Identify A Current Healthcare Policy In Your Current Role That You Would Like To See Revised. Why? What Would Be The Projected Outcomes?

Discuss 2 Please don’t combine everything. Answer each question separately for clarity

1A:Identify a current healthcare policy in your current role that you would like to see revised. Why? What would be the projected outcomes?

1B: discuss both the obvious and the non-obvious stakeholders?

1C: Which stakeholders to you have the potential to influence?

1D: What barriers do you face with reaching stakeholders and allowing them to buy in?

1F Take the identified healthcare policy and. Identify both obvious and non-obvious stakeholders.

1G:Also identify stakeholders that you have the potential to influence.

1H:Determine the effect of healthcare politics on the healthcare stakeholders, state and federal government, and the nursing profession (

1J: Analyze legislative process and the impact of special interest lobbies

SECTION 2A

2A: How have you seen the diverse interests of healthcare stakeholders impact patient care in your nursing practice or in the practice of other nurses?

2B: In general, do you think political action committees (PACs) and special interest groups (SIGs) contribute to or detract from improvements in patient healthcare? Provide an example to illustrate your thoughts.

2C: What role should politics play in healthcare reform? What role should the DNP-prepared nurse play in the political process that impacts healthcare reform?

EVERYTHING YOU NEED IS IN THE ARTICLE

 

Nurse Staffing Ratios

Policy Options

Joanne Spetz

“The problems of the world cannot possibly be solved by skeptics or cynics whose horizons are limited by the obvious realities.”

John F. Kennedy

The importance of nursing to the delivery of high-quality health care has been recognized since the inception of the practice of nursing. Various factors contribute to the quality of nursing care including the expertise of nursing staff, availability of supportive personnel and other health professionals, good communication among the care team, and the nurse/patient ratio. It was not until the early 2000s that high-quality empirical research found consistent relationships between licensed nurse staffing and the quality of patient care (Lang et al., 2004; Kane et al., 2007).

Concerns about the effects of changes in nurse staffing levels in the 1990s, combined with the increasing influence of nursing unions, resulted in the passage of California Assembly Bill (AB) 394 in 1999, the first comprehensive legislation in the United States to establish minimum staffing levels for registered nurses (RNs) and licensed vocational nurses (LVNs) in hospitals. This bill required that the California Department of Health Services (DHS) establish specific staffing ratios. These were announced in 2002 and implemented beginning in 2004. Since then, other states and the federal government have considered developing regulations for nurse staffing in hospitals. In 2014, for example, Massachusetts passed legislation mandating a ratio of one or two patients per nurse in intensive care units (Associated Press, 2014).

The Establishment of California’s Regulations

Throughout the late 1990s and early 2000s, there was substantial debate about the changes in hospital staffing that had occurred in the 1990s and the effects of such changes on the quality of care (Aiken, Sochalski, & Anderson, 1996; Spetz, 1998; Unruh & Fottler, 2006; Wunderlich, Sloan, & Davis, 1996). In some states, legislators and regulatory agencies considered staffing requirements with an aim to increase the numbers of nurses and other health care personnel working in hospitals and other settings. As the 1990s ended, a shortage of RNs emerged, and concern about poor staffing in hospitals continued (Kilborn, 1999). It was in this environment that AB 394 was passed by the California legislature. Previous Republican governors had vetoed similar legislation, but union-friendly Democratic Governor Gray Davis signed AB 394, satisfying union efforts to pass minimum-ratio legislation. AB 394 charged the California DHS with determining specific unit-by-unit nurse/patient ratios.

The DHS began an extensive effort to determine the new minimum nurse staffing ratios, with little research to guide them (Kravitz et al., 2002; Lang et al., 2004; Spetz et al., 2000). To help develop the proposed ratios, the DHS commissioned a study by researchers at the University of California, Davis (Kravitz et al., 2002). It also received recommendations about the ratios from stakeholders, ranging from the California Hospital Association (CHA) proposal of a ratio of 1 licensed nurse per 10 patients in medical-surgical units and the California Nurses Association recommendation of 1 517licensed nurse per 3 patients in medical-surgical units. The ratios established by DHS were between those recommended by the CHA and the unions, with a 1 : 6 ratio in medical-surgical units starting January 1, 2004, and a 1 : 5 ratio in medical-surgical units commencing in January 2005. Other units have higher minimum-ratio requirements. The minimum ratios do not replace the requirement that hospitals staff according to a patient classification system (PCS); if a hospital’s PCS indicates that higher staffing is needed, the hospital should staff accordingly.

What Has Happened as a Result of the Ratios?

The implementation of California’s minimum nurse staffing ratio legislation led to legal challenges and state government efforts to expand RN education. It also drove increases in hospital nurse staffing and wages in California. Several studies have found that the ratios are linked to higher nurse satisfaction, but there is little evidence that the regulations improved patient outcomes. Some research has found that there may have been negative impacts on hospitals’ finances and ability to provide charity care.

Legal Challenges

Two days before the ratios went into effect, the CHA filed a lawsuit arguing that the staffing ratios should not apply if a nurse takes a scheduled break or unscheduled restroom visit. The DHS contended that if the ratios were to have any meaning, they must be effective at all times. The judge hearing the case agreed with the DHS in a May 2004 ruling (Berestein, 2004). The second major legal challenge to the ratio regulations came from Governor Arnold Schwarzenegger, who sought to delay the implementation of the stricter ratio of one licensed nurse to five patients scheduled for January 2005 due to the severe shortage of licensed nurses (Rapaport, 2004). The CHA filed suit against the DHS in December 2004 alleging that the emergency order had illegally bypassed the legislature (LaMar, 2005). In early March, a Superior Court judge tentatively ruled that the DHS had indeed not followed the law when issuing the emergency regulation (Salladay & Chong, 2005), and the judge’s decision was finalized in May 2005 (Benson, 2005a, 2005b; Gledhill, 2005).

Expansion of Nursing Education

To assist hospitals in meeting the staffing ratio rules, both former Governor Davis and Governor Schwarzenegger dedicated funds to expanding nursing education and reducing attrition from nursing programs. Between 2004 to 2005 and 2009 to 2010, nursing graduations in California increased by 72%, reaching over 11,500 new RN graduates per year (Spetz, 2013).

Are Hospitals Meeting the Ratios?

The inspection and enforcement mechanisms of the DHS are relatively weak. The DHS does not have the authority to impose fines or monetary penalties on hospitals that are found to violate the ratios, but instead requests and monitors plans submitted by hospitals to remedy the problem. However, other mechanisms do exist to ensure that hospitals adhere to the ratios. First, government payers such as Medicare and Medi-Cal (the state Medicaid program) require that hospitals meet all state and federal regulations and can deny payment to violators. Second, California’s cap on malpractice awards does not apply in cases of negligence, and a hospital could be deemed negligent if it consistently did not adhere to minimum nurse staffing regulations (Robertson, 2004). Third, unions draw public attention to hospitals that do not meet the staffing requirements, resulting in negative publicity for hospitals and increased scrutiny from DHS inspectors. Fourth, labor organizations that represent nurses have sought to incorporate staffing standards in their contract negotiations, with some success (Gordon, 2005; Osterman, 2005).

Several studies of all California hospitals have found that annual average numbers of RN productive hours and nurse staffing ratios in medical-surgical units increased markedly between 2001 and 2006 (Conway et al., 2008; Cook et al., 2012; Mark et al., 2012; Munnich, 2013; Spetz et al., 2009; Spetz et al., 2013). Spetz and colleagues (2009) found that statewide average RN hours per patient day increased 16.2% from 1999 through 2006, to an average of 6.9 hours per patient day. Interviews 518conducted with hospital leaders by a research team at the University of California, San Francisco (UCSF) revealed that many chief nursing officers and other managers said they had hired nurses to meet the ratios, and most noted that it is challenging to adhere to the ratios at all times, including during scheduled breaks (Chapman et al., 2009).

Aiken and colleagues (2010) surveyed nearly 80,000 RNs in California, New Jersey, and Pennsylvania to learn their experiences with staffing, the work environment, and patient care. They found that nurse workloads, measured according to the average number of patients per shift, were lower in California than in New Jersey and Pennsylvania and that over 80% of California nurses reported that their assigned workloads were in compliance with the state’s regulation.

Has the Mix of Staff Changed?

There have been concerns that hospitals may have eliminated support staff positions because of the minimum licensed nurse staffing requirements (Spetz, 2001). Analyses of staffing data collected by the Collaborative Alliance for Nursing Outcomes (CALNOC) suggest that the substitution of licensed nurses for unlicensed staff may be widespread as the increase in RN staffing was much larger than the overall staffing increase among their hospitals (Bolton et al., 2007; Donaldson et al., 2005). In a series of qualitative interviews, some hospital leaders reported that they had laid off ancillary staff to use budgets to hire more RNs (Chapman et al., 2009), and the survey conducted by Aiken and colleagues found that nurses perceived reductions in LVN and aide use (Aiken et al., 2010). However, more recent analyses have measured only a slight decline in LVN staffing (Cook et al., 2012; Spetz et al., 2009; Spetz et al., 2013) and aide staffing (Cook et al., 2012; Spetz et al., 2009).

