ReadChapter on Davis Plus: Discussion of Triaxial of action: Policy, Politics,and Nursing.
ALL INFORMATION HAVE TO TAKE FROM THE FILE ATTACHED. APA Style.
References:Whitehead, D.K., Weiss, S.A. & Tappen, R.M. Essentials of Nursing Leadership and Management. (6th Ed.)
QUESTIONS
1- What is Policy?
2- Explain each of them:
Public policy—
Private policy—
Health policy—
Social policy—
Organizational policy?
3- Who was Florence Nightingale, and what was her contribution to the Nursing Field?
4- Who was Lillian Wald?
5- Who was Margaret Sanger, and in what way she helped to the developments of Nursing Field?
6_ what is (ICN), and what they do?
7- What is s (NLCA) and they do?
Jeanne Blum, RN, is a nurse on a LDRP unit. Recently, the policy and procedures manual for Jeanne’s unit included the premature rupturing of membranes of a laboring patient as a practice acceptable for nurses to perform. Jeanne and some of her coworkers shared their concern over lunch about this new responsibility.They felt uncomfortable with the possibility of cord prolapse and other potential medical complications resulting from this practice. Jeanne gathered data from her state and many others states and noted that her hospital was not in compliance with her professional organization practice standards. Jeanne shared this information with her coworkers. She volunteered to contact the state board of nursing on their behalf to request a declaratory statement on the nurse’s role in the initiation of premature rupturing of uterine membranes.
Her state board’s clinical practice committee reviewed her request for a declaratory statement and gathered information from other states. A formal declaratory statement was drafted by the board and made it available on its Web site. A letter from the board was sent to Jeanne’s institution, informing it of the declaratory statement, which stated that the task nurses were requested to perform was beyond their scope of practice based on the Nurse Practice Act.
8-Which stage of the policy model does this scenario represent? ■
Triaxial of Action: Policy, Politics, and Nursing
In the nursing profession, there is an educational void with regard to information related to policy and
politics and the nursing role. In 2009, it has become even more important that nursing students are
exposed to policy and politics during their edu- cational preparation. This preparation will lay the
foundational understanding of the political process, assisting nursing students to understand that
policy decisions are part of their environment and prepar- ing graduate nurses to become involved and
ulti- mately to drive the political process. Politics is a world that is continuously changing, and nurses
have an opportunity to choose political action and thus become participants in policy changes.
Defining Policy
Policy comes from two different Greek roots, one meaning demonstration or proof and the other
mean- ing citizenship (Chrichton, 1981). It is the citizen- ship root that we will be addressing. One
definition of a policy is “a purposeful, overall plan of action or inaction developed to deal with a
problem or a mat- ter of concern in either the public or private sector” (Milstead, 2004, p. 195). Policy
has also been defined as “the continuous chosen course of action/inaction directed toward some end”
(Kalisch and Kalisch, 1982, p. 61) or simply as “authoritative decision making” (Stimpson and Hanley,
1991, p. 61). The following definitions of policy and process will pro- vide a better understanding of
these related terms:
▪ Public policy—Affects institutional and individ- ual behaviors such as professional licensure or
legislation. Public policy can address local, state, or federal issues.
▪ Private policy—Usually refers to agency or insti- tutional rulings that address employment
through policies, procedures, directives, and guidelines.
▪ Health policy—Refers to health-care reimburse- ment, resources, and/or services related to
public or private health-care institutions.
▪ Social policy—Refers to addressing and promot- ing the public welfare.
▪ Institutional policy—Similar to public policy, but usually discusses how the institution com- plies
with public policy.
▪ Organizational policy—Positions taken by nurs- ing organizations such as specialty nursing
associations like the American Organization of Registered Nurses (AORN) and national nursing
organizations like the American Nurses
▪ Association (ANA).
■ Policy analysis—Evaluation of the total effects of
▪ a policy as it relates to political, social, economic, legal, or ethical aspects of proposed or
instituted policies. (Mason, Leavitt, and Chaffee, 2007)
▪
▪
Defining Politics as It Relates to Policy
When discussing policy, the subject of politics inevitably arises, as if these terms can be used
inter- changeably. Politics is an action or a behavior that is often used to drive the legislative
process. The goal of political action is to influence the end product— policy. Politics, closely
related to policy, opens the floodgates to many varied opinions. The term poli- tics means the
“influencing the allocation of scarce resources” (Talbott and Vance, 1982, p. 592).
Opportunities exist to influence the outcomes of the political process.
Health care deals with the allocation of scarce resources, dividing limited supplies and
resources among members of society. Scarcity means there are limitations to available
▪
▪
▪
▪
▪
resources and therefore not everyone will have equal access. Nurses are affected by and direct
the use of scarce health-care resources and dollars on a daily basis. They are impacted by the
limitations and roadblocks in the health-care system as they try to obtain authorization from
providers for patient-care services. However, the profession of nursing feels alienated from the
polit- ical arena. Even though the profession is signifi- cantly impacted and directed by policy
decisions, it has been slow to participate in the process. Nursing needs to be competent in
health-care leadership dynamics if it is to have input into the workplace.
Nurses respond inconsistently to political action. On the one hand, they traditionally have
referred to the behavior of goal-oriented colleagues as “playing politics,” a description that is
not meant in a positive way. However, when they need and want their nurse executive to be
politically aware, they express opposite views. To benefit personally and professionally, nurses
need a “go-to” person who is able to accomplish change. Whether one perceives politics as
negative or positive depends largely on the following factors:
■ Acknowledging individual biases
■ Knowing how the “game” of politics is played.
Understanding the rules in which politics is operating
Realizing whether the goals or ends are important
Realizing when one is in a position to change the rules of the system (Mason, Leavitt, and
Chaffey, 2007, p. 4)
Policy and politics are important parts of the nurs- ing profession. Nurses can either help create
policy or will be required to respond to it. Politically astute nurse executives know that
relationship- building and networking are required for successful leadership. Relationships
become valuable when issues require consensus and compromise. It is important for every new
nurse to realize that relationship-building starts early and builds throughout their professional
career. Relationship- building cannot be put off until help is needed. Networking, starting as a
personal acquaintance, builds to invaluable relationships that can be called upon in a time of
need.
History of Nursing Politics
Nursing has had many visionaries and heroines who have addressed social, cultural, and health
problems. These nurse laureates did not remain silent, but sought to use their voices to
highlight the injustices affecting broad groups of citizens in the neighborhoods and across the
world. It is important to celebrate those nurses who worked so diligently to shape policy in
their eras and had the courage to make a difference.
19th Century—Florence Nightingale and Sojourner Truth
The most famous nursing visionary, Florence Nightingale (1820–1910), was a statistician and
politician who lobbied for safer health care. After the Crimean War, Nightingale was confined to
bed for much of the time but used this time to send her message to nurses and politicians. She
sent roses and held teas for new graduates, challenging the new nurses to use principles of
infection control in their practice. Because of her training as a statisti- cian, she valued
collecting data that could support and influence people’s minds. Policy makers found the
information fascinating and came to her bed- side seeking useful information. Nightingale’s
mes- sage was clear and her methods of lobbying for her cause were successful: “She was a
leader who knew how to garner the support of her followers, colleagues and policy makers and
used her skills to change her environment” (Mason, Leavitt, Chaffee, 2007, p. 14).
Sojourner Truth, originally named Isabella Van Wagner (1795–1883), who was born into
slavery, provided nursing care to Union soldiers during the Civil War. Truth became politically
active and sought federal funds to train nurses and physicians. In her speeches, she actively
opposed slavery and advocated for women’s rights. She became famous in 1851 at the
Women’s Rights Convention in Akron, Ohio, where she challenged the audience to advocate for
the rights of black women in her speech “Ain’t I a Women.” She was largely respon- sible for
transforming the gender and racist policies of that era with regard to health care, women, and
African Americans.
Early 20th Century—Lillian Wald
The modern nursing movement tells the story of women seeking to provide better health care
for their society. They saw the nurse as needed “not only for bedside care of the sick, but to
help in seeking out the deep-lying basic causes of illness and misery, that in the future there
may be less sickness to nurse and cure” (Buhler-Wilkerson, 2001, p. 98). Between 1900 and
1930, nurses sought first to obtain access to health care for patients and then authority to
control the practice of nursing. In the 1920s, when society paid nurses directly for private duty
services, Lillian Wald (1867–1940) was instrumental in the acquisition of funding for private
duty nursing. Wald, one exam- ple of nurse leaders at this time, created the Henry Street
Settlement and a school nursing program and initiated the concept of public health nursing.
Looking back, the accomplishments of the Henry Street nurses were remarkable, especially in
light of the fact that these efforts were successful socially, economically, and politically even
though women did not gain the right to vote until 1920. Current models of public health
nursing are based on the work of these pioneers. They provided “community prevention
activities, advocacy for political change, and services to those who would otherwise not receive
care” (Chang, Price, and Pfoutz, 2001, p. 219). Lillian Wald saw a health-care system that
needed change and set out to create policy to improve societal conditions.
