To Prepare:
· Review the Healthcare Program/Policy Evaluation Analysis Template provided in the Resources.
· Select an existing healthcare program or policy evaluation or choose one of interest to you.
· Review community, state, or federal policy evaluation and reflect on the criteria used to measure the effectiveness of the program or policy described.
Based on the program or policy evaluation you selected, complete the Healthcare Program/Policy Evaluation Analysis Template. References at least 4. Be sure to address the following:
· Introduction
· Describe the healthcare program or policy outcomes.
· How was the success of the program or policy measured?
· How many people were reached by the program or policy selected?
· How much of an impact was realized with the program or policy selected?
· At what point in program implementation was the program or policy evaluation conducted?
· What data was used to conduct the program or policy evaluation?
· What specific information on unintended consequences was identified?
· What stakeholders were identified in the evaluation of the program or policy? Who would benefit most from the results and reporting of the program or policy evaluation? Be specific and provide examples.
· Did the program or policy meet the original intent and objectives? Why or why not?
· Would you recommend implementing this program or policy in your place of work? Why or why not?
· Identify at least two ways that you, as a nurse advocate, could become involved in evaluating a program or policy after 1 year of implementation.
· Conclusion
Plagiarism free…… thank you
Milstead, J. A., & Short, N. M. (2019). Health policy and politics: A nurse’s guide (6th ed.). Burlington, MA: Jones & Bartlett Learning.
· Chapter 7, “Health Policy and Social Program Evaluation” (pp. 116–124 only)
Omics research ethics considerations – Nursing Outlook
Leading by Success: Impact of a Clinical & Translational Research Infrastructure Program to Address Health Inequities (nih.gov)
S i x t h E d i t i o n
Jeri A. MilsteAd, Phd, rN, NeA-BC, FAAN
NANCy M. short, drPh, MBA, BsN, rN, FAAN
heAlth PoliCy
and PolitiCs A Nurse’s Guide
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Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii
Acknowledgments . . . . . . . . . . . . . . . . . . . . x
Contributors . . . . . . . . . . . . . . . . . . . . . . . . xi
Chapter 1 Informing Public
Policy: An Important
Role for Registered
Nurses . . . . . . . . . . . . . . 1
Jeri A. Milstead, Nancy M. Short
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
How Is Public Policy Related to
Clinical Practice? . . . . . . . . . . . . . . . . . . . . .2
Healthcare Reform at the Center
of the Public Policy Process . . . . . . . . . 11
Developing a More Sophisticated
Political Role for Nurses . . . . . . . . . . . . . 11
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Discussion Points . . . . . . . . . . . . . . . . . . . . . 13
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Chapter 2 Agenda Setting: What
Rises to a Policymaker’s
Attention? . . . . . . . . . 17
Elizabeth Ann Furlong
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Overview of Models and
Dimensions . . . . . . . . . . . . . . . . . . . . . . . . 23
Summary Analysis of a National
Policy Case Study . . . . . . . . . . . . . . . . . . 32
Theory Application to the
Nebraska Nurse Practitioner
Case Study . . . . . . . . . . . . . . . . . . . . . . . . . 32
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Discussion Points . . . . . . . . . . . . . . . . . . . . . 34
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Online Resources . . . . . . . . . . . . . . . . . . . . . 36
Chapter 3 Government Response:
Legislation . . . . . . . . . 37
Janice Kay Lanier
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Process, People, and Purse
Strings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Playing the Game: Strategizing
for Success . . . . . . . . . . . . . . . . . . . . . . . . . 50
Thinking Like a Policymaker . . . . . . . . . . . 52
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Discussion Points . . . . . . . . . . . . . . . . . . . . . 55
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Chapter 4 Government
Response:
Regulation . . . . . . . . . 57
Jacqueline M. Loversidge
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Regulation Versus Legislation . . . . . . . . . 58
Health Professions Regulation
and Licensing . . . . . . . . . . . . . . . . . . . . . . 60
The State Regulatory Process . . . . . . . . . 66
The Federal Regulatory Process . . . . . . . 72
Current Issues in Regulation
and Licensure: Regulatory
Responses . . . . . . . . . . . . . . . . . . . . . . . . . 78
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Discussion Points . . . . . . . . . . . . . . . . . . . . . 81
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Chapter 5 Public Policy
Design . . . . . . . . . . . . . 87
Catherine Liao
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 87
The Policy Design Process . . . . . . . . . . . . 90
Contents
iii
Research Informing the
Policy Process . . . . . . . . . . . . . . . . . . . . . . 91
The Design Issue . . . . . . . . . . . . . . . . . . . . . . 92
Policy Instruments
(Government Tools) . . . . . . . . . . . . . . . . 93
Behavioral Dimensions . . . . . . . . . . . . . . . 95
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Discussion Points . . . . . . . . . . . . . . . . . . . . . 97
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Chapter 6 Policy
Implementation . . . 101
Leslie Sharpe
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 101
Federal and State Policymaking
and Implementation 101 . . . . . . . . . . 103
Implementation Research . . . . . . . . . . . 104
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Discussion Points . . . . . . . . . . . . . . . . . . . . 112
References . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Chapter 7 Health Policy and
Social Program
Evaluation . . . . . . . . 115
Anne Derouin
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 116
Nurses’ Role in Policy/Program
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . 117
Challenges to Effective Policy
and Program Evaluation . . . . . . . . . . . 122
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Discussion Points . . . . . . . . . . . . . . . . . . . . 128
References . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Online Resources . . . . . . . . . . . . . . . . . . . . 130
Chapter 8 The Impact of
EHRs, Big Data, and
Evidence-Informed
Practice . . . . . . . . . . . 133
Toni Hebda
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 134
Electronic Resources: Their
Relationship to Health Care . . . . . . . 135
Big Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Implications for RNs, APRNs,
and Other Healthcare
Professionals . . . . . . . . . . . . . . . . . . . . . . 145
References . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Chapter 9 Interprofessional
Practice . . . . . . . . . . . 151
J. D. Polk, Patrick H. DeLeon
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 151
References . . . . . . . . . . . . . . . . . . . . . . . . . . 152
The Evolving Interprofessional
Universe . . . . . . . . . . . . . . . . . . . . . . . . . . 152
What Is Interprofessional
Collaboration? . . . . . . . . . . . . . . . . . . . . 152
Core Attributes of Interprofessional
Education . . . . . . . . . . . . . . . . . . . . . . . . . 153
The “Team 4” Concept . . . . . . . . . . . . . . . 155
The Future of IPE and
Interprofessional Collaboration . . . . 159
References . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Interprofessional Collaboration
to Influence Policy . . . . . . . . . . . . . . . . 160
Bipartisan–Bicameral Action . . . . . . . . . 160
Personal Reflections . . . . . . . . . . . . . . . . . 163
Discussion Points . . . . . . . . . . . . . . . . . . . . 169
References . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Suggested Readings . . . . . . . . . . . . . . . . . 169
Chapter 10 Overview: The
Economics and
Finance of
Health Care . . . . . . 171
Nancy M. Short
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 173
Economics: Opportunity Costs . . . . . . . 174
Finance: Does More Spending
Buy Us Better Health? . . . . . . . . . . . . . 174
Economics: Health Insurance
Market . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Finance: Health Insurance
Exchanges . . . . . . . . . . . . . . . . . . . . . . . . 177
Finance: Healthcare
Entitlement Programs . . . . . . . . . . . . . 180
iv Contents
Finance: Payment Models . . . . . . . . . . . . 183
Economics: Information
Asymmetry . . . . . . . . . . . . . . . . . . . . . . . 184
Finance: Comparative Effectiveness
Research and Quality-Adjusted
Life-Years . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Finance: Bending the Healthcare
Cost Curve Downward . . . . . . . . . . . . 188
Discussion Points . . . . . . . . . . . . . . . . . . . . 188
References . . . . . . . . . . . . . . . . . . . . . . . . . . 190
Online Resources . . . . . . . . . . . . . . . . . . . . 191
Chapter 11 The Impact of
Globalization: Nurses
Influencing Global
Health Policy . . . . . 193
Dorothy Lewis Powell, Jeri A. Milstead
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 194
Globalization and Its Impact on
Nursing and Health Care . . . . . . . . . . 195
The Importance of Understanding
the Cultural Context . . . . . . . . . . . . . . . 201
Nurse Involvement in Policy
Decisions . . . . . . . . . . . . . . . . . . . . . . . . . 203
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Discussion Points . . . . . . . . . . . . . . . . . . . . 205
References . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Chapter 12 An Insider’s Guide to
Engaging in Policy
Activities . . . . . . . . 215
Nancy M. Short, Jeri A. Milstead
Strategies to Recognize Political
Bias in Information Sources . . . . . . . . 215
Creating a Fact Sheet . . . . . . . . . . . . . . . . 217
Contacting Your Legislators . . . . . . . . . . 219
Example of a Fact Sheet . . . . . . . . . . . . . 220
What to Expect When You Visit
Your Policymaker . . . . . . . . . . . . . . . . . . 223
Preparing to Testify . . . . . . . . . . . . . . . . . . 224
Participating in Public Comment
Periods (Influencing
Rule Making) . . . . . . . . . . . . . . . . . . . . . . 226
How to Write an Op-Ed . . . . . . . . . . . . . . 227
For Serious Thought . . . . . . . . . . . . . . . . . 230
Recommended Nonpartisan
Twitter Feeds . . . . . . . . . . . . . . . . . . . . . . 230
Recommended
E-Subscriptions . . . . . . . . . . . . . . . . . . . 230
Influential Organizations
Affecting Health Policy . . . . . . . . . . . . 231
How to Become a Change Agent
in Policy: Betty Sturgeon—One
Exemplary Nurse’s Story . . . . . . . . . . . 232
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Contents v
© Visions of America/Joe Sohm/Photodisc/Getty
Preface
This is a contributed text for healthcare professionals who are interested in expanding the depth of their knowledge about public policy and in becoming more sophisticated in their involvement in the political and
policy processes. The scope of the content covers the whole process of making
public policy within the broad categories of agenda setting; government response;
and program/policy design, implementation, and evaluation. The primary focus
is at the federal and state levels, although the reader can adapt concepts to the
global or local level.
▸ Why a Sixth Edition?
The Sixth Edition began with succession planning, when Dr. Nancy Short became
co-editor and took on the serious job of planning for this and future editions.
Dr. Short’s expertise and credentials demonstrate her comprehensive viewpoint,
and she is dedicated to the continuation of this broad-based text on the whole
policy process. As founding editor/author, I could not have turned over this text
to just anyone. Nancy is an astute editor, has asked relevant and incisive questions,
and has been encouraging to me personally. It has been a real pleasure for me to
work with her and get to know her deep intellect and caring personality.
The Sixth Edition also introduces new authors with fresh perspectives, all
of whom have a significant experiential basis for their expertise. We welcome
Dr. Leslie Sharpe, Dr. Toni Hebda, Ms. Catherine Liao, Dr. Anne Derouin, and
Dr. Dorothy Powell. We also delight in those who have continued to contribute
to this text over the years: Dr. Elizabeth Furlong, Ms. Jan Lanier, Dr. Jaqueline
Loversidge, Dr. J. D. Polk, and Dr. Patrick DeLeon. They build on the work of
Ardith Sudduth and Dr. Patricia Smart, who retired, and of Dr. Marlene Wilken,
Dr. Kimberly Galt, Troy Spicer, and Elizabeth Barnhill. We pledge to continue
to challenge our readers to understand the serious business of making public
policy and demonstrate their commitment to a democratic republic through their
advocacy and involvement. We welcome your comments—let us know how this
text has influenced your practice.
▸ Target Audience
This text is intended for several audiences:
■ Doctoral and master’s-level students in nursing can use this text for in-depth
study of the full policy process. Works of scholars in each segment provide a
solid foundation for examining each component. This text goes beyond the
vi
narrow elementary explanation of legislation, however: It bridges the gap
by supporting understanding of a broader policy process in which multiple
opportunities for involvement exist.
■ Nurses who work in professional practice in clinical, education, admin-
istrative, research, or consultative settings can use this text as a guide for
understanding the full range of the policy components that they did not
learn in graduate school or may have forgotten. Components are brought
to life through nursing research, real-life cases, and theory. This text will
help the nurse who is searching for knowledge of how leaders of today
influence public policy toward better health care for the future. Nurses in
leadership positions clearly articulate nursing’s societal mission. Nurses,
as the largest group of healthcare workers in the United States, realize that
the way to make a permanent impact on the delivery of health care is to
be a part of the decision making that occurs at every step of the healthcare
policy process.
■ Faculty in graduate programs and other current nurse leaders can use this
text as a reference for their own policy activity. Faculty and other leaders
should be mentors both for their students and for other nurses throughout
the profession. Because the whole policy process is so broad, these leaders
can track their own experiences through the policy process by referring to
the components described in this text.
■ A wide variety of healthcare professionals who are interested in the area of
healthcare policy will find this text useful in directing their thoughts and
actions toward the complex issues of both healthcare policy and public
policy. Physicians, pharmacists, psychologists, dentists, occupational and
physical therapists, physician’s assistants, and others will discover parallels
with their own practices as they examine case studies and other research.
Nurses cannot change huge systems alone. Members of the healthcare team
can use this text as a vehicle to educate themselves so that, together, everyone
in the healthcare profession can influence policymakers.
■ Those professionals who do not provide health care directly but who are
involved in areas of the environment that produce actual and potential threats
to personal and community health and safety will find this text a valuable
resource regarding how a problem becomes known, who decides what to
do about it, and which type of governmental response might result. Envi-
ronmental scientists, public health officials, sociologists, political scientists,
anthropologists, and other professionals involved with health problems in
the public interest will benefit from the ideas generated in this text.
■ Interest groups can use this text as a tool to consider opportunities to be-
come involved in public policymaking. Interest groups can be extremely
helpful in changing systems because their members’ passion for their causes
energizes them to act. Interest groups can become partners in the political
activity of nurses by knowing how and when to use their influence to assist
advanced practice registered nurses (APRNs) at various junctures in the
policy process.
Preface vii
▸ Using This Text
Each chapter in the text is freestanding; that is, chapters do not rely, or necessar-
ily build, on one another. The sequence of the chapters is presented in a linear
fashion, but readers will note immediately that the policy process is not linear.
For example, readers of the policy implementation chapter will find reference to
scholars and concepts featured in the agenda-setting and policy design chapters.
Such is the nature of the public process of making decisions. The material covered
is a small portion of the existing research, arguments, and considered thought
about policymaking and the broader political, economic, and social concepts
and issues. Therefore, readers should use this text as a starting point for their
own scholarly inquiry.
This text can be used to initiate discussions about issues of policy and nurses’
opportunities and responsibilities throughout the process. The case studies
presented here should raise questions about what should have happened or why
something else did or did not happen. In this way, the text can serve as a guide
through what some perceive as a maze of activity with no direction but is actu-
ally a rational, albeit chaotic, system. The case studies and discussion points are
ideal for planning a class or addressing an audience. Many ideas and concepts
are presented, and we hope they serve to stimulate readers’ own creative thoughts
about how to engage others. Gone are the days of “the sage on stage”—the teacher
who had all the answers and lectured to students who had no questions. Good
teachers always have learned from students, and vice versa. Today’s teachers are
interactive, technically savvy, curious and questioning, and capable of helping
learners integrate large amounts of data and information. This text can serve as
a guide and a beginning.
viii Preface
© Visions of America/Joe Sohm/Photodisc/Getty
We continue to thank the staff of Jones & Bartlett Learning for their encourage-
ment and guidance when we were writing the Sixth Edition. Their confidence
in all the contributors has been consistent and unwavering. Christina Freitas,
Product Assistant for Nursing, and Rebecca Stephenson, Product Manager for
Nursing, have kept the authors on track in meeting deadlines and provided astute
editorial assistance.
We also thank the readers of this text for their interest in the policy and
political processes. For those of you who have integrated these components and
concepts into your nursing careers, we applaud you. You will continue to contribute
to the profession and to the broader society. For those readers who are struggling
with how to incorporate one more piece of anything into your role as professional
nurse, remember that you are advancing the cause of your own personal work,
the profession, and healthcare delivery in the United States and throughout the
world every time you use the concepts covered in this text. Nurses are a powerful
force and exercise their many talents to further good public policy—policy that,
ultimately, must improve health care for patients, consumers, and families.
For the wide range of healthcare professionals (dentists, dietitians, phar-
macists, physical and occupational therapists, physicians, physician’s assistants,
psychologists, and others) who may be reading this text for the first time, we
encourage you to collaborate as colleagues in the 21st-century definition of “team”
and integrate policymaking into your practices.
From Jeri: Finally, I want to acknowledge my forever-cheering section—my
four children, their spouses and significant others, and three grandchildren. They
are always there for me and provide continuous support, encouragement, and un-
conditional love. I love you, Kerrin, Sunny, and Heath Nethers, and George Biddle;
Joan Milstead; Kevin Milstead and Gregg Peace; and Sara and Steve, and Matthew,
Cynthia, and baby Colton Lott. You are a fun bunch, and you make me laugh.
From Nancy: I feel very grateful to have had this opportunity to be mentored
by Dr. Jeri Milstead as she plans to step away from her role as the founding editor
(for five editions!) of this text. She is a role model for whom there are not enough
words to describe: Perhaps an “Energizer bunny” metaphor fits best. I wish to
thank my husband, Jim, for his continuous support of all my career endeavors,
including shoulder rubs when I’ve been using a mouse for way too many hours.
I want to acknowledge my children as well: Kolton, Amanda, and Amber have been
consistent cheerleaders while simultaneously acknowledging that health policy may
not be the most exciting choice for light reading. I also wish to acknowledge the
support and inspiration I regularly receive from colleagues and students at the Duke
University School of Nursing—especially from Dr. Terry Valiga. Go Blue Devils!
With gratitude,
Jeri A. Milstead and Nancy M. Short
Acknowledgments
ix
© Visions of America/Joe Sohm/Photodisc/Getty
Contributors
Patrick H. DeLeon, PhD, MPH, JD, is distinguished professor at the Uniformed
Services University of the Health Sciences (Department of Defense) in the
School of Nursing and School of Medicine. He was elected to the Institute of
Medicine of the National Academies of Science in 2008 and served as president of
the American Psychological Association (APA) in 2000. For more than 38 years,
he was on the staff of U.S. Senator Daniel K. Inouye (Democrat‒Hawaii), retiring
as his chief of staff. Dr. DeLeon has received numerous national awards, includ-
ing the Order of Military Medical Merit; Distinguished Service Medal, USUHS;
National League for Nursing Council for Nursing Centers, First Public Policy
Award; Sigma Theta Tau International Honor Society of Nursing, First Public
Service Award; Ruth Knee/Milton Wittman Award for Outstanding Achievement
in Health/Mental Health Policy, NASW; Delta Omega Honor Society Award for
Outstanding Alumnus from a School of Public Health; APA Outstanding Lifetime
Contributions to Psychology Award; American Psychological Foundation Gold
Medal for Lifetime Achievement in the Practice of Psychology; and Distinguished
Alumni Award, University of Hawaii. Dr. DeLeon is currently the editor of Psy-
chological Services and has more than 200 publications to his credit. He earned a
PhD in clinical psychology, along with an MS (Purdue University), JD (Catholic
University), MPH (University of Hawaii), and BS (Amherst College). Dr. DeLeon
also has been awarded three honorary doctorates: PsyD (California School of
Professional Psychology), PsyD (Forest Institute of Professional Psychology),
and HLD (NOVA Southeastern University).
Anne Derouin, DNP, APRN, CPNP, FAANP, is assistant professor at Duke
University School of Nursing. She currently serves as lead faculty for the
PNP‒Primary Care/MSN program at Duke University School of Nursing. She
also teaches in the ABSN, DNP, and master of biological sciences programs at
Duke. Dr. Derouin is on the Executive Advisory Board for the Duke‒Johnson &
Johnson Leadership Training program and has served as a coaching circle mentor
to Duke-J&J Fellows since 2013. As a Certified Pediatric Nurse Practitioner, she
has provided adolescent primary care services at community and school-based
health centers affiliated with Duke’s Department of Community and Family
Medicine for nearly two decades. A member of the inaugural DNP program at
Duke University School of Nursing, she earned an MSN/PNP-PC from Duke
University and a BSN from the University of Michigan.
Dr. Derouin, who serves as the North Carolina advocacy chair for the
National Association of Pediatric Nurse Practitioners (NAPNAP), is considered
an adolescent clinical expert. She is active in the Society of Adolescent Health
and Medicine (SAHM) and the American Academy of Nurse Practitioners
(AANP) and is the co-chair for the Adolescent Special Interest Group of NAPNAP.
x
She has participated in pediatric, school-based health, and advanced nursing prac-
tice advocacy efforts at state and federal levels and has been selected for advocacy
fellowships for several professional organizations, including the School-Based
Health Alliance (formally National Assembly of School-Based Health Centers),
Nurse in Washington Internship (NIWI), Shot@Life (World Health Organization’s
global vaccine efforts), and as a Faculty Policy Intensive Fellow for the American
Association of Colleges of Nursing (AACN).
Elizabeth Ann Furlong, PhD, JD, MA, MS, BSN, RN, is associate professor emerita
at Creighton University, Omaha, Nebraska. Dr. Furlong developed and taught
health policy courses in a master’s program in healthcare ethics at the Center
for Health Policy and Ethics, in health administration, and at undergraduate
and graduate levels in a school of nursing. Her doctoral dissertation focused on
the policy initiation, legislative process, and eventual creation of the National
Institute of Nursing Research. Dr. Furlong has been active for decades in health
policy advocacy for vulnerable populations and for the nursing profession through
civic engagement; in partisan political activities; and through participation on
local, state, and national boards of directors of nonprofit associations and nursing
and health organizations. She currently serves on the board of directors of the
Association of Safe Patient Handling Professionals the Omaha Visiting Nurses
Association, and the Douglas County Nursing Home Foundation. Dr. Furlong
earned a JD (Creighton University, Omaha, Nebraska), a PhD and MA in political
science with a major in health policy (University of Nebraska, Lincoln), an MS
(University of Colorado, Denver), a BSN (Marycrest College, Davenport, Iowa),
and a diploma from Mercy School of Nursing (Davenport, Iowa).
Toni Hebda, PhD, MSIS, RN-BC, CNE, is professor of nursing at Chamberlain
College MSN online program and co-author of The Handbook of Informatics for
Nurses and Healthcare Professionals, now in its sixth edition. She has presented
internationally and nationally on nursing informatics, practiced as a staff nurse,
taught nursing, and worked in information services. She is nationally certified
in nursing informatics through the American Nurses Credentialing Center.
Dr. Hebda is a member of the American Medical Informatics Association, the
American Nurses Association, Sigma Theta Tau International, the American
Nursing Informatics Association, and the Healthcare Information and Manage-
ment Systems Society.
Dr. Hebda earned a PhD, MSIS, and MNEd from the University of Pittsburgh,
a BSN from Duquesne University, and a diploma from Washington (Pennsylvania)
Hospital School of Nursing. The focus of her doctoral program was on higher
education. Her dissertation examined the use of computer-assisted instruction
among baccalaureate programs.
Janice Kay Lanier, JD, RN, has spent the better part of her nursing career in the
health policy arena. Beginning in 1981, when she was selected to participate in
the competitive Ohio Legislative Service Commission Internship Program, her
involvement in public policy has taken her in many different directions. Working
for three state senators and staffing the Ohio Senate health committee for a year
gave her a look at the inner workings of the legislative process and its players. That
Contributors xi
year convinced her of how important policymaking is to nurses and the nursing
profession, so she became the director of government affairs for the Ohio Nurses
Association (ONA). During her 25-plus years as a lobbyist and consultant on behalf
of nursing, she was at the forefront of many initiatives, including recognition of
advanced practice nursing and efforts to enact safe staffing legislation in Ohio. She
also served as associate executive director of the Ohio Board of Nursing, which
provided an opportunity to be involved in the regulatory side of policymaking.
In 2008, she ran unsuccessfully for the Ohio House of Representatives—an
experience that offered her insights into yet another aspect of public policymaking.
Currently, she teaches health policy to graduate nursing students at The Ohio State
University, chairs the ONA Health Policy Council, and serves on the Ohio Asso-
ciation of Advanced Practice Nurses Full Practice Authority Committee. She has
received numerous awards in recognition of her advocacy efforts at the local, state,
and national levels. Ms. Lanier earned a JD and BA in political science from The
Ohio State University and a diploma from St. John’s Hospital School of Nursing.
Catherine Liao, MSPH, BS, is director of government relations for Duke Health
System, a position in which she is responsible for leading the implementation of
a comprehensive and diversified federal government relations program working
to strengthen Duke Health’s identity and reputation in biomedical research,
education, training, and service. Prior to joining Duke, she served for nearly
six years in the Washington, D.C., Office of Congressman David Price (North
Carolina‒04) handling health, education, labor, and housing appropriations
issues. She has worked as a research assistant at the North Carolina Institute
of Medicine, assisting staff with review of federal health reform legislation and
recommendations for implementation at the state level. She also completed an
administrative fellowship and served in the Office of the Chief of Staff at the
Durham Veterans Affairs Medical Center. Ms. Liao holds an MS in public health
from the University of North Carolina’s Gillings School of Global Public Health
and a BA in political science from the University of North Carolina at Chapel Hill.
Jacqueline M. Loversidge, PhD, RNC-AWHC, CNS, is assistant professor of clinical
nursing at The Ohio State University College of Nursing. Dr. Loversidge has been
educating undergraduate and graduate students in the areas of health policy and
regulation, evidence-based practice, and leadership in nursing and health care
for nearly 15 years. She has extensive experience in state regulation, having held
two positions on the Ohio Board of Nursing (OBN)—associate executive director
and education consultant. While at OBN, she served on several National Council
of State Boards of Nursing (NCSBN) committees, including the Committee on
Special Projects, responsible for transformation of the paper-and-pencil NCLEX
licensure examination to computer adaptive mode. Dr. Loversidge’s research
interests focus on advances in health professions education that have an impact
on healthcare quality and safety and are informed by an evidence base. Two
major areas fall under that umbrella: (1) health policy, regulation, and advocacy,
including licensure and scope of practice; and (2) interprofessional education,
including supporting foundations found in organizational structures and cultures.
Dr. Loversidge earned a PhD in higher education policy and leadership from The
Ohio State University; a master’s degree with a major in nursing from Wright
xii Contributors
State University, Dayton, Ohio; a BSN from Ohio University, Athens, Ohio; and
a diploma from Muhlenberg Hospital School of Nursing, Plainfield, New Jersey.
Jeri A. Milstead, PhD, RN, NEA-BC, FAAN, is senior nurse consultant for public
policy, leadership, and education. Dr. Milstead is professor and dean emerita at
University of Toledo College of Nursing, where she served for 10 years; was di-
rector of graduate programs at Duquesne University (Pittsburgh, Pennsylvania)
for 3 years; and was a faculty member at Clemson University (South Carolina)
for 10 years. She is the founding editor and senior author of Health Policy and
Politics: A Nurse’s Guide, with copies sold in 22 countries (6 of 7 continents), and
Handbook of Nursing Leadership: Creative Skills for a Culture of Safety. She has
authored invited chapters in four other current nursing textbooks, has published
in national and international journals, and was editor-in-chief of The Interna-
tional Nurse from 1995 to 2006, when the publication was retired. Dr. Milstead
was a policy advisor in the Washington, D.C., office of Senator Daniel K. Inouye
(Democrat‒Hawaii), was president of the State Board of Nursing for South
Carolina, and held leadership positions in the State Nurses Associations in Ohio,
Pennsylvania, and South Carolina. She is a fellow of the American Academy
of Nursing and a member of ANA/ONA and Sigma Theta Tau International.
She is board certified as a Nurse Executive‒Advanced by the American Nurses
Credentialing Commission.
Dr. Milstead has been honored with the Mildred E. Newton Distinguished
Educator award (OSU College of Nursing Alumni Society) and membership in
the Cornelius Leadership Congress (ONA’s “most prestigious” award), named a
Local Nursing Legend by the Medial Heritage Center at OSU, and placed in the
Ohio Senior Citizens Hall of Fame and the Washington Court House (Ohio)
School System Academic Hall of Fame. She was named a “Transformer of Nursing
and Health Care” (OSU CON Alumni Association) and a “Pioneer” in distance
education and a career achievement award (Utah); she also received the Creative
Teaching Award (Duquesne University) and two political activism awards. From
2005 through 2008, she was appointed to the Toledo‒Lucas County Port Authority,
where she chaired the port committee and was a member of a trade delegation to
China. She has conducted research or consultation in the Netherlands, Jordan,
Nicaragua, and Cuba.
Dr. Milstead holds a PhD in political science with majors in public policy
and comparative politics from the University of Georgia; an MS and BS, cum
laude, in nursing from The Ohio State University; and a diploma from Mt. Carmel
Hospital School of Nursing, where she is a Distinguished Alumna and current
member of the board of trustees.
J. D. Polk, DO, MS, MMM, CPE, FACOEP, is chief health and medical officer of the
National Aeronautics and Space Administration (NASA) located in Washington,
D.C. He is the former dean of medicine at Des Moines University (Iowa) College
of Osteopathic Medicine. Prior to that, Dr. Polk was the assistant secretary (acting)
for health affairs and chief medical officer of the U.S. Department of Homeland
Security (DHS), assuming this post after serving as the principal deputy assistant
secretary for health affairs and deputy chief medical officer. Before coming to DHS,
Dr. Polk was the chief of space medicine for the NASA Johnson Space Center in
Contributors xiii
Houston, Texas. He has also served as state emergency medical services medical
director for the state of Ohio and chief of Metro Life Flight in Cleveland, Ohio.
He has served on the board of directors for the Red Cross of Greater Iowa, the
board of directors of ChildServe of Iowa, the board of trustees for the American
Public University System, the board of directors of the American Association
for Physician Leadership, and has been a member of the American Osteopathic
Association’s Commission on Osteopathic College Accreditation. Dr. Polk is a
fellow of the American College of Osteopathic Emergency Physicians and an
associate fellow of the Aerospace Medicine Association.
Dr. Polk is well published in the fields of emergency medicine, disaster
medicine, space medicine, and medical management. He is a clinical associate
professor of emergency medicine at the Edward Via College of Osteopathic
Medicine and affiliate associate professor and senior fellow in the School of
Public Policy at George Mason University. He has received numerous awards and
commendations, including citations from the Federal Bureau of Investigation,
White House Medical Unit, Association of Air Medical Services, and U.S. Air
Force, and has received the NASA Center Director’s Commendation, the NASA
Exceptional Service Medal, the National Security and International Affairs Medal,
and the NASA Exceptional Achievement Medal.
Dr. Polk received his degree in osteopathic medicine from A. T. Still Univer-
sity in Kirksville, Missouri. He completed his residency in emergency medicine
with the Mt. Sinai hospitals via Ohio University and completed his training
in aerospace medicine at the University of Texas Medical Branch. He is board
certified in both emergency medicine and aerospace medicine. Dr. Polk holds
an MS in space studies from the American Military University, a master’s degree
in medical management from the University of Southern California’s Marshall
School of Business, and a master’s certificate in public health from the University
of New England.
Dorothy Lewis Powell, EdD, MS, ANEF, FAAN, is professor emeritus of nursing
and associate dean at Duke University School of Nursing, where she founded
the Office of Global and Community Health Initiatives (OGACHI). OGACHI
is responsible for the development of short-term study-abroad programs across
several continents for undergraduate and graduate students. She has been a dean
and associate dean of nursing in higher education for more than 47 years.
Throughout her professional life, Dr. Powell has been engaged in policy-oriented
endeavors, including a commitment to the poor and underserved, particularly
the homeless. She has secured grants in excess of $10 million, including funding
that established a nurse-managed clinic for the homeless and the acclaimed
Nursing Careers for the Homeless People project in Washington, D.C. She has
held local and state-level positions through the American Nurses Association,
the American Association of Colleges of Nursing, as a fellow in the American
Academy of Nursing, and the NLNAC Academy of Nursing Education. For a
number of years, she was a member of the advisory committee for Partners
Investing in Nursing’s Future, Robert Wood Johnson Foundation, and on sev-
eral Department of Health and Human Services councils. She has represented
professional nursing education associations before Congress and participated
in a variety of policy-advocacy conferences and meetings. Since her retirement
in 2014, she has become actively involved in politics at the local and state
xiv Contributors
levels, serving as precinct chair and chairman of the Durham County African
American Caucus.
Dr. Powell has traveled to 47 countries conducting projects, training students,
serving as a consultant, studying, planning and hosting conferences, and engaging
in leisure-time activities. She has a host of current and former mentees who are
excelling in practice, education, research, and policy. Dr. Powell earned an EdD
in the administration of higher education from the College of William and Mary,
Williamsburg, Virginia, with further study in higher education in the School of
Education at Harvard University; an MS in maternal‒infant nursing from Catholic
University of America, Washington, D.C.; and a BSN from Hampton University
(Hampton, Virginia).
Leslie Sharpe, DNP, FNP-BC, is a clinical assistant professor at the University of
North Carolina at Chapel Hill (UNC-CH) School of Nursing. She serves as the
lead provider and manager of Sylvan Community Health Center in North Caro-
lina. Dr. Sharpe facilitated the opening and ongoing growth of this school-based
community health center with the goal of increasing access to health care. Her
faculty role with UNC-CH School of Nursing includes establishing innovative
faculty practice settings in underserved communities. She educates nurse prac-
titioners and nurses about actively engaging in advocacy efforts related to health
policy and improving the health of North Carolinians. As chairperson of the North
Carolina Nurses Association’s Nurse Practitioner Council Executive Committee
from 2011 to 2014, she represented nurse practitioners at state legislative polit-
ical events and educated legislators and other stakeholders in health care about
advanced practice registered nurse issues. She currently serves as the NP PAC
treasurer. One of her passions is serving as a mentor for nurse practitioners in
the legislative and advocacy arena; as such, she facilitates a “leadership circle” of
local APRNs in the North Carolina Research Triangle area. Dr. Sharpe completed
her DNP at Duke University.
Nancy Munn Short, DrPH, MBA, BSN, RN, FAAN, is associate professor at Duke
University School of Nursing in Durham, North Carolina, where she has been on
faculty since 2003. From 2002 to 2006, she served as an assistant dean at the school.
Dr. Short received the School of Nursing’s Distinguished Teaching Award in 2010
and the Outstanding DNP Faculty award in 2010, 2011, 2013, 2015, 2016, and
2017 (the DNP program began in 2009). She teaches health policy, comparative
international health systems, transformational leadership, and health economics.
In 2009, she was recognized as an Arnold J. Kaluzny Distinguished Alumnus by
the School of Public Health. Dr. Short completed a postdoctoral fellowship as a
Robert Wood Johnson Foundation Health Policy Fellow from 2004 to 2007. As a
part of this fellowship, in 2005, she served as a health legislative aide for the U.S.
Senate Majority Leader Bill Frist. With Darlene Curley, she served as co-chair
of an AACN think tank charged with making recommendations to the board
regarding ways to improve health policy education for nurses.
Dr. Short is nationally known as an advocate for public health. She has
provided consultation to the University of North Carolina (UNC) Public Health
Management Academy, the UNC Institute for Public Health on international
issues related to distance learning, and the Johnson & Johnson Nurse Leadership
Program at Duke. She is a fellow in the American Academy of Nursing.
Contributors xv
Dr. Short served as a member of the Durham County (North Carolina) Board
of Health. In 2014, she completed a two-year tenure on the board of directors of
the National Association of Local Boards of Health, where she specialized in the
development of performance standards for the approximately 3,000 boards of
health in the United States. Under the auspices of the U.S. Department of State,
she delivered leadership and quality management training to a bicommunal (Turk
and Greek) program for nurses in Cyprus.
Dr. Short earned a doctor of public health degree with a major in health
policy and administration at the University of North Carolina’s Gillings School
of Global Public Health and an MBA and BSN from Duke University.
xvi Contributors
© Visions of America/Joe Sohm/Photodisc/Getty
KEY TERMS
Advanced practice registered nurse (APRN): A registered nurse with an advanced
degree, certified by a nationally recognized professional organization. Four types
of APRNs are nurse practitioner (NP), clinical nurse specialist (CNS), certified nurse–
midwife (CNM), and certified registered nurse anesthetist (CRNA). Often, nurse
executives or administrators are referred to as nurses in advanced roles.
Healthcare provider professionals (HCPs): Registered nurses, advanced
practice registered nurses (APRNs), physicians, pharmacists, dentists,
psychologists, occupational and physical therapists, dieticians, social workers
and physicians’ assistants, and others who are licensed or authorized by a state
or territory to provide health care.
Policy: A consciously chosen course of action: a law, regulation, rule, procedure,
administrative action, incentive, or voluntary practice of governments and other
institutions.
Policy process: Problem identification, agenda setting, policy design,
government/organizational response, budgeting, implementation, and
evaluation of the policy.
Politics: The process of influencing the allocation of scarce resources.
Public policy: A program, law, regulation, or other legal mandate provided by
governmental agents; also, actual legal documents, such as opinions, directives,
and briefs that record government decisions.
Rules and regulations: Rules are a set of instructions that tell us the way
things are to be done. Regulations are rules authorized by specific legislation.
Comment on proposed rules and regulations at https://www.regulations.gov.
Informing Public Policy:
An Important Role for
Registered Nurses
Jeri A. Milstead and Nancy M. Short
1
CHAPTER 1
▸ Introduction
In 2010, the Institute of Medicine* (IOM) issued a report, The Future of Nursing:
Advancing Health, Leading Change, that challenged nurses to work with other
healthcare professionals in two ways: to learn from them and to help them learn
from nurses. In this spirit of interprofessional cooperation and leadership, this text
will incorporate a variety of healthcare provider professionals (HCPs) into the
discussion of public policy, case studies, discussion points, and reader activities.
▸ How Is Public Policy Related to Clinical
Practice?
It is the authors’ belief that nurses and other HCPs are ideally positioned to
participate in the policy arena because of their history, education, practice, and
organizational involvement.
In this chapter, policy is an overarching term used to define both an entity and
a process. The purpose of public policy is to direct problems to the government’s
attention and to secure the government’s response.
The definition of public policy is important because it clarifies common
misconceptions about what constitutes policy. In this text, the terms public policy
and policy are interchangeable. The process of creating policy can be focused
in many areas, most of which are interwoven. For example, environmental pol-
icy deals with determinants of health such as hazardous materials, particulate
matter in the air or water, and safety standards in the workplace. Education
policies are more than tangentially related to health—just ask school nurses.
Regulations define who can administer medication; state laws dictate which type
of sex education can be taught. Defense policy is related to health policy when
developing, investigating, or testing biological and chemical weapons. There is a
growing awareness of the need for a health-in-all-policies approach to strategic
thinking about policy.
Statutes: Written laws passed by a legislative body. Statutes differ from “common
law” in that common law (also known as case law) is based on prior court
decisions. Statutes may be enacted by both federal and state governments and
must adhere to the rules set in the Constitution.
System (capital “S”): The U.S. healthcare delivery and finance system (usage
specific to this text).
system (lowercase “s”): A group of hospitals and/or clinics that form a large
healthcare delivery organization (usage specific to this text).
* The name of the Institute of Medicine was changed to the National Academy of Med-
icine in 2016.
2 Chapter 1 Informing Public Policy: An Important Role for Registered Nurses
Health policy directly addresses health problems and is the specific focus
of this text. In general, policy is a consciously chosen course of action: a law,
regulation, rule, procedure, administrative action, incentive, or voluntary practice
of governments and other institutions. By comparison, politics is the process of
influencing the allocation of scarce resources.
Policy as an Entity
Official government policies reflect the beliefs and values of elected members, the
administration in power, and the will of the American people. Official policies
provide direction for the philosophy and mission of government organizations.
Some policies, known as position statements, report the opinions of organizations
about issues that members believe are important. For example, state boards of
nursing (government agencies created by legislatures to protect the public through
the regulation of nursing practice) publish advisory opinions on what constitutes
competent and safe nursing practice.
Laws (or statutes) are one type of policy entity that serve as legal directives
for public and private behavior. Laws are made at the international, federal, state,
and local levels and are considered the principal source in guiding conduct.
Lawmaking usually is the purview of the legislative branch of government in
the United States, although presidential vetoes, executive orders, and judicial
interpretations of laws also have the force of law.
Judicial interpretation occurs in three ways: (1) through courts’ interpre-
tation of the meaning of broadly written laws that are vague regarding details;
(2) by determining how some laws are applied—that is, by resolving questions or
settling controversies; or (3) by interpreting the Constitution and declaring a law
unconstitutional, thereby nullifying the entire statute (Litman & Robins, 1991).
For example, the 1973 Rehabilitation Act prohibited discrimination against people
with handicaps by any program that received federal assistance. Although this
may have seemed fair and reasonable at the outset, courts adjudicated questions
of how much accommodation is “fair and reasonable” (Wilson, 1989). In general,
courts are idealized as being above the influence of political activity that surrounds
the legislature. The court system, especially the federal court system, may also
resolve conflicts between levels of government (state and federal).
Regulations and rules are another policy entity discussed elsewhere in this
text. Although they often are included in discussions of laws, regulations differ
from statutes. Once the legislative branch enacts a law, the executive branch of
government administers that law’s implementation. The executive branch consists
of the president, the White House staff, multiple agencies, commissions, and
departments that carry out the work of implementing and monitoring laws for
the public benefit. Government agencies formulate regulations that achieve the
intent of the statute. Overall, laws are written in general terms, and regulations
are written more specifically to guide the interpretation, administration, and
enforcement of the law. The Administrative Procedures Act, enacted in 1946,
ensures a structure and process that is published and open, in the spirit of the
founding fathers, so the average constituent can participate in the process of
public decision making.
All these policy entities evolve over time and are accomplished through
the efforts of a variety of actors or players. Although commonly used, the terms
How Is Public Policy Related to Clinical Practice? 3
position statement, resolution, goal, objective, program, procedure, law, and reg-
ulation really are not interchangeable with the word policy. Rather, they are the
formal expressions of policy decisions. For the purposes of understanding just
what policy is, nurses must grasp policy as a process.
Policy as a Process
For purposes of analysis, policymaking comprises five processes:
■ Agenda setting
■ Government response (usually legislation and regulation)
■ Policy design
■ Implementation
■ Evaluation of the policy outcomes
■ Economics and finance of policy
The steps in the policy process are not necessarily sequential or logical. For
example, the definition of a problem, which usually occurs in the agenda-setting
phase, may change during fact-finding and debate. Program design may be
altered significantly during implementation. Evaluation of a policy or program
(often considered the last phase of the process) may propel onto the national
agenda (often considered the first phase of the process) a problem that differs
from the originally identified issue. For the purpose of organizing one’s thoughts
and conceptualizing the policy process, we will examine the policy process from
a linear perspective in this text, but you should recognize that this path is not
always strictly followed.
The opportunities for nurse input throughout the policy process are unlim-
ited. Nurses are articulate experts who can address both the rational shaping of
policy and the emotional aspects of the process. Nurses cannot afford to limit
their actions to monitoring bills; they must seize the initiative and use their con-
siderable collective and individual influence to ensure the health, welfare, and
protection of the public and healthcare professionals.
Why You Are the Right Person to Influence Health Policy
Nursing’s education requirements, communication skills, rich history, leadership,
and trade association involvement, as well as our practice venues, uniquely qualify
nurses to influence thought leaders and policymakers. Nursing and nurses have an
ongoing impact on health and social policies. FIGURE 1-1 illustrates some aspects
of nurses’ impact on the health and well-being of populations.
Advanced studies build on education and experience and broaden the arena
in which nurses work to a systems perspective, including both regional health
systems and the overall U.S. System of healthcare delivery and finance. Nurses
not only are well prepared to provide direct care to persons and families but also
act as change agents in the work environments in which they practice and the
states/nations where they reside.
Nurses have developed theories to explain and predict phenomena they
encounter in the course of providing care. In their practice, nurses also in-
corporate theory from other disciplines such as psychology, anthropology,
education, biomedical science, and information technology. Integration of all
4 Chapter 1 Informing Public Policy: An Important Role for Registered Nurses
FIGURE 1-1 Historical timeline of nurses who influenced policy. (continues)
1852 Florence Nightingale used statistics to advocate for improved
education for nurses, sanitation, and equality.
1861 Clarissa “Clara” Barton was a hospital nurse in the American
Civil War. She founded the American Red Cross.
1879 Mary Mahoney was the first African American nurse in the United
States and a major advocate for equal opportunities for minorities.
1903 North Carolina creates first Board of Nursing in nation and
licenses the first registered nurse.
1906 Lillian D. Wald, nurse, humanitarian, and author. She was known
for contributions to human rights and was the founder of Amer-
ican Community Nursing. She helped found the NAACP.
1909 The University of Minnesota bestows the first bachelor’s degree
in nursing.
1916 Margaret Higgins Sanger was an American birth control activist,
sex educator, writer, and nurse. Sanger popularized the term “birth
control” and opened the first birth control clinic in the United
States (later evolved into Planned Parenthood).
1925 Frontier Nursing Service was established in Kentucky with ad-
vanced practice nurses (midwives).
1955 RADM Jessie M. Scott, DSc, served as assistant surgeon general in
the U.S. Public Health Service; led division of nursing for 15 years;
testimony before Congress on the need for better nursing training
led to the 1964 Nurse Training Act, the first major legislation to
provide federal support for nurse education during peacetime.
1966 NP role created by Henry Silver, MD, and Loretta Ford, RN.
1967 Luther Christman, PhD, became the first male dean of a School
of Nursing (at Vanderbilt University). Earlier in his career, he had
been refused admission to the U.S. Army Nurse Corps because
of his gender. He was the founder of the American Association
for Men in Nursing, as well as a founder of the National Student
Nurses Association.
1971 Idaho statutorily recognizes advanced practice nursing.
1978 Faye Wattleton, CNM, was elected president of the Planned Par-
enthood Federation of America—the first African American and
youngest person ever to hold that office. First African American
woman honored by the Congressional Black Caucus.
1987 Ada S. Hinshaw, PhD, became the first permanent leader at the
National Institute of Nursing Research at the National Institutes
of Health.
1989 Geraldine “Polly” Bednash, PhD, headed the American Associ-
ation of Colleges of Nursing’s legislative and regulatory advocacy
programs as director of government affairs. She became CEO of
AACN in 1989 and co-authored AACN’s landmark study of the
financial costs to students and clinical agencies of baccalaureate
and graduate nursing education.
How Is Public Policy Related to Clinical Practice? 5
1992 Eddie Bernice Johnson, BSN, was the first nurse elected to the
U.S. Congress (D-TX). Strong voice for African Americans and
pro-nursing policies.
1996 Beverly Malone, PhD, elected president of the American Nurses
Association; President Clinton appointed her to Advisory Com-
mission on Consumer Protection and Quality in the Health Care
Industry and to the post of deputy assistant secretary for health
within the Department of Health and Human Services.
1998 Lois G. Capps, BSN, California Representative to the U.S. House
from 1998–2017, where she founded the Congressional Nursing
Congress.
2001 Major General Irene Trowell-Harris, EdD, RN, USAF (Ret.),
director of Department of Veterans Affairs, Center for Women
Veterans. Instrumental in establishing fellowship for military
nurses in the office of Senator Daniel K. Inouye (D-HI).
2009 Mary Wakefield, PhD, became the first nurse appointed as di-
rector of the Health Resources and Services Administration. In
2015, she became the Acting Deputy Secretary for the Department
of Health and Human Services. Served as Chief of Staff for U.S.
Senators Quentin Burdick (D-ND) and Kent Conrad (D-ND).
2010 Mary D. Naylor, PhD, a member of the Medicare Payment Ad-
visory Commission influenced health policy with membership
on the RAND Health Board, the National Quality Forum Board
of Directors, and as pastchair of the Board of the Long-Term
Quality Alliance.
2013 Joanne Disch, PhD, influenced health policy as chair of the na-
tional board of directors for the American Association of Retired
Persons and the American Academy of Nursing.
FIGURE 1-1 Historical timeline of nurses who influenced policy. (continued)
this information reflects the extreme complexity of nursing care and its provi-
sion within an extremely complex healthcare system. Nurses understand that
partnerships are valued over competition, and that the old rules of business
that rewarded power and ownership have given way to accountability and
shared risk. Transformation of today’s broken healthcare system will require a
radical, cross-functional, futuristic change in the way people think. Observing
patterns in personal behavior can be useful when working with policymakers
as they try to figure out the best or most cost-effective way to address public
problems. Creative ways of examining problems and innovative solutions may
cause discomfort among policymakers who have learned to be cautious and go
slowly. Nurses and other professionals can help officials employ new ideas to
reach their policy goals by sharing stories and interpreting data to show how
those data affect patients and professionals.
Communication skills are integral to the education of nurses, who often must
interpret complex medical situations and terms into common, understandable,
pragmatic language. Nurse education programs have formalized a greater focus
6 Chapter 1 Informing Public Policy: An Important Role for Registered Nurses
on communications than is present in any other professional education program.
From baccalaureate curricula through all upper levels of nurse education, major
segments of nursing courses focus on individual communications and group
processes. Skills include active listening, reflection, clarification, assertiveness,
role playing, and other techniques that build nurse competence levels. These
same skills are useful when talking with policymakers. Other chapters in this
text discuss the differences in nurses’ communication with patients/colleagues
and with nonclinician policymakers.
Nursing care is not only a form of altruism but also incorporates intentional
action (or inaction) that focuses on a person or group with actual or potential
health problems. The education of nurses puts them in the position of discover-
ing and acknowledging health problems and health System problems that may
demand intervention by public policymakers. For these many reasons, accrediting
agencies require policy content within nurse education programs.
Practice and Policy
Evidence and theory provide the foundation for nursing as a practice profession.
Nurses stand tall in their multiple roles—provider of care, educator, adminis-
trator, consultant, researcher, political activist, and policymaker. In their daily
practice, nurses spot healthcare problems that may need government interven-
tion, although not all problems nurses and their patients face in the healthcare
System are amenable to solutions by government. Corporations, philanthropy, or
collective action by individuals may best solve some problems. Most nurses are
employees (as are most physicians today) and must navigate the organizations
in which they work. By being attuned to systems issues, nurses have developed
the ability to direct questions and identify solutions. This ability is reflected in
the relationships that nurses can develop with policymakers.
Nurses bring the “power of numbers” when they enter the policy arena. Ac-
cording to a 2017 report from the National Council of State Boards of Nursing,
there are 3,913,805 registered nurses (RNs) in the United States. Collectively,
nurses represent the largest group of healthcare workers in the nation.
Nurses have many personal stories that illustrate health problems and patients’
responses to them. These stories have a powerful effect when a nurse brings an
issue to the attention of policymakers. Anecdotes often make a problem more
understandable at a personal level, and nurses are credible storytellers. By ap-
plying evidence to a specific patient situation, nurses may also bring research to
legislators in ways that can be understood and can have a positive effect.
Nurses live in neighborhoods where health problems often surface and can
often rally friends to publicize a local issue. Nurses are constituents of electoral
districts and can make contacts with policymakers in their districts. Nurses
vote. It is not unusual for a nurse to become the point person for a policymaker
who is seeking information about healthcare issues. A nurse does not have to
be knowledgeable about every health problem, but she or he has knowledge of a
specific patient population as well as a vast network of colleagues and resources
to tap into when a policymaker seeks facts. The practice of nursing prepares the
practitioner to work in the policy arena. The public policy process (FIGURE 1-2),
after all, involves the application of a decision-making model in the public sector.
How Is Public Policy Related to Clinical Practice? 7
FIGURE 1-2 The policy process.
Reproduced from Centers for Disease Control and Prevention. (2012). Overview of CDC’s Policy Process. Atlanta, GA: Centers for Disease Control and Prevention, U.S.
Department of Health and Human Serivces. Retrieved from https://www.cdc.gov/policy/analysis/process/
I. Problem Identification
II.
P
o
lic
y
A
n
a
ly
si
s
IV
. P
o
licy En
actm
ent
III. Strategy and Pol
icy
Development
V.
P
ol
ic
y I
m
ple
me
nta
tion
Stakeholder
Engagement
and Education
Evaluation
All facets of nursing practice and patient care are highly regulated by po-
litical bodies. State boards of nursing and other professional regulatory boards
exert much influence in interpreting the statutes that govern nursing. Scope of
practice is legislated by elected members but then defined in the rules and reg-
ulations by boards. Because each state and jurisdiction defines the practice of
nursing differently, there is wide variation in the nursing scope of practice across
the specific states. A fear expressed by many boards is that their decisions may
interfere with Federal Trade Commission (FTC) rules that restrict monopoly
practices. In 2014, the FTC published a policy paper addressing the regulation of
the advanced practice registered nurse (APRN) that includes five key findings
with important implications for policymakers:
1. APRNs provide care that is safe and effective.
2. Physicians’ mandatory supervision of and collaboration with advanced
nurse practice is not justified by any concern for patient health or safety.
3. Supervision and collaborative agreements required by statute or
regulation lead to increased costs, decreased quality of care, fewer
innovative practices, and reduced access to services.
8 Chapter 1 Informing Public Policy: An Important Role for Registered Nurses
4. APRNs collaborate effectively with all healthcare professionals without
inflexible rules and laws.
5. APRN practice is “good for competition and consumers” (“FTC Policy
Paper,” 2014, p. 11).
Professional nurses who are knowledgeable about the regulatory process
can more readily spot opportunities to contribute or intervene prior to final
rule making.
Organizational Involvement
Professional organizations bring their influence to the policy process in ways that a
single person may not. There are a myriad of nurse-focused organizations, including
those in specialty areas, education-related organizations, and leadership-related
organizations. For example, the American Nurses Association, National League
for Nursing, and Sigma Theta Tau International state a commitment to advancing
health and health care in the United States and/or on a global scale, as noted in their
mission statements and goals, and offer nurses opportunities to develop personal
leadership skills. The Oncology Nurses Society, American Association of Critical
Care Nurses, American Association of Nurse Anesthetists, Emergency Nurses
Association, and many other specialty organizations focus on policies specific to
certain patient populations and provide continuing education. Participating on
committees within trade associations provides opportunities to learn about the
organization, its mission, and its outreach efforts in more depth.
Professional associations afford their members experiences to become
knowledgeable about issues pertinent to the organization or the profession.
These groups can expand a nurse’s perspective toward a broader view of health
and professional issues, such as at the state, national, or global level. This kind
of change in viewpoint often encourages a member’s foray into the process of
public policy. Some nurses are experienced in their political activity. They serve
as chairs of legislative committees for professional organizations, work as cam-
paign managers for elected officials, or present testimony at congressional, state,
or local hearings; a few have run for office or hold office.
Political activism is a major expectation of most professional organizations.
Many organizations employ professional lobbyists who carry those organizations’
issues and concerns forward to policymakers. These sophisticated activists are
skilled in the process of getting the attention of government and obtaining a
response. Nurses also have an opportunity to voice their own opinions and
provide information from their own practices through active participation in
organizations. This give-and-take builds knowledge and confidence when nurses
help legislators and others interpret issues.
Taking Action
Nurses cannot afford to limit their actions in relation to policy. Instead, nurses
need to share their unique perspectives with bureaucrats, agency staff, legislators,
and others in public service regarding what nurses do, what nurses and their
patients need, and how their cost-effectiveness has long-term impacts on health
care in the United States.
How Is Public Policy Related to Clinical Practice? 9
Many nurses are embracing the whole range of options available in the various
parts of the policy process. They are seizing opportunities to engage in ongoing,
meaningful dialogues with those who represent the districts and states and those
who administer public programs. Nurses are becoming indispensable sources of
information for elected and appointed officials, and they are demonstrating lead-
ership by becoming those officials and by participating with others in planning
and decision making. By working with colleagues in other health professions,
nurses often succeed in moving an issue forward owing to their well-recognized
credibility and the relatively fewer barriers they must overcome.
Addressing Nursing Shortages
Nurses can bring research and creativity to efforts geared toward solving public
policy issues such as the nursing shortage and the most efficacious use of RN and
APRNs. Aiken and colleagues have reported repeatedly that hospitals with higher
proportions of baccalaureate-prepared nurses demonstrate decreased patient
morbidity and mortality (Aiken et al., 2003, 2012, 2014; Van den Heede et al.,
2009; Wiltse-Nicely, Sloane, & Aiken, 2013; You et al., 2013). Aiken’s research
includes studies in the United States and in nine European countries. Although
the National Council of State Boards of Nursing has stated that it is not ready to
support legislation or regulation that requires a bachelor of science in nursing
(BSN) degree as the entry level into practice as a registered nurse, the marketplace
is moving in a different direction. Many healthcare agencies are limiting new hires
to those with a BSN and have developed policies that require RNs with associate’s
degrees or diplomas to complete a BSN within 5 years of employment. Academic
institutions have expanded or created RN-to-BSN programs in response to the
demand from the accrediting agency for Magnet status, the American Nurses
Credentialing Center.
Second-degree nurse education programs, reminiscent of similar programs
initiated during World War II, have flourished at the bachelor’s and master’s
degree levels. These programs were created to accept applicants with college
degrees in fields other than nursing and provide students with an opportunity
to graduate with a degree in nursing in an abbreviated time period; graduates
are eligible to sit for the National Council Licensure Examination (NCLEX-RN)
to become registered nurses. These popular programs provide new avenues that
address the nurse shortage.
Perhaps the greatest potential for change in the education of nurses will be the
effect of the IOM (2010) report, The Future of Nursing: Leading Change, Advancing
Health. Developed under the aegis of and funded by the Robert Wood Johnson
Foundation, this report explicitly recognized that nurses (the largest healthcare
workforce in the United States) must be an integral part of a healthcare team. Its
authors emphasize four key messages (IOM, 2010, pp. 1–3):
1. Nurses should practice to the full extent of their education and training.
2. Nurses should achieve higher levels of education and training through
an improved education system that promotes seamless academic
progression.
3. Nurses should be full partners with physicians and other healthcare
professionals in redesigning health care in the United States.
10 Chapter 1 Informing Public Policy: An Important Role for Registered Nurses
4. Effective workforce planning and policymaking require better data
collection and an improved information infrastructure.
A consortium of professional organizations has moved forward together to
address common problems. The Josiah Macy Jr. Foundation (2014) developed
recommendations that support working together in five areas: (1) engagement,
(2) innovative models, (3) education reform, (4) revision of regulatory standards,
and (5) realignment of resources.
▸ Healthcare Reform at the Center of the
Public Policy Process
Starting with the Harry Truman administration in the 1940s, every U.S. pres-
ident’s administration has struggled to reform the healthcare System to meet
the needs of all U.S. residents. President Barack Obama declared early in his
administration that a major priority would be health care for all, and in 2010,
the Patient Protection and Affordable Care Act (commonly known as the ACA
and “Obamacare”) was established, a huge first for the United States. Seven years
after the passage of the ACA, however, more than one-third of U.S. residents
were unable to identify that Obamacare and the ACA were one and the same
(Advisory Board, 2017).
The Affordable Care Act was being debated and amended as this text was
being revised; no one can predict how health care for the nation will be addressed
by the Trump administration. Public uncertainty about personal coverage and
methods of financing care are major issues; the former solutions may not fit
new program designs. Most care providers recognize the problems inherent in
offering care to the uninsured and underinsured. The disparities in care seen in
low-socioeconomic groups and vulnerable populations (e.g., children, the elderly)
and groups with specific health concerns (e.g., persons with diabetes, smokers)
present enormous challenges. Nurses have proffered solutions that have been
taken seriously by major policy players.
Expanding the historical boundaries of nursing will require skills in negotia-
tion, diplomacy, assertiveness, expert communication, and leadership. Sometimes
physician and nurse colleagues are threatened by these behaviors, and it takes
persistence and certainty of purpose to proceed. Nurses must speak out as artic-
ulate, knowledgeable, caring professionals who contribute to the whole health
agenda and who advocate for their patients and the community. All healthcare
professions have expanded the boundaries of practice from their beginnings.
Practice inevitably reflects societal needs and conditions; homeostasis is not an
option if the provision of health care is to be relevant.
▸ Developing a More Sophisticated Political
Role for Nurses
In addition to being clinical experts, nurses are entrepreneurs, decision makers,
and political activists. Many nurses realize that if they are to control practice and
Developing a More Sophisticated Political Role for Nurses 11
move the profession of nursing forward as major players in the healthcare arena,
they must be involved in the legal decisions about the health and welfare of the
public—decisions that often are made in the governmental arena.
For many nurses, political activism used to mean letting someone else get
involved. Today’s nurses often tune in to bills that reflect a particular passion (e.g.,
driving and texting), disease entity (e.g., diabetes), or population (e.g., childhood
obesity). Although this activity indicates a greater involvement in the political
process, it still misses a broader comprehension of the whole policymaking process
that provides many opportunities for nurse input before and after legislation is
proposed and passed.
Nurses who are serious about political activity realize that the key to establish-
ing contacts with legislators and agency directors is to forge ongoing relationships
with elected and appointed officials and their staffs. By developing credibility
with those active in the political process and demonstrating integrity and moral
purpose as client advocates, nurses are becoming players in the complex process
of policymaking.
Nurses have learned that by using nursing knowledge and skill, they can gain
the confidence of government actors. Personal stories drawn from professional
nurses’ experience anchor altruistic conversations with legislators and their staffs,
creating an important emotional link that can influence policy design. Nurses’ vast
network of clinical experts produces nurses in direct care who provide persuasive,
articulate arguments with people “on the Hill” (i.e., U. S. congressional members
and senators who work on Capitol Hill) during appropriations committee hearings
and informal meetings.
Nurses regularly participate in formal, short-term internship programs
with elected officials and in bureaucratic agencies. Most of these internships
were created by nursing organizations convinced of the importance of political
involvement. Interns and fellows learn how to handle constituent concerns, how
to write legislation, how to argue with opponents yet remain colleagues, and how
to maneuver through the bureaucracy. They carry the message of the necessity of
the political process to the larger profession, although the rank-and-file nurses
still are not active in this role.
Nurses who have been reluctant to become active in the political arena cannot
afford to ignore their obligations any longer. Each nurse counts, and collectively,
nursing is a major actor in the effort to ensure the United States’ healthy future.
Many nurses have already expanded their conception of what nursing is and how
it is practiced to include active political participation. The process is similar at
the federal or state level: Identify the problem and become part of the solution.
Working with the Political System
Many professional nurses and APRNs develop contacts with legislators, appointed
officials, and their staffs. Groups that offer nurse interaction include the House
Nursing Caucus and Senate Nursing Caucus (their membership shifts with the
election cycle). Members hold briefings on the nurse shortage, patient and nurse
safety issues, vaccination, school health, reauthorization of legislation (e.g., the
Emergency Medical System, the Ryan White Act), preparedness for bioterrorism,
and other relevant and pertinent issues and concerns.
12 Chapter 1 Informing Public Policy: An Important Role for Registered Nurses
Nurses must stay alert to issues and be assertive in bringing problems to the
attention of policymakers. It is important to bring success stories to legislators
and officials—they need to hear what good nurses do and how well they practice.
Sharing positive information will keep the image of nurses positioned within an
affirmative and constructive picture. Legislators must run for office (and U.S.
representatives do so every 2 years), so media coverage with a local nurse who is
pursuing noteworthy accomplishments is usually welcomed.
▸ Conclusion
Healthcare professionals must have expert knowledge and skills in change man-
agement, conflict resolution, active listening, assertiveness, communication,
negotiation, and group processes to function appropriately in the policy arena.
Professional autonomy and collaborative interdependence are possible within a
political system in which consumers can choose access to quality health care that
is provided by competent practitioners at a reasonable cost. Professional nurses
have a strong, persistent voice in designing such a healthcare system for today
and for the future.
The policy process is much broader and more comprehensive than the
legislative process. Although individual components can be identified for ana-
lytical study, the policy process is fluid, nonlinear, and dynamic. There are many
opportunities for nurses in advanced practice to participate throughout the
policy process. The question is not whether nurses should become involved in
the political system, but to what extent. Across the policy arena, nurses must be
involved with every aspect of this process. By knowing all the components and
issues that must be addressed in each phase, the nurse in advanced practice will
find many opportunities for providing expert advice. APRNs can use the policy
process, individual components, and models as a framework to analyze issues
and participate in alternative solutions.
▸ Discussion Points
1. Identify a problem you have encountered in school or in practice (e.g., “My
patients all have dental problems and have no means of paying for dental
care”). Discuss how the diagram of the policy process (Figure 1-2) can help
inform how you approach finding a solution to this problem. Reflect on
which level of government might address this problem and why. Identify
the stakeholders in this issue.
2. Discuss the role of research in nursing/healthcare practice as it affects
health policy. What has been the focus over the past century? What is the
pattern of nursing research vis-à-vis topic, methodology, and relevance?
To what extent do you think the current focus on evidence-based practice
has influenced research? Cite examples.
3. Trace the amount of federal funding appropriated for nursing or HCP re-
search over specific year(s). Do not limit your search to federal health-related
agencies; that is, investigate departments (e.g., commerce, environment,
13Discussion Points
transportation), military services, and the Department of Veterans Affairs.
Which funding opportunities exist for nurse scientists/HCP scientists?
4. Read books and articles about the changing paradigm in healthcare delivery
systems. Discuss the change in nursing or another healthcare profession
as an occupation versus a profession.
5. Consider a thesis, graduate project, or dissertation on a specific topic
(e.g., clinical problems, healthcare issues) using the policy process as a
framework. Identify policies within public agencies and determine how
they were developed. Interview members of a government agency’s policy
committee to discover how policies are changed.
6. Review official governmental policies. Which governmental agency is
responsible for developing the policy? For enforcing the policy? How has
the policy changed over time? What are the consequences of not complying
with the policy? What is needed to change the policy?
7. Identify nurses and healthcare professionals who are elected officials at the
local, state, or national level. Interview these officials to determine how
the nurses and HCPs were elected, what their objectives are, and to what
extent they use their nursing knowledge in their official capacities. Ask
the officials if they tapped into nurses groups during their campaigns. If
so, what did the nurses and HCPs contribute? If not, why?
8. Discuss the fluidity among the major components of the policy process.
Point out how players move among the components in a nonlinear
way. How can this knowledge facilitate entrance into the policymaking
process?
9. Watch television programs in which participants discuss national and
international issues. Analyze the patterns of verbal and nonverbal commu-
nication, pro-and-con arguments, and other methods of discussion used
on the program. Position your analysis within the framework of gender
differences in communication and utility in the political arena.
10. List ways in which healthcare professionals can become more knowledgeable
about the policy process. Choose at least three activities in which you will
participate. Develop a tool for evaluating the activity and your knowledge
and involvement.
11. Select at least one problem or irritation in a clinical area, and brainstorm
with other healthcare professionals or graduate students on how to approach
a solution. Who else could you bring into the discussion who could become
supporters? Discuss funding sources—be creative.
12. Attend a meeting of the state board of your health profession or a profes-
sional convention. Identify issues discussed, resources used, communication
techniques, and rules observed. Evaluate the usefulness of the session to
your practice.
13. Discuss which skills (e.g., task, interpersonal) and attitudes are required
for the nurse in the policy arena. Who is best prepared to teach these
skills, and which teaching techniques should be used? How will the skills
be evaluated? Develop a worksheet to facilitate planning. Discuss at least
five strategies for helping nurses integrate these skills into their practices.
14. Convene a group of healthcare professionals and discuss common problems,
potential solutions, and strategies to move forward.
14 Chapter 1 Informing Public Policy: An Important Role for Registered Nurses
References
Advisory Board. (2017, February 7). Many Americans think repealing Obamacare won’t repeal
the ACA, survey finds. Retrieved from https://www.advisory.com/daily-briefing/2017/02/09
/many-americans-think-repealing-the-aca#
Aiken, L. H., Clarke, S. R., Cheung, R. B., Sloane, D. M., & Silber, J. H. (2003). Educational
levels of hospital nurses and surgical patient mortality. Journal of the American Medical
Association, 290(12), 1617–1623.
Aiken, L. H., Cimotti, J. P., Sloane, D. M., Smith, H. L., Flynn, L., & Neff, D. E. (2012). Effects
of nurse staffing and nursing education on patient deaths in hospitals with different work
environments. Medical Care, 49(12), 1047–1053.
Aiken, L. H., Sloane, D. M., Bruyneel, L., Van den Heede, K., Griffiths, P., Busse, R., . . . Sermeus,
W. (2014). Nurse staffing and education and hospital mortality in nine European countries:
A retrospective observational study. Lancet, 383(9931), 1824–1830.
Centers for Disease Control and Prevention. (2012). Overview of CDC’s policy process. U.S.
Department of Health and Human Services. Retrieved from https://www.cdc.gov/policy
/analysis/process/docs/cdcpolicyprocess
FTC policy paper examines competition and the regulation of APRNs. (2014). American Nurse,
46(3), 11.
Institute of Medicine (IOM). (2010). The future of nursing: Leading change, advancing health.
Washington, DC: National Academies Press.
Josiah Macy Jr. Foundation. (2014). Publications. Retrieved from http://www.macyfoundation
.org/publications/publications/aligning-interprofessional-education
CASE STUDY 1-1: The Addiction Epidemic
You are an acute care nurse practitioner who works in an urban emergency room
(ER). You see many people who come to the ER who have overdosed (OD) on
heroin. Emergency medical services personnel may administer a drug that might
reverse the overdose such as naloxone (Narcan). You may see three ODs during
each 12-hour shift; some of these patients are admitted to the hospital, and others
are sent home with a consultation for psychiatric followup. You are becoming
hardened to the issue and have begun to question what you can do to address
this epidemic.
Discussion Points
1. You hear that the state health director is convening a task force. List four
actions you can take to be invited to participate in this task force.
2. Which other healthcare professionals should be included on the task force?
3. Which state agencies and regulatory boards could add value to the
discussion?
4. Which information/experience could the APRN use to lead a discussion
about widespread addiction?
5. Identify three issues that might be brought up at a meeting that could
derail a focus on public safety. Which tactics can the nurse use to bring the
discussion back to the issue of safety?
6. Which design tactics could be considered when writing a policy to address
this issue?
7. How can information about this issue be disseminated within the profession
and to those outside the profession?
15References
Litman, T. J., & Robins, L. S. (1991). Health politics and policy (2nd ed.). Albany, NY: Delmar.
National Council of State Boards of Nursing. (2017). Active RN licenses. Retrieved from http://
ncsbn.org/6161.htm
Patient Protection and Affordable Care Act of 2010. (2010). Pub. L. No. 111-148, 124 Stat. 119.
Van den Heede, K., Lesaffre, E., Diya, L., Vleugels, A., Clarke, S. P., Aiken, L. H., & Sermeus, W.
(2009). The relationship between inpatient cardiac surgery mortality and nurse numbers
and educational level: Analysis of administrative data. International Journal of Nursing
Studies, 46, 796–803.
Wilson, J. Q. (1989). American government institutions and policies (4th ed.). Albany, NY: Delmar.
Wiltse-Nicely, K. L., Sloane, D. M., & Aiken, L. H. (2013, June). Lower mortality for abdominal
aorta aneurysm repair in high volume hospitals contingent on nurse staffing. Health Systems
Research, 48(3), 972–991.
You, L.-M., Aiken, L. H., Sloane, D. M., Liu, K., He, G-P, Hu, Y., . . . Sermeus, W. (2013).
Hospital nursing, care quality, and patient satisfaction: Cross-sectional survey of nurses
and patients in hospitals in China and Europe. International Journal of Nursing Studies,
50(2), 154–161.