Have Hospitals Reduced Services and Charity Care?

The California Hospital Association warned that strict minimum nurse/patient ratio requirements would force hospitals to reduce their services. To maintain the minimum ratios, hospitals might reschedule procedures, close selected units and beds, or shut their doors entirely. However, there have been few verified reports of the minimum nurse/patient ratios causing permanent closures of inpatient hospital units or beds. There is some indication that there was lower growth in the provision of uncompensated care services among hospitals on which the regulations had the greatest impact on staffing levels (Reiter et al., 2011).

Have Hospitals Suffered Financial Losses?

Since 1999, California hospitals have been financially buffeted by numerous factors, including changes in Medicare and Medicaid payment policy and requirements that hospital facilities meet seismic standards through retrofitting or new construction (Spetz et al., 2009). Thus, it is difficult to determine whether the staffing regulations had any discernable effect on hospital finances. Qualitative evidence reported that hospital CEOs absorbed the costs of the ratios by reducing other budget areas, and some hospitals were able to obtain higher insurance reimbursement rates to cover additional staff expenses (Spetz et al., 2009). However, one analysis found that hospital prices rose even more between 1999 and 2005 than could be explained by labor cost increases that resulted from the nurse staffing ratios alone (Antwi, Gaynor, & Vogt, 2009).

In an analysis of hospital financial data, Cook (2009) found no significant change in total annual labor costs for licensed nurses, total annual hospital costs, or hospital prices. Reiter and colleagues (2012) used data from Medicare cost reports to explore whether changes in financial status differed between California hospitals that had higher versus lower preregulation staffing levels, and between California and other states. They found that relative to hospitals outside California, operating margins for California hospitals with lower preregulation staffing levels declined, and operating expenses increased significantly.

Did Wages for Nurses Increase?

In theory, when the demand for workers rises more rapidly than the supply, wages should rise. Two studies have examined whether growth in the hiring of RNs caused by the staffing regulations is linked 519to more rapid growth in RN wages. One study found that wage growth among urban RNs in California was as much as 12% higher than in other states (Mark, Harless, & Spetz, 2009). A more recent analysis measured a 4.9% increase in RN wages between 2000 and 2007 with one dataset, and no increase at all with a different dataset (Munnich, 2013).

Are Nurses More Satisfied?

Advocates of staffing ratio regulations link improved staffing to nurse satisfaction and argue that greater nurse satisfaction will reduce nurse turnover and lead to better patient outcomes (California Nurses Association, 2009; Public Policy Associates, 2004). An analysis of statewide nurse survey data found that there were significant improvements in overall job satisfaction among hospital-employed RNs between 2004 and 2006 (Spetz, 2008). Nurse satisfaction also increased with respect to the adequacy of RN staff, time for patient education, benefits, and clerical support.

Aiken and colleagues (2010) also found in their survey of nurses in three states that RNs in California were more satisfied with their working conditions. Nurses in California were significantly more likely to report that their workload was reasonable and allowed them to spend adequate time with patients and that they were able to take breaks during the workday. Nurses with lower workloads were significantly less likely to report that they received complaints from families, faced verbal abuse, were burned out, were dissatisfied, felt quality of care was poor, or were looking for new jobs.

Did the Ratios Improve the Quality of Care?

One of the main purposes of California’s minimum staffing legislation was to improve the quality of patient care. However, to date there is no convincing evidence that patient safety or the quality of care has improved. In the first paper published on this subject, rates of patient falls and hospital-acquired pressure ulcers reported to CALNOC between 2002 and 2004 were analyzed for 68 hospitals, and it was found that there was no statistically significant change that could be attributed to the ratios (Donaldson et al., 2005). A follow-up study of data through 2006 confirmed these results (Bolton et al., 2007). These analyses had two main shortcomings: They included only a subset of California’s hospitals and the two outcomes examined might not be very sensitive to changes in licensed nurse staffing. Studies that examine whether licensed nurse staffing affects rates of hospital-acquired pressure ulcers and postoperative hip fractures from a patient fall have produced mixed findings (Agency for Healthcare Research and Quality, 2005).

Aiken and colleagues linked their survey data to secondary data on patient outcomes collected by state government agencies (Aiken et al., 2010) and found that in all three states studied, higher nurse staffing levels were associated with lower rates of 30-day inpatient mortality and failure-to-rescue. These relationships were stronger in California than in other states. However, this analysis cannot confirm that the staffing regulations directly caused changes in patient outcomes. Research based on a single year of data does not measure the effect of changes in policy or practice on changes in patient outcomes. Although the responses of nurses regarding the patient safety environment suggest that the lower workloads in California are associated with more positive nurse perceptions of patient safety, these perceptions may not lead to actual improvements in patient outcomes. It’s important to note that the analysis of patient outcomes in this study was limited to two outcomes.

Several newer studies have used multiple years of statewide data and examined a wider variety of outcomes. For example, Spetz and colleagues examined OSHPD patient discharge data for all nonfederal, general acute care California hospitals from 1999 through 2006 but could not associate improvements in outcomes to the implementation of the ratios (Spetz et al., 2009). In a more rigorous analysis of OSHPD data from 2001 to 2006, Cook and colleagues (2012)found no association between changes in nurse staffing and changes in pressure ulcer rates or failure-to-rescue a patient after a 520complication. Using similar methods, Spetz and colleagues (2013) examined six patient safety indicators using OSHPD data from 2000 to 2006 and found that growth in registered nurse staffing was associated with an improvement for only one outcome, mortality following a complication. They also analyzed whether the average length of stay declined among patients who experienced adverse events to explore the possibility that improved surveillance in better-staffed hospitals might reduce the severity of any complications. They found growth in staffing was significantly associated with reduced length of stay for only one patient safety indicator: select infections due to medical care.

The most comprehensive analysis of the impact of California’s regulations on patient outcomes was published by Mark and colleagues (2012). Using patient discharge data from California and 12 comparison states they examined whether differences in staffing changes between California and other states were associated with different patient out­come trajectories. Their analysis also considered differences between hospitals with high preregulation staffing as compared with low preregulation staffing. They found that failure-to-rescue following a complication decreased significantly in some California hospitals, and infections caused by medical care increased significantly in some California hospitals as compared with comparable hospitals in other states. There were no statistically significant changes in either respiratory failure or postoperative sepsis.

Together, this research indicates that California’s regulations did not systematically improve the quality of patient care, although there remains a need for more research on this topic. The outcomes examined thus far have been relatively limited, and it is possible that patient care improvements will be found in other areas such as medication safety. It also is possible that changes in patient outcomes caused by the staffing ratios occur over a longer period of time. However, examining and interpreting data over a longer period of time will be complicated by the fact that many health systems and hospitals have established quality improvement programs in response to increased public attention to medical errors and patient outcomes.

What Next?

One remaining issue central to the debate about minimum nurse/patient ratios has yet to be addressed: What was the total cost of the ratio regulations?

Cost of the Ratios

Any positive impact of minimum staffing ratios should be weighed against their cost (Donaldson & Shapiro, 2011). As of 2014, these costs had not been accurately quantified. A careful accounting of the extent to which increases in nurse staffing were necessitated by the ratios, and the cost of any such increases, is necessary. Moreover, it is important to quantify the value of other investments hospitals might have made if they were not required to adhere to the staffing ratios. A hospital may have delayed implementation of a new infection-control system that would have reduced infection rates, and such opportunity costs should be included as part of the overall cost of the staffing regulations.

Legislative Options

The only federal regulation that directly referred to nurse staffing levels in hospitals at the time of writing is the 42 Code of Federal Regulations (42CFR 482.23[b]), which requires hospitals that participate in Medicare to have “adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed” (American Nurses Association, 2009). In 2009, Sen. Barbara Boxer (D-CA) introduced S 1031, and Rep. Janice Schakowsky (D-IL) introduced H.R. 2273, both of which would have required that hospitals implement nurse-to-patient staffing plans and meet minimum RN nurse-to-patient ratios for specified patient care units. These bills did not pass, although the bills were reintroduced in 2011 and 2013.

Some states have pursued their own staffing regulations. State regulations generally take one or more of three approaches: a requirement that hospitals develop and implement nurse staffing plans with direct input from nurses, requiring 521public disclosure of staffing levels, and/or establishment of fixed minimum staffing ratios. California is the only state to have implemented a law using this third strategy, although similar legislation has been proposed in other states including Illinois, Kentucky, Maryland, New Jersey, New York, Vermont, and West Virginia.

