Nurses making policy : from bedside to boardroom [Second edition.] 9780826142221, 0826142222

Table of contents :
Cover
Title
Copyright
Contents
Contributors
Foreword
Preface
Acknowledgments
Share Nurses Making Policy: From Bedside to Boardroom, Second Edition
Unit I: Making the Case
Chapter 1: Leading the Way in Policy
Every Nurse’s Role in Policy
Being Political
Policy Making
Policy Journey
Workforce Needs
Nurses at the Forefront of Quality and Safety
Interprofessional Collaboration
Healthcare Reform
The Environment and Health
Implications for the Future
Key Concepts
Summary
Learning Activities
E-Resources
References
Chapter 2: Advocating for Nurses and for Health
Advocacy Definitions
Professional and Societal Expectations for Advocacy
Clinical Practice and Moral Distress—The Reality of Practice Advocacy
Social Justice
Equity
Precautionary Principle
Public Expectation for Advocacy
Competencies Needed to be an Advocate
Arenas for Advocacy
When Advocacy Fails/When Advocacy Succeeds
Advocacy Organizations
Implications for the Future
Key Concepts
Summary
Learning Activities
E-Resources
References
Chapter 3: Navigating the Political System
Understanding the System
The Legislative Process
Strategies for Influencing Policy Making
Opportunities to Influence the Executive Branch of Government
Opportunities to Influence Judicial Actions
Implications for the Future
Key Concepts
Summary
Learning Activities
E-Resources
Note
References
Unit II: Analyzing Policy
Chapter 4: Identifying a Problem and Analyzing a Policy Issue
Problem Identification: More than Meets the Eye
Opening a Window: Elements for Success
Tools for Assessment
Implications for the Future
Key Concepts
Summary
Learning Activities
E-Resources
References
Chapter 5: Harnessing Evidence in the Policy Process
Controversy
Challenges in Moving Evidence into Policy
Terminology
Every Nurse’s Role in Translating Evidence into Policy
Strategies for Dissemination of Evidence
Implications for the Future
Key Concepts
Summary
Learning Activities
E-Resources
References
Chapter 6: Setting the Agenda
Agenda Identification
Developing an Agenda
Stakeholders
Focusing the Agenda
Implications for the Future
Key Concepts
Summary
Learning Activities
E-Resources
References
Unit III: Strategizing and Creating Change
Chapter 7: Building Capital: Intellectual, Social, Political, and Financial
Intellectual Capital
Social Capital
Political Capital
Financial Capital
Implications for the Future
Key Concepts
Summary
Learning Activities
E-Resources
Notes
References
Chapter 8: Changing Organizations, Institutions, and Government
Theories of Change
Successful Team Processes in Policy Formulation
Translating Policy into Action and Impact
Facilitators and Barriers to Change and Innovation
Lessons Learned
Confronting Failed Policy and Re-Energizing Engagement
Implications for the Future
Key Concepts
Summary
Learning Activities
E-Resources
References
Chapter 9: Implementing the Plan
Leadership for Implementing the Plan
Strategies for Implementing the Plan
Assessing Resources
Presentation of the Plan
Creating Narratives
The Work is Never Done
Implications for the Future
Key Concepts
Summary
Learning Activities
E-Resources
References
Chapter 10: Influencing Public Opinion and Health Policy Through Media Engagement
The Media and Health Policy
Messaging and Media Engagement in the Digital World
Tried and True: Guidelines for Working with the Media
Message Delivery
Implications for the Future
Key Concepts
Summary
Learning Activities
E-Resources
References
Chapter 11: Applying a Nursing Lens to Shape Policy
Power to Influence: Politics
The Nursing Lens
Beyond Elected Positions
Serving on Boards
Programs that Reflect the Nursing Lens
Opportunities and Support for a Nursing Lens in Policy
Getting Started
Implications for the Future
Key Concepts
Summary
Learning Activities
E-Resources
References
Unit IV: Judging Worth and Advancing the Cause
Chapter 12: Evaluating Policy: Structures, Processes, and Outcomes
Language of Policy Evaluation
Evaluating Structure, Process, and Outcome
Measuring Change
Existing Data Sources
Accountability and Transparency in Evaluation
Documenting the Impact of Policies Related to Nursing
Determining Sustainability
Outcomes Data as Guides to Next Steps in Policy
Developing Policy Scholarship in Nursing
Implications for the Future
Key Concepts
Summary
Learning Activities
E-Resources
References
Chapter 13: Eliminating Health Inequities Through National and Global Policy
Health Disparities Versus Health Inequities
Social Determinants of Health Inequities
Health Policy: Global and the United States
Implications for the Future
Key Concepts
Summary
Learning Activities
E-Resources
Acknowledgments
References
Chapter 14: Valuing Global Realities for Health Policy
Overview of Global Health Issues
Un Development Goals
Global Health Stakeholders
Global Nursing Leadership
Nursing Workforce
Advocating as a Global Citizen
Implications for the Future
Key Concepts
Summary
Learning Activities
E-Resources
References
Chapter 15: Taking Action, Shaping the Future
Nurses’ Critical Role in Advancing Policy
Leadership Strategies to Advance Nursing’s Policy Influence
Policy Roles
Policy Roles in Times of Change and Uncertainty
Implications for the Future
Key Concepts
Summary
Learning Activities
E-Resources
References
Index

Citation preview

Nurses Making Policy

Rebecca M. Patton, DNP, RN, CNOR, FAAN, is the past, two-term president of the American Nurses Association (ANA; 2006–2010) and holds the inaugural Endowed Perioperative Nursing Chair, Lucy Jo Atkinson Scholar in Perioperative Nursing at Frances Payne Bolton School of Nursing, Case Western Reserve University. As a nurse, author, and lecturer, she has presented extensively throughout the world. Dr. Patton has testified before Congress and met with major policy makers—including Presidents Obama, Bush, and Clinton—when she lobbied on healthcare issues affecting nurses and the general public. She was invited by President Bush to tour and meet with the soldiers and nurses at the Guantanamo Detainee Camp in Cuba. Dr. Patton was selected twice by the U.S. State Department to serve on the U.S. delegation at the World Health Assembly in Geneva, Switzerland. Dr. Patton serves on the American Nurse Today (ANT) editorial board and has written chapters for books on medical–surgical nursing and for nursing journals. She has received numerous recognitions, including being named a Jonas Scholar through the National League for Nursing (NLN) Jonas Scholars Program, National Student Nurses Association Honorary Membership Award, Ohio March of Dimes Nurse of the Year 2015, ANA Distinguished Membership Award, Sigma Theta Tau International Founder Dorothy Garrigus Adams Award for Excellence in Fostering Professional Standards, Modern Healthcare “Top 100 Most Influential Persons in Healthcare” in 2009 and 2010, and the Community Involved Political Action Award from the Sigma Theta Tau, Delta Xi Chapter at Kent State University. She is a fellow of the American Academy of Nursing. Margarete L. Zalon, PhD, RN, ACNS-BC, FAAN, is a professor in the Department of Nursing and director of the online master of science in Health Informatics program at the University of Scranton, Scranton, Pennsylvania, and an adult health clinical nurse specialist. She is the president of the Nursing Foundation of Pennsylvania. Dr. Zalon is a past board chair of the American Nurses Foundation and a former board member of the American Nurses Association. She also served as vice president, American Nurses Credentialing Center and as president of the Pennsylvania State Nurses Association. Dr. Zalon is a fellow of the American Academy of Nursing and a member of its Acute and Critical Care Expert Panel. Her research focuses on vulnerable elders, and her research has been funded by the National Institute of Nursing Research. She has authored book chapters, as well as articles in Nursing Research, Applied Nursing Research, Journal of Nursing Scholarship, Journal of Nursing Measurement, Journal of Nursing Education, and Nurse Educator, and numerous other professional publications. She has made research and health policy presentations at the local, state, national, and international levels. Ruth Ludwick, PhD, RN-BC, APRN-CNS, FAAN, is professor emeritus, Kent State University College of Nursing, and adjunct graduate faculty at Northeast Ohio Medical University. She is a research and policy consultant locally, nationally, and internationally. As a leader and an educator, Dr. Ludwick has transformed standards of nursing care of older people and the gerontological preparation of nurses. She has a sustained record of research and was recognized for this work by the Ohio Nurses Association with a Research in Nursing Excellence Award. Her numerous publications focus on challenging and significant gerontological nursing issues such as restraint reduction, health literacy, and advance care planning. Her funding includes grants from the Agency for Healthcare Research and Quality, National Institute on Aging, Institute of Museum and Library Services, and the National Palliative Care Research Center. She serves on the editorial boards of the Online Journal of Issues in Nursing and the International Journal of Older People Nursing and has authored over 100 articles, book chapters, editorials, and compilations appearing in a variety of renowned journals, such as Nursing Research, Advances in Nursing Science, The Gerontologist, Journal of the American Geriatrics Society, Nursing Ethics, and Journal of Pain and Symptom Management. Some examples of her advocacy include serving on committees of the Ohio Nurses Association and the American Nurses Association, and on the board of the Ohio Health Literacy Partners (OHLP), a statewide collaborative dedicated to empowering Ohioans to make informed health choices through improved health literacy.

Nurses Making Policy From Bedside to Boardroom SECOND EDITION

Rebecca M. Patton, DNP, RN, CNOR, FAAN Margarete L. Zalon, PhD, RN, ACNS-BC, FAAN Ruth Ludwick, PhD, RN-BC, APRN-CNS, FAAN Editors

Co-Published With the American Nurses Association

Copyright © 2019 Springer Publishing Company, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-6468600, [email protected] or on the Web at www.copyright.com. Springer Publishing Company, LLC 11 West 42nd Street New York, NY 10036 www.springerpub.com Acquisitions Editor: Margaret Zuccarini Compositor: diacriTech, Chennai ISBN: 978-0-8261-4222-1 ebook ISBN: 978-0-8261-4223-8 Instructor’s PowerPoint ISBN: 978-0-8261-4224-5 Instructor’s Materials: Qualified instructors may request supplements by emailing [email protected] 18 19 20 21 22 / 5 4 3 2 1 The author and the publisher of this Work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication. The author and publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the information contained in this book. The publisher has no responsibility for the persistence or accuracy of URLs for external or third-party Internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Library of Congress Cataloging-in-Publication Data Names: Patton, Rebecca M., editor. | Zalon, Margarete L., editor. | Ludwick, Ruth, editor. | American Nurses Association Title: Nurses making policy : from bedside to boardroom / [edited by] Rebecca M. Patton, Margarete L. Zalon, Ruth Ludwick. Description: Second edition. | New York, NY : Springer Publishing Company; co-published with the American Nurses Association, [2019] | Includes index. Identifiers: LCCN 2018028113| ISBN 9780826142221 | ISBN 9780826142238 (ebook) | ISBN 9780826142245 (instructors powerpoint) Subjects: | MESH: Nursing—organization & administration | Policy Making | Health Policy | Nurse’s Role | Organizational Policy | Leadership | United States Classification: LCC RT41 | NLM WY 16 AA1 | DDC 610.73—dc23 LC record available at https://lccn.loc .gov/2018028113 Contact us to receive discount rates on bulk purchases. We can also customize our books to meet your needs. For more information please contact: [email protected] Publisher’s Note: New and used products purchased from third-party sellers are not guaranteed for quality, authenticity, or access to any included digital components. Printed in the United States of America.

Contents Contributors  vii Foreword Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN, FNAP   ix Preface  xi Acknowledgments  xiii Share Nurses Making Policy: From Bedside to Boardroom, Second Edition

UNIT I: MAKING THE CASE 1. Leading the Way in Policy  3 Rebecca M. Patton, Margarete L. Zalon, and Ruth Ludwick 2. Advocating for Nurses and for Health  37 Karen Tomajan and Debbie Dawson Hatmaker 3. Navigating the Political System  73 Eileen M. Sullivan-Marx and Susan Apold

UNIT II: ANALYZING POLICY 4. Identifying a Problem and Analyzing a Policy Issue  103 Rebecca M. Patton, Margarete L. Zalon, and Ruth Ludwick 5. Harnessing Evidence in the Policy Process  129 Kathleen M. White and Audra N. Rankin 6. Setting the Agenda  163 Linda K. Groah and Amy L. Hader

UNIT III: STRATEGIZING AND CREATING CHANGE 7. Building Capital: Intellectual, Social, Political, and Financial  195 Lauren Inouye, Colleen Leners, and Suzanne Miyamoto 8. Changing Organizations, Institutions, and Government  225 Tim Porter-O’Grady, Kathy Malloch, and Ingrid Johnson 9. Implementing the Plan  261 Rebecca M. Patton, Margarete L. Zalon, and Ruth Ludwick 10. Influencing Public Opinion and Health Policy Through Media Engagement  291 Pamela F. Cipriano and Jessica Keim-Malpass 11. Applying a Nursing Lens to Shape Policy  329 Joanne Disch v

vi  CONTENTS

UNIT IV: JUDGING WORTH AND ADVANCING THE CAUSE 12. Evaluating Policy: Structures, Processes, and Outcomes  359 Sean P. Clarke and Pamela B. Linzer 13. Eliminating Health Inequities Through National and Global Policy  391 Shanita D. Williams and Janice M. Phillips 14. Valuing Global Realities for Health Policy  423 Judith Shamian and Michelle McHugh Slater 15. Taking Action, Shaping the Future  447 Rebecca M. Patton, Margarete L. Zalon, and Ruth Ludwick Index  475

Contributors Susan Apold, PhD, ANP-BC, AGNP, FAAN, FAANP  Clinical Professor of Nursing, New York University Rory Meyers College of Nursing, New York City, New York Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN  President, American Nurses Association, Silver Spring, Maryland; Research Associate Professor, University of Virginia School of Nursing, Charlottesville, Virginia Sean P. Clarke, PhD, RN, FAAN  Professor and Associate Dean, William F. Connell School of Nursing, Boston College, Boston, Massachusetts Joanne Disch, PhD, RN, FAAN  Professor ad Honorem, University of Minnesota School of Nursing, Minneapolis, Minnesota Linda K. Groah, MSN, RN, CNOR, NEA-BC, FAAN  Chief Executive Officer/ Executive Director, Association of periOperative Registered Nurses (AORN), Denver, Colorado Amy L. Hader, JD  General Counsel and Director of Government Affairs, Association of periOperative Registered Nurses (AORN), Denver, Colorado Debbie Dawson Hatmaker, PhD, RN, FAAN  Enterprise Chief Program Officer, American Nurses Association, Silver Spring, Maryland Lauren Inouye, MPP, RN  Vice President for Public Policy and Government Affairs, Council of Graduate Schools, Washington, District of Columbia Ingrid Johnson, DNP, MPP, BSN  Senior Director of Operations and Policy, Colorado Center for Nursing Excellence, Denver, Colorado Jessica Keim-Malpass, PhD, RN  Assistant Professor, University of Virginia School of Nursing, Charlottesville, Virginia Colleen Leners, DNP, APRN, FAANP  Director of Policy, American Association of Colleges of Nursing, Washington, District of Columbia Pamela B. Linzer, MSN, RN  Doctoral Candidate, William Connell School of Nursing, Boston College, Boston, Massachusetts; Employee Health and Infection Control Consultant, Winchester Hospital, Lahey Health System, Andover, Massachusetts Ruth Ludwick, PhD, RN-BC, APRN-CNS, FAAN  Professor Emeritus, Kent State University College of Nursing, Kent, Ohio; Adjunct Graduate Faculty, Northeast Ohio Medical University, Rootstown, Ohio

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viii  CONTRIBUTORS

Kathy Malloch, PhD, MBA, RN, FAAN  President, KMLS, Glendale, Arizona; Professor of Practice, College of Nursing and Health Innovation, Arizona State University, Tempe, Arizona; Clinical Professor, College of Nursing, Ohio State University, Columbus, Ohio Suzanne Miyamoto, PhD, RN, FAAN  Chief Policy Officer, American Association of Colleges of Nursing, Washington, District of Columbia Rebecca M. Patton, DNP, RN, CNOR, FAAN  Lucy Jo Atkinson Scholar in Perioperative Nursing, Case Western Reserve University Frances Payne Bolton School of Nursing Cleveland, Ohio; Past President, American Nurses Association, Silver Spring, Maryland Janice M. Phillips, PhD, RN, FAAN  Director of Nursing Research and Health Equity, Rush University Medical Center, Chicago, Illinois Tim Porter-O’Grady, DM, EdD, APRN, FAAN  Senior Partner, Health Systems, Tim Porter-O’Grady Associates, Inc., Atlanta, Georgia Audra N. Rankin, DNP, APRN, CPNP, CNE  Instructor, Johns Hopkins University School of Nursing, Baltimore, Maryland Judith Shamian, PhD, RN, DSc, LLD, FAAN  President Emerita, International Council of Nurses, Toronto, Ontario, Canada Michelle McHugh Slater, DNP, RN, CNOR  Nurse Manager and Quality Fellow, Cleveland Veterans Administration Medical Center, Cleveland, Ohio Eileen M. Sullivan-Marx, PhD, RN, FAAN  Dean and Erline Perkins McGriff Professor, New York University Rory Meyers College of Nursing, New York City, New York Karen Tomajan, MS, RN, NEA-BC  Independent Consultant, Hercules, California Kathleen M. White, PhD, RN, NEA-BC, FAAN  Professor, Johns Hopkins University School of Nursing, Baltimore, Maryland Shanita D. Williams, PhD, MPH, APRN  Deputy Director, Northeast Health Services Division, Office of Northern Health Services, Bureau of Primary Health Care, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Maryland Margarete L. Zalon, PhD, RN, ACNS-BC, FAAN  Professor, Department of Nursing, Director, Online MS in Health Informatics Program, University of Scranton, Scranton, Pennsylvania

Foreword This second edition of Nurses Making Policy: From Bedside to Boardroom, edited by Rebecca M. Patton, Margarete L. Zalon, and Ruth Ludwick, soars even higher than the inaugural edition in its inclusion of key understandings of health policy. The editors and chapter authors are experts in health policy on both the national and global level, and their insights are instructive to nurses beginning their careers, as well as to those who aspire to the highest levels of policy analysis, development, and implementation. Readers are challenged to examine their own biases about policy and politics and encouraged not to leave the policy work to others who may be less well informed. In fact, the primary purpose of the book is to inform all nurses so that they can be knowledgeable advocates for other members of society, including those who are marginalized or those who choose not to engage in the policy process. From the first chapter, written by the book editors, the learner is challenged to be engaged at the local, state, and national level. The authors assert that policy work is the role of every nurse and provide a comprehensive argument for why nurses should engage in policy. In this initial chapter, a policy challenge is presented, detailing the case study of Dr. Karen Daley’s journey from clinician to policy advocate after she suffered a sharps injury. She became a champion for provider safety to avoid needlestick injuries and successfully advocated for legislative changes related to provider safety at the local, state, and national level. This brief case study is only one of many examples presented in the chapter and throughout the book that serve as key learning modalities for students at all levels. Also in Chapter 1, the authors present a detailed history of the beginnings of the American Nurses Association (ANA) and its current programs and activities to safeguard professional nursing practice and thus empower nurses to better serve patients and the public. In addition, there are key lessons included about other specialty organizations and their impact on health policy. Yet the first chapter is truly only the beginning of a wide array of important content. The editors have gathered the experts in nursing policy development and implementation as chapter authors—the best of the best in nursing. Chapter authors provide key insights to move the nursing profession forward and position nurses in leadership roles in the health policy arena, locally, nationally, and globally. Important for both instructors and students, each chapter includes objectives, key learning activities, electronic resources, and references to guide future study. Also included throughout the book are key examples of health policy challenges that bring both policy and politics alive for the reader. This book serves as an important resource for all of us who aspire to become more involved, make more changes, and thus create a better world and improve the health of all citizens.

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x  FOREWORD

In addition to providing an excellent textbook for health policy courses, the authors and editors have told the story of nursing’s involvement in creating change through policy. The work is a tribute to the rich history of the profession and a call to action for future policy design, development, and implementation. All of the contributors should be acknowledged for their dedication and diligence in addressing this timely and important area for nurses and nursing. Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN, FNAP Elizabeth Brooks Ford Professor of Nursing Frances Payne Bolton School of Nursing Case Western Reserve University Cleveland, Ohio

Preface Being a nurse is not easy. Policies and politics often seem to create barriers to our work. We often assume that policies and politics are obstacles. In reality, they are opportunities for nurses to take ownership of advocacy. This second edition uses a hands-on approach to help nurses across a variety of settings to develop health policy competencies that can deal with an ever-changing health and uncertain policy arena. Four major units provide a framework for our approach as the chapters of the book take the reader on a journey through all the steps of the policy-making process. Numerous updates to the first edition have been made to reflect this dynamic nature of policy and politics. We have built on the unique features presented in the first edition. Each of the 15 chapters has been revised and includes recent examples of policy efforts across the broad spectrum of healthcare, from the little “p” to the big “P” policies and politics written by experts on the frontline of change. These examples are provided by both direct-care nurses and high-profile nurse leaders working nationally and globally. To emphasize the growing awareness that every nurse needs to be a global citizen, a new chapter, “Valuing Global Realities for Health Policy,” has been added. Throughout each chapter, policy development is exemplified from the grand scale of global or national work to the local work environment. We believe that work at all these levels is essential. Often, however, the interplay between levels is not always recognized or acknowledged. We also firmly believe that health policy is every nurse’s responsibility. To advance nurses’ policy leadership, we helped establish the endowed fund, Washington Fellows Program for Nurses, at the American Nurses Foundation, which is designed to ensure nurses’ placement at policy tables at the highest level of decision making. Our commitment is to engage and foster nurses’ policy activism at all levels. This will enable nurses, one step at a time, to realize the full power generated by more than 4 million nurses taking steps together to advance health. Working on policy, having the opportunity to impact the health of more people, and improving the work lives of nurses are immensely rewarding. This book is designed to help nurses gain a deeper understanding of the intricacies of policy development and the opportunities they have to shape policy across the broad spectrum of healthcare, as well as in their communities. Each chapter introduces a real-life situation in one of the many Policy Challenge features, which is directly related to a specific aspect of the policy process. Chapters also contain a number of Policy on the Scene features, which illustrate key points and specific issues at each step of the policy process, concluding with the Option for Policy Challenge that describes outcomes of the policy challenge. Key Concepts to aid in learning and

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xii  PREFACE

learning activities take readers through the steps of the policy process to enhance their policy ­expertise. The updated E-Resources provide additional details for i­ ndependent ­learning. PowerPoint ­presentations are available for instructors who email Springer ­Publishing Company at ­[email protected]. Rebecca M. Patton Margarete L. Zalon Ruth Ludwick

Acknowledgments This book is a testament to collaboration among friends and colleagues and reflects the support of numerous family members. Support from family and collaboration and encouragement from friends and colleagues are essential ingredients, whether when working late to write overdue policies, running for elected office, or writing a book on policy. As you read our acknowledgments, we encourage you to thank those who are supportive to you in your personal, work, and policy lives. Our families have provided us with ongoing support throughout the development and writing of this second edition. In the Patton family, we thank mother Mary Ellen, sister Betty Jane—both registered nurses—and brothers Bob and John. In the Zalon family, we thank husband John. In the Ludwick family, we thank husband John, son Tom, and Tom’s wife Sara, and acknowledge the joy brought by their children, Caleb and Carly. Without a doubt we owe endless thanks to the contributors—the esteemed authors of each chapter—and those who shared their real-life stories in the Policy Challenges and Policies on the Scene. This second edition could not have been completed without the support of the people who contributed chapters to the first edition. We acknowledge the work of Sheila Abood, Deborah Colton, Marianne Ditomassi, Jeannette Ives Erikson, Rose Iris Gonzalez, Mathew Keller, Virginia Totter Betts, Susan Tullai McGuinness, Eileen Weber, and Loretta Alexia Williams. We are saddened by the untimely loss of Josepha Burnley. We recognize and champion that all nurses have a significant advocacy role in p ­ romoting health. We are in deep gratitude to those who have worked tirelessly to engage nurses in this advocacy and transform policy. Let us celebrate nurses in visible positions, and those nurses behind the scenes in less visible roles who develop and support effective policies to advance healthcare for all. In keeping with our commitment to advance policy and support nurses’ d ­ evelopment of policy expertise, we continue to donate 100% of our book royalties to the Washington Policy Fellowship at the American Nurses Foundation (www.nursingworld.org/ foundation/programs/washington-policy-fellowship).

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UNIT I

MAKING THE CASE

ONE

Leading the Way in Policy Rebecca M. Patton Margarete L. Zalon Ruth Ludwick People often say, with pride, “I’m not interested in politics.” They might as well say, “I’m not interested in my standard of living, my health, my job, my rights, my future or any future.…” If we mean to keep any control over our world and lives, we must be interested in politics.—Martha Gellhorn, journalist (1984)

OBJECTIVES 1. Analyze the foundation for the role of nurses in policy. 2. Explain the vital role of nurses in policy that impacts health and wellness. 3. Examine nurses’ responsibilities to society in formulating policy. 4. Appraise the potential of nursing’s influence and impact on health, quality, and safety. 5. Describe the link between policy at the local, state, and national levels.

Given that nurses comprise the largest sector of healthcare providers, spend the most time with patients, and share a unique intimacy with patients related to functional care activities, nurses bring critical understanding and potential solutions to many high-profile, complex healthcare issues such as access, quality, cost, and value. Nurses. “…practice at the intersection of public policy and personal lives; they are, therefore, ideally situated and morally obligated to include sociopolitical advocacy in their practice” (Falk-Rafael, 2005, p. 222). Every day, nurses see how health policy decisions, such as access to care based on pre-existing conditions, impact patients and their families and how organizational staffing policies may harm patients and adversely affect nurses and their work environment. Creating and maintaining health policy is everyone’s job. Some believe that one’s position defines policy involvement. We argue that health policy is everyone’s responsibility. Nurse managers, educators, and administrators are often viewed as having more obvious roles in the successful articulation of federal and state regulations and implementation of institutional policies. Nurses providing direct care live at the edge of those policies and regulations every day, an advantage that is vital to informing, shaping, monitoring, and evaluating policy. Nurses are uniquely qualified to assume important roles in policy. We agree with Feldman and Lewenson who state that “nursing skills are political skills” (2000, p. 58). 3

4   UNIT I  MAKING THE CASE

We make the case, beginning with this chapter and throughout the book, that once policy skills are understood and practiced, nurses can successfully engage in advocacy through policy making. These skills are essential to nurses in the trenches, performing direct care across all settings, and nurses in leadership, education, and research positions. Thus, policy work is the role of every nurse. The following Policy Challenge illustrates how care at the bedside can lead to a policy journey with great impact.

POLICY CHALLENGE: Occupational Injury Becomes a Catalyst Karen A. Daley, PhD, RN, FAAN, Boston, Massachusetts, Board of Trustees, Dana Farber Cancer Institute; Past President, American Nurses Association As I think back to more than 25 years of nursing practice at a Boston teaching hospital, my thoughts are of impactful moments with patients and families as I delivered nursing care. Nurses engage in advocacy every day as they bring about change to address patients’ needs. Advocacy was an integral part of my own patients’ needs. Then I suffered a sharps injury in 1998 that infected me with HIV and HCV (www.youtube.com/watch?v=UATLtR_27YE). So, my unexpected, injury-driven departure from my clinical career propelled me into an unfamiliar world—one where I suddenly emerged not as a caregiver, but as a patient in need of care and advocacy. It was difficult to move into that space and to experience such a loss of control over my health and life. I was suddenly forced to transition from a healthy, productive existence to a world of uncertainty—a world of countless provider appointments, dozens of monthly laboratory tests, anxiety-ridden waits for results, and the constant fatigue and unpredictable toxicity of potent drug regimens. My ability to cope with my circumstances felt tenuous at times. More than anything, I worried I might not survive. After being immersed in this world for several months, my adverse reactions and tolerance of therapies slowly stabilized. I began to think beyond my immediate circumstances and realized that to get through this experience, I needed to find greater meaning and purpose in what was happening to me—particularly given the commonplace and preventable nature of my injury. At the time, sharps injuries were everyday occurrences for healthcare workers. I needed to act to help ensure that what happened to me did not happen to others. My advocacy for sharps injury prevention began with an effort to learn more about facts surrounding these injuries. I was shocked to learn that the annual estimate of hospital sharps injuries by the Centers for Disease Control and Prevention (CDC) ranged from 400,000 to 600,000. I also learned that devices with engineered mechanisms for sharps injury prevention had existed for more than two decades. At the time, fewer than 15% of hospitals were making them available. Armed with that knowledge, I embarked on a policy reform journey that began with efforts to engage Massachusetts legislators and American Nurses Association (ANA) leaders to leverage their influence and enable needed change (continued )

Chapter One  LEADING THE WAY IN POLICY  5

to help reduce sharps injuries for healthcare workers. That policy journey took me to state and federal legislative hearings and face-to-face meetings with state association and hospital leaders, as well as congressional leaders and staff. I witnessed firsthand the power of ANA, as a respected voice and expert in health policy, as it launched a national campaign to reduce sharps injuries. I also saw the importance of stakeholder collaboration that included unions, the Occupational Safety and Health Administration (OSHA), manufacturers, injury surveillance experts, and other national health and nursing organizations as we sought meaningful reform. Within one legislative session, Congress and a number of state legislatures—including Massachusetts—passed new laws designed to strengthen workplace protections and prevent future occupational sharps injuries. See Option for Policy Challenge

EVERY NURSE’S ROLE IN POLICY Nurses’ everyday practical lens, combined with nursing skills such as problem solving and communication, makes health policy competence a smart and necessary fit for nursing now, as well as for its vitality in the future. Nurse leaders experienced in policy at the national, state, local, or organizational level know that nurses possess the knowledge of the healthcare system, especially at the point of care, and essential skills, such as communication and data gathering, that can be adapted to successful policy making (Ellenbecker et al., 2017; Gebbie, Wakefield, & Kerfoot, 2000). Warner (2003) interviewed nurse activists to explore the skill set necessary for political competence. This excerpt from one nurse echoes and amplifies the essential skills that nurses have for becoming competent in policy: “We are very versatile. We are able to grasp complex issues and keep many things on the plate at one time” (Warner, 2003, p. 138). Accrediting organizations mandate that all nursing education programs have health policy education incorporated in the curriculum, and nursing organizations across the world advocate policy action. Shared governance and other forms of collective action (e.g., alliances, unions) at their core are about direct-care nurses and managers mutually making decisions and developing policies for practice. Yet nurses frequently voice that they have no control over policy and that there is no time in the fast-paced world of healthcare, with the numerous rules and regulations, to become policy experts. If we do not speak up for the policies we need and want, we find there are many others willing to step in and speak for us, but they may not represent our interests or needs regarding patient care or our work environments. Being silent provides an unspoken endorsement of the status quo. It allows others to make their voices heard in the void of our silence. Although all nurses must be fully engaged in the policy process, the level of involvement (e.g., local, state, national, international, organizational) depends on education, skill, practice, and mentoring. A necessary skill in actualizing political power is to know and comprehend the basics of the policy process. Provisions of the American Nurses Association (ANA) Code of Ethics for Nurses (ANA, 2015a) call for practicing nurses in all roles and all settings to be involved in policy as part of their duty to their profession, patients, and society (see also Chapter 2). Involvement in policy may include the spectrum of work on government activities, institutional decisions, organizational positions, or professional standards.

