited. No system has the financial resources to provide the best care, to everyone, in all situations (Hope, Reynolds, & Griffiths, 2002). Therefore, we look to the principles of distributive justice for answers.

Principles of Distributive Justice. Health care professionals, who are ideally situated to make




microdistributive decisions and whose social role enables them to speak with authority to the general population about the impact of resource allocation decisions on the health and welfare of various segments of the population, must not allow social decisions to influence their clinical decisions. First, their ethical codes require, and for good reason, that health care professionals act in the best interests of the person on whom they are laying hands. Second, the will of the citizenry, as expressed through the votes of their elected representatives, should determine the distribution of the resources they have so diligently (if unwillingly) supplied to their governments. In general, the principles of distributive justice ought to be used to guide decision making at the sociopolitical levels. They are as follows:

1. To each the same thing. One of the simplest principles of distributive justice is that of strict or radical equality. The principle says that every person should have the same level of material goods and services. Even with this ostensibly simple principle, some of the difficult specification problems of distributive principles can be seen, specifically construction of appropriate indexes for measurement and the specification of time frames. Because there are numerous proposed solutions to these problems, the principle of strict equality is not a single principle but a name for a group of closely related principles.

2. To each according to his need. The most widely discussed theory of distributive justice in the past three decades has been that proposed by John Rawls in A Theory of Justice (Rawls, 1971) and Political Liberalism (Rawls, 1993). Rawls proposes the following two principles of justice: (1) Each person has an equal claim to a fully adequate scheme of equal basic rights and liberties, and (2) social and economic inequalities are “to be to the greatest benefit of the least advantaged members of society” (Rawls, 1993, pp. 5-6). These principles give fairly clear guidance on what type of arguments will count as justifications for inequality. For example, the second principle would accept income disparities if these led to the greatest benefit to the least advantaged members of society (created job opportunities for the least well off) but would not support the rich getting richer at the expense of the poor.




3. To each according to his ability to compete in the open marketplace. Aristotle argued that virtue should be a basis for distributing rewards, but most contemporary principles owe a larger debt to John Locke. Locke argued that people deserve to have those items produced by their toil and industry, the products (or the value thereof) being a fitting reward for their effort. His underlying idea was to guarantee to individuals the fruits of their own labor and abstinence. According to some contemporary theorists (Feinberg, 1970), people freely apply their abilities and talents, in varying degrees, to socially productive work. People come to deserve varying levels of income by providing goods and services desired by others (Feinberg, 1970). Distributive systems are just insofar as they distribute incomes according to the different levels earned or deserved by the individuals in the society for their productive labors, efforts, or contributions.

4. To each according to his merits (desserts). Merit-based principles of distribution differ primarily according to what they identify as the basis for deserving. Most contemporary proposals regarding merit fit into one of three broad categories (Miller, 1976, 1989):

• Contribution: People should be rewarded for their work activity according to the value of their contribution to the social product.

• Effort: People should be rewarded according to the effort they expend in their work activity.

• Compensation: People should be rewarded according to the costs they incur in their work activity.

To illustrate some of the difficulties inherent in rationing decisions, we will discuss the case of Sarah Murnaghan. Sarah is an 11-year-old with cystic fibrosis. In June of 2013, Sarah received national media attention when her parents petitioned a federal judge to change the rules governing the allocation of organs to




allow Sarah to be placed on the adult lung transplant list (Carroll, 2013). Sarah urgently needed a lung transplant. The family argued the severity of Sarah’s illness, not her age, should be considered in deciding whether she receives an organ. Shortly thereafter, Sarah received two double lung transplants with adult lungs (Aleccia, 2013). Sarah’s case raised questions about whether it was ethical to change the transplant allocation process based on one child’s situation.

There were many concerns raised about Sarah’s case, but the main one related to the judge’s decision to allow Sarah to be listed on the adult transplant list. Many agree that politicians and judges should not intervene in this type of decision making, noting they rarely have all the information to make an informed judgment (Caplan, 2013; Tomlinson, 2013). Professional organizations and experts are better suited than government officials to decide such matters. In this situation, experts believed the decision should have been left to the United Network for Organ Sharing (UNOS), whose role is to oversee a fair and equitable process of organ allocation (UNOS, 2014). Clinicians with expertise in the area of transplantation for children agreed that if the usual process had been allowed, Sarah would not have moved to the adult list (HRSA, 2013).

Another justice issue in Sarah’s case concerned the displacement of adults from the transplant list. It is believed that children do better with child lungs than with adult lungs, so should Sarah have receive an adult lung? The transplant process is complex and the rules governing the process are meant to be fair and equitable for all. Placing Sarah on the adult list meant another recipient, with potentially a greater need, would not receive a lung.

Looking at Sarah’s transplant from an ends and means argument, it can be said that receiving a transplant to allow Sarah to live is a good end. However, considering the means to that end, it could be said that Sarah’s good end was obtained by an evil means. An ethical act is one that results in more benefits than harms to others. By displacing others from the transplant list, and by changing a previously established fair and equitable process, many would agree that Sarah’s transplant was obtained by evil means, thereby making it an unethical act.




Nurses can often experience moral distress in situations such as Sarah’s. Moral distress is experienced when nurses feel helpless to act in a way that benefits their patients. No one can fault Sarah’s parents and medical team for wanting treatment to save her life. In the day-to-day care of patients, nurses can often cite a case when patients were not afforded the same level of material goods and services as others. Many would also say that benefits go to those who complain the loudest or pay the most. The least advantaged among us are the most often forgotten. Yet, in considering Sarah’s case, nurses must be cognizant of the patients who were displaced by Sarah’s movement to the top of the list. Should the way to procure a much-needed service be the result of a media frenzy, with the best politician winning? Of course not. However, gathering data, advocating for system changes when warranted, and raising awareness of the issues are all actions nurses can take to improve the situations of the patients they serve. Nurses can assist in promoting fair and compassionate treatment decisions by publishing their research, by raising awareness of allocation issues, and by remaining good stewards of available resources.

Reflective Practice: Barriers to the Treatment of Mental Illness Austin Deeds, the son of Virginia State Senator Creigh Deeds, was discharged home in November 2013 from a Virginia hospital emergency room because there were no open psychiatric beds. He then stabbed his father and killed himself. The tragedy focused national attention on the need for a major investment in the nation’s mental health system. A 2008 report, Treatment Advocacy Center (TAC) found 17 public psychiatric beds per 100,000 U.S. citizens, down from 340 beds per 100,000 in 1955 (Torrey et al., n.d.). Although effective assisted outpatient treatment programs are available in 45 states, TAC reports that implementation of AOT is often incomplete or inconsistent because of legal, clinical, official, or personal barriers to treatment. The center lists the following clinical barriers to treatment: (1) hospitals, physicians, and mental health professionals who are unaware of the laws and/or don’t know how




to use them and (2) identification mechanisms that would enable hospital emergency rooms, law enforcement, and others to immediately recognize individuals under court-ordered outpatient treatment. Official barriers include perceived or projected fiscal impacts on local government, shortage of public personnel with knowledge or training in implementing the laws, opposition by the mental health officials charged with implementing the laws and standards, and opposition from tax-funded protection and advocacy groups (TAC, 2014).

Personal Question 1. You chair a local chapter of the Emergency Nurses Association and practice in an inner city hospital serving a large number of individuals with mental health impairments in a state without an outpatient treatment program. You would like your chapter to address everyday challenges procuring psychiatric care in your state. How can you leverage your health policy responsibilities for this population and bring about needed change?

Ethics and Work Environment Policies Politics, defined as “any activity concerned with the acquisition of power, gaining one’s own ends,” is not just for elected officials (Politics, n.d.). Politics are alive and well in every aspect of health care, from the operating room of a small community hospital to the board room of a multibillion-dollar pharmaceutical company. Every day, health care administrators make decisions that impact both nurses and the populations of patients they serve. Nurses are in key positions to influence hospital decision makers and to share the realities of the day-to-day care of patients. Nurses have the greatest influence when they are well-informed, open-minded, collaborative, and willing to do what is right even if there is a personal cost. Here we examine one workplace policy where nurses have the power to influence outcomes, the issue of mandatory flu





Mandatory Flu Vaccination: the Good of the Patient Versus Personal Choice In the opening paragraph, we asked, “What do I owe the common good or the public interest in my life as a member of society, or more specifically as a member of the nursing profession?” Discerning the right course of action is not always easy. For this discussion, we will consider the issue of mandatory flu vaccinations.

A Pennsylvania nurse was 3 months’ pregnant when she was fired from a home infusion company for refusing a mandatory flu vaccine. She was fearful that receiving the vaccine might cause her to miscarry her baby (Lowes, 2014). She had previously experienced two miscarriages before becoming pregnant again. When she presented the required documentation from a physician recommending she not be vaccinated, the note was rejected. Her agency noted the physician failed to cite a medical reason for the exemption. Fear and anxiety were not considered valid reasons. The agency was unwilling to grant the nurse the option of wearing a mask because, as a home care nurse, it would have been difficult to enforce and doing so also placed her immunocompromised patients at risk (Lowes, 2014).

Although we as individuals might make the same decision as our colleague from Pennsylvania, as a profession we also have the responsibility to serve the good of our patients. How do we maintain that balance? When considering mandatory flu vaccination policies, nurses must consider the interests of the individual with those of the population, in this case, the population of patients served. Ethical arguments in this situation weigh personal choice (autonomy) against the best interests of patients. Many argue that a nurse’s duty not to harm patients outweighs any restriction on personal choice (Antommaria, 2013; Tilburt et al., 2008). Likewise, fairness and promoting the good of patients compels nurses to consider ways to provide protection for their vulnerable patients and to keep them safe (Steckel, 2007).




Working though challenging issues is not easy. Using the Ethics Inventory to evaluate our personal approach to ethical issues is a good step toward improving our moral sensibility and moral valuing. Asking ourselves the question, “What counts as a good response?” can make us more aware of how we promote the common good and dignity of others. Do we maximize good and reduce harm for our patients? Do we act with virtue in difficult situations by speaking up when it may not be popular to do so? Do we act justly and/or advocate for justice in our work environments? Are we responsive to the vulnerabilities of others? Nurses are the most trusted of all professionals. Given our sheer numbers, think about the impact we could have if we shared one common voice to improve the care of the vulnerable.

Conclusion Denise Thornby, former president of the American Association of Critical Care Nurses, always charged nurses to make waves. She exhorted nurses to identify when health care was not working for people in need and to do whatever was necessary to address the need. She died in the summer of 2012. We cannot think of a better way to end this chapter than to repeat her charge to nurses everywhere.

Every day, every moment, you make choices on how to act or respond. Through these acts, you have the power to positively influence. As John Quincy Adams sagely said, ‘The influence of each human being on others in this life is a kind of immortality.’ So I ask you: What will be your act of courage? How will you influence your environment? What will be your legacy? (Thornby, 2001)

Discussion Questions 1. Knowledge of ethical principles that support practice and policy can help nurses to recognize moral challenges and improve their ability to seek out the right thing to do when faced with a moral




dilemma. Describe a recent clinical ethical dilemma and use the ethical terms discussed in the chapter to describe it.

2. In terms of ethnic and racial health disparities, what actions could nurses take to address these disturbing statistics from an ethical perspective?

3. Can you describe a situation in which you witnessed a health professional exhibit moral courage?

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Health Care Delivery and Financing OUTLINE

Chapter 16 The Changing United States Health Care System Chapter 17 A Primer on Health Economics of Nursing and Health Policy Chapter 18 Financing Health Care in the United States Chapter 19 The Affordable Care Act: Historical Context and an Introduction to the State of Health Care in the United States Chapter 20 Health Insurance Exchanges: Expanding Access to Health Care Chapter 21 Patient Engagement and Public Policy: Emerging New Paradigms and Roles Chapter 22 The Marinated Mind: Why Overuse Is an Epidemic and How to Reduce It Chapter 23 Policy Approaches to Address Health Disparities Chapter 24 Achieving Mental Health Parity Chapter 25 Breaking the Social Security Glass Ceiling: A Proposal to Modernize Women’s Benefits Chapter 26 The Politics of the Pharmaceutical Industry




Chapter 27 Women’s Reproductive Health Policy Chapter 28 Public Health: Promoting the Health of Populations and Communities Chapter 29 Taking Action: Blazing a Trail…and the Bumps Along the Way—A Public Health Nurse as a Health Officer Chapter 30 The Politics and Policy of Disaster Response and Public Health Emergency Preparedness Chapter 31 Chronic Care Policy: Medical Homes and Primary Care Chapter 32 Family Caregiving and Social Policy Chapter 33 Community Health Centers: Successful Advocacy for Expanding Health Care Access Chapter 34 Filling the Gaps: Retail Health Care Clinics and Nurse-Managed Health Centers Chapter 35 Developing Families Chapter 36 Dual Eligibles: Issues and Innovations Chapter 37 Home Care and Hospice: Evolving Policy Chapter 38 Long-Term Services and Supports Policy Issues Chapter 39 The United States Military and Veterans Administration Health Systems: Contemporary Overview and Policy Challenges





The Changing United States Health Care System Barbara I.H. Damron, Demetrius Chapman, Freida Hopkins Outlaw

“America’s health care system is neither healthy, caring, nor a system.” Walter Cronkite

The U.S. health care system is complex and pluralistic. It is a mix of private and public initiatives and institutions that employ millions of workers in a myriad of settings to provide a wide range of health-related services to the diverse U.S. population across geo- political environments that range from cities to rural areas. The purpose of this chapter is to provide an overview of the current major components of the American health care system, which is in the midst of dynamic change.

Overview of the U.S. Health Care System Public Insurance




The two principal health entitlement programs, Medicare and Medicaid, account for over one third of the nation’s total health spending and $1 out of every $5 of federal spending goes to these programs (National Institute for Health Care Management Foundation [NIHCM], 2012).

Medicare. Medicare was created under Title XVIII of the 1965 Social Security Act as health insurance for the aged and disabled. The federal government funds it and in 2011 it cost $549 billion (23% of total health care expenditures for the United States) to provide care to the 49 million enrollees (Centers for Disease Control and Prevention [CDC], 2013). Medicare is divided into four parts: A, B, C, and D (Klees & Wolfe, 2013). The original two components were Part A, which pays for inpatient hospitalization, home health, hospice, and skilled nursing; Part B helps pay for physician appointments and outpatient hospital services; Part C is the Medicare Advantage Program, which expands beneficiaries’ options for participation in private sector health care plans; and Part D helps pay for prescription drugs not otherwise covered by Parts A and B. Expenditures for the Medicare Drugs Program (Part D) was $67 billion in 2011 (CDC, 2013).

Medicare is reliant on financing from the nation’s general revenue, which crowds out other uses of general revenue and substantially adds to annual deficits that accumlate debt and place upward pressure on taxes (NIHCM, 2012).

Medicaid. When Congress passed the 1965 legislation that established Medicaid, Title XIX of the Social Security Act, it was a response to the widely perceived inadequacy of welfare medical care (Klees & Wolfe, 2013).

In 2009, children aged under 21 years accounted for 48% of Medicaid recipients but only 20% of Medicaid expenditures; older adults, the blind, and people with disabilities made up 21% of Medicaid recipients and accounted for 63% of expenditures (CDC, 2013). Since its inception, the cost of Medicaid programs has increased at a faster pace than the U.S. economy. In 1970, Medicaid




was 0.5% of the gross domestic product (GDP), by 2011 is was 2.8% of the GDP (Truffer et al., 2012). Medicaid is currently approximately 17% of the total health expenditure of the United States (CDC, 2013). The total Medicaid outlays in fiscal year 2011 were $432.4 billion, of which the federal government spent $275.1 billion (64%) and states spent $157.3 billion (36%) (Truffer et al., 2012).

Medicaid is financed by the combination of state general funds and federal matching funds and is now the largest single budget category for states (Trust for America’s Health, 2011). All states except Vermont are required to have balanced budgets either through statutory law, constitutional requirement, or judicial decision (National Conference of State Legislatures [NCSL], 2010). Other authorities also exclude Wyoming and North Dakota as exceptions. When Medicaid spending increases, other state spending must be curtailed or taxes must be raised, creating a dilemma for states.