Some states have opted to develop staffing regulations that offer hospitals more flexibility than fixed minimum staffing ratios. Connecticut, Illinois, Nevada, Ohio, Oregon, Texas, and Washington have signed into law requirements that hospitals implement and enforce a written nurse staffing policy. In most of these states, the staffing policy must be developed by a committee that includes staff nurses. Rhode Island requires that hospitals submit a “core staffing plan” to the state department of health annually, with specific staffing for each patient care unit and each shift (American Nurses Association, 2013).

The third, and least binding, approach to nurse staffing regulation is to mandate reporting of staffing ratios to the public or to a regulatory agency. In New York, for example, facilities must make available to the public information about nurse staffing and patient outcomes. Specific adverse events, such as medication errors and decubitus ulcers, are considered reportable information under this law. Other states with public reporting requirements are Illinois, New Jersey, Rhode Island, and Vermont. New Jersey’s regulation mandates that hospitals post daily staffing information for each unit and shift and provide these data to state regulators, and in 2009, New York added a similar posting requirement to its regulations.

Even without new legislation, hospitals are likely to continue to focus on nurse staffing improvements as the evidence suggests that nurse staffing is a good financial investment in quality improvement (Rothberg et al., 2005). More research is needed, however, to determine whether the lack of measured benefit from California’s regulation is caused by limitations of prior research or indicative of an actual lack of impact. If California’s regulation can one day be shown to have improved patient outcomes at an acceptable cost, it will be easier for other states to follow in California’s footsteps.

Discussion Questions

1. It is not clear from the research conducted thus far whether California’s staffing regulations have improved patient outcomes. However, several studies have found that nurse satisfaction has improved and that nurses perceive that they are providing better care. Is improving nurse satisfaction a sufficient reason to establish this type of regulation?

2. Several studies have suggested that hospitals responded to the staffing regulations by reducing staffing of non-RN personnel. What might be the benefits and consequences of reducing non-RN staffing?

3. Are regulations that require staffing committees likely to effectively address concerns about inadequate nurse staffing? What about laws that require public reporting of staffing levels?

References

Agency for Healthcare Research and Quality. AHRQ quality indicators—Guide to patient safety indicators, Version 2.1, Revision 3. [AHRQ Publication No. 03-R203] Agency for Healthcare Research and Quality: Rockville, MD; 2005.

Aiken LH, Sloane DM, Cimiotti JP, Clarke SP, Flynn L, Seago JA, et al. Implications of the California nurse staffing mandate for other states. Health Services Research. 2010;45(4):904–921.

Aiken LH, Sochalski J, Anderson GF. Downsizing the hospital nursing workforce. Health Affairs. 1996;15(4):88–92.

American Nurses Association. Nurse staffing plans and ratios. [Retrieved from] www.nursingworld.org/MainMenuCategories/Policy-Advocacy/State/Legislative-Agenda-Reports/State-StaffingPlansRatios; 2009.

American Nurses Association. Nurse staffing plans and ratios. [Retrieved from] www.nursingworld.org/MainMenuCategories/Policy-Advocacy/State/Legislative-Agenda-Reports/State-StaffingPlansRatios; 2013.

Antwi YA, Gaynor M, Vogt WB. A bargain at twice the price? California hospital prices in the new millennium. National Bureau of Economic Research Working Paper 15134. [Retrieved from] www.nber.org/papers/w15134.pdf; 2009.

Associated Press. Massachusetts hospital staffing law takes effect. Washington Times. 2014 [Retrieved from] www.washingtontimes.com/news/2014/oct/1/massachusetts-hospital-staffing-law-takes-effect/.

Benson, C. (2005a). Final ruling backs higher nurse ratio. Sacramento Bee, A5.

Benson, C. (2005b). Judge orders launch of nurse staffing rule. Sacramento Bee, A4.

Berestein, L. (2004). Industry group contends measure may hurt patients. San Diego Union-Tribune, C3.

Bolton LB, Aydin CE, Donaldson N, Brown DS, Sandhu M, Fridman M, et al. Mandated nurse staffing ratios in California: A comparison of staffing and nursing-sensitive outcomes pre- and post-regulation. Policy, Politics, & Nursing Practice. 2007;8(4):238–250.

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California Nurses Association. The ratio solution: CNA/NNOC’s RN-to-patient ratios work—Better care, more nurses. California Nurses Association: Oakland, CA; 2009.

Chapman S, Spetz J, Kaiser J, Seago JA, Dower C. How have mandated nurse staffing ratios impacted hospitals? Perspectives from California hospital leaders. Journal of Healthcare Management. 2009;54(5):321–336.

Conway PH, Konetzka RT, Zhu J, Volpp KG, Sochalski J. Nurse staffing ratios: Trends and policy implications for hospitalists and the safety net. Journal of Hospital Medicine. 2008;3(3):103–199.

Cook A. Is there a nurse in the house? The effect of nurse staffing increases on patient health outcomes. [Unpublished doctoral dissertation] Carnegie Mellon University: Pittsburgh, PA; 2009.

Cook A, Gaynor M, Stephens M Jr, Taylor L. The effect of a hospital nurse staffing mandate on patient health outcomes: Evidence from California’s minimum staffing regulation. Journal of Health Economics. 2012;31(2):340–348.

Donaldson N, Bolton LB, Aydin C, Brown D, Elashoff J, Sandhu M. Impact of California’s licensed nurse-patient ratios on unit-level nurse staffing and patient outcomes. Policy, Politics & Nursing Practice. 2005;6(3):1–12.

Donaldson N, Shapiro S. Impact of California mandated acute care hospital nurse staffing ratios: A literature synthesis. Policy, Politics and Nursing Practice. 2011;11(3):184–201.

Gledhill L. Governor loses to nurses in ruling: He illegally blocked law that set staffing ratios, judge says. San Francisco Chronicle. 2005 [A1].

Gordon R. Nurses pact ready for vote: Plan would raise pay, offer higher signing bonus. San Francisco Chronicle. 2005 [B4].

Kane RL, Shamliyan T, Mueller C, Duval S, Wilt TJ. Nursing staffing and quality of patient care. Evidence Report/Technology Assessment (Full Rep). 2007;(151):1–115 [Retrieved from] archive.ahrq.gov/downloads/pub/evidence/pdf/nursestaff/nursestaff.pdf.

Kilborn, P. T. (1999). Current nursing shortage more serious than those of the past. New York Times, A14.

Kravitz R, Sauve MJ, Hodge M, Romano PS, Maher M, Samuels S, et al. Hospital nursing staff ratios and quality of care. University of California, Davis: Davis, CA; 2002.

LaMar, A. (2005). Nurses protest delay of lower patient ratio, 1500 rally at Capitol to fight 3-year wait. San Jose Mercury News, B2.

Lang TA, Hodge M, Olson V, Romano PS, Kravitz RL. Nurse-patient ratios: A systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. Journal of Nursing Administration. 2004;34(7–8):326–337.

Mark B, Harless DW, Spetz J. California’s minimum nurse staffing legislation and nurses’ wages. Health Affairs. 2009;28(2):w326–w334.

Mark B, Harless DW, Spetz J, Reiter KL, Pink GH. California’s minimum nurse staffing legislation: Results from a natural experiment. Health Services Research. 2012;48(2 pt1):435–454.

Munnich E. The labor market effects of California’s minimum nurse staffing law. Health Economics. 2013;23(8):935–950.

Osterman, R. (2005). Hospitals accept nursing ratios. Sacramento Bee, D1.

Public Policy Associates. The business case for reducing patient-to-nurse staff ratios and eliminating mandatory overtime for nurses. Michigan Nurses Association: Lansing, MI; 2004.

Rapaport, L. (2004). State eases nurse-staffing law until 2008—Hospital closings and delays in patient care prompt move. Sacramento Bee, A1.

Reiter KL, Harless DW, Pink GH, Mark B. Minimum nurse staffing legislation and the financial performance of California hospitals. Health Services Research. 2012;47(3 pt1):1030–1050.

Reiter KL, Harless DW, Pink GH, Spetz J, Mark B. The effect of minimum nurse staffing legis­lation on uncompensated care provided by California hospitals. Medical Care Research and Review. 2011;67(6):694–706.

Robertson K. New nurse law fails to cause emergency. Sacramento Business Journal. 2004;21(9):1.

Rothberg MB, Abraham I, Lindenauer PK, Rose DN. Improving nurse-to-patient staffing ratios as a cost-effective safety intervention. Medical Care. 2005;43(8):785–791.

Salladay, R., & Chong, J.-R. (2005). Judge backs nurses over staffing. The Los Angeles Times, B1.