6   UNIT I  MAKING THE CASE

Levels of Policy Involvement Nurses have a duty to be active in policy, whether it is its creation or implementation or any aspect that advances the profession and issues of concern. Being active in policy often requires nurses to be knowledgeable and strategic in politics. This may seem foreign to nurses if they assume political activism means being involved in campaigns or working with legislators. This broad or top-down view of politics very often implies holding office in a major organization or the government, working actively to pass state and federal laws related to safe patient care or some such similar activity. We refer to politics on this grand scale as Politics with a big “P.” Three nurses hold office in 115th Congress in the U.S. House of Representatives, compared with six nurses in the 113th Congress. Eddie Bernice Johnson (D-TX) is one of the nurses serving currently in Congress. When she took office for the first time over 20 years ago, she became the first RN elected to Congress. Obviously, more nurses are needed at this grander scale, given that there are more than 4 million licensed RNs in the United States. Other professionals, such as physicians have done a better job in serving as members of Congress; for example, 15 physicians were seated in the 115th Congress. Obviously, we need more nurses elected and appointed to office, but nurse advocacy goes well beyond these positions which are only one of many arenas where nurses can do policy work. To address issues, for example, nurses need to have a broad perspective and use nontraditional approaches. Some non-healthcare policies impact healthcare when implemented. An example is a city regulation requiring sidewalks in all new housing developments. Without sidewalks, walking is limited. Recognizing the health impact is crucial in every policy. When addressing issues, nurses must consider an upstream approach. This approach addresses primary prevention and the root causes of disease and disability, whereas downstream approaches involve nurses working in positions providing direct care instead changing harmful systems of care (Bekemeier, 2008). The familiar classic public health story is that of rescuers frantically working to pull people out of a river instead of going upstream to figure out why people are falling into the river and preventing that from happening in the first place (Zola, as told to McKinlay, 1986). Not only is an upstream approach necessary, but also the strategies to influence upstream decisions necessarily involve collaborative or team efforts and/or political action. Some nurses may assume significant advocacy roles by holding public office or lobbying for political action, but all nurses can advocate for and with patients. They can advocate for themselves and their work environment. Politics carried out at this microlevel and the processes associated with nurses’ work environments are also called politics, but we do not capitalize the word; instead we use the term politics with a little “p.” Micropolitics is not less important; the term is used to convey a difference in scope. Examples of little “p” politics might include implementing a no-lift policy in a clinical agency or addressing bullying and violence in school settings. Nurses may be more familiar with advocacy within the context of the nurse–patient relationship because we have traditionally focused our efforts and energies on encouraging nurses to be advocates at the individual level. However, we argue that the profession and the public need nurses to be advocates at all levels to achieve our healthcare goals, that they cannot be achieved without attention to disparities, and that the advocacy competencies learned at the microlevel, or little “p” level, can be readily transferred to other arenas.

Chapter One  LEADING THE WAY IN POLICY  7

BEING POLITICAL Politics, much like nursing, is an art and a science. It is a process that requires nurses who are savvy in both the “P” and the little “p” arena. We therefore use the f­ ollowing definition: Politics “… is a process that includes not only that which is typically associated with political functions (e.g., government, police, and workers’ unions) but also that which is involved in the regulation, structure, and action of all individuals’ behavior” (O’Byrne & Holmes, 2009). All humans are political. We try every day to influence others based on our beliefs, values, and knowledge. Have you ever called fellow nurses before a meeting and work to tell them about an idea you want them to support? Have you tried to influence other nurses to more actively support an initiative that you believe in, such as breastfeeding, bedside shift reporting, or the purchase of a product such as automated sphygmomanometers? On a larger scale, an extensive impact was made by two certified nurses, Jennifer Dziuba-Pallotta and Joan Banovic, who developed a major recycling program for the OR where they work in New Jersey. After they read that many by-products in the OR could be recycled, they used an evidence-based approach, consulted with a medical waste company, and developed a plan that was expanded across the healthcare system, leading to significant savings and minimization of the hospital’s carbon footprint (Nurse-led, 2013). Although there are numerous examples of how nurses advocate daily, being politically active is still often misunderstood and often not undertaken by nurses (Ellenbecker et al., 2017). Being political can be seen as less than desirable in a world where politics is associated with disingenuous elected officials and political campaigns are perceived as increasingly uncivil and negative. Recently, a staff nurse hesitated to write a letter to the editor in response to a negative article on breastfeeding because she did not want to be viewed as “too political.” On further exploration, she said she did not want to seem “too radical.” Because of the perceptions of incivility in politics, nurses may believe aligning with a political voice to be “upsetting the apple cart.” In the software program Microsoft Word, the word radical is listed as a synonym for political. Nurses may also believe that they do not have the competencies necessary for taking political action. Sometimes it seems contradictory that nurses, who as a group are good at work-arounds and soothing hot-tempered families, patients, and coworkers, have trouble seeing that these skills are transferable to the policy-making process. With further discussion and exploration with a mentor about what it means to be political, with editorial support, and with general encouragement, the once-hesitant nurse who was worried about being “too political” publicly demonstrated her advocacy by writing her first letter to the editor.

POLICY MAKING Basic knowledge of policy making is the first step in planning how to initiate your potential political power and influence real changes in your patients’ lives, your work environment, or social policy change in your community and beyond. Policy making is a goal-oriented course of action that individuals or groups take on behalf of, or as part of, organizations, facilities, systems, and government in dealing with a problem or an issue. Understanding policy making involves understanding the steps of the policy process, as well as the process for the analysis of potential policy options.

Process The basic phases of the policy-making process have much in common with the steps of the nursing process, and the comparison is helpful in beginning to demystify the

8   UNIT I  MAKING THE CASE

EXHIBIT 1.1  NURSING PROCESS AND POLICY PROCESS COMPARISON NURSING PROCESS

• • • •

Assess and diagnose Plan interventions Implement care Evaluate

POLICY PROCESS

• • • •

Recognize and identify a problem Formulate policy Implement the policy change Monitor and evaluate the result

policy process. Like the steps of the nursing process, policy making is viewed as cyclical, involves continued feedback, and may take longer in certain phases, depending on the project being undertaken. Although this four-phase process is not fully comprehensive of all the steps in policy making, the comparison provides a solid starting point for nurses reviewing and developing policy. Much like the work nurses do every day, it starts with the identification of a problem after assessment of a patient or a situation and then logically follows the problem-solving and decision-making steps used to solve everyday patient problems. A side-by-side comparison of the policy process with the nursing process is illustrated in Exhibit 1.1. Using this type of comparison, the process becomes manageable, and one can see how all nurses have the potential to identify, formulate, implement, and evaluate change based on their work setting, their community, and their passion. However, the number of steps and the details involved in policy making vary (see Chapter 2). The most basic approach to policy identifies three policy-development phases: recognition and identification, formulation, and implementation. Since policy making is an ongoing, evolutionary process, we have added a critical but often overlooked step, monitoring and evaluating, which is consistent with the fourth phase of the nursing process. Policy making is easier to understand by breaking down the steps into pieces that are small enough to study, and seeing the pieces helps us understand the whole.

Analysis Integral to the policy-making process is policy analysis, which involves the detailed examination of various policy options in terms of their impact on the desired outcomes. Analyzing policy is a social and political activity because it impacts the well-being of large numbers of people and because the process involves professionals and interested stakeholders (Bardach & Patashnik, 2016, p. xv). One approach often used to understand policy is to take an existing policy and/or problem and conduct an in-depth analysis to provide direction for the way forward. Policy analysis involves the detailed steps and iterative process between defining the problem and developing the policy, as previously noted in Exhibit 1.1. Bardach and Patashnik’s (2016) eightfold path for policy analysis includes (a) defining the problem; (b) assembling some evidence; (c) constructing alternatives; (d) selecting criteria by which to evaluate the alternatives; (e) projecting the outcomes; (f) confronting trade-offs; (g) stopping to focus, narrow, and deepen the choices and deciding; and (h) communicating the policy. Developing skill in policy analysis is an important leadership competency in the complex world of healthcare whether it is done at the little “p” or the big “P” level. It involves understanding the broader picture. Policy analysis is an attempt to understand the desired and possible outcomes of policies, as well as their pitfalls or unintended consequences. For more detail see Chapter 4. Improving policy is a task that numerous individuals, groups, organizations, legislative bodies, and governments seek as a goal to improve health. The recommendations

Chapter One  LEADING THE WAY IN POLICY  9

of the Institute of Medicine (IOM; now the National Academy of Medicine [NAM]) report, The Future of Nursing: Leading Change, Advancing Health, are a call to action for nurses to take a leadership role in the healthcare systems of the future (Committee on the Robert Wood Johnson Foundation [RWJF] Initiative on the Future of Nursing, 2011). To take on this leadership role, one must be well versed in the strategies and tools of policy, and the IOM recommendations when achieved, will help provide the needed base structure for larger nurse involvement in policy from bedside to boardroom. As the world, healthcare, and nursing have become progressively multifaceted, uncertain, changeable, and interconnected, the policy-making process has become more complex. The potential complexity of this process is illustrated in Figure 1.1. Throughout the book, we discuss more detailed steps, tools, and techniques that are necessary for policy making from bedside to boardroom.

POLICY JOURNEY

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Ev

de r Co stand nte ing xt

y

Ma int ain ing

Po lic

Developing policy is a journey that varies depending on the context of the situation. The processes associated with the journey can be both formal and informal. Whether working to pass legislation related to preventing violence against nurses in the workplace, developing

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FIGURE 1.1   Policy-making cycle. Source: Reprinted with permission from Economic Policy Unit, Office of the First Minister and Deputy Minister. (n.d.). A practical guide to policy making in Northern Ireland. Retrieved from https://www. executiveoffice-ni.gov.uk/sites/default/files/publications/ofmdfm_dev/practical-guide-policy-makingamend-nov-16.PDF

10   UNIT I  MAKING THE CASE

a board policy that requires an RN to be a member, or reviewing a nursing policy within a hospital related to certification payment, the steps of policy making are the same, but the journey for those involved in the process may vary depending on roles and the situation. The journey varies from nurse to nurse and can and often depends on what is going on in your life and on what windows of opportunity are available. We show how the journey can vary by examining some approaches used to stop workplace violence against nurses. At the organizational level, the Emergency Nurses Association (ENA), the ANA, and state nurses associations have played instrumental roles in helping raise awareness and support legislative initiatives aimed at preventing violence against nurses and prosecuting those who act against nurses. The American Organization of Nurse Executives (AONE) and ENA jointly developed a toolkit (www.aone.org/resources/ final_toolkit.pdf) for mitigating violence in the workplace (AONE & ENA, 2015). At the federal level, the National Institute of Occupational Safety and Health (NIOSH) has an online interactive course on workplace violence prevention for nurses (NIOSH, 2017). To gain understanding about workplace safety, Press Ganey, the vendor for the National Database of Nursing Quality Indicators (NDNQI), developed a new quality indicator to measure assaults against nurses (Zimmerman, 2017). At the individual level, nurses are vital to this process by providing testimony at hearings for proposed legislation. Legislation made need to be modified; for example, New York legislation was passed in 2010 and amended in 2015 to include non-nurse healthcare workers. A Massachusetts nurse, Sheila Wilson, who herself was assaulted, is the cofounder of a nonprofit group, Stop Healthcare Violence. This group has a goal of providing a safe workplace for healthcare providers and is working to get legislation passed to make assaults on healthcare workers a felony, increase the hiring of security works, provide better lighting and panic buttons, and require the implementation of violenceprevention plans (English, 2017). State agencies might also promulgate regulations, providing another opportunity for exerting your influence. These examples illustrate the important role that each of us plays in advancing a policy position. Does your state have a law to protect nurses from violence? As of 2017, 42 states had passed legislation related to protecting nurses, compared with 21 states just a few years before (ANA, 2017b). The ANA tracks progress in state legislation for selected issues of importance to nurses. See Figure 1.2 for information about states that have passed legislation creating penalties for assaults against nurses. Note that there are different approaches to the legislation in terms of coverage of healthcare workers, with some states covering nurses only in emergency department or mental health settings. Other approaches include requirements for a workplace violence program, which in one instance is limited to public employers; incident reporting; and resolutions. The latter does not have the force of law (ANA, 2017b). If the final goal for an issue is federal legislation, then legislation usually needs to be passed by a certain number of states before Congress will take it up for consideration. Policies impacting nurses do not necessarily only protect nurses or advance the practice of nursing. Workplace violence legislation illustrates the importance of being inclusive when possible and broadening the impact of the policy. In some states, this legislation includes other healthcare professionals and first responders. Legislation at the federal level may address the limitations of state legislation. Although a nursing lens is helpful in developing policy (see Chapter 11), using a nursing lens to limit who we advocate for is shortsighted. Often, to move policy forward, nurses need to move their advocacy base beyond nursing and involve other colleagues, as well as consumers, who might benefit from the advocacy.

Chapter One  LEADING THE WAY IN POLICY  11

= Penalties for assault of nurses = Penalties in selected settings = No legislation WA

VT

ND

MT

NH

ME

MN

OR

ID WY

WI

SD IA

NE

NV UT CA AZ

IL CO

KS OK

NM

MO

AK

WV KY

RI CT NJ DE

VA

MD

NC

TN

SC

AR MS

TX

PA OH

IN

MA

NY

MI

AL

GA

LA FL

HI

FIGURE 1.2   State workplace violence legislation as of 2017. Source: American Nurses Association. (2017b). Workplace violence. Retrieved from http://www .nursingworld.org/MainMenuCategories/Policy-Advocacy/State/Legislative-Agenda-Reports/ State-WorkplaceViolence

As suggested in the earlier recounting about nurses who were assaulted, a key event that ignites a passion is often the reason that nurses become involved in advocacy and policy. Can you identify your passion? Are you motivated to prevent needlestick injuries, support healthcare reform, promote safe staffing, activate safer patient-handling policies, prevent gun violence in schools, or advocate for laws to help prevent violence against nurses? These stories of passion also hold the key to nurse political activation, as they also provide rich stories that put faces to an issue and help outsiders, such as legislators or board members, understand the richness and the complexity of healthcare issues facing frontline nurses as they provide care that impacts their constituents. The passion that often comes from personal experiences in professional caregiving or from within one’s personal life may be a catalyst, but passion alone does not account for political activism. Many nurses indicate that their life experiences from education and family played a role in their political activism. A family nurse practitioner, who is a member of the North Carolina Nurses Association and serves in the state legislature, writes in response to the question, “What got you interested in running for office or engaging in policy work?” My grassroots advocacy began in 1980 with a rewrite of the state’s nursing practice act. I spent the next 27 years as an advocacy leader in nursing and community organizations, party politics, and other people’s campaigns. I grew weary of trying to persuade elected officials—who were powerful but no smarter than I—to make good decisions about legislation affecting my patients’ health and healthcare and my day-to-day nursing practice. When it hit me that pushing for better health policy

12   UNIT I  MAKING THE CASE was pointless without an equal push for improvement in the social d ­ eterminants of health (education, employment, socioeconomic status), I decided to run. Elected office was a means to the end I had been seeking for almost three decades. I am now in my 10th year as an elected official. Representative Gale Adcock North Carolina House Representatives Formerly District D Representative, Cary (NC) Town Council Family Nurse Practitioner August 10, 2017

Gebbie et al. (2000) discussed the role of chance in political involvement and identified four common themes that emerged as the starting points for policy career trajectories: family, education, employment, and networking. Family is important in inculcating values and expectations and instilling confidence. Parents are important, especially parents who are involved in advocacy efforts; for example, Rebecca M. Patton, a past ANA president, told people when she was in nursing school that one day she would be ANA president. She attributes much of her drive to her parents and specifically her mother, Mary Ellen Patton, RN, who was a strong staff nurse advocate, was a nurse union leader, and served on the ANA Board of Directors during Patton’s adolescent years. Many of the 19 nurses interviewed by Betts, Tullai-McGuiness, and Williams (2015) cited education and mentorship as door openers in their policy involvement. Formal and informal education was essential to their policy careers. These leaders also indicated that they had important mentors in their lives and that “mentoring is a vehicle for leadership development that brings more nurses to policy tables” (Betts et al., 2015, p. 408). This is corroborated by the former CEO of the International Council of Nurses (ICN), David Benton, PhD, RGN, FFNF, FRCN, FAAN, “I was very lucky, I had very good role models” (D. Benton, personal communication, May 23, 2012). Equally important to being a mentee is being a mentor. One nurse exemplified this when she said, “I want to help those coming after me” (Betts et al., 2015, p. 410). Another critical influencer and support for policy according to Betts et al. (2015) is the “profound and critical role” that professional associations played in their development. Belonging and being engaged with the associations played a critical role in providing support, networking, and career opportunities. Nurses can be guided to influence policy in many ways. In the past 20 years, educational standards for students regarding policy, roles of nurses in shared governance, calls for more nurses with baccalaureate and advanced educational preparation, and the increased visibility of nurses in policy are positively influencing nurse involvement in policy. However, despite these strides, most would agree that widespread policy involvement by nurses and the education of nurses in policy are still lacking. Nurses are leaders. Every day you lead, often stepping forward without recognizing it as leadership and taking credit for it. However, lack of visibility does not mean lack of expertise in policy, which may contribute to the perception by some that nurses are not leaders. In over 1,500 interviews of American opinion leaders in the public and private sectors, academia, and trade organizations, government officials (75%) and health insurance executives (56%) were viewed as the groups most likely to exert a great deal of influence on healthcare reform, compared with a less influential role for nurses (14%) (Khoury, Blizzard, Wright Moore, & Hassmiller, 2011). Although nurses are consistently

Chapter One  LEADING THE WAY IN POLICY  13

rated as the most trusted professionals in Gallup polls, with 82% of ­respondents rating nurses as very high or high in honesty and ethical standards (Brenan, 2017), they are not viewed as leaders in our healthcare system. Bekemeier (2008, p. 51) takes a more proactive stance in pointing out the consequences of this dichotomy: “While improving the health of the few we may serve as individuals, as nurses we are complicit in the illness and death of many.” Our perspective on health from a nursing lens enables us to be leaders in the promotion of health and in addressing the factors that determine health in our communities by moving beyond our individual nurse–patient relationships and learning to advocate for change in our organizations, our communities, and our nation to promote health. If you have been active in policy, what influenced you and where did you start? Often, nurses report starting at a local level of involvement, such as a school board or parent–teacher association, and then branching out they develop skills and gain access to resources. See Figure 1.3 for strategies for enhancing your readiness for influencing policy development. Being apolitical is not acceptable, nor is it reality. As Florence Nightingale admonished, “I think one’s feelings waste themselves in words, they ought all to be distilled into actions, which bring results” (Cook, 1913, p. 94). Not being political limits what we do for patients. In 2011, the IOM made a clarion call for action for nurses to “have a voice in health policy decision making and be engaged in implementation efforts related to healthcare reform” (Committee on the RWJF Initiative on the Future of Nursing, 2011, p. 8). This call to action is historic because it provides a plan for nursing advocacy in healthcare at the national level and is coupled with initiatives in each state that are designed to make it happen. We are at a unique juncture in the history of nursing because of the alignment of forces that encourage and enhance nurses’ opportunities to take on a more active role in advocacy across multiple settings.

Disseminating through presentations, writing, and publications Networking and nurturing long-term relationships with influentials Listening to others, articulating your own values, and formulating your own positions Identifying key stakeholders in nursing and beyond Joining professional associations, specialty nursing organizations, community organizations, and/or boards Keeping current on government activities, institutional decisions, organizational positions, professional standards, and clinical issues

FIGURE 1.3  Getting ready for a role in the policy process.

14   UNIT I  MAKING THE CASE

Expectations for workforce needs, quality and safety initiatives, interprofessional ­collaboration, healthcare reform, and environmental health are included in the confluence of forces mandating that nurses assume a leadership role in health at the little “p” and big “P” levels. These expectations are briefly described in the subsequent sections.

WORKFORCE NEEDS Workforce needs, an arena for nursing policy development, have long been recognized as critical for quality patient outcomes and safety. These needs have long been championed by the ANA, state nurses associations, and specialty nurses associations, and they are supported by research evidence linking Magnet® recognition with improvement in the quality of work environment and patient and nurse outcomes (Kutney-Lee et al., 2015). The Triple Aim of healthcare, improving the health of populations, enhancing patients’ experience of care, and reducing per capita costs (Berwick, Nolan, & Whittington, 2008), has been widely adopted as a goal for healthcare organizations and the implementation of policy. According to the Lucian Leape Institute of the National Patient Safety Foundation (NPSF; 2013, p. 1), “if we expect the workforce to care for patients, we need to care for the workforce. Workplace safety is also inextricably linked to patient safety. Unless caregivers are given the protection, respect and support they need, they are more likely to make errors, fail to follow safe practice, and not work well in teams.” Therefore, to achieve the Triple Aim in caring for the patient, it has been recommended that it be expanded to the Quadruple Aim to include care of the provider (Bodenheimer & Sinsky, 2014). Ongoing challenges for nursing include the shortage of nurses, workforce needs, and the work environment. The workforce needs of the profession can be broadly categorized into workforce development, safety, staffing, respect and civility, health, and conditions of employment. See Exhibit 1.2 for a listing of potential areas for nursing policy development. Although not meant to be exhaustive, these areas provide opportunities for nurses to make improvements in their work environment, as well as to advance issues of relevance to the profession. In examining the range of these workforce needs, it is clear that opportunities for policy involvement exist at the little “p” level within organizations or at the big “P” level through local, state, federal, and even international initiatives. One of the reasons nurse leaders established the ANA in 1896 was to address deplorable working conditions. The complexities of nurses’ workforce needs are illustrated by the changing landscape of the workday that cuts across issues related to patient safety, staffing, fatigue, mandatory overtime, and overtime compensation. In 1903, the first nurse practice act was passed in North Carolina. The ANA and state nurses associations have been on the forefront of addressing and improving the poor working conditions of nurses. One area of workforce needs highlighted here is working hours. In 1934, the ANA House of Delegates approved a resolution, for example, calling for an 8-hour workday for nurses. Working hours remain an issue today. Many hospitals transitioned to 12-hour shifts in the late 1970s to provide an attractive incentive for nurse recruitment and retention. This schedule flexibility was a boon for some facilities, allowing nurses to return to school and providing more days and weekends off, for example. Now, nearly 50 years later, research findings justify re-examination of long

Chapter One  LEADING THE WAY IN POLICY  15

EXHIBIT 1.2   NURSING WORKFORCE NEEDS Workplace safety

Musculoskeletal injuries Occupational exposures to communicable diseases Occupational exposures to hazardous substances Reproductive rights and hazards Resources for impaired nurses Safe patient handling Safe needles, sharps, and devices Slips, trips, and falls Violence Work release during a disaster

Staffing and support services

Adequacy of support (e.g., pharmacy, housekeeping) Adequacy of access to medications, supplies, and equipment Fatigue Healthy work hours and schedules Mandatory overtime Safe staffing levels

Workforce development

Adequacy of the supply of nurses Distribution and use of nurses and advanced practice nurses Diversity Education International recruitment Role, practicing to scope of education and training

Respect and civility

Bullying Blame-free environment, just culture Harassment, sexual harassment Physical and verbal abuse Respect for all team members

Health

Healthy nurse Work engagement Work–life balance

Employment conditions

Continuing education Credentialing and privileging Disabilities Discrimination Family medical leave Full practice authority for advanced practice nurses Mandatory vaccinations Overtime Paid time off Pay for performance Pre-employment screening (smoking, weight) Reimbursement for advanced practice nurses Sick time Union representation Wage compression

16   UNIT I  MAKING THE CASE

working hours. Disadvantages include adverse health effects for nurses and quality issues for patients (e.g., care continuity). The increasingly robust accumulation of evidence demonstrates the extent of these adverse effects (Griffiths, Ball, Murrells, Jones, & Rafferty, 2016; Rogers, Hwang, Scott, Aiken, & Dinges, 2004; Sagherian, Clinton, Abu-Saad Huijer, & Geiger-Brown, 2017). For many years, nurses associations, including the ANA, and unions indicated that nurses should determine whether they could safely work an additional shift or accept an overtime assignment. Policy initiatives in 18 states have focused on restricting the use of mandatory overtime for nurses. Organizations are taking a more holistic approach by examining fatigue, sleep deprivation, human performance factors, and role expectations, in addition to shift length. Shift assignment decisions are a shared responsibility between employee and employer. With some widely publicized errors and an acknowledgment that extended working hours can impact patient safety, the New York State Board of Nursing has taken the position that nurses working beyond their normally scheduled hours, except in declared emergencies, need to demonstrate their competence. Working more than 16 hours within 24 hours is considered by the board in deciding whether the nurse willfully disregarded patient safety (New York State Education Department, 2013). Although this is only one state’s practice, it has implications for all nurses, particularly in cases of a serious lapse in safety or a sentinel event. Despite the evidence related to the negative impact of longer work shifts, developing polices to address the needs of nurses while maintaining patient safety is challenging. Staff nurses need and want fair scheduling of their work hours. Policies developed to address working hours and a host of other workforce needs must be fair, be conducted using a deliberative process, and reflect the interests of diverse stakeholder groups. These efforts are ongoing and cut across the spectrum of policy development in healthcare from policy with the little “p” (e.g., how a nurse handles the response to a supervisor’s request to work overtime or take on a heavier patient workload) to big “P” policies that are addressed with legislative proposals.