Originally, federal law mandated coverage for pregnant women, children under age 6 years from families at or below 133% of the federal poverty level (see Table 16-1 for federal poverty levels), children age 6 to 18 years at or below 100% of the federal poverty level, parents and relative caretakers of those who met the previous Aid to Families with Dependent Children cash assistance program, and older adults and the disabled who qualify for Supplemental Security Income (Kaiser Family Foundation [KFF], 2012). For states accepting the Medicaid expansion, people with household incomes at or below 133% of the federal poverty level will be eligible for coverage beginning in 2014. This expansion shifts the funding of all the participating states (100%) to the federal government for the first 3 years (2014 to 2017), and then incrementally the federal share will decrease to 90% by 2020 with each state paying the remaining 10%. With the implementation of the Affordable Care Act (ACA), the eligibility for Medicaid beginning in 2014 became broader, increasing the expected overall enrollment to 77.9 million people by 2021 (Truffer et al., 2012); in 2011, Medicaid provided health care assistance to an estimated 55.7 million people.

TABLE 16-1




Federal Poverty Guidelines*

Persons in Family/Household Poverty Guideline 133% of Federal Poverty Level 1 $11,670 $15,521.10 2 $15,730 $20,920.90 3 $19,790 $26,320.70 4 $23,850 $31,720.50 5 $27,910 $37,120.30 6 $31,970 $42,520.10 7 $36,030 $47,919.90 8 $40,090 $53,319.70

*Federal Poverty Guidelines of the U.S. Department of Health and Human Services (January 22, 2014). Applicable to the 48 contiguous states and the District of Columbia. From the Federal Register: 01303/annual-update-of-the-hhs-poverty-guidelines.

When the ACA was signed into law, 26 states and another group of plaintiffs including the National Federation of Independent Businesses filed lawsuits that the Supreme Court agreed to consider (Liptak, 2012). The court ruled (7:2) that the requirement of broader Medicaid eligibility criteria required by the ACA was unconstitutionally coercive because states lacked adequate notice and because the Secretary of the U.S. Department of Health and Human Services (HHS) has the authority to withhold all Medicaid funds, a substantial part of the overall budgets of some states (Kaiser Family Foundation, 2012). As of 2014, when the federal funding of Medicaid expansion began, 25 states and the District of Columbia implemented the expansion, 6 states are debating expansion, and 19 states are not moving forward (KFF, 2014).

Veterans Administration Health Systems Veterans benefits in the United States can be traced to the very first colonists. According to the U.S. Department of Veterans Affairs (n.d.), the Pilgrims of Plymouth Colony passed a law stating that disabled soldiers fighting the Pequot Indians would be supported by the colony. The first federal Veterans hospital was authorized in 1811. Since that time the U.S. Department of Veterans Affairs has expanded its health services to 820 clinics, 151 hospitals, and 300 Veterans Health Administration Veteran Centers (National Center for Veterans Analysis and Statistics, U.S. Department of Veterans




Affairs, 2014), The Veterans Health Administration health care system currently provides care to 8.92 million people with the FY2015 Veterans Health Administration budget at $163.9 billion to care for the 21,973,000 U.S. veterans (National Center for Veterans Analysis and Statistics, U.S. Department of Veterans Affairs, 2014). Recently, the public admonished the Veterans Health Administration over its severe backlog of disability claims. Dao (2013) reported that in March 2013 there were more than 600,000 backlogged disability applications; backlogged by Veterans Health Administration standards means pending for 125 days or longer. Many people demanded the resignation of the Secretary of Veterans Affairs, Eric Shinseki, which took place on May 30, 2014. The organization Iraq and Afghanistan Veterans of America lobbies for reform and sent President Obama a letter signed by 67 senators. By March of 2014 the backlog of disability claims was reduced to 370,000. For a more detailed discussion of the U.S. Military and Veterans Health Administration System, see Chapter 39.

Indian Health Service The Indian Health Service (IHS) (2014) is responsible for the provision of health services to members of federally recognized tribes. These obligations grew out of the special government-to- government relationships that the federal government has with Indian nations. In 1787, Article 1, Section 8 of the U.S. Constitution empowered the Congress “to regulate commerce with foreign Nations, and among the several States, and with the Indian Tribes” (National Archives, n.d.). Through numerous treaties, laws, executive orders, and Supreme Court decisions, the IHS came into existence to raise the health status of the 566 recognized tribes to parity with the general population (Shi & Singh, 2014).

The modern IHS was authorized and funded by the Indian Sanitation Facilities and Services Act of 1959 (Public Law [PL] 86- 121), but not until the ACA (PL 111-148) was signed into law did the permanent reauthorization of the Indian Health Care Improvement Act (1976) (PL94-437) occur. It was the 1921 Snyder Act (PL 67-85) (Library of Congress, 2014) which made Indians citizens and created the basis of health care to American Indians




and Alaska Native people (National Indian Health Board, 2009). American Indians have the worst health outcomes, with a life expectancy that is lower than all other Americans.

The IHS (2013) reports that American Indians and Alaska Natives born today have a life expectancy that is 4.1 years less than Americans of all races (73.6 years versus 77.7 years). When compared with Americans of all races, substantially higher death rates for American Indians and Alaska Natives exist for many diseases and preventable injuries. Infant, maternal, and pneumonia/influenza deaths are also higher in this population (Indian Health Service, 2013). It has been noted that many American Indians do not avail themselves of the health care services of the IHS for a number of reasons including a lack of American Indian health care providers (Shi & Singh, 2014). Since 1973, through funding from the National Institute of Mental Health and later transferred to the Substance Abuse and Mental Health Services Administration, the Minority Fellowship Program for Nursing was established to create a cadre of doctorally prepared minority nurses to provide leadership in research, practice, education, and policy in both private and public sectors. American Indian and Pacific Islander nurses are a part of this alumnae group who are focused on improving health care for this population.

Infrastructure Hospitals. The American Hospital Association (2014) reports that as of early 2014, there are 5723 hospitals that meet the agency’s registered criteria for accreditation as a hospital by The Joint Commission or is a certified provider of acute services under Title 18 of the Social Security Act. Of these hospitals, 2894 (50%) are nonprofit community hospitals, 1068 (18%) are for-profit community hospitals, 1037 (18%) are state and local government community hospitals, 211 (3.6%) are federal government hospitals, 413 (7.2%) are psychiatric hospitals, 89 (1.5%) are long-term care hospitals, and 11 (<1%) are institutional hospitals (prison, college infirmaries). These hospitals have 920,829 beds with 36,156,245 admissions in 2012. As of 2010, North Dakota had the highest number of




community hospital beds per capita (5.1 per 1000 people); Oregon and Washington had the lowest with 1.7 beds per 1000 people. The national average was 2.6 beds per 1000 people (CDC, 2013). Figure 16-1 summarizes the numbers and types of American hospitals.

FIGURE 16-1 Number and types of American hospitals. (From AHA Hospital Statistics. [2014]. Retrieved from

According to Dafny (2014), hospitals are scrambling to shore up their positions in the health care market, consolidate resources, and improve operational efficiency and create health systems capable of managing the health of entire populations. Some of these consolidations, horizontal mergers of providers that supply similar services in the same geographic area, as well as vertical integration of services including urgent and long-term care, are beginning to get attention as potential violations of antitrust laws. In the fall of 2013, the Federal Trade Commission challenged the Idaho Medical Group’s purchase of a rival medical group, which would have created a combined 78% of the market in adult primary care (Dafny, 2014).

Academic hospitals, compared with community hospitals, are




part of an academic health center and are referred to as teaching or university hospitals. An academic health center consists of one or more owned or affiliated teaching hospitals or health systems; an allopathic or osteopathic medical school; other health professional schools or programs, which may include nursing, dentistry, pharmacy, public health, veterinary medicine, allied health, and graduate studies; and a robust research program (Association of Academic Health Centers [AAHC], 2014). Academic health centers offer unique care that is not available elsewhere in the region. They also serve as a primary public safety net, providing almost $44 million in uncompensated patient care each year; one in seven provides more than $100 million per year (AAHC, 2014). The majority of the academic health centers belonging to the Association of Academic Health Centers (AAHC, 2014) have added clinical doctorates responding to changing educational and practice needs, with nursing being one of the common offerings (AAHC, 2009). Academic health centers lead in new interdisciplinary research models, nationally and globally, and in knowledge management and information technology. Nursing is in a prime position to lead in these academic health centers through education, administration, and building and sustaining programs of research.

Nursing Homes. As of 2011, America had 40.3 nursing home beds per 1000 people aged 65 years and older available to the 41.3 million Americans over age 64 years. According to the Centers for Medicare and Medicaid Services (CMS, 2012), the number of nursing homes participating in the Medicare and Medicaid programs has decreased steadily since 2002 with 15,671 remaining by the end of 2011. The trend has been a slight increase in larger nursing homes (100 to 199 beds) and a decrease in smaller nursing homes with fewer than 50 beds. The majority (69%) of nursing homes are for- profit. Another trend is an increase in dually participating nursing homes that are eligible for both Medicare and Medicaid funding. Only 4% of nursing homes are Medicaid-only and they decreased by 6% to 785 in 2012.

The nursing home population at the end of 2011 was 2.9% of the over-65 and 10.7% of the over-85 population (CMS, 2012). Of those




in nursing homes, 15% are under 65 years of age, whereas 7.6% are over 95 years of age. Women make up 67% of the residents, and nearly 4 out of 5 are non-Hispanic whites (78.9%).

Public Health The American Public Health Association defines public health as the practice of preventing disease and promoting good health within groups of people, from small communities to entire countries. Public health is provided by a variety of agencies, small and large, public and private. The CDC administers funding for many population-based prevention efforts (National Health Policy Forum [NHPF], 2010). State health departments are the agencies that most frequently get funding for programs associated with a specific disease or risk factor. Local health departments, such as city and county entities, can also be recipients of direct CDC funds. According to the NHPF (2010), most of the states (29; 58%) have established a decentralized public health organizational model, that is, local public health offices are independent of the state health department and are managed by local authorities. Six states have a centralized organization, in which all the local public health offices are managed from the state level, and 13 have a hybrid model. Two states, Hawaii and Rhode Island, do not have local public health agencies. The NHPF (2010) reports that there are 2794 local health departments in the United States, most of which serve counties (60%) and 9% serve multiple counties. Some health departments (18%) serve cities, towns, or townships. The American College of Physicians (2012) reports that in FY2010 to 2011, 40 states decreased their public health budgets. Of those, 29 had decreased their budgets for the second year in a row, and 15 had done it for a third year (2012). The HHS (2014) reported that the CDC will see a decrease of $432,461,000 in budget authority for FY2014 and operate with an overall budget of $6.665 billion. Program investments that are scheduled to realize an increase in funding are infectious diseases; global disease protection; preventing the leading causes of disability, disease, and death; health monitoring; and environmental and work hazard prevention. Additional funds were allotted for Vaccines for Children and the World Trade Center




Health Program. Public health has finally become included in high-profile, tertiary

care research centers. This includes the National Cancer Institute (NCI), the first and largest institute of the National Institutes of Health. The Cancer Control and Population Sciences division of the NCI is the bridge to public health research, practice, and policy. Through the NCI-designated cancer centers around the country, public health principles are the cornerstone of the departments within these centers that focus on community health, education, and the conducting of population-based research using community- based participatory approaches. An example is the NCI-designated University of New Mexico Cancer Center’s Office of Community Partnerships and Cancer Health Disparities, which conducts community-based participatory research with Hispanic and Native American populations.

Building on the accelerating pace of discoveries in human genetic variation, epigenetic, molecular, biochemical, and cellular technologies for cancer care and prevention, public health genomics (PHG) has evolved as a “multidisciplinary field concerned with the effective and responsible translation of genome based knowledge and technologies to improve population health” (Burke et al., 2006). PHG at the NCI promotes the integration of genomics and personalized medicine into public health cancer research, policy, and control. The work of Anita Kinney, PhD, RN, exemplifies the contributions nurse scientists are making in this area through her work combining behavioral science, genomics, and cancer prevention strategies.

Transforming Health Care Through Technology Health care information technology (HIT) is the future, but the current systems have flaws that need major revisions. The advancement of HIT holds the promise of providing quality of care for patients and their families; increasing efficiency in the health care system; and reducing costs for payers, providers, and patients (Thune et al., 2013). The impact of technology on the transformation




of health care is expanding rapidly, and billions of federal and private dollars are being spent. Health care providers and hospitals are benefitting from, and struggling with, software that can automate protocols, track medication, and transfer patients to different departments. The 2009 Congress passed legislation, through the Health Information Technology and Economic and Clinical Health Act (2009), allotting $35 billion to promote providers’ adoption and use of federally certified HIT (Thune et al., 2013). Venture capital funding for HIT tripled from 2009 to 2012, skyrocketing to $955 million from $343 million (PricewaterhouseCoopers, 2013). Additionally, the federal government is spending up to $29 billion in incentives to motivate health care providers to digitize health care records (NewTechCity, 2012).

Health Information Technology Health information technology includes electronic health records (EHRs) and is aimed toward making it possible for health care providers to better manage patient care through the sharing of health information in a secure manner (Office of the National Coordinator for Health Information Technology [ONCHIT], n.d.). The main goal of HIT is to improve the quality and safety of patient care. Box 16-1 summarizes key terms used in health information technology. EHR adoption requires a significant investment of time and money. As of 2012, over 144,000 payments totaling $7.1 billion have already been issued to professionals and hospitals by the Centers for Medicare and Medicaid Services. Of concern is the lack of evidence of the effectiveness of the current health information technology system. During the 113th Congress, six senators summarized the deficiencies that exist with the current state of health information technology, including (1) lack of a clear path to interoperability, (2) increased costs associated with health information technology, (3) lack of oversight for the development of health information technology through the public sector, (4) the privacy of patients being put at risk, and (5) lack of clarity regarding costs of program sustainability (Thune et al., 2013).




Box 16-1 Health Information Technology Terms

Electronic Health Records (EHRs): A digital version of patients’ paper charts. The EHR is a real-time, patient-centered record of patient information kept in a health care provider’s office or in a hospital. Ideally, the EHR can link to hospital departments and to other health care providers.

Health Information Exchange (HIE): The movement of health information electronically across multiple organizations.

Interoperability: The ability of two or more electronic systems to communicate, or exchange, information and to use the information that has been exchanged. Interoperability is not the same thing as HIE. With interoperability, the information must be exchanged and usable.

Personal Health Record (PHR): Similar to the EHR, except the patient can set up and control the information. The PHR can be an electronic storage center for most of the patient’s health information.

Source: certification_glossary.

Even in light of the challenges, the advantages of EHRs are evident in both the espousal of technology and the fact that 71% of users state they would purchase their EHR system again (Jamoom et al., 2012). Jamoom and colleagues also reported that nearly half of physicians without an EHR system are planning to purchase or use one already purchased within a year (Jamoom et al., 2012). Advantages of using EHRs for the provider include (1) accurate and complete information about a patient’s health, (2) the ability to quickly provide care, (3) the ability to better coordinate the care that is given, and (4) an improved mechanism for sharing information with patients and their family caregivers (ONCHIT, n.d.).

In 1971, Lockheed engineers designed the first commercial electronic health record system for El Camino Hospital (Thede,




2012). This system was very successful because it truly integrated physicians, nurses, and pharmacy processes and a respect for the nursing workforce was apparent in the system design (Thede, 2012). Nurses were freed from established tasks, such as multiple documentation, and thus had more time to spend with patients. This system that set a high standard was not replicated in informatics design in the U.S. health care system.