Spetz J. Hospital use of nursing personnel: Has there really been a decline? Journal of Nursing Administration. 1998;28(3):20–27.

Spetz J. What should we expect from California’s minimum nurse staffing legislation? Journal of Nursing Administration. 2001;31(3):132–140.

Spetz J. Nurse satisfaction and the implementation of minimum nurse staffing regulations. Policy, Politics & Nursing Practice. 2008;9(1):15–21.

Spetz J. Forecasts of the registered nurse workforce in California. Board of Registered Nursing: Sacramento, California; 2013.

Spetz J, Chapman S, Herrera C, Kaiser J, Seago JA, Dower C. Assessing the impact of California’s nurse staffing ratios on hospitals and patient care. California HealthCare Foundation: Oakland, CA; 2009.

Spetz J, Harless DW, Herrera C-N, Mark BA. Using minimum nurse staffing regulations to measure the relationship between nursing and hospital quality of care. Medical Care Research and Review. 2013;70(4):380–399.

Spetz J, Seago JA, Coffman J, Rosenoff E, O’Neil E. Minimum nurse staffing ratios in California acute care hospitals. California HealthCare Foundation: San Francisco; 2000.

Unruh L, Fottler M. Patient turnover and nursing staff adequacy. Health Services Research. 2006;41(2):599–612.

Wunderlich GS, Sloan FA, Davis CK. Nursing staff in hospitals and nursing homes: Is it adequate?. National Academies Press: Washington, D.C.; 1996.

Online Resources

American Nurses Association: Nurse Staffing Plans and Ratios.

www.nursingworld.org/MainMenuCategories/Policy-Advocacy/State/Legislative-Agenda-Reports/State-StaffingPlansRatios.

National Nurses United: National Campaign for Safe RN-to-Patient Staffing Ratios.

www.nationalnursesunited.org/issues/entry/ratios.

Robert Wood Johnson Foundation: The Impact of Nurse Staffing on Hospital Quality.

thefutureofnursing.org/resource/detail/impact-nurse-staffing-hospital-quality.

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Frameworks for Action in Policy and Politics

Eileen T. O’Grady, Diana J. Mason, Freida Hopkins Outlaw, Deborah B. Gardner

“The most common way people give up their power is by thinking they don’t have any.”

Alice Walker

March 31, 2013 marked an important deadline in the implementation of landmark legislation, the Affordable Care Act (ACA)1, also known as Obamacare. By that date those eligible to enroll for insurance coverage through the marketplace had to purchase a plan if they were to avoid a 2015 tax penalty of $95 or 1% of their annual income (whichever was higher). Amid a frenzy of media attention, an estimated 8 million people signed on for coverage during open enrollment—the period between October 2012 and the deadline—exceeding the revised target of 6.5 million (Kennedy, 2014). And the numbers kept increasing, as millions more enrolled in Medicaid or the Children’s Health Insurance Program (known as CHIP) (Centers for Medicare and Medicaid Services [CMS], 2014).

Nurses were essential to these enrollments. For example, Adriana Perez, PhD, ANP, RN, an assistant professor at Arizona State University College of Nursing, used her role as president of the Phoenix Chapter of the National Association of Hispanic Nurses to organize town hall meetings with Spanish-speaking state residents to explain the ACA and encourage enrollment among those with a high rate of un- or under-insurance. She also developed a training model in partnership with AARP-Arizona and used it to empower Arizona nurses to educate multicultural communities on the basic provisions of the ACA. Through many such initiatives, the United States reduced the number of uninsured people by over 10 million in 2014; the number is projected to be 20 million by 2016 (Congressional Budget Office [CBO], 2014).

However, access to coverage does not necessarily mean access to care, nor does it ensure a healthy population. Health care access means having the ability to receive the right type of care when needed at an affordable price. The U.S. health care system is grounded in expensive, high-tech acute care that does not produce the desired outcomes we ought to have and too often damages instead of heals (National Research Council, 2013). Despite spending more per person on health care than any other nation, a comparative report on health indicators by the Organisation for Economic Co-operation and Development (2013) shows that the United States performs worse than other nations on life 2expectancy at birth for both men and women, infant mortality rate, mortality rates for suicide and cardiovascular disease, the prevalence of diabetes and obesity in children, and other indicators.

In 1999, the Institute of Medicine (IOM) issued a report, To Err is Human: Building a Safer Health System, which estimated that health care errors in hospitals were the fifth leading cause of death in the U.S. (IOM, 1999). By 2011, preventable health care errors were estimated to be the third-leading cause of death (Allen, 2013; James, 2013). The ACA includes elements that can begin to create a high-performing health care system, one accountable for the provision of safe care, as well as improved clinical and financial outcomes. It aims to move the health care system in the direction of keeping people out of hospitals, in their own homes and communities, with an emphasis on wellness, health promotion, and better management of chronic illnesses.

For example, the ACA uses financial penalties to prod hospitals to reduce 30-day readmission rates. It also provides funding for demonstration projects that improve “transitional care,” services that help patients and their family caregivers to make a smoother transition from hospital or nursing home to their own homes to help reduce preventable hospital readmissions. Based, in part, on research by Mary Naylor, PhD, RN, FAAN, professor of nursing at the University of Pennsylvania School of Nursing, these demonstrations are stimulating creative methods of accountability across health care settings, with most using nurses for care coordination and transitional care providers (CMS, n.d.; Coalition for Evidence-Based Policy, n.d.; Naylor et al., 2011).

Upstream Factors

Promoting health requires more than a high-performing health care system. First and foremost, health is created where people live, work, and play. It is becoming clear that one’s health status may be more dependent on one’s zip code than on one’s genetic code (Marks, 2009). Geographic analyses of race and ethnicity, income, and health status repeatedly show that financial, racial, and ethnic disparities persist (Braveman et al., 2010). Individual health and family health are severely compromised in communities where good education, nutritious foods, safe places to exercise, and well-paying jobs are scarce (Halpin, Morales-Suárez-Varela, & Martin-Moreno, 2010). Creating a healthier nation requires that we address “upstream factors”; the broad range of issues, other than health care, that can undermine or promote health (also known as “social determinants of health” or “core determinants of health”) (World Health Organization [WHO], n.d.). Upstream factors promoting health include safe environments, adequate housing, and economically thriving communities with employment opportunities, access to affordable and healthful foods, and models for addressing conflict through dialogue rather than violence. According to Williams and colleagues (2008), the key to reducing and eliminating health disparities, which disproportionately affect racial and ethnic minorities, is to provide effective interventions that address upstream factors both in and outside of health care systems. Upstream factors have a large influence on the development and progression of illnesses (Williams et al., 2008). The core determinants of health will be used to further elucidate and make concrete the wider, more comprehensive set of upstream factors that can improve the health of the nation by reducing disparities. Figure 1-1 depicts the core determinants of health developed by the Canadian Forces Health Services Group.

FIGURE 1-1 Surgeon General’s Mental Health Strategy: Canadian Forces Health Services Group—An Evolution of Excellence. (From www.forces.gc.ca/en/about-reports-pubs-health/surg-gen-mental-health-strategy-ch-2.page.)

A focus on such factors is essential for economic and moral reasons. Even in the most affluent nations, those living in poverty have substantially shorter life expectancies and experience more illness than those who are wealthy, with high costs in human and financial terms (Wilkinson & Marmot, 2003). To date however, most of the focus on reducing disparities has been on health policy that addresses access, coverage, cost, and quality of care once the individual has entered the health care system–despite the fact that for more than a decade research has established that most health care problems begin long before people seek medical care (Williams et al., 2008). Thus, changing the paradigm requires knowledge about the political aspects of the social determinates of health and the broader 3core determinants. Political aspects of the social determinants of health appear in Box 1-1.

 

Box 1-1

 

Political Aspects of the Social Determinants of Health

• The health of individuals and populations is determined significantly by social factors.

• The social determinants of health produce great inequities in health within and between societies.

• The poor and disadvantaged experience worse health than the rich, have less access to care, and die younger in all societies.

• The social determinants of health can be measured and described.

• The measurement of the social determinants provides evidence that can serve as the basis for political action.

• Evidence is generated and used in a continuous cycle of evidence production, policy development, implementation, and evaluation.

• Evidence of the effects of policies and programs on inequities can be measured and can provide data on the effectiveness of interventions.

• Evidence regarding the social determinants of health is insufficient to bring about change on its own; political will combined with evidence offers the most powerful strategy to address the negative effects of the social determinants.

 

Adapted from National Institute for Health and Clinical Excellence. (2007). The Social Determinants of Health: Developing an Evidence Base for Political Action. Final report to the World Health Organization Commission on the Social Determinants of Health. Lead authors: J. Mackenbach, M. Exworthy, J. Popay, P. Tugwell, V. Robinson, S. Simpson, T. Narayan, L. Myer, T. Houweling, L. Jadue, and F. Florenza.