NURSES AT THE FOREFRONT OF QUALITY AND SAFETY Nurses, as the largest group of healthcare professionals, have a reach that is pervasive and has a significant influence on quality and safety; however, this reach is not necessarily matched by their influence on policy. No matter the setting, nurses are at the sharp end of healthcare because of their direct impact on patients when they provide care. However, the blunt end of care is where policy decisions are most often debated and made. Any discussion of quality and safety and any implementation of strategies to improve healthcare must include nurses as the gatekeepers at the sharp end. The IOM’s classic report, To Err Is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, 1999), dramatically publicized the statistic that 98,000 deaths occur annually from medical errors. This number equates to a jumbo jet crash every day. The IOM Committee on Quality of Health Care in America felt that safety was an integral component of quality and that quality could not be improved without addressing safety (Kohn et al., 1999). Although the IOM report did not begin the patient-safety movement, its release put the spotlight on safety organizations such as the Institute for Healthcare Improvement (IHI) and the NPSF, (now merged) and the Institute for Safe Medication Practices (ISMP). The To Err Is Human report spawned the release of

Chapter One  LEADING THE WAY IN POLICY  17

subsequent reports such as Keeping Patients Safe: Transforming the Work Environment of Nurses (Page, 2004). Patient safety advocates Leape (2015), Marx (2003; creator of the just culture movement), and others have long advocated for a systems approach to patient safety, recognizing that major errors were most likely due to a series of faults within a system and that blaming individuals for major errors did not prevent them from happening again. These quality and safety initiatives have certainly saved lives. However, we know that the adoption of a safety culture and achievement of successful outcomes are quite complex and frustratingly slow, as often, a disconnect exists among education, point of care, and policy decisions. The healthcare system is full of intricacies and hazards involving not only the unpredictability of people, but also a myriad of interacting and competing parts not limited to equipment, organizations, policies, and financial issues. If one component breaks down in this dynamic arena of healthcare, expectedly or unexpectedly, the potential for downstream failure of more components may result. Failures can and do harm patients and caregivers. Two approaches often used in working toward the goals of improved safety and quality in such a complex environment are the Quality and Safety Education for Nurses (QSEN) initiative and the high reliability organization (HRO) approach to care. The QSEN initiative established quality and safety competencies for education and subsequently for practice at the system level. The six competencies, modeled after the IOM’s (Greiner & Knebel, 2003) health professionals’ competencies, include (a) patient-centered care, (b) teamwork and collaboration, (c) evidence-based practice, (d) quality improvement, (e) informatics, and (f) safety (Cronenwett et al., 2007; QSEN Institute, 2017). HROs consistently and over time work at and achieve reductions in the number accidents that cause harm so that having a serious or catastrophic accident is very rare. They are embodied in the culture of the organization and are part of its matrix. Maintaining safety is of the utmost importance, and underpinning this goal are five pervasive ways of thinking: (a) preoccupation with failure; (b) reluctance to simplify explanations for operations, successes, and failures; (c) sensitivity to operations (situation awareness); (d) deference to frontline expertise; and (e) commitment to resilience (Agency for Healthcare Research and Quality [AHRQ], 2017; Chassin & Loeb, 2013). The watchword for both approaches (QSEN and HROs) is vigilance, which includes systems thinking. In using these systems, nurses and other providers are expected to view how the components of an organization relate and fit together as part of a bigger whole or process. We have often heard that the whole is greater than the parts, and this requires constant vigilance and many eyes to help anticipate, monitor, evaluate, and improve it. Figure 1.4 shows some nurse-led quality and safety initiatives. Despite views on system thinking, lack of input at various levels within and beyond the organization continues to be a challenge for nurses. For example, nurses serving as the early-warning system for infectious disease provides an example of how important it is for organizations to have nurses’ input. Although the impact of nursing on patient health outcomes is well documented through research and program evaluation (see Chapter 12), having one’s voice heard can still be a challenge. See Policy on the Scene 1.1 for the story of one student’s successful efforts at the sharp end of care as part of a clinical experience in the OR.

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Create NoInterruption Zones

Establish Safety Huddles

Nurse-Led Safety and Quality Initiatives Impacting Policy Exemplars

Reduce Restraint Use Use Universal Color-Coded Alert Armbands

FIGURE 1.4  Exemplars of nurse-led safety and quality initiatives.

POLICY ON THE SCENE 1.1: Student Demonstrates QSEN Competencies At Case Western Reserve University, Cleveland, Ohio, an innovative course is required for all undergraduate nursing students. Focused on quality and safety, the course uses the perioperative setting as the clinical site. Along with perioperative content, the six Quality and Safety Education for Nurses (QSEN) competencies established the foundational content covered weekly in the lecture and laboratory. The competencies are linked to optimal patient care and are essential in educating the next generation of nurses. An incident that occurred highlights the importance of the teamwork and collaboration QSEN competency during the surgical time-out for a patient undergoing an orthopedic procedure. A junior nursing student spoke out and alerted the surgical team that the patient was allergic to bees and noted that the frequently used supply item, bone wax, would be contraindicated for this patient. Bone wax is a waxy substance made with beeswax and used to control bleeding in orthopedic procedures. In a deep authoritative voice, the well-experienced surgeon wanted to know who was speaking and where she got her information. During the exchange, a surgical team member found the research article online and validated the nursing student’s comments. A dialogue followed with the team about the importance of everyone contributing during the surgical time-out because it matters for patient safety. Although it is unusual for students to have clinical experiences in the perioperative setting, this example highlights its benefits. Joanne Disch, PhD, RN, FAAN, past president of AARP and the American Academy of Nursing (personal communication, April 5, 2013) reports that 80% of all nursing students never spoke with a physician about the care of their patients. These clinical experiences provide students with the opportunity to be in the presence of the entire surgical (continued )

Chapter One  LEADING THE WAY IN POLICY  19

team for an extended period for each case. The student not only participated in team activities, but also significantly contributed to the safety of the patient. This positive learning experience in a challenging and intimidating situation reinforced the importance of being a patient advocate and speaking up. Preventing harm to patients with an allergy to bees is an ongoing concern. This potentially harmful incident was prevented by vigilance. The next step involves policy and addressing of the nomenclature for substances like this so that its composition would be readily apparent. Thus, efforts to improve quality and safety includes multiple stakeholders.

INTERPROFESSIONAL COLLABORATION Interprofessional collaboration is increasingly important because of its potential positive impact on patient outcomes through improved coordination and communication. The IOM, in four seminal reports, called for all healthcare professionals to be ­educated to deliver patient-centered care as members of interprofessional teams (Sullivan, Kiovsky, Mason, Hill, & Dukes, 2015). Interprofessional collaboration is a major focus of the QSEN program (Cronenwett et al., 2007). Health professions educators from nursing, medicine, dentistry, pharmacy, and public health recognized this need by creating the Interprofessional Education Collaborative (IPEC) in 2009 to advance interprofessional learning (IPEC, n.d.). The call for increased interprofessional collaboration provides nurses opportunities for ongoing involvement in the development of little “p” p ­ olicies within an organization such as the implementation of fall risk-reduction protocols or rapid response teams, as well as opportunities for big “P” influence on healthcare through participation in major policy groups and/or organizations. Opportunities for collaboration and influence at the big “P” level include having key seats at policy tables. Organizational choices about participation may be the direct result of both priorities and financial resources; some seats may range in cost upwards of $25,000 (see Chapter 7). A number of nurses associations hold seats at the National Quality Forum (NQF; see Exhibit 1.3). NQF members also include representatives of other health professional groups (e.g., medicine, pharmacy, and interdisciplinary groups), consumers, health plans, provider organizations, purchasers, public health/ community groups, suppliers, and industry. The NQF brings healthcare leaders together to build consensus on national priorities and goals for performance improvement, as well as provide the endorsement of standards for measuring performance. The NQF, through its Measure Applications Partnership (MAP), provides input to the Department of Health and Human Services on the selection of performance measures for public reporting and performance-based payment. Inclusion of a nurse-sensitive measure (e.g., pressure ulcers, now known as pressure injuries) as an NQF quality measure is important recognition for quantifying the daily work of nurses. Using recognized nurse-sensitive measures strengthens research, demonstrating the relationship between patient outcomes and nurse staffing. Norma Lang, PhD, RN, FAAN, a noted leader in quality who has served on the NQF and worked hard to make the work of nurses visible, noted that, “If you can’t name it, you can’t control it, finance it, teach it, or put it into public policy” (Clark & Lang, 1992). Sometimes, an organization can be a member of a policy group for years with seemingly little or no progress, but then an opportunity may arise to influence the agenda

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EXHIBIT 1.3  NATIONAL QUALITY FORUM NURSE ORGANIZATION MEMBERSa American Academy of Nursing American Association of Colleges of Nursing American Association of Nurse Anesthetists American Association of Nurse Life Care Planners American Association of Nurse Practitioners American College of Nurse-Midwives American Federation of Teachers, Nurses and Health Professionals American Nephrology Nurses Association American Nurses Association American Organization of Nurse Executives American Psychiatric Nurses Association Association of periOperative Registered Nurses

Association of Rehabilitation Nurses Association of Women’s Health, Obstetric and Neonatal Nurses Hospice and Palliative Nurses Association Infusion Nurses Society National Association of Pediatric Nurse Practitioners National Council of State Boards of Nursing Niche-Nurses Improving Care of Healthsystem Elders Nursing Alliance for Quality Care Oncology Nursing Society University of Kansas School of Nursing Wound, Ostomy and Continence Nurses Society

Note: aAs of June 2018.

in a way that makes a dramatic difference for healthcare. Participation in the NQF provides nurse leaders with not only opportunities for collaboration across professions, but also opportunities to collaborate with business leaders and consumer advocates. The ANA represents nurses at numerous other tables, including the NAM, IHI, National Council of Patient Information and Education, National Coordinating Council for Medication Error Prevention and Reporting, and the eHealth Initiative, among others. Very often, the ANA provides the only nurse representation at a policy table. The ANA represents all nurses, focusing on issues across the broad spectrum of nursing care. It also has close relationships with 21 nursing organizations that are its affiliates and more than 60 nursing organizations through the Nursing Organizations Alliance. Specialty organizations may also represent nurses in interprofessional groups focused on their practice area. In addition, the ANA and other nursing organizations make recommendations for appointments to key policy positions in governmental agencies (e.g., Centers for Medicare & Medicaid Services [CMS]) and nongovernmental organizations (e.g., The Joint Commission; see Chapter 3). It is important that we, as nurses, are proactive and that we are well positioned by being involved in interprofessional collaboration at numerous levels of important agenda-setting organizations. Interprofessional collaboration provides opportunities for building relationships when working together on areas of mutual interest and concern. Forging these relationships becomes important in crossing bridges and enabling organizations to address areas of policy disagreement in the future.

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HEALTHCARE REFORM Nurses have been leaders in social reform. The ANA was the first healthcare professional group to support legislation establishing Medicare and Medicaid in 1965. Nurses have been at the forefront of efforts to improve the quality of care and access to care. Healthcare reform with the passage of the Patient Protection and Affordable Care Act (PPACA), more commonly known as the ACA, in 2010 provided nurses with numerous opportunities to intersect with health policy initiatives to transform our healthcare system. The ACA legislation, also known as Obamacare, covers the broad spectrum of healthcare delivery, providing nurses with numerous opportunities to influence the development of health policy. See Exhibit 1.4 for areas covered by the ACA that have relevance for nurses. EXHIBIT 1.4   KEY PROVISIONS OF THE ACA AND IMPLICATIONS FOR NURSES AREA

KEY FEATURES

Primary care workforce

Scholarships and loan repayment; funding for National Health Service Corps and Public Health Service Corps

Workforce development programs

Title VII funding for advanced practice nurses, workforce diversity, education, quality and retention grants, loan repayment and scholarships (for nursing students, nurse faculty, public health professionals, allied health professionals, health professionals in pediatric or geriatric settings, and graduate nurse education); redefining health professionals shortage areas; demonstration grants for Indian Health; establishes National Healthcare Workforce Commission

National Practitioner Data Bank

Streamlining and standardizing processes for clinical privileging

Patient-centered medical homes

Grants program for community-based interdisciplinary, interprofessional teams to support primary care

Nurse-managed health centers

Grant support for nurse-managed health centers providing primary care to underserved and vulnerable populations

CNMs

Increase in reimbursement rates for CNMs to provide parity with physicians

Payment for Medicare

Bonus payment for primary care providers in health professions’ shortage areas (does not apply to CNMs) (continued )

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EXHIBIT 1.4  KEY PROVISIONS OF THE ACA AND IMPLICATIONS FOR NURSES

(continued )

AREA

KEY FEATURES

Innovation Center at Centers for Medicare & Medicaid Services

Development and testing of various innovative healthcare payment and service-delivery models

Independence at home

Demonstration program for chronically ill Medicare beneficiaries

SBHCs

Funding for new and existing SBHCs with preference to sites serving large number of children receiving medical assistance

Nursing home transparency

Public reporting of staffing and turnover data. Establishment of complaint resolution process. Mandated disclosure of ownership and wage and benefit wage data

Patient-centered outcomes research

Grants to support patient-centered comparative effectiveness research

State health insurance exchanges

All types of licensed healthcare professionals are included as providers

Essential health benefits package

Defines essential benefits covered under health insurance benefits packages

Accountable care organizations

Providers and suppliers working together to coordinate care for Medicare beneficiaries; reporting of quality improvement results; establishes nurses’ roles in quality improvement and care coordination

Center for Quality Improvement and Patient Safety

Identification of best practices for quality improvement in the delivery of healthcare services

ACA, Affordable Care Act; CNMs, certified nurse-midwives; SBHCs, school-based health centers. Source: American Nurses Association. (2014). Health care transformation: The Affordable Care Act and more. Retrieved from http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/ HealthSystemReform/HealthCareReformResources/More-on-Health-Care-Reform

Since the passage of the ACA in 2010, the number of uninsured individuals in the United States decreased from 16% to 9% in 2016 (Clarke, Norris, & Schiller, 2017). Despite this impressive decline in the number of uninsured, the public has a mixed view of the ACA, with differences of opinion reflecting party affiliation (Kaiser Family Foundation, 2018). Not all states have included the Medicaid expansion. On the other hand, because of repeated efforts to repeal the ACA and the prospects of potentially 32 million people losing their insurance with one of the proposals (Congressional Budget Office, 2017), some states are passing legislation and regulations to expand insurance coverage to all its citizens. For example, Oregon passed legislation in 2017 that provides

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healthcare coverage for people regardless of income, citizenship status, gender identity, or health insurance. It is recognized that the insurance markets need stabilization. These uncertainties about the fate of the ACA and efforts to address specific concerns carry us into the future impacting the health of the public, healthcare systems, and ways that nurses deliver care. It has also led to tremendous grassroots support for the continuation of healthcare reform, indicating that the public values healthcare and health insurance that is affordable. Tarik S. Khan, in Policy on the Scene 1.2, highlights the importance of not being silent amid controversy as he describes the importance of advocacy through letters to the editor and newspaper op-eds that highlight his clinical experiences, health insurance in the face of unexpected injury, and healthcare bills.

POLICY ON THE SCENE 1.2: Letters to the Editors and Op-Eds as Advocacy Tools Tarik S. Khan, MSN, RN, FNP-BC, CRNP, Family Practice and Counseling Network, Philadelphia, Pennsylvania As a nurse advocate, I write regularly to the public about healthcare issues. I write to support, speak against, and/or to suggest ways to make improvements that will benefit the patients I care for and the community I live in. I am a nurse practitioner and I live and work in Philadelphia. I speak from my expertise and experiences as an APRN caring for patients with high rates of obesity and diabetes and who rely on health insurance, especially Medicaid. So far, this year, I have written and had published five letters to the editor. I wrote one letter supporting a beverage tax on sugary drinks in my community and I offer an excerpt to show how a letter can provide an opportunity to not only support a project, but also be used to suggest a way to build on a related new initiative. In this case, I advocate for adding warnings to sugary drink containers: “This tax has not only meant thousands of seats in free, quality pre-K for Philadelphia children, but meant less soda consumption and better health outcomes for my patients. Instead of just defending a commonsense measure such as the soda tax, perhaps as residents we should be lobbying our legislators to force beverage companies to put warning messages on their products such as ‘Drinking Soda May Cause Hospitalization,’ ‘Consuming This Beverage Can Lead to Blindness, Erectile Dysfunction, and Dialysis,’ or simply ‘Soda Kills.’ Let’s not drink the soda companies’ Kool Aid, but rather stand up and celebrate Philadelphia’s Beverage Tax: a measure that has made my patients healthier, will make our city stronger, and will brighten the future of Philadelphia’s children.” The Philadelphia Inquirer, August 23 (Khan, 2017b). Most of my writing this year has focused on healthcare reform. I wrote four pieces opposing proposed legislation about healthcare reform such as the repeal of the Affordable Care Act (ACA), pointing out the impact on patients in my community and in my state of Pennsylvania. Of particular concern is the loss of insurance that many may face. Although these impacts are clear to me and the (continued )

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patients in my practice, the shooting of U.S. Representative Steve Scalise helped me frame this issue another way as I tell in the following letter: “When I heard of the horrific shooting of U.S. Representative Steve Scalise, my heart sank. He and his Republican colleagues were preparing for a bipartisan baseball game, a collegial ritual that we desperately need more of in Washington, DC. Capitol police, emergency personnel, and hospital workers were heroic, and their brave and decisive actions thankfully saved the congressman’s life. But the real hero for the congressman and his family will be his health insurance. It’s his insurance coverage that will make sure his hospital stay is paid for, and that will cover any medical equipment, physical or behavioral therapy, or m ­ edication the congressman may need to get back to where he was before this awful event. Sadly, if the American Health Care Act (AHCA) is passed, millions of patients with insurance, I believe, will lose the essential health benefits and patient ­protections that will save them in a medical tragedy from illness, preventable death, and bankruptcy. Furthermore, its estimated that 23 million Americans will lose their insurance altogether. As we pray for Congressman Scalise’s rapid and full ­recovery, let’s also remember to pray that millions of Americans will not lose the health coverage and patient protections that may one day be heroic for themselves and their families.” The Express, June 22 (Khan, 2017a). Being active in the political process can be accomplished not with only with letter writing, but also with knocking on a person’s door, making phone calls, getting signatures for a petition, or helping people register to vote.

Healthcare reform for the immediate foreseeable future provides nurses with opportunities to become involved at the grassroots level and beyond. Nurses need to be involved in the establishment of policies that are consistent with the values of the profession. Two examples of nurses impacting healthcare reform are care coordination and the removal of barriers to practice.

Care Coordination Nursing is taking a leadership role in care coordination—one of the profession’s traditional roles and a vital element in healthcare reform (see Exhibit 1.4). Care coordination helps ensure that patients’ needs and preferences regarding health services and information sharing are met over time and involve the deliberate organization of patient care activities to facilitate the appropriate healthcare service delivery (ANA, 2012). However, the advancement of nurses’ contributions to care coordination has met with resistance (American Academy of Family Physicians, 2012; Committee on Pediatric Workforce, 2013) as advanced practice nurses work for recognition as leaders in patient-centered medical homes (PCMH). PCMH is a care model that redesigns primary care so that it is person-centered and comprehensive, accessible, coordinated while maintaining quality and safety, and satisfying for the patient (AHRQ, n.d.). The ACA makes funds available for PCMHs to transform primary care by paying care coordinators, who very often are nurses, for their work. PCMH demonstration projects are using strategies such as team-based care, sustained partnerships, enhanced access, coordinated care, and system-based approaches to quality, all of which are promising for improving care processes. All nurses, including

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advanced practice registered nurses (APRNs), can be involved in transforming primary care practices to PCMH models. An illustration of the big “P” in policy at work was when nurses, including the ANA president at the time, Rebecca M. Patton (2006–2010), were regularly involved in the discussions and development of ACA with the president, White House staff, and members of Congress. Patton and her colleagues advocated for the use of clinician-neutral language in the ACA—specifically, primary care “practitioners” or “providers”—enabling APRNs to lead PCMH teams, depending on individual state laws and regulations. Although nurses have opportunities to participate in the political and policy processes at many levels, moving forward on these opportunities to capitalize on nursing’s traditional roles requires continued organized and concerted collaborative efforts in to achieve equitable access to high-quality care.

Removal of Practice Barriers Barriers to practicing at the full scope of one’s education and training still exist in many settings. Although barriers to practice are typically discussed in the context of advanced practice nurses (clinical nurse specialists, certified nurse-midwives [CNMs], certified RN anesthetists, and nurse practitioners), RNs providing direct care are not immune from this phenomenon. For example, some hospitals may still have a unit charge nurse who is responsible for all communications with physicians. The oft-cited reason is that nurses do not have the experience to make the decisions about calling physicians. This then creates a situation in which nurses do not have the opportunity to learn and practice competencies related to interprofessional communication and collaboration. Using a third party for communication may result in unnecessary delays and possibly errors when important details are not communicated in either direction. Yet when the charge nurse is not around, the nurse who was not allowed to communicate regularly with physicians is expected to handle the essential communications with skilled proficiency and aplomb. This type of ingrained hierarchical communication pattern limits professional autonomy and growth and can negatively impact patient safety. Gebbie (2011) describes the “socialized hesitation” of nurses to use critical thinking and decision making as a detriment to providing the highest level of care and calls on organizations to upgrade their position descriptions to include expectations for professional decision making and the use of evidence-based practice. Safe staffing, a major issue for nurses at the bedside, is also a barrier to practicing at the full scope of education and training by creating conditions that make it difficult for nurses to deliver the care that they believe meets professional standards and is safe for their patients. When nurses are forced to work faster, do not have sufficient time to complete their work, are required to work longer hours, and do not have the resources to do their work, it creates stress. The evidence that these workload stressors impact patient outcomes is substantial (Aiken et al., 2012; McHugh, et al., 2016; Trinkoff et al., 2011), as is the evidence that inadequate nurse staffing has a more significant impact on older Black surgical patients, including readmissions of these patients (Carthon, Kutney-Lee, Jarrin, Sloane, & Aiken, 2012; Lasater & McHugh, 2016). Barriers for APRNs may also contribute to patient safety problems. For example, APRNs, including nurse practitioners, clinical nurse specialists, and CNMs, along with physician assistants, are not allowed to certify patients for Medicare’s home health benefit and sign the home healthcare plan. This leads to unnecessary delays for patients who need such services, as well as delays in patient discharge from more expensive hospital settings, with 10-year saving estimates ranging from $129.2 to $309.5 million (Dobson DaVanzo & Associates, 2011). Legislation was introduced in the 113th, 114th, and 115th

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Congresses that would allow nurse practitioners, clinical nurse specialists, and CNMs to certify Medicare homecare eligibility and home healthcare plans. Despite the common sense and economic evidence, change in policy requires advocacy and persistence to achieve the desired ends.

THE ENVIRONMENT AND HEALTH Nurses have long recognized the role of the environment in maintaining health. Florence Nightingale emphasized that the environment should promote health and in no way be harmful. Her views were that the provision of fresh air, light, a quiet environment, nutrition, warmth, clean water, sanitation, and cleanliness were essential to this vision. Nurses today are continuing these efforts for the environment at the patient level and to our communities and globally. The Standards of Professional Nursing Practice address the obligation of nurses to the environment. Standard 17 reads, “The registered nurse practices in an environmentally safe and healthy manner” (ANA, 2015b). Environmental factors are central to the elimination of healthcare disparities around the world. Access to clean water is vital to preventing and treating life-threatening diarrhea, which kills yearly over a half million children younger than age 5 (World Health Organization, 2017). Cleaner air in the community where we live and work means that children are less likely to get asthma. Every day, we learn more about the relationship of certain diseases to the environment: asthma, allergies, emphysema, cancer, heart disease, and stress. In fact, it is difficult in the course of a day to come across a patient whose health is not impacted by the environment. These numbers and everyday experiences with our patients are a call to action for policies that help make improvements to the environment and strengthen our public health so that everyone can live to their fullest potential (see Chapters 13 and 14). Nurses are ideal natural advocates for environmental health because of our professional commitment to social justice and our skills in working with our communities. Nurses are uniquely situated to understand environmental issues and can articulate them to the public to garner support and build coalitions for action that can improve environmental health at work, in schools, in hospitals, and in communities. Whether nurses care for workers experiencing lung diseases from mines, factories, or farms across the world or, more regionally, care for children with lead exposure from contaminated water, they have a vital role to play to prevent harm in the environmental policy arena. Natural disasters have shown the need for, and provided the opportunity to address, environmental health issues. Nurses have responded individually and collectively when disasters have hit, often focusing their efforts broadly but also working to help the poor and often the elderly, who have fragile support systems and often bear the brunt of a disaster. Disasters, whether natural (e.g., weather-related storms) or man-made (e.g., terrorist attacks), often have a high impact on those with the least resource reserves. These socioeconomic and demographic inequities easily translate into increased healthcare disparities when disaster hits. In every year between 1994 and 2013, more than 200 million persons were impacted by the almost 7,000 recorded disasters (Centre for Research on the Epidemiology of Disasters [CRED] and United Nations Office for Disaster Risk Reduction [UNISDR], 2015). Nurses and their professional associations along with innumerable charitable and volunteer agencies have played an important role in disasters. The ANA (2017a) has

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actively pursued examining and advocating for legal and ethical roles of nurses in ­natural disasters and, as a result, issued a brief, Who Will Be There? Ethics, the Law, and a Nurse’s Duty to Respond in a Disaster. The brief discusses some of the ethical and personal issues related to the duty of a nurse to respond to disasters and raises questions to consider before disaster strikes. Also contained in the brief are principles that need to be included when developing standards of care for all healthcare providers involved in disasters, as well as information on ANA’s involvement with other interprofessional groups. Leading the way internationally have been the ICN and the World Association for Disaster and Emergency Medicine, who conducted a review of the use of the ICN Framework for Disaster Nursing Competencies (Hutton, Veenema, & Gebbie, 2016). If we can consider the familiar phrase that all politics is local, we need not look very far for an opportunity to improve environmental health. Nurses themselves, as briefly addressed in the chapter so far, may be at risk for harm from environmental hazards in their own work settings and may contribute to environmental harms by using poor practices in their work settings. Not only do we have more research that demonstrates the link between the work environment of nurses and patient outcomes, but also we have the link between the work environment and the health of nurses. Nurses can and should be at the forefront of efforts to ensure that their working conditions are safe. Nurses may be informed about the hazards associated with chemotherapeutic agents, but they may not even know about the nature of the hazards associated with chemicals such as cleaners, solvents, disinfectants, and pesticides despite ubiquitous safety data sheets. Hospitals and other healthcare organizations expose employees to a wide range of hazards: biological, chemical, ergonomical, physical, and psychological. A 2007 survey of more than 1,500 nurses across the United States (sponsored by the ANA, Environmental Working Group, Health Care Without Harm, and University of Maryland School of Nursing) indicates that a third of nurses had high exposures, defined as being exposed at least twice a week to at least five chemicals and other hazardous substances for 10 or more years (Environmental Working Group, 2007). These data indicate the need for nurses to work to implement strategies at the little “p” level by marshaling forces to replace hazardous materials and instituting engineering controls, as well as at the big “P” level to institute necessary legislative and regulatory action to ensure that nurses and their coworkers have a healthy and safe environment to deliver quality care. It is not just hazardous chemicals that are a concern for nurses. A 2011 ANA survey of nurses about health and safety in their work environment indicates that on-the-job injuries increased slightly from 2001. In addition, nearly all nurses indicate that they have worked despite experiencing musculoskeletal pain. The top-two health and safety concerns are (a) the acute or chronic effects of stress and overwork and disabling musculoskeletal injury and (b) concerns about on-the-job assault, which have increased (ANA, 2011). Also, approximately 10% of the nurses said they have had an automobile accident that was related to fatigue or shift work. The results of these surveys and the evidence drawn from the world around us indicate that we have much work to do and that each of us needs to be involved in making the environments in which we live, work, and play safer for all. What will be your level of involvement? Numerous organizations address environmental issues in healthcare (see Exhibit 1.5). Nurses can become part of these groups or access numerous resources available on their websites.

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EXHIBIT 1.5  REPRESENTATIVE ORGANIZATIONS ADDRESSING ENVIRONMENTAL ISSUES IN HEALTHCARE Agency for Toxic Substances and Disease Registry, Environmental Health Nursing Initiative: www.atsdr.cdc.gov Alliance of Nurses for Healthy Environments: www.envirn.org American Nurses Association, Healthy Work Environment: www.nursingworld.org/practice-policy/work-environment/ Health Care Without Harm: www.noharm.org National Environmental Health Foundation: www.neefusa.org Practice Green Health: www.practicegreenhealth.org

Nurses are also tackling broader issues of environmental concern. The Pennsylvania State Nurses Association (PSNA) submitted a proposal that was adopted by the ANA’s House of Delegates in 2012 and called for a national moratorium on new permits of unconventional oil and natural gas extraction (fracking) until human ecological safety could be ensured (McDermott-Levy, Kaktins, & Sattler, 2013). This was a bold move by the PSNA, which gave national voice to a problem experienced at the local level. It also illustrates the potential within the nursing community to address environmental health problems. In developing its proposal, PSNA drew on the expertise of the members of its environmental health council, one of whom is Nina Kaktins, MSN, RN, a nurse and a geologist who has willingly shared her knowledge with healthcare professionals across Pennsylvania. Access to clean water for communities is central to the national debate on this issue.

OPTION FOR POLICY CHALLENGE: Occupational Injury Becomes a Catalyst Karen A. Daley Within a few months after my injury-related infection with HIV and HCV, I made the decision to engage within the policy arena as one of the voices and faces of preventable sharps-related injuries. Several key lessons emerged. Engage others with a shared commitment to the issue. Remember that a collective voice is stronger than a solitary one. Joined together, our voices and votes represented political power and influence. I believe the chorus of credible organizations and knowledgeable voices, along with strong stakeholder engagement, made sharps safety reform possible. Use your knowledge and expertise to help identify strategic approaches for addressing the problem. Nurses are generally considered credible, and legislators rely on our expertise for guidance on many health policy issues. At the time, (continued )

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the Bloodborne Pathogens Standard needed updating to reflect the changing ­environment, and legislation was identified as the most appropriate means for enacting reforms. It was important for experts such as the American Nurses Association (ANA) to help congressional champions shape the bill’s major components to address existing gaps and strengthen worker protections. It is never enough simply to file a bill. Vision, strategic planning, and persistence are necessary for success. Passage of any bill involves a multistep process and the ability to compromise and overcome obstacles. Strategies for success include identifying and engaging with key legislators on both sides of an issue. Timing and synergy around an issue are critically important in politics and public policy. The lack of visible or vocal support for changing public policy or passage of legislation represents sure death for the issue in the political arena!!! Just because a law is passed does not ensure that the intended change occurs. Unfunded mandates hold no promise for change or implementation. Resources and longstanding commitment are needed to enact and enforce laws.