16 Chapter 1 Informing Public Policy: An Important Role for Registered Nurses
© Visions of America/Joe Sohm/Photodisc/Getty
KEY TERMS
Contextual dimensions: Studying issues in the real world, in the circumstances
or settings of what is happening at the time.
Iron triangle: Legislators or their committees, interest groups, and administrative
agencies that work together on a policy issue that will benefit all parties.
Streams: Kingdon’s classic research on agenda setting noted a streams
metaphor—the concept of the interaction of public problems, policies, and
politics that couple and uncouple throughout the process of agenda setting.
Window of opportunity: Limited time frame for action.
Agenda Setting: What
Rises to a Policymaker’s
Attention?
Elizabeth Ann Furlong
▸ Introduction
This chapter emphasizes the agenda-setting aspect of policymaking by using
exemplar case studies at local, state, and national levels. Agenda setting is the
process of moving a problem to the government’s attention so that solutions can
be considered. Registered nurses (RNs), advanced practice registered nurses
(APRNs), and other interprofessional healthcare workers (IPHCWs) can apply
the knowledge from these case studies to the many current concerns they face.
The author acknowledges the older dates of many of the references cited in this
chapter. These classic political science references on agenda setting are retained
in this chapter to further the historical knowledge of the nurse policy advocate.
Agenda setting can happen in legislative settings and in private organizations.
17
CHAPTER 2
The local example in this chapter demonstrates what can be done in the latter
venue. By seeking and obtaining a grant from a national organization, nurse leaders
are initiating and furthering a new policy practice in a health organization. The
outcomes of this new agenda policy can have potential implications for furthering
agenda setting at governmental levels.
FIGURE 2-1 illustrates the various levels of the political agenda:
■ Agenda universe: All ideas that could possibly be brought up and discussed
in a society.
■ Systemic agenda: All issues that are commonly perceived as meriting public
attention within the legitimate jurisdiction of the existing governmental
authority.
■ Institutional agenda: Items that have risen to the attention of a governing body.
■ Decision agenda: Items about to be acted on by a governing body.
APRNs and other IPHCWs, as well as policymakers and citizens, are interested
in the best public policies to address society’s concerns. Early political science
researchers mainly studied the later steps of policymaking—implementation and
evaluation—to gain an understanding of public policy and knowledge that could
be used by policymakers to create better public policies. Although all stages of the
policy process have been studied, the need for more research on the earlier parts
of policymaking—agenda setting, policy formulation, and policy design—has
been the subject of more discussion in recent times (Bosso, 1992a; Ingraham,
1987; May, 1991). Research interest in these latter areas grew during the 1980s
and 1990s and continues into the 21st century.
As noted earlier, this chapter presents examples of agenda setting at the
local, state, and national levels. The first example demonstrates how nurse and
interprofessional health leaders are changing practice interventions at the organi-
zational level with use of a grant. By seeking and obtaining a grant from a national
organization, nurse leaders can initiate new practices in a health organization.
The outcomes of this new agenda policy can have potential implications for fur-
thering agenda setting at governmental levels. Changing policies and processes in
the delivery of healthcare services in an ambulatory health center in a nonprofit
FIGURE 2-1 Levels of the political agenda.
Agenda Universe
Systemic Agenda
Institutional
Agenda
Decision Agenda
“Getting on” or creating this
level of agenda setting is the
goal of nurse leaders
18 Chapter 2 Agenda Setting: What Rises to a Policymaker’s Attention?
health organization is not only a policy end unto itself but also has implications
for other nurse leaders to set such agendas in their respective organizations.
APRNs and other IPHCWs also need to learn how issues get on legislative
agendas. The state-level example presented in the second case study involves a
nurse practitioner bill that was passed in Nebraska. The first national example
in this chapter focuses on an event that had just occurred as this text was being
written. The second national-level case study is a classic national legislative ex-
ample; research and analysis for this second national example were performed
by this author. Following that analysis, those same theories are applied to the
Nebraska nurse practitioner bill.
CASE STUDY 2-1: A Local Example
Policies can be changed in organizations as well as legislatively. This first example
demonstrates nurse and interprofessional health leaders changing practice
interventions with use of a grant. Specifically, they are setting an agenda in an
ambulatory health center, with this planning and intervention facilitated by a grant.
Two departments in Omaha Creighton University’s College of Nursing and
the Center for Interprofessional Practice, Education, and Research are furthering
interprofessional health care and education by their 2016 receipt of a $50,000
grant from the National Center for Interprofessional Practice and Education (Blue
News [daily e-newsletter, Creighton University], 2016). The grant at Creighton, titled
“Accelerating Interprofessional Community-Based Education and Practice,” will
assist in developing a nurse practitioner–led interprofessional team to be utilized in
Creighton’s healthcare-affiliated system, Catholic Health Initiative (CHI). In addition
to the grant, both Creighton University and CHI donated $25,000 to the endeavor.
Dean Catherine Todero of the College of Nursing noted, “Nurse practitioners are
increasingly taking lead roles in a number of clinical and educational health care
situations” (Blue News, 2016). This grant will further the practice, education, and
research of a nurse practitioner–led interprofessional team for a national agency.
CASE STUDY 2-2: A Nurse Practitioner–
Initiated Bill in the Spring 2014 Nebraska
Unicameral Legislature
An example of agenda setting in 2014 was an effort by the Nebraska Nurse
Practitioners (NNP), a state nursing association, to find a state senator who would
introduce a bill into the Nebraska unicameral legislative session to eliminate the
Integrated Practice Agreement (IPA) from the Nurse Practitioner Practice Act
(Nebraska Legislature, 2014). The public hearing for the bill was held on January 31,
2014; the sponsoring state senator’s goal was for the bill to emerge from the seven-
member Health and Human Services Committee with support from all or most of
the members (Senator S. Crawford, personal communication, January 2014).
(continues)
Introduction 19
Prior to the bill’s introduction, the NNP had to undergo review by the
Nebraska Credentialing Review (407) Program. This state-level review program
had been created to evaluate current Nebraska health professionals who
are seeking to expand their scope of practice or to evaluate the scope of
practice of a new type of provider (Nebraska Department of Health and
Human Services, n.d.). As part of its review, the NNP submitted extensive
documentation to three review bodies—an ad hoc Technical Review
Committee appointed by the director of the Nebraska Division of Public
Health, a second review by the State Board of Health, and a third review
by the director of the Division of Public Health. These reviews represented
input from the Department of Health and Human Services (DHHS) about
possible concerns for Nebraskans in either public health or safety. Although
the recommendations at the three levels are advisory, they serve to inform
state senators when considering and voting on proposed legislation
(D. Wesley, lobbyist, personal communication, June 2013). The NNP proposal
received support at the first two levels; at the second level, the vote was
12–5 to eliminate the IPA requirement ( Whitmire, 2013). There also were
recommendations with this second vote to (1) have practice requirements for
the new graduate nurse practitioner (NP) and (2) have ongoing competency
evaluations of all NPs. At the third level of review, the director and chief
medical director of the DHHS were strongly opposed to the NNP proposal
(Ruggles, 2013).
APRNs in Nebraska set the agenda with four goals in mind:
■ Decrease barriers to their full scope of practice
■ Provide more and needed access to health care (especially primary care and
mental health care) in rural parts of the state
■ Meet the emerging primary healthcare needs associated with an increased
Nebraska population having health insurance because of the Affordable
Care Act
■ Decrease the exodus of APRNs to contiguous states that did not have such IPA
agreements (Sundermeier, 2013/2014)
In seeking passage of this bill, Nebraska NPs wanted to join the 17 other
states and the District of Columbia that had facilitated full scope of practice
availability for nurse practitioners. As noted by Bobrow and Dryzek (1987), this case
study underscores the importance of contextual dimensions furthering agenda
setting. As noted previously, there were four important contexts in setting this
agenda topic at this time in this state.
This agenda, which was based on evidence-based practice studies and
the promotion of all nurses working to their full potential, is also advocated by
the National Academy of Medicine (Institute of Medicine, 2010). By providing
CASE STUDY 2-2: A Nurse Practitioner–
Initiated Bill in the Spring 2014 Nebraska
Unicameral Legislature (continued)
20 Chapter 2 Agenda Setting: What Rises to a Policymaker’s Attention?
Before presenting two national case studies, the reader should take note of
some salient concepts. Congress may pass a law that directs an agency to take
action on a certain subject and set a schedule for the agency to follow in issuing
rules. More often, an agency surveys its area of legal responsibility and then
decides which issues or goals have priority for rulemaking. A few of the many
factors that an agency may consider are presented here:
■ New technologies or new data on existing issues
■ Concerns arising from accidents or various problems affecting society
■ Recommendations from congressional committees or federal advisory
committees
■ Petitions from interest groups, corporations, and members of the public
■ Lawsuits filed by interest groups, corporations, states, and members of the
public
■ Presidential directives
■ “Prompt letters” from the Office of Management and Budget (OMB)
■ Requests from other agencies
■ Studies and recommendations of agency staff (https://www.federalregister
.gov/uploads/2011/01/the_rulemaking_process )
legislative language to a state senator to introduce a bill, APRNs set the agenda in
Nebraska.
A variety of strategies were implemented to further the agenda goal. This
chapter’s author served as chair of the Nebraska Nurses Association’s Legislative
Advocacy and Representation Committee (LARC). This committee worked in
unison and collaboratively with the NNP, its lobbyist, the NNA lobbyist, and the
sponsoring state senator to serve as the lead strategists and voices. APRNs used
public media to promote their perspectives. For example, following a negative
review from the Nebraska DHHS, one APRN educated the public via an op-ed
article about APRNs in the state’s largest newspaper (Holmes, 2013). She noted
several of the previously made arguments as support for why APRNs wanted the
IPA eliminated.
The bill passed by a 43–0 vote during the last day of the 2014 unicameral
session. However, the governor vetoed the legislation, and there was not time for
the unicameral legislature to enact an override.
In early 2015, the bill was reintroduced, passed, and signed by the new
governor on March 5, 2015 (Lazure, Cramer, & Hoebelheinrich, 2016). Other factors
facilitating its passage included (1) education regarding APRN capabilities along
with advocacy during the campaigns of 17 new state senators; (2) obtaining
commitments from both gubernatorial candidates that they would not veto the
bill if reintroduced in 2015; (3) ongoing advocacy by the earlier noted nursing
groups; and (4) interprofessional health groups that both supported the bill and
said they would testify at a public hearing. Nebraska is now one of 21 states in
which nurse practitioners have full practice authority (Pohl, Thomas, Barksdale, &
Werner, 2016).
Introduction 21
CASE STUDY 2-3: The Veterans Health
Administration Ruling on APRN Practice
In December 2016, the U.S. Department of Veterans Affairs (VA) announced its final
rule regarding APRN practice within the Veterans Health Administration national
health system. The decision allows nurse practitioners, certified nurse–midwives,
and clinical nurse specialists to practice without physician supervision. This
change will facilitate broader access to health care within the VA system (American
Association of Colleges of Nursing [AACN], 2016). During 2016, nurses nationally
were encouraged to post advocacy messages to the appropriate webpage (https://
www.va.gov/orpm) for changing such rules and regulations. This use of the media
was an example of promoting advocacy by the four professional associations
representing APRNs, the American Nurses Association, and other nursing groups
at national and state levels. By the time the Final Rule was released in May 2016,
more than 179,734 comments had been posted (J. Thew, personal communication,
2017). This large number of comments reflects advocacy behaviors of nurses.
CASE STUDY 2-4: The National Center for
Nursing Research Amendment
A classic example of agenda setting was the initiation of federal legislation in 1983
that increased the funding base for nursing research. An amendment to the 1985
Health Research Extension Act, which created the National Center for Nursing
Research (NCNR) on the campus of the National Institutes of Health (NIH), was the
focus of this national example of agenda setting.
Creation of the NCNR came about because a group of nurse leaders wanted
to create a national institute of nursing within the NIH. To help pass the legislation
in 1985, a political compromise was made with congressional legislators to create a
center instead of an institute (a lesser agency in the hierarchy). In 1993, however, the
NCNR was turned into an institute, and today the agency continues as the National
Institute of Nursing Research (NINR). The discussion here regarding the NCNR
amendment focuses on the agenda setting and policy formulation that occurred
from 1983 to 1985. Achievement in getting the NINR funded was an especially
notable accomplishment because no other health profession has such an institute.
The Influence of National Nurse Groups
The creation of the National Center for Nursing Research on the campus of
the National Institutes of Health in Bethesda, Maryland, was a policy victory for
national nurse organizations. Although nurses’ groups traditionally have not been
considered strong political actors, these groups recognized the importance of
political activity to bring about public policies that enhanced patient care (Warner,
2003). In the last decade of the 20th century, nurse groups were just emerging
as actors in policy networks; however, “a full cadre of nurse leaders who are
knowledgeable and experienced in the public arena, who fully understand the
design of public policy, and who are conversant with consumer, business and
22 Chapter 2 Agenda Setting: What Rises to a Policymaker’s Attention?
provider groups [did] not yet exist” (DeBack, 1990, p. 69). In a study of national
health organizations that play a key role in the health policymaking area (Laumann,
Heinz, Nelson, & Salisbury, 1991), no nurse organizations were cited. APRNs are well
aware of this absence because state legislative and regulatory activity affects their
professional practice on a daily basis.
Research on the NCNR amendment has been important because it studied
political actors who were not generally studied (e.g., nurse interest groups);
this research contributes to public policy scholars’ knowledge of all actors in
policy networks. Laumann et al. (1991) acknowledged that “we may even run a
risk of misrepresenting the sorts of actors who come to be influential in policy
deliberation” (p. 67). The significance of policy research becomes obvious when the
Schneider and Ingram (1993a) model of social construction of target populations
in policy design is applied to nurse interest groups. For example, how nurses
were viewed by policymakers—the social construction of nurses as a target
population—influenced not only the policy in which nurses were interested but
also the passage of the total NIH reauthorization bill.
Dohler (1991) compared health policy actors in the United States, Great
Britain, and Germany and found that it is much easier to have new political actors
in the United States because there are multiple ways to become involved. Dohler
has written of the great increase in new actors since 1970. Baumgartner and Jones
(1993) also described multiple paths of access to becoming involved.
▸ Overview of Models and Dimensions
Several researchers have developed models of agenda setting and policy formulation
(Baumgartner & Jones, 1993; Cobb & Elder, 1983), alternative formulation, and
policy design (Schneider & Ingram, 1993a). Data analysis reveals the importance
of the Schneider and Ingram (1993a) model of the social construction of target
populations and of the classic Kingdon (1995) model for an understanding of the
agenda-setting process for the amendment described in Case Study 2-4 to the
NIH-reauthorizing legislative bill. Analysis of this legislation over the period of
a decade also underscores the importance of Dryzek’s (1983) classic definition of
policy design. An analysis of the legislation supported the importance of study-
ing the contextual dimension that has been advocated by Bobrow and Dryzek
(1987), Bosso (1992a), DeLeon (1988–1989), Ingraham and White (1988–1989),
May (1991), and Schneider and Ingram (1993b). The value of other models—
institutional, representational communities and an institutional approach, and
the congressional motivational model—is addressed as well, as these models
contribute to an understanding of this example. These findings are discussed in
detail in this analysis. For example, during the study of interest groups opposed
to this legislation, this researcher noted two occurrences of an iron triangle in
the early 1980s, in which legislators and their staff and agency bureaucrats worked
with interested parties to resolve issues (FIGURE 2-2).
Kingdon Model
One model that served as an explanatory focus for this research was the Kingdon
(1995) model, which explains how issues get on the political agenda and, once
there, how alternative solutions are devised (FIGURE 2-3). The four important
Overview of Models and Dimensions 23
FIGURE 2-2 Iron triangle of politics.
Congress
Interest
Groups
Bureaucracy
Agencies of the
executive branch of
the federal government
Lobbyists, healthcare
professionals, manufacturers,
other governments,
constituency factions
FIGURE 2-3 Kingdon model.
Problem stream
Policy stream
Politics stream
Policy
window Agenda
concepts of this model are the three streams (problem, policy, and politics) and
the window of opportunity. A problem stream can be marked by systematic
indicators of a problem, by a sudden crisis, by feedback that a program is not
working as intended, and by the release of certain important reports. A practi-
cal application for APRNs and other IPHCWs is that they can be attentive to
these indicators and maximize such opportunities to get an issue on the agenda.
A policy stream relates to those policy actors and communities who attach their
solutions (policies) to emerging problems. This concept also relates to the actual
policy being promoted: APRNs and other IPHCWs can be attentive to identi-
fying problems and framing their solutions to such concerns. The third stream
of Kingdon’s model is the political stream, which consists of the public mood,
pressure group campaigns, election results, partisan or ideological distributions
in Congress, and changes in administrations. Other factors include congressio-
nal committee jurisdictional boundaries and turf concerns among agencies and
government branches.
APRNs and other IPHCWs need to be constantly attentive to all these po-
litical factors, which can be integrated with the fourth concept, the window of
24 Chapter 2 Agenda Setting: What Rises to a Policymaker’s Attention?
opportunity. This window opens when the three streams become integrated at a
time that is favorable to solve a problem with the preferred policy and with the
least resistance.
Interview data and a review of the literature showed many ways in which
the Kingdon model explained the agenda setting for the NCNR legislation. For
example, for the problem stream, the following were variables: (1) the need for
nursing research was recognized by many (e.g., Rep. Madigan [Republican‒Illinois],
legislative staffers, and national nurse leaders); (2) data were available regarding
the financial disparity in research funding for nurses; and (3) an Institute of
Medicine (IOM) report (Cantelon, 2010) on this problem was released in 1983.
There were two variables for the political stream: (1) the policy would be valuable
for Rep. Madigan’s re-election and (2) the policy proposal was an important way
for the Republican party to secure increased votes from women. In terms of the
policy stream, it was sound public policy. The window of opportunity opened
with the release of the 1983 IOM report in conjunction with the election cycle,
the singular presence of many national nurse leaders who were knowledgeable
about both policy and politics, and a U.S. representative who initiated the idea
for this bill—all these factors came together quickly and at an opportune time.
In summarizing these findings in relation to the Kingdon model, this example
validated the importance of the political and problem streams.
Ultimately, the NCNR amendment was passed without meeting the policy
stream processes described by Kingdon, in that it did not go through a softening-up
phase. This concept refers to several revisions being made to a particular policy
as compromises are made and negotiations take place. As stated, the NCNR
amendment was articulated once and moved forward; there was no tweaking or
change in the legislation’s language.
Professional nurses and other IPHCWs may be able to apply the Kingdon
model to ongoing priority practice issues with which they are concerned. For
example, APRNs and other IPHCWs can be attentive to the three streams (policy,
problem, and political) and recognize the existence of a window of opportunity in
which to move their agenda forward. APRNs and other IPHCWs also need to be
aware that taking part in political activity in regulatory agencies could be an ideal
way to problem solve. Case Study 2-3, for example, addressed changes to a Final
Rule and regulations within the VA system for three types of APRNs. Another
example occurred in the early part of the 21st century when nurse practitioners
encountered increased difficulty in having mail-order pharmacies recognize and
fill their prescriptions (Edmunds, 2003). Two nurse practitioners from New York
and South Carolina addressed this problem stream by working with the Food and
Drug Administration and the Federal Trade Commission. The NPs recognized
that working through regulatory agencies was the best initial solution for solving
this problem (Edmunds, 2003).
Importance of Contextual Dimensions
Some authors, notably Bobrow and Dryzek (1987), Bosso (1992a), DeLeon
(1988–1989), Ingraham and White (1988–1989), May (1991), and Schneider
and Ingram (1993b), have emphasized the need to analyze the political context
in which policies get on the agenda, alternatives are formulated, and policies are
put into effect. Although neither a definitive nor an exhaustive list, five contextual
Overview of Models and Dimensions 25
dimensions are suggested by Bobrow and Dryzek (1987) for studying the success
or failure of any designed policy:
■ Complexity and uncertainty of the decision–system environment
■ Feedback potential
■ Control of design by an actor or group of actors
■ Stability of policy actors over time
■ Stirring the audience into action
DeLeon (1988‒1989) writes that sometimes researchers, because of their
unstructured environment, have chosen to study approaches and methodolo-
gies that may meet scientific rigor better, but in doing so, come “dangerously
close to rendering the policy sciences all-but-useless in the real-life political
arenas” (p. 300).
DeLeon (1988–1989) notes that it is nearly impossible for researchers to
“structure analytically the contextual environment in which their recommended
analyses must operate” (p. 300). Whether analyzing the 1983 case study or the
2014‒2015 case study, APRNs and other IPHCWs must analyze the context in
which they find themselves, apply theory, and evaluate the outcome later for
theory application. Researchers and advocacy activists today must work in a
world characterized by great social complexity, extreme political competition,
and limited resources. Of these writers, Bosso and May are especially strong in
their advocacy of this contextual approach to the study of public policy. Bosso
(1992b) echoes DeLeon’s concern:
In many ways, the healthiest trend is the admission, albeit a grudging
one for many, that policymaking is not engineering and the study of
policy formation cannot be a laboratory science. In policy making,
contexts do matter, people do not always act according to narrow
self-interest and decisions are made on the basis of incomplete or biased
information. (p. 23)
For many healthcare professionals, this “messy” process is very uncom-
fortable. Nevertheless, data from congressional documents, archival sources,
and personal and telephone interviews highlight the importance of the political
context to all aspects of policy design for the NCNR—how the policy arrived
on the agenda, how policy alternatives were formulated, the legislative process,
implementation, and redesign of the legislation eight years later, resulting in new
legislation within two years to accomplish the original goal (Bobrow & Dryzek,
1987; Bosso, 1992b; DeLeon, 1988–1989; Ingraham & White, 1988–1989; May,
1991; Schneider & Ingram, 1993b).
Examples of Political Contextual Influence
Sixteen variables are analyzed here in regard to their contribution to the
1985 passage of the NCNR and the 1993 change of the NCNR to the NINR
(TABLE 2-1).
26 Chapter 2 Agenda Setting: What Rises to a Policymaker’s Attention?
TABLE 2-1 Variables Contributing to Passage of Legislation Creating the
National Center for Nursing Research
Partisan
political conflict
between
legislators
Influenced the initial agenda setting of the amendment and
the legislative process throughout the two years. Opposition
to Rep. Waxman’s (Democrat–California) NIH bill in the spring
and summer of 1983 resulted in Rep. Madigan’s initiating a
substitute policy. An impetus for Rep. Madigan’s bill was a
perception that Rep. Waxman yielded too much power with
NIH legislation. As noted by two congressional staffers, this
was an example of partisan conflict.
Election cycle A U.S. representative’s concern with his re-election
chances influenced the initial agenda setting because of
the congressional perception that nurses were a target
population who could help his re-election chances. Several
respondents noted that this was an important factor in the
initial decision for this type of public policy
Bipartisan
negotiation—
presence versus
absence
Bipartisan negotiations between Rep. Waxman and Rep.
Madigan in early fall 1983 resulted in a firm resolve during the
97th and 98th Congresses to stay with the proposed NINR
policy and during the 99th Congress to accept a compromise
on the NCNR. Another example of bipartisan negotiation
was the early committee work by Rep. Madigan, Rep. Broyhill
(Republican–North Carolina), and Rep. Shelby (Democrat-
Alabama) to forge a simple bipartisan four-line amendment.
The bipartisan effort of these three representatives
smoothed the way for passage of this amendment by the
subcommittee.
Interest-group
unity
Unity by nurse groups was considered by many interviewees
to be a crucial factor in the bill’s passage, and this unity also
was important in explaining why no other policy alternatives
were pursued. Because the decision to support Rep. Madigan
was officially made by the Tri-Council (the American Nurses
Association [ANA], the National League for Nursing [NLN],
the Association of Nurse Executives, and the American
Association of Colleges of Nursing) in the summer of 1983,
and although other policy alternatives were considered after
that point, the priority of presenting a united front with Rep.
Madigan was maintained by nurse organizations.
Non-interest-
group unity
Prior disunity by the American Association of Medical
Colleges had disillusioned Rep. Madigan and increased his
interest in initiating the NINR policy with the nurse providers’
groups.
(continues)
Overview of Models and Dimensions 27
Partisan conflict
between the
White House
and an interest
group
The White House and nursing organizations (which
had generally supported Democratic presidential and
vice presidential candidates) had an influence on this
legislation’s history. The 1984 campaign support by the
ANA for Democratic candidates was the reason for the
Republican presidential veto of a NINR amendment and the
NIH bill.
Ideological
and partisan
conflicts over
current issues
Concerns about fetal tissue research and animal rights
research caused much difficulty in the early 1980s.
Concerns about immigration laws and immigrants with
human immunodeficiency virus (HIV ) infection raised
concerns in the 1990s and affected compromises and
passage of the bills. These issues, although not directly
addressed in the NINR amendment, had a major effect on
the bill’s legislative history.
Federal or state
budget deficit
concerns
There was opposition to the creation of new federal entities
because of the deficit concern, and President Ronald Reagan
consistently used this argument as a reason not to create an
NINR.
Timing of
passage during
the president’s
“lame-duck”
term
The NIH bill with the NCNR amendment was passed in
1985, when President Reagan was beginning his second
term. The number of Republican members of Congress,
the lack of any constraint to vote along party lines that
was reflected in the 1985 legislative vote, and the ability to
override the president’s veto were all factors. The timing of
this vote in President Reagan’s lame-duck term helped the
bill’s passage.
History of
legislators with
administrative
agencies
Rep. Waxman’s attempts to exert control over NIH was a
factor in Rep. Madigan’s initiation of NIH legislation during
the summer of 1983. Data support the perspective that,
of all administrative agencies, the NIH consistently was
regarded positively by members of Congress, and this
positive perception was reflected in ample funding levels
on a consistent basis. Contrary to this usual positive regard
was the negative situation between Rep. Dingell (Democrat–
Michigan) and the NIH. Rep. Dingell had “captured” letters
sent by NIH officials to research scientists asking them to
lobby their congressional representatives for increased
funding—an example of the internal workings of an iron
triangle. Rep. Dingell reminded NIH officials that this activity
violated law.
TABLE 2-1 Variables Contributing to Passage of Legislation Creating the
National Center for Nursing Research (continued)
28 Chapter 2 Agenda Setting: What Rises to a Policymaker’s Attention?
(continues)
The relationship
of Congress,
administrative
agencies, and
the Office of
Management
and Budget
NIH officials became anxious when the OMB dictated that
NIH develop a last-minute revised budget to honor a 1980
promise to fund 5,000 new grants yearly. This mandated
division of NIH’s economic pie contributed to NIH officials not
wanting new research entities on their campus that would
further erode existing programs and projects. A second
similar budgetary crisis occurred at NIH in spring 1985 that,
again, caused much consternation for NIH officials and
research scientists.
Internal political
dynamics and
relationships in
Congress
Rep. Waxman was a member of the Congressional class of
1974, when the dynamic in Congress was a decentralization
of power with a large new congressional class. (A
congressional class refers to that cohort of officials elected
in a certain year.) The data show that Rep. Waxman was
interested in gaining more power and control over NIH.
Although his committee had authorizing power over the
NIH, it did not have the greater power of the Appropriations
Committee, which was responsible for funding. However,
through his ability to authorize legislation, Rep. Waxman
had leverage to gain more power. Rep. Waxman’s attempt to
micromanage the NIH resulted in Rep. Madigan’s initiating a
substitute policy.
Communication
between the
White House
and Congress
President Reagan publicly vetoed the legislation in 1984,
although he could have allowed its passage quietly by not
signing the bill. The veto was intended to alert Congress
to expect conflict the following year if the bill’s provisions
were not changed. An example of the negative relationship
between the White House and Congress can be seen
with the congressional override vote in 1985. Members of
Congress (and many members of the president’s political
party) felt betrayed over their work on this legislation and
over what they thought their communication had been with
the president about passing this policy and putting it into
effect. This sense of betrayal spurred their work in securing
the veto override.
International
politics
During the fall of 1985, the Senate waited until the Geneva
Summit was finished before beginning the veto-override
vote. This was done to keep President Reagan from losing any
credibility regarding his leadership ability during the summit
meeting because the Soviet leader would be aware of the
veto override.
Overview of Models and Dimensions 29
The skills and
abilities of an
interest group
In the early 1980s, many factors influenced the ability of
nurse interest groups to promote this policy once it was on
the agenda: (1) the formation of the Tri-Council, (2) a special
interest in public policy by the executive director of the NLN,
(3) the anticipated need to reauthorize the Nurse Education
Act, (4) the policy orientations of many deans of nursing
education programs, (5) a combination of people who saw
the need, (6) much networking by nurses, (7) the presence of
highly motivated people who were interested in furthering
the nursing profession, (8) nurses appointed to positions
within the White House, (9) more nurses working on Capitol
Hill, and (10) the study conducted by Dr. Joanne Stevenson
(personal communication, 1990) on nurse researchers’
inability to obtain NIH grants.
The wit of
“all politics is
personal” and
the importance
of personal
relationships
Data revealed the importance of personal relationships
in getting the idea on the agenda, in obtaining strategic
information, in sharing needed information, and in making
requests. For example, strategic networking at certain
cocktail parties helped with the legislation’s acceptance, as
did carpooling with selected political actors. Savvy nurse
leaders facilitated other nurses in meeting with legislators
and legislative aides in these settings so nurses could lobby
effectively. The importance of congressional staffers to the
initiation and passage of legislation must be emphasized:
Several interviewees spoke of the importance of certain
staffers in their tenacity to ensure that the NCNR amendment
was passed. Clearly, the adage that “all politics is personal”
influenced the legislation at various points.
TABLE 2-1 Variables Contributing to Passage of Legislation Creating the
National Center for Nursing Research (continued)
Control and Stability Factors
Two of Bobrow and Dryzek’s (1987) five contextual dimensions were in evidence
and contributed to the success of this policy, both because the NCNR was passed
as legislation in 1985 and because the NCNR became the National Institute of
Nursing Research in 1993. The two criteria—namely, the control of design by an
actor or group of actors and the stability of policy actors over time—were related
in this instance.
Once this policy was on the agenda and once nurses were united, the nurse
interest groups were committed to the legislation. The nurse interest groups
showed unity in working with Representative Madigan and staying the course.
Although other policy alternatives were discussed, they were never vigorously
pursued by the nurse interest groups. Once the compromise on the NCNR was
made in 1985, the nurse interest groups found the deal acceptable because they
knew they had a “foot in the door” and because they planned to accomplish their
original design (i.e., a nursing institute rather than a nursing center) at a later date.
30 Chapter 2 Agenda Setting: What Rises to a Policymaker’s Attention?
The second dimension, stability of policy actors, also relates to the nurse
interest groups. These groups of nurse leaders were stable for over a decade and
kept tenaciously to their goal. Although the policy arrived on the formal agenda
because of Rep. Madigan’s actions, a very unchanging group of nurse actors
worked for more than 10 years to see that the original policy design eventually
was enacted (i.e., change from the NCNR to the NINR).
According to May (1991), regardless of how one defines policy design, there
is the “emphasis on matching content of a given policy to the political context in
which the policy is formulated and implemented” (p. 188). This statement describes
the contextual dimension of how this public policy arrived on the formal agenda.
Rep. Madigan was going to introduce substitute legislation for Rep. Waxman’s
NIH bill. Rep. Madigan’s NINR amendment was based on an appraisal of which
policy content would best work in that political context.
Schneider and Ingram Model
In addition to emphasizing the role of the political context in agenda setting,
Schneider and Ingram (1991, 1993a, 1993b) specifically push for empirical re-
search that studies the social construction of target populations (those groups
affected by the policy). They propose that one can best understand agenda setting,
alternative formulation, and implementation of policy by knowing how elected
officials perceive different target populations—in other words, by knowing the
“social construction” (i.e., images, symbols, and traits) of such populations.
In their beginning work in this area, Schneider and Ingram proposed a theory
in which the continuum of target populations is categorized as the advantaged,
contenders, dependents, and deviants. Their model suggests that pressure to initiate
beneficial policy that helps those groups will be seen positively, whereas groups
who are seen negatively will receive punitive policy. Schneider and Ingram argue
that groups whose members are viewed positively include the “advantaged” and
the “dependents,” whereas the negatively perceived groups are the “contenders”
and the “deviants.” This is just a beginning categorization—Schneider and Ingram
call for more empirical research in this area to refine their theory. In particular,
they admit that their theory is currently lacking in three areas: (1) definitions
of target populations and social constructions; (2) an explanation of how social
constructions influence public officials in choosing agendas and designs of policy;
and (3) an explanation of how policy agendas and designs influence the political
orientations and participation patterns of target populations.
Schneider and Ingram’s proposed theory, together with Kingdon’s research,
provide the best explanation for understanding the process of the NCNR legislation.
Schneider and Ingram (1991, 1993a, 1993b) write that one can best understand
agenda setting, alternative formulation, and policy implementation by knowing
how elected officials see different target populations and by knowing the social
constructions of such populations. In the case study, the NCNR policy was ini-
tiated by Rep. Madigan because of the social construction of this target nurse
population. Proposing public policy for this target population would help him
pass his substitute NIH legislation. Nurses, as a target population, were positioned
on the continuum as positively viewed groups. Although Schneider and Ingram
acknowledge that their emerging theory needs empirical testing to refine and
define several of its components, this author found it to be of explanatory value
and extreme importance in explaining the outcomes with the NCNR legislation.
Overview of Models and Dimensions 31
Mueller (1988) wrote: “Politicians must be convinced that they will gain from
new policies—either through political success or through program effectiveness”
(p. 443). The selection of nurses as a target population at a time when congressio-
nal members, especially Republicans, needed the female vote to win re-election
contributed to a convincing argument for potential political success for the nurses.
▸ Summary Analysis of a National Policy
Case Study
“No data are ever in themselves decisive. Factors beyond only the data help decide
which policy is formulated or adopted by the people empowered to make the
decision to form policy” (James, 1991, p. 14). In this quote, James is referring to
data in a problem stream as described by Kingdon. The accuracy of this quote
was evident in this nursing research described in Case Study 2-4, as Schneider
and Ingram’s theory of the “social construction of target populations,” together
with Kingdon’s model and the contextual dimension, explained the policy process.
The contextual dimension influenced all aspects of the policy, from agenda
setting in 1983 through policy redesign in 1991, and later with the passage of the
amended legislation in 1993 that accomplished the original 1983 goal. The im-
portance of studying the political context was demonstrated by the 16 contextual
dimensions that influenced this legislative policy process.
Of particular explanatory value in the early agenda setting and policy-alternative
formulation for this legislation were Schneider and Ingram’s model and Kingdon’s
model. The particular amendment was pursued because of application of the
“social construction of target populations”; that is, the target population of nurses
was chosen because nurses would help Rep. Madigan’s and other Republican
members of Congress’s chances for re-election. Notably, Kingdon’s theory adds
to further understanding of this legislation. Within Kingdon’s model, neither
the problem stream nor the policy stream was decisive in driving the legislative
process; rather, the political stream played the key role. The factors making up
the political stream (re-election chances for Rep. Madigan and other Republican
congressional representatives, partisan ideology in Congress, the public mood
about gender issues, and turf concerns between government agencies) all strongly
influenced the placement of this issue on the national agenda. The hypotheses
supported by this empirical research include the notions that policy is more likely
to be initiated for those target populations who are positively viewed by members
of Congress; issues are more likely to reach the formal agenda when the political
stream factors are related to positively viewed target populations; and the policy
process is best understood in a contextual perspective.
▸ Theory Application to the Nebraska Nurse
Practitioner Case Study
Although this chapter has emphasized this author’s research into a national
policy case study on agenda setting, the same theories can also be applied to the
32 Chapter 2 Agenda Setting: What Rises to a Policymaker’s Attention?
Nebraska state case study. The national case study’s agenda setting was initiated
by a U.S. representative. In contrast, in the state case study, NPs initiated and set
the agenda (i.e., by seeking a state senator to introduce a bill, LB916).
In the Nebraska case, NPs were knowledgeable about the problem, policy,
and political streams as well as the window of opportunity. Further, NPs knew
the context of many variables within Nebraska and the nation that have affected
the progression of such bills, both in Nebraska and in other states. Variables
include the 2010 IOM report, evidence-based research on the quality and safety
of nurse practitioner care, the 54,000 uninsured Nebraskans, the Affordable Care
Act, whether the unicameral legislature passed a modified Medicaid expansion
bill during its sessions, the political conservatism of the state, and the structure
of the unicameral legislature as a short 60-day session in even-numbered years
(J. Sundermeier, personal communication, December 2013). Specifically, the
problem stream incorporated two variables: (1) NPs in Nebraska did not meet the
goal of the IOM report (i.e., were not working to their full scope of authority) and
(2) more Nebraskans, especially those living in rural areas, could have enhanced
access to health care if NPs had this full scope of authority. Nurse practitioners
selected a policy stream proposal that was being furthered by the IOM report
(i.e., work to one’s full authority).
Finally, NPs were aware of the key political variables: (1) the modified Med-
icaid expansion bill that did not pass in 2013, which led to an increase in the
number of uninsured people in the state; (2) the political conservatism of state;
(3) the short 60-day session (which means a prioritization of bills for passage by
the state senators); and (4) the pushback against their position by the Nebraska
Medical Association (NMA). In January 2014, the strategy of the NMA was to
delay action on LB916 by seeking another study in addition to the thorough
review conducted under the Nebraska Credentialing Review (407) Program,
which lasted for many months during 2013 (D. Wesley, personal communication,
January 28, 2014). A delaying tactic during proposed agenda setting, instead
of direct opposition, is a common strategy employed by opponents to a policy
(D. Wesley, personal communication, January 28, 2014).
All the variables listed in this state case study for the three streams eventually
converged into a window of opportunity for NPs, who saw the bill finally being
introduced in January 2014. As this example suggests, the Kingdon model continues
to facilitate policy analysis for a range of policies (Kingdon, 2001; Lieberman, 2002).
Further, the social construction theory (used in the analysis of the NCNR national
case study) was as relevant in 2014 in Nebraska with LB916 as it had been decades
earlier in the NCNR/NINR development. Nurse practitioners in Nebraska continued
to struggle with the social construction perception of NPs versus physicians and
hospital administrators and the amount of power each of these provider groups
holds. For example, the Nebraska Hospital Association took a neutral stance on
the NP bill (D. Wesley, personal communication, January 28, 2014).
In addition to taking on the specific role of setting the agenda (i.e., introducing
and shepherding a bill through a legislative body), APRNs and other healthcare
providers supported such agenda setting by their colleagues in other ways. For
example, this writer served in her third year as Chair of the Legislative Advocacy
and Representative Committee (LARC) of the Nebraska Nurses Association
(NNA). Both LARC and the NNA were fully supportive of the NNP and followed
the strategies of the NP advocacy plan. LARC, representing the NNA, provided
Theory Application to the Nebraska Nurse Practitioner Case Study 33
verbal and written testimony during the late January 2014 public hearing, and
timely email messages were prepared by LARC and sent to all NNA members to
encourage them to engage in appropriate advocacy with the respective Health
and Human Services Committee senators who were considering this bill. An-
other way this writer furthered the agenda-setting goals of the NNP was by her
membership in a League of Women Voters (LWV) chapter in a large Midwestern
city and education of LWV members on this bill. These LWV civic activists were
encouraged, after their evaluation of the bill, to also advocate as citizen consumers.
This writer utilized her participation in the monthly AARP Advocacy Forum in
the largest city in Nebraska to enlist other lay and consumer advocacy activists
for their lobby assistance.
LB916 passed the third and final vote (final reading) on April 17, 2014, with a
43–0 passage vote (six senators were either not present or abstained from voting).
This was the last day of the unicameral session. On April 22, 2014, the governor
vetoed the bill, citing a rationale based on input from the physician director of
the Nebraska Health and Human Services Department. Because April 17 was
the last day of the legislature, it was not possible to have an override of the veto.
The Nebraska Nurse Practitioner Association planned to reintroduce the bill
in the spring of 2015. As noted earlier in this chapter, the bill passed in 2015.
Even though sound policy ideas may be presented to policymakers and the
appropriate legislative process may be followed, not all ideas will take hold and not
all solutions proposed will come to fruition. In Nebraska, it is not unusual for a
proposed policy bill to move through as many as three or more unicameral sessions
before it is passed; passage the first time around is unusual. Each session is two
years, so achieving success in passing legislation calls for tenacity by policy advo-
cates. Persistence and long-term planning are integral and critical to policymaking.
▸ Conclusion
For professional nurses and IPHCWs, these four case studies contribute to an
understanding of agenda setting by illuminating the importance of the Schneider
and Ingram model, the Kingdon model, and the contextual dimensions of policy
initiation, development, implementation, and redesign. Specifically, they illustrate
how these models can be used to analyze the creation of a local grant to study the
practice and education of a nurse practitioner‒led interprofessional health team;
a state law facilitating full practice authority for NPs; a Final Rule and regulation
that facilitate the full practice authority of NPs in the national VA system; and
the National Institute for Nursing Research.
▸ Discussion Points
1. How does the Kingdon model explain the NCNR getting on the political
agenda?
2. How does the Kingdon model apply to the Nebraska case study?
3. How can APRNs and other IPHCWs become aware of factors in the prob-
lem stream to which Kingdon alluded? Which problems are you concerned
about in your specific profession?
34 Chapter 2 Agenda Setting: What Rises to a Policymaker’s Attention?
4. What are examples of policy streams that APRNs and other IPHCWs could
be advancing relative to their practice?
5. How can APRNs and other IPHCWs become involved in the political
stream? How are you involved?
6. How can APRNs and other IPHCWs anticipate windows of opportunity?
Given your profession, for which signals will you specifically be observant?
7. According to Schneider and Ingram, to which of the four target populations
does your specific health provider group belong? Discuss the relevance to
agenda setting.
8. What are ways that APRNs and other IPHCWs can network with congres-
sional members and their staffers?
9. How can APRNs and other IPHCWs promote unity among themselves
and with other healthcare providers?
10. How can all healthcare providers support one another and further some
of the IOM goals?
11. Which current contextual dimensions can promote APRNs’ and other
IPHCWs’ practices?
12. How can APRNs and other IPHCWs best use the Kingdon model and the
Schneider and Ingram model?
13. Given your specific health profession, which policy do you recognize that
needs to be on the agenda at the local, state, or national level? What can
you do to begin that process?
References
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A breakthrough for veterans health care. Message posted on the American Association of
Colleges of Nursing Listserv: web@aacn.nche.edu
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IL: University of Chicago Press.
Blue News. (2016, September 28). College of Nursing, CIPER earn prestigious national grant.
Daily e-newsletter, Creighton University.
Bobrow, D. B., & Dryzek, J. S. (1987). Policy analysis by design. Pittsburgh, PA: University of
Pittsburgh Press.
Bosso, C. J. (1992a). Designing environmental policy. Policy Currents, 2(4), 1, 4–6.
Bosso, C. J. (1992b). Policy formation: Current knowledge and practice. Paper presented at the
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Dohler, M. (1991). Policy networks, opportunity structures, and neo-conservative reform
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Verlag.
Dryzek, J. S. (1983). Don’t toss coins in garbage cans: A prologue to policy design. Journal of
Public Policy, 3(4), 345–368.
Edmunds, M. (2003). Advocating for NPs: Go and do likewise. Nurse Practitioner, 28(2), 56.
Holmes, L. (2013, December 14). Give nurse practitioners more rein [in The Public Pulse Letters
to the Editor]. Omaha World Herald, p. 4b.
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Ingraham, P. W. (1987). Toward more systematic consideration of policy design. Policy Studies
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Ingraham, P. W., & White, J. (1988–1989). The design of civil service reform: Lessons in politics
and rationality. Policy Studies Journal, 17(2), 315–330.
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-Leading-Change-Advancing-Health.aspx
James, P. (1991). Bravo to the nursing emphasis on policy research. Reflections, 17(1), 14–15.
Kingdon, J. W. (1995). Agendas, alternatives, and public policies. New York, NY: Harper Collins
College.
Kingdon, J. W. (2001). A model of agenda-setting, with applications. Law Review, MSU-DCL, 2, 331.
Laumann, E. O., Heinz, J. P., Nelson, R., & Salisbury, R. (1991). Organizations in political
action: Representing interests in national policy making. In B. Marin & R. Mayntz (Eds.),
Policy networks: Empirical evidence and theoretical considerations (pp. 63–96). Frankfurt,
Germany: Campus Verlag.
Lazure, L., Cramer, M., & Hoebelheinrich, K. (2016). Informing health policy decision makers:
A Nebraska scope of practice case study. Policy, Politics, & Nursing Practice, 17(2), 85–98.
Lieberman, J. M. (2002). Three streams and four policy entrepreneurs converge: A policy
window opens. Education and Urban Society, 34, 438–450.
May, P. J. (1991). Reconsidering policy design: Policies and publics. Journal of Public Policy,
11(2), 187–206.
Mueller, K. J. (1988). Federal programs to expire: The case of health planning. Public Administration
Review, 48(3), 719–725.
Nebraska Department of Health and Human Services. (n.d.). Credentialing review (407)
program. Retrieved from http://dhhs.ne.gov/pages/reg_admcr.aspx
Nebraska Legislature. (2014). LB916—Eliminate integrated practice agreements and provide
for transition-to-practice agreements for nurse practitioners. Retrieved from http://
nebraskalegislature.gov/bills/view_bill.php?DocumentID=21963
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citizenship and democracy. Paper presented at the annual meeting of the American Political
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contributes to problems in policy design. Policy Currents, 3(1), 1–4.
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for politics and policy. American Political Science Review, 87(2), 334–347.
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Online Resource
https://www.regulations.gov/ The types of regulations that can be found on this site include
Proposed Rules and Rules, as well as Notices from the Federal Register. Documents such
as Public Comments and Supporting and Related Materials are often associated with these
regulations, and can also be found on this site. This is an interactive site allowing pre-decision
participation in regulations formulation.
36 Chapter 2 Agenda Setting: What Rises to a Policymaker’s Attention?
© Visions of America/Joe Sohm/Photodisc/Getty
Government Response:
Legislation
Politics: Playing the Game
Janice Kay Lanier
Politics is the art of problem solving.
—Jonah Goldberg, Editor-at-Large, National Review Online
KEY TERMS
527 committees: Advocacy groups with ties to labor, big business, and
super-wealthy individuals. Unlike political action committees, these entities
can accept unlimited contributions from anyone and spend that money to
influence elections, with only limited constraints on their operations (Center for
Responsive Politics, 2016a).
Christmas tree bills: Legislations that are moving speedily through the process
when the legislative body is about to adjourn or take a prolonged break. Bills
that have been enacted in one chamber are used as the vehicle (Christmas tree)
for amendments from multiple bills that may have stalled during the process.
Many tangentially related issues are tacked onto the moving bill with little or no
formal committee consideration.
Congress: The legislative body charged with enacting laws at the federal level.
The membership of Congress changes every two years with the election cycle
and is called a congressional session. Each congressional session is numbered.
Constituents: Residents of a geographic area who can vote for a candidate and
whom the elected official represents.
District: The geographic area that a particular legislator represents. Districts may
be reconfigured every 10 years based on official census data. Reconfiguration
37
CHAPTER 3
or reshaping a particular Congressional district occurs when a state’s
population totals either increase or decrease to the extent that a new district
must be added or an existing district eliminated. The process for doing that
may differ from state to state, but the reconfiguration can have significant
political implications for future elections. State legislatures are also made
up of population-based districts that may be reconfigured based on census
data. Frequently the districts are drawn with little regard for geographic
considerations. Instead, political factors are the most compelling reasons for
how a district is configured. Concentrating the voting strength of a minority
party into as few districts as possible while giving the other party a majority in as
many districts as possible is known as gerrymandering.
Executive order: An order or directive issued by the president or governor
directed at an executive branch agency that has the force and effect of law
during the tenure of the issuing chief executive. An executive order cannot
conflict with existing law or the Constitution but can direct the agency to use its
discretion when implementing a particular program or policy.
Lame-duck session: The weeks immediately following a November general
election when an outgoing legislative body attempts to speed its priorities
through the legislative process. Legislative activity can be particularly vigorous if
control of the legislative or executive branch of government will change when
the newly elected individuals take office in January.
Legislation: The bills considered by legislators that, if approved, become laws.
Legislative language: The legal terminology and technical format that federal
and state governments require when legislators propose to enact new laws or
revise existing ones.
Legislator: An elected individual who serves in the state legislature or the U.S.
Congress. These officials make decisions regarding bills and resolutions pending
before the legislative body to which they have been elected.
Legislature: The legislative body made up of individuals authorized to enact laws.
Lobbyist: An individual who works to influence legislators and other
governmental decision makers. A professional lobbyist is required to register
with the body being lobbied.
Political action committees (PACs): Formal organizations that exist to engage
in a process through which candidates for political office are endorsed and
otherwise supported. They must adhere to state and/or federal laws in carrying
out its activities.
Special interest group: An organized group with a common cause that works to
influence the outcome of laws, regulations, or programs.
Super-majority: While many legislative actions can be taken based on a
simple majority vote, certain actions, including overriding a presidential or
gubernatorial veto, require that the legislative body achieve a two-thirds vote of
its members; the latter is termed a super-majority.
▸ Introduction
It is not possible to separate politics from policymaking, whether the policy de-
cisions are made in the public sector, the private sector, or at home. “Politic” is
defined as being wise or shrewd, while “politics” is defined as methods, opinions,
or scheming (Goldman, 2000) or the process for influencing the allocation of
scarce resources (Chaffee, 2014, p. 307). Regardless of the definition used, many
38 Chapter 3 Government Response: Legislation
nurses and other healthcare professionals see “politics” as a negative term and
perceive “playing politics” as a reason for not getting involved in political advocacy.
That position means the expertise and insights that nurses and others possess
by virtue of their hands-on experiences in caring for patients are not reflected
in the policies that come out of Washington, D.C., state capitals, or boardrooms.
Because of the contributions nurses could and do make to the decision
making that occurs in a variety of boardrooms, a coalition was formed to en-
courage more nurses to become members of policymaking boards. The Nurses
on Boards Coalition (2016), which is made up of 24 nursing organizations plus
strategic healthcare leadership and corporate partners, set a goal to have 10,000
nurses serving on corporate, health-related, and other boards by 2020. Such
participation by nurses will help the public see the breadth of expertise nurses
bring to the table and help develop a cadre of experienced nurses who can share
their knowledge with other members of the nursing profession.
Some may believe involvement in policymaking is self-serving, concerned
only with advancing selfish professional interests. Actually, the ultimate point in
participating in policymaking is to improve patient outcomes. Focusing on “politic”
(wisdom) rather than “politics” (influence) may make joining in the policy debate
more relatable and palatable. This chapter provides insights into the processes
that determine how policy is made and offers some opportunities to reflect on
why certain outcomes occur but others do not. It will help readers find their way
through the political maze by providing a basic understanding of some of the
“rules of the game”—that is, how laws are made and who is on the field of play.
Before embarking on that journey, a word is in order about one of the most
obvious displays of politics—elections. Elections matter, sometimes in ways that
are not obvious on the surface. Never has that been more evident than in the
aftermath of the 2016 presidential election. Trying to analyze what happened
given the unprecedented nature of the campaign will occupy political scientists
and others for years to come. Whether clear answers will emerge from a retro-
spective review remains to be seen, but it is certainly undeniable that the 2016
election will have lasting implications on many levels.
Clearly, election results determine who will hold office, who will be the
president or governor, and who will be in the Senate or the House of Represen-
tatives. Will one party control two elected branches of government (legislative
and executive), or will power be shared? Will the party in control have enough
members to form a super-majority that allows it to ignore the concerns of the
minority party, or will various perspectives be heeded so that bipartisan policies
eventually emerge from the legislative process? Generally, some of these ques-
tions can be answered immediately after the votes are counted or shortly after
the newly elected officials take office. For others, the answers emerge over time.
Elections matter on another level, too. As the newly elected Trump admin-
istration began to take shape, much rhetoric focused on the future of significant
policy positions taken by the Obama administration as well as on the future of
Medicare and Medicaid. Obamacare was in the headlines as Republicans saw
their opportunity to finally repeal a law that had long been a thorn in their sides.
Before the Republican majority had even been sworn in, debate began to rage
about how to make the changes: repeal and replace Obamacare immediately,
repeal immediately and replace later, or repeal later after a replacement strategy
has been determined. Out of those discussions, held behind closed doors, one
Introduction 39
revelation emerged that seemed particularly telling. Moderate Republicans
expressed concerns about the plan to repeal Obamacare within a year of Donald
Trump’s inauguration as well as the plan to revise the long-standing Medicare
and Medicaid programs. Because of all the technicalities associated with repeal or
revision of these programs (e.g., changes in insurance), putting the changes into
play—that is, implementing the changes—would run up against the next election
cycle in 2018. Inevitable implementation problems might not bode well for the
majority party’s ability to maintain its current stranglehold on both Houses of
Congress (Ferris & Wong, 2016).
The most telling insight that this peek behind closed doors offers is the
realization (for better or worse) that policymakers are not necessarily focused
on how real people will be affected by changes to Obamacare or Medicare and
Medicaid but rather on how the changes will affect their own re-election chances.
While some may find this focus disturbing, it demonstrates not just that election
results do matter but also that even the threat of an upcoming election cycle affects
what policymakers are willing or able to do. Awareness can be used in developing
strategies for appealing to what really matters to policymakers. Being shrewd or
“politic” is the takeaway lesson here. Timing is everything.
This chapter offers insight into the subtle rules governing political partici-
pation and sets out the options available to nurses for finding their way through
the political maze. To navigate this environment successfully, the nurse must
first have a basic understanding of how laws are made and who the participants
in the lawmaking process are.
▸ Process, People, and Purse Strings
Process: How a Bill Really Becomes a Law
No one would presume to play a game of football without knowing the basic rules.
Likewise, even simple board games, such as checkers or Monopoly, have rules
that one must follow to have a chance of winning. Lawmaking is no different. In
many ways it is a game, admittedly with very high stakes, and there is a process
that determines what must happen for an idea, concept, or concern to become
part of the U.S. Code or state statutes.
Most students complete a government course in high school. Although
diagrams depicting how a bill becomes a law are important, they are also very
rudimentary. There is much more to the process than can be neatly depicted on a
chart. It is also important to realize that although the process may seem straight-
forward, it can be circumvented when the will of the party in control determines
it is expedient to do so. For example, recent use of executive orders by the U.S.
President and some governors is a non-legislative strategy that affects public policy
in limited but significant ways. Parliamentary procedure maneuvers, filibusters,
internal rule changes governing chamber proceedings, a lame-duck session,
changes to committee appointments, and Christmas tree bills are all tactics or
opportunities used to achieve one’s legislative goals expeditiously. Whether these
tactics engender good public policy has been the subject of much debate among
political scientists; however, regardless of the debate, nurses must be aware of these
options so that they do not become the unwitting victims of a clever strategic move.
40 Chapter 3 Government Response: Legislation
The Federal Process
Bills are ideas that a legislator has determined need to be enacted into law. These
ideas can come from many sources: the legislator’s own experiences; issues brought
forward by constituents, a special interest group, or a lobbyist on behalf of
their clients; and not infrequently as a result of tragic events that trigger a public
outcry for a new or amended law (e.g., school shootings that intensify the debate
over gun control). Once the concept is drafted into the proper legislative
language, it is introduced into the House of Representatives or Senate, depending
on the chamber to which the bill’s chief sponsor belongs. Each bill is numbered
sequentially, and it retains this number throughout the process.
Many bills are introduced during a legislative session, but few receive much
attention in the form of committee consideration. Fewer still actually become law.
Committee Consideration
Once introduced, a bill is referred to a standing committee for further consid-
eration. These standing committees are generally subject-matter focused, such
that bills related to health care go to a health committee, finance issues to a
banking committee, farm-related matters to an agriculture committee, and so
on. Standing committees at the federal level tend to be permanent; at the state
level, they can be configured differently over time depending on the vision of
the leadership of the party in power at the beginning of each new legislative
session. Subcommittees consider particular bills in greater detail. Bills are
amended (revised) or “marked up” (voted on after being revised) in committee
and subcommittee. Hearings offer affected parties (i.e., special-interest groups)
opportunities to state their positions. A bill that emerges from committee may
bear little resemblance to the original proposal, often because of the input re-
ceived at a hearing.
Committee hearings are important, but they often appear to be more chaotic
than productive, at least to the average observer. Much of the real business of
lawmaking occurs behind the scenes, but one must also participate in the defined
committee processes to earn a place at the more informal behind-the-scenes tables.
EXHIBIT 3-1 How to Find Legislation
Go to https://www.congress.gov
Select “Legislation” and search on a topic such as “health care”
Example: H.R. 315 is the 315th bill introduced in the 115th Congress.
H.R.315—115th Congress (2017–2018) To amend the Public Health Service
Act to distribute maternity care health professionals to health professional
shortage areas identified as in need of maternity care health services.
Sponsor: Rep. Burgess, Michael C. [R-TX-26] (Introduced 01/05/2017)
Cosponsors: (2)
Committees: House—Energy and Commerce
Latest Action: 01/05/2017 Referred to the House Committee on Energy and
Commerce. (All Actions)
Tracker: This bill has the status Introduced
Process, People, and Purse Strings 41
Committee chairs (appointed by the political party in the majority) are
extremely influential, particularly with respect to the subject areas that are the
focus of the committee’s work. Chairs determine which bills will be heard and
when, and they establish the procedural framework under which the committee
operates. The chair’s position on an issue can determine the fate of a bill from the
outset. Because of the extent of their power and influence, committee chairs are
able to raise large sums of money from special-interest groups to support their
re-election—and re-election is always an important consideration for lawmakers.
The House and Senate leaders (elected by their colleagues) determine who will be
named committee chairs. Certain committees are seen as more prestigious than
others, so being named the chair of one of those committees is very important to
an ambitious legislator. “Ranking members” are the appointed committee leaders
for the political party in the minority.
Not surprisingly, political considerations play a role in this entire process.
Being aware of the dynamics that are the foundation of the overall committee
process helps ensure more effective representation by those who want to influence
the outcome of the committee’s work.
Floor Action
If a bill is able to garner committee approval, it goes to the full chamber for a vote.
The timing for scheduling a vote, as well as various attempts to amend the bill or
delay the vote, are integral parts of the lawmaking process. Much maneuvering
occurs backstage, and the ability to influence these less public interactions is as
important as the words or concepts being debated. Again, people’s relationships
and politics determine the ultimate results. To be effective in one’s efforts to in-
fluence outcomes, one must be aware of these relationships and take them into
account. Once a bill is approved in either the House or Senate, legislators begin
the process again in the other chamber.
Conference Committee
Seldom does a bill complete the journey through the second chamber without
change, which means the originating chamber must agree to the new version of
the bill. Without agreement, a bill will be referred to a conference committee made
up of representatives from the House and Senate; they reconcile the differences
in the two bills and ask their respective chambers to support the conference
committee report. If agreement cannot be reached, the bill dies.
Chief Executive Signature
If the House and Senate reach agreement, the bill goes to the chief executive
(president or governor), who must sign the bill before it can become law. If the
chief executive vetoes the bill, it goes back to the legislature for a potential veto
override, which requires a two-thirds majority of both chambers.
All this must happen within a single legislative cycle—2 years (a biennium).
It is not surprising that it often takes several years for a particular legislative issue
to finally become law, especially when powerful interest groups are on opposite
sides of the proposal.
42 Chapter 3 Government Response: Legislation
State legislatures typically follow the bicameral (two-chamber) structure
of the federal government (TABLE 3-1). The exception is Nebraska, which has a
unicameral body.
The number of legislators may vary from state to state, as may the length of
the term in office for the senators. Some states (but not the federal government)
have adopted laws that limit the number of consecutive terms a legislator may
serve in any one chamber. These term limits were adopted to deal with legislators
who served multiple years in their respective chambers. Their re-election was
seldom challenged, and voters became convinced that policymaking would be
better served by changing their lawmakers on a more regular basis.
Not surprisingly, term limits have had unintended consequences, some of
which have changed the dynamics within the legislature and affected policy-
making in general. Relationship and leadership development, which takes time,
have been short-circuited. Ambitious lawmakers frequently seek leadership
positions without the time-in-office foundations in place needed to be effective
in these roles. Institutional memory has been lost with term limits, as has the
depth of understanding of the complexity of the issues legislators must address.
The interest in developing long-term solutions to challenging problems has been
replaced with a more incremental immediate approach that focuses on short-term
solutions rather than on the underlying cause of the problems. These realities
affect the strategies adopted by interest groups seeking a legislative solution to
their problem or concerns.
Although there may be subtle differences between the state and federal law-
making processes, the political dynamics that affect the ultimate outcome of any
policymaking initiative are quite similar regardless of the venue.
TABLE 3-1 Congressional Structure
Senate House of Representatives
100 members, 2 from each
state.
435 members based on a state’s population.
The number of representatives apportioned
to each state changes every 10 years after the
national census data are obtained. Drawing
and redrawing congressional district lines
is a very political process that each state
implements according to its own laws.
6-year terms, with one-third up
for re-election every 2 years,
and no limit on the number of
terms that can be served.
2-year terms, with no limit on the number of
terms that can be served.
The vice president is the
Senate leader, but a president
pro tempore is elected each
session by the majority party.
The majority party elects the Speaker of the
House.
Process, People, and Purse Strings 43
People: Players in the Game
One might believe that the only players in the lawmaking game are the elected
officials—that is, the senators and representatives representing their respective
states or districts. Although they are certainly integral to the process, many other
individuals are keys to successfully achieving one’s legislative goals. In sports and
other games, those who take game playing seriously spend time learning the
strengths and weaknesses of the people on the field or at the table with them. They
study game film and read scouting reports and use other resources to minimize
surprises and help define their own strategies. That same attention to detail should
apply to policymaking, but it is often sadly neglected.
Many people cannot identify their federal, state, or local elected officials.
Although many can name the president of the United States, few will be able to
say with assurance who represents them in the halls of Congress and fewer still
can name their state senators or representatives. Every nurse should know the
identity of his or her U.S. senators and congressional representative. It is equally
or more important, however, for nurses to also know their state representative
and senator because so much professional regulation occurs at the state level.
Technology has made it easy to learn the identity of lawmakers at every level
by simply going to federal or state government websites and entering ZIP code
data. These sites also provide brief biographical information, photos, and other
pertinent and helpful background material.
Why is this important? Politics is at heart a “people process.” As in other
people-centered endeavors, the relationships among and between people deter-
mine outcomes in the political process. To have even the most basic conversation
with elected officials, one must know who they are and what they care about.
Legislative Aides
In addition to knowing elected officials, one must make an effort to know staff
members—aides and others—who often control access to their bosses and
influence how various issues are perceived and prioritized. At the federal level,
every legislator determines how his or her office will be staffed—usually using a
chief of staff, legislative directors, press secretary, and legislative assistants/aides
(LAs) (TABLE 3-2). Federal lawmakers also maintain local or district offices with
a small staff presence at each site. On the state level, the number of aides can
vary, but as state legislatures have become more than part-time endeavors, the
use of aides has increased. Typically, state officials have at least one aide who is
usually a generalist, whereas the aides at the federal level are more issue focused.
Regardless of whether an aide is in Washington, D.C., or at any of the state-
houses across the country, elected officials rely on aides for the details and nuances
associated with specific legislative initiatives. Aides delve more deeply into the
issues and work closely with other aides in developing strategies and alternative
concepts that they then present to their legislators for consideration.
Although communicating with legislators is important, nurses should not
underestimate the importance of aides and other staff members, who may provide
the last word to a legislator regarding the issue or concern. Including aides and
other staff members in communications and making special efforts to respectfully
integrate them into the entire process is a tactic that is likely to yield positive results.
44 Chapter 3 Government Response: Legislation
Lobbyists
Although nurses may not know the identity of specific lobbyists, it is important
to understand which role lobbyists play in the policymaking process and how
their influence affects the game of politics. No bill becomes law without lobbyists’
input. Lobbying is the act of influencing—the art of persuading—a governmental
entity to achieve a specific legislative or regulatory outcome. Although anyone
can lobby, lobbyists are most often individuals who represent special-interest
groups and are looked to as the experts by lawmakers who need information and
a rationale for supporting or not supporting a particular issue.
The role of lobbyists has become even more critical as the complexity of
legislation has increased. For example, the 1914 law creating the Federal Trade
Commission was a total of 8 pages and the Social Security Act of 1935 totaled
28 pages, but the Financial Reform bill (conference version) of 2010 contained
2,319 pages (Brill, 2010). Legislators, who are often pressed for time and/or newly
elected to the legislature, rely on lobbyists’ expertise to help them understand
what they are voting for or against. When the 21st Century Cures Act became
TABLE 3-2 Federal Staffing Patterns
Staff Member Role
Chief of staff Senior staff person; answers directly to the member.
Administrative
assistant
Oversight responsibilities for staff.
Legislative directors Responsible for day-to-day legislative activities.
Press secretary Responsible for press releases and public relations.
Legislative assistants/
aides (LAs)
Responsible for specific legislative areas/issues—for
example, health, agriculture, or Social Security. LAs have
more than one area of responsibility. They provide staff
assistance to the member at committee hearings, write
policy briefs, and prepare the member’s statements and
witness questions. They may help draft bills by working
in concert with the legislative council.
Committee staff Support the work of congressional committees.
Separate staffs are allocated to the majority and minority
parties, with a larger number serving the majority party.
These individuals’ focus usually is narrower than that
of the legislator’s personal staff, and they usually are
older and more experienced. They plan the committee
agenda, coordinate schedules, gather and analyze data,
draft committee reports, and so on.
Process, People, and Purse Strings 45
law late in 2016, Senate disclosure records showed that more than 1,400 lobby-
ists worked on that legislation, which became a Christmas tree bill as the 114th
Congress raced toward adjournment. Ultimately, the act included a wide range of
provisions that addressed everything from Food and Drug Administration reform
to substance abuse and the related mental health crisis to hospital readmission
penalty revisions (Muchmore, 2016).
A brief review of one year of lobbyist activity (TABLE 3-3) provides insights
regarding the emphasis some healthcare-sector associations place on lobbying
to further or protect their own interests. Taking a longer-term view, from 1998
to 2016, the U.S. Chamber of Commerce spent $1,304,320,680 on its lobbying
efforts. During that same time frame, the American Medical Association (AMA)
spent $347,122,500 on lobbying, the American Hospital Association (AHA) spent
$311,163,263, and the Pharmaceutical Research & Manufacturers of America
(PHARMA) spent $305,515,300. The American Nurses Association (ANA), by
comparison, spent $18,583,260 over this period, significantly less than other
healthcare-related organizations (Center for Responsive Politics, 2016b).
Former lawmakers, their staff members, and executive agencies’ staff
members often become lobbyists after leaving public service. These so-called
revolving-door lobbyists have unparalleled access, connections, and insights that
serve their clients well. While ethics laws prohibit this kind of employment for
a period of time immediately after leaving public service, these individuals may
serve as consultants while waiting out their legally imposed hiatus. The number
of revolving-door lobbyists working for a particular organization can be indicative
of how much an organization values its lobbying efforts. In a world where these
numbers matter, the gap between nursing organizations’ spending and that of
other health-sector entities cannot be ignored.
On September 18, 1793, President George Washington laid the cornerstone for
the U.S. Capitol. While the shovel, trowel, and marble gavel used for the ceremony
are still displayed, repeated efforts to locate the cornerstone itself have been
unsuccessful.
At times, policymaking seems as shrouded in mystery as the location of the
Capitol’s cornerstone. That’s why you need an experienced partner (a.k.a. lobbyist)
to help you unravel the mystery.
—A pitch for Capitol Tax Partners, a lobbying firm
Purse Strings: “Show Me the Money”
Game playing comes with a price in both athletic venues and legislative arenas.
Not only are significant sums of money spent by special-interest groups in support
of their lobbying efforts, but money is also critical to election and re-election
campaigns. The role money plays in the policymaking process causes concern
and discomfort for many nurses and other healthcare professionals. It is where
the notion of “politics,” with all of its unfavorable connotations, is on full display,
and it is the reason many nurses (and others) consider political participation to
be something to avoid.
46 Chapter 3 Government Response: Legislation
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Process, People, and Purse Strings 47
The amount of money that flows to and through the legislative process has
raised serious questions as to whether the whole process is for sale to whoever
has the deepest pockets. Unfortunately, winning an election or re-election, even
at the local level, can be a very expensive proposition, costing millions of dol-
lars. In the 2016 election, campaigning for the average U.S. Congress House seat
cost $1 million, while campaigning for the average U.S. Senate seat cost tens of
millions of dollars. Pennsylvania had the most expensive U.S. Senate race, with
expenditures exceeding $46 million; the most expensive House seat race was
in District 08 in Maryland, where the costs exceeded $20 million (Center for
Responsive Politics, 2016a). The cost of getting elected means incumbents and
challengers must focus their efforts on raising money during three of every five
workdays (Zakaria, 2013, p. E8). The most likely sources from which to obtain
the needed dollars are wealthy individuals and special-interest groups that are
willing to invest in these decision makers. The return on the investment must
be beneficial—otherwise, the money invested in political campaigns would not
continue to increase.
In fact, this spending trend is likely to continue due to the U.S. Supreme
Court decision in Citizens United v. Federal Election Commission (2010), which
basically allows unlimited spending by corporations and unions during campaigns,
provided these efforts are not coordinated with an individual’s campaign. In its
Citizens United ruling, the Supreme Court struck down the 2002 federal campaign
finance law prohibiting unions and corporations from spending money directly
advocating for or against candidates. The First Amendment was the basis for the
Court’s decision. The League of Women Voters has voiced its support of legislation
that would require disclosure of the sources of such spending.
Not only has the amount of money flowing to campaigns increased dramati-
cally, but the source of those dollars (who has the deep pockets) also has changed
and is expected to change even more in the future. For the first time, the 2014
midterm elections saw more money going into campaigns but fewer people con-
tributing. Spending by outside groups constituted 14.9% of all spending, which
was an increase of almost 5% compared with 2010 (Center for Responsive Politics,
2016b). Although the number of 527 committees has increased, contributions
from these entities have varied over time (TABLE 3-4).
According to the Federal Elections Commission, as of November 28, 2016,
the healthcare sector had contributed $236,399,000 to campaigns during the
2016 election cycle, with approximately 60% of that total going to Republican
candidates. (The top overall sector was finance, insurance, and real estate,
which contributed $962,165,528 to candidates in the 2016 elections.) Physi-
cians and other healthcare professionals are traditionally the largest source
of federal campaign contributions within the healthcare sector; however,
comparing the dollars coming from physician-related entities as opposed
to nursing organizations reveals that the amount contributed by nursing is
significantly less than the amount given by physician groups (TABLE 3-5). The
only nursing organization listed among the top 20 healthcare-sector con-
tributors during the 2016 elections was the American Association of Nurse
Anesthetists, coming in at number 13. Other nursing organizations making
contributions included the American Nurses Association, the American Asso-
ciation of Nurse Practitioners, and the American College of Nurse‒Midwives
48 Chapter 3 Government Response: Legislation
TABLE 3-4 527 Committee Fund Raising and Expenditures, 2010,
2014, and 2016
Entity: 2016 Receipts/Expenditures
Democrat/liberal $31,645,812/26,647,731
Republican/conservative $13,651,784/15,104,108
Women’s issues $10,029,733/9,863,780
Health professionals $987,693/800,491
Hospitals and nursing homes $40,524/22,520
Entity: 2014 Receipts/Expenditures
Democrat/liberal $27,130,578/23,342,697
Republican/liberal $26,876,343/30,501,588
Women’s issues $17,368,505/17,157,633
Health professionals $1,475,284/1,546,829
Hospitals and nursing homes $57,424/43,961
Entity: 2010 Receipts/Expenditures
Democrat/liberal $24,151,559/26,806,934
Republican/conservative $67,679,617/64,666,600
Women’s issues $9,374,595/10,876,045
Health professionals $1,147,486/1,945,807
Hospitals and nursing homes Not reported
Data from Center for Responsive Politics. (2016b). Influence & lobbying. Retrieved from http://www.opensecrets.org
/influence
Process, People, and Purse Strings 49
(Center for Responsive Politics, 2016a). Nurses’ willingness to pay this price
remains an open question.