The ACA begins to carve out a role for the health care system in addressing upstream factors. For example, the law requires that nonprofit hospitals demonstrate a “community benefit” to receive federal tax breaks. Hospitals must conduct a community health assessment, develop a community health improvement plan, and partner with others to implement it. This aligns with a growing emphasis on population health: the health of a group, whether defined by a common disease or health problem or by geographic or demographic characteristics (Felt-Lisk & Higgins, 2011).

Consider the 11th Street Family Health Services. Located in an underserved neighborhood in North Philadelphia, this federally qualified, nurse-managed health center (NMHC) was the brainchild of public health nurse Patricia Gerrity, PhD, RN, FAAN, a faculty member at Drexel University School of Nursing. She recognized that the leading health problems in the community were diabetes, obesity, heart failure, and depression. Working with a community advisory group, Gerrity realized that the health center had to address nutrition as an “upstream factor” that could improve the health of those living in the community. With no supermarket in the neighborhood until 2011, she invited area farmers to come to the neighborhood as part of a farmers’ market. She also created a community vegetable garden maintained by the local youth. And area residents were invited to attend nutrition classes on culturally relevant, healthful cooking. 11th Street Family Health Services is one of over 200 NMHCs in the United States that have improved clinical and financial outcomes by addressing the needs of individuals, families, and communities 4(American Academy of Nursing, n.d., b). The ACA authorizes continued support for these centers, although the law does not mandate they be funded. Congress would have to appropriate funding for NMHCs but has not done so. (See Chapter 34 for a more detailed discussion of NMHCs.)

The ACA may not go far enough in shifting attention to the health of communities and populations. One approach gaining notice is that of “health in all policies,” the idea that policymakers consider the health implications of social and economic policies that focus on other sectors, such as education, community development, tax codes, and housing (Leppo et al., 2013; Rudolph et al., 2013). As health professionals who focus on the family and community context of the patients they serve, nurses can help to raise questions about the potential health impact of public policies.

Nursing and Health Policy

Health policy affects every nurse’s daily practice. Indeed, health policy determines who gets what type of health care, when, how, from whom, and at what cost. The study of health policy is an indispensable component of professional development in nursing, whether it is undertaken to advance a healthier society, promote a safer health care system, or support nursing’s ability to care for people with equity and skill. Just as Florence Nightingale understood that health policy held the key to improving the health of poor Londoners and the British military, so are today’s nurses needed to create compelling cases and actively influence better health policies at every level of governance. With national attention focused on how to transform health care in ways that produce better outcomes and reduce health care costs, nursing has an unprecedented opportunity to provide proactive and visionary leadership. Indeed, the Institute of Medicine’s landmark report, The Future of Nursing: Leading Change, Advancing Health (2011), calls for nurses to be leaders in redesigning health care. But will nurses rise to this occasion?

Health care opinion leaders in a 2010 poll iden­tified two reasons nurses would fall short of influencing health care reform: too many nurses do not want to lead, and with over 120 national organizations, nursing often fails to present a united front (Gallup, 2010). As the largest health care profession, nursing has great potential power. Yet, similar to many professions, it has struggled to collaborate within its ranks or with other groups on pressing issues of health policy. The IOM report has provided a rallying point for nursing organizations to work together and engage other stakeholders to advance its recommendations.

Reforming Health Care

The Triple Aim

In 2008, Don Berwick, MD, and his colleagues at the Institute for Healthcare Improvement (IHI) first described the Triple Aim of a value-based health care system (Berwick, Nolan, & Whittington, 2008): (1) improving population health, (2) improving the patient experience of care, and (3) reducing per capita costs. This framework aligns with the aims of the Affordable Care Act.

The Triple Aim represents a balanced approach: by examining a health care delivery problem from all three dimensions, health care organizations and society can identify system problems and direct resources to activities that can have the greatest impact. Looking at each of these dimensions in isolation prevents organizations from discovering how a new objective, decreasing readmission rates to improve quality and reduce costs, for instance, could negatively impact the third goal of population health, as scarce community resources are directed to acute care transitions and unin­tentionally shifted away from prevention activities. Solutions must also be evaluated from these three interdependent dimensions. The Triple Aim compels delivery systems and payors to broaden their focus on acute and highly specialized care toward more integrated care, including primary and preventive care (McCarthy & Klein, 2010).

The IHI (n.d.) identified these components of any approach seeking to achieve the Triple Aim:

• A focus on individuals and families

• A redesign of primary care services

• Population health management

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• A cost-control platform

• System integration and execution

Note that these possess the goal of creating a high-performing health care system but do not focus on geographic communities or social determinants per se. However, these two concepts can be incorporated into the Triple Aim of improving the health of populations and reducing health care costs.

The Triple Aim is easy to understand but challenging to implement because it requires all pro­viders, including nurses, to broaden their focus from individuals to populations. The success of the nursing profession’s continued evolution will hinge on its ability to take on new roles, more cogently and creatively engaging with patients and stepping into executive and leadership roles in every sector of heath care. But it must do so within an interprofessional context, leading efforts to break down health professions’ silos and hierarchies and keeping the patient and family at the center of care.

The ACA and Nursing

The ACA is arguably the most significant piece of social legislation passed in the United States since the enactment of Medicare and Medicaid in 1965. Implementation continues to be a vexing process and a political flashpoint. It has defined the ideologies of U.S. political parties, and yet the public remains largely uninformed and misinformed about the legislation; 3 years after its passage, 4 out of 10 Americans were still unaware of many of its provisions and unsure that the ACA had become law (The Henry J. Kaiser Family Foundation, 2013). (Chapter 19 provides a thorough description of the ACA.) The ACA is over 2000 pages long, which reflects the complexity of creating a new health care infrastructure that addresses a wide array of issues including patient protections, health insurance industry reforms, and workforce development, to name a few. Newer systems of care are emphasized in the ACA that link patient outcomes to costs incurred in treatment and to high-value health systems. The legislation can be categorized into four main cornerstones (Figure 1-2).

FIGURE 1-2 Four cornerstones of reform. (From O’Grady, E. T., & Johnson, J. [2013]. Health policy issues in changing environments. In A. Hamric, C. Hanson, D. Way, & E. O’Grady [Eds.], Advanced practice nursing: An integrative approach [5th ed.]. St. Louis, MO: Elsevier-Saunders.)

The ACA was born out of national macroeconomic concerns. The United States spent $2.7 trillion in 2011, or $8680 per person, on health care; a rate higher than inflation that is expected to consume nearly 20% of the gross domestic product by 2020 (CMS, 2013). With businesses having to spend such large amounts on health care for employees, the United States cannot compete in the global economy. Furthermore, such high health care expenses divert funds away from addressing the upstream factors that could prevent the need for costly acute care. Although previous presidents in the past 50 years tried unsuccessfully to pass health care reform legislation, President Obama was elected at a time when many Americans agreed that the United States could no longer afford to maintain a health care system that had neither spending controls nor accountability for improving clinical outcomes. The ACA was an outgrowth, in part, to “bend the cost curve,” or reduce the rate of increase in health care spending (Cutler, 2010).

To improve the health of the public and reduce health care costs, health promotion and wellness, disease prevention, and chronic care management must be built into the foundation of the health care system (Katz, 2009; Wagner, 1998; Woolf, 2009). At 6the same time, acute care must use fewer resources, be made safer, and produce better outcomes (Conway, Mostashari, & Clancy, 2013).

Nurses are important players in shifting the focus of health care to one that prevents illnesses, promotes health, and coordinates care. Nurses have been performing in such roles without naming or measuring their activities for decades. But there are exceptions. The American Academy of Nursing’s Raise the Voice Campaign (American Academy of Nursing, n.d., a) has identified nurses who have developed innovative models of care for which there are good clinical and financial outcome data. Known as “Edge Runners,” these nurses have demonstrated that nursing’s emphasis on care coordination, health promotion, patient- and family-centeredness, and the community context of care provides evidence-based models that can help to transform the health care system.

The ACA presents many opportunities for nurses to test new models of care that have already shown promise for improving health outcomes and the experience of health care, while lowering costs. The Center for Medicare and Medicaid Innovation (CMMI) was authorized to spend $10 billion over a decade to pilot-test programs that may improve the safety and quality of care. For example, under the Bundled Payments for Care Improvement Initiative, health systems will enter into payment arrangements that include financial and performance accountability for episodes of care. Currently being studied, an episode of care includes the inpatient stay and all related services during the episode up to 90 days after hospital discharge. These models may lead to higher quality, more coordinated care at a lower cost to Medicare. If the program is successful in achieving these outcomes, they are authorized to launch the program nation-wide.