IMPLICATIONS FOR THE FUTURE We are optimistic that nurses’ roles in policy will increase in the future. Healthcare has become increasingly complex, the population is aging, and the population is increasingly experiencing more health problems because of chronic diseases and the opioid epidemic. This confluence of trends means that the need for nursing services will increase. At 4 million strong, nurses will continue to be the largest healthcare professional group. The public will continue to depend on nurses and trust them for the delivery of high-quality healthcare. We have had dramatic increases in the overall educational preparation of the nursing workforce. This means that nurses are prepared to take on a more significant role in policy from the little “p” to the big “P” level. The public will come to expect nurses to take on a more active role in policy. Nurses are positioned to take on more substantial policy roles, which is directly related to their vigilance. Nurses have opportunities to engage in policy work because they are intimately connected to patients who are experiencing life’s most difficult and challenging moments as they struggle with healthcare transitions (e.g., acute illness, management of chronic illness, illness at birth, death, and transfer from one health state to another). These experiences position nurses to identify policy problems and craft workable policy solutions. We cannot necessarily predict the future. We may not know how or when our work, family, personal life, community, education, or other circumstances occur to prompt us to take on a more active policy role. However, because of nurses’ unique perspective, we need to be nimble to take advantage of opportunities to influence population health and/or advance the profession. Work in policy is the opportunity to influence care beyond the immediate circumstance of direct care for one patient, several patients, or a larger number of patients in a practice. Nursing has a history of singular leaders who have made phenomenal strides to advance nursing and promote health. However, the increasingly interconnected and regulated world of healthcare means that advancing health and promoting health will require the ability to work in interdisciplinary teams and have exquisite policy-­making skills. Nurse educators in formal educational programs and practice settings have

30   UNIT I  MAKING THE CASE

embraced the opportunity to prepare nursing students and nurses in interprofessional collaboration. This, coupled with having advanced education, being a member of professional groups, and having a network, are critical foundational steps for influencing policy. As illustrated in this chapter’s Policy Challenge, Karen A. Daley was thrust into policy by a life-changing event, but she was also well-connected through her advocacy activities in her state nurses association. This helped position her to make a larger contribution to health policy on the national level. Gale Adcock, day in and day out, saw the needs of patients in her clinic and spent years advocating as a professional nurse. These experiences provided her with the perspectives and the passion to pursue policy making in a legislative role. People enter the nursing profession because they are passionate about caring for people and promoting their patients’ health and well-being. Participation in policy making extends that passion to impact more people. The uncertainties presented in the current healthcare climate in the United States has ignited passions across the country, and it is anticipated that we will see greater activism of nurses who are aligned with professional and consumer groups, as well as those who pursue a cause on their own. Professional associations and consumer groups need to be ready to marshal the forces of this increased activism to advance their agendas. We know that being silent within an organization has repercussions for the safety and well-being of our patients (Henriksen & Dayton, 2006). Being silent within our society, organizations, associations, community, and government has repercussions for the advancement of our profession and the well-being of the patients entrusted to our care. Action is needed to protect the policy-making processes of our democracy to protect the rights of the people we serve and the most vulnerable among us. Taking an active role in policy is every nurse’s responsibility as a member of our profession.

KEY CONCEPTS 1. The policy process includes recognition and identification of a problem, formulation of the policy, implementation of it, and then monitoring and evaluation of the results. 2. Workforce issues, including workforce development, workforce safety, adequacy of staffing and support services, respect and civility, and conditions of employment, need to be addressed to enhance the quality and safety of patient care. 3. Nurses, by being at the sharp end of care and having intimate knowledge of the healthcare system, are critical to the development, monitoring, and evaluation of policy related to safety and quality. 4. Nurses are well prepared for interprofessional collaboration, which is increasingly taking on more significance in improving patient outcomes. 5. Healthcare reform continues to provide nurses with resources for education, as well as opportunities for using nurses more effectively and shaping policies for the U.S. healthcare system. 6. Nurses have a long tradition of advocacy for our communities through the promotion of healthy environments. 7. Being a nurse means being involved in policy (regardless of the practice setting) in organizations, communities, and government at the local, state, national, and international levels.

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SUMMARY Nurses are an essential part of healthcare delivery, and as such, they have an integral leadership role and responsibility in the development of health policy. Nurses have myriad opportunities to be involved in health policy on the continuum from bedside care (with the provision of direct care) to the boardroom, with the formulation and implementation of policy at the top echelons of complex organizations at the state, national, and even international levels. Forces influencing nursing practice and healthcare include nurse workforce needs, quality and safety, interprofessional collaboration, healthcare reform, and environmental health. Nurses are increasingly being called on to be leaders at the bedside and beyond. Being a leader means being involved in policy. Policy work is every nurse’s work. It involves multiple areas and alignment of multiple forces and stakeholders to achieve a common goal in advancing health. Addressing a policy in one arena very often leads to new issues and new policy directions. Nurses are well positioned to lead the way in policy, from the bedside to the boardroom.

LEARNING ACTIVITIES 1. Compare and contrast current policy activities of the ANA and one specialty nursing organization. 2. Identify one or two policy activities that you will accomplish while in school, and then determine what three to five goals related to policy you will accomplish within 3 years of graduation. 3. Describe your goals for your policy involvement in the next 3 to 5 years and the steps necessary to achieve them. 4. On a daily basis for a week, read a paper and/or watch a news show and identify a political issue that is discussed. For every issue, discuss at least three reasons why the issue is important to nursing and/or healthcare. 5. At your workplace or clinical practicum site, identify three policy issues that are currently under discussion. What is the impetus for those policies? Describe your role, or potential role, and the impact that the policy will have on you. 6. Discuss the status of current workplace violence policies in your workplace, organization, and state. 7. Create a short advocacy video that can be used to present an issue to the public, stakeholders, or policy makers. 8. Select an issue that has inconsistent policies or inconsistent application of policies (e.g., mandatory vaccinations) for a debate.

E-RESOURCES • Agency for Healthcare Quality and Research Patient Safety Organization http://www.pso.ahrq.gov • American Academy of Nursing. (2015). Raise the voice: Transforming America’s health system through nursing solutions http://www.aannet.org/initiatives/edge-runners • American Nurses Association Policy and Advocacy http://nursingworld.org/MainMenuCategories/Policy-Advocacy • American Nurse Today: Shiftwork Sleep Disorders: The role of the nurse understanding SWSD for you and your patients

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• • •

• •

https://www.americannursetoday.com/wp-content/uploads/2014/07/ant5-SHIFTWORK-423.pdf Florence Nightingale: Theory of Public Health Policy http://www.uoguelph.ca/~cwfn/nursing/theory.htm Food and Agriculture Organization: Basics in policy analysis: How governments should design & implement policies http://www.fao.org/docs/up/easypol/540/basics_in_policy_analysis_170en.pdf International Council of Nurses. (2010). Promoting health: Advocacy guide for health professionals. Geneva, Switzerland: World Health Communication Associates Ltd. http://www.icn.ch/images/stories/documents/publications/free_publications/ICNNEW-28%203%202010.pdf United States Congress https://www.congress.gov World Health Organization. (2010). Strategic directions for strengthening nursing and midwifery services 2011–2015. Geneva, Switzerland: World Health Organization http://whqlibdoc.who.int/hq/2010/WHO_HRH_HPN_10.1_eng.pdf

REFERENCES Agency for Healthcare Research and Quality. (n.d.). Defining the PCMH. Retrieved from http:// pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/pcmh_defining_the_pcmh_v2 Agency for Healthcare Research and Quality. (2017, November). High reliability. Retrieved from https://psnet.ahrq.gov/primers/primer/31/high-reliability Aiken, L. H., Cimiotti, J. P., Sloane, D. M., Smith, H. L., Flynn, L., & Neff, D. F. (2012). Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Journal of Nursing Administration, 42(Suppl. 10), S10–S16. doi:10.1097/01. nna.0000420390.87789.67 American Academy of Family Physicians. (2012). Independent practice authority for nurse practitioners could splinter care, undermine patient-centered medical home. Annals of Family Medicine, 19(6), 572–573. doi:10.1370/afm.1457 American Nurses Association. (2011). 2011 ANA Health and safety survey. Silver Spring, MD: Author Retrieved from https://www.nursingworld.org/practice-policy/work-environment/health-safety/ health-safety-survey/. American Nurses Association. (2012). The value of nursing care coordination. A white paper of the American Nurses Association. Silver Spring, MD: Author. Retrieved from https://www.­ nursingworld.org/~4afc0d/globalassets/practiceandpolicy/health-policy/care-coordinationwhite-paper-3.pdf American Nurses Association. (2014). Health care transformation: The Affordable Care Act and more. Retrieved from https://www.nursingworld.org/~4afc9b/globalassets/practiceandpolicy/healthpolicy/healthcare-reform-document.pdf American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Author. American Nurses Association. (2015b). Nursing: Scope and standards of practice. (3rd ed). Silver Spring, MD: Author. American Nurses Association. (2017a). Who will be there? Ethics, the law, and a nurse’s duty to respond in a disaster. Silver Spring, MD: Author. Retrieved from https://www.nursingworld.org/~4ad845/ globalassets/docs/ana/who-will-be-there_disaster-preparedness_2017.pdf American Nurses Association. (2017b). Workplace violence. Retrieved from https://www.nursingworld.org/practice-policy/advocacy/state/workplace-violence2/

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American Organization of Nurse Executives, & Emergency Nurses Association. (2015). Toolkit for ­mitigating violence in the workplace. Retrieved from http://www.aone.org/resources/final_toolkit.pdf Bardach, E., & Patashnik, M. (2016). A practical guide for policy analysis: The eightfold path to more effective problem solving (5th ed). Thousand Oaks, CA: Sage. Bekemeier, B. (2008). “Upstream” nursing practice and research. Applied Nursing Research, 21(1), 50–52. doi:10.1016/j.apnr.2007.11.002 Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The Triple Aim: care, health, and cost. Health Affairs, 27(3), 759–769. doi:10.1377/hlthaff.27.3.759 Betts, V. T., Tullai-McGuiness, S., & Williams, L. A. (2015). Serving the public through policy and leadership. In R. Patton, M. Zalon, & R Ludwick (Eds.), Nurses making policy: From bedside to boardroom (pp. 397–431). New York, NY: Springer Publishing; Silver Spring, MD: American Nurses Association. Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires care of the provider. Annals of Family Medicine, 12(6), 573–576. doi:10.1370/afm.1713 Brenan, M. (2017, December 26). Nurses keep healthy lead as most honest, ethical profession. Gallup News. Retrieved from http://news.gallup.com/poll/224639/nurses-keep-healthy-lead-honest-ethical-profession.aspx?g_source=CATEGORY_SOCIAL_POLICY_ISSUES&g_medium=topic&g_ campaign=tiles Carthon, J. M., Kutney-Lee, A., Jarrin, O., Sloane, D., & Aiken, L. H. (2012). Nurse staffing and postsurgical outcomes in black adults. Journal of the American Geriatrics Society, 60(6), 1078–1084. doi:10.1111/j.1532-5415.2012.03990.x Centre for Research on the Epidemiology of Disasters, & United Nations Office for Disaster Risk Reduction. (2015). The human cost of weather related disasters: 1995-2015. Brussels, Belgium: Centre for Research on the Epidemiology of Disasters. Retrieved from https://www.unisdr.org/2015/docs/ climatechange/COP21_WeatherDisastersReport_2015_FINAL.pdf Chassin, M. R., & Loeb, J. M. (2013). High-reliability health care: Getting there from here. Milbank Quarterly, 91(3), 459–490. doi:10.1111/1468-0009.12023 Clark, J., & Lang, N. M. (1992). Nursing’s next advance. An international classification of nursing practice. International Nursing Review, 39, 109–111. Retrieved from https://onlinelibrary.wiley. com/loi/14667657 Clarke, T. C., Norris, T., & Schiller, J. S. (2017, May). Early release of selected estimates based on data from 2016 National Health Interview Survey. Retrieved from https://www.cdc.gov/nchs/data/ nhis/earlyrelease/earlyrelease201705.pdf Committee on Pediatric Workforce. (2013). Scope of practice issues in the delivery of pediatric health care. Pediatrics, 131(6), 1211–1216. doi:10.1542/peds.2013-0943 Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Congressional Budget Office. (2017, July 19). H. R. 1628 Obamacare Repeal Reconciliation Act of 2017. Retrieved from https://www.cbo.gov/publication/52939 Cook, E. T. (1913). The life of Florence Nightingale (Vol. 1, 1820–1861). London, UK: MacMillan. Retrieved from http://www.gutenberg.org/files/40057/40057-h/40057-h.htm Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., … Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122–131. doi:10.1016/j.outlook.2007.02.006 Dobson DaVanzo & Associates. (2011). Updated report: impact of proposed legislation H.R. 2267/S.277 on Medicare expenditures. Retrieved from http://www.congressweb.com/nahc/docfiles/20110923_Dobson.pdf Economic Policy Unit, Office of the First Minister and Deputy Minister. (n.d.). A practical guide to policy making in Northern Ireland. Retrieved from https://www.executiveoffice-ni.gov.uk/sites/ default/files/publications/ofmdfm_dev/practical-guide-policy-making-amend-nov-16.PDF Ellenbecker, C. H., Fawcett, J., Jones, E. J., Mahoney, D., Rowlands, B., & Waddell, A. (2017). A staged approach to educating nurses in health policy. Policy, Politics & Nursing Practice, 18(1), 44–56. doi:10.1177/1527154417709254

34   UNIT I  MAKING THE CASE English, B. (2017, July 7). This great-grandmother wants to end ‘the dirty little secret of nursing.’ This great-grandmother wants to end ‘the dirty little secret of nursing.’ The Boston Globe. Retrieved from https://www.bostonglobe.com/metro/regionals/south/2017/07/07/this-great-grandmother-wantsend-dirty-little-secret-nursing/lCffloZJ6vD83F945aiPOL/story.html Environmental Working Group. (2007). Nurses’ health. A survey on health and chemical exposures. Retrieved from https://www.ewg.org/research/nurses-health/about-survey#.WxfhovVrzcs Falk-Rafael, A. (2005). Speaking truth to power: Nursing’s legacy and moral imperative. Advances in Nursing Science, 28(3), 212–233. doi:10.1097/00012272-200507000-00004 Feldman, H. R., & Lewenson, S. B. (2000). Nurses in the political arena: The public face of nursing. New York, NY: Springer Publishing. Gebbie, K. M. (2011, October 20). Laws are not the only barriers to scope of practice [Blog post]. Retrieved from http://www.rwjf.org/en/blogs/human-capital-blog/2011/10/laws-are-notthe-only-barriers-to-scope-of-practice.html Gebbie, K. M., Wakefield, M., & Kerfoot, K. (2000). Nursing and health policy. Journal of Nursing Scholarship, 32(3), 307–315. doi:10.1111/j.1547-5069.2000.00307.x Greiner, A. C., & Knebel, E. (Eds.). (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press. Griffiths, P., Ball, J., Murrells, T., Jones, S., & Rafferty, A. M. (2016). Registered nurse, healthcare support worker, medical staffing levels and mortality in English hospital trusts: a cross-sectional study. BMJ Open, 6(2), e008751. doi:10.1136/bmjopen-2015-008751 Henriksen, K., & Dayton, E. (2006). Organizational silence and hidden threats to patient safety. Health Services Research, 41(4 Pt. 2), 1539–1554. doi:10.1111/j.1475-6773.2006.00564.x Hutton, A., Veenema, T. G., & Gebbie, K. (2016). Review of the International Council of Nurses (ICN) framework of disaster nursing competencies. Prehospital and Disaster Medicine, 31(6), 680–683. doi:10.1017/S1049023X1600100X Interprofessional Education Collaborative. (n.d.). What is interprofessional education (IPE)? Retrieved from https://www.ipecollaborative.org/about-ipec.html Kaiser Family Foundation. (2018, May 10). Kaiser Health Tracking Poll: The public’s views on the ACA. Retrieved from http://www.kff.org/interactive/kaiser-health-tracking-poll-the-publics-views-on-the-aca Khan, T. S. (2017a, June 22). Praying for U. S. Rep. Scalise and health care [Letter to the editor]. The Express. Retrieved from https://www.lockhaven.com/opinion/letters-to-the-editor/2017/06/ praying-for-u-s-rep-scalise-and-health-care/ Khan, T. S. (2017b, August 23). Soda tax showing benefits [Letter to the editor]. Philadelphia Inquirer. Retrieved from https://www.nap.edu/catalog/9728/to-err-is-human-building-a-safer-health-system Khoury, C. M., Blizzard, R., Wright Moore, L., & Hassmiller, S. (2011). Nursing leadership from bedside to boardroom: A Gallup national survey of opinion leaders. Journal of Nursing Administration, 41(7–8), 299–305. doi:10.1097/NNA.0b013e3182250a0d Kohn, L. T., Corrigan, J., & Donaldson, M. S. (Eds.). (1999). To err is human: Building a safer health system. A report of the Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academies Press. Kutney-Lee, A., Stimpfel, A. W., Sloane, D. M., Cimiotti, J. P., Quinn, L. W., & Aiken, L. H. (2015). Changes inpatient and nurse outcomes associated Magnet Hospital Recognition. Medical Care, 53(6), 550–557. doi:10.1097/MLR.0000000000000355 Lasater, K. B., & McHugh, M. D. (2016). Reducing hospital readmission disparities of older black and white adults after elective joint replacement. Journal of the American Geriatrics Society, 64(12), 2593–2598. doi:10.1111/jgs.14367 Leape, L. (2015). Patient safety in the era of healthcare reform. Clinical Orthopaedics and Related Research, 473(5), 1568–1573. doi:10.1007/s11999-014-3598-6 Lucian Leape Institute. (2013). Through the eyes of the workforce: Creating joy, meaning and safety health care. Boston, MA: National Patient Safety Foundation.

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Marx, D. (2003). How building a “just culture” helps an organization learn from errors. OR Manager, 19(5), 1, 14–15, 20. Retrieved from https://www.ormanager.com/issues McDermott-Levy, R., Kaktins, N., & Sattler, B. (2013). Fracking, the environment, and health. American Journal of Nursing, 113(6), 45–51. doi:10.1097/01.NAJ.0000431272.83277.f4 McHugh, M. D., Rochman, M. F., Sloane, D. M., Berg, R. A., Mancini, M. E., Nadkarni, V. M., . . . American Heart Association’s Get with the Guidelines-Resuscitation Investigators. (2016). Better nurse staffing and nurse work environments associated with increased survival of in-hospital cardiac arrest patients. Medical Care, 54(1), 74–80. doi:10.1097/MLR.0000000000000456 McKinlay, J. B. (1986). A case for refocusing upstream: The political economy of illness. In P. Conrad & R. Kern (Eds.), The sociology of health and illness: Critical perspectives (pp. 484–498). New York: Worth. National Institute of Occupational Safety and Health. (2017). Workplace violence prevention for nurses [CDC Course No. WB 2908, NIOSH Pub. No. 2013-155]. Retrieved from https://www.cdc.gov/ niosh/topics/violence/training_nurses.html New York State Education Department. (2013). Practice information: Working long hours. Retrieved from http://www.op.nysed.gov/prof/nurse/nursevolovertime.htm Nurse-led recycling initiative reduces OR waste at Hackensack. (2013, January 14). Nursing Spectrum (New York/New Jersey Metro), 25(1), 3. Retrieved from Nurse.com O’Byrne, P., & Holmes, D. (2009). The politics of nursing care: Correcting deviance in accordance with the social contract. Policy, Politics & Nursing Practice, 10(2), 153–162. doi:10.1177/1527154409344347 Page, A. (Ed.). (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academies Press. Quality and Safety Education for Nurses Institute. (2017). Project overview. Retrieved from http:// qsen.org/about-qsen/project-overview Rogers, A. E., Hwang, W. T., Scott, L. D., Aiken, L. H., & Dinges, D. F. (2004). The working hours of hospital staff nurses and patient safety. Health Affairs, 23(4), 202–212. doi:10.1377/hlthaff.23.4.202 Sagherian, K., Clinton, M. E., Abu-Saad Huijer, H., & Geiger-Brown, J. (2017). Fatigue, work schedules, and perceived performance in bedside care nurses. Workplace Health & Safety, 65(7), 304– 312. doi:10.1177/2165079916665398 Sullivan, M., Kiovsky, R. D., Mason, D., Hill, C. D., & Dukes, D. (2015). Interprofessional collaboration and education. American Journal of Nursing, 115(3), 47–54. doi:10.1097/01. NAJ.0000461822.40440.58 Trinkoff, A. M., Johantgen, M., Storr, C. L., Gurses, A. P., Liang, Y., & Han, K. (2011). Nurses’ work schedule characteristics, nurse staffing, and patient mortality. Nursing Research, 60(1), 1–8. doi:10.1097/NNR.0b013e3181fff15d Warner, J. R. (2003). A phenomenological approach to political competence: Stories of nurse activists. Policy, Politics & Nursing Practice, 4(2), 135–143. doi:10.1177/1527154403004002007 World Health Organization. (2017, May). Diarrheal disease. Fact sheet No. 330. Retrieved from http:// www.who.int/mediacentre/factsheets/fs330/en/index.html Zimmerman, B. (2017, August 4). Press Ganey releases first quality indicator to measure assaults on nurses. Becker’s Hospital Review: Infection Control & Clinical Quality. Retrieved from https:// www.beckershospitalreview.com/quality/press-ganey-releases-first-quality-indicator-tomeasure-assaults-on-nurses.html

TWO

Advocating for Nurses and for Health Karen Tomajan Debbie Dawson Hatmaker Our lives begin to end the day we become silent about things that matter—Martin Luther King, Jr.

OBJECTIVES 1. Investigate advocacy as a means for improving the quality and safety of healthcare delivery. 2. Demonstrate the competencies needed to be an advocate in different healthcare settings. 3. Explore the role and skills of activism and the application to nursing advocacy. 4. Illustrate the relationship of social justice and ethics to the work of advocacy. 5. Describe the public’s view of nursing in healthcare advocacy. 6. Verify barriers to advocacy that can impact success or failure. 7. Choose key resources to develop the skill set to be an effective healthcare advocate.

Modern nursing’s evolution from a vocation to a profession began in the late 1800s as Florence Nightingale published her views about how nurses should be educated and how patient care should be provided (Hegge, 2011). Although Nightingale did not directly use the word advocacy in her writings, her work was consistently about advocating for change (Selanders & Crane, 2012). Her own words speak to the importance she placed on change: “I think one’s feelings waste themselves in words; they ought all to be distilled into actions and into actions which bring results” (Cook, 1913, p. 94). Since the inception of the profession, nurses have been actively involved in advocacy and activism on behalf of patients, families, communities, and patient populations and have worked tirelessly to address healthcare and social justice issues that impact health. The concept of advocacy is part of professional nursing. Advocacy involves a complex interaction among nurses, patients, professional colleagues, and the public at large (Selanders & Crane, 2012). To be an effective nursing professional, a nurse must understand and embrace the role of advocate—advocating for health and for the nursing profession. See the Policy Challenge, which describes how a recent graduate moved 37

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from advocacy for safe patient handling on an individual level to policy development in a healthcare facility. This chapter provides an overview of the concept of advocacy, the nurse’s advocacy roles, and expectations of society and the profession regarding advocacy. The American Nurses Association (ANA) Code of Ethics for Nurses is used as a framework for describing

POLICY CHALLENGE: Advocacy for Safe Patient Handling and Mobility Robert Cameron has just passed his first anniversary as an RN and has learned a great deal in his staff nurse position on St. Joseph’s Health System’s orthopedic unit. Although the hospital has a reputation for having a positive work environment and has invested in some technology to move patients, Robert is concerned that the unit has fallen short regarding the development of a culture of safety and even lacks an organizational commitment to safe patient handling and mobility practices. He has spoken to the unit manager, who has suggested he bring this up for discussion at the next unit staff meeting and considers sharing it with the hospital’s shared governance practice council. Robert remembers from his baccalaureate education program that the role of “nurse advocate” is foundational to practice. He begins his research on the most current safe patient handling and mobility techniques to advocate on behalf of patients and nurses to promote safety and decrease injury. He is looking for the answers to questions such as: • What are the most effective ways to advocate for culture change on his unit? • Which competencies are needed to be an advocate? • What is the organization’s philosophy about advocating for cultural change? • What resources are available within the work setting to address work environment concerns? • Which advocacy organizations might be helpful in promoting these changes? • What standards, guidelines, or best practices are available to provide evidence-based support to the advocacy process? Answers to these questions can be found on healthcare organizations’ websites, in the nursing and other healthcare literature, from colleagues and support staff within the organization, and from nurse educators. Robert decides to contact a colleague who works as a clinical nurse specialist at the hospital and who had been instructive about advocacy efforts and organizational culture in the past. He also reaches out to a physical therapist colleague who has been talking about the “return on investment” that is possible when using safe patient handling technology. He discusses his concerns with the employee health nurse at his facility and has been asked to present his recommendations at the hospital safety committee. He was very interested in advocacy during his nursing education program and knows that it is a role he can develop more as he moves from beginner to expert nurse. See Option for Policy Challenge

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the application of advocacy. In addition, competencies for advocacy, resources for becoming an advocate, and advocacy arenas are identified. Advocacy exemplars are used to illustrate the various possible outcomes of nurses’ advocacy efforts.

ADVOCACY DEFINITIONS Advocacy is defined as “the act or process of pleading, supporting or recommending a cause or course of action. Advocacy may be for persons (whether an individual, group, population or society) or for an issue such as potable water or global health” (ANA, 2015a, p. 41). Much of the literature related to advocacy comes from the legal profession, nonprofit, and special interest groups that prepare supporters to influence legal proceedings or public policy. The strategies promoted by these groups are also useful for nurses and the nursing profession (Tomajan, 2012). Advocacy can take many forms and may require working through formal decisionmaking bodies to achieve a positive result. This could include various committees, the administrative chain of command within a healthcare organization, a state commission, a regulatory body, and state or federal legislative entities. The term advocacy was first included in the profession’s codes by the International Council of Nurses (ICN) in 1973 (Vaartio & Leino-Kilpi, 2005). Nursing education documents prior to the mid-1970s did not reference advocacy as a clear expectation in nursing. In fact, early nursing education historically emphasized conformity, obedience, and authority (Selanders & Crane, 2012). Since then, advocacy has increasingly been associated with the role of the professional nurse. This evolution of nursing practice from loyalty to advocacy has put forward a metaphor of the nurse as an advocate of patients’ rights. However, there are challenges associated with nursing’s evolution toward a broader social justice advocacy model while retaining the individual patient– nurse advocacy model that continues to dominate in nursing practice today (Paquin, 2011). In a review of empirical literature from 1990 to 2003, Vaartio and Leino-Kilpi (2005) identified three themes: advocacy motivated by the patient’s right to information and self-determination, advocacy stemming from the patient’s right to personal safety, and advocacy as a philosophical principle in nursing. Bu and Jezewski (2007) discuss three core attributes of nursing advocacy: safeguarding patient autonomy, acting on behalf of patients who are not able to act for themselves, and championing social justice. In recent years, increased focus on patient safety and continuity of care has helped spotlight the vital role nurses play in every setting to ensure that patients receive safe and effective care and that their rights are protected. In addition, nurses have played a key role in the evolution of healthcare, with the recognition that there is a more expansive role for the profession that could and should be realized. Advocacy is very important to enabling nurses and the nursing professional to influence change at the local, state, national, and international levels, but it is also vital that both serve as activists on important social issues. Activism is defined as “zeal to support a cause, to bring about change, to confront wrongdoing or take vigorous countermeasures against a faulty practice or law” (Snodgrass, 2009). Many historical nurse leaders began their careers as advocates for patient or population concerns and found themselves in activist roles. The terms advocacy and activism are often used interchangeably; however, it is important to think about the distinctions. Both are tools used to bring about social or political change; however, where advocacy is based on supporting a cause or proposal, activism is using vigorous strategies to effect the desired change.

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POLICY ON THE SCENE 2.1: Historical Roots of Nurse Advocacy and Activism DOROTHEA DIX, ADVOCATE FOR HUMANE CARE OF THE MENTALLY Ill Dorothea Dix (1802–1887) was an educator, humanitarian, reformer, and nurse. In 1841, Dix visited a jail and was appalled to see mentally ill individuals confined alongside criminals. In response to this experience, she embarked on a mission of advocacy to improve the care of the mentally ill in Massachusetts. She investigated and documented care in jails, prisons, and almshouses across the state, which resulted in a bill to expand the state’s mental hospital. “Her skills as a lobbyist made her the most politically active woman of her generation” (Mass Moments, n.d.). In the activist role, she became the “voice of the mad.” In a report to the state legislature, she wrote: “I … present to you the strong claims of suffering humanity. … I come as the advocate of the helpless, forgotten, insane men and women, held in cages, closets, cellars, stalls and pens! Chained, naked, beaten with rods and lashed into obedience!” (Mass Moments, n.d.) Her activism led to reforms in care for the mentally ill in 15 states, Canada, and Japan, including the construction of 32 mental health hospitals (Reddi,  2005). In addition, she collaborated with European activists to influence similar changes there.