Mid-20th Century—Margaret Sanger
Margaret Sanger (1879–1966) was responsible for changing our nation’s acceptance of family
planning. Even though she struggled with the possibility of jail and received death threats, she
continued to distrib- ute literature that educated women on the prevention of unplanned
pregnancies. Her articles “The Woman Radical” (1914) and “Family Limitations” (1915) brought
her under federal indictment and forced her exile to Europe. When she returned to the United
States, her proactive stance and educational programs reduced the maternal infections and
deaths due to unlicensed individuals performing illegal abortions. She opened the first birth
control clinic in the United States but, after 9 days, the police closed the clinic as crowds
gathered to seek information and counseling on birth control. Because she distributed birth
control information, Sanger was arrested for obscenity and she served 30 days in jail; however,
these efforts culminated in bringing the need for pol- icy change before the public eye. Sanger
died at age 87, a few months after the 1965 Supreme Court decision that made birth control
legal for married couples. It took 50 years of nurses’ efforts to gain leg- islative support for this
at-risk female population.
Nursing’s Political Growth in the 21st Century
In the 1990s and over the last decade, many nurses have made their mark in the political arena.
Khristine Gebbie, RN, served as the AIDS czar; Sheila Burke, RN, was chief of staff to Senate
Majority Leader Bob Dole; Carolyn Davis became the head of the Health Care Financing Agency
and was responsible for shaping the Medicare and
Medicaid budget, the third-largest governmental budget; Virginia Trotter Betts, former ANA
presi- dent under President Clinton’s administration, was appointed Senior Health Advisor to
the U.S. Department of Health and Human Services; also in Clinton’s administration, Dr. Beverly
Malone became the Deputy Assistant Secretary for Health and Human Services. The visions of
all these lead- ers were grounded in values that reflected a connec- tion between social issues
and health. Their passions were not always welcomed by policy mak- ers, yet they continued to
network with those in power to gain a voice in the health-care system.
Policy and Nursing Governance
Nursing has always been an active voice in support of patient safety, protection of the public,
profes- sional and ethical behaviors, competency, and stan- dardization in education and scope
of practice. Historically, however, nurse leaders have been polarized, struggling to gain a voice
for nursing but unable to reach consensus on professional direc- tion. In order to be regarded
as a profession, stan- dardization and regulation were necessary.
Regulatory Policy—International and National
The International Council of Nurses (ICN) is a federation of national nursing associations, representing more than 120 countries. This group is operated by nurses who work to ensure quality
patient care, sound global health policies, the advancement of nursing knowledge, and
worldwide respect for the nursing profession. ICN’s code of
ethics is the foundation for nursing practice throughout the world.
The National Council of State Boards of Nursing (NCSBN) was established in 1978. This not-forprofit organization’s membership is com- prised of the boards of nursing in the 50 states, the
District of Columbia, and the 5 United States territories (American Samoa, Guam, Northern
Marina Islands, Puerto Rico and the Virgin Islands). This organization’s main purposes are to
advance regulatory excellence for the protection of the public, which includes NCLEX testing,
policy analysis, research, oversight of the uniformity of regulations for nursing practice, and the
collection of data related to nursing licensure (NCSBN, 2008b). NCSBN’s values of integrity,
accountability, quality, vision, and collaboration support its goals for public health, safety, and
welfare.
History of Nursing Licensure
To define the role of the nurse in all nations, a cam- paign began in 19th-century England to
support the identification of graduate nurses through licen- sure, but there was strong
opposition to allowing nursing organizations to participate in nursing licensure. This conflict
delayed the enactment of laws to govern the profession. Isabel Hampton Robb, the first
American Nurses Association pres- ident, commented on the need for nursing regula- tion: “in
the absence of educational and professional standards, I am sadly forced to admit that the term
‘trained nurse’ means anything, everything and next to nothing” (University of North Carolina
Television, 2002, par 3). New Zealand became in 1901 the first country to license nurses. In
1903, North Carolina became the first state to enact a nursing registration law. New Jersey,
New York, and Virginia followed in that same year. These early laws recognized nursing as a
profession, provided title protection, and established standards of prac- tice to protect the
public. The laws were controver- sial, however, and there were inconsistencies from state to
state.
The ultimate purpose of regulation is to protect the public. A noted example of the need for
this protection was demonstrated as a result of the rise of industrialization in the United States.
At this time, a mass migration of people to the major cities occurred, which stressed the cities’
infrastructure and resources. These transplanted consumers of health care were now in a new
environment, in a society made up of differing cultures and languages. Health-care delivery
became a societal issue.
Professional Nursing Organizations: Where Regulation Stands Now
Today’s state nursing regulations provide guidelines for protecting the public and advancing the
profes- sion of nursing, principles to assist the nurse with decision-making, and standards for
safe and effec- tive care. The NCSBN, as the national nursing reg- ulatory body, provides guiding
principles for nurs- ing regulations and governance to all states and territories (NCSBN, 2008a).
Protection of the Public
Nursing regulation exists to protect the health, safety, and welfare of the public in their receipt
of nursing services.
Competence of All Practitioners Regulated by the Board of Nursing
■ Nursing regulation is responsible for upholding licensure requirements for competence in the
various levels of nursing practice.
■ Competence is assessed at initial licensure/entry and during the career life of all practitioners.
Due Process and Ethical Decision-Making
■ Nursing regulation is conducted in a manner to provide fair, reasoned and consistent
decisions and due process.
■ Boards of nursing hold nurses accountable for ethical decision-making and professional
responsibility.
Shared Accountability
Nursing regulation requires shared accountability for distinguishing individual versus system
errors and potential for error.
Strategic Collaboration
Nursing regulation requires collaboration with multiple strategic individuals and agencies in the
interest of public protection, patient safety, and the education of nurses.
Evidenced-Based Regulation
Nursing regulation uses evidenced-based standards of practice, advances in technology, and
demo- graphic and social research in its mission to protect the public.
Response to the Marketplace and Health-Care
Environment
■ Nursing regulation requires timely and thought- ful responsiveness to the evolving
marketplace. ■ Clarity in scope of practice and congruence with
the community needs for nursing care are essential.
▪
▪
Globalization of Nursing
Nursing regulation occurs at the state level and concurrently works to standardize regulations
and access to licensure.
Nursing regulation acknowledges and addresses the social, political and fiscal challenges of
glob- alization. (NCSBN, 2007, p. 1)
The need for regulation in the nursing field can be summed up using four critical reasons:
information asymmetry, bundling of services, secondary harm, and forum for complaints.
1. Information Asymmetry. It is almost impossi- ble for the average consumer to collect and
evalu- ate information about health care because the system is technically complicated and the
con- sumer’s use of the services may be infrequent. Even consumers who would be willing to
evaluate a number of potential resources before making critical decisions may be prevented
from doing so. People dealing with crisis may be in shock, griev- ing, or unable to make this type
of decision.
2. Bundling of Services. The majority of nurses are employees of hospitals and other healthcare agencies. The agency and the nurse are bundled. Regulation of health-care providers
creates an assurance that providers in all settings have met government requirements before
entering practice.
3. Secondary Harm. An incompetent health- care provider who fails to identify an infectious
disease may not only affect the client but also contribute to the unknowing spread of disease.
Health-care regulation attempts to provide safeguards when there can be potential risk to
multiple persons affected indirectly by services provided to others.
4. Forum for Complaints. Regulation boards serve as an objective third party when dealing
with citizen complaints regarding service. The boards of nursing provide a system of checks and
balances for the public. Their members have expertise to evaluate the technical, often
complicated, professional issues and have been charged with the responsibility of protecting
the public. These regulatory boards provide a forum to hear citizens’ concerns. (NCSBN, 1996,
p. 6)
NCLEX Testing
A consistent approach to regulation among the member states and territories allows nurses to
migrate from one state to another. Although all 50 states and territories have different Nurse
Practice acts, the entry-level measurement tool, the NCLEX exam, is recognized by all. This
uniform test allows nurses to apply for reciprocity or endorsement within the 50 states and
territories. It also is a means for internationally educated nurses seeking a U.S. nursing license
to apply for endorse- ment, providing they speak English and have tran- scripts that
demonstrate education which meets or exceeds the U.S. standards. Unless a state is a member of the multi-state licensure compact, each nurse must obtain and maintain the specific
state require- ments for each nursing license that they hold.
Multi-State Licensure Compact
The Multi-State Licensure Compact is a new way of looking at licensure and regulation of
nurses. The Nurse Licensure Compact Administrators (NLCA) officially organized on January 10,
2000, for the pur- pose of protecting the public’s health and safety by promoting compliance
with the laws governing the practice of nursing. “The mutual recognition model of nurse
licensure allows a nurse to have one license (in his or her state of residency) and to practice in
other states (both physical and electronic), subject to each state’s practice law and regulation.
Under mutual recognition, a nurse may practice across state lines unless otherwise restricted”
(NCSBN, 2008, par. 1). Each state must enact legislation authorizing the NLCA to oversee the
exchange of information between other members of the compact. States enter- ing the
compact also adopt administrative rules and regulations for implementation of the compact.