The changing U.S. health care system is dependent on the use of the EHR. Increasing numbers of providers who use this technology are reporting tangible improvements in their ability to make better decisions with more comprehensive information. Often when EHRs are discussed physicians are the focus; however, successful EHR systems have been found to be highly correlated with designs that respect nursing practice. A descriptive study of 100 nurses at a large Magnet hospital found that the majority of nurses studied (75%) thought that EHRs improved quality of documentation, whereas 76% believed patient safety and care improved (Moody et al., 2004). A number of years ago, the American Association of Colleges of Nursing and the National League of Nursing, the two nursing accrediting agencies, required that beginning informatics be added to the curriculum in all nursing schools (Thede, 2012). This requirement is in concert with the Institute of Medicine (IOM), which requires that informatics education be provided for all health care professionals (Thede, 2012). Nursing schools are now offering graduate degrees in informatics, which are largely focused on system design for hospitals, community health centers, and home care that are clinically directed (Moen & Knudsen, 2013). Intraprofessional and interprofessional collaboration is also a major component of the clinical system design by nurses. The practice, education, research, and policy implication for the purposeful use of nursing data will be fostered when the culture of health care delivery systems shifts from providing care in traditional ways to using tools such as the EHR to improve meaningful use of patient data. Thought leaders have published a new nursing informatics research agenda for 2008 to 2018. Specifically, Bakken, Stone, and Larson (2008) noted that a nursing informatics research agenda for 2008 to 2018 must expand users of interest to include interdisciplinary researchers; build upon the knowledge gained in




nursing concept representation to address genomic and environmental data; guide the reengineering of nursing practice; harness new technologies to empower patients and their caregivers for collaborative knowledge development; develop user- configurable software approaches that support complex data visualization, analysis, and predictive modeling; facilitate the development of middle-range nursing informatics theories; and encourage innovative evaluation methodologies that attend to human-computer interface factors and organizational context” (p. 206).

Health Status and Trends It is common to evaluate the health care system on three dimensions: quality, access, and cost.

Quality Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with current knowledge. Some of the national health outcome measures most commonly cited are life expectancy, infant mortality, and vaccine preventable deaths. The IOM has identified members of the nursing profession as crucial for the changing health care system. In the seminal report of the IOM entitled The Future of Nursing (2011), four key messages were presented: • Nurses should practice to the full extent of their education and

training. • Nurses should achieve higher levels of education and training

through an improved education system that promotes seamless academic progression.

• Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.

• Effective workforce planning and policymaking require better data collection and an improved information infrastructure.

Implementation of the four key messages of the IOM will enable nursing to take a leading role in the ever-challenging endeavor to




improve quality while being cost-effective. A few comparisons do help define the health systems of the

United States. Squires (2011) reported on the findings of the Organization for Economic Cooperation and Development (OECD), which tracks and reports on more than 1200 health system measures across 34 industrialized countries. Some of the highlights of the U.S. system, when compared with 10 other industrialized nations that were reported by Squires (2011), include that the United States had the fewest practicing physicians per 1000 population (2.43); the OECD mean was 3 per 1000. U.S. hospital admission rates were lower, but the spending per discharge was the highest and more than double the median of the other countries being compared. Squires noted that Americans were the most likely to have a prescribed pharmaceutical and more likely to have four prescriptions per person and that the drugs in the United States were the most expensive of all the other nations being compared. The high rates of use and the high prices resulted in the highest drug spending per capita for the United States at $897 per person in 2008. The five most expensive health conditions are: heart disease, cancer, trauma, mental disorders, and pulmonary conditions (NIHCM, 2011).

Quality improvement in nursing was first introduced by Florence Nightingale during the Crimean War. Today, nursing quality is still involved with process, but has evolved to an emphasis on patient care outcomes. Every nurse plays a pivotal role in the measurement of quality.

Access Access is the ability to obtain needed, affordable, convenient, acceptable, and effective health care in a timely manner. Despite many initiatives, access to health care remains a serious problem. Although access has many dimensions in the current health care debate, it is a euphemism for adequate health insurance coverage, and there is a growing disparity between those who have insurance and those who are not covered. The number of people with health insurance increased to 260.2 million in 2011 from 256.6 million in 2010, as did the percentage of people with health insurance (84.3%




in 2011, 83.7% in 2010) (U.S. Census Bureau, 2011).

Cost The cost of health care must be considered from several perspectives. For patients or consumers, cost is the price of purchasing needed health care goods and services and includes insurance premiums, co-pays, and deductibles; out-of-pocket health expenditures not covered by insurance; taxes (Social Security, federal, and state) that support health programs; in-kind services such as caring for aging parents or sick children; and voluntary contributions to health-related charities. For providers, the cost of health is producing health care products and services and delivering them to patients in a timely and convenient manner. The cost of health care is how much the state or nation spends on health care; the percentage of the total domestic production that health care consumes. Incentives and policy initiatives that address the cost of health may be beneficial to one, some, or none of these perspectives.

Most developed countries of the world have a health insurance system funded, subsidized, or managed by the national government, and with very few exceptions, the categorical delineation between countries with some type of national health system and those without is the country’s economic development (Fisher, 2012). The great exception is the United States. According to the World Health Organization (2013), the United States spends 17.6% of its GDP on health care expenditures. It ranks second behind Sierra Leone in terms of percentage of GDP spent on health. Sierra Leone spends 20.8% of its GDP, but that amount per capita is $171 compared with the staggering amount of $8233 per person in the United States.

The United States is far from the healthiest society in the world despite having the most expensive care. The National Institute for Health Care Management Foundation (2011) reports some of the trends in American health care spending. The first trend is the disproportionate distribution of the costs, with just 5% of patients accounting for nearly 50% of health care spending; whereas nearly 50% of the U.S. population accounts for just 3% of spending on




health care (NIHCM, 2011).

Health Status of the United States For life expectancy (at birth and at age 65 years), Healthy People 2020 reports that the United States is ranked 27th and 26th, respectively, out of the 33 peer countries determined by the OECD (Healthy People 2020, 2014). The other leading health indicators noted by Healthy People 2020 are: access to health services; clinical preventive services; environmental quality; injury and violence; maternal, infant, and child health; mental health; nutrition, physical activity, and obesity; oral health; reproductive and sexual health; social determinants; substance abuse; and tobacco. The CDC (2013) reports that the leading cause of death for men and women is heart disease, accounting for approximately 307,000 deaths for men and 290,000 deaths for women in 2010. The Institute of Medicine’s Committee on the State of the USA Health Indicators identified a framework for health indicator development. Table 16-2 summarizes their findings.

TABLE 16-2 Framework for Health and Health Indicator Development*

Social and Physical Environment Health Outcomes Socioeconomic status Race/ethnicity Social support Health literacy Limited English proficiency Physical environments (where people live, learn, work, and play)

→ Mortality Life expectancy at birth Infant mortality Life expectancy at age 65 years Injury-related mortality

Health-Related Behaviors Smoking Physical activity Excessive drinking Nutrition Obesity Condom use among youth

→ Health-related quality of life (morbidity) Self-reported health status Unhealthy days

Health Systems The health system is broadly defined as a set of institutions and players whose purpose is to maintain or improve people’s health. Cost Health care expenditures Access Insurance coverage

→ Condition specific outcomes Chronic disease prevalence Serious psychological




Unmet medical, dental, and prescription drug needs Effectiveness of care Preventive services Childhood immunizations Preventable hospitalizations


*No single measure can capture the health of the nation. Indicators are needed that reflect a broad range of factors such as health, risk for illness, and health system performance. The set of indicators presented here should not be viewed as perfect or permanent; rather, the committee identified potential indicators that met the data constraints and then applied the framework to determine the final selection of indicators. From the Committee on the State of the USA Health Indicators; Institute of Medicine of the National Academies (2009). State of the USA health indicators. Washington, DC: The National Academies Press. Retrieved record_id=12534#.

Challenges for the U.S. Health Care System The challenges facing the U.S. health care system can be traced to the rise of professional sovereignty and the transformation of medicine into an industry during the nineteenth and twentieth centuries, which Paul Starr so thoroughly described in his 1982 Pulitzer Prize–winning book, The Social Transformation of American Medicine (Starr, 1982). Although the advancements in biomedical science have been phenomenal, preventing the diseases that are the main reason for soaring costs in the health care system and increasing quality in health care delivery while lowering costs are still a struggle (American Association for Cancer Research, 2013).

Chronic Diseases One of the biggest and most costly aspects of health care is the treatment of chronic diseases. It is not possible to make insurance affordable without changing how chronic disease is treated. According to the Centers for Disease Control and Prevention (2009) chronic diseases are responsible for more than 75% of the $2.5 trillion spent annually on health care.

As a nation, 85% of health care dollars is spent on people with chronic conditions (Robert Wood Johnson Foundation [RWJF],




2010), many of which can be prevented. Yet, the majority of money, talent, and time continue to focus on tertiary care, with limited resources dedicated to prevention. The majority of costs in the U.S. health care system associated with preventable medical conditions and chronic diseases are associated with modifiable behaviors (CDC, 2009). Almost 50% of all Americans live with a chronic condition and the percentage of health care spending associated with people with chronic conditions has increased to 84% in 2009 from 78% in 2002 (RWJF, 2010). The number of Americans with chronic conditions will increase by 37% between 2000 and 2030, an increase of 46 million people (RWJF, 2010). Until, as a society, prevention is truly embraced as the most efficient approach to controlling the costs associated with chronic diseases, health care costs will continue to escalate. Nurses have a history of focusing on prevention even though it has not always been recognized in the health care environment. However, nurses are becoming much more visible in the health promotion and disease prevention field of research, as well as other areas associated with prevention, including chronic disease. For example, Loretta Jemmott, PhD, FAAN, RN is nationally and internationally recognized for her research in the field of HIV/AIDS prevention among African- American adolescents. The Centers for Disease Control has designated several of her HIV prevention curriculums for national use in a variety of settings. Another example of an evidence-based nursing intervention that has had an impact on the management of chronic illness is the Transitional Care Model spearheaded by Mary Naylor, PhD, FAAN, RN. It is an interdisciplinary model that is providing high-quality cost-effective evidence-based care for vulnerable older adults living in the community. Her focus on prevention includes recognizing the unique needs of chronically ill older adults, improving the quality of their care, and thus preventing unnecessary hospitalizations while reducing cost. An important example of transformative work in an inpatient setting is Susan Hassmiller’s and Patricia Rutherford’s program, Transforming Care at the Bedside, which incorporates a number of nursing care factors including improving patient safety, improving the quality of patient care on medical surgical units, and retaining nurses. The program has improved safety by reducing patient falls,




increased the time nurses can spend in direct care, and improved nurse retention, among other positive outcomes (Freda, 2008). Exemplars such as these inform nursing practice as well as providing models of care that can be used to educate students, influence health care policy, and improve practice while being cost- effective. (See the American Academy of Nursing website [] to learn more about the Edge Runners, nurses whose work has changed health care systems.)

Health Care Reform Health care reform is a term used through the decades to discuss a variety of health policy changes. Health care reform has been riddled with debate and encompasses a vast array of legislation. Major milestones of health care policy include the Public Health Service Act of 1944, the Social Security Amendments of 1965, the Health Insurance Portability and Accountability Act of 1996, and the Patient Protection and Affordable Care Act of 2010. Health care reform is driven by two major questions: (1) the cost of health care and (2) the right to health care.

Currently, health care reform is focused on the implementation of the ACA. This law addresses a vast array of health care delivery issues through 10 titles of the law. For more detail pertaining to the ACA, the reader is referred to Chapter 19.

Delivery system reforms are addressed in the ACA. An important aspect of delivery system reform in the law is the emphasis on comparative effectiveness research (CER). Evidence is provided on the effectiveness, benefits, and harms of different treatment options through CER; these studies compare ways to deliver health care, as well as comparing drugs, medical devices, tests, or surgeries (Agency for Healthcare Research and Quality, n.d.).

The Patient-Centered Outcomes Research Institute (PCORI) was established in the ACA and is a U.S.-based nongovernmental institute created to examine clinical effectiveness and the appropriateness of different medical treatments. It is based on the tenets of comparative clinical effectiveness research (CER) and ultimately aims to improve health care delivery and outcomes by




helping people make informed health care decisions (PCORI, 2014). The overall goal of the PCORI is “to fund research that will assist patients, caregivers, clinicians, and others in making informed health decisions” (Barksdale, Newhouse, & Miller, 2014, p. 192). The engagement of people from within the community, including patients and their caregivers, is a major strength of the PCORI and aligns very much with those in the nursing profession, who have demonstrated expertise in the engagement process, both as generalists and specialists (Pearson et al., 2014). More than other agencies that fund research, PCORI has focused on meaningful involvement of patients, which means that patients and caregivers are included in all aspects of the research process (Barksdale, Newhouse, & Miller, 2014). No longer will they be excluded until the research process has been developed, but they will be part of the funding application helping to formulate the research questions and all other essential research processes, including dissemination of findings as well as being a part of the research review panels (Barksdale, Newhouse, & Miller, 2014). PCORI is an agency where nursing leadership has the opportunity to flourish through active participation. Because nursing is culturally aligned with the principles of PCORI, it is positioned to provide thought leaders in all aspects of the institute.

The Patient-Centered Outcomes Research Trust Fund (PCORTF) was authorized by Congress as part of the ACA of 2010. It is through this trust fund that PCORI is funded. The PCORTF receives income from the general fund of the Treasury and from a fee assessed on Medicare, private health insurance, and self-insured plans. The PCORTF received $210 million in total in appropriations for FYs 2010 to 2012. For FYs 2013 to 2019, the PCORTF received $150 million from the general funding appropriation plus an annual $2 fee per individual assessed on Medicare, private health insurance, and self-insured plans, as well as an adjustment for increases in health care spending. The law mandates that each year, 20% of PCORTF funding is to be transferred to the HHS to support dissemination and research capacity-building efforts. Of that 20%, 80% is transferred to the Agency for Healthcare Research and Quality for these purposes (Patient-Centered Outcomes Research Institute, 2014).




Opportunities and Challenges for Nursing Many opportunities for nurses are unfolding, which are associated with the changing U.S. health care delivery system. Nurses are the providers with the greatest presence during health care delivery, and they provide the most holistic approach to patients. The evolving and collective nursing knowledge could solve a great many of the barriers and gaps in care for the American people if that knowledge was effectively channeled to health policies that address and solve these problems. Although nurses are very good at assessing the many systems impacting their patients’ lives, they have been less visible in arenas where policy, politics, economic, social, and professional decisions regarding the U.S. health care system change are being made. The challenge is how to get the nursing profession’s achievement recognized, not as separate accomplishments of individual nurses, selected nursing schools, or a particular hospital where nurses are making substantial contributions, but rather to create opportunities to let the public (with a focused emphasis on politicians and other decision makers and stakeholders) know that embedded in the fabric of nursing are the knowledge, skills, and desire to make significant contributions to the transformation of health care and that nursing is positioned to be part of meeting the challenges of the changing U.S. health care system.

Discussion Questions 1. What change(s) in the changing U.S. health delivery system do you think will be an opportunity for nursing to improve health care? Please describe.

2. What challenges do you think the profession of nursing will face as the U.S. health delivery system changes? Do you think these changes are going to improve patient care? Do you think they will improve the visibility and status of nursing? Please support your answer with a rationale.




3. Do you think that the merger of some of the many delivery and payment sources of American health care would streamline care or increase its complexity?

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A Primer on Health Economics of Nursing and Health Policy Len M. Nichols

“The price of light is less than the cost of darkness.” Arthur Nielsen

Economics is the study of how resources are allocated by people operating in the real world, that is, with constraints on their time, their money, and their knowledge. It can be summarized as the study of choices people make under constraints. Because some constraints are operable on everyone, economists say the real world is a world of scarcity, by which they mean no one, and certainly not everyone, can have everything they might want. Sometimes choices today can relax constraints in the future (e.g., studying for an advanced degree can enable someone to earn higher wages and have more income to spend on goods and services in the future). Sometimes choices today are extremely limited by effective constraints (e.g., when the only jobs available pay the minimum wage; no matter how hard one works or how much one makes,




there are only 24 hours in a day and every human must sleep).

Economics as a Discipline Choices under constraints produce trade-offs, which usually boil down to the fact that you can have more of one desirable thing only if you give up another. Time for money is the classic trade-off and allocating a limited budget over competing priorities is something every manager (household or business) in the modern world is familiar with. This sets up the fundamental economic concept of opportunity cost, or what must be given up to get something else. This is a better definition of cost than price or out-of-pocket payment, both of which can be distorted by insurance, taxes, or subsidies from the true total cost of acquiring any good or service.