If these can be shown to achieve the Triple Aim, the ACA authorizes the Secretary of the U.S. Department of Health and Human Services to put these programs in place permanently. The CMMI provides opportunities for nurse leaders and nurse researchers to demonstrate new methods of improving care in cost-effective ways. In addition, the ACA created the Patient-Centered Outcomes Research Institute (PCORI) with $3.5 billion to support comparative-effectiveness research that examines the outcomes that matter to consumers. Nurses serve on the governing board and review panels of PCORI. It provides nurses with opportunities to compare nursing interventions, head-to-head or with medications or other treatments that have sufficient evidence.

The following examples illustrate how nursing is embedded in the four cornerstones of reform. Some of these examples address only one cornerstone; others address all four.

1. Create Value.

NMHCs are operated by advanced practice registered nurses (APRNs), primarily nurse practitioners (NPs). These clinics are often associated with a school, college, university, department of nursing, federally qualified health center, or an independent nonprofit health care agency. Managed by APRNs, NMHCs are staffed by an interprofessional team that may include physicians, social workers, public health nurses, psychiatric mental health nurses at the generic and advanced levels, and behavioral therapists. Barkauskas and colleagues (2011) found that quality measures for NMHCs compared positively with national benchmarks, particularly in chronic disease management. The founders of several NMHCs have been designated Edge Runners, including Patricia Gerrity of the 11th Street Family Health Service, as described earlier. NMHCs serve as critical access points for keeping patients out of the emergency room and hospitals, saving millions of dollars annually (Hansen-Turton et al., 2010).

2. Coordinate Care.

The patient-centered “medical home” or “health home”2 (PCMH) model was designed to satisfy patients’ needs and to improve care access (e.g., through extended office hours and increased communication between providers and patients via e-mail and telephone), 7increase care coordination, and enhance overall quality, while simultaneously reducing costs. The medical home relies on a one-stop-shopping approach by a team of providers, such as physicians, nurses, nutritionists, pharmacists, and social wor­kers, to meet a patient’s health care needs. Peikes and colleagues (2012) found that the PCMH model’s attention to the whole person across care settings (such as from hospital to home) may improve physical and behavioral health, access to community-based social services, and management of chronic conditions. A number of NMHCs have achieved PCMH designation by the National Committee on Quality Assurance.

3. Payment Reform.

Bundling payments and paying for care coordination, including through “accountable care organizations” (ACOs), are examples of payment reform. ACOs are similar to integrated delivery systems that combine services across health care settings and focus on ways to improve care delivery and outcomes under a bundled payment plan. Bundling payments allows for reimbursement of multiple services provided during an episode of care, rather than the traditional fee-for-service payments for each service or procedure for a single illness. ACOs differ from health maintenance organizations (HMOs) in that they are not incentivized to cut services but rather to keep people healthy. Indeed, one of the major differences between HMOs in the 1990s and ACOs today is that the latter are held to a higher standard of measuring, reporting, and making transparent the process and outcome indicators of quality. Each ACO has to have a minimum of 5000 Medicare patients (population health); if the ACO demonstrates that it keeps people healthy and saves Medicare money, those savings are “shared” with the ACO. Nurses are central to preventing complications in hospitalized patients, ensuring smooth transitions to home, and coaching the patient and family caregivers in self-care and health-promoting behavioral changes. As such, they are a vital component of ACO success.

But payment reform is proving to be challenging. The CMMI, authorized under the ACA, initially funded 31 “pioneer” ACOs. By mid-2014, only 22 remained, mostly because of difficulty in managing payment to the various entities in the ACO’s net­work. Nonetheless, there is some consensus that the fee-for-service payment system encourages overtreatment (unnecessary and costly care) and must be replaced (Cutler, 2010; Gibson & Singh, 2012).

4. Improve Access to Coverage.

The ACA does not guarantee health insurance coverage for all, including undocumented immigrants, but, by 2017, it will cover up to 30 million of the 45 million who were uninsured when the bill was signed in 2010 (89% of the total nonolder adult population; 92% of nonolder adult American citizens) (Congressional Budget Office [CBO], 2014). It makes it illegal for insurance companies to deny coverage to people with preexisting conditions, to drop people once they acquire a costly illness, or to apply annual and lifetime caps on coverage. As the demand for health care surges, it is expected that APRNs will be positioned to provide much of the needed primary care, creating the need for APRNs to practice to the full extent of their education and training. Barriers preventing such practice include mandated physician supervision or collaboration in two thirds of states, insurers refusing to credential or impanel APRNs, Medicare requirements for physicians—rather than NPs—to order referrals to home care and hospice, and other local, state, and national policies that limit APRN practice.

Access to coverage does not ensure that people will have access to care. There is a lack of primary care physicians (PCPs) serving the poor, in both rural and urban regions; approximately 210,000 PCPs currently practice, and it has been estimated that another 52,000 will be needed by 2025 (Petterson et al., 2012). This shortfall has led to the development of the APRN role. A workforce analysis center at the Health Resources and Services Administration reported that if primary care NPs and physician assistants (PAs) are fully integrated into a health care delivery system that emphasizes team-based care, the projected shortage of PCPs would be “somewhat alleviated” by 2020 (U.S. Department of Health and Human Services, 2013).

Community-based health care centers will be expanded in areas where there are health care 8provider shortages. Expansion of the National Health Service Corps is expected to ensure that providers, including registered nurses (RNs) and APRNs, will be available to staff these centers. An emphasis on primary care will increase the demand for NPs and RNs, and the ACA authorizes additional support for primary care workforce development (loans, scholarships, new educational program development, and expansion of existing programs). (See Chapter 60 for more on the nursing workforce.)

Nurses as Leaders in Health Care Reform

Coinciding with the passage of the ACA was the timely publication of The Future of Nursing: Leading Change, Advancing Health (IOM, 2011). It makes four recommendations, one of which is “Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States” (Figure 1-3).

FIGURE 1-3 Four key messages: The IOM report. (From Institute of Medicine. [2011]. The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Retrieved from www.iom.edu/nursing.)

This presents a challenge to nurses: to identify opportunities to participate in policy decision making at all levels of society, the health care system, and health care organizations. Although nursing is well positioned to contribute to a reformed health care system, we cannot assume that those making the decisions about reform will automatically seek nurses’ input. And, if invited to policy tables, will nurses show up and participate fully? The IOM report calls for the profession to develop its leadership capacity, while encouraging policymakers and others to appreciate nurses’ perspectives on policy. Whether developing new models of care, sharing ideas for regulations with policymakers, developing demonstration projects that the new health care law seeks to test, or advocating new legislation to amend and improve upon the law (or preventing it from being dismantled), nurses must strengthen their social covenant with the public and more forcefully engage in shaping policy at all levels within government, workplaces, health-related organizations, and communities.

Policy and the Policy Process

What do we mean by policy? Policy has been defined as the authoritative decisions made in the legislative, executive, or judicial branches of government intended to influence the actions, behaviors, or decisions of citizens (Longest, 2010). But that definition limits its application to sectors outside of government. For example, health care organizations set policy that affects employees, patients, and even surrounding communities (for example, by closing a neighborhood clinic or buying property for hospital expansion). Thus, a broader definition of policy is “a relatively stable, purposive course of action or inaction followed by an actor or set of actors in dealing with a problem or matter of concern” (Anderson, 2015, p. 6).

Public policy is policy crafted by governments. When the intent of a public policy is to influence health or health care, it is a health policy. Social policies identify courses of action to deal with social problems. All are made within a dynamic environment and a complex policymaking process. Private policies are those made by nongovernmental entities, whether health care organizations, insurers, or 9others. Indeed, there is growing recognition that policies set by health care organizations and insurers, for example, can limit APRN practice even in states that have removed laws requiring physician supervision or collaboration. A hospital can limit what APRNs do as long as the organization does not call for APRNs to practice beyond the state’s scope-of-practice policy.

Policies are crafted everywhere, from small towns to Capitol Hill. States use policies to specify requirements for health professions’ licensure, to set criteria for Medicaid eligibility, and to require immunization for public university students, for example. Hospitals use policies to direct when visitors may visit patients, to manage staffing, and to respond to disasters. Public schools employ state policies to specify who may administer medi­cations to schoolchildren and what may be sold from a school vending machine. Towns, cities, and other municipalities use policies to manage public water, to define who may run for office, and to decide if residents may keep exotic pets.

In a capitalist economy such as that of the United States, private markets can control the production and consumption of goods and services, including health care. The government often “intervenes” with policies when private markets have failed to achieve desired public objectives. But when is it necessary for the government to intercede? Broadly speaking, in the current U.S. political system, the divide between liberal and conservative political parties is a fundamental disagreement about the degree to which government can and should solve problems (Kelly, 2004) in education, national security, the environment, and nearly every other aspect of public life. The American political landscape is continuously shifting, as public mood shifts with new Representatives being elected and senior Representatives desiring to stay in office.