Over the last 10 years, states have been slow to begin the legislative process to implement a
multi-state licen- sure option for their nurses. As of 2008, 21 of the 50 states had adopted and
implemented the nurse licensure compact (see Box 1).
Box 2-1
States That Have Adopted Through Legislation a Multi-State Compact (RN and LPN/VN)
Arizona, Arkansas, Colorado Delaware, Idaho, Iowa, Kentucky, Maine, Maryland Mississippi,
Nebraska, New Hampshire, New Mexico, North Carolina, North Dakota, Rhode Island, South
Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin.
Multi-state licensure is an important policy that assists nurses in their practice as they travel,
move, or work intrastate jobs that are covered by the com- pact. In terms of disciplinary action,
the nurse is subject to the (home) state board of nursing. (A home state is the state in which
the nurse has primary residency.) State Nurse Practice acts, how- ever, differ, and nurses,
whether or not they have a multi-state license, are to abide by the regulations of the Nurse
Practice Act of the state in which they are working. In the remaining nonparticipating states,
any nurse seeking employment as a nurse within that state must obtain state licensure prior to
the first day of work. “On August 16, 2002, the NCSBN Delegate Assembly approved the adoption of model language for a licensure compact for advanced practice registered nurses
(APRNs). Only those states that have adopted the RN and LPN/VN Nurse Licensure Compact
may imple- ment a compact for APRNs. On March 15, 2004, Utah was the first state to enter the
APRN Compact” (NCSBN, 2004).
The Nurse Practice Act is a set of state laws that govern the members of the nursing profession
in each state. The act differs from state to state but the common denominator is regulation for
the pro- tection of the public. The act “aims to protect the public from an unsafe nurse by
ensuring minimum requirements for the practice of nursing” (Mikos, 2004, p. 21). The board of
nursing influences how each state’s nursing profession implements and interprets the act based
on the authority granted to it by the state legislature and the governor. The spe- cific state
nurse practice act sets the foundation and authority of the board of nursing to establish and
maintain professional standards. The acts address common issues; establish the scope of
practice for professional, vocational and practical nursing; over- sees schools of nursing; and
sets the requirements for licensure. The acts also provide guidelines for discipline, that is,
supervision, suspension, and cor- rective actions.
Nursing is the protection, promotion, and opti- mization of health and abilities; prevention of
ill- ness and injury; alleviation of suffering through the diagnosis and treatment of human
response; and advocacy in the care of individuals, families, communities, and populations
(Nightingale, 1859, p.75). Definitions of nursing have evolved to acknowledge six features
essential to professional nursing:
■ “Provision of a caring relationship that facili- tates health and healing, “
■ Attention to the range of human experiences and responses to health and illness within the
physical and social environments, Integration of objective data with knowledge gained from an
appreciation of the patient or group’s subjective experience,
■ Application of scientific knowledge to the processes of diagnosis and treatment through the
use of judgment and critical thinking,
■ Advancement of professional nursing knowledge through scholarly inquiry, and
■ Influence on social and public policy to promote social justice. (ANA, 2004, p. 20)
The concept of ensuring ongoing competency for nurses is addressed differently in the 50 U.S.
states and territories. Some states require continuing edu- cation to document competency.
Other states feel that continuing education does not guarantee com- petency and that more
measurable standards should be sought.
State Boards of Nursing
The state boards of nursing oversee applications for the establishment of new schools of
nursing and subject them to a review to ensure the school’s quality and efficacy. Applicants are
required to demonstrate the ability to provide the material and human resources necessary for
success. Material resources include budgets, physical space alloca- tion, and library resources
for Internet and tradi- tional literature searches. Human resources involve the teaching and
administrative faculty’s clinical experience. All students should evaluate a nursing school based
on successful completion rates, NCLEX scores, and student–teacher ratios. When the students
are ready to apply to take the NCLEX examination, a Level II FBI criminal background check is
performed. Students must be aware that the Level II criminal background check includes any
and all criminal offenses regardless of the age of the applicant at the time of criminal activity.
Organizations for Political Action
The Internet allows nurses to stay connected to their profession, and it is important for today’s
nurse to remain actively involved. Tomorrow’s health-care policy changes are being developed
today and nursing can either lead these changes or remain a passive recip- ient.The Political
Action Committee (ANA-PAC) of the American Nurses Association (ANA), the national
professional organization for nursing, offers full-service representation for the entire nursing
population. The ANA-PAC is a bipartisan effort on behalf of the ANA that seeks to raise funds
used to improve health care. This committee uses the funds to endorse candidates who
demonstrate their sup- port of legislation and regulatory action that is in alliance with the goals
of the ANA (ANA, 2008a).
The National League of Nursing (NLN) strives to develop nursing leaders by setting standards
and improving nursing education. The Nursing Organization Alliance (NOA), a coalition of all
nursing organizations, offers a forum for collabora- tion on important issues that affect all the
organi- zations. The National Student Nurse Association (NSNA) provides educational and
resource support to future nurses.
American Nurse Association
The ANA is dedicated to the promotion of “health and the care of the sick [and] has served as
the forum for discussing the nation’s critical health issues throughout the last century” (ANA,
2005, p. 4). The ANA provides a structure that encour- ages and allows nurses to discuss,
debate, evaluate, and share thoughts that potentially drive the future goals of their profession.
It provides an avenue for uniting the voices of all nurses, inclusive of all practice settings. ANA’s
first meeting, in 1897, established goals “to establish and maintain a code of ethics; elevate the
standard of nursing education; and promote the usefulness and honor, the financial and other
interests of nursing” (ANA, 2005, p. 4). Over the years, these goals have been redefined based
on the core needs of current nurs- es. ANA advances nursing by encouraging high standards,
promoting nursing’s role in the work- place, and lobbying Congress and regulatory agen- cies on
health-care issues that affect nursing and the public (ANA, 2005).
The power of the ANA is seen in the strength of its affiliations. ANA’s Web site (2008) lists 21
pro- fessional nursing affiliates, which include the American Association of Critical-Care Nurses;
the American Association of Nurse Anesthetists; the American Psychiatric Nurses Association;
the American Association of Perioperative Registered Nurses; the Association of Rehabilitation
Nurses; the Association of Women’s Health, Obstetric, and Neonatal Nurses; the Emergency
Nurses Association; the National Association of Orthopedic Nurses; and the Oncology Nursing
Society. Through its current membership and the membership of its affiliates, the voice of the
ANA unites these various nursing specialties on policy issues and represents the nursing
profession of tomorrow. All nurses can benefit from the ANA’s (2003) trio of interlinked and
indis- pensable references that provide essential practice guidelines:
■ Nursing: Scope and Standards of Practice
■ Code of Ethics for Nurses with Interpretive
Statements
■ Nursing’s Social Policy Statement (ANA, 2003)
The NSNA is a 50,000-member organization that was started in 1969. The NSNA’s “mission is to
mentor students preparing for initial licensure as registered nurses, and to convey the
standards, ethics, and skills that students will need as respon- sible and accountable leaders
and members of the profession” (NSNA, 2008) This group sponsors scholarships for nursing
students, annual meetings, and educational resources.
issues throughout the last century” (ANA, 2005, p. 4). The ANA provides a structure that
encourages and allows nurses to discuss, debate, evaluate, and share thoughts that potentially
drive the future goals of their profession. It provides an avenue for uniting the voices of all
nurses, inclusive of all practice settings. ANA’s first meeting, in 1897, established goals “to
establish and maintain a code of ethics; elevate the standard of nursing education; and
promote the usefulness and honor, the financial and other interests of nursing” (ANA, 2005, p.
4). Over the years, these goals have been redefined based on the core needs of current nurses. ANA advances nursing by encouraging high standards, promoting nursing’s role in the workplace, and lobbying Congress and regulatory agencies on health-care issues that affect nursing
and the public (ANA, 2005).
The power of the ANA is seen in the strength of its affiliations. ANA’s Web site (2008) lists 21
professional nursing affiliates, which include the American Association of Critical-Care Nurses;
the American Association of Nurse Anesthetists; the American Psychiatric Nurses Association;
the American Association of Perioperative Registered Nurses; the Association of Rehabilitation
Nurses; the Association of Women’s Health, Obstetric, and Neonatal Nurses; the Emergency
Nurses Association; the National Association of Orthopedic Nurses; and the Oncology Nursing
Society. Through its current membership and the membership of its affiliates, the voice of the
ANA unites these various nursing specialties on policy issues and represents the nursing
profession of tomorrow. All nurses can benefit from the ANA’s (2003) trio of interlinked and
indis- pensable references that provide essential practice guidelines:
■ Nursing: Scope and Standards of Practice
■ Code of Ethics for Nurses with Interpretive
Statements
■ Nursing’s Social Policy Statement (ANA, 2003)
The NSNA is a 50,000-member organization that was started in 1969. The NSNA’s “mission is to
mentor students preparing for initial licensure as registered nurses, and to convey the
standards, ethics, and skills that students will need as respon- sible and accountable leaders
and members of the profession” (NSNA, 2008) This group sponsors scholarships for nursing
students, annual meetings, and educational resources.
nursing education perspectives. The organization identifies goals to meet the needs of its
diverse population in their changing health-care envi- ronment. NLN supports and champions
the advancement of nursing education (NLN, 2007). The NLN will shape and influence the
future of nursing by supporting nursing education for all nurses and nursing students,
influencing the policy decision-making process by shaping tomorrow’s health-care system.