Activist strategies include direct actions, or withholding expected actions, to influence change. Direct actions or acts of commission range from letter writing, picketing, attending rallies, marches, demonstrations, or protests to other more confrontational approaches. Examples of withholding action or acts of omission include boycotts, sit-ins, and strikes. Activists have employed both nonviolent and violent actions to advance their goals. Research on the effectiveness of nonviolent strategies has shown this approach is more effective in achieving consistent outcomes, particularly as it related to engaging with others to advance a goal to achieve enduring change (Fisher, 2013). Over the past few years, several national initiatives highlight advocacy and activism by addressing difficult social issues. These include the “Me Too” movement related to sexual harassment and/or exploitation, and the “Never Again” movement addressing gun safety in schools. Advocacy is often linked to official, less confrontational activities, including public speaking, petitions, surveys, published data or white papers, and media campaigns. In some sectors, the connotation of an activist may be linked exclusively to direct, confrontational, or radical actions; however, this view is not necessarily accurate. The distinctions are very subtle. The nursing profession has traditionally embraced the term advocate to describe the actions of the profession; however, a number of historical nurse leaders are known for their activist work, including Florence Nightingale, Lillian Wald, Dorothea Dix, Margaret Sanger, and Lavinia Dock (see Policy on the Scene 2.1).

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PROFESSIONAL AND SOCIETAL EXPECTATIONS FOR ADVOCACY It has been noted that nurses readily accept the requirement of the professional nurses’ advocacy role as it applies to their patients (Tomajan, 2012); however, advocacy ­activities that extend to broader groups or for global issues are less consistently evident. Two of the ANA’s core documents, the Code of Ethics for Nurses with Interpretive Statements (ANA, 2015a) and the Nursing: Scope and Standards of Practice (2015b) delineate the professional nurse’s responsibility to advocate at multiple levels—nurse– patient, nurse–nurse, nurse–self, nurse–others, nurse–profession, nurse–society, and nursing–society (Bazdak & Turner, 2015). The ANA’s Nursing: Scope and Standards of Practice (2015b) clearly identifies “advocacy” within the scope of nursing practice, suggesting that it is fundamental to practice. Advocacy for safe, effective practice environments is a key responsibility of the professional nurse. Standards competencies that speak directly to advocacy include the following (ANA, 2015b): • Advocates for responsible and appropriate use of interventions to minimize unwarranted or unwanted treatment and/or healthcare consumer spending (p. 59) • Advocates for the delivery of dignified and holistic care by the interprofessional team (p. 63) • Advocates for healthcare consumer’s rights to informed decision-making and selfdetermination (p. 67) • Advocates for the rights, health, and safety of the healthcare consumer and others (p. 67) • Advocates for policies that promote health and prevent harm among culturally diverse, under-served, or under-represented consumers (p. 69) • Partners with the healthcare consumer and key stakeholders to advocate for and effect change, leading to positive outcomes and quality care (p. 73) • Advocates for the ethical conduct of research and translational scholarship with particular attention to the protection of the healthcare consumer as a research participant (p. 78) • Advocates for resources that support and enhance nursing practice (p. 82) • Advocates for the safe, judicious, and appropriate use and disposal of products in healthcare (p. 84) The ANA’s Code of Ethics for Nurses with Interpretive Statements (2015a) identifies multiple advocacy expectations for the professional nurse. These include commitment to patients, families, communities, and populations served. Nurses also have an obligation to advocate for the profession through teaching, mentoring, peer review, involvement in professional associations, community service, and knowledge development/dissemination. These activities and skills are foundational for the advocacy role of the professional nurse. Advocacy is based on a foundation of ethical principles that include autonomy, beneficence, nonmaleficence, and fidelity. It is essential that advocates act in the interest of those they represent in the advocacy process and align their actions with these principles (ANA, 2011, 2015a). • Autonomy—Autonomy is respect for another’s right to self-determine a course of action and to support independent decision making. Nurses should protect

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the autonomy of those for whom they are acting, which includes involvement in decision making. • Beneficence—Beneficence is acting to help others and to protect them from harm. The desire “to do good” and help others is a core principle of advocacy. • Nonmaleficence—Nonmaleficence is the avoidance of harm or hurt. This principle is sometimes described as “do no harm” and is likewise an important role of the advocate. • Fidelity—Keeping one’s promises and being truthful and loyal to those being represented are unequivocal expectations of the advocate. Disclosing personal interests and being cognizant of one’s own goals help prevent conflict of interest when advocating on behalf of others.

CODE OF ETHICS FOR NURSES Advocacy carries with it a significant ethical dimension; therefore, principles of ethics can help to evaluate a nurse’s effectiveness as an advocate. A code of ethics is fundamental for any profession. It provides ethical and legal guidance to the members of the profession, as well as a social contract with the population served. The ANA published its original Code of Ethics (www.nursingworld.org/­codeofethics) in 1950. Through seven revisions, the code “retains nursing’s historical and ethical values, obligations, ideals and commitments” (Fowler, 2015, p. ix). Several significant changes have occurred since the Code’s original publication: (a) Conceptualization of “patient” has expanded from that of an individual receiving treatment to include the family, community, and population; (b) a provision that recognizes the nurse’s responsibilities for self-care has been added; and (c) social justice, health as a universal right, and a responsibility to advocate for global health issues such as poverty, violence, and oppression, have been emphasized (Fowler, 2015). Each of the nine code provisions includes an aspect of advocacy.

Provision 1 The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person (ANA, 2015a, p. 1). Respect for inherent dignity, worth, unique attributes, and human rights is fundamental to nursing practice. Nurses establish relationships based on trust and free from bias or prejudice. Factors such as culture, values, religious or spiritual beliefs, lifestyle, social support system, sexual orientation or gender expression, and primary language must be considered when planning care. Nurses provide the same level of care regardless of diagnosis, ethnicity, or economic status. Therefore, the nurse is ethically bound to care and advocate for all. The nurse supports the patient’s autonomy and self-determination, including informed consent: Patients have a moral and legal right to determine what will be done with their own person; to be given accurate, complete, and understandable information in a manner that facilitates an informed judgment; to be assisted with weighing the benefits, burdens, and available options in their treatment, including the choice of no treatment; to accept, refuse, or terminate treatment without deceit, undue influence, duress, coercion, or prejudice; and to be given necessary support throughout the decision making and treatment process. (ANA, 2015a, p. 2)

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This obligation to respect others extends to all interactions within the healthcare setting and includes the nurse’s responsibility to maintain an ethical environment and culture of civility.

Provision 1 Exemplar—Right to Self-Determination Mrs. Sadie Farmer is 83 years old and has recently been hospitalized with an acute myocardial infarction. She is mentally alert and lives alone, although two of her three grown children live in a town a few miles away. After initial testing, her cardiologist indicates that the results suggest this is not Mrs. Farmer’s first heart attack, and she admits to having had “spells” in the past and that she just “waited them out.” Dr. Howard is recommending more intervention, but Mrs. Farmer does not want to undergo more procedures. Her brother-in-law died a few years ago after cardiac surgery, and she indicates that she has “had a good life” and is “ready to go when the Lord calls me home.” Dr. Howard has conceded to Mrs. Farmer’s wishes, but her primary care physician is not quite ready to give in to her decision to abandon further intervention. Some of Mrs. Farmer’s children and grandchildren are urging her to accept more treatment. Her nurse, Jean Evans, is becoming concerned that Mrs. Farmer seems to be more upset about her bickering family than about her treatment decisions. Nurse Evans calls a team meeting with Mrs. Farmer’s healthcare providers and family members. Chaplain Jones has been asked to offer an ethics consult to the team to allow Mrs. Farmer to determine her own care.

Provision 2 The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population (ANA, 2015a, p. 5). Ethical dilemmas arise as the nurse attempts to balance a commitment to the patient, the family, and the community; however, this provision is clear that the nurse’s primary obligation is to the patient. “Nurses address such conflicts in ways that ensure patient safety, guard the patient’s best interests and preserve the professional integrity of the nurse” (ANA, 2015a, p. 5). Interpretation of this provision speaks to distributive justice when resources are limited, collaboration when caring for a patient in the complexity of the healthcare environment, and professional boundaries within the nurse–patient relationship. Therefore, advocacy has its limits and limitations that must be observed.

Provision 2 Exemplar—Commitment to the Patient Kathy Johnson, RN, works in the role of patient relations liaison. She receives a telephone call from a patient who had been cared for earlier that day in the emergency department for back pain. The patient was quite upset that during the visit the physician had been rude, called her a “drug seeker,” and did not offer any pain-relief treatment or medication. The patient explained that she has a chronic back injury and had just moved to the area and injured her back while unpacking boxes. Although she has an appointment with a local physician, she has not yet been seen, and the physician’s office staff directed her to the emergency department. Nurse Johnson contacts the emergency department director and arranges for the patient to be reevaluated later that day.

Provision 3 The nurse promotes, advocates for, and protects the rights, health, and safety of the patient (ANA, 2015, p. 9).

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Provision 3 interpretive statements focus on the patient’s right to privacy and confidentiality, safeguarding research participants and addressing incompetent practice (whether it involves impairment or lack of knowledge or skill). “The nurse has a duty to maintain confidentiality of all patient information, both personal and clinical in the work setting and off duty in all venues including social media or other means of ­communication” (ANA, 2015a, p. 9). The nurse must always weigh the patient’s right to privacy with protection of the patient from harm. Provision 3 outlines the nurse’s role in promoting a culture of safety, which includes responsibilities for reporting errors and near misses and for addressing the problem of incompetent practice. Whether the incompetence is due to impairment or lack of knowledge, the nurse must report the issue to the appropriate person in the organization. If not acted on, the nurse must then take the next step in the organizational hierarchy or even consider reporting to an outside accrediting or regulatory body. Such advocacy skills as maintaining standards of care, advocating for impaired colleagues, or whistle-blowing may come into play with this provision.

Provision 3 Exemplar—Addressing Impaired Practice John Smith, RN, has just completed his first year of practice on the telemetry unit. His nurse preceptor, Linda Johnson, has been a great support during his orientation, and he is feeling very confident as he enters his second year. Linda has recently separated from her husband of 20 years and has not seemed herself lately. John notices that she has been arriving late for work, is looking strained, and is disorganized. Linda has verbally blown up while interacting with several coworkers in the past week. He has noticed alcohol on her breath the past 2 days that she has come to work, and he is really concerned about Linda and her patients. When John identifies that Linda almost administered an incorrect medication—a "nearmiss" error—he realizes he must take his concerns to their nurse manager. Ethically, he is bound to address his colleague’s impaired practice and ensure the safety of patients.

Provision 4 The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and provide optimal care (ANA, 2015a, p. 15). Accountability for actions is the cornerstone of a profession due to the implied social contract with the public. Nursing has been identified repeatedly as the most honest and ethical profession because its practitioners take the issue of accountability seriously. This accountability includes self-assessing competency, seeking educational resources when less than competent to perform care, and delegating appropriately to other healthcare providers. This provision highlights the need for nurses’ acceptance of accountability and self-assessment to be effective advocates.

Provision 4 Exemplar—Accountability for Nursing Judgment and Action Denise Lawrence, a pediatric faculty member in a baccalaureate school of nursing, works per diem in the summer on the pediatric or mother–baby units of a community hospital. One Saturday, she reports to the pediatric unit only to learn that she has been assigned to float to the sixth-floor adult oncology unit due to low pediatric census and high census on the adult units. Denise has never been oriented to any of the other hospital nursing units and has not taken care of adult oncology patients since she graduated from nursing school more than a decade ago. She does not feel safe in providing nursing care to oncology patients. However, the house supervisor has not returned her call to address the issue, so

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she goes to the sixth-floor nurses’ station to tell the charge nurse that she will agree only to take patients’ vital signs and do patients’ personal care. When the supervisor makes rounds, Denise intends to inform her that she cannot ethically take accountability for complete care of these patients since she does not have the knowledge, competence, and experience to engage safely in their care.

Provision 5 The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth (ANA, 2015a, p. 19). Interpretative statements for Provision 5 focus on moral self-respect, professional growth, and maintenance of competence, as well as wholeness of character or integration of personal and professional values. Aspects of self-advocacy are inherent in this provision. Nurses should model health promotion and maintenance, including rest, diet, exercise, healthy relationships, and work/life balance. “Maintaining competence is not only important to professional growth, but is also a necessary lifelong duty” (Lachman, Swanson, & Winland-Brown, 2015, p. 364). The preservation of integrity and moral self-respect can be challenging in our daily clinical practice. Nurses may face threats to integrity when confronted with verbal threats or abuse from patients, families, or coworkers. Preservation of nurses’ integrity under this provision would also allow for the concept of “conscientious objection,” when a treatment, intervention, or activity is morally objectionable to the nurse. Although nurses cannot abandon their patients, they must make it known to administration when situations place them in moral dilemmas that they find objectionable.

Provision 5 Exemplar—Wholeness of Character, Integration of Personal, and Professional Values Mr. Wilson has just been diagnosed with lung cancer, and his physician has explained treatment options that include surgery, chemotherapy, and radiation. After his family leaves the hospital, Mr. Wilson asks his nurse, Sarah Smith, her opinion about the best course of treatment. Sarah is an experienced RN and knows that, while she could voice her opinion, ethically she should assist Mr. Wilson in clarifying his own values in reaching an informed decision, thus avoiding unintentionally persuading him in one way or another. Sarah asks Mr. Wilson what he knows about his treatment options as they have been explained and what things are most important to him as he considers the treatment side effects and possible outcomes.

Provision 6 The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality healthcare (ANA, 2015a, p. 23). Although nurses often focus on ethics and advocacy as they relate to the individual patient, Provision 6 extends the nurse’s obligation to advocate for an ethical work environment and to change unhealthy work settings that contribute to poor patient care and patient dissatisfaction. The nurse must advocate for an environment that support the values central to the nursing profession. The reciprocal relationship between the nurse and the work environment is inherent in this provision. The work environment can either obstruct or support nursing values and ethical obligations.

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This provision sets forward an expectation of moral activism; the nurse should work to change the environment if it is obstructive. The goal is for nurses to work with administration to create an environment that supports safety and quality patient care (Lachman, 2015; Lachman et al., 2015). Advocacy on a large scale is possible when nurses join with their professional associations and participate in collective action such as workforce advocacy or collective bargaining. When this is not possible and an organization refuses to support patient rights or puts nurses in a position that violates professional standards of practice, nurses may have little choice but to leave the organization.

Provision 6 Exemplar—Improving the Healthcare Environment Patricia Brown is a staff nurse in a critical care unit. She is very committed to her colleagues and believes that maintaining a healthy work environment is the responsibility of every nurse. She overhears Jean Johnson, one of her colleagues, speaking condescendingly to a new nurse who has asked a question regarding the unit routine. After the conversation concludes, Patricia pulls Jean aside and relates what she heard between the two nurses. She shares her feelings that Jean was too harsh with the new nurse and relays her concern that this is an example of lateral violence. She informs Jean that harsh communication with new staff is detrimental to the development of a positive unit environment and relays her belief that every staff member should feel comfortable asking questions of any colleague without fear of reprisal. Patricia discusses the situation with her manager who supports her actions and offers to intervene if there are further issues.

Provision 7 The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy (ANA, 2015a, p. 27). Advancement of and advocacy for the nursing profession is the focus of Provision 7. Many activities are representative of this obligation: mentorship, service on organizational shared governance committees, leadership in professional associations, and civic activity at the local, state, national, or international levels. Nurses contribute through knowledge development, research and scholarly inquiry, development and enactment of professional standards, and participation in nursing and health policy development. Nurses advocate through role-specific responsibilities that include the nurse educator’s responsibility for nursing education standards; the nurse researcher’s support of clinical practice by providing practice-based evidence; and the nurse’s role in creating environments that support ethical integrity by nurse administrators.

Provision 7 Exemplar—Advancing the Profession State nurses associations routinely review new bills being presented in state legislatures to determine the impact on the health of citizens, as well as the impact on the profession. A bill has been forwarded to the state legislature that allows clerical staff in the public schools to administer medications to students. The association’s legislative committee believes that passing this bill could compromise the safety of school children and that a better alternative would be to increase the number of school nurses employed within the state. They partner with school nurses, and involve their specialty organization, the National School Nurses Association, to jointly lobby against this bill in the legislature, c­ iting the potential risks to children.

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Provision 8 The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities (ANA, 2015a, p. 31). Provision 8 addresses advocacy for health concerns in the larger world, calling on nurses to advance health and human rights and to reduce disparities. This provision identifies health as a universal right, which includes access to healthcare, basic sanitation, potable water, food security, immunizations, injury prevention, and health promotion. Nurses are called to collaborate with others to bring attention to human rights violations such as poverty, abuse, rape, hate crimes, genocide, human trafficking, and exploitation and to address the needs of special populations such as the homeless, mentally ill, and elderly. This provision also addresses situations in which nurses are required to practice under extreme conditions, such as during disasters, epidemics, and fields of battle.

Provision 8 Exemplar—Health Needs and Concerns Soodabeh Joolaee is a recipient of the Human Rights and Nursing Award from the International Centre for Nursing Ethics. She has taught undergraduates and postgraduate nurses for more than 20 years, with a major focus on ethics. In her work to foster an ethical culture in clinical practice, she became aware that patients, physicians, and nurses were not consulted in the compilation of a patients’ bill of rights that had been posted around the hospital; furthermore, none of them were fully aware of those rights. In 2010, for her doctoral dissertation about patients’ rights, she won the prestigious Avicenna Award of the Tehran University of Medical Sciences. These accomplishments gave her entry into health policy work and cooperation with the Iranian Ministry of Health and Medical Sciences. Subsequently, she has been keenly focused on the rights of patients, negotiating with managers and leaders to educate nurses as patients’ rights advocates, which is not an easy job for a nurse in a paternalistic healthcare environment.

Provision 9 The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate the principles of social justice into nursing and health policy (ANA, 2015a, p. 35). Who advocates for the nursing profession? The focus of Provision 9 is on the profession through its associations, rather than toward the individual nurse. It calls for nursing associations and organizations to act collectively with one voice, acting in solidarity across all specialties, roles, and practice settings to articulate nursing values, maintain the integrity of the profession, and integrate the principles of social justice to reduce health disparities. The integrity of the profession is based on the covenant between nursing and society through a code of ethics, standards of nursing practice, educational requirements for practice, knowledge development, and continuing evaluation of professional nursing actions. A specific focus on social ethics reflects nursing’s historical interest in how health and illness affect society.

Provision 9 Exemplar—Articulating Nursing Values and Maintaining Professional Integrity Following the devastating hurricanes in Louisiana, Mississippi, Florida, and Texas in 2006, the ANA acted, with other professional associations and regulatory agencies, to help define the responsibilities of nurses and other healthcare professionals in disaster

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situations. The ANA worked with state and national agencies and disaster-relief organizations such as the American Red Cross to define the role of the RN in a disaster, establish structures to coordinate disaster response through the Medical Reserve Corps, and define potential legal protections for nurses acting in good faith in catastrophic situations (ANA, 2010b). These actions are examples of the association’s advocacy for nursing as a profession, which impacts all nurses, not just ANA members. This laid the groundwork to facilitate the responses of nurses in subsequent disasters.

CLINICAL PRACTICE AND MORAL DISTRESS—THE REALITY OF PRACTICE ADVOCACY Nurses in clinical practice encounter ethical issues that can lead to moral distress—negative feelings that result when one knows the ethically correct action to take but feels powerless to take that action (Epstein & Delgado, 2010; Rushton, 2017). For nurses to be effective advocates, they must understand and accept their ethical responsibilities to the patient, family, community, and profession. However, when nurses are unable to advocate due to practice barriers such as conflict between the nurse’s responsibility to the patient and duty to the employer, lack of colleague support, perceived lack of power, and even lack of education, moral distress may result, causing nurses to leave their jobs or the profession altogether (Epstein & Delgado, 2010; Hanks, 2007; Rushton, Caldwell, & Kurtz, 2016). When surveyed, nurses have identified ethical priorities to include the following (Pavlish, Brown-Saltzman, Hersh, Shirk, & Rounkle, 2011): • Patients’ quality of life—an obligation to treat distressing symptoms, pain, and suffering. • Promoting patient autonomy—the notion that patient preferences should prevail over family wishes or healthcare team values. • Substandard healthcare—situations where the healthcare team either did not adhere to standards of care or was severely conflicted over treatment options. Many healthcare agencies have processes and policies that establish the chain of command to address ethical concerns, which may include an ethics committee tasked with addressing ethical dilemmas. Nurses increasingly have a voice in advocating for their patient within these organizations. However, the literature on moral distress indicates the processes available in many settings are inadequate in addressing the day-today issues confronting nurses in practice. New approaches for assisting nurses and other healthcare professionals to cope with the impact of moral distress are being tested to promote the development of moral resilience. Moral resilience is the ability to recover from or healthfully adapt to challenges, stress, adversity, or trauma and to be “buoyant” in adverse circumstances. Interventions for cultivating moral resilience include mindful meditation, cognitive reappraisal, biofeedback, ethics education, and organizational support such as ethics rounds, debriefings, and consultations (Rodney, 2017; Rushton, 2017; Rushton et al., 2016).

SOCIAL JUSTICE Social justice speaks to how advantages and disadvantages are distributed to individuals in a society (Miller, 1999). Although multiple and competing theories of social justice exist, all are based on the idea that justice is related to fairness of treatment and that similar cases should be treated in a similar manner (Butts & Rich, 2012).

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A strong commitment to social justice requires professional nurses to advocate for the health of all persons. Advocacy activities are an expected outcome for a health profession that promotes the concept of social justice. Social justice advocacy is an inherent expectation of all nurses as expressed in the professional codes that guide nursing practice (Paquin, 2011). A community approach to social justice promotes the common good of the community rather than individual benefits and freedoms. Not being bound by borders promotes the consideration of how basic healthcare for all people can be provided and what can be done to prevent social injustice worldwide (Butts & Rich, 2012). Nursing has long maintained a strong commitment to advocacy for vulnerable populations and has embraced social justice as a core value since the inception of the profession. Early nursing leaders were strong advocates for the healthcare needs of the vulnerable and disadvantaged. In recent years, the profession has been called to reinvigorate its commitment to social justice advocacy and to build on nursing’s distinguished history of leadership on social issues (Bekemeier & Butterfield, 2005; Matwick & Woodgate, 2016; Thompson, 2014; Valderama-Wallace, 2017).

EQUITY One of the roles of the advocate is to promote equity and eliminate or mitigate the effects of health disparity at both the individual and system level. One of the features of healthcare reform has been to address disparities and promote equity within the healthcare system. Health disparity is defined as “substandard access, treatment or outcomes based on racial, ethnic or socioeconomic factors” (Hiles, 2010). Equity is defined as “the absence of systematic disparities in health (or its social determinants) between more- or less-advantaged social groups. Social advantage means wealth, power and/or prestige” (Braveman & Gruskin, 2003, p. 256). Equity is an ethical value based on social justice and is closely aligned with principles of human rights. In the landmark report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, by the Institute of Medicine (now the National Academy of Medicine; Smedley, Stith, & Nelson, 2002), it was revealed that significant racial and ethnic disparities exist in U.S. healthcare, even after controlling for factors such as insurance coverage, socioeconomic status, and other illnesses. These disparities contribute to infant mortality, disability, decreased life expectancy, and higher incidence of preventable hospitalizations (Braveman, Arkin, Orleans, Proctor, & Plough, 2017; see Chapter 13). The principle of equity has been identified as one of the IOM’s six aims for the future of the U.S. healthcare system. These six aims are healthcare that is safe, effective, efficient, patient centered, timely, and equitable. In this context, equitable is defined as the provision of care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status (Corrigan, Donaldson, Kohn, Maguire, & Pike, 2001). As a profession, nurses have led the way among healthcare professionals in their work to promote a healthcare system that is accessible to all and to address issues of disparity and inequality. In the advocacy role, nurses have worked to address the equity needs of individual patients and patient populations and to advance health policy at the healthcare system level.

PRECAUTIONARY PRINCIPLE The precautionary principle is a concept that impacts this discussion of advocacy, particularly, as it relates to advocacy at the policy-formation level. The precautionary principle advances the idea that if a product, action, or policy has a suspected risk of

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causing harm to the public or to the environment, the company, agency, or individuals responsible for the product or policy have a social responsibility to disclose the risk and act to protect the public, even when the scientific evidence has not yet found a definitive causal relationship. The precautionary principle is based on the ethical principles of social justice and nonmaleficence (“first do no harm”) and is aligned with the adage “better safe than sorry” (Science and Environmental Health Network [SEHN], 2011). Proponents of the precautionary principle assert that responsible entities should not wait for clear scientific cause-and-effect evidence between various actions or toxins and their harmful effect (Butts & Rich, 2012). Opponents of the precautionary principle believe that if science has not produced conclusive evidence that an activity or substance is harmful to humans and/or the environment, then the activity or substance is assumed to be safe until future evidence proves otherwise. Precautionary principle proponents would answer with the argument that by the time harmful causal relationships are established with certainty, irreparable damage may have already occurred. The harmful effect of cigarette smoking is one example of the precautionary principle. Long before scientific evidence was available showing a definitive causal link between cigarette smoking and lung cancer, advocates were encouraging smokers to quit. Today there is evidence that the incidence of chronic diseases, birth defects, infertility, cancer, and Alzheimer’s disease is increasing. Although we do not have conclusive evidence regarding the causes, risk factors have been identified. Proponents of the precautionary principle strongly advocate for communication of the risks to the public and action to limit exposure to potentially harmful substances when possible, even though causal evidence is not yet available (Butts & Rich, 2012).

PUBLIC EXPECTATION FOR ADVOCACY You are traveling in a foreign country where you do not know the culture or language. How will you get your needs met? You may use nonverbal cues like gestures or pictures, but you are not certain you will be understood. What if you had an advocate, someone  who knows the language, culture, and belief system? The U.S. healthcare system is foreign and challenging for many patients. There are technical terms, jargon, abbreviations, and euphemisms that complicate communication. Hospitals have hierarchies, policies and procedures, standards, routines, and rituals that are mysterious to patients, families, visitors, and students (Bosek & Savage, 2007). The public has come to expect nurses to serve in the role of advocate, assisting them to migrate through the “foreignness” of the healthcare system. Although no single profession “owns” the role of advocate, nursing has traditionally seen this role as integral to good nursing care. The American public also sees the nurse in the role of advocate in that they have rated RNs as the most honest and ethical profession for 17 of the past 18 years, according to Gallup’s annual survey (Brenan, 2017). RNs are increasingly recognized as leaders in transforming the healthcare system to meet the burgeoning demand for services, with a focus on improving quality and managing costs. Sylvia Trent-Adams, a rear admiral in the U.S. Public Health Service (USPHS) Commissioned Corps, served as the acting Surgeon General in 2017 while holding the position of Deputy Surgeon General and formerly the chief nurse officer. In her role, she directs the Corps and communicates scientific information that advances the health of the United States. In 2014, she helped lead the USPHS’s response to the Ebola virus crisis in Liberia. Although the public has come to know nurses’ advocacy activities through their patient care experiences, they do not always see nurses in key leadership roles. A 2010

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Gallup poll of 1,500 health opinion leaders said that they wanted nurses to have more influence in a variety of areas: reducing medical errors, increasing quality of care, and promoting wellness. They also believed that nurses should have more influence in planning policy development, as well as management (Khoury, Blizzard, Wright Moore, & Hassmiller, 2011). However, those findings contrast with what is in place. An American Hospital Association survey of 1,000 U.S. hospitals found that nurses account for only 6% of hospital board members. This contrasts with the number of physicians (20%) and other clinicians (about 5%) on boards (Van Dyke, Combes, & Joshi, 2011). Although nurses typically find advocacy for individual patients as integral to their nursing practice, they are less inclined to advance this advocacy role to larger systems and the public policy level. Nurses must see themselves as decision makers that influence health outcomes.

COMPETENCIES NEEDED TO BE AN ADVOCATE Two of the ANA’s foundational documents, the Code of Ethics for Nurses with Interpretive Statements (2015a) and the Nursing: Scope and Standards of Practice (2015b), address the professional nurse’s responsibilities for advocacy. The documents cover the required skills and activities of professional nurses through the care of patients, teaching, mentoring, peer review, involvement in professional associations, community service, and knowledge development/dissemination. The skills of problem solving, communication, influence, collaboration, and resource identification can be used to support a cause on behalf of a patient, a family, a community, a population, the profession, or oneself.

Problem Solving Since advocacy is directed at problems in need of a solution, the problem-solving process is a necessary skill for the effective nurse advocate. Steps in problem solving and strategies to achieve each are illustrated in Figure 2.1.