Although it may be distasteful, success in the halls of Congress and at state-
houses is integral to the advancement of nurses’ legislative agenda. That agenda
includes measures intended to advance the profession itself as well as efforts to
promote societal values that are committed to better patient outcomes. Nurses
want their issues advanced successfully, and that expectation comes with a price
tag that nurses must expect to pay.
▸ Playing the Game: Strategizing for Success
Continuing the game-playing analogy, why are some teams more successful than
others? If all the players know how to play the game, why are some consistent
winners and others are not? Why are the legislative agendas of some groups ad-
opted seemingly with minimal opposition, whereas others find it hard to get a
place at the policy table? In athletic contests, the skill of the players, the expertise
of the coaching staff, the financial investment of the team owners/supporters,
and team chemistry all contribute to success on the field. Those same factors also
determine success at the policymaking table.
Skill of the Players
Knowing the process and people, along with understanding how money affects
the policymaking dynamics, is a start, but it is not sufficient to ensure success. To
move to the next level, nurses and others must learn to think politically, to play
politics, and to strategize with the political consequences and realities always at
the forefront. In other words, they must apply their critical thinking skills in the
policymaking context.
TABLE 3-5 Political Contributions by Physician Groups, 2015–2016
Organization Amount Contributed
Cooperative of American Physicians $1,945,015
American Society of Anesthesiologists $1,926,150
American Medical Association $1, 878, 563
American Association of Orthopedic Surgeons $1,671, 575
Data from Center for Responsive Politics. (2016a). Health sector: PAC contributions to federal candidates. Retrieved from
http://www.opensecrets.org/pacs/sector.php?txt=H01&cycle=2016
50 Chapter 3 Government Response: Legislation
As political scientists have noted, politics underlies the process through which
groups of people make decisions. It is the basis for the authoritative allocation
of value. Simply put, politics is the effort and strategies used to shape a policy
choice in all group relationships.
When one “plays politics,” one is considered to be shrewd or prudent in
practical matters, tactful, and diplomatic; playing politics is also seen as being
contrived in a shrewd way, or being expedient. When one thinks like a politician,
it means he or she is looking beyond the issue itself and considering other forces
and factors that affect what is likely to work and what has no chance of success.
Deciding which of several policy options will lead to the greatest benefits and
the fewest costs, in a world where re-election is a key consideration and media
are a relentless presence, means the best solution may not be the path ultimately
chosen. The scenario in Case Study 3-1 provides an example of what thinking
politically might look like.
CASE STUDY 3-1: Workplace Safety
Emergency department (ED) nurses have expressed concern about workplace
safety, with many experiencing physical attacks on a routine basis. Many employers
have been reluctant to report assaults to law enforcement because of the bad
publicity it might engender. Nurses and others in psychiatric settings have similar
concerns, as do nurses working in home health.
Professional organizations representing these individuals, particularly ED
nurses, formed a coalition to strategize about how to protect their members.
Before the coalition had finished its work, the issue came to a head when
an agitated family member assaulted a nurse, resulting in severe injuries to
the nurse. Local media picked up the story, and a state legislator, who was a
member of the minority party and facing a difficult re-election, was surprised
to learn that although teachers and law enforcement officials are part of a
“protected class,” attacking healthcare workers was a misdemeanor rather
than a felony offense. For protected workers, the same assault carries the
more stringent criminal designation that includes possible incarceration. The
legislator decided to take on this issue, in part because he thought it might
help his re-election efforts and because nurse organizations had supported his
candidacy in the past.
Which factors must the politically savvy nurse consider if this issue is to move
successfully from concept to legislation to law?
Clearly, success at the policy table involves more than the language of the
proposal itself. Timing and the general political climate are key, unity is important,
and quid pro quo is the reality in the statehouse halls. Politically savvy nurses
must be willing to take risks but should be smart when doing so (EXHIBIT 3-2).
In other words, they should enter the policy arena fully prepared for the chal-
lenges they will face.
Playing the Game: Strategizing for Success 51
▸ Thinking Like a Policymaker
Coaching Staff: Mentoring and Support
Given all the subtle factors that affect success on Capitol Hill or in state legisla-
tures and the role money plays in the process, how can an individual hope to have
sufficient knowledge or time to make a difference in the policymaking aspects of
the profession? How can that nurse ever play the game effectively? Fortunately, the
American Nurses Association (ANA) and its state constituent associations, as well
as specialty nursing groups, can provide their members with the tools they need
to be successful. The success of these organizations’ efforts in the legislative arena
depends in large part on their members’ involvement with and understanding of
the importance of an effective legislative presence on behalf of the profession in
Washington, D.C., and in statehouses across the country. Many of these organi-
zations offer opportunities for their members to come to Washington or to state
capitals for lobbying days, which include briefings on both the issues and the ways
to be effective spokespersons for the profession. These organizations know that it is
the individual nurse—the so-called grassroots lobbyist—who has the most impact
on the decisions made by elected officials. In fact, grassroots lobbying is seen by
some as the most effective of all lobbying efforts (deVries & Vanderbilt, 1992).
Grassroots lobbyists are constituents who have the power to elect officials
through their vote. When constituents have expertise and knowledge about a partic-
ular issue (such as nurses in healthcare policymaking), they are especially valuable
resources for their elected officials. Although issues debated in Washington, D.C.,
are national in scope, members of Congress are still concerned about how those
issues are perceived back home. The connections established by a nurse constit-
uent with his or her lawmakers at the federal, state, and local levels may provide
timely access and a listening ear at key points during the policymaking process.
Some professional organizations have established liaison or key-person pro-
grams that match members with their elected officials, train them to be effective
in the grassroots lobbying role, and provide periodic updates and information
to help the nurses communicate in a timely manner with relevant messages
targeted to the specific official. In turn, grassroots lobbyists establish ongoing
connections with their elected officials that transcend specific legislative initiatives
EXHIBIT 3-2 Political Astuteness
■ Issues always have at least two sides, and maybe more, that are reasonable
depending upon one’s point of view and experiences.
■ Listen to what people are saying with an analytical ear. Critical thinking is not
just for the practice setting. Apply theories and concepts about policymaking
to the issues being considered. Use therapeutic communication techniques.
■ Utilize a variety of sources; do not just rely on those that are consistent with
your own ideology. Most sources have a bias, so broaden your reading and
listening to get a more complete perspective and perhaps move a bit closer to
the truth. Always consider the source of the information provided.
■ Connect with others who are involved in the policymaking side of the
profession. Share what you learn with colleagues.
52 Chapter 3 Government Response: Legislation
and communicate regularly with the sponsoring nursing organizations regarding
what they learn through their interactions.
Coaching and mentoring nurses who are willing to engage in these kinds of sup-
ported liaison relationships will benefit both the individual nurse and the organizations
doing the coaching. The nurse can markedly increase a legislator’s understanding
of nursing and the role nurses play in health care. With increased understanding,
the legislator is more apt to be supportive of the profession’s legislative agenda.
Investment: Time and Money
A vision without resources is an hallucination.
—Thomas Friedman
How much are nurses willing to pay in both time and money to support the
political activities of professional organizations? Are there sufficient human and
financial resources available to make the vision of success a reality, or is it destined
to be a hallucination? What does that payment look like?
Far too few nurses—only approximately 6% of all nurses (Haylock, 2014,
p. 613)—pay the membership fees needed to support the activities of nursing
organizations, including maintaining an effective presence at statehouses or on
Capitol Hill. Many of these organizations must rely primarily on busy volunteers
to do the essential work of tracking legislative action or regulatory proposals in
a timely manner. They cannot afford paid staff, even on a part-time basis. As a
consequence, the everyday work of developing key relationships and being seen
as a nursing expert cannot or does not happen. If more nurses were to become
members of professional nursing organizations, the necessary resources would
significantly increase, as would nursing’s overall influence at the policy table.
Although the convergence of politics and money is not always pretty, ignoring
the importance of financial contributions in moving a legislative agenda forward
is naïve at best. Refusing to address this factor will ultimately undermine efforts
to advance the positive aspects of the nursing profession’s agenda.
Some nurse organizations have established political action committees
(PACs) that enable them to make contributions to political candidates and office
holders who are supportive of nurses’ legislative agenda. The money comes from
the organization’s members, so it again relies on the small number of nurses who
belong to one of these organizations The amount of money raised for PAC pur-
poses by nursing organizations pales in comparison to the amounts that other
healthcare sector entities are able to contribute.
In addition to political contributions, special-interest groups may improve
their chances for successful policymaking by endorsing candidates who are run-
ning for elective office. Candidates who want to demonstrate their appeal to the
overall electorate prize these endorsements; this is particularly true for endorse-
ments issued by nursing organizations such as ANA on the federal level and state
constituent associations of ANA on the state level. This level of political activity
occurs through the associations’ PACs and must adhere to requirements set out
in federal and state election laws. The endorsement process requires significant
membership involvement, which is difficult for small nursing organizations to
mount successfully.
Both money and human resources are critical when considering the level
of investment by the members of the nursing profession. Nurses account for the
Thinking Like a Policymaker 53
largest segment of the healthcare workforce, but far too few invest in their pro-
fession through membership in professional organizations. These low numbers
significantly affect the amount of tangible and intangible resources available to
associations for their work in the political arena. The strength of nurses lies in
their numbers, and that strength is enhanced when nurses support the work of
their professional associations through their dues and volunteerism.
Team Chemistry: Getting Along With One Another
Even with skilled players, strong support systems, and sufficient resources, a team
will not succeed without an often elusive quality: team chemistry. Divisiveness
has long plagued the nursing profession, and it remains an issue today. Disunity
within the profession is a certain road to defeat and fuels the opposition’s fire.
Opponents are well aware of the potential impact that a united nursing profes-
sion could have on health policy decisions and other important issues. Nurses’
numbers alone are formidable. For that reason, competing interests subtly and
purposefully poke at the hot spots that typically divide nurses (e.g., educational
preparation, union versus non-union debates). Nurses’ tendency to align them-
selves within specialty practice groups and to lobby or get involved only when an
issue directly relevant to that particular group is being considered is encouraged
without consideration of a broader perspective. Political astuteness would dictate
that nurses recognize when they are being kept off balance by subversive divisive
messages encouraged by those who benefit from nursing’s disunity and ignore
the discordant rhetoric. Further, all nurses should have a basic understanding or
awareness of the legislative initiatives of specialty groups. They should actively
support the initiatives of their colleagues or, at a minimum, refrain from opposing
the cause publicly. Concerns should be shared privately and diligent efforts made
to find a compromise position outside of the public eye.
▸ Conclusion
Nurses with an understanding of how the policymaking process works can
contribute to the political work of the organizations to which they belong and
ultimately benefit the patients for whom they care. Such contributions are consis-
tent with the obligations set forth in the profession’s social policy statement and
its code of ethics. Nursing’s Social Policy Statement notes the connection between
policymaking and the delivery of health care and the effect on the well-being of
society. “Individual and inter-professional involvement is essential” (ANA, 2010,
p. 7). An essential feature of professional nursing is to “influence social and pub-
lic policy to promote social justice” (p. 9). The Code of Ethics for Nurses (ANA,
2015) repeatedly emphasizes the role nurses play in promoting, advocating, and
striving to protect the health, safety, and rights of the patient, which extends to
statehouses, boardrooms, and other arenas in which this advocacy can affect
public policy. Moreover, the Future of Nursing report issued by the Institute of
Medicine in 2010 states that “nurses should be full partners with physicians and
other healthcare professionals, in redesigning health care in the United States”
(p. S-3). This role will be played out, in part, in the health policy context, where
nurses should participate in, and sometimes lead, decision making and be engaged
54 Chapter 3 Government Response: Legislation
in healthcare reform–related implementation efforts. To be ready to assume this
responsibility, nurse education programs should include course content address-
ing leadership-related competencies for all nurses. These competencies include
a firm grounding in politics and policymaking processes.
There is no substitute for visibility in the legislative arena. Showing up is
what political activism is all about. “If you are not at the table, you are on the
menu” is a sentiment frequently echoed in many policymaking venues. For too
long, nurses have been on the menu rather than active participants in shaping
public policy around health care. Simply watching the game and complaining
about policy decisions will not change outcomes. Nurses must become convinced
that they do have something valuable to contribute, that they have the ability
and the time to do it, and that advocacy in the policy arena is not an option but
a non-negotiable professional responsibility.
▸ Discussion Points
1. Watch the HBO movie Iron Jawed Angels. Which political considerations
were at play in efforts to win voting rights for women?
a. To what extent have Americans today become complacent with respect
to the importance of voting?
b. Describe the similarity of the fight waged by suffragettes and the one
nurses have waged to gain recognition of advanced practice.
c. Discuss with colleagues how complacency imperils future professional
advances for nursing.
2. Respond to the following statement in the context of the Patient Protection
and Affordable Care Act (ACA), taking into consideration the results of
the 2016 election and its immediate aftermath as the Republican majority
jockeyed to enhance its power and promote its philosophical beliefs.
The suppliers of legislative benefits are legislators, and their pri-
mary goal is to be re-elected. Thus, legislators need to maximize
their chances for re-election, which requires political support.
Legislators are assumed to be rational and to make cost–benefit
calculations when faced with demands for legislation. However,
the legislator’s cost–benefit calculations are not the cost–benefits
to society of enacting particular legislation. Instead, the benefits
are the additional political support the legislator would receive
from supporting legislation and the lost political support they
would incur as a result of their action. When the benefit to leg-
islators (positive political support) exceeds their costs (negative
political support) they will support the legislation. (Feldstein,
2006, p. 10)
a. Consider how the cost–benefit analysis depicted in the statement
affected efforts to repeal/replace the ACA.
b. Discuss how the cost–benefit analysis depicted in the statement did
or did not affect decisions made by states about whether to expand
Medicaid eligibility as allowed by the ACA but put in jeopardy by
55Discussion Points
Republican control of both the legislative and the executive branches
of the federal government.
c. Discuss how the cost–benefit analysis depicted in the statement did
or did not affect decisions made by Congress to maintain or modify
the Medicare and Medicaid programs.
3. The mission of state boards of nursing is the protection of the public by
the regulation of nursing practice.
a. Compare the regulations in your state with those of at least one other
state to determine the extent that APRNs have legal authorization
to practice within the full scope of their education and experience.
b. Develop a proposal to change at least one regulation in your state’s
nurse practice act. Which tactics would you use to persuade board
members that your plan will positively affect nurses and the public?
c. Identify groups that might oppose your proposal and create responses
that defend your position.
4. Create a worksheet that requires use of the state and federal government
websites to identify one’s own elected officials, party affiliation, commit-
tee appointments, and other relevant background information. Use this
worksheet to plan your involvement in the political arena.
References
American Nurses Association (ANA). (2010). Nursing’s social policy statement. Washington,
DC: Author.
American Nurses Association (ANA). (2015). Code of ethics for nurses. Washington, DC: Author.
Brill, S. (2010). On sale: Your government. Time, 176(2), 28–33.
Center for Responsive Politics. (2016a). Health sector: PAC contributions to federal candidates.
Retrieved from http://www.opensecrets.org/pacs/sector.php?txt=H01&cycle=2016
Center for Responsive Politics. (2016b). Influence & lobbying. Retrieved from http://www
.opensecrets.org/influence
Chaffee, M. (2014). Science, policy, and politics. In D. Mason, J. Leavitt, & M. Chaffee (Eds.),
Policy and politics in nursing and health care (6th ed., pp. 307–315). St. Louis, MO: Elsevier
Saunders.
Citizens United v. Federal Elections Commission. (2010). 130 S. Ct. 876.
deVries, C. M., & Vanderbilt, M. (1992). The grassroots lobbying handbook. Washington, DC:
American Nurses Association.
Feldstein, P. (2006). The politics of health legislation: An economic perspective (3rd ed., pp. 27–84).
Chicago, IL: Health Administration Press.
Ferris, S., & Wong, S. (2016, December 2). Republicans raise red flags about speedy Obamacare
repeal. Retrieved from http://www.thehill.com./policy/healthcare/308490-republicans-raise
-red-flags-about-speedy-obamacare-repeal
Goldman, J. (2000). Webster’s new world dictionary. Cleveland, OH: Wiley.
Haylock, P. (2014). Professional nursing associations: Meeting the needs of nurses and the profession.
In D. Mason, J. Leavitt, & M. Chaffee (Eds.), Policy and politics in nursing and health care
(6th ed., pp. 609–617). St. Louis, MO: Elsevier Saunders.
Institute of Medicine. (2010). Future of nursing report: Leading change, advancing health.
Washington, DC: National Academies Press.
Muchmore, S. (2016, December 5). Add-ons ensure Cures Act easy lame-duck passage. Modern
Healthcare, 46(49), 10.
Nurses on Boards Coalition. (2016). Improving the health of communities and the nation.
Retrieved from http://nursesonboardscoalition.org/
Zakaria, F. (2013, August 4). Washington is failing everyone except lobbyists. Columbus
Dispatch, p. E8.
56 Chapter 3 Government Response: Legislation
© Visions of America/Joe Sohm/Photodisc/Getty
KEY TERMS
Administrative procedures act (APA): A state or federal law that establishes
rule-making procedures for its respective agencies.
Board of nursing (BON): An executive-branch state government administrative
agency charged with the power and duty to enforce laws and regulations
governing the practice of nursing in the interest of public protection.
Certification: A form of voluntary credentialing that denotes validation of
competency in a specialty area, with permission to use a title.
Licensure: A form of credentialing whereby permission is granted by a legal
authority to perform an act that would, without such permission, be illegal, a
trespass, a tort, or otherwise not allowable.
Multistate regulation: A provision that allows a professional to practice in more
than one state based on a single license.
National Council of State Boards of Nursing (NCSBN): A not-for-profit,
nongovernmental organization that provides a means by which state boards
of nursing may discuss and act on matters of common interest, including
development of licensing examinations.
PICOT: An acronym that serves as a format or template to identify elements of
or ask a health policy question. The letters stand for Population, Intervention,
Comparison, Outcomes, Time.
Public rule hearings: Meetings held by state or federal administrative agencies
for the purpose of receiving testimony from witnesses who support or oppose
regulations or to receive expert testimony.
Practice act: A law that regulates and defines legal responsibilities of the nurse
and scope of practice. It is intended to protect the public from harm as a result
of unsafe or unqualified nurses.
Government Response:
Regulation
Jacqueline M. Loversidge
57
CHAPTER 4
Recognition: A form of credentialing that denotes a government authority has
ratified or confirmed an individual’s credentials.
Registration: A form of credentialing that denotes enrolling or recording the
name of a qualified individual on an official agency or government roster.
Regulations (rules): Orders or directives that provide details or procedures
to operationalize a federal or state law (statute). A law directs an agency or
government to develop and implement regulations/rules to achieve the
purpose(s) of that law. Rules have the force and effect of law.
▸ Introduction
Regulation of the U.S. healthcare delivery system and of healthcare providers
exists to protect the interests of public safety, but regulatory structures are ex-
traordinarily complex. The vastness of the industry, the manner of healthcare
financing, and the proliferation of laws and regulations that govern practice and
reimbursement contribute to that complexity.
This chapter focuses on major concepts associated with the regulation of
healthcare professionals. Understanding licensure and credentialing processes
and their impact on nursing is essential. Understanding how regulations affect the
healthcare system and individual providers empowers nurses and other providers
to advocate on behalf of the profession and consumers.
All healthcare professionals are licensed by state government agencies.
Practice-specific boards or commissions (e.g., the Ohio Board of Nursing) or
multiprofessional boards (e.g., Michigan’s Department of Licensing and Regulatory
Affairs) are executive-branch regulatory agencies that govern each profession
with the goal of protecting the public. State practice-specific board processes
are similar from state to state but vary to some extent because their laws are
determined by individual state legislatures, and their regulations are determined
by the specific agency.
▸ Regulation Versus Legislation
The legislative and regulatory processes operate in parallel. Both are public
processes and equally powerful; however, their processes differ in important
ways. Legislation is shaped by elected lawmakers—for example, state legislators
or members of the U.S. Congress. Laws are written in general terms to assure
applicability over time and to establish public policy. Regulations emerge from
the law’s rule-making authority and shape details of implementation.
The legislative process is the first step in this two-layer process. Lawmakers
introduce bills and shepherd them through the complex legislative process. The
process begins when one or more (usually not more than two) legislators from
the same house sponsor introduction of a bill during a legislative or congres-
sional session. Bills may address issues of interest to the sponsoring legislator
or of concern to the sponsor’s constituents. Bills can be amended, substituted,
or “die” at any number of points during the session. Checks and balances are
built into the process; bills must be scrutinized by both houses and successfully
58 Chapter 4 Government Response: Regulation
navigate through committees during which testimony is heard. If they are passed
by both houses and signed by the president or governor, they are enacted (“en-
rolled”) and become law. Bills must pass during the session in which they are
introduced; otherwise, they “die,” with the docket for that congressional session
or state general assembly being cleared, and the bill must be reintroduced in a
subsequent session.
The terms legislation, act, law, and statute are synonyms. Legislation also
refers to both a bill-in-progress and a law that has been enacted. When referring
to laws regulating professions, the term practice act is used.
Once signed into law, statute implementation is generally the responsibility
of an administrative agency. Administrative agencies execute their responsibilities
by enforcing both law and regulations. Regulations (rules) enable reasonable
implementation of the law. Note the terms regulation and rule are also used
interchangeably. Whereas law is written in broad language, regulations are
detailed and specify how the law will be put into practice. An administrative
agency’s authority to write and implement regulations is established in the laws
that create the agency.
Example: Nurse practice acts (NPAs) generally require the board of
nursing (BON) to write rules with criteria that applicants must meet
to be eligible to sit for licensure examinations and for issuing licenses.
Rules amplifying that provision of law include specific eligibility criteria
and application procedures, designate approved examinations (e.g.,
NCLEX for registered nurses [RNs] and licensed practical nurses [LPNs]
or national certifying examinations for APRNs), and include renewal
procedures and fees.
The regulatory and legislative processes differ in other ways. Rule making
is not dependent on legislative session schedules, so rules may be promulgated
(written) at any time by an administrative agency. Also, regulations adhere to
administrative procedures act (APA) requirements; some states require eval-
uation and revision of regulations on a predictable schedule to assure regulations
reflect the current environment.
Like lawmaking, regulation promulgation is a public process and is described
in greater detail later in this chapter. The rule-making process, like lawmaking,
also includes structures to assure checks and balances. For example, a nonbiased
government body, such as Ohio’s legislative Joint Committee on Agency Rule
Review (JCARR), may be charged with oversight; it reviews all administrative
regulations to assure that (1) the filing administrative agency does not exceed
its statutory authority and (2) proposed regulations do not encroach on other
laws or regulations.
If an administrative agency finds its regulations are inadequate to serve the
needs of the public, and if the law does not support the additional rule-making
authority it needs, it may seek statutory modification to add a section in the law
that allows additional rule-making authority. To do so requires the agency to seek
law change through the full legislative process. For nursing, this may include what
is known as opening the nurse practice act.
Both laws and regulations have the same force and effect of law. Therefore, even
though regulations are written by a government agency rather than a legislative
Regulation Versus Legislation 59
body, regulations carry great weight because their origin stems from the law that
provided the agency with its rule-making authority.
From here forward, the term law will be used instead of legislation, but reg-
ulation and rule will be used interchangeably. There are uses for which the term
rule is preferable (e.g., rule-making authority).
▸ Health Professions Regulation and Licensing
Definitions and Purpose of Regulation
Regulation, as defined in Black’s Law Dictionary, means “control over something
by rule or restriction” (Garner, 2014, p. 1475). Health professions regulation is
needed as a mechanism to protect the interests of public safety. There is extraor-
dinary diversity and variability in health professions education programs—and,
therefore, in licensure and other forms of credentialing. Laypersons cannot judge
the competency of a health professional or determine whether that professional’s
practice meets acceptable and prevailing standards. For these reasons, because
of the potential risk for harm and because of the intimate nature of nursing and
health care, states protect the public by establishing laws to regulate the profession
(Russell, 2012). Health professions regulation seeks to safeguard the public by
acting as gatekeeper for entry into the health professions and by providing for
ongoing maintenance of acceptable standards of practice for those professions.
Practice acts, and the rules promulgated from those practice acts, constitute
government regulatory oversight of professions.
Practice acts vary by state, but most include the same basic elements
(Russell, 2012):
■ Creation of a agency/board that serves as the decision-making body
■ Definitions, standards, and scopes of practice
■ Scope of the board’s power and authority and its composition
■ Standards for educational programs
■ Types of titles, licensure, and certification
■ Title protection
■ Licensure requirements
■ Grounds for disciplinary action, including due process (remedies) for the
licensee charged with violation of the practice act or regulations
Requirements for mandatory continuing education and/or competency
requirements for licensure and relicensure are also found in practice acts.
The board’s rule-making authority is specified in the practice act as one
of its “powers and duties.” This rule-making authority generally includes cate-
gories such as initial licensing requirements, standards of practice, delegation
standards, requirements for prelicensure registered nurse (RN) and licensed
practical nurse/licensed vocational nurse (LPN/LVN) educational programs,
advanced practice registered nurse (APRN) standards and requirements for
practice and prescribing, disciplinary procedures, and standards for continuing
education or competence.
It cannot be presumed that silence of the law on an issue implies legislative
intent for the BON to write a rule. When there is no prior statutory authority
60 Chapter 4 Government Response: Regulation
to address an issue, the legislative process must be initiated to allow the agency
authority to promulgate new, specific regulations.
Example: An APRN with prescribing authority petitions the BON to
clarify whether prescriptive authority for Schedule II controlled substances
is within the scope of practice for the APRN. The board’s staff refers the
APRN to a provision in the statute that allows the APRN to “prescribe drugs
and therapeutic devices” as long as the APRN practices in collaboration
with a physician and in a way consistent with the nurse’s education and
certification. The staff concludes that the phrase “prescribe drugs and
therapeutic devices” may include Schedule II controlled substances if
permitted in the APRN‒physician collaboration agreement. No specific
language is found in the law that authorizes the prescribing of Schedule
II controlled substances, but neither is it specifically prohibited.
The medical board, which monitors BON opinions regarding poten-
tially overlapping areas of practice, reads the BON’s opinion and requests
a state attorney general’s opinion. The attorney general concludes that
the BON may not extend the scope of practice of the APRN through
either opinion or regulation. The expressed will of the legislature must
be sought using the legislative process.
Subsequently, the BON seeks a legislative sponsor to introduce a
bill permitting APRNs to specifically prescribe Schedule II controlled
substances.
Not all state boards of nursing are granted statutory authority to express
formal opinions; some must rely on the specific language in the practice act and
regulations, the official opinions of an attorney general’s office, or court decisions.
History of Health Professions Regulation
Physicians were the first healthcare professionals to gain legislative recognition
for their practice. Most states had physician licensing laws in place by the early
1900s. Nursing soon followed suit. North Carolina was the first state to establish
a regulatory board for nurses in 1903, and by the 1930s, state licensing had been
enacted in 40 states (Hartigan, 2011). Physician scopes of practice are broad; they
are unlimited in many states. Historically, this has been problematic for nursing
and other nonphysician healthcare providers seeking to define their unique scope,
particularly in areas that may overlap with physicians’ services. The history of
nursing regulation has been characterized by efforts to accommodate this medical
preemption (Safriet, 1992).
Early nursing regulation was permissive (voluntary). Systems were developed
that allowed nurses to register with a governing board—hence the title “registered
nurse.” In some states, nurses were registered by the medical board before sepa-
rate boards of nursing were established. Registration is a minimally restrictive
form of state regulation and does not usually require entrance qualification (e.g.,
examination). Between the 1930s and 1950s, states enacted mandatory licensure
laws (NPAs) requiring practicing nurses to obtain licensure with the state regula-
tory agency. These early NPAs defined nursing as a dependent practice focused
on physician order implementation. The American Nurses Association model
Health Professions Regulation and Licensing 61
definition, published in 1955, laid the groundwork for NPAs to define indepen-
dent functions for nurses, although the model reaffirmed prohibitions against
medical diagnosis and prescribing (Hartigan, 2011).
Over time, BONs began establishing licensure criteria and administering
licensure examinations. The early licensure examinations were BON-constructed
paper-and-pencil examinations, performance examinations, or a combination.
During that time, BONs also independently established examination passing
standards. Statutory authority to regulate schools of nursing and establish require-
ments for school structure, faculty, and curricula were added to NPAs. Because
interstate mobility was becoming more common, states developed reciprocity
agreements with other states. The National Council of State Boards of Nursing
(NCSBN) Nurse Licensure Compact has since replaced reciprocity. Not all states
participate in the compact, and this complex process should not be confused with
the obsolete two-state reciprocal arrangements (Hartigan, 2011; NCSBN, 2014b).
By the 1940s, the need for a standardized licensure exam had become ap-
parent. In 1944, the State Board Test Pool Examination (SBTPE) was established
by the National League for Nursing (NLN). The SBTPE assured standardization
and relieved state BONs of the burdens associated with writing and grading the
examination. Over the years, questions about potential for conflict of interest were
raised. Although individual BONs set their own passing standards, authority for
the creation and control of the examination had been absorbed by a professional
association (the NLN). This relationship set up conflicts between governmental
regulation and professional self-regulation, which should be separate and inde-
pendent. Concurrently, BON leaders created a forum in which they could meet
and discuss matters of common interest, although that forum was structured as
a council of the American Nurses Association (ANA). This created additional
conflict between BONs’ prescribed governmental duty to establish licensure
standards and professional associations’ rights and responsibilities to remain
independent of governmental influence.
In 1978, the NCSBN was formed, with the assistance of a Kellogg Foundation
grant, to address these issues. NCSBN is autonomous and represents the states’
interests rather than those of professional nursing organizations (Hartigan, 2011).
History of Advanced Practice Registered Nurse Regulation
In the 1960s, the birth of two federal entitlement programs, Medicare and Med-
icaid, increased the number of individuals with access to government-subsidized
health care. At the same time, a shortage of primary care physicians was predicted,
particularly in rural areas. A window of opportunity opened, and the first formal
nurse practitioner (NP) programs were begun, with the goal to increase access to
primary care in the rural areas where physicians were unlikely to locate.
In 1971, Idaho became the first state to legally recognize diagnosis and
treatment as part of the scope of nurse practitioners. APRN (nurse practitioner)
regulation in Idaho was accomplished through a joint agreement between the state
boards of nursing and medicine. The Idaho model set a precedent for other states
to include some form of joint nursing and medical board oversight for APRN
regulation. The joint regulation model compensated for the broad definitions of
medical practice but was a compromise because advanced practice nursing was
still considered to constitute “delegated medical practice,” requiring some medical
62 Chapter 4 Government Response: Regulation
board oversight (Safriet, 1992). The struggle to define APRNs’ scope of practice
and determine the necessity of medical board oversight continues in some states.
Both the ANA and the NCSBN have proposed model rules and regulations for
the governing of advanced practice nursing. The actual practice acts are inevitably
a product of individual states’ political forces, so titles, definitions, criteria for
entrance into practice, scopes of practice, reimbursement policies, and models
of regulation are state specific. Since 1988, The Nurse Practitioner has published
a map and summary of annual survey data from each state’s BON and nursing
organizations relative to the legislative status of advanced practice nursing. Signif-
icant advances have been made in many states, particularly regarding independent
APRN practice without direct physician supervision. In 2017, 15 states/jurisdictions
report that NPs are regulated solely by a BON and have both independent scope
of practice and prescriptive authority without physician supervision, delegation,
consultation, or collaboration. In 10 states, NPs are regulated by a BON, have full
autonomous practice and prescriptive authority, but additionally must complete
a postlicensure/certification supervision period or engage in a collaboration or
mentorship. In the remaining states, NPs are regulated either solely by a BON or
in combination with BON oversight (Phillips, 2017).
Methods of Professional Credentialing
Various methods are used to credential health professionals. The method accepted
in a particular state is determined by the state government and based on at least
two variables: (1) the potential for public harm if safe and acceptable standards of
practice are not met and (2) the profession’s degree of autonomy and accountability
for decision making. Historically, government agencies have been encouraged to
select the least restrictive form of regulation to achieve public protection (Pew
Health Professions Commission, 1994).
Today, four methods are used in the United State for credentialing and regu-
lation of individual providers. These are described next, beginning with the most
restrictive method and progressing to the least restrictive method.
Licensure
A license is “a privilege granted by a state. . . the recipient of the privilege then being
authorized to do some act. . . that would otherwise be impermissible” (Garner,
2014, p. 1059). Licensure is the most restrictive method of credentialing. Anyone
who practices within the defined scope must obtain the legal authority to do so
from the appropriate administrative state agency. Licensure serves as a barrier to
those who are unqualified to perform within a specific scope of practice. Licensure
also protects the monetary interests of those who are licensed to perform certain
acts by limiting economic competition with unlicensed individuals.
Licensure implies competency assessment at the point of entry into the pro-
fession. Applicants for licensure must pass an initial licensing examination, then
comply with continuing education requirements or undergo competency assess-
ment by the regulatory body that provides oversight for that profession. Because
competency is unique to the individual professional and specialty, it is difficult
to measure; most licensing agencies require mandatory continuing education in
lieu of continued competency assessment for license renewal. Licensure offers
Health Professions Regulation and Licensing 63
the public the greatest level of protection by restricting use of a specific title and
a scope of practice to professionals who meet these rigorous criteria and hold a
current valid license. Unlicensed persons cannot identify themselves by the title
identified in law (e.g., medical assistants cannot hold themselves out as nurses),
and they cannot lawfully perform any portion of the scope of practice, unless
their own practice act allows them to provide such services because of overlap.
Licensees are held accountable to practice according to provisions in law and
rule and to adhere to legal, ethical, and professional standards. A licensee holds
greater public responsibility than an unlicensed citizen. Therefore, disciplinary
action may be taken against licensees who have violated law or rule. Notably,
a revocable license means that the legal authority (e.g., a BON) may divest the
licensee of the license if it is deemed that the license holder has violated law or
regulations and that it is in the best interest of the public. Health professions are
largely regulated by licensure because of the high risk of potential for harm to the
public if unqualified or unsafe practitioners are permitted to practice.
Registration
Registration is the “act of recording or enrolling” (Garner, 2014, p. 1474). Regis-
tration provides for a review of credentials to determine compliance with criteria
for entry into a profession and permits the individual to use the title “registered.”
Registration provides title protection but does not preclude individuals who are
not registered from practicing within the scope of practice, so long as they do
not use the title “registered” or misrepresent their status.
Registration does not necessarily imply that prior competency assessment has
been conducted. Some state laws may have provisions for removing incompetent or
unethical providers from the registry or for “marking” the registry when a complaint
is lodged against a provider. However, removing the person from the registry does
not assure public protection, because the individual may practice without use of
the title. An exemplar is the states’ Nurse Aide Registry, which tracks individuals
who have met criteria to be certified for employment in long-term care settings;
this registry was required by the Omnibus Budget Reconciliation Act of 1987.
Certification
A certificate is “an official document stating that a specified standard has been
satisfied” (Garner, 2014, p. 275). In nursing, certification usually refers to the
voluntary process requiring completion of a specialty-focused education pro-
gram, competency assessment, and practice hours. This type of certification in
nursing is granted by proprietary professional nursing organizations and attests
that the individual has achieved a level of competence in nursing practice beyond
entry-level licensure.
Certification awarded by proprietary organizations does not have the force and
effect of law. However, the term certification may also be used by state government
agencies as a regulated credential; states may offer a “certificate of authority” or
an otherwise-titled certificate to practice within a prescribed scope of practice.
In this case, certification is required by law for practice in the specific role. For
example, an APRN may need to hold a certificate as a nurse practitioner from a
proprietary organization to qualify for a certificate of authority from a state BON
64 Chapter 4 Government Response: Regulation
to practice as an NP in that state. Most states have enacted regulations requiring
nationally recognized specialty nursing certification for an APRN to be eligible
to practice in the advanced role.
Astute consumers may ask whether a provider is certified as a means of
assessing competency to practice. Employers also use certification as a means
of determining eligibility for certain positions or as a requirement for internal
promotion.
Recognition
Recognition is “confirmation that an act done by another person was authorized. . .
the formal admission that a person, entity, or thing has a particular status” (Gar-
ner, 2014, p. 1463). Official recognition is used by several boards of nursing as a
method of regulating APRNs and implies the board has validated and accepted
the APRN’s credentials for the specialty area of practice. Criteria for recognition
are defined in the practice act and may include requirements for certification.
Professional Self-Regulation
Self-regulation occurs within a profession when its members establish standards,
values, ethical frameworks, and safe practice guidelines exceeding the minimum
standards defined by law. This voluntary process plays a significant role in the
regulation of the profession, equal to legal regulation in many ways. Professional
standards of practice and codes of ethics exemplify professional self-regulation.
National professional organizations set standards for specialty practice. By
means of the certification process, these organizations determine who may use
the specialty titles within their purview. Documentation of continuing educa-
tion and practice competency or reexamination is usually required for periodic
recertification. Standards are periodically reviewed and revised by committees
of the membership to assure they reflect current practice.
Although professional organizations develop standards of practice, they have
no legal authority to require compliance by certificate holders. Administrative
licensing agencies retain that authority but look to prevailing professional standards
of practice when making decisions about what constitutes safe and competent
care. Legal regulation and professional self-regulation are two sides of the same
coin, working together to fulfill the profession’s contract with society.
Regulation of Advanced Practice Registered Nurses
The evolution of APRN practice across the United States has been inconsistent
because the U.S. Constitution gives states the right to establish laws governing
professions and occupations. As a result, titles, scopes of practice, and regulatory
standards are unique to each state. To bring some uniformity to the education
and regulation of advanced nursing practice, the NCSBN convened an Advanced
Practice Task Force in 2000, at the behest of its BON membership, and invited the
American Association of Colleges of Nursing (AACN) to join in a consensus-building
process. Together they developed the Consensus Model for Regulation: Licensure,
Accreditation, Certification, and Education (LACE). The LACE report proposed
definitions of APRN practice, titling, and education requirements. It also described
Health Professions Regulation and Licensing 65
an APRN regulatory model, identified APRN roles/population foci, and offered
strategies for implementation (APRN Joint Dialogue Group, 2008). This model
served as the basis of BON regulation of advanced practice nursing for some
years. In 2016, however, the NCSBN convened an APRN Roundtable to consider
revisions in education, certification, and other factors and issues currently facing
APRN regulation (NCSBN, 2016).
APRN regulation is also dependent on relationships between national
nursing organizations and their affiliate certifying organizations (e.g., the ANA
and the American Nurses Credentialing Center [ANCC]). Together these or-
ganizations play important roles in shaping APRN preparation and practice.
The certifying organizations are nongovernmental bodies that develop practice
standards and examinations to measure the competency of nurses in an area of
clinical expertise. BONs require APRNs to hold a graduate degree in nursing and
national certification in the specialty area relevant to their educational preparation.
BONs also establish rules allowing acceptance of national APRN certification
examination results according to predetermined criteria. The NCSBN guidelines
(2002) continue to serve state BONs in determining those criteria.
Historically, the courts have held that state boards may not abdicate their
authority by passively accepting examinations from independent bodies without
having conducted a thorough evaluation of the examination’s regulatory sufficiency
and legal defensibility (NCSBN, 1993). The basis for regulatory sufficiency and
legal defensibility of licensure or certification examinations includes two elements:
(1) the ability to measure entry-level practice, based on a practice analysis that
defines job-related knowledge, skills, and abilities; and (2) development of exam-
inations using psychometrically sound test construction principles.
▸ The State Regulatory Process
The 10th Amendment of the U.S. Constitution specifies that all powers not spe-
cifically vested in the federal government are reserved for the states. One of these
powers is the duty to protect its citizens (police powers). This power is translated
in the form of states’ authority and interest in regulating the professions to protect
the health, safety, and welfare of its citizens. Administrative agencies are given
referent power, through their legislatively enacted practice acts, to promulgate
(write) regulations and enforce both the laws and the regulations for which they
are responsible. These administrative agencies have been called the “fourth branch”
of government because of their significant power to execute and enforce the law.
Boards of Nursing
Nurse practice acts vary by state, but all NPAs include the major provisions, or
elements, discussed earlier in this chapter. Provisions included in NPAs focus on
a central mission—protection of the public safety.
There are 60 boards of nursing (BONs) in the United States, including those
in the 50 states, the District of Columbia, and the U.S. territories; each of these is
known as a jurisdiction. Each BON is a member of the NCSBN. Some states have
separate boards for licensing RNs and LPNs/LVNs. Several states regulate RNs
and/or LPNs/LVNs through multiprofessional boards, which have jurisdiction
66 Chapter 4 Government Response: Regulation
over a variety of licensed professionals such as physicians, nurses, and dentists.
As members of the NCSBN, BONs represent the interest of public safety by pro-
viding oversight of the construction and administration of the National Council
Licensure Examinations (NCLEX). BONs are allowed the privilege of using
these examinations and meet to discuss and act on matters of common interest
(NCSBN, 2008).
Composition of the Board of Nursing
Boards of nursing are generally composed of licensed nurses and consumer
members. In most states, the governor appoints members. An exception is North
Carolina, where board members are elected by nurses licensed to practice in the
state. Some NPAs designate specific board member representation—for example,
from advanced practice nursing or nursing education, and in the case of joint
boards, representation from LPNs/LVNs in addition to RNs/APRNs. In other
states, criteria for appointment comprise only licensure and state residency.
Nurses interested in serving as board members may look to their professional
associations to secure endorsements or ask for support from their state district
legislators. Knowing the composition of the board and its vacancy status allows
professional organizations to influence the representation on the board.
Board Meetings
Most state administrative procedures acts (APAs) require boards to post public
notice of meetings and make agendas available, usually 30 days prior to the meeting.
State government agencies must comply with open meeting (“sunshine”) laws,
which permit the public to observe and/or participate in board meetings. Board
meetings may vary in their degree of formality. Public participation is usually
permitted, but open dialogue between board members and the public is generally
limited. Opportunities to address the board may be scheduled on the meeting
agenda (e.g., during an “open forum” time) and may require advance notification
of the individual’s name, topic, and the organization represented (if applicable).
Boards may go into closed executive session for reasons specified in the state’s
administrative procedures act (e.g., to obtain legal advice, conduct contract nego-
tiations, and discuss disciplinary or personnel matters). Boards must comply with
APA regulations regarding subject matter that may be discussed in an executive
session and report out of executive session when the public session resumes.
Board meeting participants include board members (appointed or elected),
board staff (employees of the board), and legal counsel for the board. Legal counsel
advises the board on matters of law and jurisdiction. Some boards may have “staff ”
counsel, but many state boards receive advice only from an assigned representative
of the state attorney general’s office, known as an assistant attorney general (AAG).
All voting is a matter of public record, and board action occurs only in open
public session. When board members vote, they must take into account impli-
cations for the public welfare and safety, the legal defensibility of the outcome of
the vote, and the potential statewide impact of the decision. The board must act
only within its legal jurisdiction.
BONs may publish action summaries of board meetings in their newslet-
ters, in addition to articles written by board members and staff that explain law
The State Regulatory Process 67
and rule. BON newsletters typically include disciplinary actions taken against
licensees during board meetings. The nature of the offense is included in some
states’ newsletters. Some states mail newsletters to licensees, but many BONs
now make newsletters available only electronically.
Monitoring the Competency of Nurses: Discipline and
Mandatory Reporting
Licensed nurses are accountable for knowing the laws and regulations governing
nursing in the state of licensure and for adhering to legal, ethical, and professional
standards of care. Some state regulations include standards of practice; other
states may refer to professional or ethical standards established by professional
associations. Employing agencies also define standards of practice through policies
and procedures, although these are separate from, in addition to, and superseded
by the state’s NPA and regulations.
Most NPAs include provisions for mandatory reporting that require employ-
ers to report violations of the NPA or regulations to the BON. Licensed nurses
also have a moral and ethical duty to report unsafe and incompetent practice
to the BON. In addition, the public may file complaints against licensees with
BONs. The NPA provides the BON with authority to investigate complaints
against licensees and potentially take action on the license, including the license
or certificate to practice as an APRN. State APAs assure that licensees subject to
disciplinary action are provided due process. When a nurse is found, through the
administrative processes, to have violated provisions of the NPA or regulations,
the BON can take action on the license; these actions may include a reprimand,
fine, suspension, suspension of license with stay (i.e., probation), permanent
revocation of license, or any other action permitted by the NPA.
A nurse who holds a multistate license (i.e., a license that permits a nurse to
practice in more than one state in accordance with a multistate compact agree-
ment) is held accountable for knowing and abiding by the laws and regulations
of the state of original licensure as well as the compact state in which the nurse
practices. Multistate regulation is discussed in more detail later in this chapter.
Nurses with multistate licenses should be aware that ignorance of the law in any
state of licensure and/or practice does not excuse misconduct.
Changing the Rules
Revising or Instituting New State Regulations
State agencies exercise their authority and duty to promulgate regulations am-
plifying their laws by following the state’s administrative procedures act. The
administrative procedures act of each state specifies the rule-making process,
including requirements for public notification and for providing an opportunity
for public comment. State rule-making processes differ. For example, some states
designate government commissions or committees as the authorities for review
and approval of regulations, whereas other states submit regulations to the general
assembly or to committees of the legislature. Nevertheless, all state rule-making
processes share some common elements:
68 Chapter 4 Government Response: Regulation
■ Public notice that a new regulation or modification of an existing regulation
has been proposed
■ Opportunity to submit written comment or testimony
■ Opportunity to present oral testimony at a rules hearing
■ Agency filing of the rule in final form
■ Publication of the final regulation in a state register or bulletin
Public comment may be very influential in determining the final outcome.
The administrative agency drafting the regulation has discretion in determining
which amendments are made and may make amendments based on public input
prior to final filing.
The time frame for implementation of new or revised regulations varies ac-
cording to the state’s administrative procedures act. Generally, effective dates are
within 30 to 90 days of publication of the final regulation. In some states, the agency
is required to prepare a fiscal impact statement, providing an estimate of the costs
that will be incurred as a result of the rule, both to the agency and to the public.
Board Rule-Making Processes
BONs make regulatory decisions using methods similar to those used by other
public officials in executive-branch agencies. When drafting new rules or revising
existing rules, BONs examine matters of public safety and issues administering ex-
isting regulations, invite comment from stakeholders (in particular, nursing orga-
nization representatives), and may seek counsel from BON advisory committees
or task forces. Leveraging participation opportunities early in the rule-drafting
process is important, in addition to providing testimony during formal hearings.
It is also imperative to appreciate that the process becomes complex when it is
confounded by the perspectives, values, and ethics of a variety of stakeholders.
Because rule making involves dealing with both political complexities and
content issues, BONs may use policy design or process models to facilitate decision
making. Using a process model that is both familiar in nursing and adaptable to the
health policy arena—for example, evidence-based practice (EBP)—can facilitate a
BON’s rule making because it provides an organized framework for problem solving.
The South Dakota BON has successfully used an evidence-informed health
policy (EIHP) model to analyze one of its policies (Damgaard & Young, 2017).
The EIHP model is adapted from Melnyk and Fineout-Overholt’s (2015) EBP
model and is a paradigm and problem-solving approach to health policy deci-
sion making. Like EBP, EIHP combines the use of evidence with issue expertise
and stakeholder values and ethics to inform and leverage policy discussion and
negotiation. The hoped-for outcome is the best possible health policy agenda
and improvements (Loversidge, 2016b). Using the term informed rather than
based shifts the focus of evidence to its realistic uses in policy arenas, which
include informing and influencing stakeholders, as well as mediating dialogue; it
also acknowledges the complexity of multiple factors, relationships, and rapidly
shifting priorities inherent in the political process (Loversidge, 2016a).
Since EIHP is a full-cycle process model, it can facilitate decision making
throughout the phases of regulation promulgation, rollout, implementation, and
evaluation. The model includes three components and seven steps, summarized
in TABLE 4-1. In particular, it makes use of the PICOT question. As used in health
policy, the “P” part of this question—Population of interest—generally focuses
The State Regulatory Process 69
TABLE 4-1 Loversidge’s Evidence-Informed Health Policy Model:
Components and Steps
Components of EIHP Steps of EIHP
■ External evidence: Includes best
research evidence, evidence-
informed relevant theories, and
best evidence from opinion
leaders, expert panels, and
other relevant sources.
■ Issue expertise: Includes
data from sources such as
professional and healthcare
associations/organizations
and government agencies;
also includes professions’
understanding/experience with
the issue; may include other
data resources.
■ Stakeholder values and ethics:
Considers the values and ethics
of healthcare providers, policy
shapers, healthcare consumers,
and others.
■ Step 0: Cultivate a spirit of inquiry in
the policy culture or environment.
■ Step 1: Identify the policy problem;
ask a policy question in the form of a
PICOT question.
■ Step 2: Search for/collect relevant/best
evidence.
■ Step 3: Perform critical appraisal of the
evidence.
■ Step 4: Integrate best evidence with
issue expertise and stakeholder values
and ethics; the result will be the
desired health policy decision/change.
■ Step 5: Contribute to the health
policy development/implementation
process.
■ Step 6: Frame the policy change for
dissemination.
■ Step 7: Evaluate the effectiveness of
the policy change and disseminate
findings.
Data from Loversidge, J. M. (2016b). An evidence-informed health policy model: Adapting evidence-based practice for
nursing education and regulation. Journal of Nursing Regulation, 7(2), 27–33.
on the consumer. The “I” (Intervention) refers to the policy change. “C” is the
Comparison—the current policy or lack thereof. The “O” component describes
the anticipated Outcome after policy implementation (Loversidge, 2016b). “T”
is the Time needed to implement the policy.
Monitoring State Regulations
Administrative agencies promulgate hundreds of regulations each year. In this
rapidly changing healthcare environment, conflicts related to definitions and
scopes of practice, right to reimbursement, and requirements for supervision
and collaboration may occur. Regulations that affect nursing practice may be
implemented by a variety of agencies. Knowing which agencies regulate health
care, healthcare delivery systems, and professional practice, and monitoring
legislation and regulations proposed by those agencies, is important for safe-
guarding practice. Chief among the agencies that should be tracked are the
health professions licensing boards, state agencies that govern licensing and
certification of healthcare facilities, agencies that administer public health
services (e.g., public health, mental health, and alcohol and drug agencies),
70 Chapter 4 Government Response: Regulation
and agencies that govern federal/state contribution program reimbursement
(e.g., Medicare and Medicaid).
In particular, APRNs should be aware of regulations that mandate benefits
or reimbursement policies and lobby for their inclusion as potential recipients of
these benefits or funds. Several states have instituted open-panel legislation, known
as “any willing provider” and “freedom of choice” laws. These bills mandate that
any provider who is authorized to provide the services covered in an insurance
plan must be recognized and reimbursed by the plan. Conversely, insurance
companies and business lobbyists oppose this type of legislation. As managed
care contracts are negotiated, APRNs must ensure their services are given fair
and equitable consideration. Other important areas for nurses include worker’s
compensation participation and liability insurance laws.
In summary, agencies that may potentially promulgate regulations that
could have implications for APRN and RN practice or reimbursement should be
monitored. Exhibit 4-1 provides some key questions to consider when analyzing
a regulation for its impact on nursing practice.
Serving on Boards and Commissions
One way to actively participate in the regulatory process is to seek appointment to
the state BON or to other health-related boards or commissions. Appointments
to boards and commissions should be sought strategically. It is important to
select an agency with a mission and purpose consistent with your own interests
and expertise. Because most board appointments are gubernatorial or political
appointments, it is important to obtain endorsements from legislators, influential
community leaders, and professional associations. Individuals seeking appoint-
ment are more likely to acquire endorsements if they have an established history
of service to the professional community.
Letters of support should document the appointment candidate’s primary
area of practice and contributions to professional and community service.
EXHIBIT 4-1 Questions to Ask When Analyzing Regulations
1. Which agency promulgated the regulation?
2. What is the source of the agency’s authority (the law that provides the
agency’s rule-making authority)?
3. What is the intent or rationale of the regulation, and is it clearly stated?
4. How does the regulation affect the practice of nursing? Does it constrain or
limit practice?
5. Is the language in the regulation clear or ambiguous? Can the regulation
be interpreted in different ways? Discuss the advantages of language that is
clear versus ambiguous.
6. Are there definitions to clarify terms?
7. Are any important points omitted?
8. Is there sufficient lead time to comply with the regulation?
9. What is the fiscal impact of the regulation?
The State Regulatory Process 71
Delineate involvement in local, state, and national organizations. A letter from the
employer is recommended, as both an indication of the employer’s willingness to
support time away from work to fulfill the responsibilities of the position during
the term of office and as an endorsement of the candidate’s professional merit. A
personal letter from the appointment candidate should include the rationale for
volunteering to serve on the particular board or commission, evidence of a good
match between the individual’s expertise and the board or commission purpose,
and expression of clear interest in public service. A specific application form may
be required (often found on the governor’s website), and a résumé or curriculum
vitae should be attached.
Appointment decisions take into account the individual’s potential con-
tributions to the work of the board or commission. This kind of public service
requires a substantial time commitment, so it is wise to speak to other board
members or the executive director/agency administrator to determine the extent
of that commitment.
▸ The Federal Regulatory Process
The federal government has become a central factor in health professions regu-
lation. A number of forces have influenced this trend; however, the advent of the
Medicare and Medicaid programs was especially significant. Federal initiatives that
have grown from these programs include cost containment (prospective payment),
consumer protection (combating fraud and abuse) (Jost, 1997; Roberts & Clyde,
1993), and the initiatives and programs written into the Patient Protection and
Affordable Care Act (ACA) and the Health Care and Education Reconciliation
Act of 2010 (U.S. Department of Health and Human Services [DHHS], 2014).
In July 2001, the Centers for Medicare and Medicaid Services (CMS) replaced
the former Health Care Financing Administration (HCFA). As a result of its
reformulation, this agency now provides increased emphasis on responsiveness
to beneficiaries, providers, and quality improvement. Three business centers
were established as part of the reform: Center for Beneficiary Choices, Center
for Medicare Management, and Center for Medicaid and State Operations (CMS,
2014). In 2003, President George W. Bush signed the Medicare Prescription
Drug, Improvement, and Modernization Act (MMA) into law. The act created a
prescription drug benefit for Medicare beneficiaries and established the Medicare
Advantage program (O’Sullivan, Chaikind, Tilson, Boulanger, & Morgan, 2004),
effectively providing seniors with prescription drug benefits and more choice in
accessing health care.
As the Medicare program has evolved, the practice of APRNs has likewise
been influenced by changes in Medicare reimbursement policy. In 1998, when
Medicare reimbursement reform was enacted, APRNs won the right to be directly
reimbursed for provision of Medicare Part B services that, until that time, had been
provided only by physicians. In addition, the reform lifted the geographic location
restrictions that had limited patient access to APRNs. More recent revisions to
the required qualifications, coverage criteria, billing, and payment for Medicare
services provided by APRNs are specific, depending on whether the APRN is a
certified registered nurse anesthetist (CRNA), nurse practitioner (NP), certified
nurse‒midwife (CNM), or clinical nurse specialist (CNS). Reimbursement for
72 Chapter 4 Government Response: Regulation
APRNs has generally improved; for example, NP services are now paid at 80%
of the lesser of the actual charge or 85% of the fee schedule amount a physician
is paid (U.S. DHHS, CMS, 2016). However, APRNs continue to lobby for reim-
bursement at 100% of the amount paid to physicians.
Relationships between the state and federal regulatory systems are highly
dynamic. Responsibilities once assumed by the federal government have been
shifted to the state level; administration and management of the Medicaid and
welfare programs are examples. The perspective that states are better equipped
to make decisions about how best to assist their citizens, coupled with a public
sentiment that generally seeks to diminish federal bureaucracy and its accompa-
nying tax burden, have been instrumental in moving the placement of authority
to the states. However, although states have primary authority over regulation
of the health professions, federal policies continue to have a significant effect on
healthcare workforce regulation. For example, policies related to reimbursement
and quality control over the Medicare and Medicaid programs are promulgated
by the U.S. Department of Health and Human Services and administered through
its financing agency, CMS.
The Veterans Health Administration, the Indian Health Service, and the
uniformed armed services are also regulated by the federal government. Large
numbers of health professionals, many of whom are nurses/APRNs, are employed
by these federal agencies and departments. Federally employed health professionals
must be licensed in at least one state/jurisdiction. These individuals are subject to
the laws of the state in which they are licensed and the policies established by the
federal system in which they are employed. However, the state of licensure need
not correspond with the state in which the federal agency or department resides,
because practice that occurs on federal property is not subject to state oversight.
This status reflects the fact that the Supremacy Clause of the U.S. Constitution,
Article VI, Paragraph 2, establishes that federal laws generally take precedence
over state laws (Legal Information Institute, n.d.). State laws in conflict with
federal laws cannot be enforced.
The Commerce Clause of the U.S. Constitution limits the ability of states to
erect barriers to interstate trade (Gobis, 1997). Courts have determined that the
provision of health care constitutes interstate trade under antitrust laws, which
in turn sets the stage for the federal government to preempt state licensing laws
regarding the practice of professions across state boundaries if future circumstances
make this a desirable outcome for the nation. The impact of technology on the
delivery of health care—for example, telehealth—allows providers to care for
patients in remote environments and across the geopolitical boundaries defined
by traditional state-by-state licensure. This raises the question as to whether the
federal government would have an interest in interceding in the standardization
of state licensing requirements to facilitate interstate commerce. If this occurred,
the federal government would be in the position of usurping what is presently
the state’s authority.
Licensing boards have an interest in avoiding federal intervention and are
beginning to identify ways to facilitate the practice of telehealth while simul-
taneously preserving the power and right of the state to protect its citizens by
regulating health professions at the state level. One approach to nursing regulation
that addresses this conundrum is multistate regulation, which is discussed
later in this chapter.
The Federal Regulatory Process 73
Federal Rule Making
The federal regulatory process is established by the federal administrative procedures
act. In this process, a Notice of Proposed Rulemaking (NPRM) is published in the
Federal Register, a public, daily federal government publication containing current
executive orders, presidential proclamations, rules and regulations, proposed rules,
notices, and sunshine act meetings. The NPRM includes information about the
substance of intended regulations and information about public participation in
the regulatory process, including procedures for attending meetings or hearings
and for providing comment. The agency writing the rules is mandated to consider
all public comments, and amendments to draft regulations may be made based on
public input if warranted. The agency publishes final regulations in the rules and
regulations section of the Federal Register. Rules become effective 30 days after they
are filed in final form by the agency and published in the Federal Register (FIGURE 4-1).
Emergency Regulations
Provisions for promulgating emergency regulations are defined at both the state
and the federal levels. Emergency regulations are enacted if an agency determines
that the public welfare is in jeopardy and the regulation will serve as an immediately
enforceable remedy. Emergency regulations usually take effect upon their date of
publication, are generally temporary, and are effective for a limited time period
(usually 90 days), with an option to renew them. Emergency regulations must be
followed with permanent regulations that are promulgated in accordance with the
usual APA requirements.
Locating Information
Each state government periodically publishes a document containing notices, pro-
posed regulations, final regulations, and emergency regulations. The publication
cycle for this document—usually called the State Register or State Bulletin—can
be obtained by accessing the state legislative printing office/website or the state
legislative information system office/website. Federal regulatory information is
available online: the National Archives manages the Code of Federal Regulations
(CFR) website and the U.S. Government Publishing Office oversees the eCFR
website.
Because state and federal agencies promulgate numerous regulations, it is
in one’s best interest to belong to at least one national professional organization,
most of which employ professional lobbyists who track legislation, monitor
agencies’ rule making, and report to their membership. Some state organizations
employ such lobbyists; many others do not have the financial resources to do so.
Specialty organizations’ newsletters and journals and legislative subscription and
monitoring services and bulletins can be relied upon to summarize proposed
regulation content and track status progress.
Providing Public Comment
Regulatory agencies provide a small window of opportunity for public com-
ment. Most comment periods last 30 days from the date of publication of
74 Chapter 4 Government Response: Regulation
FIGURE 4-1 The federal rule-making process.
Reproduced from Carey, M. P. (2013, June 17). The federal rulemaking process: An overview. Congressional Research Service Report RL32240. Retrieved from http://www.fas.org/sgp
/crs/misc/RL32240
Agency Develops Draft
Proposed Rule
Review/Approval of Draft
Proposal Rule Within
Agency/Department
OMB/OIRA Review Draft of
Proposed Rule*
Publication of Notice of
Proposed Rule Making
Public Comments
Response to Comments/
Development of Draft Final
Rule
Review/Approval of Draft
Final Rule Within
Agency/Department
OMB/OIRA Review of Draft
Final Rule*
Publication of Final Rule
Rule Takes EffectLegal Challenge
Initiating Event
Court Determines
Legality of Rule
Congressional Review
Congress Votes on
Disapproval Resolution
Congress Passes Statute
Requiring Issuance
of Rule
Authorizing Issuance
of Rule
* The Office of Management and Budget (OMB)/Office of Information and Regulatory Affairs (OIRA) reviews
only significant rules and does not review any rules submitted by independent regulatory agencies.
The Federal Regulatory Process 75
the proposed regulation. However, longer comment periods are sometimes
permitted if the agency anticipates the issue will draw strong public interest
or involves controversy.
Public rule hearings are held by the agency proposing the regulation. Public
agencies must comply with administrative procedures act regulations regarding public
hearings. Federal agencies are generally required to hold hearings when a numeric
threshold is reached (i.e., a certain number of individuals or agency/organization
representatives make requests to offer testimony). Written comments received by
the agency are made a part of the permanent record and must be considered by the
agency’s board or commission members prior to publication of the final regulation.
A final regulation can be challenged in the courts if the judge determines the agency
did not comply with the administrative procedures act or ignored public comments.
The Federal Register provides agency contact information on its website, making
it feasible for the public to provide comment on proposed regulations. Only written
comments are included in the public record, although agencies may permit oral
comments if time is short. Instructions for submitting electronic comments or written
submissions by mail, hand delivery, or courier are generally included on the filing
agency’s Federal Register webpage. Comments received after the comment period
posted in the Federal Register is closed can be legitimately disregarded by the agency.
Strengths and Weaknesses of the Regulatory Process
The regulatory process is somewhat more well ordered than the legislative process
in that it is directed by state or federal administrative procedures acts. These pro-
cedures guarantee opportunities for comment and public input. The regulatory
process also includes built-in delays and time constraints that slow the process of
developing and implementing regulations. However, administrative agencies are able
to exert a great deal of control over the rule-drafting process. Agency staff have an
interest in assuring the final regulation has sufficient detail that it can be reasonably
enforced. It is possible that agency staff, although skilled regulators, may not be
knowledgeable about a regulation’s impact from the practitioners’ point of view.
If the agency did not invite stakeholders to assist with the original drafting of the
regulation, then public input during the comment period is especially important.
In addition to enforcement, administrative agencies may have legislative
authority to interpret regulations. Sometimes regulations may be misinterpreted
by agency staff or board members, resulting in the imposition of a new meaning
that is not aligned with the original intent of the regulation. These interpretations
may be published as opinions, interpretive statements, and/or declaratory rulings
of the board. Opinions of the attorney general or court may also misinterpret the
original legislative intent, but the judicial branch of government is more likely to
apply sound legal standards to its fact-finding and conclusions of law. Regardless,
official opinions carry the force and effect of law even if they are not promulgated
as regulations, according to the administrative procedures act.
Regulation in a Transforming Healthcare Delivery System
In the United States, the healthcare delivery system is undergoing a period of
significant and rapid change. Evidence of system shifts began in 1995, when the
Pew Health Professions Commission (1994) published a sweeping report that
76 Chapter 4 Government Response: Regulation
stimulated new thinking about existing regulatory systems. The report suggested
that the system, based on a century-old model structured with separate health
professions agencies regulating individual health professionals with potentially
overlapping scopes of practice, was out of sync with the nation’s healthcare deliv-
ery systems and financing structures. The Pew Health Professions Commission
suggested that major reform was needed and asked states to review regulatory
processes with the following questions in mind (Dower & Finocchio, 1995, p. 1):
■ Does regulation promote effective health outcomes and protect the public
from harm?
■ Are regulatory bodies truly accountable to the public?
■ Does regulation respect consumers’ rights to choose their own healthcare
providers from a range of safe options?
■ Does regulation encourage a flexible, rational, and cost-effective healthcare
system?
■ Does regulation allow effective working relationships among healthcare
providers?
■ Does regulation promote equity among providers of equal skill?
■ Does regulation facilitate professional and geographic mobility of competent
providers?
The Pew Task Force on Health Care Workforce Regulation challenged state
and federal governments to respond to the complex health professions education
and regulation issues identified in the report. Report recommendations ad-
dressed the use of standardized and understandable language, standardization of
entry-to-practice requirements, assurance of initial and continuing competence of
healthcare practitioners, and redesign of professional boards, including creation
of super-boards in which the majority of members are consumer representatives.
The report also called for better methods of assessing the achievement of objec-
tives and improved disciplinary processes (Pew Health Professions Commission,
1995). Some of these changes have already been implemented in regulatory agency
structures, such as standardization of entry-to-practice requirements, but redesign
of professional boards has been slow to change.
Following the 1995 Pew report, the Institute of Medicine (IOM)—now known
as the National Academy of Medicine—issued a number of reports related to
safety in healthcare systems, known as the Quality Chasm Series. Several of these
reports made recommendations with regard to regulation. For example, in its first
report, To Err Is Human, the IOM called for licensing and certification bodies to
pay greater attention to safety-related performance standards and expectations
for health professionals (Kohn, Corrigan, & Donaldson, 2000).
A consensus report, focused singularly on nursing, was jointly issued by the
Robert Wood Johnson Foundation and the IOM in October 2010. This report,
which bore the title The Future of Nursing: Leading Change, Advancing Health,
provided four key messages to guide changes and remove barriers that prevent
nurses from being able to function effectively in a rapidly evolving healthcare system:
■ Nurses should be enabled to practice to the full extent of their education
and training.
■ Nurses should be able to access higher levels of education and training in an
improved education system that allows for academic progression.
The Federal Regulatory Process 77
■ Nurses should be full partners in the interprofessional redesign of the U.S.
healthcare system.
■ Effective workforce planning and policymaking need better data collection
and information infrastructures.
Eight recommendations for fundamental change are found in the report,
along with related actions for Congress, state legislatures, CMS, the Office of Per-
sonnel Management, the Federal Trade Commission, and the Antitrust Division
of the Department of Justice. The recommendation most relevant to regulation
is the first: to remove scope-of-practice barriers. Other recommendations with
implications for regulation include the call to prepare and enable nurses to lead
change to advance health—that is, nurses who serve on boards and commissions
serve in such roles—and the suggestion to build an infrastructure for the col-
lection and analysis of interprofessional healthcare workforce data (IOM, 2010).
Regulatory boards often survey their licensees as a part of renewal, providing
excellent sources of workforce data. Some progress toward accomplishment of
the Future of Nursing report recommendations has been made, but, importantly,
barriers to expansion of APRN scopes of practice remain (IOM, 2016).
Another area ripe for regulatory reform relates to structures that encourage
interprofessional collaboration. The Josiah Macy Jr. Foundation, an organization
dedicated to improving the health of the public through the advancement of health
professions education, has been instrumental in providing direction for regula-
tory reform. In 2013, this foundation held a consensus conference with health
professions education leaders to discuss a vision for a joint future of healthcare
practice and education. Recommendations for action in five areas were made;
one of these was to “revise professional regulatory standards and practices to
permit and promote innovation in interprofessional education and collaborative
practice” (Josiah Macy Jr. Foundation, 2013, p. 2).
Together these reports and recommendations provide a substantive body of
evidence that can be leveraged for health professions regulation reform, thereby
ensuring these professions can meet the needs of 21st-century healthcare con-
sumers. APRNs have a window of opportunity to act on these recommendations
but must be open to the notion that collaboration with other health professions is
essential if new regulatory models are to emerge. Regulation determines who has
access to the patient, who serves as gatekeeper in a managed care environment,
who is reimbursed, and who has autonomy to practice. APRNs must be visible
participants in the political process that authorizes APRNs to practice to the full
extent of their education in a collaborative environment as equal team members
and ensures consumer choice and protection.
▸ Current Issues in Regulation and Licensure:
Regulatory Responses
Changes to the Affordable Care Act
The ACA increased access for under-insured and uninsured U.S. residents, who
are estimated to number more than 50 million. This law/program also had a
significant impact on the estimated 6,400 shortage areas in the United States,
78 Chapter 4 Government Response: Regulation
including 66 million Americans who have limited access to primary care (ANA,
2011). The need for APRNs to work in a variety of settings, but particularly in
primary care, has been enormous, but their usefulness has been dependent on
lifting practice restrictions in their state of licensure.
The ACA is now in the midst of partisan controversy, and the future of its key
provisions is currently uncertain. Key policy issues related to the ACA include reg-
ulation of health insurance coverage and costs, potential changes to Medicaid and
Medicare, potential changes in reimbursement for prescription drugs and prescribing
practices, and handling of reproductive health services (Kaiser Family Foundation,
2016). Both state and federal regulatory agencies will play a part in enacting these
changes; regulations governing the health insurance marketplace (HealthCare.gov,
2010) and the Medicaid and Medicare programs (CMS, 2014) will need to reflect
any changes made by the U.S. Congress. Programs that rely on state matching
funds (e.g., Medicaid) will likely be forced to reevaluate their state’s contribution.
Reimbursement
Significant breakthroughs have been made in reimbursement policy for APRNs,
largely as a result of grassroots lobbying efforts and coalitions of APRN specialty
nursing organizations. With the passage of federal legislation in 1997 allowing
APRNs to bill Medicare directly for services, consumer access to care provided
by APRNs has improved. Managed care markets value efficiency and provider
effectiveness. Understanding the concept of market value has motivated APRNs
to become more skilled in costing out their services and winning contracts in a
competitive market.
Scope of Practice
The Future of Nursing progress report (IOM, 2016) noted that only minimal
change in expansion of nurses’ scopes of practice had been accomplished since
2010. APRNs continue to struggle with these issues, although progress has been
made in some states as well as at the federal level. A 2014 report from the Federal
Trade Commission (FTC) provided an unbiased analysis of the consequences of
continuing to impose restrictions on APRNs’ scopes of practice. The report noted
associations between mandatory physician supervision/collaborative practice
agreement regulations and restriction of independent APRN practice. The FTC
(2014) projected that these environmental factors would likely lead to decreased
access to healthcare services, higher costs, and reduced quality of care, leading to
minimization of nursing’s ability to innovate in the delivery of health care. The
Department of Veterans Affairs (VA) recently finalized a regulation allowing
full scope of practice for APRNs with the exception of CRNAs (Dickson, 2016).