Policy Models: A Guide
Conceptual models are important because they illustrate a process graphically. The following
poli- cy models demonstrate the evolution of political awareness in nursing. The first model,
Conceptual Model of Political Development, provides an overview of the developmental stages
of the nurs- ing profession. Over time, the profession has evolved, moving through various
stages of policy development. The second model, The Four Spheres of Political Influence,
demonstrates the power of the policy process. The model visually demonstrates the
intersection of communities that impact today’s health-care environment.
Conceptual Model of Political Development
The Conceptual Model of Political Development was published by Cohen and colleauges (1996)
and describes the political development of the profes- sion. “The model stages mirror the
stages that individual nurses navigate to become key players in policy arenas. The stages are:
■ “Buy-in
■ Self-Interest
■ Political Sophistication ■ Leadership”(p.261)
The first stage of the model addressed the awaken- ing of nursing to the importance of the
policy process and the impact it has on their profession. In the late 1960s and early 1970s,
policy decisions related to and impacting nursing were decided without the input of nursing
organizations. Nursing leaders recognized that as a profession, nursing needed to become
politically active. To gain a voice nurses needed to unite around com- mon policy issues and
thus develop Buy-In from the profession. “Nursing’s first political action com- mittee (PAC),
Nurses Coalition for Action in Politics, was formed by a small group of savvy nurse leaders in
New York” (Mason et al, 2007, p. 12). This group later became the Political Action Committee
for the ANA.
Stage 2 is Self-Interest. The nursing profession moves into this self-interest domain when, as a
professional group, it determines its policy interest and voice (Cohen et al, 1996). Nursing’s
commit- ment is demonstrated by individual donations of support. This funding provides
nursing the power needed to gain support at a state and national level. Through individual
nurses’ participation, the ANA-PAC became the third largest health-care federal interest group.
Over time, the Political Sophistication stage takes shape. By the mid- to late-1990s, policy
makers started to recognize nursing as a powerful voice in health-care reform. In 1997,
President Clinton supported nursing through the appoint- ment of national nursing leaders to
the Advisory Commission on Consumer Protection and Quality in the Healthcare Industry. The
commission’s goal was to reform the health-care system in the United States. It gave prominent
position to nurses in its recommendations for reforming health care. Although in 2004
President Clinton’s health-care reform plan failed by not passing in the Senate, nursing did
make progress. Advanced Practice Nurses (APNs) gained the ability to bill the Centers for
Medicare and Medicaid Services (CMS) under the indirect supervision of a medical physician
and the ability to deliver care to hospice patients. One result of this change was the increased
enrollment of nurses in the master’s-level nurse-practitioner track, but the outcome was not as
positive as expected because the health-care reform movement did not accomplish its original
goals. ARNPs, in many areas of the country, were left feeling as though they were caught
between medicine and nursing. Health care has yet to rem- edy the policy issues that caused
this chasm within the system.
Stage 4, Leadership, is the political identity that nursing is striving to attain and is the highest
level of political involvement. By achieving this stage, nurses will become the initiators and
directors of future policy and will acquire a multidimensional focus unified around a common
purpose. In addition, nurses at this level will be able to commu- nicate in the language of the
policy maker, feel con- fident, and gain acceptance in positions of authority. Once this stage has
been reached, nurses would potentially be considered for such roles as Secretary for Health and
Human Services, university presi- dents, cabinet positions, legislators, and appointed
government officials. Since the 1990s, nurses have achieved leadership roles in health-care
policy development (Rubotsky, 2000; Wakefield, 1997). A more consistent presence of nurses
at this leader- ship level will ensure nursing’s involvement in crit- ical policy changes.
Historically, the nurse has been an advocate for patients, and the public will benefit from
nursing’s assumption of leadership roles.
Scenario
Jeanne Blum, RN, is a nurse on a
bonus chapter 2 | Triaxial of Action: Policy, Politics, and Nursing 29
LDRP unit. Recently, the policy and procedures manual for Jeanne’s unit included the premature rupturing of membranes of a laboring patient as a practice acceptable for nurses to
perform. Jeanne and some of her coworkers shared their concern over lunch about this new
responsibility.They felt uncom- fortable with the possibility of cord prolapse and other potential
medical complications resulting from this practice. Jeanne gathered data from her state and
many others states and noted that her hospital was not in compliance with her professional
organization practice standards. Jeanne shared this information with her coworkers. She
volunteered to contact state board of nursing on their behalf to request a declaratory
statement on the nurse’s role in the initi- ation of premature rupturing of uterine membranes.
Her state board’s clinical practice committee reviewed her request for a declaratory statement
and gathered information from other states. A formal declaratory statement was drafted by the
board and made it available on its Web site. A letter from the board was sent to Jeanne’s
institution, informing it of the declaratory statement, which stated that the task nurses were
requested to perform was beyond their scope of practice based on the Nurse Practice Act.
Which stage of the policy model does this scenario represent? ■
Four Spheres of Political Influence
More than 25 years ago (1973), Wilma Scott Heide addressed nurses’ leadership roles within
society and the health-care system. As the then president of the National Organization for
Women (NOW ), she challenged nurses to become leaders and developed a model that
depicted the four spheres of political action. These spheres—Workplace, Government,
Professional Organization, and Community—are still relevant to nurses in today’s environment.
It is important to realize that the four spheres are over- lapping and interconnected. The
community sphere, however, touches all of the other spheres.
The first sphere, Workplace, is impacted by pro- fessional organizations, government, and
commu- nity standards. The mandated implementation of safety locks on all needles by the U.S.
Occupational Safety and Health Administration (OSHA) is an example of a workplace policy.
Data demonstrated that nurses were incurring a growing number of workplace needle-stick
injuries in their daily rou- tines. Nurses were most vulnerable when dealing with needles used
in the treatment of patients who may have had blood-borne pathogens. Karen Daley (2000), a
registered nurse, played a key role in the policy change regarding the mandated use of safetylock needles by health-care facilities. By sharing her personal and professional story, she
provided a human side to the dangers of needle-stick injuries. With the assistance of
professional nursing organ- izations and members of the U.S. House of Representative and
Senate, bills were submitted and eventually passed (Mason et al, 2008).
The designation Magnet Recognition Program for Nursing by the American Nurses Credentialing
Center (a subsidiary of the American Nurses Association) is another example of nurses assisting
in the development of workplace policies. The goals of this program are to
■ promote quality in a milieu that supports professional practice;
■ identify excellence in the delivery of nursing services to patients/residents: and
■ provide a mechanism for the dissemination of “best practices” in nursing services (American
Nurses Credentialing Center, 2008).
The program is based on a foundation of collaborative problem-solving and decision-making
that promotes the autonomy of the staff nurse. “When nursing is given authority in line with
their respon- sibility, autonomy, and control over patient care resources, they are in a better
position to establish positive relationships” (Aiken, Havens, and Sloane, 2000, p. 32). Nurses are
impacted by the policy and procedure in their health-care institutions. As they enter into the
work environment, nurses should take an interest in the process of policy develop- ment.
Magnet-designated nursing divisions foster this interest by delineating roles and responsibilities in governance of the staff nurse.
Government, as the second sphere, affects all of us. Government plays an important role in
nursing, defining what nursing is and what nurses do, influ- encing reimbursement, and
affecting access to care. An example of government providing leadership in addressing public
and private concerns is its reaction to the Institute of Medicine (IOM) report “To Err is Human:
Building a Safer Health System” (2000). The IOM report revealed that the U.S. health-care
system was killing anywhere from 44,000 to 98,000 people a year. It spearhead- ed active riskmanagement and performance- improvement measures and stimulated efforts to increase the
quality of care.
In another example, the Legislative Network for Nursing (LNN) discussed the Joint Commission’s
(TJC) “speak-up program,” which empowers patients to be involved in their care and
encourages them to take an active role in decision-making (LNN, 2005). This report emphasizes
the impor- tance of listening to the voice of the patient to achieve improved health-care
outcomes. The patient should be encouraged to speak up when something is not quite right
about the care being received. For example, a nurse can educate the patient to ask about a
discrepancy in medications— a different-color pill, altered day or time, and so on. The nurse
could then stop the administration of medication immediately and validate the five rights of
medication administration. (Considering that the data in the IOM report were collected in 1999
and published in 2000, one may question why the health-care system took so long to
implement cor- rective action. In 2009, we still see hospitals strug- gling to put this program
fully in place.)
Professional Organizations, represented in the third sphere, have been instrumental in shaping
nursing practice and developing standards of care. These powerful organizations have through
their lobbying efforts influenced how the public envi- sions nursing. Having a nursing presence
on the national and state levels in legislative campaigns ensures that nursing’s agenda will be
promoted. At the 2006 ANA House of Delegates meeting in June, however, it was noted “the
membership of the ANA was down to 150,000. This is a decline of about 25 percent in the past
decade and represents only 5% of the 2.9 million nurses in this country” (Mason, 2006, p. 11).