Longest (2010) describes two types of public policies the government develops:

• Allocative policies provide benefits to a distinct group of individuals or organizations, at the expense of others, to achieve a public objective (this is also referred to as the redistribution of wealth). The enactment of Medicare in 1965 was an allocative policy that provided health benefits to older adults using federal funds (largely from middle- and high-income taxpayers).

• Regulatory policies influence the actions, behavior, and decisions of individuals or groups to ensure that a public objective is met. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 regulates how individually identifiable health information is managed by users, as well as other aspects of health records.

Policymaking is an often unpredictable dance that requires a high degree of political competence. Our system is based on continuous policy modification—incremental change is exceedingly more likely than revolutionary change. But there are exceptions; once in a generation a large social program is passed such as Medicare and Medicaid in the 1960s and the ACA in 2010.

Forces That Shape Health Policy

Some of the most prominent forces that shape health policy appear in Figure 1-4.

FIGURE 1-4 The forces that shape policy.

Values

Values undergird proposed and adopted policies and influence all political and policymaking activities. Public policies reflect a society’s values and also its conflicts in values. A policy reflects which values are given priority in a specific decision (Kraft & Furlong, 2010). Once framed, a policy reveals the underlying values that shaped it. Different people value different things, and when resources are finite, policy choices ultimately bring a disadvantage to some groups; some will gain something from the policy, and some will lose (Bankowski, 1996). To support or oppose a policy requires value judgments (Majone, 1989). Conflicts between values were apparent throughout the debates on the ACA; for example, despite a strong contingent of advocates for a government-run, nonprofit insurance option that would compete with private insurers, the insurance industry opposed it, as did others who saw it as an increase in government control, and it was not included in the law.

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Politics

Politics is the use of relationships and power to gain ascendancy among competing stakeholders to influence policy and the allocation of scarce resources. Because inevitably there are competing interests for scarce resources, policymaking is done within a political context.

The definition of politics contains several important concepts. Influencing indicates that there are opportunities to shape the outcome of a process. Allocation means that decisions are being made about how to distribute resources. Scarce implies the limits to available resources and that all parties probably cannot have all they want. Finally, resourcesare usually considered to be financial but could also include human resources (personnel), time, or physical space such as offices (Mason, Leavitt, & Chaffee, 2012). Engaging in the political context of policymaking includes knowing the positions of key stakeholders and political parties, as well as the electoral process, public opinion, the influence of media coverage, and more (see Chapter 9 for an in-depth discussion of political analysis and strategies). Understanding politics is an invitation not to misuse power, people, or information but rather to align the health of the public with the interest of the policymaker. For example, a Congresswoman may have run her campaign focused on improving the economy. She may not have linked the rising obesity epidemic as a threat to the larger macroeconomy and American productivity. Nurses could link obesity to the economy by describing the catastrophic direct and indirect costs of the obesity epidemic and how it is making the United States less competitive in a global market. This is a way for nurses to use their power to create more urgency about the most pressing public health issues.

Policy Analysis and Analysts

Analysis is the examination of an object or a process to understand it better. Policy analysis uses various methods to assess a problem and determine possible solutions. This encourages deliberate critical thinking about the causes of problems, identifies the ways a government or other groups could respond, evaluates alternatives, and determines the most desirable policy choice. (See Chapter 7.) Policy analysts are individuals who, with professional training and experience, analyze problems and weigh potential solutions. Citizens can also use policy analysis to better understand a problem, 11alternatives, and potential implications of policy choices (Kraft & Furlong, 2010).

Advocacy and Activism

Advocacy of one patient at a time has long been a central role for nurses. But nurses can be advocates on a larger scale by working in policy and politics, which is endorsed in “nursing’s social policy statement” (American Nurses Association [ANA], 2003), a document that defines nursing and its social context. Political activism may be associated with protests but has grown to include additional diverse and effective strategies such as blogging, using evidence to support policy choices, and garnering media attention in sophisticated ways.

Interest Groups and Lobbyists

Interest groups advocate for policies that are advantageous to their membership. Groups often employ lobbyists to advocate on their behalf and their power cannot be underestimated. In 2009, 1814 U.S. businesses and organizations spent $554,566,269 on lobbying and employed 3527 lobbyists to advocate for their interests in the health care reform debate and other issues (Center for Responsive Politics, n.d., a). This was a peak year that coincided with interest groups’ attempts to influence the ACA. In 2013, 1299 organizations spent $483,078,712 on lobbying and used 2918 lobbyists to advance their interests, including over $1.6 million by the ANA and $940,000 by the American Association of Nurse Anesthetists (Center for Responsive Politics, n.d., b).

The Media

The power of media is demonstrated in political and issue campaigns, whether through paid political advertisements or the “talking heads” on “news” programs that present polarized views. The aim is to deliver messages that resonate with the values and emotions of a target audience to support or oppose a candidate or proposed policy. The strategic use of media is imperative in today’s cacophony of information. Gaining the attention of a target audience is power. Persuading that audience to behave the way you want is ultimate power.

In this information age, nurses must proactively use media to influence policy and make themselves available to speak with journalists about policy matters. However, nurses have not always been eager to enter the media spotlight (see Chapter 14 on using media as a policy and political tool), particularly when it comes to talking with journalists. Social media is a tool for influencing policymakers (Grande et al., 2014) and provides nurses with an opportunity to control their message. Nurse bloggers such as Barbara Glickstein are getting visibility as “media makers.” Theresa Brown writes for the Opinionator column for The New York Times. Both are bringing nursing perspectives on policy matters to the public’s attention.

Science and Research

The information age has created an emphasis on evidence-based practice and policies. Scientific findings play a powerful role in the first step of the policy process: getting attention to particular problems and moving them to the policy agenda. Research can also be valuable in defining the size and scope of a problem and substantiating policy recommendations. This can help to obtain support for a proposed policy and in lobbying for support of it. Evidence should be used to inform policy debates and shape policy choices to help ensure that the solution will be effective. That said, evidence is essential but may not be sufficient to advance policies. Values and politics can trump evidence, as has been apparent in recent debates over two issues: climate change and decreasing rates of vaccinations. Despite the evidence showing that humans are contributing to potentially devastating changes in the earth’s climate or that childhood vaccinations do not cause autism, debates about these issues continue and affect whether policies are or are not adopted to address the problems.

The Power of Presidents and Other Leaders

The president embodies the power of the executive branch of government and is the only person elected to represent the entire nation. As the most visible government official, the president is able to propel issues to the top of the nation’s policy agenda. Although the president cannot introduce legislation, he or she can provide draft legislation 12and legislative guidance. The president can also issue executive orders when he or she cannot get support for policy change from Congress. President Obama has done so in the face of a paralyzed Congress, as did his Republican and Democratic predecessors. This force also applies to the leaders of many public and private entities. Never underestimate the power of the official leader or of those who seek to remove or thwart the leader.

The Framework for Action

Nursing has a covenant with the public. The profession’s practice laws, standards, and ethics have roots in its history of activism for social justice. A social contract with society demands professional re­sponsibility. Thus, every nurse must continuously consider the policy context of daily practice in any setting. The solutions to today’s most intractable health care problems, including perverse payment mechanisms, deeply disturbing social injustice, and shocking ethnic and racial disparities, are not simple to solve. But, according to the annual Gallup poll (Gallup, 2013), the public regards nurses’ “honesty and ethical standards” more highly than those of any other profession. This public trust places a moral imperative on nurses to vigorously engage in influencing policy. Nurses see close up how policies get played out in patient care and can report on unintended consequences. This imperative requires nurses to expand their involvement in policy decisions at the institutional, community, state, federal, or international realm and need not be restricted to any one setting.

The Framework for Action (Figure 1-5) illustrates that nurses operate in four spheres: government, workplace, interest groups (including professional organizations), and community to influence policies that affect health and health care and core/social determinants of health.

FIGURE 1-5 A framework: Spheres of influence for action. Nurses need to work in multiple spheres of influence to shape health and social policy. Policies are designed to remedy problems in the health system and to address social determinants of health; both of which aim to improve health.

Spheres of Influence

The four spheres of influence provide a visual medium for understanding the policy arena. These spheres are not discrete silos. Policy can be shaped in more than one sphere at a time, and action in one sphere can influence others. To achieve greater 13access to care for the uninsured, for example, nurses may work in their own organization to alter policy to increase access to services. They may also use political strategies in the media, such as blogging or being interviewed on television, to express their support for better access to care. They may work with a professional association or an interest group to communicate their views to policymakers. Additional context (the who, what, where, when, and why of nursing’s policy influence) is provided in Figure 1-6.

FIGURE 1-6 The who, what, where, when, and why of nursing’s policy influence.