Boundary disputes within and across the health professions create tension
and are counterproductive to efforts to improve nursing’s contributions to care, as
those efforts rely on equitable teamwork. It is imperative for APRNs to be cogni-
zant of reports such as that published by the FTC and to keep abreast of inroads
such as those made in the VA. Compelling evidence (e.g., the FTC report) and
progress in high-level government agencies (e.g., the VA) can serve as leverage
when negotiating with lawmakers and other stakeholders at the state level to
enact changes in scope of practice laws.
Current Issues in Regulation and Licensure: Regulatory Responses 79
Increased Use of Unlicensed Assistive Personnel
Unlicensed assistive personnel (UAPs) are individuals who are unregulated in
many states, inexpensive, and employed in acute and primary care settings.
In many settings, UAPs are used appropriately. However, when employers misun-
derstand the UAP’s role or expand job descriptions in an effort to provide more
care at less cost, there is a risk that UAPs may be asked to function beyond their
capacity and in a way that approaches nursing practice. Potential dangers include
unsafe patient care and liability for nurses who, because of their employment
situations, feel forced to delegate more nursing tasks to UAPs than safe standards
of delegation would dictate.
Electronic Access to Healthcare Services
The impact of technology on the delivery of health care, including telehealth,
was mentioned earlier in this chapter in the context of questions about whether
the federal government has an interest in interceding in the standardization
of state licensing requirements to facilitate interstate commerce. Such action
would pre-empt the states’ authority to license health professionals. How-
ever, the states maintain their right to protect their citizens. Today, nurses
who live in one multistate-regulation state and practice telehealth in another
multistate-regulation state have the benefit of multistate regulation (but must
affirm licensure in the second state). Where no multistate compact exists
between states, however, the nurse must generally seek licensure in the state
in which the patient resides.
Interstate Mobility and Multistate Regulation
Cumbersome licensure processes across geopolitical boundaries make seamless
transition difficult or impossible, particularly for APRNs. The Nurse Licensure
Compact (NLC) model, adopted by the NCSBN, is nursing’s mutual recognition
model of multistate regulation and licensure for RNs. States adopting this model
voluntarily enter into an interstate compact, which is a legal agreement between
states to recognize the license of another state and to allow for practice between
states. This allows the nurse to possess a “home state” license and practice in
a remote state without obtaining an additional license. The compact must be
passed as law by the state legislature and implemented by the BON in each state
(NCSBN, 1998).
A number of states moved quickly to enter the compact when it was insti-
tuted, but many states remain independent. As of January 2017, 25 states were
participating as compact states (NCSBN, 2017b).
Until 2015, there was no system for APRN participation in a nursing compact.
Consequently, although the compact may apply to a nurse’s RN license, it does
not extend to cover advanced practice, and APRNs must apply for licensure in
each state of practice. In May 2015, NCSBN approved the APRN Compact model,
which would allow APRNs to hold one multistate license and extend privileges
to practice in other APRN Compact states (NCSBN, 2017a). To participate in
this system, state NPAs would need to be revised to include the Uniform APRN
Requirements. Currently, no states have enacted APRN Compact legislation.
80 Chapter 4 Government Response: Regulation
▸ Conclusion
The capacity to adapt is crucial in an era of rapid change. Today’s politically astute
nurses have many opportunities to shape public policy, by working in coalition
together and with other health professionals and consumers, and to advocate for
state and federal health policies and regulations that will allow the public greater
access to affordable, quality health care. The window of opportunity that opened
with the enactment of the comprehensive ACA will look somewhat different as we
move forward. It is essential for nurses and APRNs to develop skills to capitalize
on the chaos present in the healthcare and political environments and to create
opportunities to advance the profession as a whole.
Familiarity with the regulatory process will give nurses and APRNs the tools
needed to navigate this dynamic environment with confidence. Knowing how to
monitor the status of critical issues involving scopes of practice, licensure, and
reimbursement will allow APRNs to influence the outcomes of debates on those
issues. Participation in specialty professional nurse organizations is especially
advantageous. Participation builds a membership base, providing the foundation
for strong coalition building and a power base from which to effect change in the
political and regulatory arenas. Participation also gives members ready access to
a network of colleagues, legislative affairs information, and professional and edu-
cational opportunities. Although supporting the profession through participation
is central, it is equally important to remember that each professional nurse has
the ability to make a difference.
▸ Discussion Points
1. Compare and contrast the legislative and regulatory processes.
2. Describe the major methods of credentialing. List the benefits and weaknesses
of each method from the standpoint of public protection and protection
of the professional scope of practice.
3. Discuss the role of state BONs in regulating professional practice.
4. Obtain a copy of a proposed or recently promulgated regulation. Using the
questions in Exhibit 4-1, analyze the regulation for its impact on nursing
practice.
5. Describe the federal government’s role in the regulation of health profes-
sions. To what extent do you believe this role will increase or decrease over
time? Explain your rationale.
6. Analyze the pros and cons of multistate regulation (choose multistate
regulation of RNs, APRNs, or a combination). Based on your analysis,
develop and defend a position either for or against multistate regulation.
7. Prepare written testimony for a public hearing defending or opposing the
need for a second license for APRNs.
8. Contrast the BON and the national or state nurses association vis-à-vis
mission, membership, authority, functions, and source of funding.
9. Identify a proposed regulation. Discuss the current phase of the process,
identify methods for offering comments, and submit written comments
to the administrative agency.
81Discussion Points
10. Evaluate the APRN section of the nurse practice act in your state using
the NCSBN Model Act (NCSBN, 2012) or regulations using the NCSBN
Model Rules (NCSBN, 2014a).
11. Identify the states that have implemented nurse-staffing ratios. List some of
the obstacles one of the states has encountered in the implementation phase.
CASE STUDY 4-1: Delegation of Medication
Administration by APRNs
The authority to administer medications in one state is restricted and specific.
The NPA allows RNs to delegate medication administration only to BON-certified
medication aides in nursing homes and residential care facilities. Otherwise,
unlicensed persons may only assist an individual with self-administration of certain
medications, may give oral medication or apply topical medication in accordance
with the laws and regulations of the Department of Disabilities, and may
administer prescribed medication to a student if the RN is employed by a board
of education or charter school if those medication administration procedures
are in accordance with the laws regulating boards of education. However, with
the exception of these special instances, RNs and APRNs are not permitted to
delegate medication administration to non-nurses, including medical assistants.
This restriction is problematic for APRNs, particularly NPs and CNSs who function in
primary care settings.
Patients in primary care settings frequently need immunizations, tuberculosis
skin tests, and routine medications. Because the current law largely prohibits
APRNs from delegating medication administration to unlicensed personnel, the
flow of patient care must be interrupted. APRNs must perform all medication
administration and associated tasks themselves, unless there is another RN who
is available to administer the medication. This prohibition is a significant barrier to
productivity and efficiency.
APRNs and stakeholder nurse associations approached a legislator who
has been a friend to nursing and is interested in improving healthcare delivery
in the state. This member of the state House of Representatives sponsored a bill
to allow APRNs to delegate medication administration to a trained, unlicensed
person, such as a medical assistant, so long as certain conditions are met. These
conditions include (1) the APRN has assessed the patient prior to administration to
determine appropriateness; (2) the APRN has determined the unlicensed person
has completed the requisite education and has the knowledge, skills, and ability to
administer the drug safely; and (3) delegation is in accordance with rules that are
established by the BON. Additional safeguards include (1) the drug must be within
the formulary established by the BON for APRNs, is not a controlled substance,
and is not to be administered intravenously; (2) the employer has given the APRN
access to employment records documenting the unlicensed person’s education,
knowledge, ability, and skills with regard to medication administration; and (3) the
APRN must be physically present at the location where the drug is administered
by the unlicensed person. Language in the bill clarifies that the APRN delegating
authority would not affect or change the current law governing delegation
authority in certain facilities, including nursing homes and residential care facilities.
82 Chapter 4 Government Response: Regulation
CASE STUDY 4-2: Evidence Versus Stakeholder
Interests in Rule Making
Prelicensure nursing education in the United States is tightly regulated by BONs.
Nursing education regulations include curriculum requirements and typically
include provisions regarding what must be included in classroom instruction,
in laboratory/simulation, and in clinical experience. “Clinical” generally refers to
those faculty-supervised experiences that occur in authentic patient settings
with persons who need nursing care. Some BONs specify minimum numbers of
hours of clinical experience; some do not. Prelicensure nursing education rules
do not directly affect APRNs; however, their indirect effect can be substantial.
APRNs may serve in administrative leadership roles or oversee the care of patients
in healthcare organizations where graduates of programs will hold future
employment.
One BON was approached by rural-area nursing educator stakeholders,
who had encountered difficulties in securing clinical experiences for students in
obstetrics, newborn care, and pediatrics. The BON asked its education advisory
This legislation received four hearings in the House Health Committee
and was reported out with two sponsor amendments. One amendment added
ambulatory surgical facilities to the list of sites where an APRN cannot delegate
medication administration, and the other moved the rule authority language
to the general rule authority of the nurse practice act. Although this second
amendment is technical, it is beneficial to APRNs in that it will authorize the
BON to promulgate rules without the advice and counsel of its multidisciplinary
Committee on Prescriptive Governance.
One state nursing association and one APRN testified on behalf of nursing as
proponents for the bill. The state medical association remained neutral throughout
the process.
Discussion Points
1. Identify ways to increase the likelihood that the legislation will pass.
2. Determine a complete list of possible stakeholders. In addition to state
nurses associations, which other associations or organizations might have
an interest?
3. Discuss the position of neutrality on the part of the state medical
association. Would you expect this? Why or why not? Could this
organization’s position change? Why or why not? If so, what could you do in
anticipation to assure its continued neutrality or future support for the bill?
4. Although a number of state nurses’ associations have an interest in this bill,
only one formally provided proponent testimony for the record. In addition,
one adult NP, who represented herself as a single practitioner, provided
testimony. What are the implications of limited proponent testimony? What
does a small turnout, or silence, say to legislators? What might be done
differently, or in addition, when the bill reaches the Senate?
(continues)
83Discussion Points
committee to discuss the matter. The committee made a recommendation,
based on a simulation study conducted by NCSBN, that as many as 100% of
clinical experiences in those areas could be replaced by high-, mid-, or low-fidelity
simulation in a skills laboratory setting.
The BON heard testimony at its rules hearing from proponents, primarily
representatives from the nursing education programs having difficulty finding the
experiences for students. Testifying in opposition were individuals representing
several nursing organizations, including the deans and directors of baccalaureate
and higher-degree nursing education programs, an organization representing
all chief nursing officers in the state, the state nurses association, and the state
pediatric nurses association. Proponents verified difficulty in obtaining clinical
experiences for students and cited their rationale for substituting simulation
for authentic clinical experiences. Opponents noted the findings of the NCSBN
study that indicated a maximum of 50% of clinical experiences could be replaced
with simulation and spoke to qualitative differences between authentic clinical
experiences and simulation. The individual representing chief nursing officers
offered to work with nursing programs to facilitate procurement of clinical
experiences.
Following deliberation, the BON determined to file the rule as proposed,
allowing substitution of up to 100% of clinical experience in the three specialties
(obstetrics, neonatal, pediatrics) with simulation.
Discussion Points
1. Which additional questions would you want answered about the
methodology and detailed findings from the NCSBN simulation study?
2. Who were the stakeholders? Which specific arguments can you anticipate
stakeholders on both the proponent and the opponent sides made for or
against the rule change, respectively?
3. If you were a nursing leader or practicing APRN in one of the specialty areas,
do you have any concerns about the proposed rule? Given your position,
are there any current or future actions you might take to safeguard patients?
CASE STUDY 4-2: Evidence Versus Stakeholder
Interests in Rule Making (continued)
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National Council of State Boards of Nursing (NCSBN). (2016). APRN consensus 2016. Retrieved
from https://www.ncsbn.org/9314.htm
National Council of State Boards of Nursing (NCSBN). (2017a). APRN compact. Retrieved
from https://www.ncsbn.org/aprn-compact.htm
National Council of State Boards of Nursing (NCSBN). (2017b). Map of NLC states. Retrieved
from https://www.ncsbn.org/nurse-licensure-compact.htm
O’Sullivan, J., Chaikind, H., Tilson, S., Boulanger, J., & Morgan, P. (2004). Overview of the
Medicare Prescription Drug, Improvement and Modernization Act of 2003. Congressional
Research Service. Order Code RL31966. Washington, DC: Library of Congress.
Pew Health Professions Commission. (1994). State strategies for health care workforce reform.
San Francisco, CA: UCSF Center for the Health Professions.
Pew Health Professions Commission. (1995). Report of task force on health care workforce
regulation (executive summary). San Francisco, CA: UCSF Center for the Health Professions.
Phillips, S. J. (2017). 29th annual legislative update. Nurse Practitioner, 42(1), 18–46.
Roberts, M. J., & Clyde, A. T. (1993). Your money or your life: The health care crisis explained.
New York, NY: Doubleday.
Russell, K. A. (2012). Nurse practice acts guide and govern nursing practice. Journal of Nursing
Regulation, 3(3), 36–42.
Safriet, B. J. (1992). Health care dollars and regulatory sense: The role of advanced practice
nursing. Yale Journal of Regulation, 9(2), 419–488.
U.S. Department of Health and Human Services (DHHS). (2014). The Affordable Care Act,
section by section. Retrieved from http://www.hhs.gov/healthcare/rights/law/
U.S. Department of Health and Human Services (DHHS), Centers for Medicare and Medicaid
Services (CMS). (2016, October). Advanced practice registered nurses, anesthesiologist
assistants, and physician assistants. Medical Learning Network. ICN901623. Retrieved
from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network
-MLN/MLNProducts/Downloads/Medicare-Information-for-APRNs-AAs-PAs-Booklet
-ICN-901623
86 Chapter 4 Government Response: Regulation
© Visions of America/Joe Sohm/Photodisc/Getty
KEY TERMS
Health services research: A multidisciplinary scientific field that examines a
multitude of factors, systems, and processes in the delivery of health care.
Policy tools: Those methods chosen by policymakers to help solve a problem or
social issue.
Unfunded mandate: A statute or regulation that requires a state, local
government, organization, or individual to perform certain actions, with no
money provided for fulfilling the requirements.
Public Policy Design
Catherine Liao
With thanks to Patricia Smart, PhD, RN
This chapter retains several older but classic references from the previous texts
because they are considered seminal works that define the topics discussed.
▸ Introduction
In today’s world and political climate, it is imperative that healthcare providers,
administrators, and educators be knowledgeable about and active in the policy
process, particularly as it relates to their professional work. The purpose of this
chapter is to examine public policy formulation processes and tools that govern-
ments use to solve large and complex societal problems (FIGURE 5-1).
The scope of government’s involvement in social issues in the United States
expanded rapidly in the 20th and 21st centuries. The development of federally
funded public programs such as Medicare and Medicaid in 1965 made a major
impact on how health care is delivered by providers and accessed by the public.
National costs for health care began rising immediately after the advent of Medi-
care and swelled to $3.2 trillion—or $9,990 per person—in 2015 (CMS, 2017).
87
CHAPTER 5
Public policy related to financing health care not only must assure access and
quality but also bend this cost curve downward.
The creation of Medicare and Medicaid was preceded by efforts in the early
20th century to provide a “safety net” for more Americans in terms of ability to
afford health care. The concept of a national health insurance program for Social
Security beneficiaries was first proposed by the Surgeon General in 1937 (CMS,
2015). Nearly 10 years later, a federal agency was created to administer programs in
health, education, and social insurance. In the two decades that followed, a social
awareness of the need for a true safety net emerged. By 1965, in response to this
pressure, Congress had enacted legislation creating Medicare and Medicaid as Title
XVIII and Title XIX of the Social Security Act, granting hospital insurance (Part A)
and medical insurance (Part B) to nearly all Americans older than age 65.
According to the Centers for Medicare and Medicaid Services (CMS), the
elderly population at that time was likely to be living in poverty, and a majority
of them were uninsured. In addition to extending health insurance and coverage
to this population group, the law helped to desegregate hospitals, which were
financially motivated to integrate given the “generous” payments offered in ex-
change for compliance with the Civil Rights Act of 1964. Facility costs in the form
of building and renovating structures were high, and Medicare reimbursement
could provide more than half of a hospital’s income (Smith, 2005)—an attractive
lure to hospitals.
All health insurers tend to follow and adopt whatever Medicare will reim-
burse, making the deliberations regarding this publicly funded program critical
to the health insurance benefits available to the vast majority of the nonelderly
insured population. The impact was even greater with the passage of the Patient
Protection and Affordable Care Act (ACA) in 2010. With the recent election of
Donald Trump as president and Republican majorities in Congress, the ACA is
expected to undergo rigorous redesign or replacement.
One of the factors that most inhibits the success of public policy is the in-
ability to predict consumer behavior and participation in a social program. The
gap in matching desired behavior with appropriate government tools is discussed
in this chapter.
Health care is fraught with a multitude of factors that are difficult to
identify and control, and the issue of healthcare reform has polarized the country.
FIGURE 5-1 Stages of the policy process.
Problem
Political
context
Policy
implementation
Policy
adoption
Policy
evaluation
Policy
formulation
icationidentif
88 Chapter 5 Public Policy Design
Policies related to access to affordable, quality health care have complicated the
debate, including raising questions about the following issues:
■ How to restore Medicare and Medicaid payments to hospitals that were cut
to pay for the subsidies offered under the ACA to low-income individuals
■ How to implement new payment models that reward quality over quantity
of the healthcare service provided
■ How to provide enough public funding for basic and clinical research, provider
education and professional development programs, and loan forgiveness for
professionals who are practicing in underserved areas
The United States has one of the most sophisticated healthcare systems in the
world with respect to innovation, health information technology, and preparation
of healthcare professionals. Yet in many of the health indices designed to evaluate
the overall health of a country, the United States rates comparatively low. For
example, the average life expectancy for females in the United States is 81.6 years,
whereas in Japan, Canada, and the Netherlands—all of which are also developed
countries—female life expectancy is 86.8, 84.1, and 83.6 years, respectively (World
Health Organization, 2016). Infant mortality is another important measure of a
nation’s health. The United States ranks low among industrialized countries on
this measure and also has a high rate of low and very low birth weights, a major
contributor to infant mortality (Centers for Disease Control and Prevention
[CDC], 2016b). The U.S. healthcare system continues to evolve and, therefore, will
continue to benefit from improvements made to its performance, effectiveness,
and efficiency by way of evidence-based policymaking.
Efforts have been made by previous administrations to address the issues
of access, cost, and quality—often referred to as the three pillars of healthcare
policy—but past policy proposals have reflected the prevailing political philos-
ophies and ideologies popular at the time. For example, government programs
in the 1960s, under Democratic administrations, reflected an ideology wherein
there was less concern with outcome-based planning and more concern with
access. Two decades later, under a Republican administration, regulatory efforts
attempted to reduce costs through outcome-based choices, individual respon-
sibility for cost, and smaller expansion of healthcare coverage. Policy changes
designed to influence one of the three pillars (access to care, quality of care, and
cost of care) inevitably affect all three; that is, none of the pillars may be altered
without consequences to the other two.
Policies are usually designed to influence behavior and motivate individuals to
do what they ordinarily might not do. Although many studies regarding the policy
process have been conducted, few have examined the process of policy design
specific to individual issues of health care. The focus of most policy studies has
been on the implementation of effective programs, and data have been gathered on
statistical outcomes. A policy may be more successful if its design is incorporated
into all phases of the policy process. For example, in the agenda-setting phase,
the problem or social issue could be stated in such a way that it will capture the
attention of lawmakers and framed so that government response will be feasible
and adaptable. During the implementation phase, the policy’s design provides
guidance and an overall picture of the plan by specifying the intended outcomes.
During the evaluation phase, the program objectives are clearly identified and
measurable to ensure that the proposed change produces the desired outcome.
Introduction 89
Public policy is, by nature, complicated. The root of public problems has no
simple single answer; if it did, more than likely the effort to address those prob-
lems would take the form of a guideline, recommendation, or rule implemented
by the private sector. Health care is perhaps the most convoluted of public issues
because it is affected by a multitude of factors, such as state, federal, and inter-
national economies; social movements; education; resources; and religion. As
a result, solutions that seek to provide accessible, affordable, and quality health
care without leaving a large segment of the population uninsured, driving up the
costs of health care, and sacrificing quality are often complicated, fragmented,
and difficult to implement across various healthcare settings and populations.
The nursing profession should engage in providing stories, data, and insight
to help policymakers design the most effective policies to improve access and
quality and reduce costs.
▸ The Policy Design Process
Policies reflect public opinion as well as evidence-based data. The policymakers
comprise a collection of stakeholders whose task is to find solutions to problems
that cannot be resolved by nongovernmental or philanthropic organizations. Pol-
icies that address social problems in the United States usually are formulated by
a combination of legislators and aides, the executive branch, and special-interest
groups and advocates on both the federal and the state levels. Policies may sub-
sequently be altered or struck down by the judicial branch (the courts).
Professional experts such as registered nurses are often asked to serve as
panel members or consultants or to serve on committees that provide input to
policymakers. Other nurse leaders also are increasingly playing leadership roles
in critical policy arenas. For example, under the Obama administration, Marilyn
Tavenner became the first nurse to lead the Centers for Medicare and Medicaid
Services, while Lieutenant General Patricia Horoho became the first nurse ap-
pointed as the Surgeon General for the U.S. Army. State nurses associations also
have increasingly taken on a leadership role in advocating directly for change,
leaving the sidelines of simply monitoring policy proposals under consideration.
Nurses and organizations representing nurses advocate for policies that may be
seen as self-serving: Policies that include advanced practice registered nurses
(APRNs) in reimbursement models, eliminate supervisory requirements, or
increase scope of practice fall into this category. Labor unions representing reg-
istered nurses often advocate for policies that may improve working conditions
for nurses, with staffing and safety being perennial topics of debate.
The proliferation of participants in policy formation makes systematic program
design that is focused on outcomes difficult to achieve. In her classic research,
Safriet (2002) reports that most social issues are not brought to the attention of
policymakers until there is a crisis with multiple causative factors. The decisions
that relate to or have an impact on perceived social problems often are made hastily
because of lack of information, constituency impatience, and lack of expertise.
Much policy that regulates nursing practice is determined at the state level,
and the policy process conducted here is no less complicated than at the federal
level. In the 2016‒2017 legislative session of the North Carolina General Assembly,
for instance, legislation was introduced that would have made several changes to
90 Chapter 5 Public Policy Design
North Carolina’s Nursing Practice Act, including increasing the scope of practice
for nurses in the state. Nursing advocates, including the North Carolina Nurses
Association and the North Carolina Association of Nurse Anesthetists, played
a significant role in designing the legislation to overhaul the existing law and
expand the scope of practice of APRNs. In the most recent legislative session,
advocates for change were bolstered by an economic analysis showing North
Carolina could significantly reduce healthcare spending by removing physician
supervision of APRNs in the state (Conover, 2015). The long-running debate
over independent practice for APRNs will continue, however, as N.C. legislators
declined to act again on this issue in the 2017 session.
▸ Research Informing the Policy Process
Health services research is typically defined as a multidisciplinary scientific
field that examines a multitude of factors, systems, and processes in the delivery
of health care. More specifically, nursing health services research can inform pol-
icymakers of clinical practice areas that involve the direct patient care experience
of the nursing community (Jones & Mark, 2005). In their assessment, Jones and
Mark note that nursing health services research can lead to the development of
knowledge that improves access, health, and patient safety, among other things.
Over the long term, they argue, such research can improve nursing care and
patient outcomes—two broad policy issues that benefit in some ways from state
or federal regulation.
A recent example of how clinical practice has informed policy involves safe
patient handling to protect nurses from musculoskeletal disorders and injuries.
The American Nurses Association (ANA, n.d.) notes how common these dis-
orders are in nurses and endorses the call for safe patient handling and mobility
(SPHM) programs and policies that protect the nursing workforce from manual
lifting and repositioning of patients.
In the 114th Congress (2015‒2017), the ANA advocated for the Nurse and
Health Care Worker Protection Act, which was introduced to require the Occu-
pational Safety and Health Administration to develop and implement an SPHM
standard to eliminate manual lifting of patients by nurses; require employers to
purchase, use, and maintain equipment; and require employers to train healthcare
workers annually on proper usage of equipment. Congress did not consider the
bill before it adjourned, but it is likely similar legislation will be reintroduced in
the current Congress (115th), and the nursing workforce community will continue
to pursue a strengthening of SPHM programs.
Schneider and Ingram (2005) suggest several issues that may affect failure to
take actions needed to ameliorate social, economic, or political problems: (1) lack
of incentives or capacity; (2) disagreement with the values implicit in the means
or ends; and (3) the existence of high levels of uncertainty about the situation that
make it unclear what people should do or how to motivate them.
Health services researchers can inform policy in a myriad of ways, ranging
from identifying a problem, to weighing the risks and benefits of possible solu-
tions, to providing estimates for how much a solution may cost government and
society (Clancy, Glied, & Lurie, 2012). Such research often relies on large national
data sets that offer insight into a particular problem. The Medical Expenditure
Research Informing the Policy Process 91
Panel Survey (MEPS), for example, consists of large-scale surveys of families
and individuals, their healthcare providers, and employers across the country.
According to the Agency for Healthcare Research and Quality (AHRQ; the federal
agency responsible for producing evidence-based information to make health
care safe, high quality, and accessible), MEPS gives researchers the most com-
plete data on the cost and use of health care and health insurance coverage in the
United States (AHRQ, 2017). Another helpful resource is the National Healthcare
Quality and Disparities Reports housed on the AHRQ website and retrievable
at https://www.ahrq.gov/research/findings/nhqrdr/index.html (AHRQ, 2015).
These annual reports offer summarized data that can stimulate ideas for further
study or research as well as cursory analyses to jumpstart projects. The reports
provide reliable and updated data that can lead to meaningful policy change in
improving care, lowering costs, and reducing health disparities.
▸ The Design Issue
Unclear mandates often result in a mismatch between legislative intent and
bureaucratic behavior. For instance, Congress enacted the Emergency Medical
Treatment and Labor Act (EMTALA) in 1986 to ensure access to emergency care
for patients with unstable conditions. Although the legislation requires hospitals
to provide specific emergency services to patients seeking treatment, regardless
of their citizenship, legal status, or ability to pay, the federal government does
not reimburse for the cost of that care. EMTALA was intended to eliminate the
practice of hospitals refusing to accept or treat unstable patients without proof
of insurance; patients were sometimes sent over long distances to a public or
county hospital. Despite the good intentions to ensure care for those in need, an
unfunded mandate puts pressure on hospitals, which can face high costs when
they are required to provide uncompensated care.
Policy design became a focus of research studies several decades ago.
Linder and Peters (1987), whose work established a classical starting point for
design research, reported that poor policy design is often the reason for policy
failure. Describing some programs as “crippled at birth,” these scholars noted
that the best bureaucracies in the world may not be able to achieve desired goals
if an excessively ambitious policy is used (i.e., the problem is too complex for
a single policy or agency). A recent example of complexity was the launch of
the healthcare.gov website to guide Americans in obtaining health insurance
under the ACA (also known as “Obamacare”). The extreme complexity of this
project resulted in multiple delays and frustration with the launch. Also, if there
is a misunderstanding of the nature of the problem, inappropriate policies may
be formulated. Linder and Peters proposed that implementation should be
examined but only as one of the conditions that must be satisfied for successful
policymaking. They maintain that by shifting the focus of study to policy design,
more reliable and explicit answers can be found, leading to greater chances of
policy success.
The design phase remains an integral part of the policy process. An un-
derstanding of the policy tools or instruments chosen for policy design and the
underlying assumptions of policymakers during the design process is critical to
an understanding of the overall policy process.
92 Chapter 5 Public Policy Design
▸ Policy Instruments (Government Tools)
The study of the instruments or tools by which the government achieves desired
policy goals has shed light on lawmakers’ intentions during policymaking and
allowed researchers to infer the predictive capabilities of tools. Two scholars
proposed a framework for studying policy based on policy tools. Schneider and
Ingram (1990), in their classic work, offer a framework to analyze implicit or ex-
plicit behavioral theories found in laws, regulations, and programs. Their analysis
uses government tools or instruments and underlying behavioral assumptions
as variables that guide policy decisions and choices. Their contention is that tar-
get group compliance and utilization are important forms of political behavior
that should be examined closely. When these tools are combined with process
variables such as competition, partisanship, and public opinion, Schneider and
Ingram argue, the tools approach moves policy beyond considering the standard
analysis and improved frameworks. They note that policy tools are substitutable,
and states often use a variety of tools to address a single problem.
To understand which tools are most efficient, emphasis should be placed on
using them in conjunction with a particular policy design. According to Howlett,
Mukherjee, and Rayner (2014), policy tools—that is, those methods chosen by
policymakers to help solve a problem or social issue—are so critical in policy
design that policy implementation cannot be achieved without them.
Howlett (2011) describes five specific policy tools used by governments in
designing policy. In addition, he identifies five broad categories of tools: authority,
incentives, capacity building, symbolic or hortatory, and learning. Professional
nurses can use their knowledge of policy tools to make suggestions and recom-
mendations to government leaders who are designing policies and programs.
Authority Tools
Authority tools are used most frequently by governments to guide the behavior
of agents and officials at lower levels. Authority tools are statements backed by
the legitimate power of government that grant permission and prohibit or require
action under designated circumstances. An example of an authority tool is a law,
regulation, or mandate that requires vaccination for daycare and school entry
under regulated criteria.
Incentive Tools
Incentive tools assume individuals have access to the resources they desire most and
will not be motivated positively to take action without encouragement or coercion.
Having access to what is most desired leads to wanting to get the greatest value for
each expenditure. Incentive tools rely on tangible payoffs (positive or negative) as
motivating factors. Incentive policy tools manipulate tangible benefits, costs, and
probabilities that policy designers assume are relevant to the situation. Incentives
assume individuals have the “opportunity to make choices, recognize the opportunity,
and have adequate information and decision-making skills to select from among
alternatives that are in their best interests” (Schneider & Ingram, 1990, p. 516).
An example of an incentive tool is payment or reimbursement for travel
costs to eligible veterans seeking health care at Veterans Affairs medical centers.
Policy Instruments (Government Tools) 93
However, if the professional nurse assumes that lack of transportation is a barrier
to accessing primary care (in that transportation options do not exist, regardless
of cost), the outcome from an attempt to use this particular incentive may fail.
Capacity-Building Tools
Capacity-building tools provide information, training, education, and resources
to enable individuals, groups, or agencies to make decisions or carry out activities.
These tools assume that incentives are not an issue and that target populations will be
motivated adequately. For capacity-building tools to work, populations must be aware
of the risk factors inherent in the tools and the ways in which these tools can help.
Capacity-building tools focus on education and technical support. For ex-
ample, information may point out the risks of drugs, and information on such
risk factors may be distributed to the target population through brochures, email,
online videos, or other presentations. The underlying assumption is that informa-
tion regarding the importance of addiction cessation is considered valuable and
users will stop using substances of abuse to protect their health. Capacity-building
tools also are used to encourage people to recognize the value of health care and
to sign up for healthcare insurance.
Symbolic or Hortatory Tools
Symbolic or hortatory tools assume that people are motivated from within and
decide whether to take policy-related actions on the basis of their beliefs and
values. An example of this type of tool is the use of lower-number legislative bills
reserved by congressional leadership. Procedural rules in the U.S. House of Rep-
resentatives allow certain bill numbers, such as House of Representatives (H.R.)
1, to be reserved and assigned to significant legislation. For example, Congress
approved H.R. 1, legislation to create the Part D program under Medicare—the
Medicare Prescription Drug, Improvement, and Modernization Act—in 2003.
Some of the lowest bill numbers are also reserved for use by leadership in the U.S.
Senate (Congress.gov). The way in which bill numbers are assigned indicates their
legislative significance (often symbolic) and signals that certain policy changes
are a high priority for the majority party.
Another hortatory tool is a federal request for proposals to research a par-
ticular topic of significant interest to the government. Universities capable of
conducting such research will apply for available grant awards, both to undertake
the research and to enjoy the benefits that accompany such funding.
Learning Tools
These tools are used when the basis upon which target populations might be
moved to take problem-solving action is unknown or uncertain. Policies that use
learning tools often are open-ended in purpose and objectives and have broad
goals. A needs assessment of the target population may be conducted by a task
force, which provides knowledge and insight for policymakers. For example, if a
community program addressing childhood obesity is proposed, a needs assess-
ment must be conducted beforehand to determine which information is needed
before a proposal is presented to the county council.
94 Chapter 5 Public Policy Design
Policy tools are important resources for the professional nurse because ex-
perience using them can enlighten policymakers and persuade them to support
or oppose a policy. Policy tools are similar to educational brochures and other
materials that nurses provide to patients and families so that the patient can make
informed decisions. For example, one of the primary goals of nursing is to provide
the patient with comprehensive information regarding whether the patient has
a chronic or acute illness or has undergone a stress-causing, life-changing event.
More specific educational guidelines relating to health promotion behaviors and
signs and symptoms of illness can reinforce information received from the care
provider. Similarly, policy briefs, talking points, and factsheets about specific
health conditions often are given to policymakers to help them understand a
health policy issue.
▸ Behavioral Dimensions
In addition to understanding the types and roles of tools in formulating policy,
professional nurses must understand behavioral assumptions and the political
context in which tools exist. The political climate in which social problems are
addressed often prescribes the choice of tools to be implemented. Various tools
are used when addressing social problems, and often these tools are interchanged,
frequently resulting in differing outcomes when the tools are applied by different
agencies, states, or countries. In the United States, for example, liberal policy-
makers are inclined to use capacity-building tools when developing policies for
poor and minority groups, such as grants to communities for social programs,
whereas conservative policymakers might use the same types of tools in devel-
oping policies applicable to businesses, such as strategic planning and business
development activities.
For example, with the growing incidence and prevalence of opioid abuse across
the United States, advocacy groups, healthcare providers, and federal and state
government have sought to propose policy and other interventions that alleviate
the epidemic’s burden while maintaining access to legitimate prescription drug
care (Bagalman, Sacco, Thaul, & Yeh, 2016).
CASE STUDY 5-1: The Opioid Epidemic
In 2013, the Trust for America’s Health characterized prescription drug abuse as
an epidemic, noting drug overdose deaths had doubled in 29 states since 1999
and outnumbered deaths from heroin and cocaine combined as well as deaths
from motor vehicle–related accidents. According to the CDC (2016a, 2016b), more
than 500,000 people died from drug overdoses between 2000 and 2015, and 91
Americans die every day from an overdose of prescription pain relievers, or opioids.
In 2014, the U.S. Department of Health and Human Services estimated that
4.3 million individuals abused opioids. The amount of prescription drugs
administered and sold continues to increase significantly, despite a lack of
corresponding pain reported by Americans (Chang, Daubresse, Kruszewski, &
Alexander, 2014; Daubresse et al., 2013).
Behavioral Dimensions 95
Public opinion also may have influenced government action in addressing
the opioid epidemic. In April 2016, the Kaiser Family Foundation’s Health Track-
ing Poll found that nearly two-thirds of Americans blame the federal and state
governments for not doing enough to fight the opioid epidemic. In addition, 44%
of those surveyed said they personally knew someone addicted to prescription
painkillers.
At the federal level, multiple members of Congress introduced legislation
to address the opioid epidemic in a variety of ways. The Comprehensive Addic-
tion and Recovery Act (CARA, S. 524), which Congress enacted in July 2016,
represented a comprehensive approach to addressing the problem, ranging from
strengthening of efforts at the primary care level to improvements to criminal
justice reform. Among other things, the law authorized grants to states and fed-
erally qualified health centers (FQHCs) to improve access to overdose treatment,
reversal medicine access, and education programs. It also authorized grants to
states to develop a treatment alternative to incarceration programs and to train
first responders to administer opioid overdose treatments. Other provisions of
the law support treatment and recovery organizations and provide incentives to
states to address prescription opioid abuse through education, prescription drug
monitoring programs, and prevention efforts.
The CARA bill was the first major federal addiction legislation in 40 years.
Despite the bill being enacted following lengthy negotiations between lawmakers
and the advocacy community, including physician groups and addiction advocates,
the bill’s passage was not heralded as a complete success. Congress authorized a
number of new programs to overhaul the way in which opioid abuse is treated
and prevented, but it failed to appropriate any funding for their implementation.
Not until the end of 2016 did Congress include $1 billion in funding to states
to combat the epidemic. Congressional Republicans, who held the majority in
the 114th Congress, sought Democratic support on another comprehensive bill
designed to speed up research conducted by the National Institutes of Health and
drug approvals by the Food and Drug Administration. Funding of $1 billion for
anti-opioid programs and interventions in this bill was included solely for the
purpose of enticing Senator Democrats to support the underlying bill.
Although the federal government is working to coordinate the national
response to the opioid epidemic, states have been approving legislation and
promulgating rules at a more local level, particularly in harder-hit areas. Ohio
and Kentucky were two of the five states with the highest rates of death due
to drug overdoses in 2015, with each state seeing nearly 30 deaths for every
100,000 people, according to the CDC. In March 2017, Ohio Governor John
Kasich approved regulations that limit the amount of opiates physicians and
dentists can prescribe to adults and children, requiring prescribers to include
a diagnosis or procedure code on every controlled substance prescription. The
state made exceptions for opioids prescribed for cancer, palliative care, or hospice
care. In April 2017, Kentucky Governor Matt Bevin signed into law legislation
(HB 333) that limits physicians to issuing three-day painkiller prescriptions for
patients with acute pain.
The North Carolina General Assembly (2017) also approved legislation that
requires pharmacists to immediately enter a patient’s prescription information
into a database. Under the bill, physicians will review the information before
96 Chapter 5 Public Policy Design
prescribing, and they will be limited to giving five- to seven-day doses for the
initial treatment. Politico also reports that multiple bills aimed at curbing opioid
abuse have been introduced in the Michigan and Minnesota legislatures, including
legislation that would increase the fee drug makers pay to sell opioids; limit den-
tists to prescribing medication in four-day increments; and require physicians to
use the Prescription Drug Monitoring Program to prevent patients from “doctor
shopping” for access to pain medication.
▸ Conclusion
As a component of professional nursing, active participation in the policy process
is essential in the formulation of policies designed to provide quality health care at
sustainable costs to all individuals. To be effective in the process, RNs and APRNs
must understand how the process works and at which points the greatest impact
might be made. The design phase of the policy process is the point at which the
original intent of a solution to a problem is understood and the appropriate tools
are employed to achieve policy success.
▸ Discussion Points
1. Using the https://www.congress.gov/ website, identify recently proposed
health policy legislation.
a. Research the background for the problem or issue being addressed
by the policy.
b. Is there an evidence base to support the proposed policy?
2. Using your understanding of the behavioral assumptions underlying the
tools, predict the potential for success or failure of the policy. Identify
policy variables that will affect success or failure.
3. Using the https://www.congress.gov/ website, search the 109th Congress
to identify a policy (e.g., rule, regulation) that has been in use for several
years yet has had little success. Identify the variables that may be inhibiting
success and offer possible solutions.
4. How does the political climate affect the choice of policy tools and the
behavioral assumptions made by policymakers?
5. Identify opportunities that are currently in place for RNs and APRNs to
begin activity in policymaking.
References
Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human
Services. (2015). National healthcare quality and disparites reports. Retrieved from
https://nhqrnet.ahrq.gov/inhqrdr/
Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human
Services. (2017, April). Medical expenditure panel survey. Retrieved from https://meps
.ahrq.gov/mepsweb/
American Nurses Association (ANA). (n.d.). Safe patient handling and mobility. Retrieved
from http://www.nursingworld.org/handlewithcare
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© Visions of America/Joe Sohm/Photodisc/Getty
KEY TERMS
Deflection of goals: A type of maneuver used in policy implementation that
creates changes in the original goals.
Dissipation of energies: Actions used by implementation players that can
impede, delay, and/or cause the collapse of a program.
Diversion of resources: A type of maneuver used in policy implementation to
win favor related to budget decisions.
Implementation: The time period following the decision to adopt a new policy or
guideline until the users have fully and consistently adopted the policy into practice.
Implementation climate: The shared perception by organizational members
that the innovation to be implemented is an organizational priority.
Implementation effectiveness: The regularity and consistency that the targeted
organizational members use the innovation or policy.
Innovation effectiveness: The benefits to an organization as a result of
implementation of the innovation or new policy.
Innovation–values fit: The perception that the innovation or policy is consistent
with the mission and values of the organization.
Policy Implementation
Leslie Sharpe
▸ Introduction
Why is understanding the process of policy implementation important for nurses?
Nurses make up the largest segment of health professionals in the United States—
3.6 million strong (American Nurses Association [ANA], 2017). However, Cramer
(2002) noted that nurses are disproportionately underrepresented in actively
101
CHAPTER 6
shaping health policy. Senator Edward Kennedy pointed out many years ago that
“nurses are America’s largest group of health professionals, but they have never
played their proportionate role in helping shape policy, even though that policy
profoundly affects them as both health providers and consumers” (1985, p. xxi).
As policy implementers, patient advocates, and healthcare consumers, nurses are
overwhelmingly qualified to sit at the table as experts in health policy planning
and implementation, but many lack the confidence due to the complexity of
health policy implementation.
The United States is in the process of implementing healthcare policies that
will transform its healthcare system, and nurses can and should play a funda-
mental role in this transformation. Cramer (2002) asserts that “today, more than
ever, nurse participation is needed to shape health policy” (p. 98). The Institute
of Medicine (IOM, 2010), in its Future of Nursing report, provides key messages
that structured the discussion and recommendations presented in the report,
including the following:
■ Nurses should practice to the full extent of their education and training.
■ Nurses should be full partners, with physicians and other healthcare profes-
sionals, in redesigning health care in the United States.
■ Effective workforce planning and policymaking require better data collection
and an improved information infrastructure.
Nurses should participate in and lead decision making and be engaged in
healthcare reform–related implementation efforts. Nurses also should serve
actively on advisory boards on which policy decisions are made to advance
health systems and improve patient care. The implementation of health policy
is complex, with a variety of actors and organizations involved in this endeavor.
The power to improve the current regulatory, business, and organizational
conditions does not rest solely with any one entity, however, but rather requires
that all must play a role.
Implementation of health policy occurs when an individual, group, or com-
munity operationalizes a policy or program to protect and promote the health of
individuals and the community. The policymaking process is cyclical, dynamic,
imperfect, and often complex. The relative success or failure of a policy or program
depends heavily on what happened during the implementation process—that is,
how the organization carried out the instructions indicated in the policy/program.
Helfrich, Weiner, McKinney, and Minasian (2007, p. 281) define implementation
as “the transition period, following the decision to adopt an innovation, during
which intended users bring the innovation into sustained use.” It is difficult to
discuss policy implementation in isolation, because the success of policy imple-
mentation relies heavily on the planning process as well as on feedback from the
evaluation process. Without adequate planning to address potential barriers,
implementation can fail miserably. The evaluation framework developed by the
Centers for Disease Control and Prevention (CDC, n.d.) recommends that the
implementation evaluation questions be considered as early as the planning stage.
For example, are the steps of the implementation process clearly outlined? Are the
necessary resources available for implementation of the policy? Formulating these
questions at the beginning will facilitate a smooth planning and implementation
process to enhance the likelihood of success. For the purposes of this chapter, we
will focus only on the implementation of health policy.
102 Chapter 6 Policy Implementation
Policies come in many forms: Some are statutory and result from legislative
enactment or permanent rule; others are nonstatutory in origin, such as pro-
cedural manuals and institutional guidelines. Health policies reflect the mix of
public health needs and desires of special-interest groups and often involve the
choice of who will get health care and how, when, and where the health care will
be delivered. Implementation is about who participates, including both actors
and organizations; why and how they participate, including procedures and
techniques that reflect command, control, and incentives; and with what effect,
meaning the extent to which the program goals were supported—the output
and the measurable change (the outcome). The implementation of healthcare
laws and policies can change the physical environment in which people live and
work, affect behavior, affect human biology, and influence the availability and
accessibility of health services (Longest, 2010).
▸ Federal and State Policymaking
and Implementation 101
Formulation of health policy on the federal and state levels can originate in any
of the three branches of government—legislative (senate or house), executive
(president or governor), or judiciary (Gostin, 1995). The preferences and influ-
ence of interest groups, political bargaining, and individual and organizational
biases play a significant role in the policymaking process, especially during im-
plementation. Ideology often poses the biggest barrier to unbiased formulation
and implementation of health policy that truly protects and promotes the health
of the population. Some policies, once implemented, may have unintended neg-
ative consequences and may need the advocacy of nurses or other groups to step
in and campaign for change.
The executive branch has substantial power in the policymaking arena
through executive orders, rule making, and guidance in interpretation of laws. The
executive branch also has access to vast amounts of information, data, research,
and recommendations from experts to guide the formulation of health policy.
Whether the members of this branch choose to listen to the recommendations of
experts or follow guidelines is an entirely different matter. For example, President
Ronald Reagan never implemented the recommendations from the President’s
Commission on AIDS (Black AIDS Institute, n.d.; Presidential Commission on
the Human Immunodeficiency Virus Epidemic, 1988).
Much of U.S. health policy formulation and implementation is initiated in
the legislature. In a democratic society, the legislative branch is considered to be
diverse, independent, impartial, and accountable to the public. Like the executive
branch, the legislature has access to extensive information collection capabilities
from objective resources to gather and analyze scientific data in the creation of
sound policy. However, politics can still get in the way. The legislature may be
dominated by one political party and ideological beliefs, such that policymaking
may lack impartiality, implementation of existing policy may be blocked, and
current health policy may be repealed. Moreover, legislators’ decisions may be
influenced by large professional organizations or special-interest groups, which
may make large financial contributions to their election campaigns.
Federal and State Policymaking and Implementation 101 103
In terms of health policy on the federal level, it is important to recognize
that not all health programs are assigned to the U.S. Department of Health and
Human Services (DHHS) for implementation. Six major government healthcare
programs provide services to about one-third of Americans: Medicare, Medicaid,
the Children’s Health Insurance Program (CHIP), TriCare, the Veterans Health
Administration (VHA), and the Indian Health Service (IHS) program (IOM
Committee on Enhancing Federal Healthcare Quality Programs, 2002). Congress
can order pilot programs, demonstrations, or full implementation in any of these
six programs. For example, the decision may be made to assign implementation to
the Department of Defense (DOD) or the Department of Veterans Affairs (VA);
if implementation is successful at this level, the hope is that the broader health
community will be more willing to adopt these programs. Examples of program
implementation that relate to health but are carried out by other agencies include
TriCare, which is administered by the Office of the Assistant Secretary of Defense
(IOM Committee, 2002), and the Supplemental Nutrition Assistance Program
(SNAP—formerly known as the food stamp program), which is administered by
the U.S. Department of Agriculture (Center for the Study of the Presidency and
Congress Health and Medicine Program, 2012). These decisions may be very
political in nature, but they are often quite strategic when positioning programs
for success with implementation.
The final branch of government that affects the implementation of health
policy is the judicial branch. The court system is often called on to intervene
when a policy may intrude on basic human rights or when the programs or
policies are not implemented according to the original intent. Challengers
to implementation may have to turn to the judiciary system for resolution of
their protests. While many may perceive that the court system is impartial,
it is important to remember that judges in the higher courts are appointed
by political figures, have no accountability to the public, hold long-term ap-
pointments, have minimal experience in scientific thinking, and rarely have
any expertise in health issues. Despite these concerns, the judiciary system
has contributed to health policy in the areas of reproductive rights, the right
to die, and mental health.
▸ Implementation Research
The body of evidence from implementation research in health care is growing,
including research that provides information about factors influencing nursing’s
implementation of evidence into practice. Organizations that want to make
evidence-based practice (EBP) and best practice guidelines the norm in their
operations need to be aware of complex and varied challenges for successful im-
plementation. Helfrich and colleagues’ (2007) conceptual framework on complex
innovation implementation (adapted from Klein and Sorra, 1996) illustrates the
determinants of complex innovation implementation in large organizations;
healthcare organizations can improve their chances of success by using this frame-
work. This framework can also be useful when evaluating unsuccessful policy
implementation to determine whether the failure is due to poor implementation
or flaws in the innovation or policy.
104 Chapter 6 Policy Implementation
Conceptual Framework
Helfrich and colleagues (2007) adapted Klein and Sorra’s (1996) framework
for innovation implementation in the manufacturing setting to the healthcare
setting. Helfrich et al. found that several factors were essential to ensure effec-
tive implementation of complex innovations. Management support that clearly
emphasizes the rationale and priority for the innovation as well as allocation of
adequate financial resources to support the new innovation or policy are necessary
antecedents to successful implementation. The implementation climate—that
is, the targeted users’ “shared summary perceptions of the extent to which their
use of a specific innovation is rewarded, supported, and expected within their
organization” (Klein & Sorra, 1996, p. 1060)—is a critical factor in determining
the effectiveness of the implementation. Helfrich and colleagues expanded Klein
and Sorra’s framework by exploring the relationship between the innovation–
values fit (the perception that the innovation or policy is consistent with the
mission and values of the organization) and the use of champions and their impact
on implementation climate. They found that the implementation climate was
enhanced if the innovations–values fit was strong and champions were used to
promote the innovation. According to their research, a stronger implementation
climate is more likely to contribute to higher implementation effectiveness.
Successful policy implementation on the organizational level depends on the fit
between the organization and the objectives of the policies it must implement. “Fit
is determined by whether (1) the organization is sympathetic to the policy’s goals
and objectives and (2) the organization has the necessary resources— authority,
money, personnel, status or prestige, information and expertise, technology, and
physical facilities and equipment to implement the policy effectively” (Longest,
2010, p. 135). When policy implementation is examined or evaluated, one question
that begs discussion is the notion of what is considered acceptable compliance. Is
100% compliance realistic? If not, which measures need to be taken to get closer
to an acceptable compliance rate? Who determines what is acceptable (and based
on which data)? Does the policy need to be reexamined? What are the imple-
menters doing and reporting? Is this a policy, person, or systems problem? Do
the measures of success need to be reconsidered or redefined?
CASE STUDY 6-1: Training For New Computer
Systems Enhances Implementation
Many health systems have been upgrading to new computer systems. If you have
ever experienced this kind of change, you know that it is quite a complex process
with many opportunities to derail the project.
Several years ago, a local health system implemented a computer upgrade to a
new electronic medical record (EMR) system. Management and administration had
been preparing for this upgrade for several years. The administration allocated the
necessary resources to make the implementation a success not only financially but
also in terms of increasing information technology (IT) staff and training of “superusers”
(continues)
Implementation Research 105
or champions. These “superusers” were from within the organization and from every
level of the organization and were given extensive training well ahead of other users.
In preparation for this change, management spent time and resources
educating those working within the organization about the importance of this
upgrade in achieving the mission of the organization by increasing connectivity
with other health systems, maximizing reimbursement, and achieving meaningful
use compliance (innovations–values fit). This pre-education enhanced the
implementation climate by helping the intended users understand that the
transition to an upgraded EMR was an organizational priority, thereby enhancing
the implementation effectiveness. Over several months, the targeted users
(nursing staff, providers, managers, front desk workers, and coding and billing
personnel) were trained in preparation for the change. Target dates for the change
were set, and clinic schedules were reduced to allow time for using the new
system (another example of management support).
Although it was a bumpy ride, the upgrade to the new computer system, as
well as the implementation effectiveness, was very successful. Others may argue
that the innovation effectiveness (the benefit of the new computer system to
the organization and ease of use) is not quite so apparent.
Discussion Points
1. Who are the champions in your organization? What qualifies them to be
champions, or which qualities do they possess?
2. When your organization has implemented a major change, did it have
the benefit of a strong implementation climate? Which steps did the
organization take to ensure successful implementation effectiveness? What
could it have changed to improve the climate and effectiveness?
3. How did your organization determine the success of the implementation of
the new policy or innovation? Which measures were evaluated? Should the
organization have reexamined the implementation or made the decision to
change course? Why or why not?
CASE STUDY 6-1: Training For New Computer
Systems Enhances Implementation (continued)
The work of Ploeg, Davies, Edwards, Gifford, and Miller (2007) offers ad-
ditional insight into the perceptions of administrators, staff, and project leaders
about factors influencing implementation of nursing best practice guidelines at
the individual, organizational, and environmental levels. The factors that facilitate
implementation include learning about the guideline through group interactions,
positive staff attitudes/beliefs, the presence of champions, support from leadership
at all levels of the organization, and interprofessional teamwork and collaboration.
In addition, financial support from professional associations and partnerships
across agencies and sectors is important. Making changes in an incremental manner
(adding to current knowledge and practice) rather than as radical breaks (totally
new concepts) facilitates implementation as well (Ploeg et al., 2007).
Barriers to implementation may include negative staff attitudes and beliefs as
well as limited integration of the guideline recommendations into the organiza-
tional structure and processes. The most common examples of such barriers are
106 Chapter 6 Policy Implementation
inadequate staffing for implementation activities such as educational sessions and
lack of the recommendations’ integration into the organization’s policy, procedures,
and documents. Time and resource constraints for implementers may include a
heavy workload, being short-staffed, and feeling rushed due to the short timeline
imposed by the funder. Consideration needs to be given regarding which other
organizational changes might be occurring at the broader system level at the time
of implementation. For example, nurses have described the difficulty of adding a
practice guideline change when they were already dealing with multiple stressors
in the work environment, such as short-staffing or structural renovations on a
unit (Ploeg et al., 2007).
The majority of problems that interfere with policy implementation are “peo-
ple problems,” referring to those individuals who interact with the recipients of
the policy or program. Personal attitudes and perceptions come into play during
policy implementation. Nurses are often implementers and directly encounter
many of the dilemmas that can occur when interacting with clients. Implementers
must practice coping strategies such as negotiation and may find themselves in
unforeseen circumstances or being confronted with rules that are often vague
but with which they are compelled to comply. Implementers see themselves as
required to interpret the policy involved in a creative but justifiable way. Some-
times they may be working with scarce resources. How often have you heard
someone say, or even thought to yourself, “If they would just come down here and
see how it is in the real world, they wouldn’t make policies that are impossible to
carry out!” When faced with these kinds of pressures, implementers may decide
to alter the policy/procedure based on their perception of shortcomings in the
policy. These perceptions of policy shortcomings may reflect the implementer’s
desire to enhance his or her professionalism, strengthen leadership, and perhaps
restructure the organization (Hill & Hupe, 2002). In essence, public employees or
frontline workers, often referred to as “street-level bureaucrats,” function as policy
decision makers because they wield considerable discretion in the day-to-day
implementation of public programs or policies as they interact with the recipients
of those policies (Tummers & Bekkers, 2014).
Implementing policies in ways that please everyone involved is incredibly
difficult. When the results of a policy are determined to be disappointing or even
worse, administrators are often quick to blame the implementers. When policy-
makers find out that the policy they wrote yields disappointing results, they may
be inclined to take additional measures in hopes of ensuring tighter control. Both
policymakers and administrators may add more (internal) rules and regulations.
The following list summarizes the key elements to be considered when
making policy and examining policy implementation. Think about a policy
or program you have been involved in. Did it turn out the way you thought it
would or should? Were there gaps in the implementation process that affected
the outcomes? Take a look at the following list and see if you identify with any
of these reasons for implementation success or failure (Mazmanian & Sabatier,
1983, cited in Hill & Hupe, 2002):
1. Policy needs to be relevant, feasible, and based on sound theory with an
appropriate rationale that will correctly identify the design conditions
and the desired effect on the target groups.
2. Policy objectives need to be clear and consistent or, at a minimum,
identify criteria for resolving goal conflicts.
Implementation Research 107
3. Policy should provide the persons in charge of implementation with
sufficient jurisdiction and leverage points over the target groups to
help reach the desired goals.
4. Policy must maximize the likelihood that the implementing officials and
target groups will have sufficient resources to comply with the policy.
5. Policy needs to be examined periodically to ensure it has ongoing
support from outside and within the agency/organization and that
conditions have not changed over time in a way that might affect
implementation.
Policy implementation is a complex process and one in which it is almost
impossible to separate policies from politics. Many political barriers arise that could
potentially impede successful implementation. It is easy to understand why the
U.S. public feels frustrated with government; this frustration reflects the perceived
failure of government to turn promise into performance. Looking back at the list
of key elements for successful implementation, think about what happens when
a policy lacks clarity, such as the travel ban executive order issued by President
Trump in 2017 (Perez, Brown, & Liptak, 2017). When the ban was implemented,
few people within the Trump administration, much less airport officials trying
to implement the policy, were clear on which countries were included in the ban,
resulting in widespread confusion for travelers and airport customs officials.
The following case study illustrates how citizens negatively affected by a
policy can provide feedback and advocate for change through political activism.
CASE STUDY 6-2: When Policy Implementation
Is Rejected by Citizens: Reinstatement of the
Medical Expenses Deduction on North Carolina State
Income Taxes
In 2013, the North Carolina General Assembly overhauled the state’s tax code, which
had been in effect since the 1930s. The proposed plan eliminated several deductions
from individuals’ state income taxes. The initial proposal eliminated deductions for
mortgage and property taxes, contributions to nonprofit organizations, medical
expenses, long-term care insurance, government and private retirement income,
and contributions to the NC 529 college savings plans. In an effort to offset the
elimination of these deductions, the proposal increased the standard deduction
for single people from $3,000 to $7,500 and for married couples filing jointly from
$6,000 to $15,000. Lobbyists for realtors and nonprofit organizations were successful
in persuading the legislature to keep their deductions, although mortgage and
property tax deductions were limited to $20,000. Senior citizens did not have anyone
lobbying on their behalf, and most of the eliminated deductions affected them.
The N.C. General Assembly’s fiscal research staff forecasted that taxpayers
across all categories would see some slight reduction in their tax burden. However,
they also acknowledged that those 65 and older might pay more because several
of the categories affected them. In contrast, the N.C. Budget and Tax Center said
108 Chapter 6 Policy Implementation
those taxpayers making less than $84,000 would end up paying more in taxes. The
majority of citizens 65 and older are in that category.
The legislation took effect in 2014. It turned out that almost all senior citizens
suffered sticker shock when they filed their 2014 state income taxes. On average,
their income tax increased by $1,800. That summer, the North Carolina Continuing
Care Residents Association (NorCCRA) created a legislative committee and
organized a letter-writing campaign to members of the House Appropriations
Committee. Because nothing could happen in the 2014 short legislative session
to remedy the perceived problems, the campaign was essentially an educational
piece letting legislators know that residents would be back in the 2015 session
seeking to reinstate the medical expenses deduction.
Sindy Barker, chair of the newly formed statewide Legislative Committee,
had retired in 2006 after spending 19 years lobbying the N.C. General Assembly
on behalf of the North Carolina Nurses Association. Her knowledge of how to
successfully lobby for nursing issues enabled the NorCCRA Legislative Committee to
develop a systematic plan for approaching members of the 2015 General Assembly.
Questions were raised as to whether an organization that had never lobbied
before could pull together a successful lobbying effort, especially when there
did not appear to be much support for its issue among members of the General
Assembly. In fact, when HB46, Senior Tax Deduction for Medical Expenses, was
introduced, the Fiscal Research Division said the state would lose $37.9 million
in revenues from this deduction in 2015 alone. That forecast escalated to $44.1
million by fiscal year 2019–2020. Moreover, this loss to state revenues assumed that
the deduction was reinstated only for citizens age 65 and older.
Members of the General Assembly did understand that a high percentage of
senior citizens vote, and that retired individuals also have more time to make contact
with their legislators. Over the course of several months, the 20,000 residents living
in continuing care retirement communities (CCRCs) in North Carolina were asked to
write 650 individual letters or emails to the following legislators:
■ The 15 members of the House Committee on Aging, explaining the bill and
then thanking them for a favorable report
■ The 74 members of the Republican Caucus
■ The 42 members of the House Committee on Finance
■ The 81 members of the House Appropriations Committee
■ All 120 members of the House, thanking them for including the medical
expense deduction in the budget
■ The 50 members of the Senate, asking them to include the medical expense
deduction in their version of the budget
■ The 83 members of the Budget Conference Committee, asking them to
support the House version of the deduction with no cap
■ The 170 members of the General Assembly, thanking them for reinstating the
medical deduction in the final budget
One CCRC held a letter-writing party and sent 1,761 letters in one day. Several
simply put out petitions for their residents to sign and then forwarded those
letters to the appropriate legislators. The typical petition contained upward of 150
signatures. Members of the General Assembly soon realized this was an issue dear
to the heart of many of their regular voters.
Ms. Barker, the Legislative Committee chair, brought her husband in a
wheelchair to the General Assembly when she appeared before committees, and
he became the face of what “high medical expenses” look like. The issue made the
(continues)
Implementation Research 109
CASE STUDY 6-2: When Policy Implementation
Is Rejected by Citizens: Reinstatement of the
Medical Expenses Deduction on North Carolina State
Income Taxes (continued)
front page of several major state newspapers and was featured in online stories
and local newscasts.
By the end of March 2015, NorCCRA had been joined in its campaign by AARP,
N.C. Retired Government Employees, and organizations that represent children
and adults with chronic diseases and disabilities. This coalition meant more letters,
emails, and phone calls to legislators. In one week in April, they achieved more
than 7,000 contacts, or approximately 40 contacts per legislator.
When the reinstatement of the medical expenses deduction was included
in the House budget toward the end of May, the policy advocates were halfway
home. It was not a very smooth ride, but by the middle of September, the medical
expenses deduction was reinstated in the final budget passed by the General
Assembly.
The reinstatement of medical expenses deduction took effect for 2015 taxes,
so 2014 was the only year with the higher increase. NorCCRA conducted another
survey in 2016 following income tax filing in the spring. The senior citizens’ average
tax bill was $1,400 less than it had been in the previous year. The other deductions
that were eliminated in 2013 remain in place, but the one that clearly had the
biggest impact was the medical expenses deduction. Members of the General
Assembly again received thank-you letters from NorCCRA, letting them know what
a difference their legislation had made.
Discussion Points
1. How can legislation with such negative consequences for a large group of
citizens be prevented or stopped?
2. Using the models you have studied in this text, where did the N.C. General
Assembly “go wrong” with the policy aimed at gaining more revenue from
taxpayers?
3. Once the original policy to eliminate specific tax deductions was passed
by the legislature, which steps in the implementation process might have
prevented the backlash by citizens?
4. Why might forecasts regarding the impact of a policy be incorrect and lead
to unintended consequences?
5. Were the consequences of the original legislation intended or unintended?
Why or why not?
Successful implementation depends heavily on the manipulation of many
variables. These variables include private agencies and groups that are often con-
tractors for carrying out policies; the target groups themselves; public attitudes;
resources; the commitment and leadership of officials; and the socioeconomic,
cultural, and political conditions in the environment in which policies are
supposed to operate (Palumbo, Calista, & Policy Studies Organization, 1990).
110 Chapter 6 Policy Implementation
The presumption that regulations and policies are enacted according to their
original intent turns out to be fallacious in many cases. The conscious or un-
conscious refusal to follow the policy directives can result in noncompliance,
making the actual implementation process far from what the policymakers
originally envisioned.
Bardach (1977), in his classic study of implementation, describes political
factors and maneuvers that can impede implementation of policies and result
in poor performance, escalating costs, and delays. Types of maneuvers that may
derail policy implementation include diversion of resources, deflection of
goals, and dissipation of energies.
Diversion of resources manifests itself in several ways. Organizations and
individuals who receive government money tend to provide less in the way of
exchange for services for that money. Playing the budget game is another diversion.
Persons responsible for the budget do what they can to win favor in the eyes of
those who have power over their funding. Incentives shaped for implementers by
those who control their budgets influence what the implementers do with respect
to executing policy mandates.
During the implementation phase, goals often undergo some change result-
ing in the second type of maneuver—deflection of goals. The change in the goals
can be the result of multiple factors: (1) perception that the original goals were
too ambiguous or too specific; (2) goals that were based on a weak consensus;
(3) goals that were not thought out sufficiently; (4) an organization that realizes
the program will impose a heavy workload; (5) a program that takes the organi-
zation into controversy; or (6) required tasks that are too difficult for the workers
to perform. An agency may try to shift implementation of certain unattractive
elements to different agencies. If no one wants the responsibility of taking charge
of those elements, consumers get the runaround and each agency involved can
claim it is not their problem (Bardach, 1977).
The third maneuver—dissipation of energy—wastes a great deal of the
implementers’ time. Dissipation of energy occurs when implementers avoid
responsibility, defend themselves against others, and set themselves up for advan-
tageous situations. Some may use their power to slow or stall the progress of the
program until their own terms are met. This action can lead to delay, withdrawal
of financial and political support, or total collapse of a program.
▸ Conclusion
Policy implementation is the stage of the policy process immediately after passage
of the law. The relationships between rule making and operational activities in-
volved with implementation are cyclical. The series of decisions and actions that
occur during implementation will impact the extent to which the program goals
are supported and the measurable change that occurs. In this stage, the content
of the policy, and its impact on those affected, may be modified substantially
or even negated. In analyzing this stage in the policymaking process, one needs
to examine how, when, and where particular policies have been implemented.
Problems with policy implementation are widespread. During the imple-
mentation process, the political forces of individuals, groups, organizations, and
sometimes governmental bodies are at work. These various forces may be trying
Conclusion 111
to change the policy to meet their own needs and control a part of the imple-
mentation process. When the implementers are not working in concert to meet
the intended legislative goals, the recipients lose. Remember, the entire nursing
community and other health professionals can affect implementation in both
positive and negative ways.
CASE STUDY 6-3: Using the ICD-10 Codes
The Department of Health and Human Services (DHHS) mandated that all
healthcare organizations and hospitals transition from coding based on the
International Classification of Diseases, 9th revision (ICD-9) to the International
Classification of Diseases, 10th revision (ICD-10) by October 1, 2015 (CDC, 2015).
ICD-9 codes had been the standard classification of diseases since the 1970s
(Athenahealth, 2016). These codes are used in healthcare settings such as hospitals
and outpatient clinics and serve many purposes. The ICD-10 codes enhance
the quality of data used to aid in determination of reimbursement for services
rendered, assist with the tracking of public health conditions, aid in clinical
decision making, facilitate identification of fraud and abuse, improve the ability
to gather data for epidemiological research, and measure outcomes of patient
care (CDC, 2015). The new codes were much more specific, with the number of
diagnosis codes skyrocketing from 14,025 codes to 69,823.
While the implementation of ICD-10 had been anticipated for several years,
many issues still arose when the actual implementation occurred in 2015 (Weiner,
2015). First, the Centers for Medicare and Medicaid Services promised a “grace
period” in which it would accept codes in the correct “family” of codes, even if
they were not to the highest level of specificity (Girgis, 2015; McCarthy, 2015).
Unfortunately, other insurers expected correct coding from day one, contributing
to increased work from providers and coders to make sure the coding was correct.
Insurance companies were not fully prepared to answer questions related to the
coding issues; some websites were not available for a few days, and sometimes
billers spent hours on hold with these companies. Finally, while many facilities
had put time and money into the information technology side of the equation,
professionally trained coders were in short supply. Delays in submitting correct
coding can significantly affect timely and accurate reimbursement, so effective
implementation is crucial in this situation.
▸ Discussion Points
Evaluate the feasibility of implementing an evidence-based practice, best practice
guideline, meaningful use measures, or federal mandate in your work site.
1. Identify how the proposed innovation/policy will result in improved care
or contribute to the sustainability of the organization.
2. List the resources, including interprofessional teams, personnel, and
economic resources, you will need for implementation. Which is the best
department or agency to implement your program, innovation, or policy?
Who are the necessary team members/champions to facilitate successful
implementation?
112 Chapter 6 Policy Implementation
3. Using the Helfrich et al. (2007) conceptual framework of complex inno-
vation implementation, think about barriers that might potentially derail
the implementation. Which recommendations would you suggest to im-
prove the likelihood of success with the implementation of your EBP or
policy? How can you improve the implementation climate to enhance the
probability of successful implementation? Who are the champions in your
organization? Which qualities are important for a champion to possess?
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.nuemd.com/news/2015/10/09/5-early-problems-encountered-with-icd-10
Palumbo, D. J., Calista, D. J., & Policy Studies Organization. (1990). Implementation and the
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114 Chapter 6 Policy Implementation
© Visions of America/Joe Sohm/Photodisc/Getty
KEY TERMS
Agency: An administrative division (e.g., government department) that provides
a particular service. The majority of the independent agencies of the United
States are classified as executive agencies (they are independent in that they are
not subordinated under a Cabinet position). A small number of independent
agencies are not considered part of the executive branch, such as the Library of
Congress and the Congressional Budget Office; they are administered directly by
Congress and are considered legislative branch agencies. Agencies are largely
responsible for policy and program evaluation.
Evaluation report: A compilation of the date-driven findings of a program
evaluation. Reports are presented in a variety of formats depending on the
needs of those requesting the evaluation. Common formats include written
reports, electronic transfer, oral presentations with multimedia enhancements,
films, and videos.
Health-in-all-policies: Recognizing and evaluating the health effects of
non-health policies, scholars and others seeking to improve Americans’ health
have advocated the implementation of a culture of health that would call
attention to and prioritize health as a key outcome of policymaking across all
levels of government and in the private sector.
Health Policy and Social
Program Evaluation
Anne Derouin
What cruel mistakes are sometimes made by benevolent men and women in
matters of business about which they can know nothing and think they know
a great deal.
—Florence Nightingale, Notes on Nursing
115
CHAPTER 7
▸ Introduction
This chapter highlights the process of evaluation—the critical step in all policy
and programming that ultimately provides an informed means of feedback, im-
provement, and justification of resources. The primary discussion here relates to
the Patient Protection and Affordable Care Act of 2010 (ACA), which has been
the overarching health policy law of the United States since 2011.
We also discuss the relationship between policy evaluation and the healthcare
quality movement in the United States, which has emerged in the recent reform
era as governmental agencies required programs to plan, perform, and report
performances. Evaluation has become increasingly valuable as federal, state, and
local policymakers recognize that nearly every decision they make and every pro-
gram they propose ultimately affects the health status of the population (Rigby &
Hatch, 2016). The health-in-all policies approach applies to programs such as
urban development, education, and transportation that are being planned, as
their effects are ultimately linked to population health outcomes. Evaluation of
these policies and their economic impact requires reliable and relevant policy and
program evaluation data. It is critical that professional nurses are familiar with
evaluation principles and can apply aspects of evaluation throughout all phases
of healthcare program planning, implementation, and outcome assessment.
Informed consent: The process by which the treating healthcare provider
discloses appropriate information to a competent patient so that the patient
may make a voluntary choice to accept or refuse treatment.
Policy: A law, regulation, procedure, administrative action, incentive, or voluntary
practice of governments or other institutions that generally operates at the
systems level, aiming to improve the health and safety of a population.
Policy evaluation: An activity that uses principles and methods to examine the
content, implementation, or impact to understand the merit, worth, and utility
of a policy.
Program evaluation design: A subset of policy design, which is often left
up to the responsible agency; the method selected to collect unbiased data
for analysis to determine the extent to which a social program is meeting its
designated goals, objectives, and outcomes and to assess the program’s merit
and worth. Evaluation methods may be qualitative or quantitative.
Program/outcomes evaluation: Analysis of social programs using a set of
guidelines to gain an understanding of how well the policy, program, or
intervention is meeting the objectives and goals set forth in the policy’s design.