This professional organiza- tion represents nurses, communicates their values, and speaks on
their behalf. The organization and its affiliates are essential advocates for both nurses and
patients, but they need nurses collectively to sup- port their efforts.
The fourth sphere, Community, could be one’s neighborhood and/or extended neighborhood
via the Internet involving groups of people with like interests. The first three spheres co-exist
within the sphere of community. Nurses rely on community resources, and these resources
become invaluable in the promotion of health treatments. “Government officials, health care
administrators, patients, cor- porate managers, presidents of private and public organizations—
all players who can effect change in health policy—are affiliated with at least one com- munity:
the one in which they live”(Mason, Leavitt, and Chaffee, 2002, p. 15). Nurses need to
remember that in their community—local or worldwide—they are representing their
profession.
Nursing and Political Action
The nurse’s world has changed dramatically over the last 100 years. The profession has seen
dramatic changes in health-care policy, and these changes have reshaped the concepts and
foundations on which health-care systems have evolved. But even as the health-care systems
changed, the nurse’s role has remained pivotal as the nucleus of the health delivery system.
Unfortunately, the role of nursing often goes unnoticed until it is absent. Nurses are poor at
marketing the unique value that they bring to the health-care delivery system.
The registered nurse is the only health care profes- sional who is specifically educated to: 1)
assess the patient to determine health status and risks, unhealthy lifestyles, minor health
problems, and health education needs for patients and their fami- lies; 2) provide support and
reassurance while car- ing for present or potential health problems; and
3) advocates for primary and preventative care serv- ices. (ANA, 1997, p. 4)
Now is the time for nursing to identify and articu- late the importance of its role in the healthcare system. Nursing cannot afford to wait to be noticed or to be invited to offer its perspective
if it wishes to be part of the decision-making process in policy development.
Novice Role: Nursing and Policy
Today’s nurses are just beginning to understand and to become active in the legal decisions
that are impacting the health and wealth of the system. Historically, nurses have functioned as
an oppressed group in a patriarchal health-care system. Gender is still an issue, as over 90% of
graduating nurses are female (NLN, 1994). Based on these statistics, nurs- es should be in a
position of power, but instead, as Baer (1997) stated, “nurses blame each other for nursing’s
problems, rather than the system” (p. 257). The profession must seek to identify common
goals, unite around these goals, and communicate with a single voice. Nursing must envision
the value of lending a voice to the political process. Nurses understand the importance that
policy plays in the nursing profession and realize that if health care is to retain a caring focus
while it seeks to control the economics of the system, they must become involved. Nurses
today struggle to assure that in an industry focused on cost containment, caring remains a core
value. Political caring is the balance of caring related to values and the struggle for scare
resources (Ray, 1989).
“The perfect health care system is like perfect health—a noble aspiration but one that is
impossi- ble to attain” (Bodenheimer and Grumbach, 2002, p. 206). McLuhan and Fiore (1968)
described the world as “a global village in which each one affected all inhabitants” (Milstead,
2004, p. 249). The reality is that the United States does not have a health-care system to which
other countries aspire. The U.S. health-care system ranks poorly in comparison to other
countries’ systems, and the United States is the only industrialized country that has been
unable to implement universal health care for its citizens (Conyers, 2003, p. 193). Moreover,
the problems that plague the U.S. health-care system are not evenly distributed throughout
society. There is a correlation between poverty and lower social status and poor health,
nutrition, and limited access to health care. Gender and ethnicity also impact access to care.
Nursing assists the patient in gaining health-care access.To be effective in today’s health-care
delivery system, nurses need education in order to under- stand the economics that drive the
system. Ignoring the business rules related to health care will impact the quality of the services
nurses can deliver.
Nursing Values Policy
“Nurses represent the largest aggregate of health care professionals, well over 2 million in the
United States alone, and yet their participation in policy decisions has traditionally been
minimal” (Griepp, 2002, p. 35). Nursing has the knowledge, experience, and ability to offer
invaluable insight into the issues that are plaguing the health-care system, a complex and
chaotic system about all aspects of which nurses
are uniquely qualified to speak. Nurses, as members of an interdisciplinary team, are at the
bedside of the patient, supporting the patient’s family and carrying out the plan of care
indicated by the physician. Nurses cannot afford to be one-dimensional in their approach to
decision-making and problem-solving. Their ability to adapt to a changing environment, to
demonstrate technical knowledge, and to utilize a keen sense of intuition based on previous
experi- ence makes them key to the success of any policy effort. Who better to drive the policy
planning and development?
The policy process is a fluid system that address- es community needs, develops a strategy and
carries it through to a legislative solution. “Public policy is policy made at the legislative,
executive, and judicial branches of federal, state, and local levels of govern- ment that affects
individual and institutional behav- iors under the respective government’s jurisdiction”
(Harrington and Estes, 2008, p. 7). Once solutions are implemented, the evaluation process
cannot be undervalued or forgotten. It is important that the evaluation of policy is ongoing,
ensuring that the policy results remain positive. Without an objective evaluation of the change
implemented, alterations to policy may compound the problem instead of solve it.
Policy Position and Ethical Practice
“Ethics is a generic term for various ways of under- standing and examining the moral life”
(Beauchamp and Childress, 2001, p. 1). According to Shroeter, Derse, Junkerman, and
Schiedermayer’s book Practical Ethics for Nurses and Nursing Students (2002), today’s healthcare environment of cost containment has added ethical stressors that impact health-care
delivery. The nurse faces stressors that strain the relationships between the provider and the
patient. These pressures include the following:
■ Divided loyalties
■ Limitations on authorized tests and treatment
■ Limited choice of physician specialist and treatment facility
In addition, such problems as a CEO’s padding of profits, carriers “cherry-picking” patients,
confi- dentiality, restricted access offered to indigent patients, and limitations on medical
choices are common occurrences in today’s health-care envi- ronment. In responding to the
community’s health needs, nursing is affected by policy initiatives and ethical issues.
In today’s health-care environment, nurses strive to utilize ethical principles in their
relationships with patients, families, and other health-care pro- fessionals. Honoring patients’
wishes and listening to their needs are foundational ethical principles that build to “a first step
in transforming our healthcare environments into sanctuaries of healing and excellence”
(Rushton, 2007, p. 154). Health- care professionals frequently face ethical dilemmas. Each
member of the interdisciplinary team has a different view when approaching a complex situation that lacks a clear treatment option. It is impor- tant for the nurse facing these difficult
circum- stances to analyze the situations honestly, articulate the options, include the patient
and/or family in the decision, acknowledge the acceptance of moral conflict, and utilize best
judgment in selecting the correct path.
Nursing Policy Issues
Why should nurses become active in the develop- ment of policy and politics? To strengthen
their profession, they need to become a voice that is val- ued and heard. Legislative issues
impacting nurses today include nursing shortages, safe patient lift- ing, mandatory staffing
ratios, access to care, and nurse specialization. Starting in 1999 and for the next 7 consecutive
years, nursing rated highest in an annual honesty and ethics poll conducted by the Gallup
organization. In the most recent survey, “eighty-four percent of Americans called their honesty
and ethical standards high or very high”
(Gallup Survey, 2008, p. 1). It is not surprising that nurses consistently have ranked first over
the years, as every American family has experienced hospital- ization of a loved one. When this
occurs, nurses are ever present—meeting the needs of the patient and the family and providing
valuable support (Johnson and Johnson, 2008). As trusted profes- sionals, nursing is responsible
for championing policies that will improve nursing and health care for the future.
Nursing Shortage
According to the American Association of Colleges of Nursing (AACNa, 2008), the United States
is experiencing a nursing shortage, the negative impact of which will increase as the Baby
Boomer genera- tion moves into retirement. To compound the prob- lem, there is a significant
shortage of nurse faculty as colleges and universities try to increase their enroll- ment. Statistics
from the National Council of State Boards of Nursing (NCSBN), seen in Table 1, indi- cate that
the number of first-time nurses taking the NCLEX exam decreased each year from 1994 until
2002. The trend reversed, however, in 2003, when the numbers began to increase each year. It
took a decade (from 1995 to 2005) for the total of number of test-takers to surpass the 1995
statistics, a trend that has continued. The good news is tempered, however, when the census
data for those same years are examined. In 1995, the U.S. census counted 260 million people,
and by 2006 the number increased to over 299 million.
Also noted in Table 1 are the significant numbers of internationally educated students, which
showed a marked increase after 2002. Dr. Peter Buerhaus and colleagues conducted a study for
the Journal of the American Medical Association (2000) that pre- dicted a 20% shortage of
nurses in the year 2020. AACN published a report, 2003–2004 Enrollment and Graduations in
Baccalaureate and Graduate Programs in Nursing, stating that 15,944 qualified nursing
applicants were turned away from baccalau- reate nursing programs due to a lack of faculty and
facilities (AACN, 2004b). This issue is being addressed at the state and national legislative levels
through bills that offer scholarships to entry-level nurses and advanced degrees to encourage
pursuit of faculty positions. Funding is being sought to increase the number of nurse educators;
however, with many state budgets being reduced during the economic recession, these dollars
may be difficult to find.