The Government

Government action and policy affect lives from birth until death. It funds prenatal care, inspects food, controls the safety of toys and cars, operates schools, builds highways, and regulates what is transmitted on airwaves. It provides for the common defense; supplies fire and police protection; and gives financial assistance to the poor, aged, and others who cannot maintain a minimal standard of living. The government responds to disaster, subsidizes agriculture, and licenses funeral homes.

Although most U.S. health care is provided in the private sector, much is paid for and regulated by the government. So, how the government crafts health policy is extremely important (Weissert & Weissert, 2012). Government plays a significant role in influencing nursing and nursing practice. States determine the scope of professional activities considered to be nursing, with notable exceptions of the military, veterans’ administration, and Indian health service. Federal and state governments determine who is eligible for care under specific benefit programs and who can be reimbursed 14for providing care. Sometimes government provides leadership in defining problems for both the public and private sectors to address. There are more than a dozen House and Senate committees and subcommittees that shape policy on health, and many more committees address social problems that affect health. In the House of Representatives, the Congressional Nursing Caucus, an informal, bipartisan group of legislators who have declared their interest in helping nurses, lobbies for federal funding for nursing education (Walker, 2009).

Abraham Lincoln’s description of a “government of the people, by the people, for the people” (Lincoln, 1863) captures the intricate nature of the relationship of government and its people. There are many ways nurses can influence policymaking in the government sphere, at local, state, and federal levels of government. Examples include:

• Obtaining appointment to influential government positions

• Serving in federal, state, and local agencies

• Serving as elected officials

• Working as paid lobbyists

• Communicating positions to policymakers

• Providing testimony at government hearings

• Participating in grassroots efforts, such as rallies, to draw attention to problems

The Workforce and Workplace

Nurses work in a variety of settings: hospitals, clinics, schools, private sector firms, government agencies, military services, research centers, nursing homes, and home health agencies. All of these environments are political ones; resources are finite, and nurses must work in each to influence the allocation of organizational resources. Policies guide many activities in the health care workplaces where nurses are employed. Many that affect nursing and patient care are internal organizational policies such as staffing policies, clinical procedures, and patient care guidelines. External policies are operative in the health care workplace also; for example, state laws regulating nursing licensure. Federal laws and regulations are evident in the nursing workplace such as Occupational Health and Safety Administration regulations regarding worker protection from bloodborne pathogens.

Policy influences the size and composition of the nursing workforce. The ACA authorizes increased funding for scholarships and loans for nursing education, potentially augmenting existing workforce programs funded under Title VII and Title VIII of the Public Health Service Act. The nongovernmental Commission on Graduates of Foreign Nursing Schools is authorized by the federal government to protect the public by ensuring that nurses and other health care professionals educated outside the United States are eligible and qualified to meet U.S. licensure, immigration, and other practice requirements (Commission on Graduates of Foreign Nursing Schools, 2009). The National Council of State Boards of Nursing is a not-for-profit organization that brings together state boards of nursing to act on matters of common interest affecting the public’s health, safety, and welfare, including the development of licensing examinations in nursing (National Council of State Boards of Nursing, 2009). These are just a few examples of the external forces that shape workforce and workplace policy.

Associations and Interest Groups

Professional nursing associations have played a significant role in influencing practice. Many associations have legislative or policy committees that advocate policies supporting their members’ practice and advance the interests of their patient populations. Working with a group increases the effectiveness of advocacy, provides for the sharing of resources, and enhances networking and learning. In fact, these associations can be excellent training grounds for novice nurses to learn about policy and political action (see Chapter 4). Nurses can be effective in association policy activities by serving on public policy or legislative work groups, providing testimony, and preparing position statements.

When nursing organizations join forces through coalitions, their influence can be multiplied. For example, The Nursing Community (www.thenursingcommunity.org) is an informal coalition of national nursing organizations that formed to speak with one voice on matters important to national policy and political appointments (see 15Chapter 75). The Coalition for Patients’ Rights (www.patientsrightscoalition.org) is a group of more than 35 national organizations representing health care professionals that is working to fight the American Medical Association’s attempts to limit patients’ access to nonphysician providers. Twenty members are nursing organizations.

Nurses can be influential, not just in nursing associations, but by working with other interest groups such as the American Public Health Association or the Sierra Club. Some interest groups have a broad portfolio of policy interests, whereas others focus on one disease (e.g., National Breast Cancer Coalition) or one issue (e.g., driving while intoxicated, the primary focus of Mothers Against Drunk Driving). Interest groups have become powerful players in policy debates; those with large funding streams are able to shape public opinion with media advertisements.

The Community

A limited number of nurses will have the opportunity to influence policy at the highest levels of government, but extensive opportunities exist for nurses to influence health and social policy in communities. Nursing has a rich history of community activism with remarkable examples provided by leaders such as Lillian Wald, Harriet Tubman, and Ruth Lubic. This legacy con­tinues today with the community advocacy efforts of nurses such as Cora Tomalinas, Mary Behrens, Ellie Lopez-Bowlan, the Nightingales who took on Big Tobacco, and the nurses who are a part of the Canary Coalition for Clean Air (their stories appear in this book).

A community is a group of people who share something in common and interact with one another, who may exhibit a commitment to one another or share a geographic boundary (Lundy & Janes, 2001). A community may be a neigh­borhood, a city, an online group with a common interest, or a faith-based network. Nurses can be influential in communities by identifying problems, strategizing with others, mobilizing support, and advocating change. In residential communities (such as towns, villages, and urban districts), there are opportunities to serve in positions that influence policy. Many groups, such as planning boards, civic organizations, and parent-teacher associations, offer opportunities for involvement.

Health

The Framework for Action includes health as an element of the model to represent that optimal health is viewed as the goal of nursing’s policy efforts. Optimal health (whether for the individual patient, family, a population, or community) is the central focus of the political and policy activity described in this book. This focus makes it clear that the ultimate goal for advancing nursing’s interests must be to promote the public’s health.

Nursing embraces a broad definition of health that aligns with the World Health Organization (1948): “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” It incorporates the concept of positive health, not just ill health (Greene et al., 2014). This definition requires a focus on creating communities that thrive economically, have safe environments, and use resources to ensure that their members have access to good nutrition and other elements that can promote health.

Health and Social Policy

This definition of health leads to the focus on health and social policy as key elements in the Framework for Action. Many factors that affect health are social ones, such as income, education, and housing. Although nurses involved in policy often focus on health policies, the emphasis on upstream factors requires a broader focus on the socioeconomic factors that affect health, including labor policy, laws that can stimulate job creation, or local ordinances on smoking bans.

Health Systems and Social Determinants of Health

The health care system is the focus of most discussions of health policy to date. Much of this book focuses on understanding the complex and sometimes chaotic U.S. health care system, the ACA’s role in augmenting the system’s performance, and other 16policies needed to achieve the Triple Aim. It also addresses the powerful impact that upstream factors have on the health of populations. A singular focus on the health care system is limited in the extent to which it can lead to higher levels of health for individuals, families, and communities.

Nursing Essentials

Nursing has also developed a competency-based educational curriculum supporting future nurses’ involvement in policy. The American Association of Colleges of Nursing (AACN) publishes the necessary curriculum content and expected compe­tencies of all nursing school graduates from bacca­laureate, master’s, doctor of nursing practice, and research doctorate (PhD) programs. These documents serve as a framework for twenty-first-century nursing and ground the profession in the direct and indirect care of individuals, families, communities, and populations. The content builds on nursing knowledge, theory, and research and derives knowledge from a wide array of fields and professions.

A study by Byrd and colleagues (2012) found that undergraduate nursing students for the most part are largely unaware of the importance of political activity for nurses. After participating in a robust and active public policy learning activity, students measured high on a political astuteness scale. This study suggests that political skills can be learned when presented with relevance to nursing and used to hone skills such as inquiry, critical thinking, and complex problem solving. These results highlight the importance of increasing students’ awareness of how to participate in the political process, as well as encouraging their participation in student and professional organizations.

For each level of nursing education—BSN, MSN, DNP, and PhD—there is a clear expectation that graduates will have policy competency, with increasing emphasis on policy leadership as nursing students progress academically, although this is less well defined for PhD graduates (AACN, 2006; AACN Task Force, n.d.). These essentials make it clear that health policy directly influences nursing practice and every aspect of the health care system. It is understood that patient safety and quality cannot be addressed outside of the context of policy. The broader policy context is emphasized throughout nursing degree programs. It is expected that DNP graduates are able to design, implement, and advocate health policies that improve the health of populations. The powerful practice experiences of nurses can become potent influencers in policy formation. Additionally, a DNP graduate integrates these practice experiences with two additional skill sets: the ability to analyze the policy process and the ability to engage in politically competent action (AACN, 2006). See Table 1-1 for a summary of the policy competencies in successive nursing education programs.