Economics is a social science, which means it uses logic and analytic tools to develop models which attempt to characterize and explain the essence of a human choice situation. Models must omit some details to be manageable, and the art of creating models is deciding which details are essential (and measurable) and which can be omitted. The results of the models are predictions or hypotheses about how the real world works, how choices will be made, or what the implications of choices already made will be. These predictions and hypotheses can then be tested against real world observations or data.

When the models are confirmed as correct, then the results are added to the body of economic knowledge and passed on to others. When the models and predictions are shown to be inaccurate then the models and thinking about the type of problem under study is revised. In that sense, economics is empirically driven or evidence based. Economics has evolved over time and continues to evolve, as new data emerge and new models, theories, and hypotheses are created; they compete with old models, theories, and hypotheses virtually all the time. This constant evolution is also partly why economists rarely reach unanimous consensus, but if a preponderance of evidence exists at a point in time then a majority of economists will lean in a certain direction, just like health or other professionals do as evidence evolves in their fields.




Why Health Care Is a Hard Economic Case. Health care has some particular features that make it different from most markets, even though economic analysis can still be applied with appropriate attention to these details. Number one is unavoidable information asymmetry. This means either buyers or sellers have knowledge the other does not about a good or service. This asymmetry violates one of the key tenets of competitive markets and creates the opportunity for some market participants to take advantage of others without safeguards and institutions to protect them. Health professionals know more than most patients will ever fully understand about the patient’s condition and treatment options. This information gap is why the Hippocratic Oath and the Nursing Code of Ethics came into being and use long ago. In the extreme case, malpractice law and the procedures that health care organizations undertake to protect themselves from liability claims also protect patients. Plans and employers and consumer-oriented organizations try to act as agents on the patient’s behalf, but they are almost always working from an informational disadvantage that affects market outcomes. The current movement toward transparent quality metrics is helping, but informational asymmetry is present in almost every health care transaction.

The second big difference in health care is the importance of third party payers compared with most markets. Public and private insurers (and sometimes employers, as self-insured organizations) pay the bulk of the cost of health care, but decisions about what services to deliver are made by clinicians and patients, sometimes far removed from knowledge of total cost. Therefore, direct market participants cannot weigh the true cost and benefit of choices, which again violates a key assumption of competitive markets.

Finally, the reality is that health care is sometimes a matter of life and death, and for humanitarian and professional ethics reasons, services are sometimes delivered regardless of a patient’s ability to pay. This uncompensated care must be financed, and it is, by a combination of government subsidies, higher charges to private payers who can pay more, and some health care workers accepting little or no compensation for some of their efforts. Each of these three deviations from normal competitive conditions means that




market signals from health care transactions can be distorted, which can in turn distort investment and resource allocation decisions across the board. Distortions from competitive market norms require that economic analysis takes these features into account when analyzing health care markets.

A Fundamental Economic Tool Supply and Demand. The first tool in the economists’ tool kit is supply and demand analysis, which we apply to registered nurses (RNs) in a hospital setting to illustrate its use. This tool can explain wage and employment trends and help make predictions about the future.

Let’s start with the demand curve for nurses. Centuries of evidence suggest that almost all demand curves are downward sloping, that is, as the price of whatever falls, consumers will want more of it, and vice versa. The price of a nurse to a consumer is the wage or salary, plus the costs of necessary benefits that an employer, the hospital, and consumer in this case must pay. Thus, economists postulate that the demand for nurses in the hospital setting looks something like what is shown in Figure 17-1.

FIGURE 17-1 Demand for nurses in the hospital. The vertical axis is wage, W, which could be hourly,




weekly, monthly, or annually, but must be specified to be precise. The horizontal axis is the number of

nurses, N.

U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) (2010) provides the most recent estimates at the annual level, so we will use annual figures for this illustration. The average wage was $63,994 and 1.7 million were employed in hospitals (2.8 million were working nurses in all fields).

As wages fall, more nurses would be demanded by hospitals, and conversely, as wages rise, fewer nurses will be sought after. We will discuss cycles of nursing wages and employment trends in a bit, but for now, we want to make clear what might shift the entire curve or demand schedule and thus change the number of nurses that would be demanded at each wage. Graphically, we are asking what might shift the curve from D1 to D2, as in Figure 17-2.

FIGURE 17-2 Demand for nurses in the hospital.

Factors that are assumed to be constant for each demand curve and, if they change, will shift the entire demand curve, include: • The size and health of the population that might need hospital

care, inpatient or outpatient




• The percentage of that population that is well managed and coordinated by an independent primary care group that minimizes the need for hospital care

• The number of hospitals, the number of beds in those hospitals • The number of outpatient units • The number of physicians and or advanced nursing practices,

nursing homes, or home health agencies the hospitals own • The production function of delivering care (substituting more or

fewer other health professionals for RNs in the technology of care delivery)

• The prices/wages of potential substitutes or other complementary health professionals (e.g., licensed practical nurses, advanced practice nurses, or physicians)

Changes in any of these factors can shift the curve outward from D1 to D2, or inward (not shown). Changes in these factors help explain employment and wage trends for nurses over time.

The supply curve for hospital nurses is even more straightforward. The greater the wage, the more nurses are willing to work in the hospital setting or settings the hospital owns, as shown in Figure 17-3.

FIGURE 17-3 The supply of nurses in the hospital.




The factors that would shift the entire supply curve for nurses include: • Net growth in qualified nursing personnel willing to work in

hospitals, such as new entrants from nursing schools and programs minus retirements

• Working conditions in hospitals versus other employment alternatives (e.g., nursing homes, skilled nursing facilities, assisted living facilities, independent physician’s offices, home health agencies, other ambulatory clinics, ambulatory surgery centers, diagnostic laboratories)

• Wages in alternative employment • Other household income (either from a spouse or invested

wealth) Note the first supply-shifting factor, net growth in qualified

nursing personnel, reflects the impact of nursing faculty, federal support for nursing education, and preceptor shortage realities. Combing the pieces of the tool, Figure 17-4 displays equilibrium in the market for hospital nurses. Figure 17-4 depicts an equilibrium in the economist’s sense that the wage has no tendency to rise or fall, because the quantity demanded equals the quantity supplied. A change in the number of hospitals or the wages of nurses in nursing homes, for example, would shift demand or supply, respectively, and upset the equilibrium in this market over time. Demand and supply curves, once stable, do engender forces that tend to push prices/wages to the market clearing levels, which is when the market reaches equilibrium and the demand equals supply and there is then no tendency to change.




FIGURE 17-4 The demand and supply of nurses in the hospital.

One could construct supply and demand curves for each distinct market for nursing services, reflecting the employment levels in various RN workforce segments (Table 17-1) (HHS HRSA, 2013).

TABLE 17-1 Estimated Number of Registered Nurses by Setting of Employment

Census 2000 Estimate

ACS 2008-2010 Estimate

Estimated Growth/Decline

% Change in Growth

Hospitals 1,427,497 1,785,304 357,807 25.1% Nursing care facilities 189,594 208,051 18,457 9.7% Offices of physicians 156,559 134,231 –22,328 –143% Home health care services 101,895 105,922 4027 40% Outpatient care centers 70,224 131,022 60,798 866% Other health care services 66,723 153,449 86,726 1300% Elementary and secondary schools

51,495 61,323 9828 19.1%

Employment services 45,835 58,362 12,527 27.3% Insurance carriers and related activities

22,919 25,155 2236 9.8%

Administration of human resource programs

20,509 38,136 17,627 85.9%

Justice, public order (and safety activities)

14,793 18,137 3344 22.6%

Offices of other health practitioners

13,346 7596 –5750 –43.1%

Colleges and universities, 12,637 16,320 3683 29.1%




including junior colleges Residential care facilities, without nursing

10,853 9928 –925 –8.5%

All other settings 70,397 71,706 1308 1.9% Total 2,275,276 2,824,641 549,365 24.1%

Pay attention to the fact that hospital employment is the largest single category, by far, and that it is growing fast enough to offset the considerable decline in employment in physician offices. This may be surprising to those who think hospital employment is shrinking along with admissions and readmissions. Nursing demand has increased because hospital outpatient growth plus hospital acquisition of physician practices has increased the ambulatory service mix of hospitals and the need for nurses that goes with that.

Vacancy Rates. The purpose of this primer is to use economics to explain key dimensions of the markets for nurses and their implications for health policy. All nurse managers know that hospitals usually face nursing vacancies, so they might be wondering, how can there be a positive vacancy rate in hospitals and also strong tendencies to equilibrium wages? Doesn’t the persistence of vacancy rates that never go away render the traditional tools of economics inaccurate for nursing markets? No, and here’s why.

A vacancy rate, the percentage of nursing positions that are unfilled, is a reflection of a shortage, where demand exceeds supply. Shortages should not persist if wages adjust upward to market (equilibrium) clearing levels. The actual history of vacancy rates and nursing wage adjustments suggests that the standard economic model works reasonably well to explain movements in wages and employment, but with a lag for real world inertia. This inertia in raising wages is commonly caused by reluctance to raise nurses’ pay until other options for recruitment are exhausted, as well as the time lag before information about higher wages and aggressive recruitment is well known enough to encourage more entry into nursing schools, reentry to work, or increasing hours of nursing work (Figure 17-5) (Feldstein, 2011).




FIGURE 17-5 Registered nurse (RN) vacancy rate and real wage growth.

One technical note about Figure 17-5; the blue line shows real wage growth, or wages adjusted for inflation. This is a relevant concept, because if wages do not rise as much as inflation, this amounts to a wage cut, because actual purchasing power of the wage level would have declined.

Two inferences should be drawn from Figure 17-5: (1) Real wage growth can be negative if vacancy rates are low enough or falling long enough and (2) vacancy rates have not ever fallen below 4% since 1979. This suggests there is a natural floor in vacancy rates below which hospital administrators are not comfortable hiring; that is, they do not really want the market for nurses to clear completely, possibly because they fear how high equilibrium wages might actually be at that moment, and those high wages would significantly increase hospital costs, very possibly forever. Thus, equilibrium in nursing markets is effectively reached when hospital vacancy rates are around 4%.

Cost-Effectiveness of Nursing Services In this era of hyper-cost consciousness, every part of the health care system is often required and wants to demonstrate its unique value.




Cost-effectiveness is a technique that allows analysts to compare the costs and outcomes, in nonmonetary units such as body mass index reduction or quality adjusted life years (QALYs) saved, across two or more possible strategies. It differs from cost-benefit analysis in that the outcomes are not measured in monetary terms but in health-related terms. Thus, if intervention A is more cost-effective than intervention B, either it yields the same health benefit for a lower cost or it delivers more health benefit per dollar cost. The relevant metric is usually cost per QALY saved.

Cost-effectiveness studies are surprisingly rarely done on alternative nursing staffing patterns and care delivery modalities. The literature is much more likely to report analyses of a small number of advanced practice nurses partially or wholly replacing physicians or being added to a physician-led team. It is far simpler, frankly, to investigate the impact on cost and outcomes from a specific marginal intervention, for example, adding a care- coordination nurse to a primary care practice, than to compare the cost-effectiveness of 7 : 1 versus 5 : 1 hospital patient to nurse staffing ratios across hospitals in the United States. The former requires only an accounting of changes in costs and outcomes, and marginal costs are typically just the nurses’ salaries, whereas the marginal outcome effect might be reduced admissions, reduced emergency room visits, better hypertension control, and so on. The latter requires complete transparency of different hospital accounting systems, congruence on allocation of fixed costs and variable costs, and so on. This is why the few studies of the effect of nurse staffing patterns on cost that have been done have typically focused on the impact on quality or patient outcomes, not overall hospital costs. It is simply too difficult to compare costs across hospitals because of variable accounting practices.

A notable exception is the paper by Rothberg and colleagues (2005) that estimated the cost-effectiveness of moving the patient/nurse ratio from 8 : 1 to 4 : 1, using total hospital costs as the cost metric. Those costs depend on nursing wages, and how much they would have to rise to call forth the proposed increase in staffing ratios (acknowledging the supply curve for nursing labor is upward sloping, as we postulated and drew above); cost per hospital day; impact of more nursing hours on adverse events,




mortality, and length of stay; and the risk of nurse dissatisfaction from high patient/nurse ratios and the cost of turnover. The most important feature of a good cost-effectiveness analysis is to do a complete inventory of existing and differential costs and impacts on outcomes. Rothberg and colleagues (2005) used estimates of the range of these costs and impacts from the published literature and did sensitivity analyses of the values of the key variables along with a Monte Carlo technique, which essentially runs the experimental calculation (or gamble, hence the name) repeatedly to yield the range of possible outcomes and the best possible estimate of the most likely outcome from lower patient-to-nurse ratios.

Rothberg and colleagues (2005) found that reducing patient/nurse ratios from 8 : 1 to 4 : 1 reduced mortality and increased costs, but that the incremental mortality gain per dollar fell as the ratio got closer to 4 : 1. In other words, cost per life saved rose as the ratio fell toward 4 : 1. Moving from 8 : 1 to 7 : 1 cost $24,900 per life saved (in 2005 dollars), whereas moving from 5 : 1 to 4 : 1 cost $136,300 per life saved, more than 5 times as much. The former would clearly be within the $50,000 per life saved threshold typically used by U.S. insurers and government agencies around the developed world to decide if a treatment is worth covering (Grosse, 2008; Hirth et al., 2000; Neumann & Greenberg, 2009; Weinstein, 2008). The latter incremental gain in mortality would not pass this threshold test. Still, most states leave staffing decisions to hospitals, and they are, predictably, all over the map in the absence of a definitive empirical study and national regulation. Thus, the final decision is left to the market.

Impact of Health Reform on Nursing Economics The Patient Protection and Affordable Care Act (ACA) has many features which impact nursing and the entire health care system, but the most far reaching for nursing are those which relate to payment and delivery reforms. The increasingly explicit aim of the ACA is to catalyze, through public programs and multipayer incentives, a transformation across the health care system from fee-




for-service medicine (which is basically pay-for-volume) to more accountable health care that will be closer to pay-for-value. This approach is reflected in the ACA’s shared savings programs, especially Pioneer Accountable Care Organizations, the ACA Patient-Centered Medical Home (PCMH) experiment, and the Comprehensive Primary Care Initiative, as well as with bundled payments. The underlying assumption, widely shared, is that enabling most health delivery organizations to provide high-value care is the only way the health system as a whole is going to be financially sustainable, while serving all of us, as the ACA also envisions, rather than some of us, as the U.S. health care system does now.

Although the new emerging models of care obviously differ in details, they share one common theme, which is to pay groups of providers for larger and larger units of service. For example, instead of paying physicians separately for each visit and associated tests with fee-for-service and then paying hospitals separately for each admission with a diagnosis-related group (DRG)–based payment, pay one lump sum to a team to take care of the patient for a given episode (bundled payment) or length of time (global capitation). The opportunity for nursing is that nurses’ inherent skill set, patient-focused care, communication, and coordination across silos of care can help both physicians and hospitals deliver higher quality care more efficiently than today. The challenge for nursing is that the price is largely hidden, within the per visit charges of physicians and within the per diem charges of hospitals. This means that current data systems are unable to credibly estimate the value of nursing services and the optimal configuration of nurses within multidisciplinary clinical teams. Keeping a clear eye on nursing value to the team is essential for truly cost-effective and high-quality care to be priced and delivered, and not all managers are able to do this at the moment (Beurhaus, Welton, & Rosenthal, 2010).

These types of payment reforms are being adopted by private payers, in some cases faster than the government pilots can spread, such as with PCMHs. What they all have in common, for the first time in American health care (except for the closed staff model health maintenance organizations such as Kaiser Permanente and




Group Health Cooperative), is that providers have powerful incentives to reorganize care delivery and coordination processes to seek the triple aim: cost-effective, timely, and efficacious care. Although this transformation is likely to be good for nurses at the RN level and above in the medium and long term, the transformation is not without risks and probably bodes some pain for some nurses in the short term.

The first-order effect of these incentive changes will be to modernize the nation’s nurse practice acts to reflect current standards. The intense battles in half of the state houses may become relatively moot, because now health delivery organizations will gain from using advanced practice nurses and others to the limit of their training, not the limit of their current scope of practice. Restrictive state nurse practice acts, even at this late date, too often are still intent on protecting physicians’ short-run economic interests at the expense of higher-cost care and limited access to qualified providers for all concerned. The ACA and the incentives it unleashed will eventually lead physician groups to demand scope of practice liberalization or simply refuse to complain and prosecute its technical breach.