Mandatory Staffing Ratios
The Department of Human Services (DHS) man- dated that California implement a mandatory
nurse-to-patient ratio as of January 2002. The California Hospital Associations (CHA) and
Association of California Nurse Leaders (ACNL) proposed the minimum ratios. The health-care
industry lobbied against the mandatory nursing ratios, feeling that the cost of the minimum
staffing standards would be a burden when it came to recruitment and salaries. The mandatory
staffing ratios has resulted in closures of patient units and increases in staffing expense as a
result of not having the staff on hand to meet the ratio requirement. California has struggled to
meet the staffing requirements and has recruited from out- side the United States in an effort
to bolster the pool of potential nurses. Nationally, a trend has developed of nurses within the
United States being willing to go to California for short periods of time. These nurses are drawn
by the high salaries and short-term commitment. Short working stays and high hourly salary
rates in California allow the nurses to return to their home states, having achieved their
previous yearly income in far fewer months. The high cost of liv- ing in California relative to
other states makes permanent relocation not a desirable option.
However, the shift of working nurses to California has produced a nursing resource deficit in
other states.
Policy recommendations on this issue are pending in many states, and the nursing profes- sion
needs to actively engage legislators on the proposed bills. Proponents of this legislation cite
research studies that document a direct rela- tionship between higher nursing staffing ratios
and negative patient outcomes (Aiken et al, 2002; Needleman et al, 2002). Nurses support
ratios, seeking to improve their working condi- tions and enhance safe patient care. The following is an excerpt from “Experienced Nurses Tell Their Story” published by the ANA in June 2008:
I have been a nurse for 13 years. I f ind myself strug- gling day to day with the increase in
patient acuity and the nurse to patient ratios. You stand on your feet for more than thirteen
hours without lunch breaks most days! There needs to be change in the whole country, and
lawmakers need to enforce the safe staffing act or hospitals will continually subject nurses to
unsafe working conditions. The majority of skin breakdown and falls could be prevented if
ratios were lower, and nurse burnout would be another area that would decrease! I hope
someone listens, I hope positive results will happen, because I will probably be joining that
group of RNs that decided to leave the profession for good.
–A Registered Nurse who practices in Connecticut. (ANA, 2008b, p. 1)
“However, mandatory ratios, if imposed nationally, may result in increased overall costs of care
with no guarantees for improvement in quality or positive outcomes of hospitalization”
(Welton, 2007, p. 1). A recent review of nearly 100 staffing studies by the Agency for Healthcare
Research and Quality AHQR did not find a causal relationship between nurse staffing levels and
patient adverse events and mortality (Kane et al, 2007). The status of the eco- nomic health of
the United States in 2008 and beyond as well as the shortage of available nurses makes it
appear that mandatory nurse staffing ratios will be a difficult legislative initiative to sell.
In 2008, ANA launched a campaign called Safe Staffing Saves Lives. ANA is committed to safeguarding the critical role that nurses play in patient safety and quality care. The ANA has,
however, tempered its approach to legislative mandated ratios, as was used in California, with a
less pre- scriptive proposal, maintaining the roles of hospi- tals and nursing in accountability
and decision- making on this issue. ANA’s proposal offers a broad approach that allows each
facility to tailor nurse staffing to the specific needs of each unit, based on factors including
1. patient acuity, the experience of the nursing staff, 2. the skill mix of the staff,
3. available technology,
4. and the support services available to the nurses
(ANA, 2008).
This stance protects the professional status of nurses, allowing them to govern their
environment and to make key decisions related to their patients. The IOM stated, “nursing is a
critical factor in deter- mining the quality of care in hospitals and the nature of patient
outcomes” (ANA, 2008, p. 2). These efforts seem congruent with the need to fos- ter a positive
working environment that in turn will help retain nurses.
Policy Affecting Nursing
Nurses are seeking practice environments that allow them to work efficiently, effectively, and
comfortably while at the same time integrating patient-centered
care. Due to increasing fragmentation, the poor coor- dination of health-care services, and the
resulting acceleration of costs, the current health-care system can no longer support additional
spending. Health- care providers are resigned to the need to identify and offer the highest
possible quality of care at the avail- able level of expenditure. Nursing is affected by these costcontainment efforts. At the same time, the pub- lic and payers are demanding improved patient
safe- ty and clinical outcomes. In order to increase the public’s trust in the health-care system,
legislators have implemented regulation to increase the trans- parency of health-care outcomes
and have made this information available to the public. Facilities are now required (either by
regulation or through reduced reimbursement) to report patient safety and outcome
information to various agencies. Multiple agencies are involved in this patient safety effort.
Cost-Containment Initiatives
For over two decades, the U.S. health-care system has made incremental changes to reduce
spending. The efforts have not succeeded, and some might say that the efforts to rein in
spending have created a more bureaucratic system, adding administrative costs. “National
health spending is estimated to have grown almost 7 percent in 2007, reaching over $2 trillion,
or roughly $7,800 person. The growth rate is expected to hold steady at nearly 7 percent
through 2017, reaching more that $4 trillion dollars” (Keehan et al, 2008). In 2008, the United
States was the only industrialized country without federally supported health care. In addition,
Americans today spend more out-of-pocket dollars on health care than citizens in any other
industrial- ized countries (Bodenheimer and Grumbach, 2009). The rising health-care costs have
been asso- ciated with increased barriers to access and the inclination of patients to choose,
because of their personal budgets, not to follow their plan of care (e.g., refilling prescriptions,
scheduling nonacute surgical procedures, seeking preventative care, visit- ing the physician for
nonacute health problems, etc.) (Commonwealth Fund, 2008). As a result, hospital emergency
rooms are experiencing an increased number of patients who are uninsured and underinsured.
In 2007, the number of unin- sured persons in the United States had risen to over 47 million,
with 25% of these individuals making less than $25,000 per year (Bodenheimer and Grumbach,
2009). Uncompensated care provided to these citizens has further increased the health- care
expense to providers across the country.
Managed care has responded by increasing insurance premiums to employers and patients. The
cost of the Medicare and Medicaid programs, as a percentage of the gross domestic product
(GDP), has risen dramatically and is predicted to rise even higher with the aging of the Baby
Boomer genera- tion. Medicare and Medicaid programs have imple- mented guidelines aimed
at ensuring that the services provided are appropriate and necessary and address the patient’s
problem. When compared to the other industrialized countries, a large part of the higher level
of health-care spending in the United States is related to the utilization of technology.The
United States develops, implements, and utilizes technology at a higher volume that other
nations, yet the outcomes do not demonstrate a higher level of outcomes for the
patient.(Bodenheimer and Grumbach, 2009).
During the 2008 presidential election, the nation cast its vote, in part, for health-care reform.
The current system cannot be sustained and will be particularly strained at a time when the
nation has limited surplus money. Most providers feel there is overuse of the resources in the
system, yet feel the public expects this level of care. In 2006, 74% of the people felt the system
was in a state of crisis (Bodenheimer and Grumbach, 2009).
A national health plan, making health care an entitlement for all citizens, has been attempted
many times in the 20th century, and each time opposition has successfully defeated the efforts.
In 2009, President Obama pledged to improve health- care access to all citizens while reducing
unneces- sary health-care spending. The U.S. health-care system has been called a paradox of
excess and dep- rivation (Enthoven and Kronick, 1989). Health care is distributed unequally
across the nation; spending varies for the same needed services from state to state and citizens
who have paid for insur- ance feel they are entitled to the highest level of care. Yet, there
remains a large subset of the popu- lation, commonly the poor and minorities, who consistently
receive the lowest level of care.
Nursing has an opportunity to support and par- ticipate in the health-care reform effort. The
nurse’s perspective offers a unique view of health-care delivery. Nursing provides insight that is
needed to ensure that health-care reform choices make sense. Nursing’s role in this process will
be an
important investment toward ensuring that quality health care is made available to all, that the
system investment in nursing will support successful implementation of these changes, and that
all citi- zens are afforded equal health-care choices.
Quality Data Reporting
Quality initiatives are changing the health-care environment by requiring ongoing monitoring of
outcomes. Many organizations, including the ANA Quality Initiative in 1994, the National
Database of Nursing Quality Indicators (NDNQI) in1997, the National Quality Forum (NQF) in
2006, CMS in 2007, and TJC in 2007, have endorsed mandated data reporting of patientfocused indicators. These indicators offer transparency of high-volume, problem-prone,
patient-care outcomes (Swan, 2008; Table 2).
NDNQI data submission is voluntary. “More than 1,200 hospitals in fifty states including the
District of Columbia participate in NDNQI as of early 2008” (Swan, 2008, p. 195). Nursesensitive indicators are based on three concepts that are felt to be directly impacted by nursing
interven- tions: (a) structure (FTEs and staff mix), (b) process (assessment), and (c) patient
outcomes. The analysis of quality data has provided identification, measure- ment, and
benchmarking of patients outcomes related to interventions of acute-care registered nurses.