Theory: An idea used to design a program and its interventions and to explain
and predict broad phenomena observed after data analysis.
Triple aim: A framework developed by the Institute for Healthcare Improvement
that asserts health system performance will be optimized through healthcare
designs that simultaneously pursue three dimensions: improving the patient
experience of care (including quality and satisfaction), improving the health of
populations, and reducing the per capita cost of health care.
Unintended consequences: Outcomes of evaluation that are not the ones foreseen
by a purposeful action or a program or policy. These effects can be viewed as either
positive (“luck” or a “windfall”) or negative (“drawback” or “backfire”).
116 Chapter 7 Health Policy and Social Program Evaluation
▸ Nurses’ Role in Policy/Program Evaluation
Professional nurses, regardless of their practice setting, expertise, and level of
education, are typically well versed in evaluating and analyzing the effectiveness
of their assessment, planning, and implementation efforts; the foundational
theory of the nursing process includes the critical step of evaluation. The same
principles that nurses use to assess the impact and effectiveness of clinical inter-
ventions, procedures, or clinical practices can be applied to program/outcomes
evaluation or policy evaluation. Assessing impact, effectiveness, and value in
improving the health, social, and economic conditions of various stakeholders
and determining the need for enhancement or improvement are essential aspects
of quality healthcare policy and programming (Centers for Disease Control and
Prevention [CDC], 2011; Her Majesty’s Treasury, 2011). Like the nursing process,
which is intended to ensure safe and effective patient care, create and facilitate
excellent health professional academic and training programs, and ensure reliable
research data and dissemination, qualitative and quantitative program evaluations
are integral to effective policy and programming.
Two emerging themes of healthcare policy planning and evaluation over
the past decade were accelerated and brought into the light by the passage of the
ACA in 2010: (1) promotion and demonstration of leadership among all profes-
sional nurses and (2) an overarching goal to meet the quadruple aim. The term
quadruple aim was coined in 2014 to highlight the four main aims of healthcare
reform efforts (and evaluation thereof ) that were the focus of the ACA: improved
quality of patient care, reduced healthcare costs, improved population health
status, and job satisfaction among healthcare workers (Bodenheimer & Sinsky,
2014). Prior to this time, evaluation of the healthcare reform policy had been
termed the triple aim; this evaluation focused only on quality, cost savings, and
effectiveness of patient care evaluations. The triple aim was expanded to the
quadruple aim owing to the emerging shortage of healthcare providers, especially
physicians and nurses, along with evaluation data that demonstrated dissatisfied
healthcare providers had a negative impact on the triple aim goals. Along the way,
the value of reliable data became clear to policymakers, healthcare providers, and
the public: Rational changes cannot be made to policies and programs without
such data because evaluation often is the “missing link” in the policy process.
See the chapter entitled The Impact of EHRs, Big Data, and Evidence-Informed
Practice for further discussion of big data.
Concurrently, a call for enhanced nursing leadership was highlighted in the
Institute of Medicine’s (IOM, 2010) landmark report, The Future of Nursing. The
report noted that nurses were vital to the redesign of healthcare systems, needed
to be viewed as partners of physicians and other healthcare providers, and needed
to be “at the table” to ensure effective planning, implementation, and ongoing
evaluation of healthcare policies. The IOM report prompted the proliferation of
leadership training and interprofessional learning opportunities for nurses in the
United States, which in turn contributed to the advancement of nurses in roles of
advocacy, quality improvement, healthcare research, and innovative healthcare
programming and policy planning.
As members of the largest segment of the healthcare workforce, which is
currently in the midst of an evolution (or revolution), nurses have an important
role in policy and program evaluation. The American Nurses Association (ANA)
Nurses’ Role in Policy/Program Evaluation 117
is the largest professional U.S. nursing organization responsible for professional
advocacy and offers a Code of Ethics, stating that professional nurses are “responsible
for . . . shaping and reshaping health care in our nation, specifically in areas of
health care policy and legislation that affect accessibility, quality, and the cost of
health care” (Fowler, 2010). Evaluation is a critical aspect of the efforts to reshape
the U.S. healthcare system, helping all stakeholders understand the true impact
of each step of the gradual process of change and helping direct and define the
aims and goals for the future. Evaluation is also a critical aspect of the nursing
profession, serving as the key to improving quality, safety, efficiency of clinical
practice as well as assessing the impact of emerging innovations and science
(Polit & Beck, 2012).
Processes of Evaluation
The process of evaluating policy and programs may be instituted informally or
formally. In small clinical settings such as private practices and in rural health
centers with limited resources, internal policies and programming occasionally
will be evaluated informally through word of mouth, in a “water-cooler discussion”
among a small group, by sharing opinions and experiences through social media,
or during in-person team meetings or debriefings. As one might imagine, infor-
mal evaluation may actually be gossip: The data can be skewed, disjointed, and
inaccurate, making any improvement processes ineffective. In contrast, a formal
evaluation process, termed program evaluation design, relies on standardized
strategic evaluation processes that ensure all stakeholders are involved in plan-
ning and evaluation after implementation of policy or programming. Andersen,
Fagerhaug, and Beltz (2009) note that formal evaluation is the appropriate stage
after policy implementation to assess effectiveness in terms of accomplishing goals
and objectives. The researchers suggest policy evaluation plans should be designed
to discover the short-term and long-term expected outcomes of implementation,
include an explanation of how the data relative to healthcare policy will be collected,
and outline a clear plan for how the results will be used.
Evaluation processes may also be considered formative or summative in
nature. Formative evaluations assist program developers and stakeholders in
understanding the progress throughout the development of a program, address-
ing concerns or unintended consequences and providing opportunities for
improvements or enhancements in the program or policy. Summative evalua-
tion occurs at the end point of a program (summing up the data) and seeks to
determine the extent to which goals were achieved. Both types of evaluation are
critical in assessing healthcare policies and invaluable for nurses to utilize and
understand the policies’ implications.
Evaluation of federal healthcare policies and programs was first mandated
through the National Performance Review and the Government Performance
and Results Act of 1993 (GPRA), updated in 2010, to focus on accountability,
performance measurement, and results (Office of Management and Budget [OMB],
2011). States, because of funding matches provided by the federal government,
also require that programs be evaluated.
Program evaluation follows a standard set of guidelines or a framework,
with the aim being to provide information that assists others in making accurate
and well-informed judgments about a program, service, policy, organization, or
118 Chapter 7 Health Policy and Social Program Evaluation
practice (CDC, 2011). Evaluation is used to examine programs, gain an under-
standing of the achievement of predetermined goals and objectives, and assist
in determining how human services policies and programs are solving the social
problems they were designed to alleviate (Sonpal-Valias, 2009; Westat, 2010).
TABLE 7-1 highlights the overarching benefits of evaluation.
To promote a national standardized framework for evaluation of healthcare
policies, the CDC (2014) designed a theoretic model, or “map,” for evaluating
healthcare policies and program effectiveness. Illustrated in FIGURE 7-1, the five-step
framework guides nurses, healthcare team members, economists, politicians,
scientists, and administrators in strategically planning processes for collecting and
utilizing evaluation data throughout the entire policy or program development
process in an effort to ensure new policies are feasible, useful, accurate, and effective.
TABLE 7-1 Policy and Program Evaluation Benefits
Assess
effectiveness
(short/
long-term
performance
measurements)
Assess
achievement
of goals/aims
(accountability
measures)
Assess
efficiency
(cost–benefit
relationship)
Determine
impact
(unintended
consequences)
Establish
future
improvements
and goals
FIGURE 7-1 CDC framework for evaluation in public health.
Reproduced from Centers for Disease Control and Prevention. (2017). A framework for program evaluation. Retrieved from https://www.cdc.gov/eval/framework/
Engage
stakeholders
Describe the
program
Focus
evaluation
design
Gather
credible
evidence
Justify
conclusions
Use and
share
lessons
learned
Standards
Utility
Feasibility
Propriety
Accuracy
The CDC framework also offers practical guidelines for planning, implementing,
and disseminating evaluation results. It highlights the value of evaluation in the
context of the entire policy process as a means to promote effective changes and
improvements to health care and society. Within the framework, three main types
of evaluation can be systematically performed: policy content (clearly articulated
goals, implementation and evaluation plans of the policy), the implementation
of the policy (Was the policy implemented as planned?), and the outcome of the
policy (Did the policy produce the intended outcomes or impact?).
Nurses’ Role in Policy/Program Evaluation 119
Steps in the Evaluation Framework
The first step in the program/policy evaluation process begins as the program
or policy is being planned. This step engages key stakeholders in discussions to
determine their interest and degree of buy-in on the development of the proposed
policy. It also seeks to establish goals, preliminary objectives, and timelines.
Step 2 is the development of a formalized process that involves identifying
the person(s) responsible for each part of the process, choosing which qualitative
and quantitative data will be collected (and by whom), and selecting a timeline.
In Step 3, data are gathered using the determined format and analyzed to reach a
conclusion. In Step 4, the evaluator tries to understand the extent of the success
of the policy or programs in attaining the objectives and goals.
Step 5 involves formally sharing the data conclusions and lessons with
stakeholders in the evaluation report, a formalized document that highlights
the evaluation methods and results. The dissemination of this report is the last
step in the CDC framework, and it leads to planning for the next consequential
cycle of policy/program evaluation. Typically, a report of the results provides
data measurements, discusses the “lessons learned” through the implementation
phase of the project, and highlights objectives of the healthcare policy or pro-
gram that were achieved (if the policy reached its outcomes) and next steps for
improvement and sustainability.
The CDC framework for evaluation in public health is an example of a
process evaluation cycle that can be continually repeated to analyze outcomes,
assess program/policy effectiveness, and plan for improvements and adaptations,
similar to the nurse process. At the federal level, oversight and evaluation of
policies through this process occurs in the executive agencies and in the General
Accounting Office, which has mandated reporting guidelines.
The process evaluation framework may be used to evaluate apparent problems
or unintended effects of a policy or program. When evaluating an untoward effect,
such as an unplanned budget deficit, the evaluation cycle may be called a rapid
cycle quality improvement (RCQI) evaluation. Rather than occurring at planned
intervals of evaluation, such as an annual report, the RCQI would be implemented
expediently at the time of a problem’s discovery to address an immediate con-
cern. The RCQI does not replace the standard outcome evaluation (summative
evaluation) but rather would be completed in addition to the standard cycle to
address a specific concern (formative evaluation).
Another example of using both evaluation cycles would be the planned
monthly, mid-year, and end-of-fiscal-year outcome evaluations undertaken by
accredited healthcare facilities, which must comply with standards and criteria to
maintain their funding and status (summative). If the agency noted a shortfall in
its financial budget due to high patient readmission rates, it could also perform
a RCQI to determine the patient population being readmitted and the factors
associated with the problem, using the results to strategically plan to decrease
the readmission rates (formative).
The formal evaluations of accredited agencies help assure the public of the
agency’s reliability and trustworthiness. RCQI program evaluation helps discover
causes of problems and aims to address any “unexpected effects that resulted
from politics surrounding a policy or the development and implementation of a
policy” (Porche, 2012, p. 3).
120 Chapter 7 Health Policy and Social Program Evaluation
A more complex formal evaluation process is called policy analysis. This
process, which is commonly used by legislatures to create federal and state policies
and laws, focuses on the political costs and benefits of healthcare policy reform
(Harrington & Estes, 2004). Policymakers formulate their decisions (and legislative
votes) for reforms based on factors such as the following:
■ The proposed technical merits, costs, and benefits of the policy or program
■ The potential effects of the reform policy on the political relationships among
the bureaucracy, government groups (political parties), and their beneficiaries,
including the potential impact on governmental stability
■ The perceived severity of the problem and whether the government is in a crisis
■ Pressure or support from national and international healthcare agencies and
political activities or interest groups
Before federal healthcare policies or programs are proposed and approved,
and funds are appropriated for their enactment, each of these factors is carefully
considered by the policymakers. Results of the analysis are used to determine
the extent of support for a proposed healthcare policy or program. The details
of the analysis provide specific examples of the degree to which a program or
policy has met its goals and objectives and, in some cases, whether the desired
change has occurred. The complexity of policy analysis at the federal level often
impacts state and local policies and programs, making evaluation methods and
the results of healthcare reform programs difficult to interpret.
Implications of Evaluation for Healthcare Reform
Although formative and summative evaluations have provided valuable data
for planning and implementing healthcare reform policies in the United States,
both informal and formal evaluation processes have had a profound effect on the
healthcare policy landscape over the past several years. Informal evaluation of the
ACA began long before the policy became law in the United States; the nation was
awash with a wide variety of opinions of and misconceptions about the ACA (also
known as “Obamacare”) and its probability of effectiveness and success, risks to
the national landscape, costs, and various implications for the nation’s citizens,
economy, health, and national and state infrastructure. Both the federal and the
state policy analyses included cost‒benefit analysis; healthcare insurance coverage
rates for children, elderly, disabled, and formerly uninsured Americans; costs
of annual insurance coverage and tax benefits or penalties; and the impact on
Medicare, Medicaid, and private healthcare insurance rates and costs. Monitoring
health status on a national scale, within each state, and most recently at the county
level was also an important aspect of evaluating effects of legislation.
As the ACA was implemented, policy analysis also included implications
for national and state employment rates, risks to small-business owners, lack
of medical providers to meet healthcare demands of the population, and finan-
cial impacts on state hospital and public health departments. These analyses
incorporated the expertise of financial and policy stakeholders, healthcare
providers, and the general public. Professional nurses were urged to engage in
the evaluation process, advocate for cost transparency, campaign for patient
education regarding enrollment in subsidized health insurance plans, and assist
with the dissemination of accurate evaluation results. Many professional nursing
Nurses’ Role in Policy/Program Evaluation 121
organizations—such as the American Nurses Association (ANA), the National
League of Nursing (NLN), the American Association of Colleges of Nurses
(AACN), and the American Association of Nurse Practitioners (AANP)—
provided formative data to lawmakers throughout the evaluation processes of
the ACA. These groups were asked to assist with data collection and eventual
dissemination of summative evaluation data through their professional com-
munication networks, to patients, to interprofessional team members, and to
other stakeholders.
Dissemination of the initial outcome analysis of the impact of the ACA began
in 2014. For many reasons, including the complexity of the results, the overall
impact of the policy initially proved difficult for many to clearly understand.
Informal evaluation of the ACA’s impact was evident in political debates, news
reports, and social media. The effectiveness, value, and unintended consequences
of the many aspects of the ACA vary depending on personal ideology, information
sources, and geographic location.
At the time of this writing, the future of the ACA was the subject of conten-
tious debates in Congress, where the final “repeal, replace, repair, or improve”
decisions were still unknown. It is clear that informal evaluation and RCQI will
continue throughout the process, but ongoing cycles of formal evaluation with
summative reports have become paramount to healthcare and social policy and
programming.
▸ Challenges to Effective Policy
and Program Evaluation
Most challenges in program evaluation can be addressed with appropriate planning,
the use of effective evaluation design, and the use of reliable or consistent indicators
that can be measured using standardized methods of data collection, analysis,
and reporting. Having a skilled and knowledgeable point person (a champion),
a skilled analyst who is responsible for completing the evaluation, and adequate
resources is key to a successful evaluation.
Conditions of program or policy evaluation that may be beyond the con-
trol of the evaluators include the rapid (or delayed) pace of policy changes,
executive-branch pressure for expedient production of evaluation results, and
public scrutiny of the results. Some stakeholders may be dissatisfied with the data
collection or analysis methods, believe results are politically tainted, or request
further data collection, analysis, or explanation of the findings. Other external
factors influencing evaluation results include economic conditions of the affected
communities or systems, public awareness of the policy or program, social media,
and political campaigns. Policy evaluation results may be difficult to interpret
when similar communities or contexts for making comparisons cannot be read-
ily identified. As new innovations or policies are implemented and evaluated,
there may be a lack of appropriate comparative data results, making it difficult
to clearly understand their impact. EXHIBIT 7-1 summarizes the challenges that
policy evaluators may face.
In some situations, evaluation results can polarize communities and lead to a
new focus of social or health policies that were unexpected and must be addressed
122 Chapter 7 Health Policy and Social Program Evaluation
by governmental and healthcare professionals. For example, the water quality
policy evaluation reports in Flint, Michigan, in 2014 showed significant health
risks due to contamination of the city’s water supply over a two-year period. In
a policy decision to save money during the ongoing economic depression, city
officials decided to change the city water source to the Flint River, which had been
previously deemed unhealthy. Ongoing public health concerns by public health
officials and residents living in Flint, media attention, and analysis of the water
(led by a local pediatrician and research team) eventually spurred city government
action. This is a recent example of the power of the national media spotlight and
highlights the importance of considering a health-in-all-policy approach. The
evaluation of Flint’s water after the city switched its water source to the Flint River
revealed that the number of children with elevated lead levels in their blood had
nearly doubled. In neighborhoods with the most severe contamination problems,
lead levels in children had tripled. (See the timeline here: https://www.nytimes
.com/interactive/2016/01/21/us/flint-lead-water-timeline.html.)
When implementing policies or programs designed to improve the health
of populations and communities, professional nurses must adopt strategies to
minimize the evaluation challenges. Resources are available to guide effective
evaluation and offer solutions to common challenges. When reading evaluation
results and reports, carefully consider the following questions:
■ Were data strategically collected, analyzed, and disseminated by a reliable
research team, and is the report unbiased and complete?
■ Does the evaluation answer the question, “Is this program or policy achieving
the objectives and goals for which is was designed?”
Ethical Considerations
Ethical issues represent another set of challenges relevant to policy and program
evaluation. The Flint water crisis is an example of an ethical dilemma that faced
researchers, advocates, and policymakers when significant concerns among
many stakeholders were ignored and principles of ethical conduct were violated.
To avoid conflicts and dilemmas, many professional organizations—including
the American Psychological Association (2010), the American Counseling Asso-
ciation (2014), and the American Evaluation Association (2011)—have published
ethical guidelines for evaluation. The CDC (2011) also offers guidelines to program
EXHIBIT 7-1 Challenges to Health Policy Evaluation
■ Lack of resources to complete evaluation
■ Lack of a champion
■ Lack of stakeholder collaboration/buy-in
■ Lack of comparative results
■ Rapid pace of policy/program evolution
■ Demands for early (preliminary) results
■ Request for further evaluation and details
■ Social media, public opinion, and campaigning
Challenges to Effective Policy and Program Evaluation 123
and policy evaluators that include a brief review of ethical principles and questions
that professional nurses can ask themselves when faced with an ethical challenge.
The fact that these principles are specifically addressed by so many professional
groups highlights both the risks and the impact of ethics related to healthcare pro-
gramming and policy. The overarching themes of each guideline include the key
principles of ethics: (1) Healthcare policy and programming should help people
while avoiding harm, and (2) application and evaluation of programs should be
fair and respectful.
These themes of beneficence, safety (nonmaleficence), autonomy, and justice
resonate with nurses who are guided by the ANA Code of Ethics (ANA, 2015).
Although all the included provisions are helpful in guiding the practice of profes-
sional nursing, three of the nine provisions in the Code of Ethics directly relate
to the ethical principles of policy and program evaluation (TABLE 7-2).
The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
mandated privacy standards that protect participants’ medical information, thereby
addressing a key area of ethical concern. Most large agencies, universities, and
clinical settings have established institutional review boards (IRBs) to guide safe
and ethically sound evaluations. In such an evaluation, only pertinent patient
information is collected during the evaluation phase, and all data are kept in
a secure and private location. Evaluation data are analyzed by evaluation team
members only; no outlying data or personal information is shared outside of the
study team. After analysis and dissemination of results, all data are disposed of
in a secure and permanent manner in accordance with federal policies governing
human subject studies (FIGURE 7-2).
Avoiding ethical conflicts that threaten the safe implementation of programs
or policies is a paramount concern, highlighting the importance of planning and
thoughtful preparation for evaluation throughout all phases of a project. Conflicts
and unintended ethical issues can be avoided through clear delineation of roles
(who is responsible for communicating) and clear evaluation objectives (what will
be communicated) related to program/policy evaluation. Disseminating results
described using culturally appropriate, nonbiased jargon or terminology elimi-
nates an ethical conflict by communicating effectively so that data can be readily
interpreted by interdisciplinary professionals, patients, families, or populations.
Communication Strategies That Reduce Conflicts
Due to the complex nature of the U.S. federal, state, and local political environ-
ments, the expanse of social programs, and the ongoing quality-focused healthcare
delivery revolution, difficult ethical conflicts are bound to occur. Social programs
tend to engage stakeholders who range from savvy political and social leaders
to healthcare workers, staff, and program recipients—and each of these parties
requires an understanding of how a given program or policy is applicable to them.
Clarke (1999) suggested five strategies related to communication that can
reduce conflict and ethical risks during program evaluation:
1. Identify specific cultural, political, and social environmental factors
to address critical aspects of program evaluation.
2. Identify stakeholders and ensure objectives and goals of the project
are established and communicated routinely and consistently to all.
3. Recognize the potential for conflicts among stakeholders and diplo-
matically address any contentious issues promptly.
124 Chapter 7 Health Policy and Social Program Evaluation
TA
B
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7
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A
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s.
Challenges to Effective Policy and Program Evaluation 125
4. Involve multiple stakeholders throughout the project planning, design,
implementation, and dissemination of results.
5. Routinely communicate the progress of the project as it evolves through
the implementation and evaluation cycles.
These strategies will be familiar to professional nurses, who typically engage
in similar communication approaches when collaborating in patient care settings
and with intraprofessional and interprofessional team members in clinical or aca-
demic environments. These strategies, in combination with the use of healthcare
program and policy evaluation theories and the application of professional ethical
guidelines, have helped elevate the value and impact of improvement efforts and
outcome reporting while also diminishing ethical dilemmas. FIGURE 7-3 summa-
rizes effective strategies for communicating evaluation results.
▸ Conclusion
Evaluation is an invaluable component of all policy and social programs resulting
from the policy process. Evaluation provides data, commentary, and critical ev-
idence for ongoing improvement, enhancement, and effectiveness of programs.
It helps policymakers, administrators, clinicians, financial stakeholders, and the
general public understand what works and what needs to change to improve the
health and well-being of individuals, populations, and communities. Participa-
tion of nurses in all aspects of healthcare policy and programming evaluation
(planning, implementing, collecting data, and disseminating results) is vital.
Given that nurses represent the largest segment of the healthcare workforce and
have critical insights into the application of policies and programs, the voice and
FIGURE 7-2 Ethical consequences.
• Inappropriate data sharing
• Failure to gain informed consent
• Failure to protect identities
• Preliminary results shared prior to evaluation
• Sharing opinions (rather than facts)
• Promoting/negating program prior to analysis
Ethical
consequences
related to patient
information
FIGURE 7-3 Effective program development communication.
Effective Communication Strategies
Identify and use culturally appropriate
tools for evaluation and dissemination
Routinely communicate with stakeholders
throughout entire process of project
Identify key stakeholders to set common
goals and objectives
Involve stakeholders throughout project
and address conflicts promptly
126 Chapter 7 Health Policy and Social Program Evaluation
wisdom of professional nurses must be considered during all stages of evaluation.
The importance of the engagement of nurses in policy and programming cannot
be overemphasized in the era of healthcare reform.
When they embrace the health-in-all-policies mentality, professional nurses
utilize their critical thinking and expert communications skills to consider the
benefits of all programs and public policies, much in the same way they might
consider the effectiveness of a nursing intervention for a patient receiving care,
the implementation of a new clinic policy, or an innovative community health
program. As our understanding of the breadth and impact of social determinants
on the well-being of people grows, it is becoming evident that all social and
economic policies ultimately impact population health and should be carefully
considered by nurses. Evaluation, therefore, is a critical part of the ongoing cycle
of health improvement and quality programming.
Program evaluation may create anxiety and a sense of vulnerability among
government officials, health economists, lawmakers, bureaucrats, and other stake-
holders (including nurses), but careful evaluation planning, methods of analysis,
and dissemination of evaluation results can prevent conflicts, circumvent ethical
dilemmas, and avoid unintended negative consequences. An example of unintended
consequences can be seen in Education Week commentary “Good Intentions, Bad
Intentions” by Robert Sternberg (2004), which addresses the many negative im-
plications that resulted from the No Child Left Behind Act (NCLB) (PL107-110).
NCLB was intended to improve the academic standards and performance of U.S.
primary school students but did not effectively use stakeholder buy-in and effective
evaluation planning strategies throughout the policy’s implementation process. Unin-
tended consequences of NCLB included educator dissatisfaction; claims of students,
teachers, and schools cheating on tests; students dropping out of school prior to
graduation; and inappropriate assessments of disabled and non-English-speaking
students. Many of these consequences might have been avoided if the program
developers had paid careful attention to evaluation principles and strategies.
Evaluation efforts that are carefully outlined and planned for during the early
stages of the program implementation cycle can help ensure the data collected
later will provide evidence that shows whether the policy or program met its
intended goals and outcomes. This cycle, known as quality improvement, can
be applied in either rapid/short or extended time periods across the life of pro-
grams, in healthcare innovations, and in policies to evaluate effectiveness and
opportunities for improvement or enhancement.
The use of evaluation as a tool to ensure reliability and effectiveness should
be perceived as an opportunity rather than as a daunting or fearsome challenge.
Standardized frameworks, theories, and tools are readily available to guide ef-
fective quantitative and qualitative program evaluation methods and to ensure
that reported data can be trusted as reliable and meaningful for all stakeholders.
Evaluation is an essential step in policy and program development and offers
lawmakers, administrators, and program planners a compass for direction in the
journey toward a future characterized by improved efficiency, effectiveness, and
quality of health outcomes in the United States.
Nurses historically have been under-utilized in policy planning and eval-
uation efforts but are increasingly being recognized as valuable members of
policy and healthcare teams. Nurses are poised to participate in national, state,
and local policy planning and ongoing evaluation as healthcare reform and social
Conclusion 127
programming continue in the post-ACA era. As service leaders, the largest seg-
ment of the healthcare workforce, and the “hub” of all healthcare delivery systems,
professional nurses are urged to use their voices, expertise, and collective power
to influence all levels of healthcare systems and to support a future of positive
(and measurable!) change.
▸ Discussion Points
1. List three advantages of using a theoretical framework or model to evaluate
policy and social or healthcare programs.
2. Describe the impact of policy, policy evaluation, and social program eval-
uation on professional nursing practice.
3. What does health-in-all-policies imply? What are the implications of
health-in-all-policies for professional nurses?
4. Describe common challenges to policy and program reporting and strat-
egies to diminish the effects of these challenges.
5. Analyze potential ethical conflicts in policy and program evaluation and
reporting. How can these conflicts be avoided or addressed?
6. Describe specific ways in which professional nurses can become engaged
in evaluation of program and policy evaluation efforts.
7. Describe useful resources available to professional nurses who are planning
a healthcare program or innovation.
CASE STUDY 7-1: Evaluating Clinical Services
A school-based health clinic (SBHC), located in an isolated region of the county, has
been serving high school students from the school and surrounding community for
more than 15 years through financial support from the state and a regional healthcare
system. The advanced practice registered nurse (APRN) working in the clinic
has provided services to more than 5,000 clients in the past years and has partnered
with a number of education and health professionals to promote the benefits of the
SBHC. Due to budget constraints related to the ACA, the state no longer intends to
fund the SBHCs in the coming year. The APRN has been asked to address both the
health system and the administrative teams to discuss closure of the clinic.
Discussion Points
1. Where should the APRN begin?
2. Which evaluation methods and data should the APRN be prepared to share
with the administrative team at the health system and with policymakers?
3. Who are the stakeholders in this evaluation process, and how should they
be engaged?
4. Describe some ethical considerations and role conflicts the APRN may face.
5. Which communication strategies might the APRN utilize to ensure that an
effective message is shared with the stakeholders?
6. Describe possible unintended consequences (positive and negative) of the
evaluation effort.
7. How can RNs and APRNs use similar evaluation data to influence the state
policymakers to reinstitute funding for school clinics?
128 Chapter 7 Health Policy and Social Program Evaluation
CASE STUDY 7-2: Walk-In Versus Scheduled
Appointments
A state-funded teen clinic located in an urban setting has routinely used
appointment-only visits to schedule adolescents for well-health and acute
visits, including contraception counseling and treatment and screening for
sexually transmitted infections. The clinic, led by an APRN, serves as a teaching
site for graduate nursing and medical students and receives reimbursement for
precepting students from the local professional schools. Recently, the medical
school threatened to withdraw its learners from the clinic because of low patient
volume, which has limited the learning experiences of the students. This threat
prompted the clinic administrators to evaluate clinic usage. The analysis found
that more than half of the appointments scheduled resulted in “no shows.” The
administrators have decided to change the clinic to a walk-in only scheduling
format and have suggested using social media to promote availability.
Discussion Points
1. As the APRN working in the teen clinic, do you agree with this decision?
Why or why not?
2. Describe the next steps for evaluating this proposal.
3. Which evaluation data would be important for this clinic to collect?
4. Who are the stakeholders in this scenario, and who would be essential in
the evaluation process?
5. Suggest how the planned scheduling changes might be evaluated and the
results disseminated.
6. Discuss ethical considerations anticipated when changing the clinics’
scheduling format and the use of social media to promote enrollment.
7. Who would be most appropriate to evaluate the clinic policy, and who
would pay for the evaluation?
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Institute of Medicine (IOM). (2010). Future of nursing 2010 report. Retrieved from
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related materials. Retrieved from http://www.whitehouse.gov/omb/management.grpa
/index-grpa
PL107-110 No Child Left Behind Act of 2001. https://www.congress.gov/bill/107th-congress
/house-bill/1
Polit, D., & Beck, C. (2012). Nursing research: Generating and assessing evidence for nursing
practice. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins.
Porche, D. (2012). Health policy: Application for nurses and other healthcare professionals.
Burlington, MA: Jones and Bartlett.
Rigby, E., & Hatch, M. (2016). Incorporating economic policies into a health-in-all-policies
agenda. Health Affairs, 35(11), 2044–2052.
Sonpal-Valias, N. (2009). Outcome evaluation: Definition and overview. Retrieved from
http://www.acds.ca/images/webpages/evaluation/MTD_Module_1_Outcome_Evaluation
_Definition_and_Overview
Sternberg, R. (2004). Good intentions bad intentions: A dozen reasons why the No Child Left
Behind Act is failing our schools. Education Week. Retrieved from http://www.edweek.org
/ew/articles/2004/10/27/09sternberg.h24.html
Westat, J. F. (2010). The 2010 user-friendly handbook for project evaluation. National Science
Foundation Directorate for Education & Human Resources, Division of Research, Evaluation,
and Communication. Arlington, VA: National Science Foundation.
Online Resources
AcademyHealth (http://www.academyhealth.org): Provides links to health services researchers
in health policy and practice and fosters networking among a diverse membership.
Agency for Healthcare Research and Quality (http://www.ahrq.gov): Provides links to multiple
resources. The mission of this agency is to improve the quality, safety, efficiency, and
effectiveness of health care for all Americans.
American Evaluation Association (http://gsociology.icaap.org/methods/): Free resources for
program evaluation and social research methods.
ANA Code of Ethics (http://nursingworld.org/DocumentVault/Ethics-1/Code-of-Ethics-for
-Nurses.html): The American Nurses Association’s code of ethics for nursing practice,
including interpretative statements.
Centers for Disease Control and Prevention, Program Performance and Evaluation Office
(http://www.cdc.gov/eval/resources/index.htm): Provides links to multiple resources for
information or assistance in conducting an evaluation project.
Education Week (http://www.edweek.org/ew/index.html?intc=main-topnav): An online weekly
resource that provides commentary on evaluation results and unintended consequences
related to federal policy. This resource may be useful to view when considering health-in-
all-policies for children, education, and communities.
130 Chapter 7 Health Policy and Social Program Evaluation
Free Management Library (http://www.managementhelp.org): Developed by Authenticity
Consulting. Provides extensive online resources for program evaluation and personal,
professional, and organization development, including many detailed guidelines, worksheets,
and more.
National Registry of Evidence-Based Programs and Practices (https://www.healthdata.gov
/dataset/national-registry-evidence-based-programs-and-practices-nrepp): Focuses on
mental health, but the module to develop and evaluate a program is well organized, concise,
and easy to read.
National Science Foundation (http://www.nsf.gov/): An independent government agency
responsible for advancing science and engineering. In this role, the NSF has developed
multiple tools to use in the evaluation of programs that are applicable to a variety of
programs.
United Nations World Food Programme (http://www.wfp.org/): Focuses on the United Nations’
food program. The site presents links to 14 modules providing step-by-step advice on
monitoring and evaluation guidelines. A useful resource to review.
131Online Resources
© Visions of America/Joe Sohm/Photodisc/Getty
KEY TERMS
Big data: Very large data sets beyond human capability to analyze or manage
without the aid of technology used to reveal patterns and discover new learning.
Clinical decision support: Tools that guide healthcare providers’ judgments.
Comparative effectiveness research: Research that examines the benefits and
harms of various methods used to prevent, diagnose, treat, or monitor a health
condition or to improve care.
Crowdsourcing: A process in which a problem is posed, help solicited, and help
offered by an unofficial group of geographically dispersed people.
Database: A collection of information organized and used for ease of access,
management, and updates.
Data governance: The process of converting data and information into an
electronic format so that it can be accessed, processed, stored, or transmitted
via the use of computer technology.
Data science: The systematic study of digital data.
Data scientists: People who specialize in the analysis and interpretation of
complex digital data.
Digitization: Process of converting data and information into an electronic format
so that it can be accessed, processed, stored, or transmitted via the use of
computer technology.
The Impact of
EHRs, Big Data,
and Evidence-
Informed Practice
Toni Hebda
133
CHAPTER 8
▸ Introduction
As a society, we are situated at a virtual junction. Technological advances now
allow us to collect, store, and manipulate huge pools of data, which can reveal
previously unknown patterns to inform us, guide our decisions, and improve
outcomes (Boulton, 2014). Businesses leverage technology daily to collect in-
formation on shopper preferences with each use of a preferred shopper’s card,
completion of a survey, or product registration; the information is then used
to improve services, target specific populations, and improve efficiencies. The
healthcare delivery system in the United States has begun to embrace the same
types of tools used by business and industry in an attempt to achieve some of the
same types of benefits (Spencer, 2016). Electronic health records (EHRs) from one
organization, or from many organizations, with data in those records collected
through Meaningful Use, represent one source of data.
Collectively, the enormity of the available data sets dwarfs the results from a
single study or even a meta-analysis. This capability to collect large data sets (i.e.,
big data), and to manipulate and analyze those data to discover new knowledge,
is exciting and consistent with our transformation from an information society
to a knowledge society (Mehmood, Rehman, & Haider Rizvi, 2014; Ricaurte,
2016). A knowledge society exists when there is the ability to create new meanings
from data, allowing for improvement of the human condition. The theoretical
underpinnings for a knowledge society are attributed to the writings of Peter
Drucker, a sage known for his work in management theory and knowledge work,
including his classic 1985 work, Innovation and Entrepreneurship: Practice and
Principles (Karpov, 2016; Turriago-Hoyos, Thoene, & Arjoon, 2016).
Discovery informatics: A specialty that focuses on scientific models and theories
to create computer discovery of new learning with big data rather than through
reliance upon human cognition.
Knowledge society: A state in which new meanings can be created from data,
allowing for improvement of the human condition.
Meaningful Use: A Medicare and Medicaid incentive program that established
requirements for electronic capture and submission of patient information to
the Centers for Medicare and Medicaid Services.
Meta-analysis: A systematic review that summarizes the results of prior eligible
studies to answer a specific research question.
Nurse informaticist: A specialist who uses nursing and other sciences to manage
and communicate data, information, knowledge, and wisdom to support
nurses, healthcare professionals, consumers, and other stakeholders in their
decision making.
Personalized medicine: Treatment customized for the individual on the basis of
his or her genetic make-up.
Population health: Initiatives that support care and reimbursement models that
reward positive health outcomes.
Predictive analytics: A facet of data mining that uses extracted data to forecast
trends.
134 Chapter 8 The Impact of EHRs, Big Data, and Evidence-Informed Practice
The transition to a knowledge society holds great potential to improve
health care but also requires the development of new skills and responsibilities
to realize those advances. Education in research methods is integral to social-
ization of all young people for life in a knowledge society (Karpov, 2016). As
Brennan and Bakken (2015) noted, in the healthcare realm, nurses must play
a pivotal role in developing and using the tools and methods associated with
big data and the subsequent knowledge generated so as to influence health
policies that consider healthcare consumer needs and provide for the best use
of resources. This role is consistent with the American Nurses Association’s
Social Policy Statement. Nurse involvement is imperative to ensure that dis-
coveries are useful for nursing.
In an effort to prepare nurses for this role, this chapter addresses the fol-
lowing aims:
■ Provide an overview of electronic resources and their relationship to health care.
■ Define and discuss big data, its significance for health care and nursing, and
its uses and issues.
■ Review the relationship between evidence-informed practice and big data.
■ Outline initiatives that support big data.
■ Examine the relationship among big data, policy, and health care.
■ Discuss implications for registered nurses (RNs), advanced practice registered
nurses (APRNs), and other healthcare professionals.
▸ Electronic Resources: Their
Relationship to Health Care
Healthcare professionals and consumers alike have ready access to a wide variety
of electronic resources that serve to expedite access to information and services.
TABLE 8-1 provides an overview of the types of available resources, while TABLE 8-2
lists some of the many services that are available online. A critical consideration
for both healthcare professionals and consumers is whether sources provide
truly reliable and valid information. Government, academic, and professional
organization websites are considered to be good sources, although they are not
entirely free of bias. Scrutinizing a website for the sponsoring organization’s mis-
sion statement, funding sources, and background information on who sits on the
board of directors can sometimes reveal political bias (for more information on
how to discern bias in a source, refer to the chapter entitled An Insider’s Guide
to Engaging in Policy Activities). Information with no clear authorship, date of
publication or review, or evidence of subject-matter expertise for posted content
should be avoided.
The process of making text, audio, and images available electronically for
ease of access, processing, storage, and transmittal via computer technology is
known as digitization. Nearly all the world’s stored data have been converted
to a digital format (McNeely & Hahm, 2014). In addition to increased availability
and access, digitization affords new opportunities to examine collected data and
is fundamental to the big data phenomena.
Electronic Resources: Their Relationship to Health Care 135
TABLE 8-1 Types of Electronic Resources with Some Exemplars
Type Exemplar
Websites Professional organizations
American Nurses Association
American Association of Nurse Practitioners
American Medical Association
American Association of Medical Colleges
American Association of Colleges of Nursing
Social media Social networking: Facebook, Google+, LinkedIn
Photo sharing: Pinterest, Snapchat, Flickr, Instagram
Video sharing: YouTube, Vimeo, Yahoo video, Shutterfly video
Microblogging: Twitter, tumblr
Blogging: WordPress, Blogger
Crowdsourcing: Ishahidi, CrowdFunding
Live streaming: Facebook Live, Blab, Periscope, YouTube Live
Search engines
(in order of
volume of users)
Google
Bing
Yahoo
Baidu
Ask
AOL Search
Wolfram Alpha (for computational searches)
DuckDuckGo (does not retain your search histories)
DogPile (uses other search engines to compile results)
Others
Electronic
databases
Literature
PubMed/Medline
CINAHL
Ovid
Specialty databases
ClinicalTrials.gov
TOXNET
National Cancer Database
U.S. National Library of Medicine: electronic databases and
directories by alphabetical listing
Information
systems
Electronic health records (vendors): Epic, Cerner, Allscripts,
NextGen, Athena Health
Clinical support systems
Administrative systems
136 Chapter 8 The Impact of EHRs, Big Data, and Evidence-Informed Practice
▸ Big Data
The term big data originally referred to very large data sets (Spencer, 2016). It
includes data of different types, levels of complexity, formats (structured and un-
structured), and processed and unprocessed items from several sources that can
be analyzed to reveal patterns, trends, and associations (Jukić, Sharma, Nestorov,
& Jukić, 2015; Manerikar, 2016). The healthcare industry defines big data by its
size, the ability to make sense of the data, its complexity, and the degree to which
the data flow into the organization (Spencer, 2016). Big data is beyond human
capability to comprehend or manage without the aid of computers (Brennan &
Bakken, 2015). In many cases, it endeavors to encompass entire, complex processes
(Gharabaghi & Anderson-Nathe, 2014). Healthcare professionals and health
services researchers manipulate and analyze big data to provide policymakers
and thought leaders with vital information.
TABLE 8-2 Types of Services Available Electronically
Information Professional
Political/policy
Opinions
Consumer health advice
Comparing providers, facilities
Networking/
communication
Job searches
Webinars/conferencing
Document sharing
Real-time patient communication (Twitter, texting)
Language translation
Education Online degrees
Continuing education
Libraries
Personalized learning assessments
Provision of services Manage appointments and schedules
Professional license application, renewal, and verification
Patient registration and history
Reminders to patients
Communicate with healthcare providers
Marketing Branding
Advertising
Price comparisons
Maintain or view
records
Access patient portal: ask questions, renew medications
Big Data 137
Background
Data, information, and knowledge are valuable assets. Examination of big data
internally enables an organization to identify effective processes, eliminate waste-
ful processes, improve products, improve customer experience, and establish a
competitive advantage (Spencer, 2016). In the healthcare arena, big data provides
a tool to benchmark performance against other organizations, improve patient
outcomes, reform healthcare delivery, and lead to significant cost savings. In this
way, big data complements traditional sources of data, such as the data obtained
from the trending of vital signs for a single patient or the findings of a study; the
latter data are sometimes referred to as small data because they can be analyzed
by a single person (Brennan & Bakken, 2015; Sacristán & Dilla, 2015).
The ability to use big data as a tool requires an understanding of what it is,
what its background and sources are, which surrounding issues are relevant, and
how it can be applied to healthcare delivery and policy. Nurse informaticists, health
services researchers, and data scientists have special expertise in these areas
and can facilitate the collection, analysis, and application of knowledge gleaned
from big data. A nurse informaticist is a specialist who integrates nursing and
other sciences to “identify, define, manage, and communicate data, information,
knowledge, and wisdom” (American Nurses Association [ANA], 2015, pp. 2‒3) to
support nurses and healthcare professionals, consumers, and other stakeholders
in their decision making.
Significance for Healthcare Delivery and Policy
As Americans struggle to reform the U.S. healthcare delivery system and
improve patient outcomes, scarce resources and increased demands for ac-
countability call for informed decision making, which in turn requires data;
increasingly, these data equate to big data (Gharabaghi & Anderson-Nathe, 2014;
McNeely & Hahm, 2014). Big data has the potential to create approximately
$300 billion annually in value in the healthcare realm (Roski, 2014). Much
of that value would likely come from lower costs associated with the more
effective outcomes obtained with personalized medicine. Additional value
would come from data generated by individual healthcare consumers to tailor
diagnostic and treatment decisions, educational messages to foster desired
health practices, and improved population health analysis. Big data also
supports tools for improved fraud detection and prevention.
Big Data Sources
By definition, big data is derived from multiple data sources. The list of sources
discussed in this chapter is not comprehensive but does serve to acquaint the
reader with a few reputable big data sources relevant to health care. Exemplars of
both traditional and emerging data sources are discussed, followed by a discussion
of issues related to big data.
Traditional data sets are collected with an express purpose or objectives in
mind. This purpose provides direction for which data are collected, its format,
and methods to safeguard integrity and security. The structure in traditional data
sets is at odds with the definition for big data, but the potential of these sources
138 Chapter 8 The Impact of EHRs, Big Data, and Evidence-Informed Practice
to contribute to new knowledge is rich. Electronic health records and databases
are two examples of traditional sources of big data.
Electronic health records (EHRs) represent one of the best sources of big
data in health care today. Individual organizations commonly use data found in
EHRs to track metrics such as patient outcomes, length of stay, number of sentinel
incidents, and costs to support research. EHRs may offer users the opportunity
to customize views of patient data for individuals or groups, access clinical de-
cision support using evidence-based practice guidelines and literature, provide
treatment reminders, use lockout features and alarms, and integrate the EHR
with monitoring devices and other clinical systems. Integration with monitoring
devices and point-of-care devices, such as glucometers or urine output, provides
additional data streams for EHRs while eliminating the need to manually enter
measurements such as vital signs, thereby simultaneously streamlining workflow
and improving data quality. Data may also be transmitted in a real-time manner
from EHRs directly into databases, also saving time and money. This approach
has been demonstrated successfully on a limited basis to collect data on patients
who have undergone thoracic surgery and bariatric procedures (Salati et al., 2014;
Wood et al., 2012). Currently, the realization of large-scale data collection on a
real-time basis for research purposes requires resolution of issues that include, but
are not limited to, interoperability across different vendor platforms (Coorevits
et al., 2013). Today’s EHRs are composed of a mix of different data types that
include text and images.
A database is a collection of information organized and used to provide ease
of access, management, and updates to its contents. EHRs fit this basic definition
because of their reliance upon database technology to house information, but
EHRs’ emphasis on their content rather than overall functionality leads most
individuals to consider databases to be a separate entity from EHRs. A staggering
amount of health-related information now exists in different databases across
various settings. One example that is familiar to U.S. healthcare providers and
consumers is the Hospital Consumer Assessment of Healthcare Providers and
Systems (HCAHPS) survey. HCAHPS collects data on hospitalized patients’
perspectives on their care experience (Centers for Medicare and Medicaid Ser-
vices [CMS], n.d.). It has created a national standard that enables comparison
across all participating hospitals. HCAHPS scores provide financial incentives
in the form of increased or decreased Medicare reimbursement for hospitals to
improve the quality of care provided; results are available to the public. Notably,
hospital reimbursement from the Centers for Medicare and Medicaid Services is
determined by HCAHPS ranking (Keith, Doucette, Zimbro, & Woolwine, 2015).
Other databases collect information about specific diseases, encounter infor-
mation, and clinical data. Disease registries enable tracking of clinical care and
outcomes for specific patient populations, such as those impacted by cancer, heart
disease, trauma, infectious diseases, diabetes, or asthma. Input is accepted from
multiple sources. The underlying intention in creating such a registry is to mini-
mize fragmentation of care, identify at-risk populations, and improve care through
evidence-based practices (Davis, 2016). Chronic disease registries also support
evaluation of providers to ensure that they use current evidence; however, this
evaluation may not include data that reflect patient choice and provider judgment.
The Healthcare Cost and Utilization Project (HCUP) maintains encounter-level
information on inpatient hospital stays, emergency department visits, and
Big Data 139
ambulatory surgery in U.S. hospitals. The HCUP databases are created by the
U.S. Department of Health and Human Services’ Agency for Healthcare Research
and Quality (AHRQ) through a federal‒state‒industry partnership. An excellent
resource of databases and repositories is Health Services Research Information
Central, which can be accessed through the HCUP website (https://www.hcup-us
.ahrq.gov/databases.jsp).
The National Patient-Centered Clinical Research Network (PCORnet)
supports a repository of clinical data gathered in a variety of healthcare settings,
including hospitals, physician offices, and community clinics, for the purpose of
conducting comparative effectiveness research. PCORnet collects and stores
data in standardized, interoperable formats to facilitate secure sharing designed
to ensure confidentiality of the data (Patient-Centered Outcomes Research In-
stitute, 2017). Interoperable refers to the exchange of data and information while
retaining their meaning.
Although global digitization makes it easier to create, post, and transmit
information for healthcare professionals and the public, there is no mechanism in
place to uniformly ensure the accuracy of information available on the Internet.
Healthcare professionals recognize the potential to study data gleaned from a variety
of electronic resources, including Internet searches, social media, crowdsourcing,
mobile applications (apps), and body sensors; these data may serve as a valuable
source of research and knowledge and learning through big data exploration.
The Internet facilitates the creation, collection, sharing, and use of informa-
tion, but it can also be used to collect research information and big data. In excess
of 2 billion people are connected to the Internet, with projections estimating
there will be 50 billion connected devices by 2020 (Khan et al., 2014). Internet
searches to find health information to aid healthcare decision making are one
common use of this resource by healthcare consumers. Researchers continue to
work to determine how consumers choose these websites, how many searches
are performed, and which websites are visited (Song, Song, An, Hayman, & Woo,
2014; Zhang, Sun, & Kim, 2017).
Social media data have been mined to detect early signs of disease outbreaks,
recruit subjects, provide interventions, and monitor population health and behavior
(Kuehn, 2015; Sinnenberg et al., 2017). One specific social networking site that
has been explored is Twitter, where users interact via messages limited to 140
characters. EXHIBIT 8-1 describes features of Twitter that make it an effective
source of data for disease detection and management.
In excess of 6,000 mobile apps now exist to track activity, food intake, and
calories (Peek, 2015). Real-time data streams from fitness tracking apps and sen-
sors, particularly when combined with Twitter data, might be mined to provide
early warnings of emergency situations, adverse drug reactions or drug misuse,
EXHIBIT 8-1 Advantages of Twitter for Disease Detection and Management
■ Real-time nature
■ Used across the globe
■ High volume of messages
■ Ability to search messages for content, frequency of discussion, or response by topic
■ Analysis of content as a means to predict demand for services or patient outcomes
140 Chapter 8 The Impact of EHRs, Big Data, and Evidence-Informed Practice
and the development of chronic disease issues. These kinds of apps may allow
public health officials, healthcare delivery systems, and individual nurses to better
prepare for these events, assuming that someone is analyzing data for trends and
that agency policy supports this approach (Kuehn, 2015).
Crowdsourcing is a process in which a task or problem is posed and solutions
solicited, resulting in the formation of an unofficial group of individuals who are
geographically dispersed and who offer their help. The PatientsLikeMe platform
is a healthcare-related example, which allows patients and their families to share
medical data and experiences to help others learn. This platform compiles data to
answer frequently asked questions (Chiauzzi & Lowe, 2016). It can also provide
insights for healthcare professionals into the patient experience. As with other
forms of social media, there is no assurance of the accuracy of all posted infor-
mation. Along with its potential benefits, this form of publicly available medical
data presents concerns related to privacy and the possibility of discrimination,
erroneous research findings, and even litigation (Hoffman, 2015).
Issues
Issues associated with big data include, but are not limited to, data quality, dif-
ferent data types and formats that complicate the ability to exchange data, data
governance, barriers to sharing data, understanding results, available tools and
human resources, uneven production of learning, and possible misinterpretation
or misuse. Quality data are accurate, complete, consistent, clear, precise, and useful
(Otto, 2015). Poor data quality can occur when, for example, fields are left blank,
a wrong choice is entered, or a typing or spelling error is made. Organizations
can improve poor quality data through machine methods (computer applications
or software) that scrub or clean data, but correct entry from the beginning is
always the best option (Vaziri, Mohsenzadeh, & Habibi, 2016). Poor-quality data
negatively impacts decision making, raises information management costs, and
compromises big data findings (Clarke, 2016).
At present, there is a lack of standardization in methods to share big data, along
with a mix of raw and processed types and of structured and unstructured data
(Copping & Li, 2016; Spencer, 2016). Structured data are typically organized into
a repository or database for effective processing. Unstructured data may exhibit
internal organization but do not reside in databases. Examples of unstructured
data include documents, emails, and multimedia resources. The lack of data
standardization can lead to lost opportunities for learning when it impacts the
type and amount of data analyzed (Auffray et al., 2016).
Data governance refers to the policies, standards, processes, and controls applied
to the organization’s data to ensure that it is available when, where, and to whom it
is needed; is usable; and is appropriately secured (Dutta, 2016). At present, the
growth in new information is outpacing the ability to develop policies and tech-
nology, thereby exposing organizations to legal, financial, and organizational risks
(Marbury, 2014). Data governance needs to reflect knowledgeable and appropriate
use of data both within and beyond the walls of any one organization (Roski, 2014).
Big data benefits cannot be realized unless the vast amounts of diverse data
are amassed and analyzed. This outcome will require sharing of data. Barriers to
sharing include concerns by healthcare delivery systems that divulging informa-
tion to competitors may negatively impact market share (Bordone, 2013; Roski,
2014) and an inconsistent slate of state and federal privacy laws (Habte, 2015).
Big Data 141
There are also concerns about the ethics of the process of collecting and storing
data that may be about or from vulnerable populations in the event that those
data may prove useful at a future date (Gharabaghi & Anderson-Nathe, 2014).
Conventional strategies do not support big data analysis. A knowledge strategy
and infrastructure, expertise, and tools are required to discover new learning and
knowledge in big data (Dulin, Lovin, & Wright, 2016; Kabir & Carayannis, 2013).
The late arrival of healthcare organizations to the big data phenomenon and the
shortage of skilled personnel capable of dealing with this resource have placed
this industry at a disadvantage for turning data first into knowledge and then into
actionable results (Copping & Li, 2016; Spencer, 2016; Steinwachs, 2015). Adding
to the chaos is the fact that many critics believe that the adoption of EHRs may
not yield the consistent results desired by health policymakers.
The Relationship Between Evidence-Informed
Practice and Big Data
The terms evidence-informed practice (EIP) and evidence-based practice (EBP)
are sometimes used interchangeably but actually refer to different concepts
(Melnyk & Newhouse, 2014). EBP is an approach that takes the best evidence,
evidence-based theories, clinician expertise, and patient preferences and values
to make decisions about patient care using a five-step process. EIP requires prac-
titioners to be familiar with the levels of research evidence and clinical insights
and to use them creatively without introducing nonscientific bias or the need
to go through the five-step process of EBP (Nevo & Slonim-Nevo, 2011). EIP
extends beyond evidence to incorporate other factors that influence the nurse’s
care decisions—namely, context and patient values (Florczak, 2017).
The demand for the best evidence leads healthcare professionals to consider
options that include combining data from separate studies for a greater impact
of research findings as well as analyzing big data. Combining data from separate
studies requires common data elements (Cohen, Thompson, Yates, Zimmerman, &
Pullen, 2015). Increasingly, big data is seen as a form of evidence either on its own
or as a supplement to clinical trials and is being used to inform policy and practice
decisions (de Lusignan, Crawford, & Munro, 2015; Kennedy, 2016). A learning
health system captures and delivers the best available evidence to guide and support
decision making (Steinwachs, 2015).
Laying the Groundwork for Big Data
Effective big data use requires a combination of policy, legislation, and a knowledge
strategy, infrastructure, and skills. Health policies need clear objectives if they are
to be effective (Heitmueller et al., 2014). The following questions, among others,
should be considered when formulating policies for big data use:
■ Which aspects of big data are relevant for health care?
■ What is the intent of the policy/data use?
■ Which barriers exist to achieving the objectives of the policy?
■ What are the incentives to share information?
Examination of these questions will determine whether data are classified as
personal, proprietary, or government-held, leading to strategies for how to link or
142 Chapter 8 The Impact of EHRs, Big Data, and Evidence-Informed Practice
share the appropriate types of data. Intent speaks to the ways that the data may be
used. In health care, improvement of patient outcomes and reform of payments
to providers constitute examples of intent. Barriers include concerns over how
data will be used, privacy, loss of competitive advantage, technology issues, and
user fatigue with technology, among others. Incentives revolve around building
a case for data sharing as well as providing financial incentives for this practice.
The paradox is that while health policy helps to establish a framework for big
data, big data also serves to inform policy. Legislation establishes requirements and
incentives so that policies can be carried out. Some important exemplars of U.S.
legislation and initiatives that helped to provide a framework for use of big data
in the healthcare realm appear in TABLE 8-3. As big data use increases, legislation
and professional practices will need to keep pace to ensure that data are always
used appropriately and mistakes are avoided (Williamson, 2014).
TABLE 8-3 Important Legislation and Initiatives for Big Data in Health Care
Public Laws,
Executive
Orders, and
Initiatives
Year
Enacted Major Content Related to Data
Health Insurance
Portability and
Accountability
Act
1996 Impacts healthcare data availability.
Assures a bridge for health insurance coverage
for persons who have a change in employment.
Requires national electronic standards for
claim submission.
Provisions protect the privacy of personal
health information.
Medicare
Improvements
for Patients and
Providers Act
2008 Provides financial incentives for electronic
prescribing (e-prescribing), which creates
digital data for analysis.
American
Recovery and
Reinvestment
Act
2009 Economic stimulus package.
Allocated funds to create jobs, boost
economic growth, and increase accountability
and transparency in government spending.
Funded comparative effectiveness
research.
Created a nationwide health information
network.
Provided financial incentives for hospitals and
physicians who adopted and began using EHRs.
Strengthened HIPAA privacy and security
requirements.
Included Title VIII Health Information
Technology for Economic and Clinical Health Act.
(continues)
Big Data 143
Public Laws,
Executive
Orders, and
Initiatives
Year
Enacted Major Content Related to Data
Health
Information
Technology
for Economic
and Clinical
Health Act
2009 Offers financial incentives to providers partici-
pating in Medicare and Medicaid for adoption of
certified EHRs; ushered in widespread adoption
of EHRs in the United States.
Goals included improvements in care and
reduced disparities.
Increased digital data for big data purposes.
Patient
Protection
and Affordable
Care Act
2010 With its amendment, the Health Care and
Education Reconciliation Act is known as
Obamacare.
Provides incentives for reporting provider
performance; established public reporting of
quality and cost metrics.
Increases hospital data collection and analysis.
Increases the ability to share data across
settings.
Genetic
Information
Nondiscrimination
Act
2008 Protects individuals from discrimination by
insurers and employers based on the results
of genetic information and test results,
encouraging data collection and use.
Medicare
Access and CHIP
Reauthorization
Act of 2015
2015 Reforms Medicare payments to physicians,
other providers, and suppliers to reflect a
value-based payment model, effective 2019.
Monitors program effectiveness and reports
on Medicare-eligible provider performance.
Executive order
13642: Making
Open and
Machine Readable
the New Default
for Government
Information
2013 Federal government requirement to make
information easy to find, access, and use.
Adds to the amount of digital data
available for exploration and to support
decision making.
Precision
Medicine
Initiative
2015 Research initiative that considers individual
differences in genetic makeup, environments,
and lifestyles.
Seeks to improve treatments for cancer,
expand research, create new public–private
partnerships, and infrastructure needed to
expand cancer genomics.
TABLE 8-3 Important Legislation and Initiatives for Big Data
in Health Care (continued)
144 Chapter 8 The Impact of EHRs, Big Data, and Evidence-Informed Practice
▸ Implications for RNs, APRNs,
and Other Healthcare Professionals
More than at any previous point in history, RNs, APRNs, and other healthcare
professionals now have the power of knowledge gleaned from large pools of
information within reach primarily through EHRs and various databases and
increasingly via additional data streams from mobile technology, wearable sensors,
social medial, and tracking apps. The ability to harness and use this knowledge
requires awareness of the potential of big data as a new form of evidence, a plan
for how it may be used, skills to understand the significance of findings, and the
ability to apply the evidence and learning in practice settings. Working to obtain
this level of awareness and learning will necessitate the combination of personal
and professional strategies, professional accountability, and advocacy.
Nurses have experience in the traditional uses of EHRs, claims data, and
public health data, and this experience provides good foundational skills to
use big data. RNs, APRNs, and other healthcare professionals need to consider
which data and information they would like to be able to retrieve from EHRs as
evidence to better support their work and patient outcomes. As an example, it
would be logical for patients rated as being at a high risk of falling to require more
staff attention, but the current fall risk assessments may not provide the real-time
aggregate information on increased acuity levels that is needed for safe staffing
on a unit-by-unit basis or throughout the organization. This type of information
would support safe staffing levels, enhance patient safety, and demonstrate the
need for increased staffing (and costs) when greater numbers of at-risk patients
are receiving care. APRNs concerned about the possibility of position cuts could
request data that would demonstrate a link between level of staff preparation and
patient outcomes. There are an infinite number of ways to apply big data from
EHRs, public databases, and other data streams so as to further contribute to
learning, patient safety, patient satisfaction, and lower costs.
Understanding Big Data
Nurses in practice settings need to have a grasp of big data within the context of
evidence-informed practice (Brennan & Bakken, 2015). Although the concept
of evidence gleaned from big data is not difficult to understand, the ability to
discern patterns in big data requires expertise provided through data science.
There is a shortage of data scientists in all fields at present, with this shortage
being especially pronounced in health care. There is also a lag in the inclusion
of data science into course content in formal academic programs. As with other
emerging areas of competencies, all healthcare professionals must make an effort
to keep abreast of ongoing developments in this area. Brennan and Bakken (2015)
listed the training, roles, and activities for nurses at different levels of practice
relative to data science.
Data science is “the systematic study of digital data” (National Consortium
for Data Science, 2017, Para. 2). This emerging discipline incorporates techniques
and theories from many areas, including predictive analytics, a facet of data
mining that uses extracted data to forecast trends. Brennan and Bakken (2015)
espoused the hope that data science will support the complex inquiries needed
Implications for RNs, APRNs, and Other Healthcare Professionals 145
by nurses to understand health within day-to-day life to deliver contextually rel-
evant interventions. Data science differs from traditional nursing inquiry, which
is guided by theory that determines the data selected for analysis. Data science
can also benefit from nurses’ expertise in the following areas:
■ Data types and sets (e.g., the Nursing Minimum Data Set)
■ Defining and providing context for data sets
■ Use of theories to organize variables
■ Creation of interventions that can help healthcare consumers interpret the
results of big data analysis
■ A patient-centered approach
Another emerging specialty, known as discovery informatics, focuses on
scientific models and theories to create computer-based discovery of new learn-
ing in big data—something that in the past has been dependent upon human
cognition—with the goal of accelerating discovery and learning (Honavar, 2014).
As nurses at all levels are exposed to data science content, both baccalaureate-level
and advanced practice nurses will become able to evaluate and use findings gen-
erated through data science methods; in addition, the doctoral-prepared nurse
could lead research supported by data science methods (Brennan & Bakken, 2015).
Nurses, however, must do even more. As knowledge workers, nurses must be
involved in knowledge management (Soares, Jacobs, Bolis, Brunoro, & Sznelwar,
2012). Starting at the point of data entry, all nurses have an obligation to ensure
data quality. Input of accurate data and clear, unambiguous entries provide a solid
foundation for usable data later. A concrete example in which information quality
is critical is family history documentation that, when well done, can predict health
risks and contribute to a personalized treatment approach (Hickey, Katapodi,
Coleman, Reuter-Rice, & Starkweather, 2017), Nurses can provide feedback on
electronic systems design and adoption of data standards to ensure that important
information is collected, available in a usable format, and available for reuse later.
Nurses should craft and implement data policies and integrate findings from
big data at the point of care. The doctoral-prepared nurse should use data science
methods to research nursing phenomena (Brennan & Bakken, 2015). Advanced
practice registered nurses have an obligation to shape health policy to support
big data and to use big data findings to influence policy and resource allocation
(Kostas-Polston, Thanavaro, Arvidson, & Taub, 2015). The ANA’s Social Policy
Statement provides a moral compass on the use of big data and data science.
CASE STUDY 8-1: Research Evidence Versus
Big Data
Your hospital’s evidence-based practice council has looked at levels of traditional
research and ways to incorporate evidence into care, with an emphasis on building
evidence into clinical pathways used to guide care and documentation. As the
APRN leading the council, you believe that the members now demonstrate a good
146 Chapter 8 The Impact of EHRs, Big Data, and Evidence-Informed Practice
grasp of different levels of research findings and are making excellent progress
with their work to integrate evidence into practice. Your chief nursing officer,
however, states that this is not enough: He expects to see the integration
of findings from big data at the point of care. Council members have expressed
great anxiety relative to the push to use big data findings, protesting that they
have limited knowledge about big data, let alone how to make the best use of its
related findings.
Discussion Points
1. As the APRN leading the council, do you agree with this decision by the
chief nursing officer? Defend your position.
2. Write a one-page explanation for the council outlining the differences
between data and big data.
3. Compare the use of research outcomes for a specific patient problem and
the use of big data in addressing population-based health problems.
4. Which resources (e.g., people, technology) would your hospital need to use
big data appropriately?
5. Describe how population-based data (e.g., pre/post-intervention data) can
be used to create community-level health policy.
6. Which implications does the integration of big data findings at your facility
and elsewhere have for healthcare policy development at the local, state,
and national levels?
CASE STUDY 8-2: Implications of Using
Various Data Sources
The technology committee at your medical center has been asked to look at
current applications within the facility that generate data streams to determine
which applications should feed into patient records. Some devices, such as
glucometers and other point-of-care testing devices, automatically feed results
into the patient’s electronic health record. Other devices that track fitness, for
example, are heavily used outside of the medical center but have not been linked
with health records. As the APRN representative on the committee, you have been
asked to provide your expert opinion on the integration of these additional data
streams.
Discussion Points
1. Which types of body sensors, tracking devices, and applications would
provide valuable information to nurses and other healthcare professionals
when providing care to a patient? Discuss the pros and cons of the value of
each item vis-à-vis EHRs.
2. What relationships do you see between these types of data streams and the
ability to inform and shape healthcare policy in your medical center?
(continues)
Implications for RNs, APRNs, and Other Healthcare Professionals 147
3. Describe the relationship between the policy at your organization and the
inclusion of additional data streams into electronic health records. How
do individual hospitals stream their EHR data into big data sets? How does
national healthcare policy support, or not support, the inclusion of additional
data streams into electronic health records? Into big data findings?
4. Discuss how nurse-sensitive data can be used to create health policy at the
state or national level.
5. Describe ethical and security issues involved in including patients’ personal
information in EHRs.
6. Create a framework or model that illustrates how the integration of multiple
data streams collected from point-of-service devices can be used to inform
healthcare policy.
CASE STUDY 8-2: Implications of Using
Various Data Sources (continued)
CASE STUDY 8-3: Magnet Status and Big Data
Your 600-bed medical center is a Magnet facility and was one of the first healthcare
delivery systems in the nation to attain Magnet recognition. Maintaining Magnet
recognition is a goal for the organization that requires planning and resources. You
recently joined a committee that is responsible for overseeing the process to apply
for Magnet recognition.
Discussion Points
1. How can aggregate data collected from this facility be used to demonstrate
the value of nursing (e.g., a correlation between nurse credentials and
patient outcomes)?
2. Analyze how data obtained from all Magnet facilities in the United States can
be used to influence national healthcare policy relative to the following issues:
a. The value of nursing care
b. Allocation of resources for specific populations
c. Funding for further education for nurses
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150 Chapter 8 The Impact of EHRs, Big Data, and Evidence-Informed Practice
© Visions of America/Joe Sohm/Photodisc/Getty
Interprofessional Practice
J. D. Polk and Patrick H. DeLeon
▸ Introduction
The United States entered the 21st century with a fragmented “sick care” delivery
system rather than a well-designed system for maintaining health and wellness.
Despite well-intended laws, rules, and regulations, the country faced ongoing issues
with access to care, quality and safety of care, and costs of care spiraling upward
faster than the economy at large was growing. Paul Starr’s seminal works, The
Social Transformation of American Medicine (1982) and Remedy and Reaction: The
Peculiar American Struggle Over Health Reform (2011), chronicle the incentives,
traditions, culture of thought, laws, and policies that led to the fragmentation of
care we continue to experience today. Nongovernmental organizations, thought
leaders, health services researchers, and policymakers recognize the importance
of an “all hands on deck” approach to reforming the health system. One approach
calls for greater collaboration in education, practice, and research among health
professionals.
This chapter provides examples from the perspectives of two distinguished
thought leaders regarding interprofessional collaboration to achieve reform in the
healthcare delivery system. The editors hope that the examples shared by these
professionals will inspire all who read this text and who work as healthcare pro-
fessionals to seek collaboration with their colleagues to transform the healthcare
system in the United States.
If the U.S. healthcare system is to be transformed, not just reorganized, all of
us must set aside old biases and habits so that educators, researchers, organiza-
tions, government, and health systems can move forward together in conceiving,
writing, implementing, and evaluating public policy. The patient will be the
ultimate benefactor.
151
CHAPTER 9
References
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Starr, P. (2011). Remedy and reaction: The peculiar American struggle over health reform. New
Haven, CT: Yale University Press.
***
THE EVOLVING INTERPROFESSIONAL UNIVERSE
J. D. Polk
KEY TERM
Crowdsourcing: Convening professionals from many disciplines to focus on a
problem by means of innovative tactics.
▸ What Is Interprofessional Collaboration?
By the time you read this chapter, the definition of interprofessional education
(IPE) will have evolved. In the early days of IPE, the purpose was to show that
healthcare providers other than the physician were just as important to the out-
comes of the patient. Many would say that IPE was focused on teaching physicians
that they were no longer in charge. This concept has since evolved into something
that looks more at all the healthcare providers working as a team toward the end
goal of better health outcomes for the patient (Aston et al., 2012).
Even this definition of IPE is too narrow, however. Technology, connectedness,
and the changing landscape of medicine necessitate that healthcare policy take
into account care by many different levels of practitioners, patient self-care, and
multiple entry points of the patient into a virtual healthcare system. Technology
drives the access to and usability of information in relation to patient outcomes
to such a degree that IPE and the collaboration of many partners has no bounds
and will continue to evolve and expand. For example, at the National Aeronautics
and Space Administration (NASA), the astronaut patients may perform tests on
themselves, such as an exam with an ophthalmoscope. Exam results are then
transferred by satellite to the flight surgeon console. Biomedical engineers, ultra-
sound technicians, and nurses may interact with those data and the evaluation
process. A second opinion may be obtained by sending the data across to a ter-
tiary care center. For a cosmonaut, the data would be sent to Russia for Russian
medical experts to evaluate. The astronaut is traveling at 17,500 miles per hour
and is 230 nautical miles above the Earth. The data have passed through two
satellites and crossed numerous countries. Interprofessional collaboration for that
one exam required the astronaut patient, engineers, satellite experts, biomedical
engineer, nurses, ultrasound technicians, flight surgeons, and ophthalmologists
to all collaborate across numerous boundaries. NASA’s health policy must take
into account the technology, the international politics, and the patient.
152 Chapter 9 Interprofessional Practice
▸ Core Attributes of Interprofessional
Education
The need for and value of interprofessional education are not new concepts; IPE
has been around for several decades. The World Health Organization put for-
ward the idea of including IPE in medical education around the world in 1978,
knowing that not all communities have physicians or access to quality medical
care, and that the care and outcome of the patient depend on many caregivers,
especially in developing countries.
The Institute of Medicine (now the National Academy of Medicine) soon
followed with recommendations on incorporating IPE into medical education in
its 2000 report, To Err Is Human: Building a Safer Health System, and in its 2003
report, Health Professions Education: A Bridge to Quality. Much of the current
IPE movement has centered on increasing quality through teaming. Despite the
United States being at the top of the scale in terms of healthcare spending, U.S.
patient care outcomes are still woefully behind those in many other countries
that do a better job in regard to that team-based approach.
The core attributes that constitute interprofessional education vary depending
on the institution and authorship. Many of the publications from the Health
Resources and Services Administration (HRSA) and the National Academy
of Medicine (NAM) have focused on the need to have physician assistants,
nurses, and advanced practice registered nurses fill the void that has arisen
due to a physician shortage in primary care, on acceptance of nonphysician
providers, and on the perceived inflection point that the Patient Protection
and Affordable Care Act (ACA) requires more primary care providers. But
even that goal is too narrow and not quite holistic enough. Indeed, all the
various incarnations and articles describing an attribute or core educational
component can be boiled down to one succinct statement and goal: to teach
all healthcare providers to partner and utilize any and all resources available,
both medical and nonmedical, to bring about a sustained positive outcome
for the patient.