This general incentive realignment will then extend to reorganizing physician offices, starting with primary care because of the sheer number of PCMHs already in existence (attributable to public and private initiatives), but it will soon extend to specialists and hospitals also. Care-coordination nurses and nurses who can function well within and even lead team-based delivery of care will earn premium wages, because communication across former silos of care will be paramount to reduce the avoidable hospital admissions and readmissions that have been huge cost drivers for patients with multiple chronic conditions. Systems which learn how to lower the costs on high-cost patients who spend most of the 17% of gross domestic product without attaining satisfactory outcomes compared with other OECD (relatively rich) countries will be the systems that will flourish. It is very likely that effective nurses will be the backbone and sinew of care coordination and these new more efficient systems of care.

A short-run cost could materialize for those nurses who work for hospitals and physician groups who deny, delay, or resist this




incentive realignment and do not clearly see the value of nursing services, long past the point of being behind their peers. Top-level managers of these organizations may not be doing appropriate cost- effectiveness analyses of how best to reorganize care to align with new incentive structures, but may rather be focused on preserving their top-level incomes even as overall revenue inevitably falls. The only solution they may see is to increase patient/nurse ratios by laying off relatively expensive RNs and either not replacing them or replacing them with lower trained and less expensive health professionals. And some small outlying hospitals will close owing to lack of demand for their services in a world focused on the ability of enhanced primary care to prevent hospitalizations and readmissions.

The marketplace will then have two strategies in competition: (1) a lower cost and more team-based approach and (2) a higher cost and more libertarian or traditional cowboy style go-it-alone health care. The lower cost and team-based approach will surely win, but it may take a while before the evidence is clear to the common public, and the traditional providers will, in the meantime, claim loudly that they are the only high-quality alternative left. Credible quality measurement infrastructures, price, and quality transparency for consumers to make comparison shopping possible will hasten the demise of the old school strategy, but even so it may take 10 years at least before it disappears altogether.

The ACA will then ultimately create a more welcoming environment for nurses and their many talents, but some might have a more painful transition to this better world than others.

Discussion Questions 1. Describe at least three issues that make the health care market behave differently from other markets.

2. According to economic principles, what forces go into play as demand for nursing goes up?

3. What role could nurses play, enlarge, or expand in value-driven care delivery models such as Primary Care Medical Homes and




Accountable Care Organizations?

References Beurhaus P, Welton J, Rosenthal M. Health care payment

reform: Implications for nurses. Nursing Economic$. 2010;28(1):49.

Feldstein PJ. Health policy issues: An economic perspective. Health Administration Press: Chicago, IL; 2011.

Grosse S. Assessing cost-effectiveness in healthcare: history of the $50,000 per QALY threshold. Expert Review of Pharmacoeconomics & Outcomes Research. 2008;8(2):165–178.

Hirth R, Chernew M, Miller E, Fendrick AM, Weissert WG. Willingness to pay for a quality-adjusted life year: In search of a standard. Medical Decision Making. 2000;20(3):332–342.

Neumann P, Greenberg M. Is the United States ready for QALYs? Health Affairs. 2009;28(5):1366–1371.

Rothberg M, Abraham I, Lindenauer P, Rose D. Improving nurse to patient staffing ratios as a cost-effective safety intervention. Medical Care. 2005;43(8):785–791.

U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Bureau of Health Professions. The registered nurse population: Initial findings from the 2008 National Sample Survey of Registered Nurses. [Retrieved from] 2010.

U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Bureau of Health Professions, National Center for Workforce Analysis. The U.S. nursing workforce: Trends in supply and education. [Retrieved from] 2013.

Weinstein M. How much are Americans willing to pay for a quality-adjusted life year? Medical Care. 2008;46(4):343–344.






Financing Health Care in the United States Joyce A. Pulcini, Mary Ann Hart

“There are more than 9000 billing codes for individual procedures and units of care. But there is not a single billing code for patient adherence or improvement, or for helping patients stay well.” Clayton M. Christensen

Health care financing in the United States is fragmented, complex, and the most costly in the world. The Affordable Care Act (ACA) of 2010 takes some steps to reshape how health care is paid for, but its primary purpose is to extend insurance coverage to approximately 30 million uninsured Americans through private insurance regulation, expansion of pubic insurance programs, and creation of health insurance marketplaces to foster competition in the private health insurance market. As the ACA is implemented, making health insurance more affordable and containing the rise in health care costs are significant ongoing policy challenges in system transformation. This chapter will provide an overview of the current system of health care financing in the United States, including the impact of the ACA.




Historical Perspectives on Health Care Financing Understanding today’s complex and often confusing approaches to financing health care requires an examination of the nation’s values and historical context. Some dominant values underpin the U.S. political and economic systems. The United States has a long history of individualism, an emphasis on freedom to choose alternatives and an aversion to large-scale government intervention into the private realm. Compared with other developed nations with capitalist economies, social programs have been the exception rather than the rule and have been adopted primarily during times of great need or social and political upheaval. Examples of these exceptions include the passage of the Social Security Act of 1935 and the passage of Medicare and Medicaid in 1965.

Because health care in the United States had its origins in the private sector market, not government, and because of the growing political power of physicians, hospitals, and insurance companies, the degree to which government should be involved in health care remains controversial. Other developed capitalist countries, such as Canada, the United Kingdom, France, Germany, and Switzerland, view health care as a social good that should be available to all. In contrast, the United States has viewed health care as a market- based commodity, readily available to those who can pay for it but not available universally to all people. With its capitalist orientation and politically powerful financial stakeholders, the United States has been resistant to significant health care reform, especially as it relates to expanding access to affordable health insurance.

The debate over the role of government in social programs intensified in the decades after the Great Depression. Although the Social Security Act of 1935 brought sweeping social welfare legislation, providing for Social Security payments, workman’s compensation, welfare assistance for the poor, and certain public health, maternal, and child health services, it did not provide for health care insurance coverage for all Americans. Also, during the decade following the Great Depression, nonprofit Blue Cross and Blue Shield (BC/BS) emerged as a private insurance plan to cover hospital and physician care. The idea that people should pay for




their medical care before they actually got sick, through insurance, ensured some level of security for both providers and consumers of medical services. The creation of insurance plans effectively defused a strong political movement toward legislating a broader, compulsory government-run health insurance plan at the time (Starr, 1982). After a failed attempt by President Truman in the late 1940s to provide Americans with a national health plan, no progress occurred on this issue until the 1960s, when Medicare and Medicaid were enacted.

BC/BS dominated the health insurance industry until the 1950s, when for-profit commercial insurance companies entered the market and were able to compete with BC/BS by holding down costs through their practice of excluding sick (with preexisting conditions) people from insurance coverage. Over time, the distinction between BC/BS and commercial insurance companies became increasingly blurred as BC/BS began to offer competitive for-profit plans (Kovner, Knickman, & Weisfeld, 2011. In the 1960s, the United States enjoyed relative prosperity, along with a burgeoning social conscience, and an appetite for change that led to a heightened concern for the poor and older adults and the impact of catastrophic illness. In response, Medicaid and Medicare, two separate but related programs, were created in 1965 by amendments to the Social Security Act. Medicare is a federal government-administered health insurance program for the disabled and those over 65 years (Kaiser Family Foundation [KFF], 2014c), and Medicaid, until recently, has been a state and federal government-administered health insurance program for low- income people, who are in certain categories, such as pregnant women with children.

Government Programs Current Public/Federal Funding for Health Care in the United States In the United States, no single public entity oversees or controls the entire health care system, making the payment for and delivery of health care complex, inefficient, and expensive. Instead, the system




is composed of many public and private programs that form interrelated parts at the federal, state, and local levels. The public funding systems, which include Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), the U.S. Department of Veterans Affairs (VA), and the Defense Health Program (TRICARE) for military personnel, their families, military retirees, and some others, continue to represent a larger and larger proportion of health care spending. Other examples of federal programs are the Indian Health Service, which covers American Indians and Alaskan Natives, and the Federal Employees Health Benefits (FEHB) Program, which covers all federal employees unless excluded by law or regulation.

Federal health expenditures for these programs totaled $731.6 billion or 26% of all health care expenditures in 2012 (Martin et al., 2014). Medicare outlays were $572.5 billion in 2012 and accounted for 20% of all national health care expenditures with Medicare Advantage (a Medicare-managed care program provided by insurance plans that can be chosen by beneficiaries instead of the traditional Medicare program) growing most rapidly (Martin et al., 2014). Medicaid outlays in 2012 were $412.2 billion and accounted for 15% of total national health care expenditures, and its spending growth also decelerated that year (Martin et al., 2014).

Medicare Before the enactment of Medicare in 1965, older adults were more likely to be uninsured and more likely to be impoverished by excessive health care costs. Half of older Americans had no health insurance; but by 2000, 96% of seniors had health care coverage through Medicare (Federal Interagency Forum on Age-Related Statistics, 2000).

Medicare had a beneficial effect on the health of older adults by facilitating access to care and medical technology, and, in 2006, prescription drug coverage helped improve the economic status of older adults. The percentage of persons over age 65 years living below the poverty line decreased from 35% in 1959 (when older adults had the highest poverty rate of the population) to 9% in 2012 (U.S. Census Bureau, 2014).




Americans are eligible for Medicare Part A at age 65 years, the age for Social Security eligibility, or sooner, if they are determined to be disabled. Medicare Part A accounted for 31% of benefit spending in 2012 and covers 52 million Americans. Medicare Part A covers hospital and related costs and is financed through payroll deduction to the Hospital Insurance Trust Fund at the payroll tax rate of 2.9% of earnings paid by employers and employees (1.45% each) (KFF, 2014a). Medicare Part B, which accounted for approximately one third of benefit spending in 2012, covers 80% of the fees for physician services, outpatient medical services and supplies, home care, durable medical equipment, laboratory services, physical and occupational therapy, and outpatient mental health services. Part B is financed through subscriber premiums and general revenue funding as well as cost-sharing with beneficiaries.

Medicare Part C, or the Medicare Advantage Program, through which beneficiaries can enroll in a private health plan and also receive some extra services such as vision or hearing services, accounted for 23% of benefit spending in 2012 and had more than 14.1 million enrollees, or 28% of all Medicare beneficiaries in 2013 (Medpac, 2013). Medicare Advantage enrollment has been increasing and is up 30% since 2010 (KFF, 2014a). Extra payments that the federal government has made to private Medicare Advantage Plans are due to be phased out by the ACA, raising concerns that insurers will drop their Medicare Advantage Plans as a result.

Medicare Part D is a voluntary, subsidized outpatient prescription drug plan with additional subsidies for low- and modest-income individuals. It accounted for 10% of benefit spending in 2012 and enrolled 39 million beneficiaries in 2013 (KFF, 2014a, 2014b). Figure 18-1 presents Medicare benefit payments by type of service in 2012 (KFF, 2014a). Medicare Part D is financed through general revenues and beneficiary premiums as well as state payments for recipients who get both Medicare and Medicaid, also known as “dual eligibles” (KFF, 2014b). The ACA phases out the Medicare Part D “donut hole,” a period of noncoverage for prescription drugs that left many seniors unable to pay out-of- pocket for their medications.




FIGURE 18-1 Medicare benefit payments by type of service, 2012. (From Kaiser Family Foundation. [2014]. Retrieved from

The ACA authorized that certified nurse midwives (CNMs) be reimbursed at 100% of the physician payment rate. Other advanced practice registered nurses (APRNs), including nurse practitioners (NPs), are paid 85% of the physician rate for the same services. In addition, Medicare will not pay for home care or hospice services unless they are ordered by a physician. And, unfortunately, the ACA required physician orders for durable medical equipment for Medicare beneficiaries.

Medicaid Medicaid is the public insurance program jointly funded by state and federal governments but administered by individual states under guidelines of the federal government. Medicaid is a means- tested program because eligibility is determined by financial status. Before changes by the ACA, only low-income people within certain




categories, such as recipients of Supplemental Social Security Income (SSI), families receiving Temporary Assistance to Needy Families (TANF), and children and pregnant women whose family income is at or below 133% of the poverty level were eligible. To qualify for federal Medicaid matching grants, a state must provide a minimum set of benefits, including hospitalization, physician care, laboratory services, radiology studies, prenatal care, and preventive services; nursing home and home health care; and medically necessary transportation. Medicaid programs are also required to pay the Medicare premiums, deductibles, and copayments for certain low-income persons who are eligible for both programs. Medicaid is increasingly becoming a long-term care financing program of last resort for older adults in nursing homes. Many older adults have to spend down their life savings to become low income and be eligible for Medicaid. Family and pediatric NPs and CNMs are also required to be reimbursed under federal Medicaid rules if, in accordance with state regulations, they are legally authorized to provide Medicaid-covered services.

In keeping with its goal to expand health insurance coverage to more Americans, the ACA expands eligibility for the Medicaid program to any legal resident under the age of 65 years with an income up to 138% of the federal poverty level. The intent of the health reform law was to have one eligibility standard across all states and eliminate eligibility by specific categories (Commonwealth Fund, 2011; Rosenbaum, 2011). The federal government has agreed to pay for nearly all the expansion costs to insure more low-income people. The U.S. Supreme Court, however, struck down the mandate to expand Medicaid and ruled that states could decide whether or not to expand the program. Figure 18-2 indicates that as of April 2014, 27 states had decided to expand Medicaid, 5 are still debating this, and 19 are not moving forward (KFF, 2014d). States that decide to opt out of the expansion can follow old federal guidelines for eligibility, leaving wide disparities in health insurance coverage between states and leaving uninsured large proportions of the population below 138% of the poverty level. Of the states that have opted out of expansion, all have Republican political leaders explicit in their opposition to the ACA, although Republican Governor Jan Brewer of Arizona pushed her




state to expand Medicaid in 2013 so that 300,000 more poor and disabled residents of the state would have coverage (Schwartz, 2013). In many of the nonparticipating states, physicians, nurses, hospitals, and other health care organizations and stakeholders are pressuring their state governments to expand Medicaid as a way to improve access to health care for more low-income people.

FIGURE 18-2 State Medicaid expansion, November 2014. (From FamiliesUSA. [2014]. Retrieved from; and Kaiser Family Foundation. [2014]. Retrieved from closer-look-at-the-impact-of-state-decisions-not-to-expand-medicaid-on-


CHIP was created in 1997 to help cover uninsured children whose families were not eligible for Medicaid. It has been funded through state and federal funds, but states set their own eligibility standards. The ACA commits the federal government to paying most of its costs, beginning in 2015, up to 100%. It also requires states to maintain their eligibility standards for CHIP (Emanuel,




2014). CHIP will be reauthorized in 2015, and, because it is expected that many more children will have gained coverage through family health insurance plans, debate is expected over the role of the program. CHIP is enrolling a record number of children now estimated to be one third of all children in the United States. Advocates want to maintain these high child health insurance rates until the ACA is fully implemented and full coverage for children under the provisions of the ACA is assured.

State Health Care Financing State governments not only administer and partially fund some public insurance programs such as Medicaid and CHIP but they are also responsible for individual state public health programs. The definition of public health as compared with other types of health programs is not always well understood. The mission of public health as defined by the Institute of Medicine (IOM) is to ensure conditions in which people can be healthy (IOM, 1988). Whereas medicine focuses on the individual patient, public health focuses on whole populations. Medical care for the individual patient is associated with payment by health insurance, but population-based public health programs are funded by local, county, state revenues, often combined with grants from the federal government in areas such as maternal and child health, obesity prevention, HIV/AIDS, substance abuse, and environmental health. Even with a greater federal role in health care through the ACA, states will continue to have a major responsibility for the regulation of health insurance, health care providers and professionals, and public health activities.

Reduction of budgets for public health programs during times of fiscal constraint has resulted in the resurgence of infectious diseases such as tuberculosis and sexually transmitted diseases in some communities. A series of natural disasters such as tornados also brought to light gaps in the public health system, especially the ability to respond, for example, to mass casualty events. Although the ACA authorized $15 billion for the creation of a Prevention and Public Health Fund to invest in public health and disease prevention, Congress reduced by one third the amount of funding mandated by the law in 2012 and President Obama signed the




legislation to pay for other initiatives (Health Policy Brief, 2012).