“The CMS incentivized conditions, NDNQI nursing-sensitive acute care indicators, and the
fifteen nursing-sensitive indicators endorsed by the national quality forum (NQF) address many
similar issues”; their integration and intersection is depicted in Table 2 (Swan, 2008, p. 196). It is
interesting to note that the IOM report “To Err is Human” was published in 2000, and the study,
revisited in 2002, showed only minor quality improvement in the U.S health-care system. CMS,
beginning in 2007, announced that it would cease to pay extra for specific hospital-acquired
conditions that have been identified as avoidable.
Payment for Performance
Stimulated by the quality initiatives, the need for accountability, and public disclosure, the Bush
administration enacted the Deficit Reduction Act (DRA) of 2005. This legislation required a
quality adjustment in the Medicare DRG payment for certain hospital-acquired conditions,
because indicators pointed to a growth in the number of hospital-acquired complicating
conditions. Based on the nurse’s visible position as the provider directly responsible for patient
assessment and intervention, many of these hospital-acquired con- ditions can be prevented.
Competent nursing care, therefore, can help hospitals minimize lost revenue while at the same
time safeguard the outcomes of its patients. The program, titled “Hospital- Acquired Conditions
and Present on Admission Indicators Reporting” (HAC & POA), is a dramat- ic payment rule
change for Medicare. CMS is responsible for safeguarding the Medicare Trust Fund and is a
response to the predicted shortfall in this fund over the next 10 years. Commercial insur- ance
carriers have also implemented payment rules that are aligned with these new CMS practices.
In preparation for this program, hospitals in selected states began coding POA complication
codes and gathering data in October 2007. Beginning in October 2008, patients with these
codes, not indicated as POA and with no other severity complicating condition (cc) as described
in the bill, are no longer qualified for the higher DRG (Federal Register, May 3, 2007). This policy
is based on an economic and quality perspective designed to improve and safeguard the U.S.
health- care system for tomorrow’s citizens.
Report Cards—Transparency
“Regulators, employers, and payers say that public reporting can encourage best practices”
(Hanys, 2007, p. 11). The publication of the IOM’s 2000 report stimulated a number of patient
quality initiatives and encouraged many public and private organizations to seek ways to
communicate and provide transparency about safety to the public. Following the IOM report,
state and federal legislatures stepped in and implemented data-collecting and reporting tools
aimed at making health quality transparent to the public. The Leapfrog Group, comprised of
150 pub- lic and private organizations, was formed to encour- age significant change in the
safety of health care in America (Binder, 2008). It collected data and format- ted it to be
understandable and accessible to the public, the ones making the decisions regarding care sites
and providers. In addition, this group sought to create financial rewards for reported positive
out- comes to promote high-quality health care.
The Quality Initiative was launched nationally in 2002 for nursing homes and was expanded in
2003 to home health agencies and hospitals. In 2004, the Quality Initiative was further
expanded to include care settings for the end stage renal disease ESRD patient. With the
support of the CMS, AHRQ, The Joint Commission, and many other organizations, a hospital
quality report card was created for the pub- lic. Private organizations and state repositories
were compiled to offer consumers access. Web sites such as www.healthgrades.com provided
comparative mortality data and corrective reporting related to a physician and/or a facility.
These reports are offered for a nominal sum to the consumer.
In 2005, the CMS launched a Web site, www.hospitalcompare.hhs.gov, allowing patients to
look at how the hospitals in their city performed. The reporting on this site, created through the
efforts of the CMS, the Department of Health and Human Services, and other members of the
Hospital Quality Alliance (HQA), was considered voluntary; however, an incentive of a 0.4%
reduction in CMS payments was instituted in 2005 for nonparticipating facilities. Specific
measures of medical and surgical outcomes were collected from patient surveys, which were
sent to recent patients and contained questions regarding the quality of care they received
during their hospital stay. The survey responses were sorted into “process of care measures,”
providing percentages that allowed the public to see how the respondents rated the health
care provided. The process of care measures included the following:
■ Eight measures related to heart attack care
■ Four measures related to heart failure care
■ Seven measures related to pneumonia care
■ Five measures related to surgical care improvement ■ Two measures related to asthma care
for
children only (CMS, 2008)
This information is made available to health- care consumers on the Web site and was designed
to provide the patient with information to allow comparison of one health-care facility with
another (Hospital Compare, 2008). Researchers continue to evaluate evidence and measures
that warrant reporting. These data also support guide- lines that are created to assure
evidence-based and safe health-care practices.
Growing Need for Policy Action
The role of the Health and Human Services Department includes directing the nation’s efforts
to protect the health of all Americans and provide services to the needy.This department is one
of the largest civilian departments in the government. Following the departure of Tommy
Thompson, the 20th secretary, Michael O. Leavitt was sworn into office. His efforts during his
tenure have included enrolling millions of seniors and disabled persons in the new Medicare
prescription drug program; mobilizing the nation’s pandemic preparedness; increasing the
implementation of health informa- tion technology standards; overseeing the medical response
to national disasters; changing Medicaid statutes to provide insurance coverage to more people; and initiating a nationwide campaign to trans- form the health-care sector into a valuedriven sys- tem. His focus includes a desire to make health care more transparent in both
quality and price. Leavitt is also challenging the drug manufacturers to reduce the time and
expense of bringing safe and effective drugs to market.
Historically, nurses have separated the roles of policy and practice as health-care providers.
White (1985) offered one explanation grounded in the nursing belief that “policy is the domain
of man- agers and practice the domain of nurses” (p. 28). In 1992, Sohier stated that while
nurses are positioned to influence policy-making and development, few have the knowledge or
hold the power positions that allow them to do so. In order to change the course of policy
events, nurses need the knowledge of leadership and decision-making skills to influ- ence
future legislation and policy; however, nurses have demonstrated a deficiency in these areas.
But today’s nurses find themselves in a challenging
industry in which the U.S. economy can no longer support the rising costs of health care. Nursebased expenses are examined closely. To ensure that soci- ety does not underinvest in nursing,
nurses must develop knowledge of public policy and the legisla- tive process. Education
programs offered to under- graduate and graduate nurses that include public health policy as a
requirement for preparation will help nurses gain the skills needed to influence the political
process.
Nursing has an opportunity to comment and participate in policy changes via the Internet and
through professional organizations. The CMS publishes proposed policy changes in the Federal
Register and notifies providers, offering a comment period. CMS regulations and policy are
commonly implemented by other commercial carriers. All nurses can participate in these CMS
comment periods easily from work or home. Professional nursing organizations—such as the
ANA, NLN, Nursing Specialty Organization, and so on—can unify efforts for lobbying and
political action activ- ities, synthesizing proposed legislative bills and set- ting nursing’s own
political agenda. Based on the numbers and specializations within the nursing field, it may not
be realistic to think that the pro- fession will ever agree on a specific course of action for any
one legislative action. Consensus may, how- ever, be reached when enough members
participate and become active. It is important to contact pro- fessional nursing organizations
and provide feed- back or attend meetings. The nursing voice is the only way the nursing
perspective will be heard.
Patient Advocacy
determined by work and income criteria that differ between states.” (National Academy of
Science, 2003a, p. 1)
“To see what is right, not do it, is want of courage or of principles” (Confucius circa 551–479
BC). This quote from an ancient Chinese philosopher supports the more current definition of
advocacy by Corish (2005): “the term advocacy can be stated in its simplest form as standing up
for what one believes and for both self and others” (p. 478). Smith (2004) stated that advocacy
has been recog- nized as an important nursing responsibility since the time of Florence
Nightingale. The definition and responsibilities assigned to the action of advo- cacy, however,
are multifocal. Nurses, as advocates, promote the ability of the patient to make informed
decisions, acting as the liaison between other providers and individuals (Marguis and Huston,
2009).
Access to Care
Who are the uninsured in the United States today? They include people of all ages, races,
educational levels, and geographic regions. The number of uninsured Americans has risen
significantly over the last 10 years, and it is estimated that over 47 million people are now
without health insurance (U.S. Census Bureau, 2007). Over the years, this topic has been
discussed in the media and debated by policy makers, with no resolution. The IOM’s Web site
(2008) mentions that the result of the ris- ing number of uninsured means that a population of
citizens in diminished health—who use more resources when they access health care—is more
likely to die prematurely. Often the care of the uninsured goes unpaid, and these costs are
often absorbed by physicians, hospitals, and other providers. “As insurance premiums rise and
more employers drop coverage, an increasing number of Americans are living without health
insurance. Nearly 90 million people—more than one in three non-elderly Americans—went
without health coverage for all or part of 2006–2007” (Families USA, 2007, p. 1). Issues and
facts that broaden our understanding of the magnitude of the problem of limited access to care
include the following:
1. Four out of five of uninsured individuals repre- sent working families. (Families USA, 2007)
2. Employment and geographic demographics are
important and affect the uninsured numbers as private insurance is “closely tied to
employment and eligibility for public programs are partly
3. Families with incomes lower than 150% of the Federal Poverty Level (FPL) show a rise in the
number of uninsured. (National Academy of Science, 2003a)
4. New Census data show that 8.1 million chil- dren under the age of 18 were uninsured in
2007. This is a slight decrease since the previ- ous year, but 428,000 more than in 2004, the last
year there was a decline in the number of uninsured children. (Families USA, 2007)
5. The United States health-care system has failed to provide universal health care and has
evolved through incremental advances into a “patch- work of care in which many holes
remain.” (Etheredge and Uhlig, 2003, p. 1)
6. Single-parent homes or homes with minorities and young adults between 18 and 34 years of
age are most likely to have no insurance. It is important to note that public coverage for
children ends at their 19th birthday unless they are in school. (National Academy of Science,
2003b)
The risk of becoming uninsured touches us all. Policy initiatives appear to be a long way off
from achieving the goal of universal care. The ANA has lobbied and supported universal health
care since the early 1900s, stating “only a single-payer system, fairly funded and universally
applied, will make healthcare a right of everyone living within our borders” (ANA, 1999, p. 6).