Health policy can be used as an instrument to incentivize collaboration and
teamwork where none previously existed. For example, after a medical error
occurs, a hospital or health system could have a policy that an interdisciplinary
investigative team will be used to assess where issues occurred and make recom-
mendations for correction or improvement. Such a team would take a holistic
approach, looking at all facets and disciplines that interacted with the patient.
One of the highest-risk areas in patient care is the hand-off of the patient from
one caregiver or discipline to another. Typically, nursing staff hand off patients to
nursing staff, physicians hand off patients to physicians, and therapists hand off
patients to therapists during a shift change or after a procedure to the recovery
team. As an alternative to this series of hand-offs, a hospital or health system could
implement a policy whereby there was also an interdisciplinary team hand-off.
Gordon and Findley (2011) discovered there is a paucity of studies related to
hand-offs completed in an interdisciplinary manner, and education focusing on
hand-offs is severely lacking. This is one area in which IPE training and health
policy can make a difference not just in improving outcomes but also in decreasing
risk. Case Studies 9-1 and 9-2 exemplify this holistic concept and illustrate why
we need to broaden our vision of IPE.
Core Attributes of Interprofessional Education 153
CASE STUDY 9-1: Implications of the Effects
of Weightlessness in Space on Health Policy
A retired 62-year-old astronaut has just fractured his hip after taking a fall while playing
tennis. The astronaut is currently being worked up in the emergency department,
and the orthopedic surgeon is on his way. A NASA flight surgeon calls the attending
physician in the emergency department and advises her that, although the patient is
retired from NASA, the fracture may be related to the astronaut’s spaceflight experience
and bone density loss as a result of spending six months on the International Space
Station, thus making this injury potentially work related. He also advises that the
surgical procedure, rehabilitation, and forward plan may need to be revised secondary
to this occupational exposure. With regard to the surgical procedure, although most
young patients with hip fractures have uncemented prosthetics, this patient may need
a cemented prosthetic due to loss of trabecular bone as a result of the microgravity
of spaceflight. The emergency physician has asked you as the nurse manager in the
emergency department to coordinate the interactions and inputs of all the caregivers
at the hospital, the patient and family, and NASA.
Discussion Points
1. Assess all the potential policy implications for this collaborative team.
How will the team share information from a government healthcare entity
(NASA) and the hospital? Whose policies regarding electronic health
records, the Health Information Portability and Accountability Act, and
information sharing will take precedence? How will the team members
impart the knowledge of the physiological changes from spaceflight to the
surgery, nursing, and physical therapy staff so they can devise the proper
plans? How can this scenario be made into an interprofessional plan?
2. Discuss the implications of this patient’s injury potentially being related to
a work experience in the remote past. Are there health policy or payment
implications? If so, who else should be included in an expanded team (e.g.,
social worker, government relations personnel)?
3. NASA is governed by specific legislation related to health policy concerning
the care of astronauts. Who should be liaisons with NASA, and how should
communication be coordinated with the care providers, risk management,
and administration at your facility?
CASE STUDY 9-2: Reframing Treatment
Options Within a Policy Context
Continuing with the scenario described in Case Study 9-1, a partnership and
intercollaborative agreement must be forged between NASA, the healthcare
providers and their individual specialty groups, and the hospital. NASA would have
the responsibility of educating the providers about the implications of specific
changes related to the care of astronaut patients, such as the potential need for
154 Chapter 9 Interprofessional Practice
IPE is about more than having the pharmacist, nutritional counselor, physician
assistant, nurse practitioner, and physician work as a team. It is about utilizing
every potential resource to bring about positive change in healthcare outcomes
(U.S. Department of Health and Human Services, 2014).
▸ The “Team 4” Concept
NASA is known for being innovative and collaborative but also pretty smart. Its
employees are, after all, rocket scientists! In addition, the agency has developed
a concept that aligns very well with IPE.
Many readers will have seen or recall the movie Apollo 13, starring Tom
Hanks (Howard, 1995). In one scene in the movie, the scientists at the NASA
Space Center need to build a carbon dioxide scrubber, or at least alter the interface
for it, so as to lower the carbon dioxide (CO2) level in the vehicle. The engineer
on the ground puts all the equipment that is currently on board the spacecraft
on the table and states, “We need to make this fit into this . . . using only these”
(Howard, 1995). You might think that scene was a Hollywood invention meant
to dramatize the movie; in reality, it is what actually occurred. Beyond that ex-
ample, NASA has developed a concept of teamwork that can serve as a potential
example for IPE. Typically, for any space mission, there are three shifts or teams
in the flight control room. In addition, NASA has a “Team 4”: a group of people
from nearly every discipline who get together to solve a problem that develops
during a mission. The members of Team 4 are not just engineers; instead, the
team is collaborative, cross-cultural, and cross-disciplinary.
For example, on one mission, one of the lights on the side of an astronaut’s
helmet had a fractured bracket. The light would not stay on the side of the
a cemented hip. Signed agreements, to include the patient’s informed consent,
would need to be written in regard to records transfer and private information
conveyance, as well as payment method.
Discussion Points
1. Which kinds of operational policies might a hospital need for such
specialized cases?
2. Which types of partnerships with government and perhaps private
entities (commercial spaceflight organizations) might enable members to
collaborate and exchange information quickly?
3. How should NASA work with policymakers to obtain specific legislation
regarding astronaut health care? Why might this issue be important
to NASA before the agency embarks on further long-distance human
exploration journeys?
4. If you were a NASA healthcare provider, what research could you bring to or
interpret for a policymaker that would help the policymaker sell the idea to
his or her colleagues?
5. Would it be better for NASA to brief all the different practitioners
independently or together? What are the advantages of an interprofessional
educational briefing in this case?
The “Team 4” Concept 155
helmet. The light was essential for conducting “space walks.” The ground team
got together to figure out which method they could use to affix the light to the
helmet. Whatever solution they used had to withstand the vast 200°F temperature
variations between light and dark in space, as well as the vacuum of space. The
team developed a unique solution to this problem: It recommended that the as-
tronauts use dental cement, like that typically used in the emergency department
after a tooth fracture. The medical kit on board the spacecraft contained this
cement just in case an astronaut suffered a tooth fracture in orbit. The cement
withstands hot and cold temperatures and is not bothered by the vacuum of space.
The cement was used to adhere the light bracket to the helmet, and it worked
perfectly (Simpson, 2007).
In another example, the thermal blanket that protects the space shuttle from
extreme heat had become torn on entry. It was feared that this tear would allow
superhot gases to encroach on the vehicle during reentry, with catastrophic conse-
quences. The Team 4 solution was less about engineering than it was about simple
patient care. Specifically, the astronauts were coached to perform a two-layer
closure using skin staples and sutures to repair the blanket on the exterior of the
space lab, not unlike a surgeon would close a wound.
The ideas and “solvers” for solutions sometimes come from unlikely sources,
and NASA’s Team 4 concept recognizes this reality. No idea is dismissed out of
hand, and very often the solution comes from an unlikely source. Indeed, in
the two examples cited here, the ideas came from the medical community and
medical kits, not from engineering.
NASA also uses collaborative approaches when crafting health policy to
incentivize IPE and holistic approaches. For example, a healthcare policy created
the Johnson Space Center’s Human System Risk Board and defined its function.
This interdisciplinary board is made up of researchers, biomedical engineers,
scientists, flight surgeons, and healthcare providers, and its primary function
is identifying, quantifying, and prioritizing human-centered risk in spaceflight.
Each discipline brings its individual expertise to the table, and every contribution
from each discipline is weighed in a holistic manner to assess and manage risks
related to the human system in the endeavor of spaceflight.
An astronaut on a spacewalk. Note the light affixed to the helmet by dental
cement.
Photo courtesy of NASA.
156 Chapter 9 Interprofessional Practice
What can we learn from NASA about teaming? In health care, we tend to
think of IPE as the physician, pharmacist, nurse, nurse practitioner, and physician
assistant all getting along and working cohesively. NASA, however, would say we
were still thinking much too narrowly.
The business of innovation has taken a cue from NASA. InnoCentive (n.d.)
is a private company that focuses on crowdsourcing problems and challenges
for customers using a worldwide network of solvers from many different
walks of life, professions, and specialties in a host of countries (Allio, 2004).
Rather than sending out a chemistry problem to only chemists, the problem or
challenge is crowdsourced to a host of many different solvers. Sometimes—in
fact, often—the answer comes from outside the specialty that would normally
be looking at the problem. For example, an engineer who specializes in fluid
mechanics might look at a problem much differently than the typical chemist
would. He or she might offer a solution upon seeing similarities in the fluid
mechanics world or work that the chemist would not have imagined. In 2007,
InnoCentive helped the Oil Spill Recovery Institute post three challenges that
all dealt with oil spill recovery issues. Who solved the first of the three chal-
lenges? The source of the solution was not someone from the oil industry but
rather someone from the concrete industry, who looked at the problem in a
whole new light.
CASE STUDY 9-3: Innovation and IPE in
a Chilean Mine
The Chilean government took IPE to a whole new level after the collapse of one of
its gold and copper mines trapped 33 miners 2,400 feet below ground in solid rock.
The miners were trapped after 600,000 tons of rock collapsed in the 100-year-old
mine in Copiapo, Chile. After 17 days of using a small drill to poke a hole into the
caverns to see if the miners were alive or if they had perished, the miners were
found alive. The movie The 33 (2015), starring Antonio Banderas, captures the many
problems encountered by rescuers.
The Chilean government did something that most governments would never
think of doing: it crowdsourced solutions and collaborated with multiple countries,
industries, and teams to achieve the desired outcome. Government officials threw
off the cloak of bureaucracy, streamlined and flattened the leadership chain,
and began an odyssey of interprofessional collaboration that was unmatched
and never seen before in this type of problem and rescue. They invited NASA to
participate and advise them, because the space program is well versed in the
challenges of keeping people alive in enclosed spaces for prolonged periods of
time and is also known for its great engineering prowess. The government invited
the Chilean Navy, miners and drillers from every specialty, and members of a host
of medical professions (including this author) to help them problem-solve the
issues and complex problems related to feeding the miners, treating them for their
ailments, drilling to rescue them, developing new drilling techniques, developing
a rescue capsule, and inventing never-before-seen or -used procedures toward the
successful rescue.
(continues)
The “Team 4” Concept 157
Until their rescue, no miners had ever survived a collapse of this magnitude,
so deep within the Earth, for so long a period. Multinational, multidisciplinary
teams would bounce ideas off one another, and the Chilean leadership would
implement those ideas that they felt were the most promising. What was the result
of their interprofessional collaboration? All 33 miners were rescued 69 days into
their ordeal as the world watched.
Dr. J. D. Polk (center) at a team meeting among engineers, miners,
physicians, and drilling experts from three different countries, the Chilean
Navy, and NASA.
Photo courtesy of J. D. Polk.
Discussion Points
1. Which resources would you need when team members speak various
languages?
2. What are the implications of a team composed of people from different
cultures who are addressing a crisis such as the one described in this case
study?
3. Which health resources would you assemble in anticipation of bringing the
miners to the surface or of resolving the crisis at hand?
4. What are the health policy implications of having many different
practitioners from many different countries giving medical advice?
5. Which health policy considerations and actions do you think the country of
Chile had to take into consideration, especially considering the international
and interprofessional aspects of the situation?
CASE STUDY 9-3: Innovation and IPE in
a Chilean Mine (continued)
158 Chapter 9 Interprofessional Practice
▸ The Future of IPE and Interprofessional
Collaboration
Prior to 1967, there were no physician assistants, and prior to 1965, there were
no nurse practitioners. The healthcare field has grown in leaps and bounds
since those years, and the need for multiple layers of care and multiple team
members to care for the many facets of a patient’s needs to guarantee a posi-
tive outcome has long been recognized. Clearly, though, the ability to create
positive patient outcomes in the future may rely on more than the current
subset of medical practitioners. It will require integration with public health,
with industry, and with the private sector and will touch almost everything
and everyone with whom the patient interacts on some level. Technology will
radically change how health care is delivered, especially in regard to where
patients get their information (Interprofessional Education Collaborative
Expert Panel, 2011).
Today, most patients have surfed the web thoroughly before presenting to
their caregiver’s office. Imagine a vending machine in the future that recognizes
that the customer has diabetes based on a bracelet worn, or some other method,
and suggests healthy choices tailored to the customer. Imagine point-of-care
testing at home to test for a Streptococcus infection. Technology will change how
the patient interacts with the healthcare provider. It may also serve to connect
and allow many disciplines to collaborate and crowdsource what is best for the
patient. A nurse practitioner in a rural area can get a virtual consultation from
a specialist in a major city without much difficulty, and the idea of the patient
always having to go to a tertiary care center to get specialized care will become
a thing of the past.
References
Allio, R. J. (2004). CEO interview: The InnoCentive model of open innovation. Strategy and
Leadership, 32(4), 4–9.
Aston, S. J., Rheault, W., Arenson, C., Tappert, S. K., Stoecker, J., Orzoff, J., . . . Mackintosh, S.
(2012). Interprofessional education: A review and analysis of programs from three academic
health centers. Academic Medicine, 87(7), 949–955.
Gordon, M., & Findley, R. (2011). Educational interventions to improve handover in healthcare:
A systematic review. Medical Education, 45(11), 1081‒1089.
Howard, R. (1995). Apollo 13 [Motion picture]. United States: Imagine Entertainment, distributed
by Universal Pictures.
InnoCentive. (n.d.). About us. Retrieved from https://www.innocentive.com/about-innocentive
Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC:
National Academy Press.
Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington,
DC: National Academy of Sciences.
Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for
interprofessional collaborative practice: Report of an expert panel. Washington, DC:
Author.
Simpson, C. (2007). Atlantis completes spectacular mission. Spaceflight, 49(8), 293.
U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality.
(2014). TeamSTEPPS®: National implementation. Retrieved from http://teamstepps
.ahrq.gov
159References
World Health Organization. (1978). Alma-Ata 1978: Primary health care, report of the
International Conference on Primary Health Care. 6–12 September 1978; Alma-Ata, USSR.
Geneva, Switzerland: Author.
***
INTERPROFESSIONAL COLLABORATION
TO INFLUENCE POLIC Y
Patrick H. DeLeon
The views expressed are those of the author and do not reflect the official policy
or position of the Uniformed Services University of the Health Sciences, the
Department of Defense, or the United States Government.
I want to acknowledge the assistance of 1st Lt. Rachael Antone, BSN, a graduate
student in nursing at the Uniformed Services University of the Health Sciences.
KEY TERM
Societal need: A gap or lack in a service in a population that creates a hardship
for that population.
▸ Bipartisan–Bicameral Action
When observing the creation of far-reaching and exciting programmatic initiatives
(whether they are administratively or legislatively accomplished) at the state or
federal level, those interested in the public policy (i.e., political) process should
strive to recognize the ongoing interaction of certain underlying principles that
are essential for lasting success. Perhaps the most important principle is address-
ing a substantive societal need in a manner in which other equally competent
concerned individuals had previously not contemplated. Over the years, we have
learned that this kind of effort requires vision, persistence, and presence. It is
often necessary to remind oneself that seeking perfection can be the enemy of
the possible. Substantive change always takes time—and frequently longer than
one would initially expect.
In 1984, President Ronald Reagan signed into law the Preventive Health
Amendments of 1984 (P.L. 98-555), which established a new program entitled the
Emergency Medical Services for Children (ESMC) initiative. Funding was authorized
at $2 million for fiscal year 1985 and for each of the two succeeding fiscal years.
From the beginning, this was to be a pilot (or demonstration) project that would
not be expansive in nature. The legislation’s prime sponsors were U.S. Senators
Daniel K. Inouye (Democrat‒Hawaii) and Orrin G. Hatch (Republican‒Utah). At
the time, Senator Hatch was chairman of what today is the Senate Health, Educa-
tion, Labor, and Pensions (HELP) Committee (i.e., the authorization committee).
160 Chapter 9 Interprofessional Practice
At the 10th anniversary of this legislation, Dr. C. Everett Koop opined:
I am pleased to remember that in 1984, while I was U.S. Surgeon General,
the United States Congress passed legislation to improve emergency
medical services for children (EMSC). It received my full support and
that of many of my colleagues, because critically ill and injured children
were not receiving the same high quality of emergency health care we
provided for adults. But this is not unusual; throughout history children
have not been our first priority. The 1984 EMSC legislation, cosponsored
by Senators Inouye and Hatch, was a step toward reversing this trend.
This year, 1995, represents a milestone. It has been 10 years since the
first four state grants were funded. Since then, 36 more states, the Dis-
trict of Columbia, and Puerto Rico have received grants. I believe it is
one of the most effective investments we have ever made. These grant
monies have reached across the nation, and have begun the building of
an infrastructure for integrating children into the Emergency Medical
Services (EMS) systems of 40 states. . . . [I]n 1984 there was virtually no
pediatric emergency interest. (Feely & Athey, 1995, p. ix)
EMSC addressed a real and substantive societal need. Nearly a decade after
its creation, the Institute of Medicine (IOM) still reported:
Each year, injury alone claims more lives of children between the ages of
1 and 19 than do all forms of illness. . . . Overall, some 21,000 children
and young people under the age of 20 died from injuries in 1988. . . .
When prevention fails, families should have access to timely care by
trained personnel within a well-organized emergency medical services
(EMS) system. . . . For too many children and their families, however,
these resources have not been available when they were needed. Although
EMS systems and hospital EDs are widely assumed to be equally capable
of caring for children and adults, this is not true. In many EMS systems,
children’s needs have been overlooked. . . . Care for seriously ill and
injured children cannot presume that they are simply “little adults.” . . .
Attempts to ensure that children receive adequate emergency medical care
are a recent development in the field of EMS. (IOM, 1993, pp. 1‒3, 22)
The leadership of the EMSC program emphasized a data-driven and
evidence-based orientation for improving the quality of care available to injured
children and their families. Their approach envisioned encouraging EMSC to
become an integrated component of the nation’s overall emergency medical system
(EMS). Ultimately, they succeeded in building the necessary capacity (including
clinical training, treatment guidelines, and data collection ability) in all states,
the District of Columbia, and the territories and freely associated states. Pediatric
EMS was no longer an afterthought. Along with an impressive local hands-on
orientation, there evolved a visionary national perspective. Although support for
the adult EMS system (especially under the prevailing block-grant approach) was
in a constant state of ebb and flow, a steady (and increasing) funding for EMSC
actually provided a base for both the pediatric and the adult federal emergency
medical efforts for a number of years, especially for the expansion of regionalized
(multistate, tribal-state) systems of care.
Bipartisan–Bicameral Action 161
The needs of rural America were especially acute, as was the catalytic
impact of having identified advocates at all levels of policy development. De-
veloping a regionalized system of pediatric care, as well as exploring necessary
changes in the prehospital and emergency department settings, became a na-
tional priority. Systemic efforts were made to target federal research support
for investigators who focused on high-volume child-specific injuries (e.g.,
those most likely to be incurred while playing sports, such as head trauma),
unusual adverse drug reactions, issues relevant to school personnel respon-
sibilities when natural disasters occur (e.g., training for school nurses and
teachers’ aides), and dealing with families’ emotional trauma of experiencing
the death of a loved one. From a historical perspective, one must appreciate
that previous experience would strongly suggest that each of these issues, no
matter how remarkable in retrospect the research findings might appear, would
undoubtedly have remained a low priority for funding without the continued
voice of EMSC advocates.
In many ways, the longevity of the EMSC program is particularly impressive
and reflects the ongoing collaboration between congressional and administration
staff, regardless of their political affiliation. Both Republicans and Democrats
agreed that the core issue was child health. Senator Inouye, who was one of the
program’s prime sponsors while serving on the Senate Appropriations Commit-
tee, died in 2012; Senator Hatch still serves in the U.S. Senate. These two leaders
worked “across the aisle” for a common purpose.
From the beginning, those administering the program within the Department
of Health and Human Services (DHHS) possessed the vision to appreciate that
for EMSC to be sustained in the long run, they would have to effectively engage
a wide range of potential stakeholders, including the DHHS’s budget personnel.
To simply proclaim that this particular discretionary program might be “good for
children” or was of “special interest to Congress” would simply not be sufficient,
given the perennial budgetary constraints and competing domestic priorities and
the ongoing leadership changes within presidential administrations. Program
administrators seized upon this unique opportunity to undertake an exciting
voyage through unchartered waters—they embraced the opportunity to work
with multiple agencies and bipartisan legislators.
From the very beginning, a conscious effort was made to reach out to all
professional disciplines and organizations that were involved in caring for in-
jured children, as well as to other potentially relevant federal and state agencies.
This group of stakeholders included, at a minimum, organizations representing
nursing, psychology, social work, emergency physicians, surgeons, emergency
medical technicians, state health departments, children’s hospitals, and, most
fortuitously in the long run, the American Academy of Pediatrics (AAP). EMSC
was envisioned as becoming part of the national EMS system—as a distinct but
complementary unit. Notwithstanding concerns regularly expressed by associa-
tion lobbyists that the funding level was insufficient given the considerable needs
of the nation’s children, those involved at the staff level continued to focus on
supporting innovative and strategic programmatic initiatives rather than funding
clinical care per se. Staff did not allow seeking the perfect to become the enemy
of the possible. Instead, they constantly kept their focus on the bigger picture.
At its current (perhaps to some, modest) level of funding, EMSC persists in its
underlying mission of serving as a catalyst for fostering innovative programmatic
162 Chapter 9 Interprofessional Practice
and clinical change that continues to improve the quality of care provided for
injured children and their families.
In developing administrative support, the EMSC programmatic staff were
especially creative in collaborating with the Federal Interagency Committee on
EMS, a legislated federal entity with a composite of key agencies that intersect
with the EMS system. Primary partners soon became the Department of Trans-
portation’s National Highway Safety Administration, as well as DHHS’s Agency
for Health Care Research and Quality and the Department of Defense’s Uniformed
Services University of the Health Sciences. In essence, DHHS staff cast a wide
net of potentially interested partners rather than settle for a more comfortable
smaller group of like-minded colleagues; the latter is all too frequently the case
in jury-rigged systems. Importantly, staff did not consider the health of children
as exclusively the purview of any one discipline (e.g., medicine) or organization
(e.g., children’s hospitals). Ensuring quality health care for injured children could
reasonably be considered a priority of a wide range of health disciplines.
By ensuring the continued presence of EMSC spokespersons at a range of
professional meetings every year, the Health Resources and Services Administra-
tion (HRSA) effectively reminded all potential stakeholders of the importance of
their ongoing commitment to this important initiative. In retrospect, involvement
with AAP turned out to be particularly beneficial, as that organization, more than
any other, continued to make EMSC one of its top legislative priorities over the
years—in contrast to several other organizations that had initially been expected
to be extremely supportive given their public rhetoric. AAP followed through each
year. EMSC initially received $2,000,000 in funding; by comparison, the fiscal
year 2017 DHHS budget recommended $20,162,000 for this program, thereby
maintaining a consistent level of funding over the past five years, regardless of
which political party controlled the Congress. The interaction of multiple agencies,
legislators, and healthcare professionals who served as consultants is a shining
example of a powerful, positive response to a broad societal need.
▸ Personal Reflections
During its three-plus decades of existence, EMSC has faced several significant
challenges. Some years, DHHS leadership declined to include the program within
their budget request—thereby sending a message to the Congress that other
funded programs were now meeting this need and indicating that EMSC was a
lower priority. One year, when additional funding was initially included within
a “must pass” antidrug bill, a major national newspaper published an editorial
expressing outrage over this non-drug-related proposed federal expenditure.
From time to time, proponents of other (allegedly similar) programs attempted
to incorporate the successful EMSC budget within their own areas of personal
priority (e.g., poison control centers, children’s hospitals, and a broader trauma
initiative), attempting once again to combine children’s health needs with adult
care. Staff from one national organization were convinced that EMSC would
result in a separate, parallel, and competing system that might result in the loss
of block-grant funding.
Each of these perhaps well-meaning efforts was turned back primarily because
concerned child-focused congressional and administration staff were engaged.
Personal Reflections 163
That is, staff members from both areas were persistent and present throughout
the related negotiations and strenuously objected to diluting the unique child
focus of EMSC. Fortunately for EMSC, Senator Brian Schatz (Democrat‒Hawaii)
was elected to replace Senator Inouye after the latter’s death, and a University
of Hawaii‒trained pediatrician on his staff has assumed the role of specifically
advocating for the program, thereby providing the necessary continuation of
congressional support. Owing to both her personal and professional background,
this pediatrician-staffer appreciates the critical importance of EMSC’s unique
focus on children.
As is often the case, there is a personal “behind the scenes” story for EMSC.
Over the decades, key HRSA staff were individuals who thought of the needs of
children before those of their particular professional disciplines. One might say
that they made “children” the noun and not the adjective while truly appreciat-
ing children’s unique needs. Each of the two congressional staff members who
were most engaged in shepherding this initiative through the legislative process
experienced a need to rely upon their local emergency room personnel for the
care of their young children. One, who was at the time a professor of medicine,
reported receiving outstanding care. The other described quite a different story.
His family was informed that their young daughter would be dead by morning
or brain damaged for life. There was absolutely no attention paid by the emer-
gency department personnel to the emotional/psychological aspects of being an
impacted family. Fortunately, both children survived their trauma with no long-
term adverse consequences. However, these dramatically different experiences
led to numerous informal discussions among many stakeholders about how to
ensure that all Americans, regardless of their geographical location and social
status, would be able to receive the quality of emergency care that they expected
for their children.
There was no immediate solution to ensuring care for all American chil-
dren. Involved HRSA staff agreed that only those with the best of intentions
were involved in providing necessary clinical care. Therefore, the staff felt that
a demonstration approach might be the most productive answer in the long
run. Staff hoped that from these pilot experiences and public hearings, future
legislative direction might evolve. DHHS was not initially supportive of the
proposed child-oriented demonstration. As the likelihood of enactment of the
project became clearer, the discussion broadened into whether the Centers for
Disease Control and Prevention (CDC) or HRSA would be the appropriate venue
for implementation. Since the underlying objectives were to improve the qual-
ity of care provided (i.e., improve provider competency in the unique needs of
children) and to explore potential system innovations (e.g., develop the capacity
for approaching ambulances and helicopters to alert the designated emergency
room personnel as to which types of equipment and medications should be
readily available), HRSA was chosen.
At the 10th anniversary celebration of EMSC held in the U.S. Senate, it was
emotionally gratifying to listen to the grandparents of the survivors of the tragic
Oklahoma City bombing (which occurred at the Alfred P. Murrah Federal Building
on April 19, 1995) describe how just the previous week the EMSC program had
trained their city’s first responders on how best to treat their injured loved ones.
In a similar vein, it was heartwarming to see both members of the North Dakota
Senate delegation (Senators Dorgan and Conrad) laud the EMSC program after
164 Chapter 9 Interprofessional Practice
CASE STUDY 9-4: Collaboration Among
Healthcare Professionals to Influence Health
Policy
Rachael Antone, 1st Lt., USAF, NC, BSN, Family Nurse Practitioner student, Uniformed
Services University of the Health Sciences, Bethesda, Maryland
Within a patient care setting, it is common to see nurses, physicians, pharmacists,
physical therapists, and nutritionists working in silos. From the patient’s standpoint,
there are multiple people coming into the room throughout the hospital stay, and
often they give differing, sometimes conflicting, information and guidance. This
type of disjointed interaction is known as fragmentation of care.
Having a medical team that cares for a panel of patients allows for greater
collaboration among healthcare professionals and better patient outcomes
as evidenced and informed by the patient-centered medical home model,
the Wagner chronic care model, and the creation of rules for accountable care
organizations. Legislation such as the ACA defined and facilitated intercollegial
teams by rewarding high-quality outcomes of care with higher reimbursement.
Discussion Questions
1. Why might it be difficult to get health professionals to reach consensus on a
policy agenda?
2. Using www.Congress.gov, enter the search term (including the quotation
marks) “patient-centered medical home” and perform a search of All
Legislation. Scroll to see how many bills have been introduced related to this
subject since the 110th Congress (2007–2008). Can you find any evidence
in literature searches of a consensus in Congress regarding how to reduce
fragmentation of care, improve communications, and improve quality of
care?
3. What prompted the current emphasis on intercollegial teams?
4. To what extent do you think the force of law can change the silo practices
of nurses, physicians, pharmacists, and other healthcare providers? Identify
other approaches that might be successful in changing the silo practice of
healthcare professionals.
5. Other than healthcare professionals, who (individuals and organizations)
are stakeholders involved in reducing fragmented care? (Hint: Follow the
money.) Which collaborations have the American Medical Association,
American Academy of Family Physicians, American Association of Nurse
Practitioners, American Academy of Nursing, and American Nurses
Association already created regarding patient-centered care? To what
extent are the Association of American Medicine Colleges and the American
Association of Colleges of Nursing influential in this regard? Give examples.
the Wakefield family who had suffered an extraordinarily horrible automobile
accident in the ice and snows of North Dakota’s winter; they were close family
members of long-time public servant Mary Wakefield, PhD, RN, the former
administrator of HRSA and deputy secretary of DHHS under President Obama.
The spirit of EMSC definitely lives on.
165Personal Reflections
CASE STUDY 9-5: Interprofessional
Collaboration on Health Policy Related to Critical
Congenital Heart Defects
Donna Ryan, DNP, RN, CNE, Assistant Professor, Elmira College (New York)
It was 7:00 a.m. when Christine began to breastfeed her seemingly healthy 5-day-old
baby. Zach was vaginally delivered after a normal pregnancy and routine labor.
Despite Christine’s exhaustion as a first-time mother, everything was going fine so
far. Christine looked up at her husband, Jeff, who was just out of the shower and
getting ready for work. She then looked back down at Zach to find him a sickly blue-
gray color: Zach had stopped breathing. Christine screamed to Jeff, and he called
911. The parents were not trained to perform infant cardiopulmonary resuscitation
(CPR) and as they anxiously waited for the ambulance to arrive, they decided to rush
Zach to the hospital themselves. Despite attempts to revive Zach in the emergency
department of their local hospital, he was pronounced dead a few hours later. The
couple’s baby was dead, and they did not know why: There had been no warning
signs of the heart defect that took Zach’s life. A week later, Christine and Jeff were
told that Zach was born with a critical congenital heart defect (CCHD). They later
learned that screening for CCHD with commonly available pulse oximetry might
have prevented Zach’s death (Save Babies Through Screening Foundation, 2012).
Congenital heart disease (CHD) is the most common birth defect among
the major anomalies involving the structure of the heart or the blood flow of the
heart (Hom & Martin, 2016). Approximately 8 to 12 of every 1,000 newborns have
a form of CHD (Frank, Bradshaw, Beekman, Mahle, & Martin, 2013). A prenatal
diagnosis of CHD is made in only 50% of infants with this type of disease (Koppel
et al., 2003; Mahle et al., 2009; Thangaratinam, Daniels, Ewer, Zamora, & Khan, 2007).
Some forms of CHD cause no, or very few, problems in the health, growth, and
development of the infant (CDC, 2015). CHD accounts for 24% of all infant deaths
due to birth defects in the United States (CDC, 2014).
Approximately one in four babies with a heart defect has CCHD (Oster
et al., 2013). CCHD is a form of CHD that is usually associated with hypoxia in the
newborn period and requires intervention during the first months of life (CDC,
2015; Martin & Bradshaw, 2012). Approximately 30% to 50% of infants with CCHD
may leave the hospital undiagnosed (Kumar, 2016). The consequences of delaying
treatment until the infant becomes critically ill are often a higher mortality rate,
a much longer stay in the intensive care unit, and a higher incidence of serious
complications such as neurological impairment (Mahle et al., 2009).
Interprofessional stakeholders generally agree that sufficient evidence exists
to support CCHD screening by pulse oximetry after 24 hours of age and before
discharge of a newborn. Screening to promote early detection of CCHD has been
endorsed by the Health and Human Services Secretary’s Advisory Committee
on Heritable Disorders in Newborns and Children (SACHDNC), the American
Heart Association, the American Academy of Pediatrics, the American College
of Cardiology Foundation (Mahle, Martin, Beekman, & Morrow, 2012), and the
March of Dimes. Nurses are well positioned to play a leadership role in ensuring all
newborns are screened for critical congenital heart disease.
Since newborn screening for CCHD was added to the U.S. Recommended
Uniform Screening Panel in 2011, most states have passed legislation that
166 Chapter 9 Interprofessional Practice
promotes routine newborn screening for CCHD (AAP, 2015; Mahle et al., 2012; Oster
et al., 2016). CCHD screening with pulse oximetry is simple and inexpensive—
comparable to the cost of a diaper change. According to Ewer (2016), such
screening increases the overall detection rate for CCHD to more than 90%. Ailes,
Gilboa, Honein, and Oster (2015, p. 1000) estimate that approximately 875 infants
with CCHD might be detected, and approximately 880 missed, annually through
universal CCHD screening in the United States.
Once parents understood that in some cases, their newborn infants might
not have died if they had received CCHD screening prior to discharge, they
became instrumental in raising awareness of this screening and its significance in
preventing undiagnosed CCHD through social media. Many parents shared their
personal tragedies and advocated to state legislators to pass mandatory screening
bills throughout the United States. After hearing these heart-wrenching stories
from parents, policymakers were more supportive in exploring legislation.
One example of interprofessional collaboration to achieve legislation
occurred in North Carolina in October 2012. Dr. Alex Kemper—a Duke pediatrician,
co-editor of Journal of Pediatrics, and member of the SACHDNC—spoke to the
Perinatal Health Committee, which is a subcommittee of the Child Fatality Task
Force and the North Carolina Healthcare Senate Standing Committee (SACHDNC,
2012). Dr. Kemper, along with several parents of children with CCHD, discussed
how CCHD screening by pulse oximetry could save the lives of newborns across
North Carolina. They explained that this screening is a painless, noninvasive test
that increases the ability to identify newborns with CCHD before they clinically
decompensate.
In North Carolina, a wide range of stakeholders, including families of children
with CCHD, pediatricians, neonatologists, nurse practitioners, nurse–midwives, and
representatives from the N.C. Hospital Association, the N.C. Chapter of the American
Heart Association, the N.C. Chapter of the March of Dimes, the Perinatal Quality
Collaborative of North Carolina, the N.C. Board of Nursing, the N.C. Academy of
Family Physicians, and the N.C. Academy of Physician Assistants, engaged in the
development of the guidelines for CCHD screening (Perinatal Quality Collaborative
of North Carolina [PQCNC], n.d., para 2). The North Carolina state legislature passed
Session Law 2013-15 on July 25, 2014 (PQCNC, n.d.); it required all newborns
born in hospitals, birthing centers, and homes to be screened for CCHD by 24–48
hours of age. PQCNC developed a database to handle the reporting requirements
for CCHD and provides resources on this issue, including provider continuing
education webinars and educational materials for parents.
Discussion Points
1. Argue the advantages and disadvantages of approaching congressional
legislators versus state legislators to get this issue on the agenda.
2. Identify at least four people or organizations that would have a stake in this
issue. Which information could you provide to persuade them to join you in
your plan to seek a legislative solution? Do not limit yourself to research.
3. Which government agencies might have an interest in this issue? How
could you find a legislator who has had personal experience with this issue
who could become a policy entrepreneur/champion?
4. Suppose that one person/organization agrees to join you but has a different
(albeit related) focus. Which tactics can you construct that could end with a
win–win outcome? Which options do you have if the other’s goal becomes
a barrier to your goal?
(continues)
167Personal Reflections
5. Develop potential language for a bill. What are three policy tools that could
be used to encourage compliance with the law if passed?
6. Who might oppose this law? Develop responses to address the opposition.
7. Determine criteria for evaluating the effectiveness and efficiency of the
policy/program. Develop a tool to measure the outcomes. Who will use the
tool? At which point(s) should the policy/program be evaluated?
References
Ailes, E. C., Gilboa, S. M., Honein, M. A., & Oster, M. E. (2015). Pediatrics, 135(6), 100–1008.
American Academy of Pediatrics (AAP). (2015). American Academy of Pediatrics newborn
screening for CCHD 2015 state actions. Retrieved from https://www.cdc.gov/ncbddd
/heartdefects/documents/2015-critical-chd-newborn-screening-by-state
Centers for Disease Control and Prevention (CDC). (2014). Newborn screening for critical
congenital heart disease. Retrieved from https://www.cdc.gov/ncbddd/heartdefects
/documents/newborn-screening-for-cchd
Centers for Disease Control and Prevention (CDC). (2015). Congenital heart defects. Retrieved
from https://www.cdc.gov/ncbddd/heartdefects/cchd-facts.html
Ewer, A. (2016). Screening for critical congenital heart defects with pulse oximetry: Medical
aspects. American Journal of Perinatology, 33(11), 1062–1066.
Frank, L. H., Bradshaw, E., Beekman, R., Mahle, W. T., & Martin, G. R. (2013). Critical congenital
heart disease screening using pulse oximetry. Journal of Pediatrics, 162(3), 445–453.
Hom, L. A., & Martin, G. (2016). Newborn critical congenital heart disease screening using
pulse oximetry: Nursing aspects. American Journal of Perinatology, 33(11), 1072–1075.
Koppel, R. I., Druschel, C. M., Carter, T., Goldberg, B. E., Mehta, P. N., Talwar, R., & Bierman, F. Z.
(2003). Effectiveness of pulse oximetry screening for congenital heart disease in
asymptomatic newborns. Pediatrics, 111(3), 451–455.
Kumar, P. (2016). Universal pulse oximetry screening for early detection of critical congenital
heart disease. Clinical Medicine Insights: Pediatrics, 10, 35–41.
Mahle, W. T., Martin, G. R., Beekman, R. H., & Morrow, W. R. (2012). Endorsement of Health and
Human Services recommendation for pulse oximetry screening for critical congenital
heart disease. Pediatrics, 129(1), 190–192.
Mahle, W. T., Newburger, J. W., Matherne, G. P., Smith, F. C., Hoke, T. R., Koppel, R., . . . Grosse, S.
D. (2009). Role of pulse oximetry in examining newborns for congenital heart disease:
A scientific statement from the AHA and AAP. Pediatrics, 124(2), 823–836.
Martin, G. R., & Bradshaw, E. A. (2012). Sensitivity of pulse oximetry for detection of critical
congenital heart defects in newborn infants higher than that of antenatal ultrasound
with few false positives. Evidence-Based Medicine, 17(2), 57–58.
Oster, M., Aucott, S. W., Glidewell, J., Hackell, J., Kochilas, L., Martin, G. R., . . . Kemper, A. R.
(2016). Lessons learned from newborn screening for critical congenital heart defects.
Pediatrics, 137(5), 1–14.
Oster, M., Lee, K., Honein, M., Colarusso, T., Shin, M., & Correa, A. (2013). Temporal trends in
survival for infants with critical congenital heart defects. Pediatrics, 131(5), e1502–e1508.
Perinatal Quality Collaborative of North Carolina (PQCNC). (n.d.). Critical congenital heart
disease. Retrieved from https://www.pqcnc.org/node/13639
CASE STUDY 9-5: Interprofessional
Collaboration on Health Policy Related to Critical
Congenital Heart Defects (continued)
168 Chapter 9 Interprofessional Practice
▸ Discussion Points
In an effort to make this example of interprofessional and interagency collaboration
an exemplar for understanding persistence, consider the following:
1. Have the stakeholders changed? If so, what is the impact on the overall
process of collaboration?
2. Has the focus changed? If so, how should those who are involved in the
policy process make changes to reach the desired outcome?
3. Are there other factors that have or are having an impact on the future of
the program?
References
Feely, H. B., & Athey, J. L. (1995). Emergency medical services for children: 10 year report.
Arlington, VA: National Center for Education in Maternal and Child Health.
Institute of Medicine (IOM). (1993). Emergency medical services for children. Washington, DC:
National Academy Press.
Suggested Readings
DeLeon, P. H., Kjervik, D. K., Kraut, A. G., & VandenBos, G. R. (1985). Psychology and nursing:
A natural alliance. American Psychologist, 40, 1153‒1164.
Gausche-Hill, M., Ely, M., Schmuhl, P., Telford, R., Remick, K. E., Edgerton, E. A., & Olson, L. M.
(2015). A national assessment of pediatric readiness of emergency departments. JAMA
Pediatrics, 169(6), 527‒534. Erratum in: JAMA Pediatrics (2015), 169(8), 791.
Preventive Health Amendments of 1984. [P.L. 98–555]. (October 30, 1984). 98 STAT. 2854. (S 2301).
42 USC 201 note.
Schenk, E., & Edgerton, E. A. (2015). A tale of two populations: Addressing pediatric needs in
the continuum of emergency care. Annals of Emergency Medicine, 65(6), 673‒678.
Save Babies Through Screening Foundation. (2012). Cora’s story: The need for pulse
oximetry. Retrieved from http://www.savebabies.org/blog/2012/01/cora%E2
%80%99s-story-the-need-for-pulse-oximetry-screening-for-cchd/
Secretary’s Advisory Committee on Heritable Disorders in Newborns and Children
(SACHDNC). (2012). Implementing point of care newborn screening. Retrieved from
http://www.hrsa.gov/advisorycommittees/mchbadvisory/heritabledisorders
/recommendations/correspondence/implementpocnewbornscreen
Thangaratinam, S., Daniels, J., Ewer, A. K., Zamora, J., & Khan, K. S. (2007). Accuracy of pulse
oximetry in screening for congenital heart disease in asymptomatic newborns: A
systematic review. Archives of Disease in Childhood: Fetal and Neonatal Edition, 92(3),
F176–F180.
169Suggested Readings
© Visions of America/Joe Sohm/Photodisc/Getty
KEY TERMS
Adverse selection: A situation in which, as a result of private information, the
insured are more likely to suffer a loss than the uninsured. A form of information
asymmetry.
Affordable Care Act (ACA): The combination of the Patient Protection and
Affordable Care Act of 2010 and the Health Care and Education Affordability Act
of 2010. There are nine titles (or sections) within this law; mandatory personal
health insurance, as required in this law, is commonly referred to as “Obamacare”
and is only one of these titles.
Alternative Payment Models (APMs): A quality payment program for providers
administered by the Centers for Medicare and Medicaid Services.
Coinsurance: The share of the costs of a covered healthcare service paid by the
consumer, calculated as a percentage (for example, 20%) of the allowed amount
for the service. The consumer pays coinsurance plus any deductibles owed. This
should not be confused with a health plan that pays for a specific percentage of
“essential health benefits.”
Overview: The
Economics and Finance
of Health Care
Nancy M. Short
Other people, including the politicians who make economic policy, know even less
about economics than economists.
—Herbert Stein, Washington Bedtime Stories (1986)
171
CHAPTER 10
Comparative effectiveness research (CER): A category of studies to determine
the effectiveness of clinical interventions specifically when compared to
differing treatments for the same condition or for different subgroups of
patients. The newly created Patient-Centered Outcomes Research Institute
(PCORI) is charged with identifying priorities and carrying out this type of
research.
Essential health benefits: A set of healthcare service categories that, starting in
2014, had to be covered by certain plans. Insurance policies must cover these
benefits to be certified and offered in the health insurance marketplace. States
expanding their Medicaid programs must provide these benefits to people
newly eligible for Medicaid.
Health insurance exchanges (HIXs): Markets set up to facilitate the purchase
of health insurance in accordance with the Patient Protection and Affordable
Care Act of 2010. Exchanges are either state, federal, or jointly run depending
on the state.
Information asymmetry: The condition in which some parties to business
transactions have an information advantage over others. There is often
information asymmetry between patients and providers regarding therapies
and prices.
Means testing: A process undertaken to determine whether a person’s income
qualifies him or her to participate in a social program. It is often used to
determine eligibility for Medicaid coverage of long-term care and to determine
eligibility for subsidies for health insurance.
Medicare Access and CHIP Reauthorization Act (MACRA) of 2015: A program
that combines parts of three government quality incentive programs into one
single program to determine physicians’ and advanced practice registered
nurses’ reimbursement.
Moral hazard: The change in behavior as a result of a perceived reduction in the
costs of misfortune (e.g., health insurance changes the costs of becoming ill or
injured). A form of information asymmetry.
Opportunity costs: The value of the next best choice that one gives up when
making a decision; also called economic costs.
Qualified health insurance plan (QHP): An insurance plan that has been
certified by the health insurance marketplace, provides essential health
benefits, follows established limits on cost-sharing (e.g., deductibles,
copayments, and out-of-pocket maximum amounts), and meets other
requirements under the Affordable Care Act. Sometimes referred to as
essential minimum coverage.
Quality-adjusted life-years (QALYs): Calculated life expectancy adjusted for the
quality of life, where quality of life is measured on a scale from 1 (full health) to
0 (dead). Originally developed as a broader measure of disease burden beyond
mortality, QALYs are now used in cost-effectiveness analyses to aid coverage and
reimbursement decisions worldwide.
“Repeal, replace, repair, or starve”: A slogan referring to a primarily
conservative political ideology with regard to the Affordable Care Act. Another
possible action to reduce the impact of the ACA would be for Congress not
to fund implementation of specific parts of the law—an approach known as
“starving” a law.
Risk pool: A multiple-beneficiary risk-sharing arrangement to limit an insurance
company’s exposure, liability, or risk or some combination of the three. A
combination of young, healthy beneficiaries balancing the risk for high expenses
for older, sicker beneficiaries is an ideal risk pool.
172 Chapter 10 Overview: The Economics and Finance of Health Care
▸ Introduction
Three important concepts that form the framework for health policy discussions
are quality/safety of care, access to care, and cost of care. All health policy dis-
cussions boil down to one of these categories or to the synergies among these
categories. This chapter focuses on the “cost” category, including some economic
theories supporting current health policies and some of the structures created to
implement these policies.
Health economics and the finance of health care are often erroneously used as
interchangeable terms. How does health finance differ from health economics?
In a nutshell, economics is the science that informs the processes of finance. The
two disciplines share common ground such as cost–benefit analysis and analysis
of risk, but they are not synonymous. Economics is amoral—that is, it is neither
a moral science nor an immoral science. The science of health economics can
suggest what makes a person, a population, a region, or a nation better off, but
philosophy and ethics must be debated elsewhere and are represented by political
trade-offs when policy is made. Similarly, the healthcare market as viewed by
economists is amoral: When confronted with finite resources, there will be losers
and winners. This is a tough concept for nurses to swallow.
Economic theory is based on the principle that all resources are scarce.
Politics is the process for determining how scarce resources will be used and
apportioned. Policy is the end result of the political process. Health policy is
one type of policy determined in the political process and is made largely at the
national level but also at state and local levels of government. Health economics
is a growing research field within the discipline of economics.
Economic science studies markets such as the labor market for nurses and
physicians, the pharmaceutical market, and the insurance market. Together
these markets form the universe that is termed the “healthcare market.” Within
the healthcare market are nonprofit organizations, government organizations,
shareholder-owned corporations, and other financial entities. Economics informs
policy, and policy determines finance (FIGURE 10-1).
To better understand these relationships, think about the supply and demand
for oranges. When significant weather events affect the orange crop, prices go up
for all products made from oranges. In response to price variation, consumers
choose whether they will continue to purchase orange juice or instead purchase
a substitute such as apple juice.
In health care, shortages of resources lead to increased demand, discontin-
uation of manufacturing or loss of a manufacturing site, lack of raw materials at
FIGURE 10-1 The intersection of health policy and health finance.
EconomicsHealthcare
Policy
Health
Finance
Introduction 173
reasonable prices, quality issues in manufacturing, and delays or capacity problems
(e.g., labor strikes). In January 2017, nearly 200 drugs were listed as “in shortage”
in the United States: Sterile injectables such as saline and atropine sulfate topped
the list. Pharmaceutical manufacturers report to the Food and Drug Adminis-
tration (FDA) when there are shortages, and the FDA posts this information in
the form of the Current Drug Shortage Index (https://www.accessdata.fda.gov
/scripts/drugshortages/default.cfm). Because pharmaceutical manufacturing is
not owned and operated by the U.S. government, the government does not control
choices of what and how much to produce. Can consumers choose to go without
a medication, or will they simply pay the higher price charged for a medication?
Consumers frequently do choose to skip medications, sometimes at great risk. This
added risk to health and life makes the healthcare market very different from all
other economic markets. There are few ready-to-use substitutes for health care.
▸ Economics: Opportunity Costs
There is no such thing as a free lunch: For every opportunity taken and for every
option discarded, there are trade-off costs. When you purchased the 2017 Nissan
Juke, you did not purchase the 2016 Kia Soul. You also did not take a vacation,
buy a new wardrobe, or pay off your college debt. Not acquiring the Soul, the
vacation, the new wardrobe, or eliminating your debt, are the opportunity costs
of purchasing the Juke.
Opportunity costs may also be described in terms of time spent on an activity
(researching the safety of the Juke) and other indirect measures or intangibles. An
example of opportunity costs related to health policy is current Medicare policy:
90% of Medicare funds are used for 10% of Medicare beneficiaries. Most Medicare
dollars are expended in the final events of a person’s life. Because there are finite
funds available, legislative policy directing payments for an elderly person’s last
weeks of life represent an opportunity cost. For example, the funds could also be
used for preventive care of 30-year-olds, more school nurses, or health research.
These hard choices are the core of perennial political debates at the federal, state,
and local levels. The economic consequences of a policy may last for years and
may be argued equally eloquently by economists who fall on both sides of an issue.
The most important contribution economists can make to the operation
of the health care system is to be relentless in pointing out that every
choice involves a trade-off—that certain difficult questions regarding
who gets what, and who must give up what, are inevitable and must be
faced even when politicians, the public, and patients would rather avoid
them. (Getzen, 2010, p. 429)
▸ Finance: Does More Spending Buy Us
Better Health?
Studies continue to show that there is no correlation between increased spending
on health care in the United States and reductions in population mortality (Hussey,
174 Chapter 10 Overview: The Economics and Finance of Health Care
Wertheimer, & Mehrota, 2013). Paradoxically, achieving increased quality may
require increased spending, whereas lowering costs may require higher quality
or efficiency to avoid rework. In the 1900s, spending on infrastructure that pro-
vided clean water and hygiene, vaccination programs, and better access to health
care resulted in large improvements in quality of life and life expectancy. As the
United States approached $5,000 annual per capita spending on health care, gains
in population health and life expectancy slowed. In 2016, U.S. spending reached
$9,451 per capita (Organisation for Economic Co-operation and Development,
2017), but the marginal gains to health were almost imperceptible. (FIGURE 10-2
illustrates U.S. spending compared to other developed countries.) Routinely used
indicators of health status—for example, infant mortality, prevalence of chronic
diseases, Health Adjusted Life Expectancy, and feeling that one has good health—
also do not correlate with per capita spending on health care.
Health care is not a true “normal good” in economic parlance. The market
for a normal good or service experiences an increase in demand when income
increases. There is a correlation between seeking healthcare goods and services
when income rises; however, the necessity for health care even when income is
extremely low makes it a special case in economics. In the absence of a national
ideology and commitment that health care is a right for all people, a highly regulated
market determines the haves and have nots for health care in the United States.
▸ Economics: Health Insurance Market
Health insurance in the United States is a misnomer: What we are actually pur-
chasing is sickness insurance. Like other forms of insurance, health insurance
is a form of collectivism in which people pool their risks—in this case, the risk
of incurring medical expenses. Risk pooling is key to how insurance markets
work: Each participant with marginal or poor health and a high risk of accruing
high expenses is financially “balanced” by several participants with good health
FIGURE 10-2 Life expectancy in relation to per capita spending on health care.
Data from Central Intelligence Agency. (n.d.). The world factbook. Retrieved from https://www.cia.gov/library/publications/the-world-factbook/; Organisation for Economic
Co-operation and Development. (2017). OECD Health Statistics 2016. Retrieved from http://www.oecd.org/els/health-systems/health-data.htm
$10,000
$9,000
$8,000
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$-
United
States
U
.S
. D
o
lla
rs
Switzerland Norway Canada France Japan United
Kingdom
$9,541
$6,935
$6,567
$4,608 $4,407 $4,150 $4,003
7
9
.8
Y
e
a
rs
8
2
.4
Y
e
a
rs
8
1.
7
Y
e
a
rs
8
1.
9
Y
e
a
rs
8
1.
8
Y
e
a
rs
8
5
Y
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a
rs
8
0
.7
Y
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rs
Life expectancy in relation to per capita spending on health care
Economics: Health Insurance Market 175
and low risk of high expenses. Barring the participation of individuals who
already have disease or injury (preexisting conditions) allows insurers to manage
adverse selection (explained in a later section). The health insurance mandate
in the Affordable Care Act (ACA) provided for the enlargement and balance
of the risk pool. Without the option to refuse to cover preexisting conditions
or the increased risk pool created by the ACA’s mandate, the business model for
the insurance market would collapse: in 2017, many insurers pulled out of the
Health Insurance Exchanges because of uncertainty about the continuation of
the mandate. To repeal mandated individual health insurance from the ACA and
maintain the very popular feature that no one can be denied health insurance
because of a preexisting condition, Congress must grapple with how insurers will
balance risk pools so as to remain solvent.
As this book went to press, Congress and the Trump administration were
engaging in debate over how to “repeal, replace, repair, or starve” health-
care finance in the United States. In general, liberal thinkers wish to maintain
the ACA with possible improvements. Hard-right conservatives have made
election campaign promises to repeal and replace the ACA, while more mod-
erate conservatives are more open to repairing what they see as flaws in the
law. Changing the manner in which all Americans obtain health insurance is
extremely complex; any changes enacted by legislators will take years to imple-
ment. The American public is strongly divided about how to finance health care
in the country (FIGURE 10-3).
The market for health insurance is divided into public and private insurance.
The six major government healthcare programs are Medicare, Medicaid, the Chil-
dren’s Health Insurance Program (CHIP), the Department of Defense TriCare
and TriCare for Life programs, the Veterans Health Administration program,
and the Indian Health Service program. The insurance industry is organized into
group and nongroup (or individual) insurance. For example, employer-sponsored
health insurance (ESHI) is a form of group insurance. In 2016, more than 15 mil-
lion Americans purchased individual insurance; by comparison, more than half
the U.S. population younger than age 65 had health insurance through their jobs
or a family member’s job. The National Conference of State Legislatures (2017)
reports that the average health insurance premium was $18,142 per family in
2016. The cost of insurance premiums does not include out-of-pocket payments
for deductibles, copays, non-covered treatments/medications, or other fees.
One of the primary factors influencing how much you pay for health in-
surance is the state in which you live. Each state has a department of insurance
regulating the industry within its borders. Under the ACA, all 50 states offer either
the HealthCare.gov marketplace platform or a state-based marketplace (these
marketplaces are also known as health insurance exchanges) designed to help
individuals purchase affordable health insurance. The number of participating
insurance companies, as well as variable policies and prices, are driven by market
forces in each state (Assistant Secretary of Planning and Evaluation, 2016).
Some providers and organizations refuse to accept health insurance; they
accept only cash-based financing. This practice, known as direct pay, arguably
reduces the cost of health care by eliminating the profits insurers make and
eliminating time and resources for practices to work with various insurers; allows
patients to choose whomever they want as a provider; reduces gaps in consumer
knowledge about prices or costs; and allows providers to lower prices to reflect
the savings of having a smaller billing function (TABLE 10-1).
176 Chapter 10 Overview: The Economics and Finance of Health Care
▸ Finance: Health Insurance Exchanges
Introduced in October 2013, health insurance exchanges (HIXs) are intended to
create a more organized and competitive market for health insurance by offering
a choice of plans, establishing common rules regarding the offering and pricing
of insurance, and providing information to help consumers better understand the
options available to them. Depending on the state, the HIX serving that state will
be implemented by the state government, by the federal government, or jointly
by both the state and the federal government. A HIX marketplace is where
people (individuals or small businesses) not covered through their employers or
by public insurance may shop for health insurance at competitive rates. Private
plans, outside of the HIXs, continue to be available; however, private plans are
now more likely to be available for purchase only in designated “open enrollment”
periods that coincide with those of the HIXs’ open enrollment periods.
Insurance plans in the HIX marketplace are primarily separated into four
health plan categories—Bronze, Silver, Gold, or Platinum—based on the percentage
the plan pays of the average overall cost of providing essential health benefits
to members. The plan category a person chooses affects the total amount that
individual will spend for essential health benefits during the year. The percentages
the plans will spend, on average, are 60% (Bronze), 70% (Silver), 80% (Gold), and
90% (Platinum). For example, Bronze plans tend to have the lowest premiums, and
they provide an average cost-sharing value of 60%. In other words, a Bronze plan
FIGURE 10-3 U.S. public divided on repeal and replacement of the ACA.
Reproduced from Kaiser Family Foundation. (2017c). U.S. public opinion on health care reform, 2017. Retrieved from http://kff.org/slideshow/us-public-opinion-on-health
-care-reform-2017/
Vote to repeal the
law immediately and
work out the details
of a replacement
plan later
19%
Should not vote to
repeal
51%
Wait to vote to repeal
the law until the details
of a replacement plan
have been announced
24%45%
NET who say
lawmakers
should vote
to repeal
Don’t know/refused
6%
Percent who say they would like to see lawmakers do each of the following with the
2010 healthcare law:
Finance: Health Insurance Exchanges 177
TABLE 10-1 Free Market (Direct Pay) Compared to Traditional
Finance Methods
Insurance
Self-
Funded
Employer
Medicare
and
Medicaid Out-of-Pocket
Traditional:
Insurers
negotiate
discounted rates
with the medical
providers in
their network.
Providers
charge different
amounts to
different insurers
for the same
procedure, but
these rates are
not publicly
available.
Traditional:
Employers hire
a preferred
provider
organization
(PPO), which
negotiates
discounted
rates with
medical
providers on
the employer’s
behalf.
Employers pay
claims out of
their operating
budgets.
Traditional:
Government
determines
how much
to reimburse
medical providers
for all procedures
on the basis of
recommendations
from the
American
Medical
Association. Rates
are often modest,
leading some
physicians to
refuse to accept
or limit such
coverage.
Traditional:
Patients pay
medical providers
directly. In the
past, uninsured
patients’ bills were
based on the
artificially inflated
prices providers
used to begin
negotiations
with insurers.
Some traditional
providers are
offering cash-
only prices
that are lower
than insurers’
negotiated rates.
With direct
pay: The idea
is that health
insurance begins
to look more like
auto insurance:
Insurers estimate
the cost of a
procedure and
send a check to
the patient, who
compares prices
and chooses a
provider.
With direct
pay: Employers
partner with
medical
providers on
the basis of
their publicly
available prices
and then pay
them directly.
Employers pay
medical bills
out of their
operating
budget.
With direct
pay: If most
medical
providers posted
their prices, the
government
could
potentially set
reimbursement
rates based on
the average
regional price of
a procedure.
With direct
pay: Patients still
pay providers
directly, but since
price lists are
posted publicly,
regional providers
compete on
price, quality, and
reputation.
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178 Chapter 10 Overview: The Economics and Finance of Health Care
covers an average of 60% of all plan enrollees’ covered out-of-pocket costs. This
does not mean that 60% of actual costs will be covered for any one given person;
it is not the same as coinsurance, in which a person pays a specific percentage of
the cost of a specific service. These “metal” categories as well as the essential health
benefits required by the ACA are the subjects of scrutiny and debate in Congress.
The ACA requires the following essential health benefits to be included in
every qualified health insurance plan (QHP):
■ Well-baby and well-child care for children younger than age 21
■ Oral health and vision services for children
■ Preventive services and immunizations
■ Ambulatory patient services, including laboratory services
■ Chronic disease management
■ Mental health and substance abuse coverage at parity with physical ailment
coverage
■ Hospital/emergency services
■ Rehabilitation and habilitative services and devices
■ Prescription drug coverage
■ Maternity care
■ No cost sharing for these services
Additionally, insurers cannot impose annual or lifetime limits on health
coverage, and they must offer parents the choice of covering their children up
to their 26th birthday through the parent’s health insurance coverage. This re-
quirement also applies to those persons who “age out” of the foster care system
and were covered by Medicaid.
Federal subsidies are available to help individuals pay for a qualified health
plan. There are two kinds of subsidies: advance premium tax credits and cost
sharing. Advance premium tax credits help to pay health insurance premiums each
month for people with incomes 100–400% of the federal poverty level (FPL). Cost
sharing helps pay for all other health costs, such as copayments, deductibles, and
coinsurance, for families with incomes 100–250% of the FPL who are enrolling in a
Silver-level plan in the marketplace. Both kinds of subsidies are determined based
on a sliding scale (means tested). The subsidy is determined during the initial
application based on the individual/family’s annual projected income. There is no
penalty for good-faith estimates that are lower than the actual income at year’s end.
The ACA requires citizens and legal immigrants to pay a penalty if they do
not have a qualified health plan. The mandate for a qualified health plan can be
met if an individual has public health insurance coverage, employer-sponsored
health insurance, or an individual health plan purchased from either the HIX
marketplace or the private insurance market. The penalties for having no health
insurance may be amended by the U.S. Department of Health and Human Ser-
vices or Congress.
The small business health insurance options program (SHOP) opened
to employers with 50 or fewer full-time equivalent (FTE) employees in 2014.
(Note: 50 FTEs is not the same as 50 employees.) In 2016, all SHOPs opened to
employers with up to 100 FTEs. If a business wants to use SHOP, it must offer
coverage to all of its full-time employees (generally those working 30 or more
hours per week on average) and at least 70% of full-time employees must enroll
in the business/SHOP plan (as opposed to being covered by a spouse’s insurance
Finance: Health Insurance Exchanges 179
or as an individual on the HIX). More information on SHOP can be obtained
from the Center for Consumer Information and Insurance Oversight.
Penalties for Not Having a Qualified Health Plan
In 2017, the penalty/responsibility for not having a QHP—that is, the “individual
shared responsibility payment”—was $695 per adult and $347 per child younger
than 18. The maximum penalty was $2,085 or 2.5% of household taxable income
(whichever is greater).
Any penalties are paid when income tax forms are filed with the Internal
Revenue Service (IRS) the following year. If a person obtains insurance outside
of the marketplace, he or she must report that insurance coverage to the IRS ev-
ery year when filing the tax return. The insurer and the employer (if applicable)
provide the necessary proof of coverage to include in the tax return. There are
no liens, levies, or criminal penalties for failing to pay the fee. Penalties beyond
2017 had not been announced when this text was being written.
Exemptions From Penalties
In general, exemptions are income related, hardship related, group-membership
related, and health-coverage related:
1. Those who have to pay more than 8% of their income for the lowest-cost
premium
2. People who do not pay taxes because their income is too low
3. People with certain religious exemptions
4. Prisoners, while incarcerated
5. Those experiencing a hardship (e.g., victims of domestic violence,
persons being evicted from their place of residence)
6. Native Americans and Alaskan Natives
7. People who would have been covered had their state of residence
elected to expand Medicaid
8. Mixed-status families (documented and undocumented immigrants
within one nuclear family)
FIGURE 10-4 depicts cartoonist Kevin Kallaugher’s perspective on President
Trump’s approach to Obamacare.
▸ Finance: Healthcare Entitlement Programs
Medicare and Medicaid are publicly funded social entitlement programs and are
the “third rail” of healthcare politics. Anyone meeting the eligibility requirements
for Medicare (Part A) or Medicaid is entitled to all the promised benefits, no
matter the condition of the government’s (state or federal) finances. As an analogy,
think of your personal budget: You plan for rent, transportation expenses, utili-
ties, clothing, entertainment, gifts, and the like in your budget, and you balance
these amounts against your anticipated income to assure that your income covers
your expenses. Expenses for Medicare and Medicaid are projected every year, but
unlike your clothing allowance, if the government runs short of revenue (e.g.,
180 Chapter 10 Overview: The Economics and Finance of Health Care
fewer taxes are collected during an economic downturn), there is no legal option
to cut back on entitlement programs. Likewise, if expenses for Medicare and
Medicaid are higher than projected (e.g., perhaps more seniors are seriously ill),
the government cannot choose not to provide payment for the overage in services.
If the government fails to meet its obligation, beneficiaries are entitled to sue.
By law, state governments must balance their budgets; the federal government
may run deficits up to a ceiling set by Congress. This important concept explains
many of the policies at the state and federal levels. In simple terms, Medicare is a
federally funded program, and Medicaid is funded by federal and state funds along
with some local funds. The full reality is more complex, but these generalities suffice
for our discussion. Funding for Medicare comes primarily from general revenues
(40%) and payroll taxes (38%), followed by premiums paid by beneficiaries (12%).
In 2015, the Kaiser Family Foundation reported that Medicare provided
insurance coverage to 55.5 million people, including those age 65 and older (if
they or their spouse made payroll tax contributions for 10 or more years) and
younger people with permanent disabilities (after 24 months of receiving Social
Security Disability Insurance payments), end-stage renal disease, and amyotrophic
lateral sclerosis (Lou Gehrig’s disease). Medicare covers most healthcare services
but does not cover long-term care services such as nursing home care (Kaiser
Family Foundation, 2017b).
■ Medicare Part A (hospital insurance program) helps pay for inpatient hospi-
talizations, skilled nursing home care (up to 100 days), home health (limited
post-hospital care), and hospice care. The beneficiary must pay a deductible.
■ Medicare Part B (supplementary medical insurance) is voluntary and covers
95% of all Part A beneficiaries. Part B helps pay for physician visits, outpa-
tient hospital services, preventive services, mental health services, durable
medical equipment, and home health. Beneficiaries pay a monthly premium
plus some copayments.
■ Medicare Part C is also called Medicare Advantage. It includes private health
plans that receive payments from Medicare to provide Medicare-covered
FIGURE 10-4 “Time to Hit the Road”
Courtesy of Kevin KAL Kallaugher, Kaltoons.com
Finance: Healthcare Entitlement Programs 181
benefits to enrollees. Plans provide benefits covered under Parts A and B
and often Part D.
■ Medicare Part D is a voluntary program that helps pay for outpatient prescrip-
tion drugs and is administered exclusively through private plans. Premiums
and cost sharing vary according to the plan purchased. The Affordable Care
Act improves coverage by gradually closing the “doughnut hole”—an unusual
gap in coverage in which 100% of costs become out-of-pocket expenses. The
cost of Part D is increasing at a faster rate than costs for the rest of Medicare.
Prior to the implementation of the Affordable Care Act, Medicare served all
eligible beneficiaries without regard to income or medical history. As health reform
rolled out, means testing was applied to those with very high incomes. In 2017,
Medicare beneficiaries with incomes greater than $85,000 for individuals and
$170,000 for couples paid premiums ranging from $170.50 to $389.80 per month,
depending on the level of income, compared with the standard premium of $121.80.
Extra Part D premiums range from $12.70 to $72.90 per month. Beginning in 2018,
beneficiaries with incomes greater than $133,500 pay a higher premium subsidy
than the current amount due to a provision in the Medicare Access and CHIP
Reauthorization Act (MACRA) of 2015. Increasing means testing reaches far
down into the middle class. The income thresholds for income-related premiums
are frozen under current law until 2019, when it is estimated that the number of
Medicare beneficiaries subjected to higher premiums will increase from 5% to 10%
of Part B enrollees. Some members of Congress and administration officials have
proposed increasing means testing until 25% of beneficiaries are subject to higher
premiums.
Note: Maryland has a 36-year-old waiver from the federal government to opera-
tionalize Medicare in a unique manner. The details are beyond the scope of this
chapter; however, some economists believe that Maryland’s reimbursement system
may become the model for the rest of the nation.
Medicaid was enacted under the Social Security Act in 1965 as a compan-
ion to Medicare. It entitles participating states to federal matching funds on an
open-ended basis, entitles eligible individuals to a set of specific benefits, is means
tested, and allows states to provide broader coverage. In addition to providing
health insurance coverage, Medicaid provides assistance to low-income Medicare
beneficiaries (dual-eligible), long-term care assistance (nursing home and in-home
community-based services), and support for the safety-net system of health care.
The largest source of federal funding to the states, Medicaid is the largest health
insurance program in the United States.
Medicaid fills large gaps in the U.S. health insurance market, finances the
lion’s share of long-term care, and provides core support for the health centers
and safety-net hospitals that serve the nation’s uninsured population and millions
of others. Within broad federal guidelines, states design their own Medicaid pro-
grams. Medicaid reimburses private providers to provide services to beneficiaries.
In 2017, 20% of the U.S. population received health insurance from Medicaid.
Disabled and elderly adults make up only 25% of enrollees, but they account for
approximately 70% of Medicaid expenditures. Of the 12 million Americans in
long-term care, 87% are covered by Medicaid, making Medicaid the major pro-
gram paying for long-term care (Kaiser Family Foundation, 2017a).
182 Chapter 10 Overview: The Economics and Finance of Health Care
In those 18 states that opted out of the ACA Medicaid expansion plan, Med-
icaid coverage requires that beneficiaries have low incomes (defined by each state
using the federal poverty guidelines) and meet one of these categories of need:
■ Pregnant or recent postpartum
■ Younger than age 18 years
■ Older than age 65 years and blind or disabled
These restrictions were in place across all Medicaid programs prior to the
implementation of the ACA.
Medically needy persons whose incomes are too high to be eligible for Medicaid
may also be covered. (Each state determines eligibility.) In addition, states may
define optional eligibility groups. In 2014, the federal poverty level for a family
of four was $23,850 in the continental United States and a little higher in Alaska
and Hawaii (U.S. Department of Health and Human Services, 2014). As of April
2017, 32 states had expanded Medicaid by eliminating medical need categories
and providing coverage to those with incomes at or below 138% of the FPL.
One of the arguments against expanding Medicaid is a fear of increasing
the overall health expenditures for the United States (Rosenbaum, Rothenburg,
Gunsalus, & Schmucker, 2017). FIGURE 10-5 indicates the percentage paid by each
type of payer in the U.S. healthcare system.
▸ Finance: Payment Models
The long-term goal of the federal government is to move providers (physicians,
advanced practice registered nurses [APRNs], hospitals, all other health profession-
als who are reimbursed by federal programs) from a payment system rewarding
volume of care to a model based on the quality of management of the health of
populations. The term population management can translate into examples such
FIGURE 10-5 National health expenditures in the United States by source of
payment, 2015.
Data from Centers for Medicare & Medicaid Services. (2016). National health expenditure data. Retrieved from https://www.cms.gov/research-statistics-data-and-systems
/statistics-trends-and-reports/nationalhealthexpenddata/nationalhealthaccountshistorical.html
Medicare
20%
Medicaid &
CHIP
17%
Private insurers
33%
Out-of-Pocket
11%
Finance: Payment Models 183
as a ZIP code as defining a population, or a population of patients with diabetes
being treated within a specific practice, or the population of patients undergoing
hip replacement in a hospital. Since 2016, selected hospitals and providers have
acted as “laboratories” to demonstrate the efficacy of various organizational formats
and payment models to advance the goal of stabilizing and lowering healthcare
costs while maintaining or increasing quality and safety.
Medicare Access and CHIP Reauthorization (MACRA) of 2015 is a complex
federal law that ended the prior physician and APRN reimbursement model known
as the sustainable growth rate (SGR). Payment for quality of outcomes is at the
heart of the changes instituted by MACRA, which took effect in 2017: Providers
must choose one program for reimbursement from Medicare. The options under
the Quality Payment Program consist of the Alternative Payment Models
(APMs) and the Merit-Based Incentive Payment System (MIPS). Principles of
the Alternative Payment Models are:
1. Changing providers’ financial incentives is not sufficient to achieve
person-centered care, so it will be essential to empower patients to
be partners in healthcare transformation.