Local/County Level Similar to state governments, local and county governments in many states also have the responsibility of protecting public health. Some provide indigent care by funding and running public hospitals and clinics, such as New York City’s Health and Hospitals Corporation and Chicago’s Cook County Hospital. Although receiving a subsidy from their local government, these hospitals, which have served primarily poor patients and those without health insurance, have gotten significant special payments, especially from Medicare to serve these populations. These disproportionate share hospital (DSH) payments are being gradually reduced under the ACA because it is presumed that eventually, under the ACA, many more people will gain health insurance coverage. Because public hospitals and clinics are so dependent on public funds, their budgets are historically squeezed during times of fiscal restraint by local, state, and federal governments, making them vulnerable to long-term sustainability. In fact, many public health hospitals have closed, and in many parts of the country, the populations they have served have been absorbed by other types of hospital providers (KFF, 2013).

The Private Health Insurance and Delivery Systems The U.S. health care system has been predominantly a private one that operates more like a business and, more or less, according to free market principles. Private health insurance has been the dominant payer and, for most Americans, it is obtained as a benefit of employment in the form of group health insurance. However, until the passage of the ACA employers have had no obligation to provide employee health insurance, leaving many Americans uninsured or underinsured, especially those working in lower- wage jobs. As private health insurance premiums have risen, employers asked employees to pay for a greater percentage of their




insurance premium, and to enroll in plans that required more cost- sharing in the form of copayment, deductibles, and coinsurance. Approximately 15% of insured Americans have purchased their health insurance from the nongroup individual insurance market. Typically, these plans were more expensive and insurers in all but a few states had been able to deny insurance to applicants with preexisting medical conditions, until the practice of discrimination based on medical history was outlawed by the ACA in 2010. Because private insurers are regulated by individual states, there are wide disparities in coverage from state to state, as private insurers are powerful political stakeholders who resist attempts at state or federal regulations to make insurance more accessible and affordable. Whereas private health insurance will continue to be a cornerstone of the U.S. health care financing system, public insurers such as Medicare and Medicaid are paying for an increasing percentage of health care costs.

It should be noted that health insurance is regulated by the states. Some states now mandate that NPs be considered primary care providers and eligible for credentialing and payment by private insurers. But there is wide variation in the extent to which APRNs are included in insurers’ provider panels. This variation can be seen among states, among insurers within a given state, and among the plans offered by an insurer (Brassard, 2014).

Most care in the United States is provided by nonprofit or for- profit hospitals and health care systems and private insurance plans (Truffer et al., 2010). Pharmaceutical companies, suppliers of health care technology, and the various service industries that support the health care system in the United States are part of what has been called the medical industrial complex (Meyers, 1970), and there is little government regulation of these industries. Although the private delivery system is dependent on payment from private insurers as well as government insurers, it has usually been resistant to government-directed efforts to expand access to care or cost-containment measures. Well-financed special interest groups representing industry stakeholders have had a great deal of influence over the political process at both the state and federal levels. For example, the medical device industry is lobbying Congress hard to repeal or reduce the medical device tax that the




ACA levied to help pay for the expansion of insurance coverage under the health care law and has gained significant support in Congress (Kramer & Kasselheim, 2013).

The Problem of Continually Rising Health Care Costs From the 1970s to the present, continually rising insurance premiums and health care delivery costs have strained government budgets, become a costly expense to businesses that offer health insurance to their employees, and put health care increasingly out of reach for individuals and families. Figure 18-3 depicts the annual percentage change in national health expenditures by selected sources of funds, 1960 to 2012 (KFF, 2014e).




FIGURE 18-3 Annual percentage change in national health expenditures, by selected sources of funds,

1960 to 2012. (From Kaiser Family Foundation. [2014]. Retrieved from

change-in-national-health-expenditures-by-selected-sources-of-funds-1960- 2012-healthcosts.png.)

Stakeholders in small and large businesses, government, organized labor, health care providers, and consumer groups have convened over the years to tackle the problem of rising health care costs, with little lasting success. Although a range of strategies was employed to curb rising health care costs over those 40 years, health care expenditures as a percentage of the gross domestic product (GDP) increased steadily over that time. Although multiple factors




are responsible for rising health care costs as a percentage of GDP, the key one is that, unlike other capitalist democracies, the federal and state governments have little, if any, role in regulating what can be charged for health care services and supplies. Prices are largely negotiated between health insurances and providers, resulting in wide variances in prices for similar or exact services, largely based on the market clout of providers to negotiate higher prices. Other contributing factors to high health care costs include the complex administrative systems of insurers and providers, the use of expensive medical technology and medical specialists, and the incentive in fee-for-service reimbursement for providers to increase their volume of services and provide unnecessary health care. Consumers have also lacked knowledge of the actual cost of their care, leading to an inability of the market to accurately respond to cost and differential health care prices by region, type of hospital, or health care facility.

Future costs will also be impacted by the aging of the population and increasing number of people with complex chronic illness who use a disproportionately high percentage of the health care dollars. For example, from 1977 to 2007, a very stable 5% of the population who had complex chronic illness accounted for nearly 50% of the health care expenditures (KFF, 2010; Stanton, 2006), despite efforts to control costs among this population. In 2009, the costliest 5% of beneficiaries accounted for 39% of all Medicare fee-for-service spending. The least costly 50% of beneficiaries accounted for 5% of all spending (Medpac, 2013). The majority of those in the high- expenditure group are not older adults but rather those with complex chronic illnesses (Stanton, 2006).

All other industrialized countries spend significantly less on health care but have better health outcomes and a longer life expectancy. For example, the United States ranks among the worst of industrialized nations on important health indicators such as infant mortality, maternal mortality, and life expectancy at birth (Squires, 2014). Yet, in 2012, it ranked first in health care costs per capita at approximately $8915 per person (Organization for Economic Co-operation and Development [OECD], 2013b). This amounted to close to 18% of its GDP, compared with The Netherlands, which ranked second at 12% of its GDP (OECD,





Cost-Containment Efforts Over time, several approaches have been used to contain costs, including the following.

Regulation Versus Competition. During the 1970s, modest government regulation attempted to contain health care costs through state rate-setting agencies and health planning mechanisms, such as Certificate of Need (CON) programs and regional Health Systems Agencies (HSAs), which evaluated and approved applications for the construction of new facilities, beds, and new technology. During the 1980s and early 1990s, when proponents of competition and free market health care became politically more influential, rate setting and CON programs were weakened and HSAs were eliminated. While free-market principles, as they apply to health care, have few similarities to a fully competitive market in economic terms, the rise of managed care programs and competition among health insurance plans in the 1980s may have temporarily slowed the growth of health costs before they began to rise again. As health insurers expanded the use of copayments, deductibles, and coinsurance as economic incentives to discourage care, the onus of cost-containment fell more heavily on the consumer/patient. However, ample research shows that low-income people may avoid necessary care because of copayments and deductibles. Chapter 17 more fully describes the mechanisms underlying the market system in health care.

Managed Care. The origins of today’s managed care plans were in early prepaid health plans of the 1920s, which evolved into Health Maintenance Organizations (HMOs) in the 1970s, and into a variety of models in the subsequent 30 years, including Preferred Provider Organizations (PPOs). A managed care system shifts health care delivery and payment from open-ended access to providers, paid for through fee-for-service reimbursement, toward one in which the provider is a gatekeeper or manager of the patient’s health care and




assumes some degree of financial responsibility for the care that is given through a capitated budget in which to pay for the patient’s care. Managed care implies not only that spending will be controlled but also that other aspects of care will be managed, such as quality and accessibility. In managed care, the primary care provider has traditionally been the gatekeeper, deciding what specialty services are appropriate and where these services can be obtained at the lowest cost. In the 1990s, negative media attention concerning the incentives to restrict care in the managed care model fueled a political backlash. Consumer and provider demands for greater choice for services and access to providers caused managed care plans to loosen gatekeeper requirements and provide more direct access to specialists. As a result, managed care became less effective in holding down expenditures and fueled a rise in health insurance premiums.

In addition, concerns of consumers and providers challenging the quality of care provided by some Managed Care Organizations (MCOs) resulted in state and federal laws to further regulate managed care plans (Kongstvedt, 2001). These laws included provisions related to grievance procedures, confidentiality of health information, requirements for informing patients of the benefits they will receive, antidiscrimination clauses, and assurances that various quality mechanisms were in place so that patient satisfaction was measured and efforts to control costs did not curtail needed care. In addition, most states adopted policies giving health plan enrollees a right to appeal plan determinations involving a denial of coverage to an independent medical review entity, which is often a private organization approved by the state (American Association of Health Plans, 2001). Efforts to pass into law the federal Patient’s Bill of Rights, which contained many consumer protections related to managed care, were not successful.

Medicaid and Medicare also promoted managed care plans to control their expenditures for health care by using capitated payment and managing patient care. All 50 states offer some type of Medicaid-managed care plans, and states can decide if participation is voluntary or mandatory. Some states have created state-run Medicaid-only plans, but others enroll Medicaid recipients in private MCOs. By 2010, 70% of the Medicaid population received




some or all of their services through Medicaid-managed plans (Kaiser Health News, 2010).

Financing Mechanisms Fee-for-Service Reimbursement. Until the 1980s, Medicare and private health insurers paid providers through fee-for-service (FFS) reimbursement. In FFS, providers charge a fee for each service, and then providers or patients submit claims to insurers for payment. There is a strong incentive under the FFS payment for providers to increase the volume of services and raise prices to increase their revenue. In addition, through the reimbursement mechanisms of their patients who are on Medicare, the federal government has paid hospitals according to the percentage of Medicare recipients, which has been inherently inflationary. Both health care organizations (such as hospitals) and individual providers (such as physicians) were historically paid through FFS reimbursement. By contrast, nursing services in hospitals continue to be grouped into an aggregate hospital fee or as part of the room fee, rendering nursing care to be in effect a cost center rather than a revenue generator. This mechanism makes it difficult to measure quality of nursing care in hospital situations.

Physician/Clinician Reimbursement Under Fee-for- Service. Payment for physician services is approximately 20% of total national health expenditures (Emanuel, 2014), a significant cost- driver in health care. FFS is still the predominant way of reimbursing for physician and clinician services. Public and private health insurers pay physicians through a complicated formula related to medical coding and medical billing to determine the final payment (Emanuel, 2014).

The American Medical Association (AMA) created Current Procedural Terminology (CPT), a coding system for visits to physicians and other providers. There are codes for evaluation and management, office visits, emergency room visits, prevention services, anesthesia, radiology, pathology, laboratory codes, and




medicine codes, such as for dialysis (Emanuel, 2014). These codes are then linked to a specific diagnosis as outlined in the International Classification of Diseases IDC-9 (soon to be IDC-10) and then assigned payment levels.

Prospective Payment Systems. In the 1980s, the federal government replaced the old FFS system for Medicare Part A with a prospective payment system (PPS) for hospital care, establishing payment based on diagnosis-related groups (DRGs). DRGs set a payment level for each of the approximately 500 diagnostic groups typically used in inpatient care. The prospective payment approach helped to slow the rate of growth of payment for hospital care, shortening average length of stay, and increasing patient acuity in hospitals (Heffler et al., 2001).

In the past, insurers paid whatever physicians billed. But in 1992, under Medicare Part B physician payment reform, payment was linked to a Resource-Based Relative Value Scale (RBRVS). In this physician reimbursement system under Medicare, the relative value unit (RVU) for each service is based on the degree of physician work (time, skill, training, intensity), practice expertise (nonphysician labor and practice expenses), and the cost of malpractice for the specialty, as well as the geographic cost of living (Emmanuel, 2014). Its goal was not only cost savings but also to redistribute physician services to increase primary care services and decrease the use of highly specialized physicians. However, the RVU system has been criticized for still favoring specialist care and hospital-based care. The Centers for Medicare and Medicaid Services (CMS) adopts over 80% of the recommendations of the AMA’s recommendations for RVUs for each service. This mechanism has been criticized as a conflict of interest, especially as specialists and surgeons comprise a significant proportion of the AMA committee making the recommendations (Emanuel, 2014). In addition, the same procedure done in a hospital is reimbursed at a higher rate than if done in a physician’s office. Hence, the incentive is to do more procedures in hospital-owned facilities. The Medicare RVUs per service ratings have been adopted by private insurers, but they use different conversion factors, enabling them to pay more for each service.




Since 1997, the Medicare program has also attempted to contain costs by limiting how much physician payments can increase through the Sustainable Growth Rate (SGR), a target based on physician costs, Medicare enrollment, and the GDP (Emanuel, 2014). There is no incentive in the SGR for individual physicians to contain costs because the SGR is calculated for physician services for the entire country. The intent of the original law was to reduce Medicare payments to physicians if the SGR was exceeded. However, Congress regularly passes a so-called “doc-fix” bill to prevent SGR cuts from going into effect, enabling higher Medicare payment rates for physicians, APRNs, and other providers (Lowrey, 2014). The SGR continues to be a controversial issue, and Congress has been unable to address the problem, except on an episodic basis.

Bundled Payments/Global Payments. An estimated 85% of payment to providers is still through an FFS payment system, creating an inherent incentive to increase volume and costs (Emanuel, 2014). More recently, policymakers are promoting bundled and global payments as a way to not only contain costs but to also provide an incentive for providers to better coordinate and manage patient care.

Under payment bundling, hospitals, doctors, and providers are paid a flat rate for an episode of care, rather than by individual service. Bundled payment is a form of prospective payment that is being tested by Medicare, private insurers, and provider systems, such as Accountable Care Organizations (ACOs). Global payment is a form of capitation in which the insurer is usually paid per member per month. Proponents of both argue that these payment models differ from traditional capitation in that payment is risk- adjusted and providers can share in savings if care is coordinated and managed and patients are kept healthy. Massachusetts is an example of a state that has provided incentives to insurers and providers to move to bundled and global payment reform.

The ACA and Health Care Costs Although improving access to care by enabling more Americans to




gain health insurance coverage is the main objective of the ACA, the law is also expected to have a significant impact on containing health care costs. According to the Congressional Budget Office (2014), the ACA will reduce projected federal spending on health care by $109 billion between 2014 and 2024 (Jost, 2014). The ACA does this through reducing prices and controlling the use of services while maintaining quality (Emanuel, 2014). As of December 2014, there was evidence that spending was indeed decreasing. CMS reported that health care spending for 2013 increased by only 3.5%, the lowest rate of growth since 1960. This has been attributed at least in part to the ACA (Carey, 2014).

The ACA seeks to contain Medicare costs and pay for coverage expansion through: • Medicare will phase out the extra payments it was making to

insurers who offered Medicare Advantage Plans, the managed care private plans that older adults can choose instead of traditional FFS Medicare.

• Medicare will pay a lower annual increase in hospital, home, skilled nursing, and hospice care.

• Medicare will pay less for durable medical equipment such as wheelchairs, walkers, and oxygen equipment because of a mandated competitive bidding process for these supplies (Emanuel, 2014).

Additional provisions to control costs include: • Reduction of special payments the federal government has

historically made to hospitals serving disproportionate numbers of uninsured, with the expectation that more people will have health insurance under the ACA

• Taxing employers who offer high-cost private insurance plans to employees, encouraging them to redesign their health benefits and provide more affordable choices for their employees, scheduled to go into effect in 2018

• Encouraging the development of ACOs for Medicare recipients, integrated networks of providers responsible for managing and coordinating care of patients, especially those with costly chronic conditions

• Penalizing hospitals if they have excessive 30-day readmissions




and hospital-acquired infections, by reducing their Medicare reimbursement and providing an incentive for them to improve the quality of care (Centers for Medicare and Medicaid Services, 2013)

• Implementing aggressive Medicare/Medicaid fraud and abuse prevention measures, which are projected to save the federal budget $7 billion over 10 years (McDonough, 2011)

• Establishing an Independent Payment Advisory Board (IPAB), which will recommend how to reduce the per capita growth of Medicare and reduce health care spending when health care inflation reaches a certain point

• Implementing administrative simplification measures that are aimed at the entire health sector and could save more than $11.6 billion in federal budget spending (McDonough, 2011)

• Conducting comparative effectiveness research, which will help physicians, other providers, and patients to determine which treatments work

Other provisions that have a major impact on nurses in primary care include some of the points that have been mentioned such as increases for reimbursement for primary care services, a strong focus on preventative health care (which is best delivered by nurses), and promotion of Patient-Centered Medical or Health Care Homes (PCMHs). As more and more Americans gain access to primary care services, nurses will be on the front lines of care. In addition, the Graduate Nursing Education (GNE) demonstration at five hospitals was part of the ACA. The demonstration is testing the use of Medicare funds to support clinical training of graduate nursing students, as is done with physicians (Graduate Medical Education, or GME). The outcomes of this demonstration may provide the evidence to move nursing’s share of these funds from diploma nursing programs to graduate education. In another example, the Health Resources and Services Administration (HRSA) provided $250 million for nursing workforce demonstrations projects as well as ways to enlarge and refinance APRN workforce education.