Identify the Problem

Analyze the Problem

Develop a Range of Solutions

ACT

• Be as specific as possible • Evaluate the present state and how it differs from the goal state

• Seek out other perspectives • Brainstorm about all possibilities and implications • Research problems for which you lack complete information • Get help • Weigh advantages/disadvantages of each possible solution • Develop goals, strategies, and a plan of action • Establish a timeline • Approach decision makers with a compelling request • Patience and timing are essential • Most advocacy initiatives require a series of actions over time

FIGURE 2.1   Problem-solving process.

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Communication Communication is key to an effective advocacy strategy. Verbal, written, and electronic forms of communication are used when advocates pull individuals together to work collectively on a problem. It is important that all messages be based in fact and that messaging across time is consistent. Although advocates are often “armed” with facts and figures when they attempt to influence decisions makers, it is equally important to tell a story of how the problem impacts patient care. Giving specific examples of patient care situations (without violating patient privacy) can demonstrate how the problem and suggested solution has a real-world impact (see Policy on the Scene 2.2).

Influence To be effective, the nurse advocate must be able to influence others. Influencing an individual’s or group’s thoughts, beliefs, or actions is essential and built on competence, credibility, and trustworthiness (Tomajan, 2012). Advocates attempt to use influence to effect change in a number of ways. Access to legislators may be gained through tactics such as letter-writing campaigns, face-to-face interactions, legislative testimony, and financial campaign contributions.

POLICY ON THE SCENE 2.2: A Nurse-Managed Clinic The story of Kelly Barnett, DNP, FNP-BC, and a nurse-managed clinic in the rural mountains of north Georgia communicates a strong message of advocacy and action. Kelly, a family nurse practitioner (FNP), operates a nurse-managed clinic in the rural mountains of north Georgia. She received notice from her malpractice insurer that her contract was being canceled in 90 days because, under her collaborative physician–nurse protocol, the physician was not “directly supervising” her practice. The insurer suggested that Ms. Barnett’s clinic must be “under the same roof ” as her supervision physician, despite this not being a requirement under current Georgia law. Kelly’s panic set in because she was the sole provider for her family and many of her patients would have to access their healthcare from clinics as far as 25 to 50 miles away from their community. She knew she needed help when her initial requests to the insurer were unheeded, and in her communication to the Georgia Nurses Association (GNA), Kelly said, “If I cannot bill the insurer, I will have to close my practice. There is no way I can make it financially otherwise. This means me and my other four employees will be out of our jobs. Where will my patients go if I close my doors?” GNA responded swiftly to assist Kelly and to save her north Georgia clinic. They worked closely with Kelly and acquired a memorandum of law on the actions of the insurer, which cited legal precedent, suggesting that if a collaborative agreement was in place, she is operating within what the current law allows. After reviewing the memorandum of law provided by GNA, the insurer decided to rewrite their policy to allow NPs to be participating providers in their network. As long as it meets the insurer’s criteria and eligibility requirements, this nurse-managed clinic will continue to operate and provide much needed care to patients of rural Georgia. “I couldn’t have done this without GNA’s help and expert advice,” Kelly stated. “This is another step in the advancement of Georgia’s NPs in healthcare practice.”

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Using an influential leader or spokesperson can also bring attention to the issue. Celebrities, such as Michael J. Fox for Parkinson’s disease research and Marlo Thomas for cancer in children, are regularly tapped to bring their influence to important issues. To influence most effectively, the advocate must build a compelling case for change by using facts, figures, and examples. Most important, the advocate must be able to influence with a strong delivery to decision makers. Developing an “elevator speech” is a valuable tool for the advocacy toolkit (see Exhibit 2.1; see also Chapter 10).

Collaboration In the complex world of healthcare, few changes are made in isolation. Collaboration and partnership are necessary to effect major changes. Collaboration is a process of working together for a common purpose. As opposed to cooperation (groups working together but focused on their own goals), collaborative ventures involve the development of common goals, as well as common strategies and activities, that will achieve those goals (Tomajan, 2012). Successful collaboration can be a time-intensive process requiring continuous com­munication with those involved, validating information, and reporting on progress toward the goal. When collaborations are developed, it is helpful to consider all possible stakeholders to strengthen the advocacy efforts. Nurses may to partner with other nurses or nursing organizations when the issue is directly related to professional nursing practice, but collaborations with other healthcare providers can strengthen the advocacy efforts and message. An example of a coalition designed to address issues for advanced practice nurses and other healthcare providers is the Coalition for Patients’ Rights (CPR). This coalition consists of more than 35 healthcare organizations working to offset the efforts of the American Medical Association’s Scope of Practice Partnership (SOPP) initiative that was developed to limit patients’ choice of healthcare practitioners. CPR is predicated on the principle of patients having the right to choose their type of provider and having access to the right type of care at the right time (www.patientsrightscoalition.org). EXHIBIT 2.1   KEY ELEMENTS OF A GOOD ELEVATOR SPEECH Follow these guidelines when preparing an elevator speech: • Keep it short. After hearing a few sentences, your audience should know what you do and what you want. Limit your pitch to 60 seconds. • Have a “grabber” an opening line that grabs the person’s attention and piques interest in hearing more. • Show your passion. Your energy and dedication will help sell your proposal. • Make a request. At the end of your speech, mention what you need. Do you want that person’s business card? Do you want to schedule a meeting? Ask for a referral? Getting the person to take the next step is crucial. It is the reason you came up with your speech in the first place. • Practice. Rehearse your elevator speech so that when the opportunity to use it comes up, you can do it well. Always be prepared to give your pitch so you can use it in a chance encounter. Memorize it. Revise as needed to keep it fresh and updated. Source: Reprinted with permission. Copyright ©2018, HealthCom Media. All rights reserved. From Pagana, K. D. (2013). Ride to the top with a good elevator speech. American Nurse Today, 8(3), 14–16. Retrieved from https://www.americannursetoday.com/ride-to-the-top-with-a-good-elevator-speech

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Resource Identification Another important skill for the nurse advocate is the ability to identify valuable resources. Although this competency is necessary for any problem solving, searching for health policy information on the Internet is an essential skill when it comes to legislative advocacy (White, Olsan, Bianchi, Glessner, & Mapstone, 2010). Searching the Internet for resources has become commonplace; however, with the explosion of webbased information, much of it lacking credibility validation, the task can be daunting. Steps to a successful health policy Internet search are illustrated in Figure 2.2. Credible resources on the Internet that the nurse advocate should be using include peer-reviewed and professional databases (e.g., PubMed, Cumulative Index to Nursing and Allied Health Literature [CINAHL]), organizations that focus on health policy (e.g., ANA, American Association of Colleges of Nursing, National League for Nursing, Robert Wood Johnson Foundation [RWJF], and Kaiser Family Foundation), and governmental entities (e.g., Centers for Medicare & Medicaid Services [CMS], Centers for Disease Control and Prevention [CDC], U.S. Department of Health and Human Services [USDHHS]). White et al. (2010) suggest the following criteria for evaluating websites: • Accuracy and expertise: The qualifications, affiliations, and reputations of the authors are vital for reliability and credibility. Attention to details, especially in relation to scholarly references, is a hallmark of quality. • Content and focus: The website’s information should be examined for whether it presents information in a complete, balanced, and unbiased manner. Reputable websites often include a mission statement, are clear about their perspective, and include contact information. • Currency: The information should be recent unless it is of a historical nature. Broken URL links and websites without recent update information indicate a poorly maintained website and raise questions about credibility. • Organization and ease of use: Navigation should be user friendly. The information may have limited use if the web pages, documents, and PDF files do not load easily and quickly. Member-based organizations often place valuable information behind a “For Members Only” section.

Formulate a clear, concise issue statement that describes and quantifies the problem

Identify the target audience for the advocacy efforts

Identify key words and phrases to look for information using an Internet search engine

FIGURE 2.2   Steps for successful health policy searches on the Internet.

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Extra care to ensure information accuracy is essential. Given the environment of fake news, alternate facts, and the plethora of misinformation available on the Internet, it is incumbent on the nurse advocate to validate the accuracy and currency of information. Nurses should be members of their professional associations and other groups that support their advocacy work to get the most current and complete information (see Chapter 10). The skills of the advocate—problem solving, communication, influence, collaboration, and resource identification—are a natural fit for nurses. A successful nurse uses these skills in the course of day-to-day nursing care while working with patients, families, and the healthcare team. Applying these skills within a broader context may seem intimidating; however, these are the skills that the public has come to know and trust. Taking them from the bedside to the campaign headquarters, legislature, notfor-profit foundation office, and beyond requires confidence that builds with every success. As a profession, nurses are welcome partners in any initiative that requires hard work, dedication, and collaboration. Nurses are recognized for professionalism, practicality, and sincerity, qualities valued in any setting. Most important, nurses have frontline experience with the life-and-death implications of important social issues; from healthcare reform to violence to poverty, nurses deliver a unique sense of reality few others can (Bond & Exley, 2016).

ARENAS FOR ADVOCACY Nurses have numerous opportunities for advocacy. The one that most often comes to mind is the workplace. However, additional arenas for nurse advocacy include community, state, national, and international arenas.

Workplace Nurses most commonly engage in advocacy on behalf of their patients in the clinical setting. Thus, the workplace, be it a hospital, public health clinic, long-term care facility, or primary care office, is often the location where nurses most frequently use their advocacy skills. Advocacy works best in environments that encourage its activity, where leaders are supportive, and where tools are available to make change happen. The work environment of nurses has been studied extensively, with strong links to patient and nurse outcomes. Factors that define the work environment include workload, staffing, managerial support at the unit and organizational level, work team dynamics, and interprofessional relationships. The work environment impacts patient outcomes, including the patient experience, the incidence of infections, falls, pressure injuries, and other complications, as well as patient mortality. Nurse-focused outcomes that are the result of factors in the work environment include job satisfaction, turnover, exhaustion and burnout, and perceptions of quality of care (Aiken, Clarke, Sloane, Lake, & Cheney, 2008; Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Aiken et al., 2012; Clarke & Aiken, 2003; Press Ganey, 2015). The American Association of Critical Care Nurses (AACN) developed AACN Standards for Establishing and Sustaining Healthy Work Environments (AACN, 2016) that address not only the physical environment, but also less tangible barriers to staff and patient safety. The AACN highlights the ingredients for success as skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful

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recognition, and authentic leadership. These standards are guidelines that the nurse as advocate can use to support a healthy work environment. Mounting evidence is making the connection between positive work environments and patient and nurse outcomes (Aiken et al., 2008; Press Ganey, 2015). Along with its partners and through its organizational relationships, the ANA is a leader in promoting improved work environments. It protects, defends, and educates nurses about their rights as employees by addressing occupational hazards such as needlestick safety, back injuries, and violence. The ANA and specialty organizations have developed a number of position statements and resources to support advocacy in the workplace (see Exhibit 2.2).

EXHIBIT 2.2  POSITION STATEMENTS SUPPORTING ADVOCACY IN THE WORKPLACE AMERICAN NURSES ASSOCIATION POSITION STATEMENTS ON WORKPLACE ISSUES

Addressing Nurse Fatigue to Promote Patient Safety and Health: Joint Responsibility of RNs and Employers to Reduce Risks—12/8/06, revised 9/10/14 Given the well-documented relationship between nurse fatigue and an increased risk of nurse error with the potential for compromising patient care and safety, it is the position of ANA that RNs and employers have joint responsibilities to create and sustain a culture of safety, healthy work environment, and work/ life balance. Both RNs and employers have an ethical responsibility to carefully consider the need for adequate rest and sleep when deciding whether to offer or accept work assignments, including on call, voluntary, or mandatory overtime. Elimination of Manual Patient Handling to Prevent Work-Related Musculoskeletal Disorders—6/21/03, revised 3/14/08 In order to establish a safe environment of care for nurses and patients, the ANA supports actions and policies that result in the elimination of manual patient handling. Patient handling, such as lifting, repositioning, and transferring, has conventionally been performed by nurses. The performance of these tasks exposes nurses to increased risk for work-related musculoskeletal disorders. With the development of assistive equipment, such as lift and transfer devices, the risk of musculoskeletal injury can be significantly reduced. Effective use of assistive equipment and devices for patient handling creates a safe healthcare environment by separating the physical burden from the nurse and ensuring the safety, comfort, and dignity of the patient. Incivility, Bullying, and Workplace Violence—7/22/2015 The ANA supports safe work environments for nurses in all settings that are free of incivility, bullying, and workplace violence. RNs and employers across the healthcare continuum, including academia, have a responsibility to create healthy and safe work environment for RNs and all members of the healthcare team, healthcare consumers, families, and communities. Just Culture—1/28/10 The ANA supports the Just Culture concept and its use in healthcare to improve patient safety. The ANA supports the collaboration of state boards of nursing, professional nursing associations, hospital associations, patient safety centers, and individual healthcare organizations in developing regional and statewide initiatives. (continued )

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EXHIBIT 2.2  POSITION STATEMENTS SUPPORTING ADVOCACY IN THE WORKPLACE (continued ) Patient Safety: Rights of RNs When Considering a Patient Assignment—3/12/09 The ANA upholds that RNs—based on their professional and ethical responsibilities—have the professional right to accept, reject, or object in writing to any patient assignment that puts patients, colleagues, or themselves at serious risk for harm. RNs have the professional obligation to raise concerns regarding any patient assignment that puts patients or themselves at risk for harm. The professional obligations of the RN to safeguard patients are grounded in Nursing’s Social Policy Statement (ANA, 2010a), Code of Ethics for Nurses with Interpretive Statements (ANA, 2015a), Nursing: Scope and Standards of Practice (ANA, 2015b), as well as state laws and rules and regulations governing nursing practice such as the Nurse Practice Act. RNs’ Rights and Responsibilities Related to Work Release During a Disaster—6/24/02 The ANA recommends that RNs use the following guidelines to clarify the process of release from work for the purpose of addressing a disaster. A companion position statement titled “Work Release During a Disaster— Guidelines for Employers” offers guidance for healthcare employers in establishing work release policies and procedures during a disaster. The ANA strongly believes that nurses should be released as part of organized medical teams; however, individual nurses may still want to respond and should be given due consideration. Work Release During a Disaster—Guidelines for Employers—6/24/02 The ANA recommends that employers adopt the following work release policy to guide the process of releasing RNs from work for the purpose of addressing a disaster. A companion position statement titled: “Registered Nurses’ Rights and Responsibilities Related to Work Release During a Disaster” clarifies the role of the RN who wishes to participate in disaster relief work. ANA strongly believes that RNs should be released as part of organized medical rescue teams during disasters; however, individual nurses may still want to respond and should be given due consideration. Reprinted with permission from the ANA (n.d.-a, n.d.-b). ANA position statements may be accessed on the ANA website, Nursing World, at www.nursingworld.org/positionstatements POSITION STATEMENTS OF SPECIALTY NURSES ASSOCIATIONS ON WORKPLACE ISSUES

Moral Distress—American Association of Critical Care Nurses—8/2008 Moral distress is a serious issue in the critical care setting. Moral distress results in significant emotional and physical distress which can result in loss of integrity, disrupted relationships, turnover, and affects quality and costs of nursing care. Calls for nurses to understand the impact of moral distress and implement changes in the work environment to preserve personal integrity and authenticity. Calls on employers to monitor for situations that cause moral distress, to implement support systems to address ethical decisions and support for clinicians faced with ethical dilemmas. www.aacn.org/nursing-excellence/healthy-work-environments/hwe-resources (continued )

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EXHIBIT 2.2  POSITION STATEMENTS SUPPORTING ADVOCACY IN THE WORKPLACE (continued ) Violence in the Emergency Care Setting—Emergency Nurses Association—1/2014 The incidence of workplace violence in healthcare is higher than any other industry in the United States, and emergency department staffs are highly vulnerable to violent acts that include verbal abuse, coercive or threatening behavior, and physical assaults. Specific strategies including adopting zero tolerance for abuse, a call for staff training on violence recognition/ management/mitigation, and administrative support are recommended. www.ena.org/practice-resources/resource-library/position-statements Responsibility for Mentoring—Association of periOperative Registered Nurses—2/2017 Defines the practice of mentorship within the perioperative setting, and the importance of this role. A predicted shortage of preoperative nurses within the next 7 years creates the need to recruit and retain new nurses into this practice setting. www.aorn.org/guidelines/clinical-resources/position-statements ANA, American Nurses Association.

Community When nurses are advocating in their community for increased access to care or other healthcare resources, the respect they have from the public strengthens their ability to persuade others to create the needed changes regarding patient care and services. The cost of healthcare continues to create barriers for patients. Patients and families often share with the nurse the difficulties they are experiencing in obtaining needed care due to the costs of treatments and medications. Nurses find themselves advocating for individual patients related to access issues and at the community level specific to inadequate funding and its impact on patients’ failure to receive appropriate healthcare services. Nurses have been engaged in identifying community resources for patients and establishing resources when they are inadequate. Because of the high expense of prescription drugs, many patients forego treatment when they do not have the funds to obtain their needed medication. Nurses may be aware of community resources for drug discounts or even pharmaceutical companies’ resources to allocate the needed treatment. Nurses have established many community-based clinics for those who do not have adequate access to healthcare. These nurse-managed health centers under the direction of APRNs provide primary, secondary, and tertiary prevention services to the uninsured and underinsured populations; there are approximately 250 such centers across the country (Holt, Zabler, & Baisch, 2014). Although nurses may feel comfortable taking on the advocate role within their workplace or community, they may be hesitant to take it to the next level and use their advocacy skills at the state level. They may not feel confident about their presentation skills or believe that others know more about the issue than they do. However, they quickly find that their passion and healthcare knowledge will take them far in state

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advocacy. The ANA represents the interest of the 3.6 million RNs across the United States through its constituent and state nurses associations and its specialty nursing and affiliate organizations. With the implementation of the Patient Protection and Affordable Care Act (PPACA), more commonly known as the ACA, and the ongoing state-level scope of practice issues that are barriers to APRNs, there is much to be done at the state level. One important provision of the ACA that highlights the need for effective state and national partnerships was the establishment of state insurance exchanges. These exchanges—online marketplaces where individuals can purchase health plans—have been established at the state level. The ANA works with the CMS to use language that includes NPs and certified nurse-midwives to ensure that patients have improved access to care. With the continuing debate about healthcare reform, this collaboration is even more important to ensure that these gains continue within the structures of any new or revised legislation passed by Congress. Most of the barriers to APRN practice are at the state level as the result of state laws and regulations. It is vital for nurses to advocate within their state for removal of practice barriers such as requirements for physician supervision and prescriptive authority restrictions. The IOM report, The Future of Nursing: Leading Change, Advancing Health (Committee on the RWJF Initiative on the Future of Nursing, 2011, p. 34), recommended that “nurses should be able to practice to the full extent of their education and training.” State nurses associations and state-based coalitions have been vital in moving advocacy activities and educating nurses to take on the additional responsibilities that are required at this level. State Lobby Days are one of the many activities that can be held to educate nurses about the important practice issues requiring focus and about the ways that they can make a difference when speaking to legislators, mayors

POLICY ON THE SCENE 2.3: What Has My Association Done for Me? FRAN BEALL, RN, ANP-BC, PAST PRESIDENT, GEORGIA NURSES ASSOCIATION, ATHENS, GEORGIA Q: Over the years, what has the Georgia Nurses Association (GNA) done for you? A: [Fran Beall, GNA President 2009–2011] That is the wrong question! The question should be, “What have you done for yourself and your fellow nurses through your membership in GNA?” It always amazes me to think that any nurse would not understand that professional membership is a professional responsibility, and it is something you do for yourself and your profession. Period. GNA has made me a better nurse! It turned me into a nurse activist early on, and my nursing career has been so much more interesting because of that! My patients have benefited from having a nurse with a clear sense of who I am and an awareness of my own responsibility and power to change things when they are not working. On a more personal note, back in January of 1992, I experienced a ruptured AVM [arteriovenous malformation] over the right parietal lobe about 2 weeks before I was supposed to give the keynote address at the annual GNA Legislative Workshop. As (continued )

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the word got out, my husband Pat started receiving phone calls from GNA nurses he had never met who recommended rehab facilities and who told him to get me moved to rehab as quickly as possible after I was medically stable. You cannot imagine how comforting that was to have expert opinions during a time of great crisis. During that time, I was vice chair of the GNA Cabinet on Governmental Affairs. [The chair of the Cabinet] suddenly had to back out of a scheduled meeting, necessitating that I, as vice chair, take over the meeting. So, the whole Cabinet came to the [rehab hospital], so that I could run the meeting. This became the “higher cognitive project” that my team of rehab specialists wanted me to do, to test my ability to eventually go back to work as a nurse practitioner (NP). Now what can you say about friends and colleagues like that? They never let me think for a minute that I would not be able to return to nursing, despite total left hemiplegia.

and city council members, community activists, or the public at large. See Policy on the Scene 6.3 for how one state nurses association’s president reflected on her role as an advocate and leader.

National Moving advocacy to the national level typically takes nurses from their familiar practice settings to the unfamiliar world of policy and politics, a world in which many nurses do not feel prepared to effectively maneuver. Successful policy advocacy requires one to have the power, will, time, and energy, along with the political skills, needed to “play the game” in the legislative arena (Abood, 2007). This move into national advocacy is challenging and time consuming but offers the nurse a unique opportunity to make a difference in patient care and the satisfaction of playing a role in improving the healthcare system. Many nurses who are active in the national arena first honed their experiences at policy and legislative events sponsored by their state nurses association. Policy fellowships and workshops can also provide the needed opportunities to learn more about healthcare issues and the legislative process (see the Section “E-Resource” on the RWJF Policy Fellows program and the ANA’s American Nurses Advocacy Institute Leadership Program). There are multiple ways to get actively involved: Write a letter or email or make a call to your representative in Congress; attend a state or national Lobby Day event; educate your colleagues on national aspects of health policy such as healthcare reform; and even run for elective office. Many complex health policy issues require collaboration and sustained efforts to effect change. Organized nursing groups, the assistance of professional lobbyists, and sustained activity for months or even years are required when issues are as complex as healthcare reform or changing models of care delivery. Nurses who participate in their state and national nurses associations have access to important resources and can strategize collaboratively to bring nursing’s perspective to those legislative or regulatory decision makers. Professional nursing organizations such as the ANA maintain as their core work the monitoring of public policy and education of their members about the impact of policy issues. This is illustrated by the ANA’s collaborative work conducted over many years in support of healthcare reform. In 2015, when the U.S. Supreme Court was debating the constitutionality of President Obama’s key legislation, ACA, the ANA rallied its members once again for support (see Figure 2.3). Congressional efforts to

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FIGURE 2.3  Members of the American Nurses Association rally at the Supreme Court in support of access to healthcare.

“repeal and replace” the ACA in 2017 were met with opposition from every healthcare provider association.

International Advocacy on the international stage seems quite daunting; the ICN leads the profession in these efforts. The ICN launched a global vision for the 21st century in 1999 to “lead our societies to better health” (Benton, 2012, p. 1). The ICN, ­representing the interests of over 16 million nurses worldwide, works to shape health policy at the international level: publishing, disseminating, and updating position statements and educating nurses and the public at large about issues. The ICN advocates for policies that contribute to the health of populations, sustainable development, and the security and just treatment of nurses and healthcare professionals. ICN’s joint working paper (International Physicians for the Prevention of Nuclear War, World Medical Association, ICN, & World Federation of Public Health Associations, 2017) on banning and eliminating nuclear weapons was instrumental in the passage of the Treaty on the Prohibition of Nuclear Weapons adopted by the United Nations. The ICN (2016) has taken its Leadership for Change™ (LFC) program to China to develop stronger nursing leaders at the national level. The LFC program is now running in more than 40 countries and focuses on the development of nursing knowledge and leadership skills in this era of reform. As a federation of more than 130 national nurses associations, the ICN works to effect global change (see Chapter 14). Nurses across the globe are focused on the concept of advocacy as they provide care to their patients. Scandinavian nurse researchers examined how advocacy is defined by patients and nurses (Vaartio, Leino-Kilpi, Salanterä, & Suominen, 2006). Turkish nurses studied how intensive care unit nurses make decisions about the distribution of scarce beds to their patients (Ersoy & Akpinar, 2010), and Iranian nurses developed their own patients’ bill of rights and code of ethics while studying the extent of involvement in patient advocacy among their country’s nurses (Negarandeh & Dehghan Nayeri, 2012; Salehi, Dehghan Nayeri, & Negarandeh, 2010).

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WHEN ADVOCACY FAILS/WHEN ADVOCACY SUCCEEDS One needs only to review the case example of U.S. healthcare reform to understand the arduous and complex nature of advocacy. From President Theodore Roosevelt’s efforts toward national health insurance in the early 20th century, to the creation of Medicare and Medicaid in 1965 under President Johnson, and finally to the 2010 passage of the ACA under President Obama, the advocacy efforts of more than 100 years have brought us many improved programs but with many challenges left unresolved. If advocacy is such an important aspect of nursing care, why do efforts sometimes fail? What are the barriers that prevent nurses from being effective advocates on behalf of their patients, themselves, or their profession? In a concept analysis of barriers to nursing advocacy, Hanks (2007) identified the most common barriers as conflict of interest between the nurse’s responsibility to the patient and the nurse’s duty to the employer, lack of support, lack of power, the nurse’s lack of education, time constraints, threats of punishment, and the historical barrier of being in a feminine profession with a tradition of subservience to the medical profession. Institutional barriers to advocacy are challenging and often difficult to address. Nurses must know their legal scope of practice in their state and in their healthcare facility. Knowing the statutes and regulations assists nurses in being more effective advocates. If more assistance is needed with the state nurse practice act or practice guidelines, nurses should contact their state nurses associations; however, it is important for nurses to understand that membership organizations can best support only those dues-paying members who contribute to their profession. Clear, effective communication is central to overcoming advocacy barriers. The nurse’s ideas and suggestions are more effective when spoken clearly and without overt emotions such as anger and frustration. Even body language makes a difference. Using loud voices, leaning into another person’s space, pointing fingers, or crossing arms conveys hostility and prevents the nurse’s message from being received. Patient-centered language is the best approach when seeking to be an effective advocate. Written documentation may also prove important if the situation escalates or there are negative patient outcomes. The nurse must understand and use the employer’s chain of command. There are important organizational policies for reporting concerns and issues that arise. The employer may have an administrative structure that includes committees supporting advocacy efforts (e.g., ethics, shared governance, and/or staffing). Education has a major role to play in teaching effective advocacy. Faculty must teach the issues related to nursing advocacy, as well as role model what it means to be an advocate—at the individual patient level and the political/policy level. The practicing nurse should seek a preceptor or mentor who demonstrates strong a­ dvocacy skills to assist in navigating difficult clinical issues and organizational processes. The following advocacy exemplars illustrate the range of issues, the different forms that an advocacy effort might take, and the different outcomes for the advocacy efforts.

Advocacy Exemplar: Understaffing Labor and delivery nurse Mary Washington was tired, frustrated, and worried—her unit had been dealing with high census and low staffing for many months. The staff nurses had been complaining for a while and had met with the unit manager to voice their concerns. Mary had even presented her professional organization’s staffing guidelines to nursing leadership in an effort to make the case for improved staffing. However, it seemed that cost constraints were not allowing new staff to be hired, and Mary knew it was just

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a matter of time before understaffing would cause a problem. Some signs of fetal distress might be missed, and then a negative outcome would throw light on the consequences of the unit’s staffing patterns. She was just a few years out of her undergraduate program, so Mary consulted with one of her maternal–child health faculty members, who gave her suggestions for advocacy efforts. She also consulted with her state nurses association to see if there were any regulations or other guidelines that might apply. She took all the suggestions to her unit manager and the house supervisor, to advocate for safe patient care and protection of her own practice. Ultimately, Mary realized that she was being labeled a “troublemaker,” so after discussing the situation with her colleagues, she determined she had no recourse but to resign and take a position at a different hospital in the city.

Advocacy Exemplar: Removing Scope of Practice Barriers The value of APRNs is increasingly recognized by policy makers and consumers. As ­nursing practice is regulated by state boards of nursing, the United States continues to have a jumble of different regulations across state boundaries. However, a shift to full practice authority for APRNs is taking hold across the country as nursing associations advocate for it and consumers demand better access to primary care providers. States are continuing to pass legislation to allow full practice authority for nurse practitioners (see Chapter 1).

Advocacy Exemplar: The Whistle-Blowing Nurses From Winkler County, Texas In 2009, two nurses, Anne Mitchell and Vickilyn Galle, anonymously reported Dr. Rolando Arafiles Jr. to the Texas Medical Board for unsafe care. Dr. Arafiles urged the county sheriff and county attorney to uncover who made the report and then struck back at the nurses who were charged with misuse of official information, a third-degree felony, and fired from their jobs. After their case was nationally publicized by the Texas Nurses Association and the ANA, Dr. Arafiles’s attempts at retaliation against the two whistle-blower nurses were uncovered. Subsequently, Dr. Arafiles was charged with misuse of official information and retaliation, also a third-degree felony. He was sentenced to 60 days in jail and fined $5,000. Three others involved in the case received jail sentences and lost their jobs as a result of the roles they played: Sheriff Robert Roberts Jr., Attorney Scott Tidwell, and Hospital Administrator Stan Wiley. Nurses Mitchell and Galle were completely exonerated and received a civil suit settlement of $375,000.