Trust in the System
“Trust is the expectation that individuals and institutions will meet their responsibilities to us”
(Kirkman, 2003, p. 174). Over the last 10 years, an increasing number of patients have lost trust
in the health-care system and providers have lost trust in the patients whom they are trying to
help. Patients feel that their wants and needs are not the priority of the medical care system.
Greed, as a motivating fac- tor, appears to be a growing concern. The relation- ships have
changed among patient, provider, and carrier, leaving few satisfied with the health-care
industry. An adversarial atmosphere has resulted.
As payers have reduced health-care benefits, patients are upset and frustrated. There appears
to be a lack of patient understanding and education
related to the system. Patients invest in insurance to avoid the risk of high medical costs should
an ill- ness occur, but when services are required, payment seems limited. Patients’ coinsurance payments and deductibles have risen as the payer portion of their bill decreased, and
patients have become angry and confused by misleading billing. The costs of tech- nology and
pharmaceuticals have only increased their dissatisfaction. Price gouging and poorly designed
billing rules add to their mistrust. Health- care out-of-pocket costs have risen beyond what an
average person can afford to pay (Bodenheimer and Grumbach, 2009).
Initially, patients blamed their mistrust on hospi- tal regulations; when the system only got
worse, this feeling extended to their physician. The physician/ patient relationship changed
dramatically after the 1980s. Today, feelings about the system have evolved to the point where
physicians assess the patients under their care in terms of their potential for litigation .The
number of malpractice claims rises each year, with many claims costing providers lawyer’s fees
before ultimately being dropped prior to litigation. Approximately 40% of legal claims do not
represent medical errors yet result in patients receiving monetary benefits. The legal fees from
these cases represent 54% of the provider’s original fee (Bodenheimer and Grumbach, 2009).
Today’s health-care system “is burdened with expensive, unfounded litigation that harasses
physi- cians who have done nothing wrong, while failing to discipline or educate most
physicians commit- ting actual medical negligence and to compensate most true victims of
negligence”(Bodenheimer and Grumbach, 2009, p. 125). The malpractice system—to
compensate patients injured during medical care and to prevent negligent physicians and
providers f rom harming patients—does not seem to be achieving its goals (Sage and Kersh,
2006). Gone is the mutual symbiotic relationship that existed between a patient and the
provider. Today’s environment causes patients to select their primary care physician according
to their insurance physician network. Relationships become fleeting, as employers’ are forced
to annually shop for the lowest health-care premium.
Ease of access to health-care information via the Internet has also changed the
practitioner/patient relationship. Historically, health-care education, delivered by the
practitioner, functioned in a one- way direction. The Internet now offers a conflicting
plethora of informational resources that patients often review prior to treatment. Patients now
actively engage in a search for health-care informa- tion and expect a two-way conversation
about their condition and options for treatment. Gone is the previous elevated societal view of
the benevolent practitioner. Human error and near misses make headlines and have become a
concern.
The nurse/patient relationship has also seen changes. Suddenly nursing loyalties are pulled in
two directions: “Nurses may act as advocates by either helping others to make informed
decisions, by acting as an intermediary in the environment, or by directly intervening on the
behalf of others” (Marquis and Huston, 2009, p. 120). But nurses are impacted by rules and
policies designed to keep expenses down, increase profits, and reduce the time they are
required to spend with their patients. “Most nurses believe that patients have a prima facie, or
conditional right, to autonomy or self-determination. In other words, clients ought to be able to
choose the type, extent, and quantity of health care services” (Raines, 1997, p. 43). Managed
care, however, has created a contract atmosphere. Care is predetermined, and length of
hospital stay has become a benchmark that is tar- geted for reduction and for comparisons to
simi- lar facilities on a national basis. With shorter lengths of stay, nurses are forced to respond
by providing higher levels of self-care education as they discharge a patient who may not be
com- pletely recovered. Nurses have become frustrated with their work environment, limited
staffing, and inability to change the system. They have begun to communicate their frustrations
to the patient and to others.
The mistrust of the health-care system in the United States has been compounded by the fact
that patients have very high expectations of medi- cal care that are not tempered by financial
respon- sibilities for the services they seek. Insured patients rarely pay medical expenses
themselves. “When spending other people’s money, patients and their doctors are much less
concerned about the size of the final bill. Thus many decisions about medical care are made
either by the govern- ment or by private insurers, the third party in the relationship between
provider and patient” (Mark and Hlatky, 2002, p. 517). In the for-profit arena, “what will be
done for patients and what services are provided depends not on any sense of
bonus chapter 2 | Triaxial of Action: Policy, Politics, and Nursing 41
42 bonus chapter 2 | Triaxial of Action: Policy, Politics, and Nursing
corporate social responsibility, but on whether the organization will be paid for the provision of
the service” (Mohr, 1996, p. 18). New insurance plans are being developed and programs such
as health savings accounts and health reimbursement arrangements are beginning to alter and
to increase the patient’s responsibilities related to the use of health-care resources. Carriers are
design- ing plans that increase the patient’s out-of-pocket expense, forcing clients to become
more intelli- gent consumers. The results have shown that con- sumer consumption is
decreasing, but it is too early to say conclusively how these plans have affected health
outcomes.
Conclusion
One voice can echo loudly across a canyon. So too can each nurse make a significant impact by
sharing voice, knowledge, and perspective. Florence Nightingale stated, “in our perfect state of
conscience and enlight- enment, publicity and the collision resulting from publicity are the best
guardians of the interest in the sick” (Marquis and Huston, 2009, p. 119). Policy can be
impacted by the voice of each individual. The nurs- ing profession cannot leave policy and
politics up to someone else. Nurses and their role as patient and professional advocates, as well
as their voice on issues of health-care delivery, have been recognized. Smith (2004) and Green
and Jordan (2004) cited the IOM report, Keeping Patients Safe: Transforming the Work
Environment for Nurses, as evidence that the quality of nursing has an impact on health care
and is gaining national attention.
Policy issues affecting nursing must be addressed by nurses. Previously, political competence
was a skill discussed at the master’s and doctoral level of nursing education. Today’s
environment calls for all levels of nursing be involved and active in the policy process. “Political
competence is defined by Longest (1998) as the dual capacity to accurately assess the impact of
public policies on one’s area of responsibility and to influence public policy making at both the
state and local levels” (Porter-O’Grady and Malloch, 2007, p. 243). Key to that definition is the
concept of “one’s area of responsibility.” Nurses must speak up about their specialty. To
become effective as a profession, all levels of nursing must be knowledgeable about the issues
and must verbalize concerns as nursing leaders.
Nursing is responsible for communicating, edu- cating, and assisting legislators to arrive at
solutions that meet the needs of the health-care environ- ment. Nurses are knowledgeable and
able to impact actions occurring both within and outside the faci- lity. Within the facility, nurses
are responsible for ensuring a safe and effective health-care environ- ment for their patients.
“Organizational policies and procedures are designed to incorporate profes- sional standards,
define expectations, and enhance service quality” (Porter-O’Grady and Malloch, 2007, p. 244).
If policies are ineffective, it is the provider’s responsibility to communicate concerns and to
assist in implementing a solution. Outside the facility, nurses must be aware of the regulations
and laws affecting nursing and health-care policy.
When nursing looks at the history of its policy involvement, it realizes that the profession may
be at only the novice stage. AACN BSN Essentials (2008) describes the elements that should be
included in baccalaureate education and states that all BSN programs should produce graduates
who “will understand how healthcare issues are identi- fied, how healthcare policy is both
developed and changed, and how that process can be influenced through the efforts of nurses,
and other healthcare professionals, as well as lay and special advocacy groups” (p. 20). With
this educational exposure, it is hoped that a greater number of nurses will pursue their interests
in shaping health-care policy. Falk-Rafael (2005) links caring to Nightingale’s legacy of political,
social, and economic activism:
Nurses, who practice at the intersection of public policy and personal lives are, therefore,
ideally situ- ated and morally obligated to include political advocacy and efforts in influencing
health policy in their practice. The health of the public and the future of the profession may
depend upon it. (Falk-Rafael, 2005, p. 212)
This chapter was designed to provide an overview of policy and to stimulate political awareness and action that belongs in the hands of nurses. The future of the nursing profession will be
better when all nurses are involved in its design.
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