Discussion Questions 1. What forces have had an effect on increasing health care costs over the past 30 years?

2. What components of the ACA do you think will have a positive effect on improving health care outcomes and decreasing costs?

3. How has nursing fared in health care cost containment and what are the implications of the ACA on nursing?

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The Affordable Care Act

Historical Context and an Introduction to the State of Health Care in the United States

Andréa Sonenberg, Ellen S. Murray, Ellen-Marie Whelan

“So never lose an opportunity of urging a practical beginning, however small, for it is wonderful how often in such matters the mustard-seed germinates and roots itself.” Florence Nightingale

Historical, Political, and Legal Context Health care reform in the United States is an important issue, but since the 1930s, Presidents who have attempted to reform the system have faced significant political obstacles. The administrations of Presidents Franklin D. Roosevelt, Harry S. Truman, and John F. Kennedy all failed to garner enough political support to pass legislation for National Health Insurance programs through Congress. President Lyndon B. Johnson was able to gain




enough congressional support to pass the 1965 Social Security Act, which established Medicaid and Medicare, two federal health care programs that were desperately needed at the time (Kaiser Family Foundation [KFF], 2009). Additional reforms, however, failed to pass during the administrations of Presidents Richard M. Nixon, Jimmy E. Carter, and William J. Clinton, and the need to address U.S. health care policy became increasingly imperative.

The lack of comprehensive health care reform in the United States has had harmful effects on the health of the U.S. population and has increased the cost of health care. Although the United States has the most expensive health care system in the world, far exceeding expenditures in other Organisation of Economic Co-operation and Development (OECD) countries, the United States ranks last among industrialized nations in preventable mortality (OECD, 2013) and ranks surprisingly low in other important health quality measures, such as maternal and child mortality. In 2010, there were 49.9 million uninsured people in the United States, and the U.S. Census Bureau reported a decline in employer-based health insurance coverage for the 11th year in a row (Physicians for a National Health Program [PHNP], 2011). Without action, these trends would have continued, and health care costs would have become prohibitively expensive for more and more of the population.

In an effort to address these issues, Congress passed the Patient Protection and Affordable Care Act (PPACA), and President Barack Obama signed it into law on March 23, 2010. A few days later, Congress negotiated and passed the Health Care and Education Reconciliation Act (HCERA). This legislation made significant amendments to the PPACA. The final, revised law, as amended by HCERA, is commonly referred to as the Affordable Care Act (ACA) (McDonough, 2011).

Some aspects of the law were put into effect immediately, whereas other portions will take effect in the years to come, with full implementation expected by 2023. One of the most significant pieces of the law, the creation of state health insurance exchanges and expansion of Medicaid, was implemented in January 2014 (U.S. Centers for Medicare and Medicaid Services [USCMS], 2014c).

The passage and implementation of the ACA, thus far, has been extremely controversial and politically divisive. In the days after




President Obama signed the ACA law, lawsuits were filed by various groups challenging the constitutionality of the ACA, focusing specifically on the law’s two major provisions: the minimum essential coverage provision, known as the individual mandate, and Medicaid expansion. The U.S. Supreme Court agreed to consider two of these cases: Florida v. U.S. Dept. of Health and Human Svcs. and National Federation of Independent Business v. Sebelius. In a 5 to 4 vote, the majority of the court ruled the individual mandate constitutional. However, the court ruled in a 7 to 2 vote that the mandated state Medicaid expansion under the ACA was unconstitutionally coercive to states, both because the law did not provide states with enough time for voluntary consent to the changes the law made to the structure of Medicaid, thus states were likely to be deemed noncompliant, and because the Secretary of the U.S. Department of Health and Human Services (HHS) held the power to withhold all existing Medicaid funds from noncompliant states. To remedy this, the court ruled in a 5 to 4 vote that the HHS Secretary would not be allowed to withhold existing Medicaid funds from noncompliant states, but all other Medicaid reforms under the ACA would remain intact and on schedule (KFF, 2012).

Although the Supreme Court voted largely in favor of the ACA, its decision to circumscribe the Secretary’s power to withhold existing Medicaid funds renders the Medicaid expansion by states an optional element of the ACA. Analysts estimate that approximately 3 to 5 million fewer people will receive coverage owing to states that opt out of the Medicaid expansion funds (KFF, 2014b; Pear, 2012); as of February 2014, 26 states, including the District of Columbia, had decided to move forward with Medicaid expansion, 6 states were continuing to debate their decision, and 19 states had decided not to move forward with the expansion (KFF, 2014a). States that have decided against expansion may choose at any time to move forward with expansion and receive the full federal subsidies provided under the law, which includes 100% of the cost of new Medicaid recipients for the first three years (through 2016) and no less than 90% coverage of costs through 2022 (Angeles, 2012). The ACA will transform the U.S. health care system by expanding health care access and coverage, reforming




payment systems, and increasing the quality and coordination of care (McDonough, 2011).

Content of the Affordable Care Act Expansion of Access and Health Insurance Coverage The provisions in the ACA related to insurance coverage are what most Americans think of as the Affordable Care Act, or Obamacare. Although providing health insurance to the previously uninsured does not guarantee improved access to care, it is a crucial first step. The insurance provisions in the ACA generally fall into three categories: • Improves insurance coverage currently held by most Americans • Expands insurance options for more Americans • Increases the number of Americans with insurance

Improving Health Insurance Coverage. Much of what people know about the ACA are the changes to and expansion of health insurance coverage. Some improvements were made to the health insurance system immediately and others were phased in over time. Elimination of lifetime and unreasonable annual limits on benefits went into effect immediately and annual limits were prohibited in 2014. Other immediate provisions included the prohibition of cancellations of health insurance policies, prohibition of preexisting condition exclusions for children, and required coverage of preventive services. Prohibition of preexisting exclusion for adults went into effect in January 2014. Additional changes to public and private insurance coverage include: • Insurers cannot discriminate when offering coverage based on an

employee’s wages, health status, medical condition or history, claims experience, genetic information, disability, or evidence of insurability, as well as other factors the HHS deems appropriate.

• Insurance rating variability (the variation in individual out-of-




pocket premium rates) can be based only on age, family composition, geographic location, and tobacco use, with no rating based on health or gender.

• Full coverage without copayments is required for preventive services, including most screening tests and contraceptive methods, with a waiver of that last aspect for payers furnishing coverage to religiously observant organizations and employers.

• Quality reporting to the HHS is required in relation to coverage benefits and provider reimbursement structures that carry out patient safety initiatives through use of best clinical practices, evidence-based medicine, and health information technologies (ANA, 2010a, 2010b).

Minimum Essential Coverage. A minimum essential coverage provision (commonly referred to as the individual mandate) was established, requiring most individuals to obtain health care coverage for themselves and their dependents or face a shared responsibility payment (tax penalty) of either $95 or 1% of household income, starting in 2014 and increasing thereafter. Coverage can be obtained through employer- sponsored health insurance, new state health exchanges, government programs (Medicaid/Medicare), or grandfathered health plans, if the plan meets the ACA’s minimum essential coverage insurance standards. The Minimal Essential Benefits coverage “must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care” (USCMS, 2014b).

Insurance Amendments and the Indian Health Care Improvement Act. The ACA makes an additional series of amendments to the current health care system, which includes adjusting the implementation




and structure of the ban on lifetime and annual insurance caps; continuation of federal exclusion of coverage for abortion services using federal funds; and permanently reauthorizing the Indian Health Care Improvement Act that provides legal authority for the provision of health care to Native Americans and Alaska Natives.

Expanding the Recipients of Health Insurance To cover more of uninsured people, the ACA includes the following three elements:

1. Young adults: The law requires third-party payers to cover dependents up until age 26 years.

2. Individual mandate (everyone): As of January 2014, individuals (and their dependents) were required to be protected by essential coverage (USCMS, 2014b). The only allowable exemptions are for hardship and religious reasons. The state exchanges are meant to provide competition among third-party plans to promote affordability (ANA, 2010a, 2010b).

3. Making insurance more affordable (for low-income Americans): To ease the burden of purchasing health insurance on consumers, premium tax credits will be made available to households and individuals with incomes between 100% and 400% of the federal poverty level (FPL) to offset the cost of purchasing insurance through state or federal health exchanges. Cost-sharing assistance will be made available for those at 250% FPL and under.

Expanding Options for Health Insurance Coverage Expanding Employer-Based Coverage. Employers with more than 50 employees are mandated to provide minimal essential benefits (USCMS, 2014d), and employers with more than 200 employees are mandated to automatically enroll new employees into third-party plans. There are penalties for




noncompliance with these regulations ($750 per full-time employee, capped) for employers with more than 50 full-time employees that do not offer coverage or offer coverage deemed unaffordable or below the minimum essential coverage standard. The small business mandate to provide coverage has been delayed and is expected to be implemented between 2015 and 2016 (USCMS, 2014a). Employers are also permitted to reward participation in wellness programs (McDonough, 2011).

Medicaid and CHIP Expansion. Starting in January 2014, states were required to provide health coverage for all children, parents, and childless adults who are not entitled to Medicare and are at or below 133% FPL. The federal government is initially covering 100% of the cost of the expansion, with federal aid dropping to 90% starting in 2017. As per the Supreme Court’s decision noted above, states may decide to opt out of the ACA’s Medicaid expansion. States are required to maintain income eligibility levels for children covered by Medicaid and the Children’s Health Insurance Program (CHIP) through September 30, 2019 to receive all federal matching funds.

The State and Federal Exchanges. State-based health insurance exchanges are a major component of the ACA, which will enable individuals, families, and small employers to shop for coverage in a competitive marketplace. States were required to begin enrollment through exchanges by October 1, 2013 and have fully operational exchanges by January 1, 2014. States had the options of partnering with the federal government to operate the exchange, defaulting to a federally facilitated exchange, or creating their own exchange, provided it meets or exceeds the federal government’s minimum coverage standards. As of June 2014, 13 states had implemented their own exchange; 7 decided to partner with the federal government to implement and operated their exchange; and 19 decided to operate a federally facilitated exchange (The Commonwealth Fund, 2014).

Initially, enrollment through the federally facilitated exchange at and some state exchanges experienced a number of problems, largely dealing with technology and website issues. The




state-run exchanges of Oregon, Minnesota, Massachusetts, and Maryland, in particular, had a number of technical difficulties (Ornstein, 2014). This led to a smaller number of enrollees than expected, although the push for people to sign up by March 31, 2014 to avoid a tax penalty in 2015 resulted in more enrollments than the 6 million target. The KFF’s website ( is a good source for up-to-date statistics and U.S. and state enrollment numbers and state exchange issues.

All exchanges must be accessible to potential enrollees via telephone, in person, and online. Nurses can play a key role in educating the public about the exchanges.

Payment Systems Reform There are numerous payment reform provisions in the new law that will change how providers are reimbursed for the services they provide. These changes are often tied to increased provider accountability: moving from paying merely for quantity to paying more for quality of care and improved patient outcomes. • Enhanced payment for primary care providers: There is a 10% increase

in Medicare payments to primary care providers from 2011 through 2016. This provision includes nurse practitioners but not nurse midwives or other advanced practice registered nurses (ANA, 2014).

• Value-based payments: The law requires the Secretary to develop and implement a budget-neutral payment system that will use a value-based payment modifier to adjust Medicare physician payments based on the quality of care delivered. It will be phased in over time, starting with large practices (over 100 physicians) in 2015 and all eligible professionals by 2017. Payments will be based on quality measures in the Physician Quality Reporting System (PQRS) as a way to pay for value (value is quality relative to cost). Higher value gets higher reimbursement; lower value gets lower reimbursement.

• Testing new payment models: As a provision of the ACA, the Centers for Medicare and Medicaid (CMS) was also charged with starting a Center for Medicare and Medicaid Innovation (CMMI) to research, develop, and test effective payment and delivery




models to improve the quality of care while lowering costs. Congress also granted a new, unique authority to the Secretary of the HHS to expand the duration and scope of the testing for successful models (Shrank, 2013). Since its inception, the CMMI has initiated a wide variety of models that aim to realign incentives for providers to reward quality and the coordination of care instead of volume of services provided.

The following are examples of new payment initiatives.

Accountable Care Organizations. There are several regulations of the ACA that pertain to the eligibility, implementation, and quality monitoring of accountable care organizations (ACOs). ACO rules link the percentage of shared savings an entity is eligible to receive to its quality standards performance. Each new ACO model uses 32 quality measures to grade ACOs in five general areas that impact the beneficiary’s care: patient/caregiver experience of care, care coordination, patient safety, preventive health, and at-risk population/frail older adult health (HHS, 2012). There is a defined set of performance standards and a scoring procedure in the regulation, including a methodology to account for more complex patients (HHS, 2012). Eligibility to be a member of an ACO that participates in the Shared Savings Program is dependent on the ACO’s agreement to meet specific conditions including accountability to quality, cost, and comprehensive care of its assigned Medicare beneficiaries; a 3-year commitment to participate in the program; development of a legal structure to manage shared savings receipt and distribution; an adequate primary care workforce to care for the assigned number of beneficiaries; a management structure encompassing both clinical and administrative structures; and policies and procedures to implement evidence-based and coordinated care (Correia, 2011; HHS, 2012).

Advanced Primary Care Models. The CMMI created many different models of care to enhance and improve primary care. Medical homes (also known as patient- centered medical homes [PCMHs], primary care homes, or health




homes) and nurse-managed health centers (NMHCs) are well- known examples of models of delivery of comprehensive or advanced primary care. Given this diversity of developing advanced primary care models, the CMMI is testing a variety of approaches to enhanced primary care because there is no single, agreed-upon model (Baron, 2012).

Comprehensive Primary Care Initiative. This model of advanced primary care has both payment and system delivery reform components. Nearly 500 primary care practices were selected in seven markets where commercial and state health insurance plans agreed to join Medicare in providing increased access to data and bonus payments for increased care coordination.

Independence at Home. Home-based primary care allows clinicians to spend more time with their patients, perform assessments in a patient’s home environment, and assume greater accountability for all aspects of the patient’s care. In the Independence at Home program, practices led by physicians or nurse practitioners provide primary care home visits tailored to the needs of beneficiaries with chronic conditions and functional limitations.

Federally Qualified Health Center Advanced Primary Care. In this program, Federally Qualified Health Centers (FQHCs) that achieve a National Committee for Quality Assurance Level 3 PCMH Recognition receive additional funding to support care coordination for each of their Medicare patients. Nearly 500 FQHCs were accepted into this program to provide advanced primary care to approximately 195,000 patients with Medicare insurance (National Association of Community Health Centers, 2012).

Medicaid Health Home. The ACA created an option for states to permit Medicaid enrollees with at least two chronic conditions to designate a provider as a health home. States that implement this option will receive enhanced financial resources (90% federal matching payments for 2 years for health home related services) to support health homes in




their Medicaid programs.