ADVOCACY ORGANIZATIONS Nurses advocate to support patient autonomy and rights; however, they are less effective when challenging problems such as inadequate staffing or patient access to care unless they collectively respond to such systemic issues. Within direct-care clinical situations, individual nurses are staunch patient advocates, yet this focus of patient advocacy overlooks systemic problems that can cause harm to all patients (Mahlin, 2010). Although patient advocacy is most often framed in terms of an obligation to individual patients, it must include social and political activism to address the full spectrum of patient care issues. Collective activism for nurses is best accomplished through pro­ fessional associations. For professional nurses associations to effectively advocate for their professionals, they must rely on their members to report instances of inadequate and substandard care, as well as participate in the process of raising awareness.

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Professional nurses organizations in the United States began two decades after formal education programs were established. The first training school for nurses in the United States opened in 1873, and by 1893, nursing school administrators worked to form the American Society of Superintendents of Training Schools for Nurses (later becoming the National League for Nursing) to network, share best practices, and maintain a universal standard for training nurses (Matthews, 2012). When graduate nurses were seeking consistent standards in education and competency, they formed the Nurses Associated Alumnae of the United States and Canada (later renamed the ANA) in 1896 to elevate the standards of nursing education, establish a code of ethics, and promote the interests of nursing. Three documents developed by the ANA form the foundation of nursing as a profession and establish the role of advocacy for the professional nurse: Code of Ethics for Nurses with Interpretive Statements (2015a), Nursing: Scope and Standards of Practice (2015b), and Nursing’s Social Policy Statement: The Essence of the Profession (2010a). Depending on the classification, there are approximately 100 national nurses associations in the United States. Most are specialty focused, demonstrating the maturation, increased demands, and specialization that have occurred in nursing over the past 120 years. These organizations focus on missions that include legislative and broad-scale advocacy, education, professional development, and support for the professional nurse and patients’ rights. These organizations with differing strategic plans have identified the value of working collaboratively on a large number of issues. Formal structures such as the Nursing Organizations Alliance (www .­nursingalliance.org) and the ANA’s Organizational Affiliates (www.nursingworld.org/ FunctionalMenuCategories/AboutANA/WhoWeAre/AffiliatedOrganizations), as well as informal coalitions and groups come together to address a specific problem or issue. See the Option for Policy Challenge for how an advocacy organization provides resources for nurses to address issues in their practice.

OPTION FOR POLICY CHALLENGE: Advocacy for Safe Patient Handling and Mobility Robert and his clinical nurse specialist colleague, Jane, have been gathering and appraising resources for safe patient handling and mobility to create change on his unit. They have discovered that the American Nurses Association (ANA, 2013) publishes guidelines titled: Safe Patient Handling and Mobility: Interprofessional National Standards. They review the standards and ask to have this as an agenda item for the hospital’s Nursing Practice Committee. In addition, they learned that the ANA has a comprehensive website for Safe Patient Handling and Mobility that includes tools and resources such as position statements, national resources from government agencies and other organizations, webinars, and continuing education (www.nursingworld.org/practice-policy/work-environment/health-safety/ handle-with-care). They are pleased to learn that “Establish a Culture of Safety” is Standard 1, so they are excited to begin the advocacy journey to plan, implement, and evaluate the needed changes on Robert’s unit and throughout the hospital.

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IMPLICATIONS FOR THE FUTURE Advocacy at its best is about transformation. Wolf (2012) uses complexity science to demonstrate how events, patterns, and system structures can be helpful in transforming an organization. Successful nurse advocates can look beyond the events of today, see patterns and trends that are occurring, and map the direction needed for tomorrow. Future orientation causes the nurse advocate to ask the following: What type of care will patients look for in the future? What patterns need to change to improve the care given today? What outcomes require focus now? How might our patient population be different in future years, and what must we do to prepare for that? What structures would support that difference? What policies need to change? “The changes that are needed for patients will drive the changes that are needed for professional practice and become the source of advocacy” (Wolf, 2012, p. 309). The importance of transformational leaders to drive toward this future view of advocacy cannot be understated. The American Nurses Credentialing Center’s (ANCC) Magnet® Recognition Program recognizes organizations for quality patient care, nursing excellence, and innovations in professional nursing practice. Transformational leadership is a required element of Magnet recognition and these leaders convey a strong sense of advocacy, influence, and support on behalf of all staff and patients in a healthcare organization (ANCC, 2014). As nursing leaders explore the facts and observe how patterns fit together, they develop goals and objectives that will move the organization forward. They must use their influence to build collaboration and confidence, seeking staff input on how changes impact patient care, nurse satisfaction, and patient outcomes. When advocacy works best, all in the organization feel valued and engaged. Transformation in healthcare occurs only when advocacy is embraced by healthcare professionals and seen as an inherent part of their practice.

KEY CONCEPTS 1. The concept of advocacy is part of professional nursing. 2. Nurses readily accept the requirement of the professional nurse’s advocacy role as it applies to their patients; however, advocacy activities on behalf of colleagues, the profession, or even oneself are often lacking. 3. The ANA Code of Ethics for Nurses with Interpretive Statements defines the expectations of advocacy in which the professional nurse is expected to be engaged. 4. A strong commitment to social justice requires professional nurses to advocate for health for all persons. 5. The American public sees the nurse in the role of advocate in that they have rated RNs as the most honest and ethical profession for 17 of the past 18 years. 6. Nurse advocates need to have the competencies of problem solving, communication, influence, collaboration, and resource identification. 7. Advocacy works best in environments that encourage its activity, where leaders are supportive, and where tools are available to make it happen. 8. Moving advocacy to the state, national, and international levels typically takes nurses from their familiar practice settings to the unfamiliar world of policy and politics, a world in which many nurses do not feel prepared to effectively maneuver. 9. Common barriers to advocacy include conflict of interest between the nurse’s responsibility to the patient and duty to the employer, lack of support, lack of

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power, the nurse’s lack of education, time constraints, threats of punishment, and the historical barrier of being in a feminine profession with a tradition of subservience to the medical profession.

SUMMARY Healthcare is undergoing dramatic changes and the role of the professional RN is also evolving. The importance of nursing advocacy cannot be understated because more than 20 ­million uninsured in the United States gained access to healthcare under the provisions of the ACA and are in jeopardy of losing their coverage as the ACA is challenged in the current political environment. Nurses in direct care continue their important role of advocating for individual patients. Collectively, nurses must collaborate among themselves and with other healthcare professionals to transform healthcare. Nurse managers and administrators advocate to obtain adequate resources for their staff and to promote positive work environments in which advocacy efforts can flourish. Nursing educators must prepare their students to take on the mantle of advocacy to strengthen the profession. Every nurse in every setting has the opportunity and responsibility to make a positive difference in the lives of patients and the quality of nursing care. Advocacy is the key.

LEARNING ACTIVITIES 1. Describe two specific actions you could use to advocate for a “culture of safety.” 2. Explain how you would apply the precautionary principle to an issue in your practice or to an issue of concern to you. 3. Describe one example of how you could infuse the Code of Ethics for Nurses into your daily practice. 4. Evaluate the resources available in your state for nurses who have been reported for impaired practice to the Board of Nursing in terms of addressing the nurses’ needs. 5. Select an issue described in a Code of Ethics Provision Exemplar and describe the steps necessary to extend advocacy activities beyond a specific healthcare facility to the community, state, national, or international level. 6. What programs are available to assist with advocacy efforts in your workplace or state? Identify three individuals you could consult to assist you with workplace concerns. 7. Identify a current issue that you have experienced or read about, and identify advocacy and/or activist strategies to promote solutions to address the issue. 8. Explore the lives and accomplishments of a historical nursing leader. Think about this person’s enduring contributions to society. Identify whether he or she was an advocate, an activist, or possibly both—and why. Examples of nursing leaders include, but are not limited to, Dorothea Dix, Jane Delano, Lillian Wald, Mary Breckinridge, Clara Barton, Florence Nightingale, Margaret Sanger, and Edith Clavell.

E-RESOURCES • Advocacy Project http://advocacynet.org • Agency for Healthcare Research and Quality http://www.ahrq.gov • American Association of Colleges of Nursing (AACN) http://www.aacnnursing.org

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• American Association of Nurse Practitioners 2018 Nurse Practitioner State Practice Environment. https://aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdf • American Nurses Advocacy Institute (ANAI) https://www.nursingworld.org/practice-policy/advocacy • American Nurses Association http://www.NursingWorld.org • American Nurses Association. Code of Ethics for Nurses http://www.nursingworld.org/codeofethics • American Nurses Association. Policy & Advocacy http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy • American Public Health Association. Advocacy & Policy https://www.apha.org/~/media/files/pdf/advocacy/power_of_advocacy.ashx • Centers for Medicare & Medicaid Services http://www.cms.gov • Child Health Advocacy Institute http://www.childrensnational.org/advocacy • Commonwealth Fund http://www.commonwealthfund.org • Department of Health and Human Services http://www.hhs.gov • Indivisible Movement Guide http://www.indivisible.org/guide • Institute for Healthcare Improvement (IHI) http://www.ihi.org • Institute of Safe Medication Practice (ISMP) https://www.ismp.org • International Council of Nurses (ICN) http://www.icn.ch • Johnson & Johnson Discover Nursing/Nurse Advocate http://www.discovernursing.com/specialty/nurse-advocate • National Academy of Medicine http://www.nam.edu • National Council of State Legislatures http://www.ncsl.org • National Patient Safety Foundation (NPSF) http://www.npsf.org • Nurse-Family Partnership http://www.nursefamilypartnership.org/public-policy/advocacy-resources • Occupational Safety and Health Administration (OSHA) https://www.osha.gov • RN Activist Toolkit, ANA Governmental Affairs https://www.nursingworld.org/practice-policy/advocacy • Robert Wood Johnson Foundation (RWJF) Health Policy Fellows Program http://www.healthpolicyfellows.org/aboutus.php • Trust for America’s Health http://healthyamericans.org/policy • United States House of Representatives http://www.house.gov

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• United States Senate http://www.senate.gov

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70   UNIT I  MAKING THE CASE http://www.icn.ch/images/stories/documents/projects/nursing_policy/Ban%20treaty%20 joint%20health%20statement%2018%20Sept%202017%20Final.pdf Khoury, C. M., Blizzard, R., Wright Moore, L., & Hassmiller, S. (2011). Nursing leadership from bedside to boardroom: A Gallup national survey of opinion leaders. Journal of Nursing Administration, 41(7–8), 299–305. doi:10.1097/NNA.0b013e3182250a0d Lachman, V. D. (2015). Conscientious objection in nursing: Definition and criteria for acceptance. Medsurg Nursing, 23(3), 196–198. Retrieved from http://www.medsurgnursing.net/cgi-bin/ WebObjects/MSNJournal.woa Lachman, V. D., Swanson, E. O., & Winland-Brown, J. (2015). The new “code of ethics for nurses with interpretive statements” (2015): Practical clinical application, Part II. Medsurg Nursing, 24(5), 363–366, 368. Retrieved from http://www.medsurgnursing.net/cgi-bin/WebObjects/ MSNJournal.woa Mahlin, M. (2010). Individual patient advocacy, collective responsibility and activism within professional nursing associations. Nursing Ethics, 17(2), 247–254. doi:10.1177/0969733009351949 Mass Moments. (n.d.). Dorothea Dix begins her crusade. March 28, 1841. Retrieved from http://www .massmoments.org/moment.cfm?mid=96 Matthews, J. H. (2012). Role of professional organizations in advocating for the nursing profession. Online Journal of Issues in Nursing, 17(1), 3. doi:10.3912/OJIN.Vol17No01Man03 Matwick, A. L., & Woodgate, R. L. (2016). Social justice: A concept analysis. Public Health Nursing, 34(2), 176–184. doi:10.1111/phn.12288 Miller, D. (1999). Principles of social justice. Cambridge, MA: Harvard University Press. Negarandeh, R., & Dehghan Nayeri, N. (2012). Patient advocacy practice among Iranian nurses. Indian Medical Ethics, 9(3), 190–195. doi:10.20529/ijme.2012.063 Pagana, K. D. (2013). Ride to the top with a good elevator speech. American Nurse Today, 8(3), 14–16. Retrieved from https://www.americannursetoday.com/ride-to-the-top-with-a-good -elevator-speech Paquin, S. O. (2011). Social justice advocacy in nursing: What is it? How do we get there? Creative Nursing, 17(2), 63–67. doi:10.1891/1078-4535.17.2.63 Pavlish, C., Brown-Saltzman, K., Hersh, M., Shirk, M., & Rounkle, A. (2011). Nursing priorities, actions and regret for ethical situations in clinical practice. Journal of Nursing Scholarship, 43(4), 385–395. doi:10.1111/j.1547-5069.2011.01422.x Press Ganey. (2015). Nursing Special Report: The influence of nurse work environment on patient, payment and nurse outcomes in acute care settings. Retrieved from http://www.pressganey. com/about/news/nursing-special-report-the-influence-of-nurse-work-environment-on-patient -payment-and-nurse-outcomes Reddi, V. (2005). Dorothea Lynde Dix (1802–1887). Retrieved from http://www.truthaboutnursing .org/press/pioneers/dix.html Rodney, P. A. (2017). What we know about moral distress. American Journal of Nursing, 117(2 Suppl. 1), S7–S10. doi:10.1097/01.NAJ.0000512204.85973.04 Rushton, C. (2017). Cultivating moral resilience: Shifting the narrative from powerlessness to possibility. American Journal of Nursing, 117(2 Suppl. 1), S11–S15. doi:10.1097/01.NAJ.0000512205.93596.00 Rushton, C., Caldwell, M., & Kurtz, M. (2016). CE: Moral distress: A catalyst in building moral resilience. American Journal of Nursing, 116(7): 40–49. doi:10.1097/01.NAJ.0000484933.40476.5b Salehi, T., Dehghan Nayeri, N., & Negarandeh, R. (2010). Ethics: Patients’ rights and the code of nursing ethics in Iran. Online Journal of Issues in Nursing, 15(3). doi:10.3912/OJIN.Vol15No03EthCol01 Science and Environmental Health Network. (2011). Wingspread statement on precautionary principle. Retrieved from http://www.sehn.org/precaution.html Selanders, L., & Crane, P. (2012). The voice of Florence Nightingale on advocacy. Online Journal of Issues in Nursing, 17(1), 1. doi:10.3912/OJIN.Vol17No01Man01 Smedley, B. D., Stith, A. Y., & Nelson, A. R. (Eds.). (2002). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press.

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Snodgrass, M. E. (2009). Civil disobedience: An encyclopedic history of dissidence in the United States. New York, NY: Routledge Taylor Francis. Thompson, J. (2014). Discourses of social justice: Examining the ethics of democratic professionalism in nursing. Advances in Nursing Science, 37(3), E17–E34. doi:10.1097/ANS.0000000000000045 Tomajan, K. (2012). Advocating for nurses and nursing. Online Journal of Issues in Nursing, 17(1), 4. doi:10.3912/OJIN.Vol17No01Man04 Vaartio, H., & Leino-Kilpi, H. (2005). Nursing advocacy—A review of the empirical research ­1990–2003. International Journal of Nursing Studies, 42(6), 282–292. doi:10.1016/j.ijnurstu.2004.10.005 Vaartio, H., Leino-Kilpi, H., Salanterä, S., & Suominen, T. (2006). Nursing advocacy: How is it defined by patients and nurses, what does it involve and how is it experienced? Scandinavian Journal of Caring Sciences, 20(3), 282–292. doi:10.1111/j.1471-6712.2006.00406.x Valderama-Wallace, C. P. (2017). Critical discourse analysis of social justice in nursing’s foundational documents. Public Health Nursing, 35(1), 1–7. doi:10.1111/phn.12327 Van Dyke, K., Combes, J., & Joshi, M. (2011). AHA health care governance survey report. Chicago, IL: Center for Healthcare Governance. White, P., Olsan, T. H., Bianchi, C., Glessner, T., & Mapstone, P. (2010). Legislative: Searching for health policy information on the Internet: An essential advocacy skill. Online Journal of Issues in Nursing, 15(2). doi:10.3912/OJIN.Vol15No02LegCol01 Wolf, G. (2012). Transformational leadership: The art of advocacy and influence. Journal of Nursing Administration, 42(6), 309–310. doi:10.1097/NNA.03e3182573989

THREE

Navigating the Political System Eileen M. Sullivan-Marx Susan Apold All politics is local. —Tip O’Neill, Jr., 55th Speaker of the U.S. House of Representatives

OBJECTIVES 1. Compare and contrast functions among the executive, legislative, and judicial government branches in the creation and implementation of policy. 2. Critique policy solutions obtained through regulatory and legislative processes. 3. Differentiate among local, state, and federal jurisdictions. 4. Analyze strategies to create or influence policy during all phases of the policy cycle.

In the United States, more than 200 years ago, the founding fathers envisioned a ­government in which democratic principles would rule the nation. Fundamental to a democratic system is the participation of all citizens in the creation and evolution of that government. The U.S. system was created to specifically address the needs of its people to ensure that the voices of the people would be heard and that no one entity had the power to overrule the voice of the people. This system, while over 200 years old, is relatively new in the history of governance, but it has persisted in this nation, and it appears that this “Great Experiment” is here to stay. It can survive only if its basic premise is upheld and carefully nurtured: The people must participate and diligently protect our democracy. All citizens of our nation have the opportunity and responsibility to participate in the creation of our nation. As the largest healthcare workforce in the country, with more than 3 million practicing, nurses have unprecedented power to exert influence on almost any aspect of life in the United States but most particularly their area of expertise: the healthcare needs of our nation and the profession itself. The Kaiser Family Foundation (2017) reported that there were 3,316,111 RNs who are “professionally active,” which represents 85% of all RNs in the United States. This translates to approximately one RN for each 1,000 people. Gallup polls consistently rank nursing as number one for ethics and honesty (Brenan, 2017). Paradoxically, 73

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although society holds nursing in high esteem, only 14% of American opinion leaders from the public and private sector, academia, and trade organizations believed nurses were likely to exert a great deal of influence on healthcare in comparison to 75% and 56% respectively for government and insurance executives (Khoury, Blizzard, Wright Moore, & Hassmiller, 2011). Nurses have exerted exceptional influence on individual patients, families, and communities; however, they have not historically harnessed the power of their numbers, knowledge, or economic force into a cohesive unit with the potential for a powerful collective voice in healthcare. Nursing has reacted and responded to a number of healthcare policies; however, nurses’ reactions remain peripheral to policy making. Nurses have the potential political power to make momentous contributions to the national healthcare system. Although a cadre of individual nurses have exhibited exceptional records of accomplishments in policy making (see Chapter 12 in the first edition of this book) as a unified profession, nurses has historically experienced tension between their perceived role as caretakers and their role as p ­ olitical activists. Politics is often perceived as dirty and dishonest, and nurses often do not embrace the reality that in their role as patient advocates, political engagement with its solutions and challenges, is an essential responsibility in keeping nursing’s social contract with society (Des Jardin, 2001). Nurses need look no further than their own professional documents to discover their imperative to engage in the policy process. Nursing arises out of society’s need for the promotion of health and care of the sick; it is society that entrusts nursing with autonomy and responsibility for addressing these needs. The American Nurses Association (ANA) defines nursing as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (ANA, 2010). Nursing’s Social Policy Statement (ANA, 2010), which describes the social contract between society and the nursing profession, requires that the profession advocate for public health; organization, delivery, and financing of healthcare; expansion of healthcare resources and health policy; and planning of health policy and regulation (see Chapter 2). To embrace the full responsibility for the privilege of serving as a professional RN, individual nurses must participate in politics and the policy-making process. Realization of the Triple Aim, improved patient healthcare experiences, decreased healthcare cost, high quality healthcare, and now the Quadruple Aim with the addition of care of the provider, cannot be achieved without the voice of nursing at every table where healthcare is discussed—hospitals, colleges, universities, professional nursing organizations, government agencies, and board rooms of every company in this nation (Berwick, Nolan, & Whittington, 2008; Bodenheimer & Sinsky, 2014). Nurses can be engaged with a full cycle of policy activities through a continuum of engagement, from local municipalities to international venues from participation in workplace committees to election to public office. Nurses are well recognized as a potent political force when they coalesce through organized campaigns to write letters, speak through nursing leadership, and represent themselves as a significant voting bloc. Despite these abilities and strides, nurses remain relatively invisible in the policy process. Few nurses run for elected office, hold a political appointment, work as a staff member for a legislator, or work on a candidate or issue campaign. They are more commonly employed in staff positions within government administrative agencies, where they are responsible for implementing administrative policies and

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clarifying and informing their respective employing agency regarding health and nursing issues. However, these positions are not widely known in nursing. This chapter discusses opportunities for nurses to engage in the policy process that are not as widely known or as visible. These include actively participating in professional association memberships, contributing to political action committees (PACs), writing letters, sitting on local community boards (e.g., parent–teacher associations), registering to vote and voting, engaging in the development of proposed legislation, testifying, or writing comments on federal or state regulatory rule making, working on campaigns, and vetting local politicians for endorsement by organizations. Before the details of these activities are examined, the key features of governmental processes are discussed because understanding these processes is vital to accepting policy opportunities. Much of our focus is on the processes at the federal level, recognizing that there are similarities, but diversity in structure and processes, at the state and local levels. Equally important is appreciating the long view of policy; creation and implementation can take years, with many different stakeholders. This chapter’s Policy Challenge illustrates several aspects of policy making and how long the process can take. This exemplar further illustrates how professional groups set goals for policy making, legislation, and regulation. All elements are important to those seeking to teach in nursing programs, those looking to hire high-value advanced practice registered nurses (APRNs), and those interested in title protection and minimum requirements for licensure and safe practice. This Policy Challenge illustrates the numerous ways that regulations and laws can be developed to complement the needs of nursing practice. Furthermore, it illustrates how complex policies require the efforts of multiple stakeholders and can take years to evolve and develop into sustainable and agreed-on policy, legislation, or regulation. Often, numerous stakeholders, years of work, and various political and policy strategies are needed for effective long-term defensible solutions. An example of an issue specific to nursing policy is the evolution and status of the doctor of nursing practice (DNP) degree. The dramatic changes in healthcare and prominent reports cited the need for a better and differently educated workforce using a seamless and efficient strategy for nursing education. These reports included the Competencies for the 21st Century (PEW Health Professions Commission, 1998), Crossing the Quality Chasm (Institute for Medicine [IOM], 2001), Health Professions Education (Greiner & Knebel, 2003), and The Future of Nursing (Committee on the Robert Wood Johnson Foundation [RWJF] Initiative on the Future of Nursing, 2011). Specifically, the identified need was for the development of advanced competencies for increasingly complex clinical, faculty, and leadership roles, along with the need for enhanced knowledge to improve nursing practice and patient outcomes. The first nursing doctoral program was established in 1924 at Teachers College at Columbia University. It was a program designed for nurses interested in the science of nursing education and conferred an EdD. In 1934, the first PhD program was offered to nurses at New York University and concentrated on advanced knowledge in nursing and nursing science (Apold, 2008). Within the profession, conversations emerged regarding the need for a clinical doctorate, a terminal degree for nurses that focused on the implementation of nursing research, development of quality science in nursing, and the further development of clinical expertise. Attempts were made to provide such a degree, with DNS and DNSc programs emerging to fill that need; however, these programs soon closely resembled traditional PhD programs. A nursing doctorate (ND) program was introduced in 1979 as an innovative clinical entry-level program at Case Western Reserve University in Cleveland, Ohio (Patzek, 2010). This was designed as the first clinically

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POLICY CHALLENGE: American Veterans’ Access to Care: Full Practice Authority for Nurse Practitioners, Clinical Nurse Specialists, and Nurse-Midwives in the Veterans Administration System Cindy Cooke, DNP, FNP-BC, FAANP, Past President American Association of Nurse Practitioners, Austin, Texas An essential value to all Americans is the commitment to provide healthcare to our veterans. The Veterans Health Administration (VHA) system serves millions of veterans across the nation in over 1,240 medical and outpatient centers. With an increasing number of veterans returning from active duty across the globe and the aging of veterans, their needs are complex and growing. APRNs, including clinical nurse specialists (CNSs), nurse practitioners (NPs), certified nurse-midwives (CNMs), and certified registered nurse anesthetists (CRNAs), have been part of the Department of Veterans Affairs (VA) system, providing quality care to this nation’s veterans for decades. In a system that requires all the resources—economic and human—that this nation can provide, APRNs fill important needs. This requires statutory regulation of APRN practice. Licensure falls to state, not federal, jurisdiction. Thus, APRN professional licensure laws and regulations are not standardized across states, nor across APRN specializations. Examples of the variation include the amount or type of collaborative practice required and the ability to prescribe Schedule II and III medications. Since the VHA system is a federal system and hospital and healthcare facilities exist in every state, the VHA system operates under the APRN laws and regulations in each state where VA facilities exist. The complicated regulatory environment for each APRN category was problematic. Where APRN practice was highly regulated, (a) veterans had decreased access to care; (b) the system incurred increased costs of care (physician payment for NP oversight and physician time spent supervising APRN practice at the expense of engaging in patient care); and (c) administrative oversight of APRN practice was burdensome. A change in federal regulations at the federal level to allow APRNs to have full practice authority (FPA) (i.e., to practice to the full extent of their education and clinical training) would maximize the VHA’s professional workforce; increase access to care, particularly in underserved areas; and decrease wait time for services. In the report, The Future of Nursing: Leading Change, Advancing Health (Committee on the RWJF Initiative on the Future of Nursing, 2011), the first key message was that “nurses should practice to the full extent of their education and training” (p. 29). In states restricting practice, APRNs practice in accordance with regulations, not their education and clinical training. During the 2010s, the VA experienced serious problems related to increased numbers of veterans seeking care and decreased numbers of qualified, available ­providers. This  presented an opportunity to develop sound policy to solve (continued )

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the national problem of veterans needing care and APRNS being available to ­provide that care. The IOM supported FPA for all APRNs. The VA system experienced severe resource problems that adversely affected the health of one of the nation’s most precious resources. What policy solutions were available? The policy option illustrates nursing’s power to advocate for change that focuses on high-quality patient care and the profession. See Option for Policy Challenge.

focused doctoral program in nursing in the nation. With the increasing need for and growth of nursing research, PhD and DNSc programs continued the focus on development of researchers to create the evidence base for nursing. However, the changing perspectives on nursing education called for visionary leadership to guide future policy discussion and decisions, create parity with other health professions, and address advanced clinical education for nurses. Stakeholders were convened and made a recommendation to the American Association of Colleges of Nursing (AACN) that a clinical doctorate, the DNP, be established and standardized as the terminal clinical degree for nurses. The DNP has emerged as the terminal graduate clinical degree for advanced nursing practice preparation (e.g., clinical nurse specialist [CNS], nurse practitioner [NP], certified nurse-midwife [CNM], certified registered nurse anesthetist [CRNA], and other nursing leaders). The National Organization of Nurse Practitioner Faculties (NONPF) now recommends that the DNP be considered entry-level preparation for NPs. This Policy Challenge and the emergence of the DNP degree are examples of how policy making is often an amalgamation of processes that can span a combination of policy activities. It is not one piece of legislation, but several, that are required to achieve the desired policy outcome, or it may be a combination of an executive order and subsequent legislation that is needed. It may not be legislation at all, but an evolution of policy change at the professional level. No one strategy fits across all healthcare policy making. Furthermore, the process is often evolutionary, taking time, a commitment to long-term policy goals, and an ongoing understanding of the policy-making process at both the little “p” and the big “P” levels.

UNDERSTANDING THE SYSTEM To navigate the system, nurses need to understand the it. Often, nurses and the U.S. public in general avoid policy and politics because the system of government appears complex and confusing. The following section provides a brief overview of the system and structure of government in the United States. (For a more comprehensive understanding of the U.S. government, see www.congress.org.) The U.S. Constitution is the legal basis for all government and governmental activity. It consists of a (a) preamble containing perhaps, the most famous words in our nation, “We the People”; (b) seven original articles defining the branches of government, providing for interaction between state and federal government and providing for the process of amendment and ratification; and (c) amendments (27), the first 10 of which compose the Bill of Rights. The Constitution is based on “Six Big Ideas” (Exhibit 3.1) that underscore the values of the founding fathers and the American people.