2. The goal for payment reform is to shift U.S. healthcare spending
significantly toward population-based (and more person-focused)
payments.
3. Value-based incentives ideally should reach the providers who deliver
care.
4. Payment models that do not take quality into account are not con-
sidered APMs in the APM framework and do not count as progress
toward payment reform.
5. Value-based incentives should be intense enough to motivate providers
to invest in and adopt new approaches to care delivery.
6. APMs are classified according to the dominant form of payment when
more than one type of payment is used.
7. Centers of excellence, accountable care organizations, and patient-
centered medical homes are examples, rather than categories, in the
APM framework because they are delivery systems that can be applied
to and supported by a variety of payment models.
Types of payment models include fee-for-service, bundled care, accountable
care, shared decision making, and the direct decision support model. Physician
and APRN providers must choose whether to participate in APMs or in the
MIPS. Both the APM and MIPS programs are beyond the scope of this chapter.
FIGURE 10-6 depicts the overall trajectory of the payment framework models.
▸ Economics: Information Asymmetry
Information asymmetry is the term used by economists to point out that health-
care consumption differs from purchasing other goods and services because
of the inability of patients, providers, or payers to possess all the information
needed for completely informed decision making. Optimal rational decision
making requires “perfect information”—that is, the situation in which consumers
are just as knowledgeable as sellers.
184 Chapter 10 Overview: The Economics and Finance of Health Care
As an example, imagine you want to buy a car. You gather all the informa-
tion that you can to eliminate any advantage the car seller may have in terms
of the worth of this particular car. Being newly informed, you may choose to
go to several dealerships before you find a seller that meets your expectations
(or utility).
Now think about the typical healthcare experience. You go to your primary
care provider (PCP) for your annual physical examination, and the PCP finds an
abnormality and refers you to a specialist. Depending on your level of information,
you will blindly trust the specialist or you may “shop around.” You may be very
hard-pressed to learn about the quality or performance of either your primary
care provider or the specialist. If you are referred to a hospital, you are probably
unable to learn the nurse-to-patient ratio even though evidence shows that this
factor is critical to your well-being. Clearly, information asymmetry is present
at many points in this scenario.
Healthcare professionals might argue that they generally know what is “best”
for patients. The problem of asymmetric information differs from a simple infor-
mation problem in that one party possesses knowledge needed to enable rational
decision making that the other party lacks. However, the healthcare professional
and the insurer have a potential conflict of interest because of the exchange of
money. The potential for benefiting monetarily from a decision may affect the
decision-making process. In health care, the patient delegates much decision
making to the healthcare professional (and sometimes even to the insurer).
Asymmetric information also affects healthcare professionals when patients
conceal lifestyle information or state that they are in compliance with a treatment
when they are not. In addition, a patient’s caregiver may withhold or distort in-
formation that would be helpful to the provider. Insurers face information asym-
metry as well: Clients (consumers who are the buyers of insurance) know much
more about the state of their health and their future plans than an insurer knows.
Two specific types of information asymmetry are adverse selection and
moral hazard.
FIGURE 10-6 Centers for Medicare and Medicaid Services’ payment framework
trajectory.
Category 1
Fee-for-service
(no link to
quality & value)
Payments based
on volume of
services
Category 2
Fee-for-service
(linked to quality
& value)
At least a
portion of
payments based
on quality or
efficiency of
healthcare
delivery. Pay for
reporting.
Rewards for
performance.
Category 3
APMs (built on
FFS
architecture)
Some payment
is linked to the
effective
management of
a segment of a
population or an
episode of care.
Gainsharing and
risk are both
involved.
Category 4
Population-
based payment
Payment is not
directly triggered
by service
delivery, so
payment is not
linked to volume.
Clinicians and
organizations
are paid and
responsible for
the care of a
iciary for a benef
long period
(≥ 1 yr)
Economics: Information Asymmetry 185
Economics: Adverse Selection and Moral Hazard
Economists use the terms adverse selection and moral hazard to describe the situ-
ations insurers face when consumers have greater information about their health
than insurers or payers. Adverse selection occurs when a person participates in a
health plan based solely on the likelihood that he or she will have higher than usual
health expenses (e.g., planning to get pregnant). Moral hazard occurs when a
health plan member uses more health services than that person ordinarily would
simply because he or she is insured (e.g., a person with orthodontic coverage gets
braces on his teeth for cosmetic purposes only). Insurers and payers may also lack
sufficient information regarding the choices and decisions of providers and may
be unable to ascertain if a procedure is truly medically necessary.
The patient, who does not pay the bill, demands as much care as possible.
In contrast:
[T]he insurance company maximizes profits by paying for as little
as possible; . . . it is very costly for either the patient or the insurance
company to prove the “right” course of treatment. In short, information
asymmetry makes health care different from the rest of the economy.
(Wheelan, 2002, p. 86)
Imagine that you have consciously chosen not to purchase health insurance
because you are young and enjoy good health; you decide it is cheaper to pay the
annual penalty. Recall that insurers may no longer deny health insurance to those
who have preexisting health conditions. Within a few months, you unexpectedly
become pregnant and decide that you do not want to pay the full cost of prenatal
care, delivery, and postpartum care, so you seek a private insurer such as Blue
Cross and Blue Shield (BCBS) to purchase insurance. After the baby is born, and
BCBS has paid for the costs of your pregnancy and delivery, you decide that you
no longer need insurance and drop your coverage. This is an example of adverse
selection.
If millions of people made this kind of choice, it would have dire effects on
the insurance market. Insurance markets rely upon having a mix of customers
who will not require payouts for healthcare episodes and customers who will. In
other words, in the health insurance market, the healthy subsidize the sick. If only
the old, the sick, or the disabled purchased health insurance, the market would
collapse under the weight of their expenses. The scenario in health insurance is
similar to that for other types of insurance, such as fire, life, and automobile—
those customers who do not use the benefits subsidize those who do. Mandating
the purchase of health insurance is an economic strategy designed to create a
sustainable risk pool of beneficiaries.
▸ Finance: Comparative Effectiveness
Research and Quality-Adjusted Life-Years
Imagine a system of research in which new discoveries or approaches to reduce
or eliminate disease are tested for effectiveness against doing nothing at all. The
current gold standard for research in the United States is the randomized control
186 Chapter 10 Overview: The Economics and Finance of Health Care
trial (RCT), in which a group of subjects receives a treatment while another
group receives no treatment. Effectiveness is decided by whether the disease or
condition responded to the new approach, but the new approach is not compared
to any other approach.
As a result of the 2009 American Recovery and Reinvestment Act (ARRA) and
the 2010 ACA, the federal government made major investments in comparative
effectiveness research (CER). CER compares the overall benefits of one
therapeutic approach with those of another for the majority of patients. These
investments are yielding new information about which treatments work best
for which population of patients. But how will this research be used beyond
informing provider decisions?
Here is an example of a current dilemma: Solvadi is a new drug developed
to treat hepatitis C, a life-threatening disease that often goes unrecognized
until it reaches its final stages. Solvadi costs $1,000 per dose, and a full treat-
ment regimen costs $84,000. In March 2014, the high price of this medication
led to street protests in San Francisco. Health experts say that treating every
person with advanced liver disease (from hepatitis C) in California would cost
$6.3 billion if Solvadi was given to all those patients. With a success rate of
about 90%, Solvadi is an improvement over older drugs, for which regimens
cost only $25,000.
Should public insurance pay for Solvadi? Does a regimen of Solvadi have
cost benefits when compared to a liver transplant and lifelong immunotherapy? Is
avoiding chronic disease “worth” the cost? How many productive years of life are
gained? If California’s Medicaid program typically spends $3,500/beneficiary/year,
how many new beneficiaries could be covered for the $6.3 billion? Economists
and health services researchers tackle these types of questions by conducting CER
and using a concept called quality-adjusted life-years (QALYs).
QALY is an economic concept developed in the 1960s to facilitate cost-effectiveness
analysis. Economists have attempted to include personal preferences regarding
age and health conditions and have created a catalog known as the EQ-5D Index.
For instance, if you have colon cancer and you are a 65-year-old white female,
your EQ-5D index for QALYs is 0.93. That is, if you live 1 year with colon can-
cer, it is only worth 93% of a year with full health and no diseases. If you have
two conditions at the same time (e.g., colon cancer and neurotic disorder), your
EQ-5D index is 0.79. Once economists know how many QALYs a treatment
is worth, they can figure out its cost per QALY—the broadest measure of the
cost-effectiveness of health care.
In general, a QALY carries an economic value of between $70,000 and $150,000
per quality life-year gained by applying a treatment or approach (Anderson et al.,
2014). Will CER be used to determine not only a treatment’s effectiveness but
also the cost-effectiveness and ultimately payment decisions? CER findings can
be translated into practice in a variety of ways, some of which may be more ac-
ceptable to the public than others. QALYs have been linked to CER in the United
Kingdom by the National Institute for Clinical Excellence and have led to debates
about rationing care. This “R” word represents a slippery slope for opponents of
government funding for CER.
The Patient-Centered Outcomes Research Institute (PCORI) was created
under the ACA to coordinate government activity around CER. The ACA does
not include cost-effectiveness determinations among the guidelines for PCORI.
Finance: Comparative Effectiveness Research and Quality-Adjusted Life-Years 187
PCORI conducts research to provide information about the best available
evidence to help patients and their healthcare providers make more informed
decisions. PCORI’s research is intended to give patients a better understanding
of the prevention, treatment, and care options available and the science that
supports those options.
▸ Finance: Bending the Healthcare Cost Curve
Downward
Historically, physicians and hospitals have been paid for each procedure, test,
visit, and consultation; that is, they received more pay for doing “more,” whether
or not “more” resulted in good patient outcomes. This kind of practice drives up
costs for health care. One of the ways the ACA seeks to reduce healthcare costs
in the United States is by encouraging providers and hospitals to form networks
to provide good-quality care to Medicare beneficiaries while holding costs down.
In such a system, providers get paid more if they keep their patients well. One
of the challenges for hospitals and providers is that the incentives seek to reduce
hospital stays, emergency room visits, and use of expensive specialist and testing
services—all the ways that hospitals and physicians make money in the current
fee-for-service system.
Unlike in other industries, prices for health care vary dramatically depending
on who is paying and on geography. The U.S. system is a bit like shopping in a
department store where there are no prices marked on the goods. You check out,
and a few weeks later, you receive a bill that reads, “Pay this.” Growing movements
toward price transparency in health care hope to empower patients to overcome
information asymmetry, make wise choices, and foment competition that may
lower prices. Physicians and hospitals that rarely competed on cost have been
cushioned by third-party payers who pay the bulk of the bills. The advent of the
Healthcare Blue Book (https://healthcarebluebook.com/) aims to do what the
Kelley Blue Book does for used cars—namely, identify a “fair price” for specific
healthcare services in the patient’s local area. Some argue that true price trans-
parency will destabilize the healthcare industry. Others think that transparency
may confuse consumers (Beck, 2014).
▸ Discussion Points
1. Discuss the role of economists in the healthcare policy process. Read about
the work of current health economists (e.g., Joseph Antos, James Capretta,
Jeffrey Sachs, and Gail Wilensky) to understand their role.
2. Access the blog created by the journal Health Affairs (http://www. health
affairs.org/blog/) and use the keyword “economics” to search for the latest
articles about healthcare economics.
3. Discuss the gross national product in terms of healthcare expenditures.
Which sorts of programs will not receive funding when health care con-
sumes a large percentage of federal expenditures?
188 Chapter 10 Overview: The Economics and Finance of Health Care
4. Define “social capital.” How does social capital differ from economic capital?
Discuss how you benefit from social capital in your own life. How does
social capital determine or affect the health of populations?
5. Research some articles on cost shifting in health care. Identify policies
that use this method. Argue the benefits and losses of cost shifting. Also
research cross-subsidization in health care. How does this differ from
cost shifting?
6. Who finances most long-term care in the United States? Take a poll of
your peers prior to researching this question to see what they think is the
answer. Are nurses well informed about this economic issue, and does this
meet your expectation?
7. How does QALY analysis benefit the young over the old?
8. What does the RAND Corporation do? Review its online series, “Small
Ideas for Saving Big Health Care Dollars” (http://www.rand.org/pubs
/research_reports/RR390.html). Choose one idea for reducing healthcare
spending and discuss three new things you learned, three things that sur-
prised you, and how you can use this information in your own practice.
CASE STUDY 10-1: Economic Value of BSN
Education for RNs
Retrieve and read the study Nurse Staffing and Education and Hospital Mortality
in Nine European Countries: A Retrospective Observational Study by Linda Aiken,
PhD (and colleagues), of the Center for Health Outcomes and Policy Research
at the University of Pennsylvania School of Nursing. This study shows that
increasing a nurse’s workload by one patient increases the likelihood of an
inpatient dying within 30 days of admission by 7% (odds ratio [OR], 1.068;
95% confidence interval [CI], 1.031–1.106), and every 10% increase in bachelor’s
degree nurses is associated with a 7% decrease in this likelihood (OR, 0.929;
95% CI, 0.886–0.973). These associations imply that patients in hospitals in
which 60% of nurses have bachelor’s degrees and where nurses care for an
average of 6 patients will have almost 30% lower mortality than patients in
hospitals in which only 30% of nurses have bachelor’s degrees and nurses care
for an average of 8 patients.
Discussion Points
1. State your interpretation of these data. Using these conclusions, discuss the
implications for hospital leaders when making staffing decisions.
2. Discover the percentage of BSN-prepared nurses licensed in your state. If
possible, discover the percentage of BSN-prepared nurses in a hospital or
facility in your area.
3. How easily can an average person find out the RN–patient and BSN RN–
patient ratio in hospitals? Why do you think this situation exists? What does
it mean to you and your family? Who or which entities can change this
situation?
189Discussion Points
CASE STUDY 10-2: Economic Impact of
States Declining Medicaid Expansion
Recall that Medicaid is a joint federal and state entitlement health insurance
program. The ACA of 2010 required all states to eliminate the use of categories to
determine eligibility and expand the Medicaid program to all persons younger
than age 65 with incomes at or below 138% of the federal poverty level. However,
in June 2012, the U.S. Supreme Court ruled that requiring states to expand their
Medicaid programs was unconstitutional: Each state could make its own decision
on whether to expand the program. By 2016, 32 states and Washington, D.C.,
had opted to expand their Medicaid programs. Declining expansion means that
Medicaid continues as it was prior to the ACA’s implementation, with category-
based eligibility.
Discussion Points
1. Determine whether your state has expanded its Medicaid program.
2. Explain why a very poor person (income below FPL) living in one of the
states that declined Medicaid expansion may be ineligible to participate in
the health insurance exchanges.
3. What is the economic effect on the state (and on the hospital or site where
you work or are being trained) of having a large population of uninsured
people?
4. Why would a state choose not to participate in Medicaid expansion despite
the federal promise of paying for the additional beneficiaries?
5. There is no “right” to health care in the U.S. Constitution. Debate the pros
and cons of a universal Medicare-for-all healthcare finance program for the
United States. Refer to the ANA Code of Ethics to inform your debate.
6. Refer to the following article: Sommers, B. D., Gourevitch, R., Maylone, B.,
Blendon, R., & Epstein, A. M. (2016, October). Insurance churning rates for
low income adults under health reform: Lower than expected but still
harmful for many. Health Affairs, 35(10), 1816–1824. Answer the following
questions: In terms of health insurance, what is “churning”? What effect does
churning have on access to care and quality of care? What is the relationship
among access to care, quality of care, and cost of care?
References
Anderson, J. L., Heidenreich, P. A., Barnett, P. G., Creager, M. A., Fonarow, G. C., Gibbons, R. J.,
. . . Shaw, L. J. (2014, March 27). ACC/AHA statement on cost/value methodology in
clinical practice guidelines and performance measures: A report of the American College
of Cardiology/American Heart Association Task Force on Performance Measures and Task
Force on Practice Guidelines. Circulation. Retrieved from http://circ.ahajournals.org/lookup
/doi/10.1161/CIR.0000000000000042
Assistant Secretary of Planning and Evaluation. (2016, October 24). Research brief: Health
plan choice and premiums in the 2017 health insurance marketplace. U.S. Department
of Health and Human Services. Retrieved from https://aspe.hhs.gov/system/files
/pdf/212721/2017MarketplaceLandscapeBrief
190 Chapter 10 Overview: The Economics and Finance of Health Care
Beck, Melinda (2014, February 23). How to bring the price of health care into the open. Wall
Street Journal. Retrieved from http://online.wsj.com/news/articles/SB1000142405270230
3650204579375242842086688
Central Intelligence Agency. (n.d.). The world factbook. Retrieved from https://www.cia.gov
/library/publications/the-world-factbook/
Centers for Medicare and Medicaid Services. (2017, June). National health expenditure data.
Retrieved from https://www.cms.gov/research-statistics-data-and-systems/statistics-trends
-and-reports/nationalhealthexpenddata/nationalhealthaccountshistorical.html
Getzen, T. (2010). Health economics and financing (4th ed.). Hoboken, NJ: John Wiley & Sons.
Hussey, P. S., Wertheimer, S., & Mehrota, A. (2013). The association between health care quality
and cost: A systematic review. Annals of Internal Medicine, 158(1), 27–34.
Kaiser Family Foundation. (2017a, January). Status of state action on the Medicaid expansion decision.
Retrieved from http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion
-decision/
Kaiser Family Foundation. (2017b, April 16). State health facts: Total number of Medicare
beneficiaries. Retrieved from http://kff.org/medicare/state-indicator/total-medicare-ben
eficiaries/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22
sort%22:%22asc%22%7D
Kaiser Family Foundation. (2017c). U.S. public opinion on health care reform, 2017. Retrieved
from http://kff.org/slideshow/us-public-opinion-on-health-care-reform-2017/
National Conference of State Legislatures. (2017, January 3). Health insurance: Premiums and
increases. Retrieved from http://www.ncsl.org/research/health/health-insurance-premiums
.aspx
Organisation for Economic Co-operation and Development. (2017). OECD health statistics
2016. Retrieved from http://www.oecd.org/els/health-systems/health-data.htm
Patient Protection and Affordable Care Act of 2010. Pub. L. No. 111–148, § 3022.
Rosenbaum, S., Rothenberg, S., Gunsalus, R., & Schmucker, R. (2017, January 12). Medicaid’s
future: What might ACA repeal mean? Commonwealth Fund. Retrieved from http://www
.commonwealthfund.org/publications/issue-briefs/2017/jan/medicaids-future-aca-repeal
Stein, H. (1986). Washington bedtime stories: The politics of money and jobs. New York, NY:
Free Press.
U.S. Department of Health and Human Services. (2014, January 22). Annual update of the HHS
poverty guidelines. Retrieved from https://Federalregister.gov/a/2014-01303
Wheelan, C. (2002). Naked economics: Undressing the dismal science. New York, NY: W. W. Norton.
Online Resources
Alliance for Health Policy (http://www.allhealthpolicy.org): Nonpartisan, well-respected
organization providing analytical materials and webcasts by health economists and other
health experts.
America’s Health Insurance Plan (https://www.ahip.org): The national association for insurance
companies providing coverage for healthcare and related services.
California HealthCare Foundation (http://www.chcf.org): This organization’s annual chartbook
provides a wealth of data and graphics.
Centers for Medicare and Medicaid Services (https://www.cms.gov/NationalHealthExpendData/):
National health expenditure data.
Centers for Medicare and Medicaid Services (CMS) Data Navigator (https://www.cms.gov
/home/rsds.asp): The Data Navigator introduces healthcare data users to the Medicare and
Medicaid program data maintained by CMS. Intended for use by researchers and analysts.
Commonwealth Fund (http://www.commonwealthfund.org): Supports independent research
on healthcare issues and makes grants to improve healthcare practice and policy. Not to
be confused with the Commonwealth Foundation.
Consumer Expenditure Survey, Bureau of Labor Statistics (https://www.bls.gov/cex/): Details
of consumer healthcare expenditures.
191Online Resources
Consumer Price Indexes, Bureau of Labor Statistics (https://www.bls.gov/cpi/): Monthly data
on changes in the prices paid by urban consumers for a representative basket of goods
and services.
Current Population Survey, U.S. Census Bureau (https://www.census.gov): Everything you want
to know about the census and the U.S. population.
Dartmouth Atlas of Health Care (http://www.dartmouthatlas.org): Brings together researchers in
diverse disciplines—including epidemiology, economics, and statistics—and focuses on the
accurate description of how medical resources are distributed and used in the United States.
HealthCare.gov (https://www.healthcare.gov): Federal government website maintained by the
U.S. Department of Health and Human Services. The web location for health insurance
exchange information.
Kaiser Family Foundation (http://www.kff.org): Nonpartisan, nongovernmental organization
in Washington, D.C., providing excellent data, facts, and analysis of healthcare issues and
health policy.
Organisation for Economic Co-operation and Development (http://www.oecd.org/): An
organization of 35 member countries with the mission to promote policies that will improve
the economic and social well-being of people around the world. It works with governments
to understand what drives economic, social, and environmental change.
192 Chapter 10 Overview: The Economics and Finance of Health Care
© Visions of America/Joe Sohm/Photodisc/Getty
KEY TERMS
Commission on Graduates of Foreign Nursing Schools International
(CGFNS): An immigration-neutral, nonprofit organization with nongovernmental
organization (NGO) consultative status to the United Nations. It evaluates
professional and academic credentials for nurses educated outside the United
States. It is the only organization named in the U.S. federal statute to administer
visa screening of foreign-educated nurses and other professionals in seven
healthcare fields (http://www.cgfns.org, 2017).
Global burden of disease: The impact of a health problem as measured by
financial cost, mortality, morbidity, or other indicators.
Globalization: “A process of interaction and integration among the people,
companies, and governments of different nations driven by international
trade and investment and aided by information technology” with “effects on
the environment, on culture, on political systems, on economic development
and prosperity, and on human physical well-being in societies around the
world” (Retrieved from globalization101.org/about-us (p. 1), (visited on
08/29/17)).
International Council of Nurses (ICN): A federation for worldwide advocacy for
nursing, with a membership of 130 national nurses associations. Its mission is “to
The Impact of
Globalization: Nurses
Influencing Global
Health Policy
Dorothy Lewis Powell and Jeri A. Milstead
193
CHAPTER 11
▸ Introduction
McLuhan and Fiore (1968) described the world as a global village in which each
person is affected by and affects all inhabitants. Franklin Shaffer (2014), president
and chief executive officer of the Commission on Graduates of Foreign Nurs-
ing Schools International (CGFNS), reminds us that “the world is gradually
becoming a borderless society” (p. 3). Shaffer’s thoughts compel us to consider
health and illness as well as those who address health status, whether direct and
indirect care providers or policymakers, in a different way.
Professional nurses have long recognized their potential for influencing health
policy around the world. The International Council of Nurses (ICN) “rallies
nurses to make a major contribution in promoting and shaping effective health
policy, given their close interaction with clients and ability to gain an appreciation
of the health needs of the population and factors that influence those needs”
(Benton, 2012, p. 1). Benton, who was chief executive officer at ICN in 2012,
noted that “nurses associations can serve as key vehicles for influencing policy,
both nationally and globally” (p. 2). He also observed that “initial improvements
in the profession can be traced to the organization’s commitment of individuals
working under the auspices of nursing associations” but with recognition that
“policy development has traditionally been nursing’s area of slowest advancement”
(Benton, 2012, p. 2). Multiple groups and nurse leaders note that “nurses must
do more than care for patients and conduct research. . . . They need to also be
actively involved in shaping health policy” (Abood, 2007, p. 2).
represent nursing worldwide, advancing the profession and influencing health
policy” (ICN, 2017, p. 1).
International Monetary Fund: An organization of 189 countries working
to foster global monetary cooperation, secure financial stability, facilitate
international trade, promote high employment and sustainable economic
growth, and reduce poverty around the world.
Migration of human capital: The movement of people, with their stock of
knowledge, habits, and social and personality attributes, including creativity,
along with the ability to perform labor so as to produce economic value across
international borders.
Push–pull factors: Those factors that either forcefully push people into migration
or attract them. A push factor is generally some problem that results in people
wanting to migrate.
World Bank: A source of financial and technical assistance to developing
countries around the world. It is not a bank in the ordinary sense but rather a
partnership to reduce poverty and support development.
World Health Organization (WHO): A specialized agency of the United Nations
that is concerned with international public health. Its mission is “to combat
infectious and noncommunicable diseases and ensure the safety of air, food,
water and medicines/vaccines” (WHO, 2017b, p. 1). It was established in 1948;
is headquartered in Geneva, Switzerland; and has six regions—African, South-
East Asian, European, Eastern Mediterranean, Western Pacific, and Region of the
Americas.
194 Chapter 11 The Impact of Globalization: Nurses Influencing Global Health Policy
Globalization has the potential to link nations around the world. It affects all
sectors of society, including health care. However, there are uneven benefits and
other effects within and across global regions and sectors of society, particularly
within and across developing countries. Former President Barack Obama, in an
interview with The New York Times the week before he left office, took note of the
“clash of cultures brought about by globalization and technology and migration”
(Kakutani, 2017). Nursing and other healthcare professions and institutions are
profoundly affected by the globalization process, including its disparate effects
on developed and developing countries (Seloilwe, 2005).
In this chapter, we conduct a general analysis of globalization and its
positive and negative effects on critical issues regarding nursing and access
to quality health care in developed and developing countries. We also discuss
nursing’s involvement in healthcare policy formulation and politics from a
global perspective, differentiating between developing and developed countries.
Finally, we examine the various factors affecting the out-migration of nurses
from less developed countries and the consequent impact on health care in
those countries.
The roles and responsibilities of nurses in developed and developing coun-
tries have much in common. Neither nurses in developed countries nor their
counterparts in developing countries are as involved in policy formulation and
politics as they could be—and probably should be (Benton, 2012).
▸ Globalization and Its Impact on Nursing
and Health Care
Globalization is “a process of interaction and integration among the people,
companies, and governments of different nations driven by international trade
and investment and aided by information technology . . . with effects on the
environment, on culture, on political systems, on economic development and
prosperity, and on human physical well-being in societies around the world”
(Levin Institute, 2016). Globalization is a controversial phenomenon, particularly
with regard to its impact on poor and developing countries. On the one hand,
globalization benefits multinational corporations and industrialized nations
and extends to poor and developing countries an opportunity to improve their
economies and raise their standards of living through foreign collaboration. On
the other hand, globalization can cripple developing countries by harming local
businesses and services and eroding the culture and traditions of local popula-
tions (McCubbrey, 2016).
There is a worldwide shortage of healthcare workers, with the greatest shortage
being nurses (Khaliq, Broyles, & Mwachofi, 2009; Senior, 2010). This imbalance
is critical to understanding the effects of public policy on the global migration
of nurses. Developing countries experience severe shortages of nurses triggered,
in part, by “international funding agency requirements aimed at promoting
growth, increasing employment, stabilizing prices and currencies, evolving better
balances of payment equilibrium, and encouraging balanced budgets in targeted
countries” (WHO, 2006a).
Globalization and Its Impact on Nursing and Health Care 195
The impact of loan policies, such as those of the International Structural
Adjustment Programs of the World Bank and the International Monetary
Fund (begun in the mid-1980s), resulted in reductions in the number of health
workers employed within various sectors of government, particularly health
and education sectors, even as recruitment was restricted or frozen (WHO,
2006a). The competing expectations of meeting international loan payments
on time and balancing the public budget have the effect of reducing public
expenditures on critical public services, including adequate nursing care.
These reductions in expenditures frequently take the form of hiring freezes,
severely limiting the number of new nurses allowed to enter the workforce,
failing to replace practicing nurses lost due to HIV/AIDS, reducing benefits and
salaries, adhering strictly to retirement guidelines, suspending any financial
promotions, increasing the nurse-to-population and nurse-to-patient ratios
to unsafe levels, and limiting career and professional development opportu-
nities (Shah, 2013).
One might question why nurses affected by restrictive workplace con-
ditions and the inability to effectively care for their patients fail to advocate
for better working conditions and accessible patient care. In the past, na-
tional nursing associations have often tried to broker favorable conditions
of service for nurses and midwives but were barred in their efforts to act as
a labor union; they were allowed to have some input only into regulating
professional and educational issues within the Nursing Council, a quasi-gov-
ernmental agency charged with statutory requirements to regulate nursing
and midwifery (WHO, 2006a).
Regulatory bodies and associations are concerned with scope of nursing
practice, providing guidance on practice and education for nurses and midwives;
examining ethics, conduct, and competency of professional nurses; and maintain-
ing a register of qualified nurses (WHO, 2006a). While nursing associations may
also seek to have some influence on human resources policies within a country’s
Ministry of Health, little has been achieved on a worldwide scale. The exception
is in South Africa, where there is an autonomous and independent nursing coun-
cil that receives no government funding (WHO, 2006a); it is similar to nursing
councils in developed countries. Such autonomy makes it possible for nurses
to have greater authority over advocacy and influence on nursing practice and
work conditions. By contrast, all other nursing councils in Sub-Saharan Africa
and other developing countries have a statutory link with the Ministry of Health,
the official agency for health.
The chief nursing officer (CNO), who is the highest-ranking nursing official
in the country, is considered a key stakeholder in driving nursing and mid-
wifery workforce strategies in collaboration with World Health Organization
(WHO) policy and management functions (WHO, 2015). Ideally, according
to the WHO (2015) document on Roles and Responsibilities of Government
Chief Nursing and Midwifery Officers, the person in this role provides “lead-
ership and influence, policy advice, planning and developing health systems
and services, and promotes WHO programs for health status improvement”
(p. 11). Countries differ in their abilities and level of execution of the CNO
role. WHO provides training materials and conferences to facilitate CNO
competencies.
196 Chapter 11 The Impact of Globalization: Nurses Influencing Global Health Policy
Recommendations and Actions for Sustainable
Development Goals
In 2016, the ICN expressed its strong support for the recommendations of the
United Nations’ High-Level Commission on Health Employment and Economic
Growth (HEEG) at a ministerial meeting held in Geneva, Switzerland (WHO,
2017a). In the report entitled Working for Health and Growth: Investing in the
Health Workforce, the Commission on HEEG identified 10 recommendations and
five immediate actions to transform the health workforce for the achievement of
the United Nations’ Sustainable Development Goals. These recommendations will
require major interventions and action by national governments, led by their min-
istries of health, education, employment, and finance, as well as the international
community. The recommendations are expected to stimulate the creation of health
and social jobs to promote economic growth (High Level Commission, 2014).
The United Nations’ SDGs listed in FIGURE 11-1 offer an opportunity for nurses
to demonstrate how their actions make a difference and how they help shape
decision-making processes and healthcare policies. Nurses’ ability to effect change
is just as important as their technical ability to deliver safe and effective care. Policy
development is a practical tool for change, and participation in policymaking is a
logical extension and expression of the nursing profession’s care and compassion.
The 2006 World Health Report demonstrates an inverse relationship among
the burden of disease, the global proportion of healthcare workers, and expen-
ditures on health by WHO regions (WHO, 2006b, p. 9) (FIGURE 11-2). There is a
direct relationship among the distribution of high burden of disease, low quantity
and quality of health workers, and suboptimal level of dedicated resources. As
shown in Figure 11-2, approximately 24% of the global burden of disease is
found in the African region, which has only 2% of the global health workforce and
the least financial support of all six WHO regions. By contrast, the populations
FIGURE 11-1 United Nations’ sustainable development goals.
Reproduced from United Nations. (n.d.). Sustainable development goals: 17 goals to transform our world. Retrieved from http://www.un.org/sustainabledevelopment
/news/communications-material/
Globalization and Its Impact on Nursing and Health Care 197
FIGURE 11-2 Distribution of health workers by WHO region, level of health
expenditure, and burden of disease.
Reproduced from WHO. (2006). Health workers: A global profile. In Working together for health: The World Health Report 2006 (pp. 1–17). Retrieved from http://www.who
.int/whr/2006/06_chap1_en . Used with permission of the World Health Organization.
%
o
f
g
lo
b
a
l b
u
rd
e
n
o
f
d
is
e
a
se
% of global workforce
Data sources: (3, 18, 19)
Eastern Mediterranean
Africa
South-East Asia
Western Pacific
Europe Americas
35
30
25
20
15
10
5
0
0 5 10 15 20 25 30 35 40 45
of United States and Europe have about 10% of the global burden of disease,
with the United States employing 38% of the global healthcare workforce, while
Europe employs another 27%. Health expenditures for these two countries rank
as number one for the United States and number two for Europe, according to
WHO (2006b, p. 9).
Logic suggests that the quality of health outcomes is negatively impacted
by the continuously dwindling number of health workers and minimal financial
resources to support adequate healthcare facilities accessible to the popula-
tion served. Other factors that negatively affected health outcomes include
failure to provide adequate pay and incentives for healthcare staff, failure to
maintain a sufficient number of staff to ensure proper care and medicines are
administered, and inadequate access to realistic health promotion and disease
prevention. Given the opposite parameters, the result would likely be more
accessible care, more staff with better staff-to-patient ratios, and availability
of greater numbers of healthcare dollars, regardless of notable imperfections
in the system.
McCubbrey (2016, p. 1) documented the following potential negative impacts
of globalization on developing countries:
■ “Free trade” exacerbates income inequality between industrialized countries
and developing countries.
■ Commerce is increasingly dominated by transnational corporations, which
may seek to maximize profits without regard for the developmental needs
of individual countries.
198 Chapter 11 The Impact of Globalization: Nurses Influencing Global Health Policy
■ Protectionist policies of industrialized countries preclude many products
from developing countries from being exported.
■ Volume/volatility of capital flow increases risks of currency and banking crises.
■ Foreign investment in developing countries leads to a “race to the bottom”
in which targeted countries hover close to dangerously lower environmental
standards.
■ Cultural uniqueness is lost in favor of homogenization and a universal culture
that draws heavily on the American culture.
These negative impacts of globalization are more likely to be present in de-
veloping regions of the worlds, such as Sub-Saharan Africa and Latin America,
whereas positive impacts of globalization are more likely to be evident in Eastern
Asia, where countries such as China, Japan, Korea, Taiwan, Malaysia, Indonesia,
and Singapore are among the greatest beneficiaries of globalization. Globalization
has driven economic growth in the latter countries through robust exports, large
flows of foreign investments, and rising social indicators, as well as by tapping
into large world markets, technology, human capital, and cheaper import markets
(McCubbrey, 2016). Successful economies, such as Eastern Asia, are quite different
from those countries included in the lower economic tier of developing countries.
Migration of Human Capital
Another characteristic of globalization is migration of human capital—that is,
relocation of people from a nation considered their home country to a destination
country in an effort to improve their working conditions, salary, and opportunities.
Both developed and developing countries experience challenges associated with
migration and the geographic shortage of nurses. The Organization for Economic
Cooperation and Development (OECD) is “a group of 34 member countries that
discuss and develop economic and social policy . . . and are democratic countries
that support free market economies” (OECD, 2015). OECD has reported data
comparing migration from the top 25 sources of healthcare workers for 2000/2001
to similar migration for 2010/2011 (International Migration Outlook, 2017). The
most recent comprehensive nurse migration data are reported in International
Migration Outlook 2017 (OECD 2017).
The provider density ratio is a means of comparatively gauging, by country,
the number of professional nurse and midwife providers for every 1,000 popu-
lation (WHO, 2006b). A larger ratio—that is, a larger number of providers per
population—likely signals higher levels of job satisfaction and higher quality and
accuracy of care than a smaller ratio (Kingma, 2007). According to WHO, 1.7
million healthcare workers migrated in 2009 (Batalova, 2014). The WHO data track
aide-level healthcare workers (including nursing, psychiatric, and home health
aides) and registered nurses from foreign countries. The nonprofessional or lay
worker group accounted for the largest group of healthcare migrants—463,000
individuals—representing 27% of healthcare worker migrants. Professional reg-
istered nurses and midwives were the second largest group immigrating to the
United States in 2009, representing 23% of all health worker migrants. Among
the aide-level workforce, 41% of these migrants came from Asia, 17% from
Latin America, 17% from the Caribbean, 10% from Africa, and 15% from North
America, Europe, and Oceania.
Globalization and Its Impact on Nursing and Health Care 199
Factors Affecting Out-Migration
Globalization and the severe and worsening imbalance of nurses/midwives to
population density, combined with the inability of nurses to care for the varied
health needs of specific populations (particularly in low-income and developing
countries), has contributed to the extensive migration of nurses out of their home
countries. When they emigrate, they often leave behind a skeletal workforce whose
wages, benefits, nurse‒patient ratios, quality of life, and workplace satisfaction
are unsatisfactory and unsafe (Kingma, 2007).
Migrants are people who make choices about when to leave and where
to go, even though these choices are sometimes extremely constrained. In the
healthcare context, the term migrant does not refer to refugees, displaced persons,
or others forced or compelled to leave their homes (UNESCO, 2017). Today,
overall migration patterns reflect world economic trends (Levin Institute, 2016)
in relation to the “swell in international capital investments and manufacturing
businesses seeking cheap land and cheap labor” (p. 7). Associated with migration
are push–pull factors, which serve as major contributors to the emigration of
nurses from developing and low-income countries where working conditions
and rewards are increasingly unsatisfactory.
Push factors are those factors that “drive people away from their home coun-
tries,” whereas pull factors are those factors that “attract workers to where they
end up” (Levin Institute, 2016, p. 14). Key push factors for migration include
poverty-level incomes, low wages (particularly in rural areas), low standards of
living, and lack of employment opportunities in poorer countries. Additional
push factors contributing to healthcare workers’ emigration include a constantly
dwindling workforce, patient care concerns, little anticipation of gaining any
new nurses, a resurgence of communicable diseases, poor healthcare human
resources management systems, inefficiencies in the public health sector, and
limited career and professional opportunities. Nurses in “push” countries often
experience feelings of powerlessness that contribute to their migration from
low-income countries to higher-income countries. In the latter countries, an
ongoing shortage of nurses simultaneously creates a “pull” phenomenon, fueling
vigorous international recruitment campaigns.
Push and pull factors associated with the worldwide shortage of nurses
present a critical challenge for countries seeking to control the movement of
populations. For a long period of time, most nations seemed to be satisfied
with the status quo regarding the movement of people across national bound-
aries. The Levin Institute (2016) describes the chief pull factors for healthcare
workers in developed countries as higher standards of living and higher wages,
a constant demand for nurses, and political and religious freedom. These
factors typically afford immigrants higher wages in the new country for the
same work done at home and offer them the opportunity to send money to
their families back home. According to the World Bank, these kinds of remit-
tances totaled $529 billion worldwide in 2012. There is growing recognition
that “the developed world fills its vacancies by enticing nurses from other
countries, while developing countries are unable to compete with better pay,
better professional development, and the lure of excitement offered elsewhere”
(Senior, 2010, p. 1).
200 Chapter 11 The Impact of Globalization: Nurses Influencing Global Health Policy
The Caribbean Community Market (CARICOM, 2017) is a multinational,
English-speaking organization composed of 20 countries from the Bahamas to
South America. CARICOM’s main purposes are to promote economic integration
and cooperation among its members, to ensure that the benefits of integration
are equitably shared, and to coordinate foreign policy. The Regional Nursing
Body (RNB) of CARICOM links nursing in the member states together through
the chief nursing officers of the countries, who provide advisory services to the
ministers of health of CARICOM. The RNB advises the organization on mat-
ters related to improvements of nursing and its contributions to health care in
the region; identifies needs for basic, post-basic, and continuing education for
nurses; monitors nursing and healthcare trends in the region; updates nursing
legislation; and engages in programs of quality assurance in nursing.
The RNB is an important regional force in advancing education, practice,
research, and the policy agenda relative to nursing and midwifery (UIA, 2017).
The mandated relationship between the RNB and CARICOM gives nursing the
capacity to guide its own professional development and self-regulation. The
University of the West Indies at Mona is expected to share nurse graduates with
other CARICOM member states and in competition with more distant interna-
tional locations.
Jamaica loses many generalist nurses and specialist nurses to developed
countries and neighboring islands each year. Jamaica, along with regional and
international partners, initiated a Managed Migration Program for the Caribbean
region with the goal of meeting its own need for nurses and midwives while
simultaneously accommodating the inevitable pull by neighboring islands and
developed countries—specifically, Canada, the United Kingdom, and the United
States (Salmon, Yan, & Hewitt, 2007).
Filipino nursing schools have been educating professional nurses for export
(inclusive of English language competence) since 1965. Even while recognizing
the importance of this out-migration, the schools continue to train nurses in the
national Tagalog language and prepare them to work in Filipino hospitals and
patient care settings—particularly in rural areas, where patients tend to follow
more traditional ways of life and speak more traditional languages.
▸ The Importance of Understanding
the Cultural Context
Nurses cannot work successfully in any healthcare situation if they do not grasp
the importance of having a basic understanding of the culture of the patient and
the healthcare system. Philosophy about health, disease, customs, and traditions
influences whether a person believes he or she has a health problem and, if so,
how the problem should be acknowledged and treated. For example, Fadiman
(1997) wrote a classic book about her work with the Hmong people. The Hmong,
who live in mountainous regions of Southeast Asia, believe that a person with
epilepsy has a special gift. According to their belief system, during seizures, the
patient should be revered, not treated as if having a disease. When people from
this region emigrate to another country and seek health care from a system that
The Importance of Understanding the Cultural Context 201
considers status epilepticus to be a medical emergency, major challenges arise in
terms of communication between the patient/family and the provider.
Researchers must be cognizant of cultural norms when planning to study a
disease, population, or issue. For example, “‘saving face’ can imperil the research
process” (Chen et al., 2013, p. 149) if researchers are not aware that on-site staff
fear that participants might disclose something that might embarrass the study.
Researchers also should realize that some cultures value individual effort less than
collective effort; this can affect how the study results are written and disseminated.
Opportunities for conducting global research may be limited by one’s own
mindset. In 2014, Journal of Nursing Scholarship began a series of commentaries
on the global state of nursing (Gennaro, 2014). The editorial board emphasized
that all nurses must think globally while acting locally. This author challenges
nurses to think globally and act globally to address health issues common to
many countries.
The American Academy of Nursing (AAN), a prestigious group of nurse
leaders, is organized through expert panels. The Expert Panel on Global Nursing
and Health created a task force to examine cultural competence on a global level.
The members of the task force had experience as nurses and researchers in many
cultures and worked diligently to create a document without ethnocentric biases.
In this effort, the group worked with members of the Transcultural Nursing So-
ciety. The final version of the guidelines they developed, which was published in
Journal of Transcultural Nursing (Douglas et al., 2014), was adopted by the ICN. As
this chapter was being written, the Expert Panel on Emerging Infectious Diseases
was preparing a document (policy brief, white paper, or article for publication)
that addresses the policy implications when “local” diseases have the potential
to become global issues.
Nurses are often the first providers to see clearly when and how the health-
care system is, or is not, effectively meeting patient needs (Abood, 2007) and
supporting their own needs in the work environment. Nurses not only see the
impact of healthcare policies on individual patients but also understand the need
for more comprehensive changes in policies that address many health-related
issues (Benton, 2009; Shariff, 2014). During troubling times, with serious global
healthcare issues, nurses have first-line insights into the level of adequacy of
providers, services, resources, and environmental support to fight communicable
and noncommunicable diseases; public health practices to prevent the spread of
contagion; (in)adequate access to care; availability of medications; and availability
of life-sustaining resources such as food and water, conditions of living, and social
practices that support good health.
Addressing nursing’s insights and ability to inform these issues, Princess
Muna Al-Hussein of Jordan, speaking during a 2014 Nursing Leadership in
Global Health Symposium at Vanderbilt University (WHO, 2014b), noted that
“global health is facing unprecedented challenges, and nurses worldwide are
potentially at the heart of meeting them. Nurses worldwide represent a force of
abilities that can shape and advance health care” (Rivers, 2014, pp. 1, 2). Princess
Muna spoke in favor of programs “that support Sustainable Development Goals
with emphasis on alleviating poverty, promoting the health of mothers and in-
fants, and strengthening the health workforce” (WHO, 2014b, p. 1). The holder
of several honorary posts in nursing, she has taken a special interest in nursing
and midwifery to enhance quality, equity, and efficiency of care (WHO, 2014b).
202 Chapter 11 The Impact of Globalization: Nurses Influencing Global Health Policy
During the sixth Global Forum for Government and Chief Nursing and Mid-
wifery Officers (CNOs and CMOs), she called for continued support for CNOs
and CMOs, educational institutions, WHO Collaborating Centers for nursing
and midwives, and professional associations to support universal healthcare
coverage (WHO, 2014a, 2016).
▸ Nurse Involvement in Policy Decisions
To what extent have nurses been involved in influencing governmental policies
that affect health, the delivery of care, and nursing practice? Research conducted
by Asp et al. (2014), for example, identified a lack of knowledge of neonatal danger
signals among women in rural Uganda. This research opens up opportunities for
nurse interventions for neonates who otherwise might die. Asp and colleagues
also identified a link between media exposure and birth preparedness among
women in southwestern Uganda.
Nursing Education to Improve Involvement in
Policymaking
There is a strong relationship among nursing education, post-secondary educa-
tion, leadership, and participation in advocacy and policymaking. Professional
nursing education in the United States, as an example of a developed country,
includes a focus on health policy and advocacy, with students in baccalaureate,
master’s, and doctoral programs being targeted for policy education. Academic
outcome competencies and curriculum guidelines include advocating for “pa-
tients, families, communities, the nursing profession and changes in the health
care system . . . [and] . . . advocacy for vulnerable populations and promoting
social justice” (American Association of Colleges of Nursing [AACN], 2008,
p. 20). Building on the advocacy foundation of baccalaureate nursing education,
the AACN’s (2011) Essentials of Masters’ Education in Nursing prepares nurses to
“use their political efficacy and competence to improve the health outcomes of
populations and improve the quality of the healthcare delivery system” (p. 20). At
the doctoral level, “political activism and a commitment to policy development
are essential elements of professional nursing practice” (AACN, 2006).
Nursing education in developing countries has a primary focus on clinical
practice and generally lacks a curricular focus on advocacy. The involvement of
health professionals, especially nurses, in policymaking and the development
of health programs requires skills that have not been part of the spectrum of
competences for even senior-level nurses in developing countries, with the ex-
ception of limited instruction on strategic policy development. The entry-level
government-sanctioned nursing programs in most developing countries maintain
a primary focus on clinical practice, and the standard state-certified curriculum
does not emphasize either advocacy or strategic policy development.
Historically, on a worldwide scale, nurses with entry-level education generally
did not advocate or seek to influence their practice or health policies. Nursing,
considered to be a female profession, was also limited by the culturally perceived
subordinate role of women, especially in developing countries. Physicians were
Nurse Involvement in Policy Decisions 203
considered leaders of the healthcare team and were largely male, which in turn
meant they had a greater potential than women to elevate their roles and authority.
Despite these stereotypical gender and role conflicts, a greater sense of collegiality,
collaboration, and teamwork has emerged in many regions of the world, primar-
ily in developed countries. Many developing countries, meanwhile, continue to
operate within the context of a male-dominated society.
Facilitators of and Barriers to Advocacy and
Policymaking
Despite worldwide efforts to recognize and promote nursing involvement in
policymaking, the profession of nursing continues to underperform in terms of
its potential to influence policy within the legislative and policymaking arena.
A study by Shariff (2014) offers insight into how identified factors influence the
extent of advocacy practiced by nurses in developing countries, particularly in
Sub-Saharan Africa.
Shariff (2014) examined a subset of data from East African nations on
factors that act as facilitators of and barriers to nurse leaders’ participation in
health policy development. A Delphi survey methodology was applied, with
the research including expert panelists (national nurse leaders), three iterative
rounds, statistical analysis, and consensus building. Consensus results identified
four facilitative factors:
■ Being involved (having experience and exposure, being accorded opportunity,
being present at all stages of policy development, seeking opportunity to be
involved, and being an active participant)
■ Being knowledgeable and skilled (developing health policy, benefiting from
role models, possessing university education, and having curriculum content
related to health policy)
■ Being supported (benefiting from role models, supportive mentorship, and
networks for support and for sharing experiences)
■ Being perceived in a positive manner (considered a valuable partner in pol-
icy development, appointed to policymaking positions, and engaging with
policymakers and the media)
▸ Conclusion
Nurses have the opportunity to influence all aspects and sectors of society. When
this opportunity is viewed from the vantage point of residents of developed
countries versus developing countries, strategies for impact may vary due to
tradition, local policy, and culture. Nurses have the potential to bring to policy
discussions or committees in the workplace their observed objective perspectives
on the contribution of some policies (institutional, local, or national) regarding
the health or illness of patients, families, and communities while maintaining a
subject’s anonymity. They can provide objective input based on the knowledge,
values, and skills of their profession, augmented by their specialized and personal
experiences and exposure.
204 Chapter 11 The Impact of Globalization: Nurses Influencing Global Health Policy
Ethical and legal responsibilities require nurses to act on behalf of their
patients, to safeguard their rights and well-being, and to promote egalitarian
human rights. Some nurses feel called upon to address social and policy is-
sues, including advocating, like Florence Nightingale, for egalitarian human
rights. Many nurses working in health care are motivated to assume some
kind of advocacy role so as to influence changes in policies, laws, or regula-
tions that govern the larger healthcare system (Abood, 2007). Advocacy adds
a welcome dimension to the professional practice of nursing, which offers
involved nurses an opportunity to have some control over patient care and
outcomes (p. 1).
▸ Discussion Points
1. List at least three health problems at your local level that have implications
at the global level. Which data did you need (and from which sources) to
determine the global nature of the problem?
2. If you have not been involved in health issues in a country or culture
different from your own, which steps would you take to find a good fit
for your talents (e.g., your specialty, experience, personal demographics)?
3. Discuss some challenges and successes encountered by the nurse heroes
noted in the following international vignettes. Compare these experiences
with some of your own. Which advice would you give to colleagues or
nurses early in their careers to prepare them for the challenges and suc-
cesses they will encounter?
CASE STUDY 11-1: The Resurgence of Polio
Imagine you work in a rural clinic in Bolivia. You have completed an examination
of a 10-year-old child who presented with a high fever (104°F) that has lasted for
2 days, pain and stiffness in all joints, and an inability to stand or walk. You suspect
polio and recognize that the disease has had a resurgence in incidence in this
country. Ask yourself the following questions.
International Setting/Level of Analysis
1. Am I practicing in a country that offers the polio vaccine to everyone?
2. Which governmental level offers the vaccine?
3. How do I find out about the government structure and function?
4. If I am not familiar with the type of government (e.g., parliamentary, monarchy,
democracy, dictatorship), what resources are available to educate me?
5. Which level of government is most likely to hear my concerns?
6. Are there governmental (i.e., public) policies that encourage or discourage
vaccination for polio?
(continues)
205Discussion Points
Policy Process
1. Which component(s) of the policy process does this health problem most
likely “fit”?
2. If this is a matter that should be put on the government agenda, what
methods could I use when approaching officials?
3. How can I phrase the problem so that officials will pay attention?
4. Who would be important to enlist in expressing my concerns?
5. If this matter needs a government response, what are the formal and
informal means of communicating with officials?
6. Is there a person with prestige or influence who will help carry my message
to the government?
7. Which policy tools can I use to design a government response to the
problem? Is a law or regulation already in place that addresses this problem?
If so, where was the breakdown in implementation?
8. Were the legal objectives clear when written? Were the program objectives
changed during implementation?
9. Was the program or law ever evaluated? By whom? For what purpose?
10. Were any recommendations made? If so, were the recommendations
followed?
Sociocultural System
Policies that are studied without regard to the human systems in which they
function have little relevance. One must start by identifying the context—that is,
the values of those who are affected by and affect the policy.
1. In the rural area in which you are practicing, is vaccination an accepted
method of disease prevention? If not, what are the arguments against it?
2. If the procedure is accepted, was this child vaccinated? If not, why not?
3. Who was responsible for vaccinating the child?
4. Does polio hold a special meaning in this culture?
5. Is there a clear system of patriarchy or matriarchy? Does family hold a special
meaning? Is the family a nuclear unit or an extended unit?
6. Is the patient/family part of a minority group that is treated differently from
the majority? Is that person/family adherent in other areas of health care?
7. Are there religious or personal philosophical reasons why vaccination was
not administered?
8. Are there myths about polio that keep some people from accepting
vaccination? Do you believe these myths? If not, how can you help others
dispel the myths?
9. Are there foods, clothing, sanitation practices, or language differences
(vernacular phrases, intonations, regional or tribal accents) that could be
barriers to vaccination? Is there geography or history that has contributed to
the problem under study?
Economic and Political Systems
1. If there is a government mandate to vaccinate, was funding made available?
2. Was there enough vaccine available for the population?
3. Did other governmental priorities supersede vaccination programs?
CASE STUDY 11-1: The Resurgence of
Polio (continued)
206 Chapter 11 The Impact of Globalization: Nurses Influencing Global Health Policy
4. Is vaccine still available? Would pharmaceutical companies be asked to
produce more vaccine for a small population? If so, what is the cost, and
who will pay for it?
5. Which interest groups could be rallied to support a current government
program? A new program?
6. Which private resources could be tapped to assist with solving the
problem?
7. Could resources such as the legal system, media, or interest groups be
enlisted to address the problem?
The Health System
1. Is there a governmental health system available to help with the vaccination
question?
2. At which level (national, regional/district, local/tribal) would this system
exist? If not, how are children protected against common diseases?
EXHIBIT 11-1 Personal Stories of International Nurse Policy Leaders
The Caribbean Community
Hermi Hyacinth Hewitt, OD, PhD, MPH, RN, RM, FAAN
Dr. Hermi Hewitt, with advanced degrees from Tulane University and the University
of Iowa, is an iconic leader in Jamaica and throughout the English-speaking
Caribbean Community (CARICOM) and beyond. Established in July 1973, CARICOM
is a progressive development from the former Caribbean Free Trade Association
(CARIFTA). The 15 member states of the CARICOM trade block have gone beyond
being a mere free-trade area to encompass programs for sustained economic
development within the region as well as unified trade, economic, and foreign
policies with states outside the region.
For nearly 40 years, Dr. Hewitt has excelled as an educator, leader, and
advocate, becoming one of the strongest and most powerful policymakers for
nursing in the Caribbean. She was instrumental in the development and pursuit
of advancements in nursing in Jamaica and throughout the region. Most notable
were the following accomplishments:
■ Transformation of the hospital certificate RN training program into an
entry-level BSC program at the University of the West Indies–Mona
■ Initiation of access to BSC nursing education for practicing nurses throughout
the Caribbean region through technology
■ Designation of UWI-Mona as a PAHO/WHO Collaborating Center for nursing
and midwifery
■ Cultivation of global partnerships to strengthen academics, research, and
publications among nurses in the region
■ Implementation of a master’s-level clinical nurse specialist role in geriatrics to
enhance care to elderly persons along the wellness–illness continuum
(continues)
207Discussion Points
■ Facilitation of a mandate by the Regional Nursing Body (RNB) to require
practicing RNs without a professional practice degree to upgrade to a
bachelor’s level
■ Collaboration with various area governments to institute managed migration
of nurses to maintain an adequate nursing workforce for the region
Dr. Hewitt has described various governmental, professional, and institutional
entities with which advocacy and collaboration were required for progress in
nursing (personal communication, February 2, 2017). Major negotiators included
CARICOM (through the RNB), the hospital board chairman and chief executive
officer, the university faculty of medical sciences, the chief nurse at the Ministry
of Health, the Nursing Council of Jamaica, the National Nursing Organization, and
several funding sources.
Policy advocacy activities, according to Dr. Hewitt, are usually confronted
with multiple challenges to efforts to facilitate change. Within the context
of her own setting, Dr. Hewitt notes the lack of adequate qualified nursing
faculty to implement a new baccalaureate program at UWI, a major challenge
associated with migration, and the resistance to change among hospital nursing
faculty, along with reassignments of hospital nursing faculty to other hospital
duties. Cultural challenges were also significant, especially in transforming the
culture from a hospital educational culture to a university culture of teaching,
research, and community involvement. The inadequacy of physical facilities,
along with major budgetary needs and other competing priorities at the
university, were often overwhelming obstacles, taking considerable time for
resolution. Long-term changes can span more than one administration, and
lack of continuity in leadership and vision can compromise momentum and
direction. Despite the challenges faced by Dr. Hewitt and her colleagues, they
successfully opened a new 17,014-square-feet nursing building at UWI-Mona
in January 2009. Trying to attract and maintain the type and number of faculty
and resources needed is a constant struggle, requiring ongoing projections,
evidence, and networks of support. Nursing leadership, like that demonstrated
by Dr. Hewitt, is advocacy at its best.
The Making of a Nurse Leader, Policymaker, and
Politician in the CARICOM
Audrey Gittens, RN, BScN, MScN, DNP
Audrey Gittens entered this world to be a leader and to bring about positive
change wherever she would be planted. On reflection, she sees her pathway
toward becoming a nurse leader in the Caribbean as divinely inspired. As a
young woman in 1994, she was confronted with the difficult decision of whether
to accept a public service post or to enter the nursing profession. Constantly
seeking truth, she sought out various nurses to explore the reality of what nursing
truly is. She was greatly influenced by a nurse–midwife who left an indelible mark
on her, including the realization that there is no other profession as rewarding as
nursing.
The importance of a mentor and coach became evident when Dr. Gittens was
a second-year nursing student. Her own words reflect this guidance best:
EXHIBIT 11-1 Personal Stories of International Nurse Policy
Leaders (continued)
208 Chapter 11 The Impact of Globalization: Nurses Influencing Global Health Policy
I approached the then principal of the school, Aberdeen Browne, and
informed her that I would like to be the chief nursing officer [of the country
within the Ministry of Health]. She laughed, commended me on my
ambition, but told me that her [own] desire is to be the holder of the post
before I do. She, however, asked me to concentrate on becoming a nurse
and then get back to her at the end of my training. I did.
According to Dr. Gittens, Ms. Browne “provided guidance, applauded when
I performed well, and challenged me whenever she was not pleased with any
aspect of my performance. I gained strength from her encouragement as she
boldly told me that I was a natural leader. I fed off this encouragement and
presented myself for several leadership roles” (personal communication, February
15, 2017).
Dr. Gittens ably prepared herself academically for practice and leadership in
nursing as well as public service. She holds certificates in nursing, midwifery, and
administration. She earned a BSc and an MSc from the University of the West Indies at
Mona, Jamaica, in 1997 and 2004, respectively. In 2013, she completed her doctor of
nursing practice (DNP) degree at Duke University School of Nursing. Dr. Gittens’s love
of nursing, educational preparation, leadership qualities, vast network of relationships
and associations at all levels of community and government, and commitment and
sheer tenacity to make a difference have facilitated a dynamic career.
As a relatively young nurse, Dr. Gittens became the president of the National
Nurses Association (NNA) of St. Vincent-Grenadines (SVG) and served this
professional organization as public relations officer, secretary, and committee
member. (SVG is a member of CARICOM.) Her political aspirations surfaced, leading
her to agitate and champion the nursing workforce to join a national disobedience
movement to protest against the government of SVG in 2000, rallying for better
working conditions for nurses. It was the success of this act of advocacy that
confirmed for her that she could make a difference for nurses and health care
in general. As a staff nurse and the president of NNA, Dr. Gittens negotiated an
increase in salary for nurses, a night-duty differential, and closed the pay gap
between nurses and other health professionals with comparable responsibilities.
Other leadership and policy roles she achieved include:
■ Appointed and served as chief nursing officer for SVG for 7 years.
■ Chairman of the Regional Nursing Body of CARICOM for 7 years.
■ Negotiated a relationship with the Caribbean Examination Council for the
management of the CARICOM Regional Examination for Nurse Registration.
■ Provided leadership on the review of policies and procedures for evaluation
and approval for CARICOM-wide nursing education programs.
■ Contributed to drafting new competencies for midwives and nursing
assistants.
■ Coordinated a policy-level meeting with top government officials in Guyana
to encourage a Guyanese nursing affiliation with the RNB of CARICOM. After
several rounds of high-level negotiations, Guyana joined the RNB. It has since
benefited from a regional nursing curriculum, a professionally managed
licensure service, enhanced instructional and evaluation processes, and
internationally recognized standards for entry into professional practice for
Guyana’s nurses.
■ Initiated and helped negotiate a contract with a professional management
service for managing the Regional Examination for Nurse Registration (RENR).
■ Contributed to new competencies for midwives and nursing assistants.
(continues)
209Discussion Points
■ Appointed in 2006 as the first chair of the community college board of
governors in SVG. Dr. Gittens’s responsibilities included the merger of a
technical college, a nursing school, a teacher’s college, and an A-1 (advanced
level) post-secondary institution into a highly functional community college
with far-reaching and notable impact on SVG and the CARICOM region. She
resigned as board chair in 2013 after 7 years of service.
■ Was elected in a national election as vice president of the women’s arm of the
governing Unity Labour Party and later as deputy chair of the Unity Labour
Party (one of four parties in Jamaica).
Dr. Gittens credits her accomplishments and her commitment to continuous
lifelong learning (formally and informally); peer relationships and mentors;
engagement with individuals, groups, and communities; a sense of comfort with
advocacy, policymaking, and politics; and personal commitment to risk taking and
the belief that she can make a difference.
See http://today.caricom.org/ for more information about this part of the world.
Early Nurse Advocacy for Health Policies in Botswana
Serara Selelo-Kupe, RN, BSc, MA, ME, EdD
This vignette reflects the context of pre-independence (from British rule) nursing
in Bechuanaland Protectorate, southern Africa (which became the Republic of
Botswana in 1966), and the policy role and strategies of Dr. Serara Selelo-Kupe
beginning during the latter part of the 1960s that advanced registered nurse
education in the country. Dr. Selelo-Kupe chronicled the history of professional
nursing in this region of Africa in her 1993 book, An Uneasy Walk to Quality: The
Evolution of Black Nursing Education in the Republic of Botswana, 1922–1980. The
book served as the source for this vignette, along with this author’s collegial
relationship with Dr. Selelo-Kupe dating back to the early 1980s. I last visited with
her in her home in Gaborone in March 2014.
Several significant trends and events occurred during the latter part of the
1960s in Botswana:
■ A practice of sending girls with A-level secondary school diplomas and the
necessary qualifications abroad to study nursing and post-graduate nursing
■ The inauguration of a national nurses association (the Nurses Association
of Botswana), which was to play a significant role in the education and
socialization of professional nurses in the next decade
■ The appointment of a new chief nursing officer, Dr. Selelo-Kupe, in mid-1999 in
the Ministry of Health and Wellness (MOH)
The Nursing Council, which advises the MOH, regulates the practice of nursing
in Botswana and oversees nurse training and education. Dr. Selelo-Kupe, a native
of Botswana, received her basic nursing preparation from McCord Zulu Hospital in
South Africa, a BS in nursing education from the University of Ottawa in Canada,
and master of arts, master of education, and doctorate in education degrees from
Columbia University in New York City. She was exceedingly well prepared, with
a U.S. orientation to nursing education and practice, a strong determination and
commitment to quality, and highly respected professional nursing status. Though
small in stature, she was powerful, fearless, and convincing with her pen, her
EXHIBIT 11-1 Personal Stories of International Nurse Policy
Leaders (continued)
210 Chapter 11 The Impact of Globalization: Nurses Influencing Global Health Policy
voice, and her strategic thinking—qualities that ultimately led to her becoming a
recognized worldwide advocate for nursing.
When Dr. Selelo-Kupe began her work for the MOH, there were five nursing
students enrolled in the four-year diploma program and two tutors or teachers.
Soon after assuming her position as CNO in 1999, she inspected the one
authorized national hospital training school for nurses in the mining town of
Lobatse, 70 kilometers from the current capital of Gaborone. She was very troubled
and concerned by her findings:
“I was sadly disappointed by the training conditions, including student
accommodation, classroom, facilities, and all that is necessary for the
education of nurses. I was left in no doubt why there is such a high attrition
rate of candidates with better educational qualification. I honestly feel that
the hospital has not got suitable facilities for the training of nurses, nor is it
adequately staffed for the purpose.” (Selelo-Kupe, 1993, p. 145)
Based on this straightforward, objective evidence, Dr. Selelo-Kupe
recommended to the director of medical services that the school at Lobatse be
moved to Princess Marina Hospital in Gaborone as soon as possible. She offered
succinct, concrete reasons why this solution would address the observed deficits:
(1) More doctors practiced in Gaborone with multiple areas of specialization, which
would improve teaching; (2) her own proximity to the Gaborone Hospital meant
she could help the tutors in developing the program and supervise the program’s
implementation more closely; (3) the improved condition of the Princess Marina
Nurses Home (i.e., the dormitory for nurses) would boost morale of students; and
(4) the availability of the hospital laboratory in Gaborone would aid in teaching
natural sciences.
The school moved one month later, and the student housing accommodations
were deemed excellent. The classrooms were limited, but a teaching facility was
quickly erected consisting of a large classroom, a nursing arts laboratory, and an
office for the two tutors. Student and faculty morale were high. By December 1969,
there was a new policy regarding the education of nurses and “a new program
aimed at relating the training of nurses to their responsibilities within the new
health care system” (Selelo-Kupe, 1993, p. 146).
Dr. Selelo-Kupe’s influence continued to be manifested in the growth
and development of nursing in Botswana, throughout Africa, and around
the world. She has served on the World Health Organization’s Committee on
Nursing, consulted with USAID/Howard University, served on the board of
directors for the ICN, and was instrumental in the development of the first
degree program in nursing for black nurses in all of Africa south of the equator.
Today, the home for the School of Nursing is within the University of Botswana
in Gaborone.
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213References
© Visions of America/Joe Sohm/Photodisc/Getty
An Insider’s Guide to
Engaging in Policy
Activities
Nancy M. Short and Jeri A. Milstead
▸ Strategies to Recognize Political Bias
in Information Sources
Political language . . . is designed to make lies sound truthful and murder respectable and to
give an appearance of solidity to pure wind.
—George Orwell, Politics in the English Language
Bias is the presence of a preference that interferes with or inhibits impartial judg-
ment. Bias is exhibited by unfair actions and policies stemming from prejudiced
thinking. In essence, bias may be thought of as “having an agenda.” Most of us,
and most of the organizations we inhabit, have an agenda; therefore, few sources
are bias free. Just because a source is biased, however, it does not mean that you
cannot obtain important information from the source. You must identify ideo-
logical or political bias when using sources to influence or craft health policy.
You need to know your primary source: What are the interests? Which
language is being used (inflammatory, educational, persuasive)? Whom does
the source represent? How might the information presented be relevant to you?
Toward which purpose is this source geared? When was the source last updated
with current information? Where does the source get its funding? If the source
is an organization, who serves on the board of directors—that is, who is setting
the agenda?
215
ChAPter 12
Often you must do some homework to discover if a source is biased: It is
not sufficient to note that the source declares itself to be nonpartisan. Do you
think that the American Nurses Association (ANA) is biased? Would you freely,
without hesitation or annotation of materials, use content from the ANA? The
ANA is a trade association/special-interest group for professional nurses and
educators. It is biased in favor of the welfare of its members and all nurses. If
you search for endorsements of political candidates by ANA, you will learn that
ANA predominantly supports Democrats. This is not earth-shattering news and
should not prevent you from using ANA materials; however, it should inform
you about how and when to use these references.
There are thousands of special-interest groups and organizations in the United
States. In the following subsections, we take a look at two influential organizations
located in Washington, D.C.
Heritage Foundation
Heritage Foundation (http://www.heritage.org/) is widely considered one of the
world’s most influential public policy research institutes. A right-wing think
tank, Heritage Foundation enjoyed particular prominence during the Reagan
administration. The word “conservative” is prominent in several places on the
website, including the mission statement of the organization.
Who is setting the agenda? Senior executives of equity firms, lawyers, authors,
journalists, and a college professor comprise the board of directors.
What are Heritage Foundation’s interests? The website has an extensive list of
topics and accompanying position statements that are too numerous to list
here. You can expect sources with a conservative political ideology to advocate
for a range of regulations on all businesses (market forces allowed to guide
commerce), strong defense and military, limited government social programs
(conservatives believe individuals are responsible for their own welfare),
support for the rights of the unborn, and opportunities to own and carry
firearms. In contrast, such sources tend to frown on “political correctness.”
When was the site updated? Position and opinion statements are very current
and are in step with the news cycle within the past 48 hours.
Where does Heritage Foundation get its funding? Initial funding was provided
by Joseph Coors, of the Coors beer empire, and Richard Mellon Scaife, heir
to the Mellon industrial and banking fortune. Heritage Foundation is a
501(c)3 nonprofit organization. Its annual report states that “we rely on the
financial contributions of the general public: individuals, foundations and
corporations. We accept no government funds and perform no contract
work.” Heritage Foundation receives funding from organizations with con-
nections to the Koch Brothers, the Lambe Foundation, Donors Trust and
Donors Capital Fund, and the conservative Bradley Foundation. In 2016, it
had revenues in excess of $100 million.
Families USA
Families USA (http://familiesusa.org/) calls itself “The Voice for Healthcare Con-
sumers.” Families USA is an influential left-wing lobbying organization, although
216 Chapter 12 An Insider’s Guide to Engaging in Policy Activities
it frequently refers to itself as a nonpartisan media operation. Descriptive words
and phrases that predominate on this organization’s website include social activism,
community organizing, justice, equity, and protect the disadvantaged—typical of
a liberal or progressive ideology. Nevertheless, the word “liberal” is never used
on this site.
Who is setting the agenda? Ron Pollack, founder of Families USA, has been
most important in setting its agenda. He stepped down from his position
as director/chief executive officer in March 2017. He is a well-known fire-
brand in Washington, D.C., who has successfully argued to the Supreme
Court (he is a lawyer) for secure food aid for low-income Americans as well
as for federal litigation that resulted in the creation of the Women, Infants,
and Children (WIC) program for malnourished mothers and infants. The
board of directors for Families USA includes a Catholic nun with a history of
activism for social justice, leaders from humanitarian foundations, a physician
who has worked for a Democratic senator and governor, a librarian who is a
champion for Medicaid, a faculty member of Harvard Medical School, the
director of a large labor union, and academics with backgrounds indicating
liberal philosophies.
What are Families USA’s interests? The main interest is to secure affordable,
quality health care for all people in the United States. The organization pro-
motes a patient- and community-centered health system.
When was the site updated? A blog provides analysis of current policy debates
on healthcare finance; entries are no more than 3 days old. Other resources
are much older—available slide shows are 11 months old.
Where does Families USA get its funding? ProPublica reports that Families
USA’s 2014 990 tax return showed revenues of $7 million. Donors include
the Kellogg Foundation, Gordon and Betty Moore Foundation, and others.
As you can see, learning about Ron Pollock, finding the 990s, and discover-
ing which causes the Kellogg Foundation and other donors usually support
takes some digging.
Summing it up, you should never assume that any reference or source is un-
biased. Do not take content as factual until you have determined what the agenda
and motivations of the authors or publishers may be. This kind of critical thinking
requires you to be a skeptical, sophisticated user of data and information. This
is not to say that you cannot use references from organizations such as Heritage
Foundation or Families USA; however, seeking balance in your understanding is
important. Balance your knowledge by reading and exploring a variety of points
of view. As a starting point, Table 12-1 describes the five major political parties
(and their general ideology) in the United States.
▸ Creating a Fact Sheet
You must be prepared when you visit a congressional or state legislative office.