Transitional Models of Care. With the aim of decreasing readmission rates of the chronically ill discharged after hospitalization, the ACA has allocated $500 million to pilot transitional care projects for Medicare recipients. Transitional care has been described by many but the most well- known models are by Eric Coleman and Mary Naylor. Eric Colman’s model pairs a transition coach with a patient with complex care needs. Patients learn self-management skills to ensure their needs are met during the transition from hospital to home (Coleman, 2003). Mary Naylor’s model uses transitional care nurses to manage hospital discharge and follow-up in the home. Her research has documented its effectiveness in lengthening the time between Medicare recipient discharge and rehospitalization or death, as well as in reducing the overall number of readmissions and lowering health care costs (Brooten et al., 2002 and Naylor, 2000 as cited by Robert Wood Johnson Foundation [RWJF], 2014b). The CMMI’s community-based care transitions program funds community-based organizations to use care transition services to effectively manage Medicare patients’ transitions and improve their quality of care.

Payment Reform to Improve Equity for Nursing Services Nurse-Managed Health Center. Managed by an APRN, nurse-managed health centers (NMHCs) are another model of coordinated care and advanced primary care (Keeling & Lewenson, 2013). In addition to expanding primary care capacity, the ACA authorized, but did not mandate, funding for NMHCs to serve as training sites for students in primary care and enhance nursing practice.

Nurse Midwives. The ACA provides an enhanced Medicare reimbursement rate for certified nurse-midwives (CNMs) to 100% of the physician




schedule; this had been 65% since CNMs were first designated primary care providers with the Omnibus Reconciliation Act of 1987 (U.S. Centers for Medicare and Medicaid, 2011). Since January 2011, the ACA has provided an enhanced Medicare reimbursement rate for certified nurse-midwives (CNMs) to 100% of the physician schedule (Title III, Section 3114) (Patient Protection and Affordable Care Act, 2010). This had been 65% since CNMs were first designated as primary care providers under the Omnibus Reconciliation Act of 1987 (U.S. Centers for Medicare and Medicaid, 2011).

Non-Discrimination in Health Care. Another payment issue, which directly improves access to nurse practitioner (NP) services, is that, effective in 2014, the ACA amended the Public Health Service Act entitled Non-Discrimination in Health Care. This Act mandates that neither group nor individual health plans shall discriminate against any health care provider’s participation under the plan or coverage for their chosen provider, given that the health care provider is practicing within the scope of her or his applicable state license or certification (American Academy of Nursing, 2010). Once licensed, however, NP reimbursement under Medicaid continues to be determined by individual state regulations. Despite the disparity between the focus on expansion of an NP workforce and the regulatory barriers it faces in practice, both of these issues are significant concerns.

Coordination of Care and Prevention The ACA includes a variety of provisions to improve the performance of the health care system and the health status of the population through care coordination and prevention.

No Copays for Preventive Services. The ACA requires most health plans to cover recommended preventive services without copays or cost-sharing. This provision requires plans to cover the services listed in the HHS comprehensive list of preventive services. To assist in determining which preventive services should be covered for women, the HHS




requested the Institute of Medicine (IOM) to examine the scientific evidence and identify critical gaps in preventive services for women as well as measures to further ensure women’s health (IOM, 2011b). On August 1, 2011, the HHS adopted new guidelines for women’s preventive services that are required to be covered without cost-sharing in most nongrandfathered health plans starting with the first plan or policy year beginning on or after August 1, 2012.

Federal Coordinated Health Care. The law establishes Federal Coordinated Health Care at the CMS to integrate care and improve coordination for “dual eligibles”: those people who are covered by both Medicaid and Medicare.

Prevention and Public Health Investment Fund. The ACA creates a new Prevention and Public Health Investment Fund to support community and public health initiatives that aim to prevent injury and disease and eliminate access barriers to community health centers and clinical practices.

Home Visitation. The ACA expands and provides additional funding for evidence- based home visitation programs that foster health promotion and illness prevention. One of these programs is for at-risk pregnant women and children and is best represented by the Nurse-Family Partnership, a nationwide program with a substantial research base related to the short-term and long-term benefits for mothers and children. The evidence supports that home visits to low-income mothers, providing education and support during pregnancy and the early childhood years, result in a variety of social and health benefits to children and families (HHS, Administration for Children and Families, 2014; Mathematica, 2014). This program is run out of the Health Resources and Services Administration (HRSA), Bureau of Maternal and Child Health.

Expanding Health Care Workforce Capacity




The ACA includes provisions to develop and expand a competent primary health care workforce. Approaches to expanding health care workforce capacity are: encourage models of care that promote use of all types of primary care providers and facilitate training and funding of services of all primary care providers, while expanding health care services access and improving quality of care.

The ACA enhances health care workforce education and training, particularly for primary care and mental/behavioral health education. It provides training grants to schools for the development, expansion, and enhancement of training programs in social work, primary care, graduate psychology, professional training in child and adolescent mental health, and preservice or inservice training to paraprofessionals in child and adolescent mental health. Additionally, the ACA updates provisions in the Public Health Services Act and provides significant increases in discretionary funding for building the nurse workforce, including: funds for NMHCs; establishment of nurse education, training, and loan repayment grants; creation of a nurse faculty loan program; creation of a family NP training program; funds to support training in home visitation services for maternal and prenatal care; and funds for graduate nursing schools (Association of University Centers on Disabilities, 2010). Lastly, the ACA provides competitive grants for workforce planning and workforce development strategies at the state level, as well as competitive grants for coordinated and integrated care in mental and behavioral health.

Expanding the Nursing Workforce. Through a variety of funding and regulatory provisions, the ACA is indirectly focused on nursing by addressing: (1) the demand for a larger primary care workforce to improve access to care and (2) regulation of advanced nursing practice. Key elements of the ACA that address workforce shortages include funding for nursing education, reimbursement of nursing services, and reform of practice regulatory policy (e.g., Medicaid reimbursement, expanded CNM reimbursement under Medicare, allowance of NPs to own/manage NMHCs [and ultimately ACOs], and nondiscrimination in health care) (American Association of Nurse Practitioners, 2013b).




Expansion of funding for nursing education includes: • Increased federal loan limits for nursing students, which increases

the amounts nursing students can borrow from the federal government for their education. Narrowing the disparity between nursing students’ educational costs and potential resources will facilitate increased enrollments and produce more nurses to address the health care demands of the nation (RWJF, 2014a).

• Expansion of the National Health Service Corps Loan Repayment Program will repay 60% of a student loan, including nursing, in exchange for a commitment of 2 years of service in a critical health workforce shortage area.

• Establishing a Medicare Graduate Nurse Education (GNE) Demonstration, which is funded by the CMS and operated by the CMMI. The Demonstration Program, which will run for 4 years, will reimburse up to 5 hospitals (already in progress) the cost to clinically train APRN students. To be eligible, the hospitals had to partner with accredited schools of nursing and non-hospital community-based care settings (RWJF, 2014a).

• Expanding the Public Health Service Act to provide demonstration grants for family NP training programs, offering 1- year residencies for NPs in FQHCs and NMHCs (American Association of Colleges of Nursing [AACN], 2012; American Association of Nurse Practitioners, 2013a).

Public Health Provisions of the Affordable Care Act According to Healthy People 2020 (HHS, 2014), a public health infrastructure “includes 3 key components that enable a public health organization at the Federal, Tribal, State, or local level to deliver public health services: (1) a capable and qualified workforce; (2) up-to-date data and information systems; and (3) public health agencies capable of assessing and responding to public health needs.” These components enable the public health system to care for the nation’s population health through a variety of services. A health care system reform that attempts to address improving access to care for a larger percentage of the population,




cost (to the individual and system), and quality strives to improve the public’s health. The provisions of the ACA aim to meet the health needs of the nation’s population through such a framework.

Impact on Nursing Profession: Direct and Indirect The implications of the ACA for nursing fall into two categories: those that are related to the provisions directed specifically to nursing and those that are related to the provisions that will either indirectly affect nursing or invite and demand nursing’s involvement by affording new opportunities. It was the intention of the ACA to create a National Health Care Workforce Commission established under Title V (Health Care Workforce) of the ACA. The law aimed to monitor and influence national health workforce policy to further explore the health workforce needs of the nation (AACN, 2012; White House, n.d.). A nurse was appointed as Chair of this Commission, although, as of 2015, it remained unfunded by Congress, and thus has never met. Through a combination of training programs, loans, loan repayment programs, and scholarships (Commonwealth Fund, 2011), as previously summarized, the ACA will fulfill one of its other more direct roles, that of capacity building of the primary care workforce. It also eases criteria and expands the federal student loan program for schools and students focusing on primary care, increases funding of clinical education of APRNs through the GNE Demonstration, and increases funding to community health centers and the National Health Service Corps. In striving to expand workforce resources, the ACA addresses both the supply and regulation of practice of APRNs. Although the ACA does not directly address APRN practice regulation, it calls for modernization of scope of practice policies to facilitate the ability of APRNs to be a major source of primary care services.

Indirect Impact on Nursing An estimated 22 million of the 60 million uninsured people in




America will be covered as a result of the ACA, with half of them covered through the private insurance markets and half covered through the expansion of Medicaid (Patel & Sanghavi, 2013). There is a growing concern regarding the existing capacity of primary care providers to meet the substantial and increasing demand for access to care that is emerging (Institute of Medicine, 2011a). One answer that has been put forth to assist in meeting this growing demand for primary care is to optimize use of APRNs, specifically NPs (Fairman et al., 2011; IOM, 2011a). Evidence supports that APRNs and NPs deliver high-quality health care and improved health outcomes at a lower cost than the traditional medical model (Newhouse et al., 2011). The expansion of the availability of primary care providers is an important rationale for continuing efforts to remove barriers to the scope of practice and payment of APRNs.

Overall Cost of the Aca Cost to the Nation At the time the ACA was signed into law, scorekeepers estimated the net cost of the ACA to equal $940 billion. In April 2014, the Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT) updated these numbers to reflect a number of implementation changes and to take into account the Supreme Court’s decision on Medicaid expansion. In total, the ACA’s coverage provisions will cost $1383 billion for the 2015 to 2024 period (CBO, 2014a, 2014b). The ultimate cost of the ACA will largely depend on the final implementation of the law and how closely it follows and resembles the original legislation. Owing to unforeseen challenges, the gross cost of the ACA could increase or decrease significantly, and it is best to keep apprised of accurate and up-to-date numbers by reviewing CBO updates and estimates at

Cost for Individuals and Households For individuals and families who do not fall under the Medicaid




expansion (133% or less of the FPL), there are both premium tax credits and cost-sharing assistance available to lower the financial burden of purchasing health insurance. Subsidies for purchasing health insurance went into effect in January 2014 alongside the rollout of state health exchanges. Premium tax credits are available to all individuals and families with incomes between 100% and 400% of the FPL. In 2013, 100% FPL was $23,000 for a family of four, and 400% FPL was $94,000 for a family of four. Additionally, the ACA provides cost-sharing assistance for individuals and households with incomes under 250% FPL ($59,000 and under for a family of four in 2013).

Families and individuals have the option to purchase four types of plans, bronze, silver, gold, and platinum, on the state exchange market. Coverage and benefits in these plans vary, with bronze plans being the least comprehensive and platinum plans the most comprehensive. All premium credits are tax credits and will be delivered in advance directly to the insurers that a family or individual chooses in the health exchange. The remaining balance will be the responsibility of the family or individual. As an example, a family of four with an income of $47,000 who purchases a silver plan will end up paying approximately $247 a month to cover the entire family after factoring in premium credits and cost- sharing assistance (Angeles, 2013).

Owing to variability in state exchange models, the number of insurance options in state exchanges, and the implementation challenges several states faced in the fall and winter of 2014, individual and household insurance premiums and costs vary widely. The ACA aims to lower overall population health costs and ensure that individuals and households have insurance that adequately covers primary, preventative, and emergency health services. As of April 2014, over 8 million people had signed up for health insurance through the marketplace (state health exchanges), and the CBO estimated that an additional 5 million individuals have purchased ACA-compliant plans outside of the marketplace. Although comprehensive data on effectuated enrollments has not been obtained, initial public statements from issuers indicate that 80% to 90% of individuals who purchased a marketplace plan have made premium payments (Office of the Assistant Secretary for




Planning and Evaluation, HHS, 2014).

Political and Implementation Challenges The successful implementation and the realized benefits of the ACA will depend on a variety of factors, some of which are related to the political challenges the legislation has and will continue to face.

After the initial Supreme Court decision about the ACA, many states decided to forego Medicaid expansion. Public health officials fear that the very poorest populations living in noncompliant states will be left without support and without affordable health insurance options (Pear, 2012). As an example, Texas, a state that has refused to expand Medicaid, will leave 1.3 million uninsured people without viable health insurance options. In Florida, another nonparticipating state, 1 million people will be left without support (Kenney et al., 2012). Furthermore, the lack of Medicaid expansion in noncompliant states will have an even greater impact on rural communities where people are more likely to live in poverty and less likely to have employer-sponsored health coverage (Mueller et al., 2012). Many noncompliant states suggest that Medicaid expansion would overwhelm state budgets, but independent, nonpartisan analysis has shown that states would have an incremental cost of only 0.3% ($8 billion) more between 2013 and 2022 if they implement the Medicaid expansion than they would without it (Holahan et al., 2012).

In June 2014, the U.S. Supreme Court issued a ruling in Burwell v. Hobby Lobby Inc. Stores that further dismantled the law. Prior to the ruling, the ACA required health insurance plans to cover preventative reproductive health services for women, including all FDA-approved contraceptives, without cost-sharing (commonly referred to as the contraception mandate). Under the law, employers with 50 or more workers with insurance plans that did not meet this standard faced significant fines. In the Supreme Court case, Hobby Lobby Inc. argued that this mandate violated the Religious Freedom Restoration Act (RFRA), which states that the government must not “substantially burden a person’s exercise of religion”




unless there is a “compelling government interest” or if the law uses methods that are the “least restrictive way of furthering that interest.” The Supreme Court, in a 5-4 decision, judged in favor of Hobby Lobby Inc., ruling that the government cannot force corporations to cover employees’ birth control, effectively nullifying the contraception mandate. While this judgment directly impacts women’s access to contraceptives, some analyst worry that employers will now use religious objections to opt out of other aspects of the ACA, which could have a significant impact on the future of the law (Carey, 2014).

Since the start of the implementation of the law, polling suggests that the overall public has both a lack of understanding of the ACA and mixed feelings on the law attributable to partisan politics and the ensuing misinformation. In 2013, a Kaiser Family Foundation poll found that 57% of individuals stated that they did not feel they had enough information about the ACA to understand how it will impact them personally. When filtered by income, this percentage increased to 68% for those with household incomes less than $40,000 (Kaiser Family Foundation, 2013). Furthermore, it is apparent that politics plays a significant role in the public’s degree of approval of the law. In April of 2014, the CNN/ORC International Poll, which used the term the Affordable Care Act, released a poll that showed 61% of participants who were either in favor of the ACA or wished to see small changes in the law; 38% of participants wished to see it repealed. In comparison, a Washington Post/ABC Poll also released in April of 2014, and which used the term Barack Obama’s health care plan, showed that only 36% of respondents felt the law was a good idea, and 49% felt that the law needed a major overhaul, or be repealed entirely (Fuller, 2014). Nonpartisan, clear messaging, and education campaigns are critical to the long-term success of the ACA.

Conclusion Although there may be revisions throughout the period of implementation of this landmark legislation, as occurred with the Social Security Act, the ACA provisions aim to increase access to care; change the culture of health care from one of cure to one of




health promotion and illness prevention; mitigate barriers to practice for primary care providers of all disciplines; capitalize on the skill and expertise of nursing in areas of leadership, practice, research, and innovation; and, through these mechanisms, improve population health outcomes. The challenge for nursing is to rise to the call and seize this moment of opportunity in becoming the leaders in health care that so many already recognize they should be. Understanding the reforms and realizing the potential implications to nursing are the first steps in achieving these roles.

Discussion Questions 1. What are the key areas that the ACA provisions address and examples of each?

2. What are key opportunities for nursing leadership related to ACA implementation and monitoring?

3. What are specific provisions within the ACA that will directly impact the delivery and type or method of care you give to your patients?

4. Many of the payment reform changes in the ACA move away from physician fee-for-service payment to more value-based payment, taking into consideration improved quality measures and better patient outcomes. How will this change maximize the role of the entire health team, including nurses? How will this create new leadership opportunities for nurses?

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