Novices to the policy and politics world often visit their representative with
others as an activity related to a conference or convention. At conferences,
you may be handed materials to take with you to a legislative meet-and-greet.
Creating a Fact Sheet 217
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© Matt trommer/Shutterstock
© hafakot/Shutterstock
Courtesy of Libertarian Party
Courtesy of Green Party
Courtesy of Constitution Party
218 Chapter 12 An Insider’s Guide to Engaging in Policy Activities
These materials are intended to be left with the member or staff to serve as a
reminder or give a nudge to action after you leave the office. This kind of fact
sheet (also known as a “leave-behind”) is a reasonable way to get introduced
to the process but is not a highly effective way to share a message. The most
effective meeting is one-to-one (e.g., face-to-face) with the member or health
staff (legislative aide).
You should prepare a fact sheet that is customized to your message. Criteria
for a fact sheet are as follows:
■ Keep the document to one page; you may use both the front and the back.
■ Use attractive, easily readable font (of at least 12), and eliminate all typos
and spelling errors.
■ Title your issue at the top of the page. Use plain English—no medical terms.
■ State your “ask,” succinctly at the top of the page directly under the title.
■ Do not use citations or references. This is not an academic document.
■ Bullets, lists, tables, and text boxes must be clearly readable (never use a tiny
map or graph).
■ List organizations in support of your position (state-level organizations for
state issues).
■ Know who opposes your “ask,” and be ready to address this opposition verbally.
■ Your full contact information (name, credentials, phone, email) must be
readable. Unless you have permission to represent your place of work, do
not give the impressions that you are speaking on your employer’s behalf.
For more information about how to construct a fact sheet and see samples,
visit http://www.cthealthpolicy.org/toolbox/tools/fact_sheets.htm.
▸ Contacting Your Legislators
It is crucial that healthcare professionals know how to contact their legislators,
agency heads, government staff, and other policymakers. We recommend calling
or emailing to avoid security testing and delays imposed on standard mail and
packages. Do not send an attachment—no one will open it because it may contain
a virus or malware.
A. In general:
1. Know the correct title and spelling of the Member’s (or staff ’s)
name and correct address. If in doubt, call the office and ask (staff
are eager to provide this information). If there are credentials,
get them right!
2. Direct your message to the right level: federal issues to U.S. sen-
ators and representatives in Washington, D.C.; state messages to
state senators and representatives at the state capital.
3. Be polite. Choose language that is not confrontational or angry.
4. Avoid healthcare jargon, such as “I’m an APRN working in SICU
with GSW patients.”
5. If you use Twitter or other social media, be very careful about
what you say—your messages may be read by many others and
potentially misinterpreted.
Contacting Your Legislators 219
Example of a Fact Sheet for Folic Acid
Supplementation for the Prevention of
Neural Tube Defects
Asking That You:
Expand the Women, Infants, and Children (WIC) program to allow the
purchase of over-the-counter folic acid supplements
Increase funding for the WIC program to allow the program to cover these
supplements for pregnant women already enrolled in WIC
Fast Facts About Neural Tube Defects
The neural tube is present in early fetal development and develops into the
infant brain and spinal cord
Neural tube defects (NTDs) result when the fetal neural tube doesn’t close
properly, resulting in spinal cord or brain defects
NTDs are among the most common congenital defects in the United States
■ 3,000 pregnancies are affected by NTDs in the United States every year
■ 840 infants die of NTDs in the United States every year
Types of NTDs:
Spina bifida is the most common NTD involving the spinal cord
ô Infants with spina bifida have disabilities that range widely in
severity
ô Disabilities related to spina bifida are permanent and lifelong,
resulting in significant economic impacts
Lifetime Costs for an Infant With Spina Bifida
Medical costs $513,500
Special education and developmental
services
$63,500
Estimated lost parental economic output $214,900
Total anticipated lifetime costs $791,900
■ Anencephaly is the most common NTD related to the brain and results in
the death of nearly all afflicted infants
CONTACT: I. M. Involved, BS, BSN, RN, CCRN
Iminvolved@gmail.com 512-555-1100
220 Chapter 12 An Insider’s Guide to Engaging in Policy Activities
Facts About NTDs and Folic Acid
Folate is required for proper DNA synthesis and function
Folic acid supplementation is associated with a decreased risk for NTDs
Folic acid supplementation provides maximum benefit for NTD prevention
when started 1 month before conception and continued through the first
2–3 months of pregnancy
The U.S. Preventative Services Task Force (USPSTF) has determined that the net
benefit of supplementation is substantial and the risks are minimal
USPSTF recommends that all women who are pregnant or may become
pregnant take a daily supplement containing 0.4 to 0.8 mg of folic acid
Projected Costs of Proposed WIC Expansion
North Carolina WIC Participation Totals (2012 data)
Total number of WIC participants in N.C. 284,995
Total number of pregnant women participating in
WIC in N.C.
27,052
North Carolina WIC Expansion Anticipated Costs (2014 dollars)
Annual current food costs for WIC program in N.C. $127,920,051.00
Folic acid supplement cost, per pregnant WIC participant $1.94
Estimated annual cost of proposed WIC expansion in N.C. $52,480.88
Summary
Addition of folic acid supplement coverage would expand WIC program food
costs by less than 0.04%
Folic acid supplementation has the potential to prevent 2–3 cases of spina
bifida per year among infants born to WIC program participants in N.C.
Potential taxpayer cost savings could exceed $1.1 million annually
Supporting Organizations
Centers for Disease Control and Prevention
Flour Fortification Initiative
U.S. Preventative Services Task Force
International Clearinghouse for Birth
Defects Surveillance
World Health Organization
American College of Obstetrics and
Gynecology
U.S. Food and Drug Administration
International Federation for Spina
Bifida and Hydrocephalus
221Contacting Your Legislators
6. Do your homework. What is the position of the Member on
similar issues? Know whether the member has sponsored or
opposed similar legislation.
B. Via email: Keep your message to three paragraphs.
First paragraph:
1. Use a salutation: Dear Senator or Dear Representative (or Mr.,
Ms., Mrs., Dr.).
2. State who you are (e.g., name, constituent, APRN/MD/DO).
3. Declare your support/opposition to a specific issue; state a bill
number if possible. Legislative Aides (LAs) keep track of “sup-
port” and “do not support” messages.
Second paragraph:
1. Rationale: one or two reasons to support your position; be brief
(limit to one regular page).
2. Use ordinary language—no medical terminology, three- or
more-syllable words, vague words, or vernacular/local lingo.
3. Identify any major opposition and include your response to it;
include a talking point that the Member may use later.
4. Include a personal story if you have one—it can be very per-
suasive evidence. Do not use names or circumstances that are
considered privileged or private.
Third paragraph:
1. Make your “ask.” Be specific: vote for/against a bill or amendment;
hold a hearing; call a press conference (not just “support” or “oppose”).
2. Do not thank the representative or senator in advance—save this
for after he or she has acted.
3. Offer to be the contact for this issue.
4. Close with “Sincerely,” plus your name/credentials, address, and
preferred phone number.
C. If you call the Member/staff ’s office:
1. You probably will not talk with the Member. Ask for the Health
LA, and write down the name of the person to whom you speak.
2. Do not expect to talk with the staffer more than 5 minutes, so use
notes and talk in a conversational tone—do not read your mes-
sage, as it will be obvious that you do not know your own words.
D. If you fax a message, be sure you have the right fax number; otherwise,
it may get lost and may not be read by relevant staff. Again, be brief,
be focused, and use ordinary language.
E. What not to include:
1. All reasons you support or oppose the policy—pick one or two
reasons. You should write only one-page emails or letters.
2. Threats: “If you don’t vote for this bill, I will not vote for you.”
3. “Thank you”—save it until you know the Member’s action, then
be sure to write a thank-you note.
F. Follow up:
1. Within 2 weeks, email or phone the Member’s office: Received
email? Any questions? Any action on the issue? Anything I can do?
222 Chapter 12 An Insider’s Guide to Engaging in Policy Activities
▸ What to Expect When You Visit Your
Policymaker
1. Make an appointment—don’t just show up.
2. You may visit in pairs, but if there are many of you, make sure the
staff know in advance so that they can arrange a place large enough
to accommodate all of you.
3. Dress professionally. Do not show up in jeans or clothing with of-
fensive logos.
4. Don’t expect to see the policymaker in person; you probably will
talk with a staff member. Staff are very important. Depending on
the prestige and length of time in the position, a policymaker may
have a small or large staff; each staffer will have one or more specific
areas to cover, such as health, agriculture, economic development, or
transportation. Staff are responsible for filtering information that is
presented to the policymaker.
5. Research the person you are visiting. If it is a legislator, go to the rel-
evant website—you probably will find information about his or her
education, family, interests, and community service, as well as current
service on committees. There may be a picture.
6. Know the district or constituency that the policymaker represents.
This will give you clues about the person’s interests and background.
Note any leadership positions the person has held. It is best to visit
your own representative, but if you have a particular area of interest,
you can choose a person who is the chair or an officer of a relevant
committee.
7. Expect your visit to last no more than 5 to 10 minutes—so be focused
with your message.
8. Shake hands and look the people you meet in the eye. Speak clearly
and with authority.
9. Do not spend much time in “pleasantries”—get to the point of your
visit.
10. State why you are there—the specific issue/bill number, your position
(“for” or “against”), and why.
11. Be prepared to defend your position. Use evidence-based research
(translated into ordinary language), best practice, and other
supports.
12. Focus on only one issue per visit. You may be tempted to interject
several issues, but you have a very limited amount of time, so do not
undercut yourself.
13. Have one or two 1-page documents that support your issue ready for
the staff after you leave. For example, you may have “talking points”
that summarize your issue. If you are representing an organization,
make sure its logo appears on the documents.
14. Leave your business card so that the staff can contact you.
15. Hand-write a thank-you note within two weeks after your visit.
What to Expect When You Visit Your Policymaker 223
▸ Preparing to Testify
You may be asked to testify at a hearing about an issue in which you are involved.
A hearing is an official meeting of a committee or group of policymakers (i.e.,
legislators) in which they “hear” arguments for and against an issue. You must
follow protocols about who and when and how long you testify.
1. Know where the hearing room is located. Be there before the hearing
begins.
2. You may be required to sign in as a witness. You will be called in the
order in which you sign in.
3. Know the name of the committee chair and who will be attending
the hearing.
4. Provide copies of your testimony to each member of the committee.
Distribute these copies to their staffs.
5. Have with you a one- to two-page testimony document in a font
large enough to read without glasses. If your issue demands a longer
response, provide copies to the committee staff.
6. Dress as a professional (e.g., no jeans or hoodies). You are representing
your organization or issue. Look credible.
Tips on Testifying
1. Always address the chair first, then any particular members. For
example, if a member asks a question, you respond by saying,
“Mr. Chairman, Representative (or Senator) XXX, . . . Do this every
time you speak. You may want to practice with a colleague.
2. Do not read your testimony. You have provided written copies to each
member of the committee, so now is your time to have a “conversa-
tion” with them.
3. Make a single point. Now is not the time to bring up all the issues
relevant to your case.
4. Provide a personal story that emphasizes your point; state it quickly.
5. You have only a very short time to testify (3–5 minutes),* but you may
be able to extend this window if there are questions from committee
members. To make best use of the opportunity, have your rationale
in your head so you do not hem and haw and waste time.
6. Speak clearly and loudly. Stand up straight. Dress conservatively and
appropriately. Act as a professional. Do not slouch. Do not say “Uh . . .”
during your precious speaking time.
7. Do not use medical terminology or other confusing language. For
example, do not use abbreviations or acronyms (e.g., CABG, IV, MI).
* There may be a three-light bulb system used for keeping time. As one U.S. senator
said, “Talk when the light is green, talk fast when the light is yellow, and talk
damned-fast when the light is red!”
224 Chapter 12 An Insider’s Guide to Engaging in Policy Activities
8. If you refer to research or evidence, summarize it.
9. Speak positively and with conviction. Use “power” words (e.g., exper-
tise, overwhelming evidence, significance).
10. Do not equivocate; that is, do not say “kinda,” “sorta,” “maybe,” or “like.”
11. Do not threaten anyone or become violent. You are there as
a guest.
12. Always close the loop—that is, bring your remarks back to how this
issue will affect the constituents of the policymakers and your patients.
Otherwise, you are likely to be seen as self-serving.
13. Be prepared to answer any questions from those who oppose part or
all of the bill. Again, have a response in your head that you can pull
out for a 30-second reply.
14. If you cannot think of a response to a question, go back to your
original position and restate your argument. Remember: Just be-
cause you are asked a question does not mean you have to answer
it. If you get nervous and the question stumps you, keep to your
point.
15. If you are asked a question that you cannot answer immediately,
tell the questioner that you will get back to him or her with a solid
answer promptly.
16. Thank the chair and committee for hearing your testimony. Tell them
you are available for comments or questions.
Providing Testimony for a Regulatory Hearing
Jacqueline Loversidge
When providing comments in writing or as written/oral testimony at a hearing,
it is important to follow these guidelines:
■ Be transparent about your identity, background, and representation status;
that is, be clear about whether comments/testimony represent an organiza-
tion’s position or your own.
■ Be specific regarding whether the position you are representing is in support
of or in opposition to the regulation. Give examples using brief scenarios or
experiences when possible.
■ Assure there is a body of credible evidence to back up your position. Explain
major points using common language; avoid nursing/medical jargon.
■ Know the agency’s position and respond to those concerns.
■ Know the opposition’s position and respond to those concerns.
■ Convey a willingness to negotiate or compromise toward mutually acceptable
resolutions.
■ Demonstrate concern for the public good rather than self-interest.
■ Be brief and succinct. Limit your remarks to one or two pages. Regulatory
agencies may limit the number of minutes for oral testimony; 5 minutes is
average.
Regulatory agencies charged with public protection are more likely to address
concerns that deal with how the public may be harmed or benefited rather than
concerns that give the impression of turf protection and professional jealousy.
Preparing to Testify 225
Demonstrate support for your position by asking colleagues who represent a
variety of organizations, professions, and interests to submit comments; inter-
professional solidarity projects a powerful message. When a significant number
and variety of professionals and organizations form a coalition around a single
issue, their collaboration demonstrates an elevated degree of concern and a
high level of commitment toward finding a solution. In this way, the volume
and breadth of interest expressed in a proposed regulation can serve as the
deciding factor in assisting an agency to assess support or nonsupport for the
proposed regulation.
▸ Participating in Public Comment Periods
(Influencing Rule Making)
The U.S. federal government requires all agencies to post proposed rules to
the Federal Register (https://www.federalregister.gov/) and provide for public
commentary to be collected for a specific time interval. All comments must be
summarized and the summary made public prior to a rule being adopted. Pro-
fessional nurses are extremely well positioned to provide public comments on
proposed rules and regulations affecting healthcare delivery, patient care, working
conditions for nurses, and many other aspects of the healthcare universe that are
subject to regulation.
An excellent site for participation is located at https://www.regulations.gov/.
On this site, you may search for regulations by keyword, by date, by agency of
origin, and by category.
Tips for Submitting Effective Comments
A comment can express simple support or dissent for a regulatory action.
However, a constructive, information-rich comment that clearly communicates
and supports its claims is more likely to have a positive impact on regulatory
decision making.
The following tips are meant to help the public submit comments that have
an impact and help agency policymakers improve federal regulations:
■ Read and understand the regulatory document on which you are commenting.
■ Be concise, but support your claims.
■ Base your justification on sound reasoning, scientific evidence, and/or how
you will be impacted.
■ Address trade-offs and opposing views in your comment.
■ There is no minimum or maximum length for an effective comment.
■ The comment process is not a vote: One well-supported comment is often
more influential than a thousand form letters.
■ Attempt to fully understand each issue. If you have questions or do not un-
derstand a part of the regulatory document, you may ask for help from the
agency contact listed in the document.
226 Chapter 12 An Insider’s Guide to Engaging in Policy Activities
■ If a rule raises many issues, do not feel obligated to comment on every one.
Instead, select those issues that concern and affect you the most and/or you
understand the best.
■ If you disagree with a proposed action, suggest an alternative (includ-
ing not regulating the issue at all), and include an explanation and/or
analysis of how the alternative might meet the same objective or be
more effective.
■ Identify your credentials and experience that may distinguish your comments
from others. If you are commenting in an area in which you have relevant
personal or professional experience (e.g., registered nurse, APRN, scientist,
attorney, hospital executive), say so.
■ You may provide personal experience in your comment, as may be appro-
priate. The stories every nurse has to share can be powerful.
■ Include examples of how the proposed rule would impact you negatively
or positively.
■ Keep a copy of your comment in a separate file. This practice helps ensure
that you will not lose your comment if you have a problem submitting it
using the web form.
Form Letters
Organizations often encourage their members to submit form letters designed to
address issues common to their membership. Many in the public mistakenly believe
that a submitted form letter constitutes a “vote” regarding the issues concerning
them. Although public support or opposition may help guide important public
policies, agencies make determinations for a proposed action based on sound
reasoning and scientific evidence rather than on a majority of votes.
Visit https://www.regulations.gov/docs/Tips_For_Submitting_Effective_
Comments for more information on submitting effective comments.
▸ How to Write an Op-Ed
A brief history: Op-ed is an abbreviation for “opposite the editorial page” (al-
though it is often mistaken for “opinion-editorial”). This sort of newspaper arti-
cle expresses the informed opinions of a named writer (often an expert) who is
usually unaffiliated with the newspaper’s editorial board. An op-ed differs from
an editorial, which is usually unsigned and written by the newspaper’s editorial
board members. An op-ed is also distinct from a “letter to the editor,” in which
a reader responds to a previously written article.
The first modern op-ed page was created in 1921 by Herbert Swope of
The New York Evening World; he realized that the page opposite the editorials
was “a catchall for book reviews, society boilerplate, and obituaries.” Swope
explained:
It occurred to me that nothing is more interesting than opinion when
opinion is interesting, so I devised a method of cleaning off the page
opposite the editorial, which became the most important in America . . .
and thereon I decided to print opinions, ignoring facts.
How to Write an Op-Ed 227
Beginning in the 1930s, radio began to threaten the primacy of print jour-
nalism, a process that later moved even more quickly with the rise of television.
To combat this trend, major newspapers such as The New York Times and The
Washington Post began including more openly subjective and opinionated jour-
nalism, adding more columns, and growing their op-ed pages. Today, digital blogs
and social media threaten print media as the preferred method for obtaining
information and forming opinions.
Op-eds are an excellent way for individuals, organizations, businesses, and
institutions to articulate a unique position on a particular issue. Think of an op-ed
as persuasive writing in its most compelling form. It is not simply educational—it
must offer a solution to an issue that has a political solution. Unlike a letter to
the editor, an op-ed combines an influential opinion with facts, figures, and ex-
amples to deliver a thoughtful viewpoint to the thought leaders who often read
a newspaper’s opinion pages. These articles are also the “bread and butter” of
online media outlets, such as Huffington Post, Daily Caller, and The Health Care
Blog. Critical to the success of an op-ed is to write about a topic that is timely
and on the public’s radar. Prior to attempting to write an op-ed, you should read
op-eds in the newspaper, journal, or digital source to which you plan to submit
your own article.
Newspapers have policies on how to submit articles to their opinion
page, and most limit the length to 500‒750 words. The length limit is also a
“suggested” length: Editors have a certain amount of space to fill, so an article
that is too short or too long is unacceptable. Digital editors usually require a
head shot of the author and a very short biographical sketch, so include this
material as an attachment. The email to the editor, with the op-ed attached,
should be written as a brief note (in a letter format) pitching your writing.
Use an email address that you use frequently, and tag the email to give you
a receipt notice.
“Striking while the iron is hot” is essential for op-eds. For this reason,
writing an op-ed ahead of an event, holding it until you see the right time, and
submitting it as an event unfolds may be your best assurance of getting it pub-
lished. For example, if the Nobel Prize is awarded for research into the physics
of brain injury, it is timely to submit your op-ed on why the legislature needs
to pass a law regarding tackle football in pee-wee leagues. Your op-ed about
violence against nurses in emergency departments is timely if the legislature
is debating workplace violence. Right after the president orders a bombing
run on a chemical factory in Syria is not the time to try to get your op-ed on
legislative funding for diabetes education published; your article will not find
space on the op-ed page.
As a professional nurse, you have expertise that nonclinicians (most people)
do not have. You have experiences that you can draw on to illustrate problems in
the healthcare system and the need for government intervention.
Good sources for more help can be found at the Duke University and
Health System’s News Office (https://styleguide.duke.edu/toolkits/writing-media
/how-to-write-an-op-ed-article/), Harvard’s Kennedy School of Government
communications program (http://shorensteincenter.org/wp-content/uploads
/2012/07/HO_NEW_HOW-TO-WRITE-AN-OPED-OR-COLUMN ), and
The Op-Ed Project (http://www.theopedproject.org).
228 Chapter 12 An Insider’s Guide to Engaging in Policy Activities
S
te
p
1
:
Id
en
ti
fy
yo
u
r
to
p
ic
■
Se
le
ct
a
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a
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a
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at
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o
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k
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m
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cr
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fir
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■
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■
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p
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•
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) c
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p
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■
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ak
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a
ca
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to
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: D
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cr
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is
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.
S
te
p
3
■
Le
t
yo
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fir
st
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ft
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st
. A
ft
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, r
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El
im
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. P
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fr
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st
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.
■
C
la
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: A
sk
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f,
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it
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p
4
■
Fo
llo
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fo
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ta
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p
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b
lic
at
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.
■
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rm
is
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t m
en
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p
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ub
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ith
it
(o
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How to Write an Op-Ed 229
▸ For Serious Thought
1. World’s best op-ed: http://www.chicagotribune.com/news/nationworld
/politics/ct-talk-huppke-obit-facts-20120419-story.html
2. Omar Ahmad talks about political change with pen and paper at TED
2010: http://www.ted.com/talks/omar_ahmad_political_change_with
_pen_and_paper.html
3. The Op-Ed Project: http://www.theopedproject.org
4. The New York Times: http://www.nytimes.com/pages/opinion/index.html
5. Chicago Tribune: http://www.chicagotribune.com/news/opinion
/editorials/
6. Raleigh News & Observer: http://www.newsobserver.com/opinion/
7. The Chronicle (Duke University’s daily newspaper): http://www
.dukechronicle.com/section/opinion/
8. National Nurses United: http://www.nationalnursesunited.org/site
/entry/101-voice-respect\
9. Listen to a clip of journalist Suzanne Gordon speaking to school nurses
about the media’s image of nurses and nursing: http://suzannecgordon
.com/lectures-workshops/
10. Read five to eight examples of congressional testimony on ANA’s site:
http://www.rnaction.org/site/PageServer?pagename=%2Fnstat_congressional
_testimony#ACA
11. Reaching for Health Equity: http://www.cdc.gov/minorityhealth/strategies
2016/
12. “Your health depends on where you live” Ted Talk by Bill Davenhall:
https://www.ted.com/talks/bill_davenhall_your_health_depends_on_where
_you_live?language=en
13. Families USA on health equity: http://familiesusa.org/issues/health
-equity
14. Health Resources and Services Administration’s Office of Health Equity:
http://www.hrsa.gov/about/organization/bureaus/ohe/
15. Campaign for Equity of Care: http://www.equityofcare.org/
▸ Recommended Nonpartisan Twitter Feeds
@Politifact
Rand Congressional @RAND_OCR
Fact Check @factcheckdotorg
Kaiser Family Foundation Health News @KHNews
Alliance for Health Policy @AllHealthPolicy
@CSPAN
Commonwealth Fund (not Foundation) @Commonwealthfnd
▸ Recommended E-Subscriptions
■ Kaiser Health News updates: Subscribe to this daily email at http://khn
.org/email-signup/. Once you enter your email address, you will be given a
230 Chapter 12 An Insider’s Guide to Engaging in Policy Activities
choice to select the subscriptions you want. Select “First Edition” and KHN
Morning Briefing. You also may want to subscribe to Breaking News Alert.
■ Congressional Bill Tracker: http://dyn.realclearpolitics.com/congressional_bill
_tracker/.
■ Subscribe to bills that your elected officials introduce at https://www.govtrack
.us/congress/bills/subjects/house_of_representatives/5947?congress=113.
Type in the names of your representatives as “sponsors” or “co-sponsors.”
■ Subscribe to Health Affairs Health Policy Brief at http://www.healthaffairs
.org/1260_opt_in.php. Check the box for Health Policy Brief.
■ Congressional Quarterly (CQ) Roll Call: Sign up for a free trial to track state
and federal policy updates at http://cqrollcall.com.
■ Subscribe to the American Nurses Association’s Daily SmartBrief at http://
www.smartbrief.com/ana/index.jsp?campaign=story.
■ Subscribe to the American Association of Nurse Practitioners’ Daily SmartBrief
at https://www.smartbrief.com/signupSystem/subscribe. action?pageSequence
=1&briefName=aanp&campaign=in_brief_signup_link&utm_source
=brief.
■ Subscribe to the New England Journal of Medicine’s Health Policy and Reform
blog at https://cdf.nejm.org/register/reg_multistep.aspx?ea=health- policy
-and- reform&promo=ONFQSU23&cpc=FMAAALLV0612C. Select “health
policy & reform.”
▸ Influential Organizations Affecting
Health Policy
■ Library of Congress for text/summaries of legislation: http://thomas.loc.gov
■ U.S. House of Representatives: http://www.house.gov
• Committee on Ways and Means: http://waysandmeans.house.gov
• Committee of Energy and Commerce (oversees Medicare and Medicaid):
http://energycommerce.house.gov
• Committee on Appropriations: http://appropriations.house.gov
■ U.S. Senate: http://www.senate.gov
• Health, Education, Labor and Pensions Committee (HELP): http://
help.senate.gov
• Finance Committee: http://finance.senate.gov
■ White House: https://www.whitehouse.gov
■ Federal Register: https://www.federalregister.gov/
■ U.S. Department of Health and Human Services: https://www.hhs.gov
■ Bureau of Health Workforce: https://bhw.hrsa.gov/
■ Centers for Medicare and Medicaid Services: https://www.cms.gov/
■ Medicare Payment Advisory Commission: http://www.medpac.gov/
■ American Nurses Association: http://www.nursingworld.org
■ National Quality Forum: http://www.qualityforum.org/
■ Baldrige National Quality Program: http://baldrigefoundation.org/
■ Institute for Healthcare Improvement: http://www.ihi.org/ihi
■ National Association for Healthcare Quality: http://www.nahq.org/
■ National Academy of Medicine (quality series): https://nam.edu
Influential Organizations Affecting Health Policy 231
■ National Committee for Quality Assurance: http://www.ncqa.org/
■ American Academy of Applied Science: https://www.eurekalert.org
■ Kaiser Family Foundation: http://www.kff.org
■ Commonwealth Fund: http://www.commonwealthfund.org/
■ Center for Studying Health System Change: http://www.hschange.com/
■ Urban Institute: http://www.urban.org/health/index.cfm
■ American Enterprise Institute: http://www.aei.org/
■ Heritage Foundation: http://www.heritage.org/
■ Cato Institute: http://www.cato.org/
■ Physicians for a National Health Program: http://www.pnhp.org/
▸ How to Become a Change Agent
in Policy: Betty Sturgeon—One
Exemplary Nurse’s Story
A personal and professional story of one nurse in Nebraska serves as a resource for
many current nurse practitioners (NPs), student NPs, and patients. Betty Sturgeon
made a difference in Nebraska by (1) demonstrating nurse practitioner political
activism; (2) implementing interprofessional team education and practice four
decades before the concept was fostered as it is now; (3) serving as a pioneer NP
in Nebraska; and (4) facilitating the practice of NP care in a university’s student
health center so that hundreds of college students would learn about this type of
health provider and this type of care.
Ms. Sturgeon, age 93, died in 2017 (Obituary, Omaha World Herald, January 12,
2017). She lived her professional life daily as a NP who made a difference for
several populations in this state. She taught in a university NP program and
also taught a physical assessment course for students in the School of Pharmacy.
Her facilitation of NPs working in this university’s student health center would
change the knowledge base of hundreds of students regarding health provider
possibilities. Finally, as one of the first few NPs four decades ago in Nebraska,
Ms. Sturgeon literally “set the scene” for what NPs could later do in 2015 at the
state legislative level. The professional behaviors that she exemplified daily re-
sulted in advocacy behaviors in two academic departments in a university and
in its student health center. Her service as one of the first NPs in Nebraska laid
the groundwork for all who have practiced since then. In addition to the specific
legislative policy advocacy articulated in this chapter, she personified the kinds
of lived advocacy one does daily to effect change.
232 Chapter 12 An Insider’s Guide to Engaging in Policy Activities
Design Credits: Place header image credit here.
Note: Page numbers followed by f, b and t indicate materials in figures, boxes
and tables respectively
A
AACN. See American Association of Colleges
of Nursing
AAG. See assistant attorney general
AANP. See American Association of Nurse
Practitioners
AAP. See American Academy of Pediatrics
administrative agencies, 28t, 59, 69, 76
administrative procedures act (APA), 3, 57,
59, 68–69
advance premium tax credits, 179
advanced practice registered nurses
(APRNs), 17, 18, 19, 25, 58, 60,
61, 78, 80, 90, 128
definition of, 1
delegation of medication administration
by, 82–83
history of, 62–63
implications for, 145–146
in Nebraska, 20–21
policymakers, findings for, 8–9
regulation of, 65–66
reimbursement for, 72–73, 79
scope of practice for, 79
adverse selection, 171, 176, 186
Affordable Care Act (ACA), 11, 33, 72,
88, 116, 121–122, 144t, 153,
182–183, 188
changes to, 78–79
definition of, 171
essential health benefits, 179
health insurance market, 176
key policy issues to, 79
repeal, replace, repair or starve health
care finance, 176, 177f
agency, definition of, 115, 120
Agency for Healthcare Research and Quality
(AHRQ), 92, 140, 163
agenda setting
definition, 17–18
levels of, 18f
models and dimensions, 22–32, 24f,
27–30t
AHRQ. See Agency for Healthcare Research
and Quality
alternative payment models (APMs),
171, 184
AMA. See American Medical Association
American Academy of Nursing (AAN),
Expert Panel on Global Nursing and
Health, 202
American Academy of Pediatrics (AAP), 162,
163, 167
American Association of Colleges of Nursing
(AACN), 22, 65, 122, 203
American Association of Critical Care
Nurses, 9
American Association of Nurse Anesthetists,
9, 47t, 48
American Association of Nurse Practitioners
(AANP), 47t, 48, 122
American College of Cardiology
Foundation, 166
American College of Nurse‒Midwives, 48
American Counseling Association, 123
American Evaluation Association, 123
American Heart Association, 167
American Hospital Association (AHA), 46
American Medical Association (AMA),
46, 47t
American Nurses Association (ANA), 9, 22,
27t, 46, 47t, 48, 52, 53, 61–62, 63, 91,
117–118, 122, 216
Code of Ethics, provisions and
applications to policy and program
evaluation, 124, 125t
American Nurses Credentialing Center
(ANCC), 10, 66
Index
233
American Psychological Association,
47t, 123
American Recovery and Reinvestment Act
(ARRA), 143t, 187
An Uneasy Walk to Quality: The Evolution
of Black Nursing Education in the
Republic of Botswana, 210
ANA. See American Nurses Association
ANCC. See American Nurses Credentialing
Center
anencephaly, 220
“any willing provider” laws, 71
APA. See administrative procedures act, and
American Psychological Association
APMs. See alternative payment models
Apollo 13, 155
APRNs. See advanced practice registered
nurses
ARRA. See American Recovery and
Reinvestment Act
assistant attorney general (AAG), 67
Assistant Secretary of Defense, 104
Assistant Secretary of Planning and
Evaluation (2016), 176
authority tools, for public policy design, 93
B
bachelor of science in nursing (BSN), 10
BCBS. See Blue Cross and Blue Shield
behavioral dimensions, in public policy
design, 95–97
big data
background, 138
definition, 133, 134, 137
evidence-informed practice and, 142
healthcare delivery and policy,
significance for, 138
issues, 141–142
laying groundwork for, 142–143,
143–144t
magnet status and, 148
sources of, 138–141, 140b
understanding, 145–146
vs. research evidence, 146–147
bills becoming laws, process of, 58–59
chief executive signature, 42–43, 43t
committee consideration, 41–42
conference committee, 42
description, 40
federal process, 41
floor action, 42
bipartisan negotiation, 27t
Bipartisan–Bicameral action, 160–163
Black’s Law Dictionary, 60
Blue Cross and Blue Shield (BCBS), 186
board meetings, 67–68
boards of nursing (BONs), 59, 61, 66
composition of, 67
definition of, 57
licensure criteria establishment, 62
overview, 66–67
rule-making authority, 60
rule-making processes, 69–70, 70t
serving on, 71–72
BONs. See boards of nursing
BSN. See bachelor of science in nursing
Bush, George W., 72
C
capacity-building tools, for public policy
design, 94
CARA. See Comprehensive Addiction and
Recovery Act
Caribbean Community Market (CARICOM),
201, 207–208
nurse leader, policymaker, and politician
in, 208–211
CARICOM. See Caribbean Community
Catholic Health Initiative (CHI), 19
CCRCs. See continuing care retirement
communities
CDC. See Centers for Disease Control and
Prevention
Center for Beneficiary Choices, 72
Center for Interprofessional Practice,
Education, and Research, 19
Center for Medicaid and State
Operations, 72
Center for Medicare Management, 72
Centers for Disease Control and Prevention
(CDC), 102, 164
framework, for evaluation in public
health, 119, 119f, 120
Centers for Medicare and Medicaid Services
(CMS), 72, 88, 90, 112, 139
payment framework trajectory, 185f
CER. See comparative effectiveness research
certification
examinations, 66
professional, 57, 64–65
certified nurse‒midwife (CNM), 72
certified registered nurse anesthetist (CRNA),
1, 72
CFR. See Code of Federal Regulations
CGFNS. See Commission on Graduates
of Foreign Nursing Schools
International
CHI. See Catholic Health Initiative
234 Index
CHIP. See Children’s Health Insurance
Program
chief executive signature, 42–43, 43t
Chief Midwifery Officers (CMOs), 203
chief nursing officers (CNOs), 196, 203
Children’s Health Insurance Program
(CHIP), 104, 172, 176, 182, 183, 184
Child Fatality Task Force, 167
Chilean mine, IPE in, 157–158
Christmas tree bills, 37, 40
Citizens United v. Federal Election
Commission (2010), 48
Civil Rights Act of 1964, 88
clinical decision support, 133, 139
clinical nurse specialist (CNS), 72
clinical services, evaluating, 128
CMOs. See Chief Midwifery Officers
CMS. See Centers for Medicare and Medicaid
Services
CNLs. See clinical nurse leaders
CNM. See certified nurse‒midwife
CNOs. See chief nursing officers
CNS. See clinical nurse specialist
Code of Ethics
ANA, provisions and applications to policy
and program evaluation, 124, 125t
for policy and program evaluation, 118
Code of Federal Regulations (CFR), 74
coinsurance, 171, 179
Commerce Clause of the U.S. Constitution, 73
Commission on Graduates of Foreign
Nursing Schools International
(CGFNS), 193, 194
committee consideration, 41–42
committee hearings, 41
communication strategies, reduce conflicts,
during policy and program
evaluation, 124, 126, 126f
comparative effectiveness research (CER),
133, 140, 172, 186–188
competency of nurses, monitoring, 68
Comprehensive Addiction and Recovery Act
(CARA), 96
conceptual framework, 105–108, 110–111
conference committee, 42
congenital heart disease (CHD), health policy
related to, 166–169
definition, 37
internal political dynamics and, 29t
and White House, 29t
congressional class, 29t
congressional structure, 43t
Consensus Model for Regulation: Licensure,
Accreditation, Certification, and
Education (LACE), 65–66
constituents, 37, 41
contextual dimensions, 20, 23
definition, 17
examples, 26, 27–30t
importance of, 25–26
list of, 25–26
continuing care retirement communities
(CCRCs), 109
control and stability factors, 26, 30–31
cost sharing, 179
court system, 3, 104
credentialing, professional, methods of, 63
Creighton University’s College of Nursing, 19
critical congenital heart defect (CCHD),
health policy related to, 166–169
CRNA. See certified registered nurse
anesthetist
crowdsourcing, 133, 141, 152, 157
cultural context of global health care,
importance of, 201–203
D
data governance, 133, 141
data quality, 141
data science, 133, 145–146
data scientist, 133, 138
data sets, traditional, 138–139
database, definition, 133, 139
decision agenda, 18
defense policy, 2
deflection of goals, in policy implementation,
101, 111
delegated medical practice, 62–63
Department of Defense (DOD), 104,
160, 163
TriCare, 176
dependents target population, 31
design issue, policy, 92
deviants target population, 31
DHHS. See Department of Health and
Human Services
digitization, definition, 133, 135
discovery informatics, definition, 134, 146
disease registries, 139
disparities in health care, nursing role in, 11
dissipation of energies, in policy
implementation, 101, 111
districts, 37–38, 43t, 44
disunity, politics, 54
diversion of resources, in policy
implementation, 101, 111
divisiveness, politics, 54
DOD. See Department of Defense
doughnut hole of Medicare Part D
coverage, 182
Index 235
E
e-subscriptions, 230–231
EBP. See evidence-based practice
economic costs, 172
economic theory, 173
economics and finance of health care
adverse selection, 171, 186
APMs, 184
CER and, 172, 186–188
cost for, 188
essential health benefits, 172, 177, 179
health insurance exchanges, 177–180, 181f
health insurance market, 175–176,
177f, 178t
healthcare entitlement programs,
180–183, 183f
information asymmetry, 172, 184–186
life expectancy vs. spending, 174–175, 175f
means testing, 182
Medicare Access and CHIP
Reauthorization Act (MACRA) of
2015, 144t, 172, 182, 184
Medicaid expansion, impact of, 190
MIPS, 184
moral hazard, 172, 186
opportunity costs, 174
overview, 173–174, 173f
payment models, 183–184, 185f
per capita spending, 175
QALYs, 172, 186–188
spending vs. life expectancy, 174–175, 175f
value of BSN education for RNs, 189
ED nurses. See emergency department nurses
education policies, 2
EHRs. See electronic health records
EIHP model. See evidence-informed health
policy model
EIP. See evidence-informed practice
elected officials, relationships with, 12
electronic health records (EHRs), 134, 139, 145
electronic medical record (EMR), 105–106
electronic resources, relationship to health
care, 135, 136–137t
emergency department (ED) nurses, 51
emergency medical services (EMS) system,
161–163
emergency medical services for children
(ESMC), 160–165
Emergency Medical Treatment and Labor Act
(EMTALA), 92
Emergency Nurses Association, 9
emergency regulations, federal regulatory
process, 74
employer-sponsored health insurance
(ESHI), 176, 179
EMR. See electronic medical record
EMS system. See emergency medical services
system
EMTALA. See Emergency Medical Treatment
and Labor Act
environmental policy, 2
epilepsy, cultural context and, 201
EQ-5D index, 187
ESHI. See employer-sponsored health
insurance
ESMC. See emergency medical services for
children
essential health benefits, 172, 177, 179
ethical considerations, during policy
and program evaluation, 123–124,
125t, 126f
evaluation reports, 115, 120
evidence-based practice (EBP), 69, 104, 142
evidence-informed health policy (EIHP)
model, 69, 70t
evidence-informed practice (EIP)
and big data, relationship between, 142
evidence, vs. stakeholder interests in rule
making, 83–84
executive order, 38, 40
Expert Panel on Emerging Infectious
Diseases, 202
F
fact sheet
creation of, 217, 219
Families USA, 216–217, 218t
FDA. See Food and Drug Administration
federal and state policymaking and
implementation 101, 103–104
federal court system, 3
federal deficit, 28t
Federal Elections Commission, 48
Federal Interagency Committee
on EMS, 163
federal lawmakers, 44
federal poverty level (FPL), 179, 183
Federal Register
public comments and, 76, 226
purpose of, 74, 75f
federal regulatory process
emergency regulations, 74
federal rule making, 74, 75f
healthcare delivery system, regulation in
transforming, 76–78
locating information, 74
need for, 72–78
public comment period, 74, 76
strengths and weaknesses of, 76
236 Index
federal rule making, 74, 75f
federally qualified health centers
(FQHCs), 96
Filipino nursing schools, 201
Financial Reform bill, 45
527 committees, 37, 484
fund raising and expenditures, 49t
Food and Drug Administration (FDA), 25,
46, 96, 174
form letters, public comment
periods, 227
formal evaluation process, 118, 121
formative evaluations, 118, 120
FPL. See federal poverty level
FQHCs. See federally qualified
health centers
free market, vs. traditional finance
methods, 178t
free trade, 198
“freedom of choice” laws, 71
FTC. See Federal Trade Commission
Future of Nursing: Leading Change, Advancing
Health, The, 2, 10, 117
key messages and recommendations,
77–78, 102
G
Genetic Information Nondiscrimination
Act, 144t
global burden of disease, 193,
197–198, 198f
global connectivity of health care
cultural context, 201–203
public policy, nurse involvement in,
203–204
Global Forum for Government, 203
globalization
definition, 193, 195
and its impact on nursing and health
care, 195–196
factors affecting out-migration,
200–201
migration of human capital, 199
sustainable development goals,
recommendations and actions for,
197–199, 197–198f
goals, public policy vs., 4
Government Performance and Results Act
(GPRA), 118
government tools, for public policy design,
93–95
GPRA. See Government Performance and
Results Act
grassroots lobbyist, 52–53
H
Hatch, Orrin G., 160
HCAHPS. See Hospital Consumer
Assessment of Healthcare Providers
and Systems
HCFA. See Health Care Financing
Administration
HCPs. See healthcare provider professionals
HCUP. See Healthcare Cost and Utilization
Project
life expectancy, 175, 175f
health care. See also disparities in health care;
economics and finance of health care
life expectancy, 175, 175f
Health Care and Education Reconciliation
Act, 72, 144t
Health Care Financing Administration
(HCFA), becomes CMS 72
Health, Education, Labor, and Pensions
(HELP) Committee, 161
Health Employment and Economic Growth
(HEEG), 197
health finance and health policy
intersection, 173f
health-in-all-policies, 115, 116
Health Information Technology for
Economic and Clinical Health
Act, 144t
health insurance exchanges (HIXs), 172,
177–180, 181f
health insurance market, 175–176, 177f, 178t
Health Insurance Portability and
Accountability Act (HIPAA), 124, 143t
health policy, 153, 173
in Botswana, nurse advocacy for, 210–211
and health finance intersection, 173f
healthcare professionals to influence, 165
influential organizations affecting,
231–232
and social program evaluation
benefits of, 119t
effective, challenges to, 122–126, 123b,
125t, 126f
for healthcare reform, implications of,
121–122
nurses’ role in, 117–118
overview, 116
processes of, 118–119, 119t, 119f
steps in, 120–121
Health Professions Education: A Bridge to
Quality, 153
health professions regulation, history of, 61–62
Health Research Extension Act of 1985, 22
Health Resources and Services Administration
(HRSA), 153, 163, 164
Index 237
health services research (HSR), 87, 91–92,
137, 138, 151, 187
Health Services Research Information
Central, 140
healthcare consumers, 135, 139, 140
Healthcare Cost and Utilization Project
(HCUP), 139–140
healthcare cost curve, 188
healthcare delivery and policy, significance
for, 138
healthcare delivery system, regulation in
transforming, 76–78
healthcare entitlement programs, 180–183, 183f
healthcare market, 173, 174
healthcare professionals, 135, 137, 140, 185
implications for, 145–146
to influence health policy, 165
healthcare provider professionals (HCPs), 1, 2
healthcare reform, public policy process, 11
healthcare services, electronic access to, 80
hearings
providing testimony for, 225–226
public rule, 57, 76
HEEG. See Health Employment and
Economic Growth
HELP committee. See Health, Education,
Labor, and Pensions Committee
Heritage Foundation, 216
HIPAA. See Health Insurance Portability and
Accountability Act
HIXs. See health insurance exchanges
Hmong people, 201
Horoho, Patricia, 90
hortatory tools, for public policy design, 94
Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS), 139
hospital insurance program, 181
House Nursing Caucus, 12
House and Senate committee chairs, 42
HRSA. See Health Resources and Services
Administration
HSR. See health services research
human capital, migration of, 194, 199
Human System Risk Board, 156
I
ICD-10 codes. See International
Classification of Diseases, 10th
revision codes
ICN. See International Council of Nurses
ideological conflicts, over current issues, 28t
IHS. See Indian Health Service
implementation climate, 101, 105
implementation effectiveness, 101, 105
implementation of health policy, 119
definition, 101, 102
key elements to be considered, 107–108
overview, 101–103
rejected by citizens, 108–110
research, 104–111
conceptual framework, 105–108,
110–111
implications
for RNs, APRNs, and healthcare
professionals, 145–146
of using various data sources, 147–148
incentive tools, for public policy design,
93–94
Indian Health Service (IHS), 73, 104, 176
infant mortality, 89
informal evaluation, of ACA, 121, 122
information asymmetry, 172, 184–186
information sources, political bias in,
strategies to recognize, 215–217
informed consent, 116, 125t
InnoCentive, 157
Innovation and Entrepreneurship: Practice and
Principles, 134
innovation effectiveness, 101, 106
innovation–values fit, 101, 105, 106
Inouye, Daniel K., 160
Institute of Medicine (IOM), See National
Academy of Medicine
institutional agenda, 18
institutional review boards (IRBs), 124
Integrated Practice Agreement (IPA), 19
interdisciplinary investigative team, 153
interest groups
influence of, 30t
special, 38, 41
unity of, 27t
International Classification of Diseases,
10th revision (ICD-10) codes, 112
International Council of Nurses (ICN),
193–194, 197
International Monetary Fund, 194, 196
international nurse policy leaders, personal
stories of, 207–211
international politics, 29t
International Structural Adjustment
Programs, 196
Internet, 140
internships, political, 12
interprofessional collaboration, 152
core attributes of, 153–155
future of, 159
on health policy related to critical
congenital heart defects, 166–169
to influence policy, 160
238 Index
Bipartisan–Bicameral action,
160–163
personal reflections, 163–165
interprofessional education (IPE), 152
in Chilean mine, 157–158
future of, 159
interprofessional healthcare workers
(IPHCWs), 17, 18, 19, 25
interprofessional universe, evolving
interprofessional collaboration, 152
interprofessional education, core
attributes of, 153–155
interstate compacts, 80
interstate mobility, 80
IOM. See Institute of Medicine
IPA. See Integrated Practice Agreement
IPE. See interprofessional education
IPHCWs. See interprofessional healthcare
workers
IRBs. See institutional review boards
iron triangle, definition, 17, 23, 24f
issues, with big data, 141–142
J
JCARR. See Joint Committee on Agency Rule
Review
Johnson Space Center, See NASA
Joint Committee on Agency Rule Review
(JCARR), 59
Josiah Macy Jr. Foundation, 11, 78
Journal of Nursing Scholarship, 202
Journal of Transcultural Nursing, 202
judicial interpretation, 3
jurisdiction, 66–67
K
Kaiser Family Foundation, 79, 181–182
Health Tracking Poll, 96
Kingdon model, 23–25, 24f, 32–33
knowledge society, 134, 135
Koop, C. Everett, 161
L
lame duck presidential terms, 28t
lame duck sessions, 38, 40
LARC. See Legislative Advocacy and
Representation Committee
LAs. See legislative assistants/aides
laws. See also legislative process
implementation of, 58–59
people in, making of, 44–46, 45t, 47t
in policy entity, 3
public policy vs., 4
League of Women Voters (LWV), 34, 48
learning tools, for public policy design,
94–95
legislation
complexity of, 45
definition, 38
finding, 41
and initiatives for big data in health care,
143, 143–144t
introduction, 38–40
process, people, and purse strings, 40–50,
43t, 45t, 47t, 49–50t
strategizing for success, 50–51, 52b
thinking like policymaker, 52–54
vs. regulation, 58–60
Legislative Advocacy and Representation
Committee (LARC), 21, 33–34
legislative assistants/aides (LAs), 44, 45t
legislative language, 38, 41
legislative process. See also laws
regulatory process vs., 58–60
legislators, 38, 41
agencies, 28t
communicating with, 44
contacting, 219–222
legislature, 38, 42, 103
licensed practical nurse/licensed vocational
nurse (LPN/LVN) educational
programs, 60
licensure
definition and purpose, 57, 58, 63–64
issues in, 78–80
life expectancy, healthcare spending and,
174–175, 175f
lobbying and lobbyists, 38, 41, 45–46, 47t
LPN/LVN educational programs. See licensed
practical nurse/licensed vocational
nurse educational programs
LWV. See League of Women Voters
M
MACRA. See Medicare Access and CHIP
Reauthorization Act of 2015
Madigan, Michael J., 25
magnet status, and big data, 148
mandatory reporting, 68
Meaningful Use, electronic health records, 134
means testing, 172, 179, 182
Index 239
Medicaid, 40–41, 88, 104, 180–183
expansion, economic impact of, 190
health insurance market and, 176
Medical Expenditure Panel Survey (MEPS),
91–92
Medicare, 40–41, 88, 104, 180–182
health insurance market and, 176
reimbursement policies, 72
Medicare Access and CHIP Reauthorization
Act (MACRA) of 2015, 144t, 172,
182, 184
Medicare Advantage, 72, 181–182
Medicare Improvements for Patients and
Providers Act, 143t
Medicare Part A, 181
Medicare Part B, 181
Medicare Part C, 181–182
Medicare Part D, 182
Medicare Prescription Drug, Improvement,
and Modernization Act (MMA), 72, 94
MEPS. See Medical Expenditure Panel Survey
Merit-Based Incentive Payment System
(MIPS), 184
meta-analysis, 134
Michigan’s Department of Licensing and
Regulatory Affairs, 58
migration of human capital, 194, 199
Ministry of Health and Wellness (MOH),
210–211
MIPS. See Merit-Based Incentive Payment
System
MMA. See Medicare Prescription Drug,
Improvement, and Modernization Act
MOH. See Ministry of Health and Wellness
moral hazard, 172, 186
multistate regulation, 57, 73, 80
mutual recognition model of multistate
licensure, 80
N
NAM. See National Academy of Medicine
NASA. See National Aeronautics and Space
Administration
National Academy of Medicine, 10, 77, 102,
117, 153, 161
National Aeronautics and Space
Administration (NASA), 152,
154–155, 155–158
National Center for Interprofessional Practice
and Education, 19
National Center for Nursing Research
(NCNR) amendment
control and stability factors, 26, 30–31
importance of, 23
Kingdon model and, 23–25, 24f
overview, 22–23
policy design for, 26
Schneider and Ingram model, 31–32
variables contributing to passage of
legislation creating, 27–30t
National Conference of State Legislatures, 176
National Council Licensure Examinations
(NCLEX), 10, 67
National Council of State Boards of Nursing
(NCSBN), 3, 7, 8, 10, 57, 62, 63, 80
regulation of APRNs and, 65–66
national health insurance program, for Social
Security beneficiaries, 88
National Healthcare Quality and Disparities
Reports, 92
National Institute of Nursing Research
(NINR), 22, 30
National Institutes of Health (NIH), 22,
27–29t, 30t, 96
National League for Nursing (NLN),
9, 62, 122
National Nurses Association (NNA), 219
National Patient-Centered Clinical Research
Network (PCORnet), 140
National Performance Review, 118
national policy, analysis of, 32
NCLEX. See National Council Licensure
Examinations
NCNR amendment. See National Center for
Nursing Research amendment
NCSBN. See National Council of State Boards
of Nursing
Nebraska Credentialing Review (407)
Program, 20, 33
Nebraska Department of Health and Human
Services, 20, 34
Nebraska Hospital Association, 33
Nebraska Medical Association (NMA), 33
Nebraska nurse practitioner (NNP), 19–21
theory application to, 32–34
Nebraska Nurses Association (NNA), 33–34
Nebraska unicameral legislature, 19–21
NGO. See nongovernmental organization
NIH. See National Institutes of Health
NINR. See National Institute of Nursing
Research
NLC model. See Nurse Licensure Compact
model
NLN. See National League for Nursing
NMA. See Nebraska Medical Association
NNA. See National Nurses Association;
Nebraska Nurses Association
NNP. See Nebraska nurse practitioner
non-interest group, unity of, 27t
240 Index
nongovernmental organization (NGO),
151, 193
North Carolina Academy of Family
Physicians, 167
North Carolina Academy of Physician
Assistants, 167
North Carolina Association of Nurse
Anesthetists, 91
North Carolina Board of Nursing, 167
North Carolina Chapter of American Heart
Association, 167
North Carolina Chapter of March of Dimes, 167
North Carolina General Assembly, 90, 96,
108–110
North Carolina Healthcare Senate Standing
Committee, 167
North Carolina Hospital Association, 167
North Carolina Nurses Association, 91, 109
North Carolina state income taxes,
reinstatement of medical expenses
deduction on, 108–110
North Carolina’s Nursing Practice Act, 91
notice of proposed rulemaking (NPRM), 74
NPAs. See nurse practice acts
NPRM. See notice of proposed rulemaking
NPs. See nurse practitioners
Nurse Aide Registry, 64
Nurse and Health Care Worker Protection
Act, 91
nurse informaticist, 138
Nurse Licensure Compact (NLC) model, 80
nurse practice acts (NPAs), 59, 61–62, 66
Nurse Practitioner Practice Act, 19
Nurse Practitioner, The, 63
nurse practitioners (NPs), 1, 19, 25, 62, 72,
155, 159, 232
in Nebraska, 32–34
nurses. See also advanced practice registered
nurses (APRNs)
action taking, 9–10
advocacy
for health policies in Botswana, 210–211
and policymaking, barriers to, 204
coaching and mentoring, 52–53
education programs, 4–7
influence health policy, 4–7, 5–6f
informaticist, 134, 138
involvement in policy decisions, 203–204
policy/program evaluation, role in, 117–118
for healthcare reform, implications of,
121–122
processes of, 118–119, 119t, 119f
steps in, 120–121
required skills, 12
researchers, NIH grants and, 30t
role of, 11–13
Nurses on Boards Coalition, 39
nursing and health care
globalization and its impact on, 195–196
factors affecting out-migration, 200–201
migration of human capital, 199
sustainable development goals,
recommendations and actions for,
197–199, 197–198f
nursing education, to improve involvement in
policymaking, 203–204
Nursing Leadership in Global Health
Symposium, 202
nursing organizations, national,
influence of, 22–23
nursing practice, 7–9, 8f
nursing shortages, addressing, 10–11
O
objectives, public policy vs., 4
Occupational Safety and Health
Administration, 91
OECD. See Organisation for Economic
Cooperation and Development
Office of Management and Budget (OMB),
21, 29t, 118
official recognition, 65
Ohio Board of Nursing, 58
Oil Spill Recovery Institute, 157
OMB. See Office of Management and Budget
Omnibus Budget Reconciliation Act of 1987, 64
Oncology Nurses Society, 9
op-ed (opposite the editorial page), writing,
227–229
opioid epidemic, 95, 96
opportunity costs, 172, 174
Organisation for Economic Cooperation and
Development (OECD), 199
organizational involvement, 9
out-migration, factors affecting, 200–201
outcome evaluations. See program
evaluations
P
PACs. See political action committees
partisan conflict
between legislators, 27t
between White House and interest
group, 28t
major political parties, 220t
over current issues, 28t
Index 241
Patient-Centered Outcomes Research
Institute (PCORI), 140, 187–188
Patient Protection and Affordable Care Act.
See Affordable Care Act
PatientsLikeMe platform, 141
payment models, economics and finance of
health care, 183–184, 185f
PCORI. See Patient-Centered Outcomes
Research Institute
PCORnet. See National Patient-Centered
Clinical Research Network
PCP. See primary care provider
Perinatal Health Committee, 167
Perinatal Quality Collaborative of North
Carolina (PQCNC), 167
personalized medicine, 134, 138
Pew Health Professions Commission,
76–77
Pew Task Force on Health Care Workforce
Regulation, 77
PHARMA. See Pharmaceutical Research &
Manufacturers of America
Pharmaceutical Research & Manufacturers
of America (PHARMA), 46
PICOT, 57, 69–70
policy
actors, stability of, 30
advocacy, 208
analysis, 121
change agent in, becoming, 232
content, 119
context, reframing treatment options
within, 154–155
definition, 1, 3, 116
design, issue, 92
evaluation, definition, 116
implementation of, 119
implementation. See implementation of
health policy
instruments, 93–95
outcome of, 119
process, 2
definition, 1
design, 90–91
research informing, 91–92
stages of, 88f
steps in, 4
stream, 24–25
tools, 87, 93, 95
policymaker, visiting, 223
policymaking
barriers to advocacy and, facilitators of, 204
federal and state, 103–104
nursing education to improve
involvement in, 203–204
process, money role in, 46
polio, resurgence of, 205–207
political action committees (PACs), 38, 53
political activism, 9, 12
political agenda, 18, 18f
political astuteness, 52b, 54
political bias, in information sources,
strategies to recognize, 215–217
political contextual influence,
examples of, 26, 27–30t
political role for nurses, developing, 11–13
political streams, 24–25, 32
political system, working with, 12–13
politics
coaching staff, 52–53
defined, 173
definition, 1, 3, 38–39
investment (time and money), 53–54
players skills, 50–51
purse strings, 46, 48–50, 49–50t
strategizing for success, 50–51, 52b
team chemistry, 54
thinking like policymaker, 52–54
population health, 134, 138
population management, 183–184
position statements, public policy vs., 3, 4
PQCNC. See Perinatal Quality Collaborative
of North Carolina
practice acts, 57, 59, 60, 63
Precision Medicine Initiative, 144t
predictive analytics, 134, 145–146
Prescription Drug Monitoring
Program, 96, 97
prescriptive authority, 61, 63
Preventive Health Amendments of 1984, 160
primary care provider (PCP), 185
problem streams, 24–25
professional organizations, 9
program evaluations
definition, 116, 117
design, 116, 118
public comment periods, 74, 76
participating in, 226
form letters, 227
tips for submitting, 226–227
public health insurance, 179
public policy
as an entity, 3–4
definition, 1, 2
design
behavioral dimensions in, 95–97
issues of, 92
overview, 87–90, 88f
policy instruments (government tools),
93–95
process of, 90–91
process, research informing, 91–92
242 Index
global, nurse involvement in, 203–204
political role for nurses, 11–13
process, 4, 7, 8f
healthcare reform, 11
purpose of, 2
related to clinical practice, 2–11
action taking, 9–10
as entity, 3–4
nursing shortages, addressing, 10–11
organizational involvement, 9
and practice, 7–9, 8f
as process, 4
right person to influence, 4–7, 5–6f
public rule hearings, 57, 76
purse strings, 46, 48–50, 49–50t
push–pull factors, 194, 200
Q
QALYs. See quality adjusted life years
QHPs. See qualified health insurance plans
quadruple aim, 117
qualified health insurance plans (QHPs),
172, 179
qualified health plan, penalties for, 180
quality adjusted life years (QALYs), 172,
186–188
Quality Chasm Series, 77
Quality Payment Program, 184
R
randomized control trial (RCT), 186–187
rapid cycle quality improvement (RCQI)
evaluation, 120, 122
RCQI evaluation. See rapid cycle quality
improvement evaluation
RCT. See randomized control trial
Reagan, Ronald, 28–29t, 103, 160
recognition, 58
legislative, 61
official, 65
Regional Nursing Body (RNB), 201,
208, 209
registered nurses (RNs), 17, 60, 61, 90
economic value of BSN education for, 189
implications for, 145–146
registration, professional, 58, 61, 64
regulations (rules), 8
definitions, 1, 2
and purpose of, 58, 60–61
implementation of, 59
issues in, 78–80
monitoring, 70–71, 71b
in policy entity, 3–4
public policy vs., 4
vs. legislation, 58–60
regulatory process
APRNs, history, 62–63
definition, 58
health professions, 60–66
state level, 66–72
strengths and weaknesses of, 76
in transforming healthcare system,
76–78
regulatory responses
Affordable Care Act, changes to, 78–79
electronic access to healthcare
services, 80
interstate mobility and multistate
regulation, 80
reimbursement, 79
scope of practice, 79
unlicensed assistive personnel (UAPs),
use of, 80
Rehabilitation Act of 1973, 3
reimbursement
for APRNs, 79
policies, Medicare and Medicaid, 72
Remedy and Reaction: The Peculiar American
Struggle Over Health Reform
(2011), 151
“repeal, replace, repair, or starve,”
172, 175
research evidence vs. big data, 146–147
resolutions, public policy vs., 4
risk pool, 172, 175–176
RNB. See Regional Nursing Body
RNs. See registered nurses
Robert Wood Johnson Foundation (RWJF)
funded projects, 10
publications, 77
rule making, influencing, 226–227
rules and regulations. See regulations (rules)
RWJF. See Robert Wood Johnson
Foundation
S
safe patient handling and mobility (SPHM)
programs, 91
SBHC. See school-based health clinic
SBTPE. See State Board Test Pool
Examination
scheduled vs. walk-in appointments, 129
Schneider and Ingram model, 31–32
Index 243
school-based health clinic (SBHC), 128
scope of practice, for APRNs, 79
self-regulation, professional, 65
Senate Nursing Caucus, 12
SGR. See sustainable growth rate
SHOP. See small business health insurance
options program
sickness insurance, 175
Sigma Theta Tau International, 9
small business health insurance options
program (SHOP), 179–180
SNAP. See Supplemental Nutrition Assistance
Program
social constructions, 31
social media, 140
Social Policy Statement, ANA, 146
Social Security Act, 45, 88, 182
Social Transformation of American Medicine,
The (1982), 151
societal need, 160, 161, 163
SPHM programs. See safe patient handling
and mobility programs
staffing patterns, federal, 45t
stakeholder, vs. evidence interests in rule
making, 83–84
standing committees, 41
State Board Test Pool Examination
(SBTPE), 62
state budget deficit, 28t
State Bulletin, 74
state legislatures, 43
State Register, 74
state regulatory process, 66
board meetings, 67–68
board rule-making processes,
69–70, 70t
boards and commissions serving,
71–72
boards of nursing, 66–67
monitoring, 70–71, 71b
nurses competency monitoring, 68
revising or instituting new state
regulations, 68–69
statutes
definition, 2
in policy as entity, 3
Stevenson, Joanne, 30t
streams, definition, 17, 24–25
street-level bureaucrats, 107
structured data, 141
summative evaluation process, 118, 121
“sunshine” laws, 67
super-majority votes, 38, 39
Supplemental Nutrition Assistance Program
(SNAP), 104
supplementary medical insurance, 181
Supremacy Clause of the U.S.
Constitution, 73
sustainable development goals,
recommendations and actions for,
197–199, 197–198f
sustainable growth rate (SGR), 184
symbolic tools, for public policy design, 94
systemic agenda, 18
T
target populations, social construction of, 31
Tavenner, Marilyn, 90
“Team 4” concept, 155–158
telehealth, 73, 80
testify
preparing to, 224–226
tips on, 224–225
theory, definition of, 116, 117
To Err Is Human: Building a Safer Health
System, 77, 153
traditional finance methods, vs. free market,
178t
Transcultural Nursing Society, 202
TriCare, 104
for Life programs, 176
triple aim, definition of, 116, 117
Twitter, 140
for disease detection and management,
advantages of, 140b
feeds, 230
U
UAPs. See unlicensed assistive
personnel
unfunded mandate, 87, 92
Uniformed Services University of the Health
Sciences, 160, 163, 165
unintended consequences, 116, 118
United Nations’ Sustainable Development
Goals, 197–199, 197–198f
United States
national health expenditures in, 183f
RCT, 186–187
and their ideological perspectives,
political parties in, 218t
unlicensed assistive personnel
(UAPs), 80
unstructured data, 141
U.S. Chamber of Commerce, 46
U.S. Congress, 44
U.S. Department of Agriculture, 104
244 Index
U.S. Department of Health and Human
Services (DHHS), 20, 73, 95, 104, 112,
140, 162, 163, 164, 179, 183
U.S. Department of Transportation’s National
Highway Safety Administration, 163
U.S. Department of Veterans Affairs, 22, 79, 104
U.S. Preventative Services Task Force
(USPSTF), 221
USPSTF. See U.S. Preventative Services Task
Force
V
Veterans Health Administration (VHA), 73,
104, 176
on APRN practice, 22
veto-override votes, 29t
VHA. See Veterans Health Administration
w
Waxman, Henry, 28–29t
WIC program. See Women, Infants, and
Children program
window of opportunity, definition, 17,
24–25
Women, Infants, and Children (WIC)
program, 217, 220–221
Working for Health and Growth: Investing in
the Health Workforce, 197
workplace safety, government response, 51
World Bank, 194, 196, 200
World Health Organization (WHO),
153, 194, 196, 197–198,
198f, 199
World Health Report, 197
Index 245
Title Page
Copyright
Contents
Preface
Acknowledgments
Contributors
CHAPTER 1 Informing Public Policy: An Important Role for Registered Nurses���������������������������������������������������������������������������������
Introduction�������������������
How Is Public Policy Related to Clinical Practice?���������������������������������������������������������
Healthcare Reform at the Center of the Public Policy Process�������������������������������������������������������������������
Developing a More Sophisticated Political Role for Nurses����������������������������������������������������������������
Conclusion�����������������
Discussion Points������������������������
References�����������������
CHAPTER 2 Agenda Setting: What Rises to a Policymaker’s Attention?�������������������������������������������������������������������������
Introduction�������������������
Overview of Models and Dimensions����������������������������������������
Summary Analysis of a National Policy Case Study�������������������������������������������������������
Theory Application to the Nebraska Nurse Practitioner Case Study�����������������������������������������������������������������������
Conclusion�����������������
Discussion Points������������������������
References�����������������
Online Resources�����������������������
CHAPTER 3 Government Response: Legislation�������������������������������������������������
Introduction�������������������
Process, People, and Purse Strings�����������������������������������������
Playing the Game: Strategizing for Success�������������������������������������������������
Thinking Like a Policymaker����������������������������������
Conclusion�����������������
Discussion Points������������������������
References�����������������
CHAPTER 4 Government Response: Regulation������������������������������������������������
Introduction�������������������
Regulation Versus Legislation������������������������������������
Health Professions Regulation and Licensing��������������������������������������������������
The State Regulatory Process�����������������������������������
The Federal Regulatory Process�������������������������������������
Current Issues in Regulation and Licensure: Regulatory Responses�����������������������������������������������������������������������
Conclusion�����������������
Discussion Points������������������������
References�����������������
CHAPTER 5 Public Policy Design�������������������������������������
Introduction�������������������
The Policy Design Process��������������������������������
Research Informing the Policy Process��������������������������������������������
The Design Issue�����������������������
Policy Instruments (Government Tools)��������������������������������������������
Behavioral Dimensions����������������������������
Conclusion�����������������
Discussion Points������������������������
References�����������������
CHAPTER 6 Policy Implementation��������������������������������������
Introduction�������������������
Federal and State Policymaking and Implementation 101������������������������������������������������������������
Implementation Research������������������������������
Conclusion�����������������
Discussion Points������������������������
References�����������������
CHAPTER 7 Health Policy and Social Program Evaluation������������������������������������������������������������
Introduction�������������������
Nurses’ Role in Policy/Program Evaluation������������������������������������������������
Challenges to Effective Policy and Program Evaluation������������������������������������������������������������
Conclusion�����������������
Discussion Points������������������������
References�����������������
Online Resources�����������������������
CHAPTER 8 The Impact of EHRs, Big Data, and Evidence-Informed Practice�����������������������������������������������������������������������������
Introduction�������������������
Electronic Resources: Their Relationship to Health Care��������������������������������������������������������������
Big Data���������������
Implications for RNs, APRNs, and Other Healthcare Professionals����������������������������������������������������������������������
References�����������������
CHAPTER 9 Interprofessional Practice�������������������������������������������
Introduction�������������������
References�����������������
The Evolving Interprofessional Universe����������������������������������������������
What Is Interprofessional Collaboration?�����������������������������������������������
Core Attributes of Interprofessional Education�����������������������������������������������������
The “Team 4” Concept���������������������������
The Future of IPE and Interprofessional Collaboration������������������������������������������������������������
References�����������������
Interprofessional Collaboration to Influence Policy����������������������������������������������������������
Bipartisan–Bicameral Action����������������������������������
Personal Reflections���������������������������
Discussion Points������������������������
References�����������������
Suggested Readings�������������������������
CHAPTER 10 Overview: The Economics and Finance of Health Care��������������������������������������������������������������������
Introduction�������������������
Economics: Opportunity Costs�����������������������������������
Finance: Does More Spending Buy Us Better Health?��������������������������������������������������������
Economics: Health Insurance Market�����������������������������������������
Finance: Health Insurance Exchanges������������������������������������������
Finance: Healthcare Entitlement Programs�����������������������������������������������
Finance: Payment Models������������������������������
Economics: Information Asymmetry���������������������������������������
Finance: Comparative Effectiveness Research and Quality-Adjusted Life-Years����������������������������������������������������������������������������������
Finance: Bending the Healthcare Cost Curve Downward����������������������������������������������������������
Discussion Points������������������������
References�����������������
Online Resources�����������������������
CHAPTER 11 The Impact of Globalization: Nurses Influencing Global Health Policy��������������������������������������������������������������������������������������
Introduction�������������������
Globalization and Its Impact on Nursing and Health Care��������������������������������������������������������������
The Importance of Understanding the Cultural Context�����������������������������������������������������������
Nurse Involvement in Policy Decisions��������������������������������������������
Conclusion�����������������
Discussion Points������������������������
References�����������������
CHAPTER 12 An Insider’s Guide to Engaging in Policy Activities���������������������������������������������������������������������
Strategies to Recognize Political Bias in Information Sources��������������������������������������������������������������������
Creating a Fact Sheet����������������������������
Contacting Your Legislators����������������������������������
Example of a Fact Sheet������������������������������
What to Expect When You Visit Your Policymaker�����������������������������������������������������
Preparing to Testify���������������������������
Participating in Public Comment Periods (Influencing Rule Making)������������������������������������������������������������������������
How to Write an Op-Ed����������������������������
For Serious Thought��������������������������
Recommended Nonpartisan Twitter Feeds��������������������������������������������
Recommended E-Subscriptions����������������������������������
Influential Organizations Affecting Health Policy��������������������������������������������������������
How to Become a Change Agent in Policy: Betty Sturgeon—One Exemplary Nurse’s Story�����������������������������������������������������������������������������������������
Index������������
Healthcare Program/Policy Evaluation Analysis
Template
Use this document to complete the Module 5 Assessment
Assessing a Healthcare Program/Policy Evaluation
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Healthcare Program/Policy Evaluation |
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Description |
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How was the success of the program or policy measured? |
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How many people were reached by the program or policy selected? How much of an impact was realized with the program or policy selected? |
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At what point in program implementation was the program or policy evaluation conducted? |
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What data was used to conduct the program or policy evaluation? |
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What specific information on unintended consequences were identified? |
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What stakeholders were identified in the evaluation of the program or policy? Who would benefit most from the results and reporting of the program or policy evaluation? Be specific and provide examples. |
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Did the program or policy meet the original intent and objectives? Why or why not? |
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Would you recommend implementing this program or policy in your place of work? Why or why not? |
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Identify at least three ways that you, as a nurse advocate, could become involved in evaluating a program or policy after one year of implementation. |
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General Notes/Comments |
Healthcare Program/Policy Evaluation Analysis
Template
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