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EXHIBIT 3.1  “SIX BIG IDEAS” IN THE U.S. CONSTITUTION CONCEPT

APPLICATION

Limited government

The restriction of the power that government has over its people

Republicanism

A government that requires the active involvement of its people

Checks and balances

The division of power such that the power to govern does not rest completely in any one branch

Federalism

Shared government between the federal and state governments

Separation of powers

Established branches of government, each with its own responsibilities

Popular sovereignty

Government ruling at the consent of its people through elected officials

As laid out in the Constitution, each branch of government has specific p ­ owers to ensure that no one branch gains too much control or has too much power (see Exhibit  3.2). Also, the Constitution provides for a federalist system whereby governance is shared between federal and state entities. It is essential for nurses to understand which branches of government are responsible for which laws, policies, and regulations; for example, professional licensing and insurance laws and regulations are under the jurisdiction of the states, and civil rights and immigration laws fall under federal jurisdiction. This distinction is important when speaking with policy makers to ensure that the right issues get to the policy maker or legislator that has jurisdiction over them. The U.S. government was designed to allow for a thoughtful, contemplative, and lengthy decision-making process. It takes years, sometimes decades, for legislation to be enacted. The doctrine of “states’ rights” is secured by the U.S. Constitution. Each state, therefore, has a constitution and a formal government structure that is like the federal governmental structure. All states have an executive branch (led by the governor), a legislative branch (usually a bicameral legislature consisting of a state senate and state house of representatives or state assembly), and a judicial branch. State constitutions cannot conflict with the U.S. Constitution; when a conflict arises, the federal constitution prevails. The formal legislative process is depicted in Figure 3.1. The informal legislative process is the stuff of politics. Policy does not only happen in formal political and governmental arenas. As former Speaker of the House, Tip O’Neill, famously stated, “All politics is local.” All systems are political! Local governments are often the place where issues close to the people are identified as problems requiring political action and policy solutions. Professional associations are also the source of many contributions to formal policy making. Most organizations have structures similar to governmental structures. These include constitutions (bylaws), governing bodies with elected and appointed positions (presidents, executive directors, and boards of directors or trustees), and committees who conduct business and make recommendations (see Chapter 11). Navigating any political

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system requires a thorough understanding of the its bylaws (constitution), structure, ­governance, mission, vision, and processes. As nurses become increasingly involved in all systems political, navigation of those systems requires careful consideration of political and structural processes. EXHIBIT 3.2  BRANCHES OF THE U.S. GOVERNMENT BRANCHES

LEGISLATIVE (MAKES LAWS)

EXECUTIVE (ENFORCES LAWS)

JUDICIAL (EVALUATES LAWS)

Composition

Congress • U.S. Senate • 50 members • Elected every 6 years • U.S. House of Representatives • 435 members • Elected every 2 years

• President • Vice-president • Cabinet secretaries of federal agencies • Executive Office of the White House

• Supreme Court • Appellate courts • District courts

Powers and duties

• Both Houses create new or amend existing laws • Both Houses must agree on a bill before it can become a law. • Congress can override a Presidential veto • U.S. Senate • Confirms presidential appointments • Ratifies treaties • U.S. House of Representatives • Initiates revenue bills • Approves budget • Impeaches federal officials • Elects the president in the event of an electoral college tie

• Executes and enforces laws created by Congress • Executes and enforces treaties • Commands the armed forces • Determines military deployments • Signs legislation or vetoes bills • Appoints over 1,000 positions in federal agencies and judiciary, including Supreme Court • Issues executive orders

• Interprets the Constitution • Protects individual constitutional rights • Determines constitutionality of laws • Determines constitutionality of executive actions • Resolves legal disputes • Provides the check over the power of executive and legislative branches

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FIGURE 3.1  The legislative process. Source: From Congress.gov. (n.d.). The legislative process. Retrieved from https://beta.congress .gov/content/legprocess/legislative-process-poster.jpg

THE LEGISLATIVE PROCESS The first step in the legislative process at the local, state, or federal level is the ­introduction and referral of bills. What happens before a bill is referred is as important to understand as the legislative process itself. Once a bill becomes a law (statute), the opportunity for influence does not end. Nurses have an enormous role in the development of a regulation. After a bill is passed and signed into law, it is sent to the agency responsible for proposing rules and regulations so that it can implement the law. This phase at the federal or state level is a great opportunity to influence policy. Each rule in the regulation has the potential to be an effective, powerful policy. At the federal level, the executive branch is responsible for developing final regulations. Prior to the publication of proposed rules, however, interested parties can recommend language and meet with agency staff responsible for rulemaking to express points of view. Even if nurses did not fully support a newly formed law, they can use their influence to address specific issues or mitigate action in proposed regulation that may be a detriment to nursing’s position. It is not easy to get legislation passed. This is by design. Before laws are passed, careful assessment of the values underpinning them must be made; stakeholders engaged; intended and unintended consequences evaluated; and economic, legal, social, and political costs determined. Like many policy issues, legislative solutions usually occur over time and with representation from many stakeholders representing a variety of special interest groups. While considered complex, the legislative process is a series

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of well-documented steps in which a bill can become a law. The process is essentially the same for both state and federal legislation. However, it is very common that a bill, once introduced, never becomes law. Since the 109th Congress, fewer than 5% of bills introduced became law, with the 114th Congress passing only 329 of the 12,063 bills introduced (GovTrack, n.d.). Nurses can influence the development and implementation of policy and legislation at every step of the process. Specific examples of active participation in the legislative process are listed in Exhibit 3.3. Policy making takes place in many forums. Frequently, as one considers policy solutions, legislation is often seen as the most obvious one. However, multiple options exist for nurses to exert influence and activities in other venues both legislative and nonlegislative. Nurses are included in many panels and provide input into expert clinical decision making. Nurses are employed in, and serve as consultants to, many powerful organizations that inform healthcare policy, including the Agency for Healthcare Research and Quality (AHRQ), Centers for Medicare & Medicaid Services (CMS), and the National Council on Quality Assurance (NCQA). Strategies for influencing policy making are most often planned after a policy agenda is formulated. Where to take the issue, how to get it there, and how to make sure it moves forward are all points discussed when planning the implementation of a policy agenda (see Chapter 6). By virtue of nurses’ education, clinical expertise, and advocacy roles, they are well situated to engage in a variety of strategies to influence at every level where policy needs discussion. Laws may be written in such a way that they are funded for a limited time and then must come back to a legislative body for reenactment or funding. Anticipating reenactment legislation and expressing opinions early on why a particular program or piece of legislation remains important or how it can be updated and renewed for the current healthcare environment is very important. An important example of necessary vigilance occurs in states with sunset clauses in their legislation and regulations for governmental agencies and boards. These sunset clauses need monitoring because they require periodic legislative action to reauthorize or extend the law. Agencies, such as boards of nursing (BONs) in some states, are susceptible to these regulations and may possibly change or be eliminated if action is not taken. Some states have witnessed their BON come precipitously close to dissolution and elimination. Without renewed legislation, these BONs would not exist or EXHIBIT 3.3  LEGISLATIVE STEPS IN WHICH NURSES HAVE INFLUENCE • Electing legislators whose positions are aligned with the nursing profession’s views and values • Drafting legislative language • Participating in committee hearings • Testifying at local, state, or federal committee hearings • Informing congressional offices before voting on legislation • Informing the White House before the president signs or vetoes passed legislation • Providing comments to agency-proposed regulations to implement legislation • Alerting and informing stakeholders about common legislative issues • Attending legislative forums such as town halls

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therefore have no authority to regulate nursing. The unintended consequence is that anyone would be allowed to practice nursing, that newly graduated nurses or nurses moving to the state would not be able to obtain licensure and/or employment, and that no one would investigate nurse practice violations. Typically, it is nurses (through state nurses associations) who monitor these activities to ensure that any sunset legislation is managed through review and reauthorization to protect the practice of nursing within their states. Most laws and BONs do not have sunset clauses and therefore remain in force indefinitely. However, it is the responsibility of nurses to be aware of such legislation and to make sure that such processes go smoothly. Another example is the funding for nursing education, which needs annual reauthorization (see Chapter 7 and Policy on the Scene 7.2)

STRATEGIES FOR INFLUENCING POLICY MAKING Whether influencing legislators or serving on committees, boards, or expert panels, there are some standard strategies for influencing policy making (see Figure 3.2).

FIND AND USE VOICE CONTACT A POLICY MAKER

JOIN AND ENGAGE IN PROFESSIONAL ORGANIZATION

SERVE ON A BOARD OF DIRECTORS

PROVIDE TESTIMONY

POLICY AND POLITICS

DEVELOP A GOOD STORY

VOTE

RUN FOR OFFICE

DONATE TO A PAC VOLUNTEER FOR A POLITICAL CAMPAIGN

FIGURE 3.2  Strategies for influencing policy and politics. PAC, political action committee.

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Engaging With Professional Associations All RNs in the United States have an opportunity and an obligation to join a ­professional nurses association. Professional associations collectively speak for the profession and patients. Membership allows for nurse representation at every table where healthcare and health policy are discussed. Nurses professional associations promote nursing’s position on issues of importance in the political arena. Associations with larger memberships (and therefore, resources) can hire staff and lobbyists, form PACs to back candidates who support nursing’s agenda, and engage in the political process. Professional associations have played strong roles in identifying nursing and healthcare issues needing scrutiny; lobbying for legislation, regulation, or policy change; monitoring the progress of pending legislation; moving legislation through committees and onto the House and Senate floors; crafting rule-making language and options after laws are passed; overseeing the implementation of newly passed legislation; and monitoring the impact of legislation for intended and unintended consequences. Healthcare delivery and finance are important issues, and the public needs to hear a nursing voice and perspective. Professional nurses associations have played a major role in healthcare reform conversations, which are partisan, passionate, personal, and political. National nurses associations have taken the position that access to highquality healthcare should be guaranteed. During the 8-year implementation timeline (2010–2018) of the Affordable Care Act (ACA), a focused nursing community remained engaged to achieve the intent of the legislation. At times, monitoring the Federal Register (www.gpo.gov/fdsys) resulted in a call to action for the profession to react or suggest draft language for regulation and implementation of the ACA’s hundreds of provisions. For example, because agencies determine who can be eligible healthcare providers in new, patient-centered, team-based models of care, such as “medical homes” and “accountable care organizations,” draft language was submitted urging that APRNs be specifically identified as primary care providers. At other times, the judicial processes are essential to upholding the legislation’s interpretation and intent. For example, the ANA joined five other healthcare groups representing millions of healthcare professionals in filing an amicus brief with the U.S. Supreme Court in support of the ACA minimum coverage provision, or “individual mandate” (ANA, 2012) (see the section, Opportunities to Influence Judicial Actions). As frontline witnesses to those who are uninsured and defer needed care, nurses have a unique perspective to share and guide the Supreme Court regarding the consequences of changes to healthcare legislation. More expansive opportunities for individual nurses to influence policy often emerge from professional association engagement. A powerful mechanism for informing and influencing legislators is providing testimony at public hearings and congressional committees. Public hearings are not only held on a variety of topics for legislation, but also are routinely held by congressional committees, appointed commissions, and federal or state agencies seeking information (see Figure 3.2). Professional associations work with their members to identify opportunities to provide testimony, select articulate members to provide the testimony, and prepare the remarks to be made during hearings. Hearings as a part of a formal process provide a distinct opportunity for providing detailed reports and answering questions at all levels of government. Hearings are often a major step toward enactment of legislation and symbolize its importance. Legislative committees use this method to assemble information and solicit opinions from officials of the executive branch, other members of Congress, representatives of interest groups, experts, and concerned citizens. Hearings include written testimony that can be

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submitted alone or with an oral presentation and questioning by ­members of Congress. Presenters usually represent organizations such as the ANA or state nurses association, but individuals can provide both written and oral testimony. See www.rnaction.org for selective testimony presented by the ANA, or www.loc.gov/law/find/hearings.php for the Law Library of Congress, which has a collaborative collection of the Library’s complete collection of printed hearings. Processes for hearings are typically well established with common expectations. Exhibit 3.4 lists common sense approaches to hearing preparation and presentation. The committee chairperson or host of the hearing selects the number and timing of oral presenters. Nurses can participate in several important ways in the testimonial process by providing (a) contextual information on the topic, (b) examples that emphasize the critical nature of the topic, or (c) oral testimony and answering questions. Individual nurse clinicians and researchers who present as members of their organization and who have close working knowledge of the topic are often able to bring a sense of proportion and reality to the discussion. Exhibit 3.5 lists some of the congressional committees that often play a role in issues that impact nursing and healthcare and that often conduct hearings. Because nurses are a trusted by the public, and represent many potential voters, they are valued participants during hearings. Having multiple presentations by representatives from numerous nurses associations supporting an issue creates a powerful presence. It is critical that the presentations are accurate and reflect consistency in voice as appropriate. Working and coordinating with nurses associations in which you hold membership is a benefit. The association can help support individuals participating in hearings by providing collaboration and background information that can further enhance talking points. This additional help and the presence of a representative of the association at the hearing to supplement responses can help build confidence and reassure the presenters. Numerous federal and state agencies appreciate the working relationship with nurses associations when there is alignment of interests with the agencies’ core missions. Examples of issues that nurses can address by working with specific agencies are illustrated in Exhibit 3.5 EXHIBIT 3.4  APPROACHES TO HEARING PREPARATION AND PRESENTATION • Follow specific hearing guidelines. • Talk ahead of time with the staff member assigned to the hearing chairperson. • Dress well—professional business attire. • Come early, be on time, and be prepared to spend the entire day. • Rehearse your spoken testimony before the hearing. • Keep it under time limits. • Address legislators politely and answer questions if asked. Say “Thank you” for the opportunity to speak. • Be courteous and respectful of the legislators, regardless of their opinion, as well as respectful and courteous to all who testify. • “Pass” when called to speak if you are uncomfortable or answer simply, “Representative/Senator, I will have to look into your question and get back to you.” • Realize that elected and/or appointed officials come in and out of the room during the hearing.

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EXHIBIT 3.5  SELECTED ISSUES IMPORTANT TO NURSING AND THE RELATED

FEDERAL AGENCY ISSUE

RELATED FEDERAL AGENCY

Lead poisoning

Environmental Protection Agency

Food safety Healthy eating

Department of Agriculture

Affordable housing

Federal Housing Finance Agency

Disabilities Aging Home care

Department of Health & Human Services

Brain injuries Posttraumatic stress disorders Family health

Department of Defense Department of Veterans Affairs

Nurses in practice, research, and education can provide data and context for these agencies when developing hearing testimony or public statements. Exhibit 3.6 lists selected congressional committees and governmental agencies that play a role in issues impacting nursing and healthcare. Writing proposed legislation for federal statutes occurs in congressional committees. Thus, committees have enormous power, for it is here where issues are discussed, debated, and negotiated. Legislation must move through and out of committee before legislation can get to the floor of the House or Senate for a vote. Constituents do play an important role in moving legislation through committees because they have the power to influence their legislators by contacting them through a variety of means and encouraging them to move or hold legislation. Attending public hearings as a speaker or as an observer, as well as attending in numbers at all levels (local, state, federal) can be strategic. Moreover, being at hearings provides an excellent opportunity to network with staff and other interested stakeholders. Exchanging contact information, discussing an issue, or commenting on presentations can lead to future opportunities. Building relationships is an invaluable task in policy making. Sharing an interest or assisting someone in policy-making duties will be greatly appreciated and could lead to future contacts and opportunities related to other issues. Federal hearing schedules are published in advance and can be viewed in the Federal Register. Tracking hearing schedules requires regular review of the Federal Register (www.federalregister.gov), committees’ and agencies’ websites, or local publications for schedule announcements. Typically, state governments also have established mechanisms to review hearing schedules and can be acquired by contacting your state legislator for assistance. State nurses associations often publish state h ­ earing schedules and identify nurse experts to deliver comments. Some associations have ­created databases of experts to provide critical presentations. It is not enough to just belong. Nurses must support and engage with their professional associations economically by paying dues and serving on committees and philosophically by contributing to white papers, accepting invitations for the delivery of public testimony, attending public hearings, contributing to PACs, and responding for requests for action.

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EXHIBIT 3.6  CONGRESSIONAL COMMITTEES FOR NURSING AND HEALTHCARE

ISSUES

SENATE

HOUSE OF REPRESENTATIVES

Appropriations Committee Controls the federal purse strings and determines federal funding for all government functions, from defense to biomedical research

Appropriations Committee Controls the federal purse strings and determines federal funding for all government functions, from defense to biomedical research

LHHS-Education Appropriations Subcommittee Determines federal funding for federal agencies, including the HHS, NIH, CDC, and HRSA, which administers the nursing workforce development programs

LHHS-Education Appropriations Subcommittee Determines federal funding for federal agencies, including the HHS, NIH, CDC, and HRSA, which administers the nursing workforce development programs

Health, Education, Labor, and Pensions Has jurisdiction over all non-Medicare and non-Medicaid healthcare policy issues

Energy and Commerce Committee and Its Health Subcommittee Has policy jurisdiction over the Medicaid program, Part B of the Medicare program, and all non-Medicare and non-Medicaid healthcare issues

Finance Committee and Its Health Care Subcommittee Has policy jurisdiction over Medicare and Medicaid

Ways and Means Committee and Its Health Subcommittee Has policy jurisdiction over the Medicare program (shares jurisdiction over certain parts of Medicare with the House Energy & Commerce Committee)

Committee on Veterans Affairs Provides oversight of U.S. veterans’ issues

Veterans Affairs Committee Has oversight responsibility and monitors and evaluates the operations of the VA

Special Committee on Aging Serves as a focal point for discussion and debate on matters relating to older Americans and reviews Medicare’s performance, pension coverage, and employment opportunities for older Americans CDC, Centers for Disease Control and Prevention; HHS, Health and Human Services; HRSA, Health Resources and Services Administration; LHHS, Labor, Health, and Human Service; NIH, National Institutes of Health; VA, Veterans Administration.

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Reaching Out to Policy Makers and Legislators Whether through Lobby Days sponsored by professional nurses associations, letter writing or meeting individually with representatives in the community, one of the most powerful ways to influence policy and navigate the political system is to get to know the legislator and staff responsible for representing the district that you live and vote in and to communicate with them regularly. Nurses initially may find meeting with their legislators an intimidating task, but legislators need to hear from their constituents. They need to understand the position of their constituents and are profoundly interested and invested in maintaining their legislative positions. Nurses who get to know legislators are powerful influencers of the political system. Generally, congressional visits are handled by staff who welcome information about issues of importance to their legislator. Staff and legislators alike are generally gracious and welcome the opportunity to speak to constituents. Exhibit 3.7 provides an overview of when nurses should make visits. One should investigate the legislator’s views on an issue prior to the visit. When visiting a legislator to ask for support, never leave without clarifying where the legislator stands on an issue. Always leave materials (e.g., a policy brief, fact sheet) for the staff to review (see Chapter 10). Exchange business cards and offer to be available to answer questions. When visiting a legislator, it is useful to have a compelling story that illustrates why the legislator should put resources into the issue, a story that will convince the legislator of the legitimacy of nursing’s position. Well-planned, well-articulated stories about how an issue affects a constituent are the keys to making a legislator understand. Stories, far more than statistics, grab a legislator’s attention (see Policy on the Scene 3.1). Visits are not the only way to communicate with a legislator; letter writing is powerful. With the widespread and mainstream use of electronic communication, it is no longer necessary to produce a physical letter; indeed, for a variety of reasons, letters sent to legislators through the mail may never be opened. However, communication in the form of an email, and the use of an association’s legislative communication tools can send powerful messages. Letters in support of or in opposition to legislation are categorized as such and counted so that legislators get a sense of their constituents’ positions. Professional associations often request that members send letters; these requests are also accompanied by sample letters or data to assist nurses with preparing letters. Letters must be professional, addressing the legislator by the correct title; focused; and polite and respectful. For example, legislation requiring RNs to obtain a baccalaureate degree in nursing within EXHIBIT 3.7  WHEN TO REACH OUT TO A LEGISLATOR • • • • • • • •

Introducing yourself as a constituent and as an RN Speaking on behalf of your professional association Offering your assistance as an expert on healthcare Presenting your positions on important legislative and policy issues Determining interest and potential support or opposition for an issue Requesting sponsorship or cosponsorship of a bill Seeking information on a legislator’s position on a bill Asking that a bill move from a committee to a floor vote/after a vote to the executive branch for signature • Thanking legislators for their support and work on behalf of issues important to a policy agenda

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POLICY ON THE SCENE 3.1: Framing a Message for Full Practice Authority for Nurse Practitioners The Honorable Gale Adcock, MSN, RN, FNP FAAN, FAANP North Carolina General Assembly, District 41 Nurse practitioners (NPs) routinely consider culture, language, and values when having important conversations with patients. However, we often fail to follow these same basic ground rules when our audience is a legislator instead. I see NP colleagues making communication blunders that I have been guilty of myself in the past: using technical jargon, getting emotional, offering obscure facts, and relying on a ream of research studies to make our case. I often hear NPs bitterly complain after legislative visits, “All the data and logic are behind us! Why do not they get it?” Sometimes, they do not get it because we use the same message, the same words, and the same context for every legislator regardless of who they are, what they do for a living and what experience they have had with our issues—and with us. I know effective NPs do not take this approach with patients. We understand in our clinical work that each patient is different, and we must change our style of talking to better match their style of listening and learning. NPs’ message becomes most effective when it can be related to what legislators already care about. We can learn to make our point—and make our message memorable—by using background knowledge plus the language and key concepts already familiar to them. Here is one example straight from my experience in the North Carolina House of Representatives. I use this knowledge, key concepts, and language to tell this story and make my points about full practice authority: • North Carolina spends a lot on public education—only healthcare ­expenditures top education expenditures. • Most of the state’s NP programs are part of the University of North Carolina (UNC) system, which is heavily subsidized by state funds. • Every legislator touts their support of education in their campaign and in their voting record. • North Carolina spends a lot on transportation, especially interstate highways. We have been referred to as “the good roads” state for decades. • North Carolina’s current legislative majority prides themselves on cutting government spending, lowering taxes, and giving taxpayers a good return on their investment (i.e., taxes). If the state of North Carolina spent $100 million to build a six-lane highway, would it make sense to you to have a state law that limits drivers to the use of only three lanes? Of course not. Subsidizing the education of hundreds of nurse practitioners who graduate from the UNC system and who are then restricted— by state law—from using every bit of their taxpayer-funded education to benefit North Carolina’s citizens is just like building that six-lane highway and wasting money on the three lanes that no one can use. Notice not one statistic or one study is mentioned. There is not a hint of emotion. Instead it is a story that resonates with the intended audience because their language and their values are paramount. It is a pithy and memorable story. And believe me, they get it.

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10 years of initial licensure was passed in New York’s Assembly and Senate (see Chapter 6’s Policy Challenge). While the bill awaited the governor’s signature, colleges, universities, and professional associations across the state encouraged nurses to write letters of support to the governor to demonstrate nursing’s commitment to this legislation. Nurses support for this legislation was communicated to Governor Andrew Cuomo who signed the bill into law on December 19, 2017. New York State is the first state in the nation to have such legislation. Nurses exerting influence on their legislators made the difference. Exerting policy influence can be accomplished not only by working with legislators, but also by working with other key stakeholders. It is essential that nurses network and seek mentors in a variety of settings. Professional associations are an excellent place to start this work. Many opportunities to engage in this process happen because nurses show up (see Policy on the Scene 3.2).

Additional Strategies for Influencing Policy Exerting influence requires a variety of approaches that yield a cumulative effect to achieve policy goals. These include, for example, capitalizing on opportunities presented by current events, seeking key positions, volunteering, and providing ­financial support.

POLICY ON THE SCENE 3.2: Saying Yes and Showing Up Susan Apold, PhD, ANP-BC, AGNP, FAAN, FAANP I have always found activism interesting. The fact that I live in a national where I am free to use my voice, whether in support of opposition to my government, is a cherished freedom, one that I know was hard won and one that I know requires constant vigilance. I watched with fascination during the protests of the 1960s and 1970s— protests against an unpopular war, protests against an unpopular president, protests demanding civil rights, protests demanding equal rights—so it is no surprise that by the time college came around, I was interested in participating in venues that supported social justice. I was taught by hippies who told us we were nursing leaders and nursing’s future. On graduation, we were given a free 6-month membership to the Pennsylvania State Nurses Association and the American Nurses Association. I was hooked on professional engagement through professional associations from the start of my career. I was interested, I volunteered for the legislation committee, and I showed up for a meeting. At that meeting, I learned a vital lesson: 75% of activism is being there! From then until now, I have been showing up. When presented with an opportunity to represent nursing and our patients, I have always said yes. Those yeses are the stuff of a career focus in policy. When there were no other interested candidates, I ran for office at the district level in the New York State Nurses Association; I showed up at meetings of the Nurse Practitioner Association New York State and served two terms as president and several terms on the Board of Directors. I showed up at American College of Nurse Practitioner meetings and served on that Board as well. At every yes, I met people who mentored me and connected me to more and more nurses committed to professional advocacy: people who taught me how to advocate in the halls of Congress and people who presented me with opportunities to sit on expert panels and bring nursing’s message to policy makers, legislators, and the public. Professional engagement requires only two ingredients: interest and showing up.

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Seizing the Moment With the Nursing Voice No one has a nursing perspective on healthcare except nurses (see Chapter 9). Nurses view healthcare through an authentically holistic framework, with a unique understanding of health and illness as it is lived and experienced by individuals, families, and communities every single day. Our values are clear to us as professionals and to a society who consistently views us as trustworthy and ethical. The nursing perspective on health, illness, people, and systems is essential to an improved healthcare system. Nursing historically has not been known for “speaking truth to power”1; however, it is no longer acceptable (it never has been acceptable) for nurses to remain silent or disengaged. Nurses must use every forum, political, social, educational, employment, and organizational, to speak about the issues and concerns of our profession and ourselves. Our voices, our knowledge and our experiences are valued. The development of a nursing voice is essential when articulating issues of concern to legislators and policy makers. Using this voice can be risky; it requires a measure of courage. On July 26, 2017, RN Alex Wubbels was discussing a blood-draw procedure with a police officer at the University Hospital in Salt Lake City. The officer, a member of the police department’s blood-draw team, had been sent to the hospital to draw blood for an alcohol level from the unconscious accident victim. Nurse Wubbels refused to allow the officer to draw blood, explaining hospital policy under which he could draw blood: patient consent, a warrant to obtain the blood, or an arrest of the victim. She explained “I’m just a nurse trying to protect a patient.” Nurse Wubbels was arrested for obstruction of justice. She was released 20 minutes later. Nurse Wubbels’s responsibilities were clear, the hospital policies were clear, and the law was clear. She used her voice to advocate for her patient. She released a video of the incident that sparked national outrage. Ms. Wubbels’s actions created a national conversation forcing examination of policies and procedures (www.sltrib.com/news/health/2017/09/04/on-today-nurse-alex-­wubbels-again-sayspolice-need-to-police-themselves-to-regain-trust). Often, as noted by Wubbels’s lawyer, these types of incidents do not have this corroboration. Nurses associations have seized the moment to draw attention to the violence that nurses and healthcare workers experience on the job. This is illustrated by ANA president Pam Cipriano’s statement to a national news reporter, “Nurses should not be subject to any kind of violence…we feel so strongly, particularly in this situation, where another type of worker who the public needs to trust acted in an unconscionable way” (Almendrala, 2017). Being an advocate is not easy. Nurse Wubbels states she waited to release the video until September because she needed to deal with it personally. She soon realized that it needed to be released to change policy. It exemplifies the importance of seizing the moment and strategically using a nursing voice. Registering, Voting, and Communicating With Elected Officials A vote is a unit of political power. A vote is the ultimate expression of support or opposition to a formalized set of values. In the United States, careers have been built, wars have been fought, and lives have been lost over the acquisition and exercise of this right. Even in the 21st century, our nation continues to engage in strategies and enact laws and regulations to ensure that every citizen has the unencumbered right to vote. Exercising the right to vote is one of the most influential actions a nurse—or any citizen—can perform. With rights come responsibilities. Registering to vote and then voting is a fundamental civic duty. Nurses can encourage their friends, families, and colleagues to vote. When nurses point out to legislators at the local, state, and federal levels that they are voting members of their constituency, legislators pay attention.

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Nurses have earned the respect of many and are in positions to influence others with their thoughtful ­comments and the power of their vote. Registering and voting help create credibility and influence beyond the poll booth. The central goal of all legislators is to obtain and then keep their office. When speaking or writing to a legislator, be sure to communicate that you are an RN and a voting constituent and state your role in nursing. Most important, your vote influences all branches of government. Votes elect legislators at the local, state, and federal levels who make the laws, and votes elect executives—the president, governor, and mayor, who make appointments to the executive branch, the implementer of laws and regulations, and to the judiciary, the evaluator of laws. Vote.

Volunteering to Work on a Campaign Nurses are welcome additions to political campaigns. Candidates need volunteers to make their campaigns effective. Campaign volunteerism can be as all-encompassing as full-time work or as brief as participating in telephone polls, posting signs, or getting out the vote. Volunteering provides first-hand experience about the political system. Nurse volunteers provide candidates, their staff, and others with valuable knowledge about nursing and healthcare. Working on political campaigns and educating candidates about issues can be invaluable in the long run. If elected, the candidate, now legislator, will remember your support during the campaign but more important, will be potentially influenced about issues discussed. Other activities related to navigating campaigns can be found in Chapter 7. Seeking Board Positions The report, The Future of Nursing: Leading Change Advancing Health (Committee on the RWJF Initiative on the Future of Nursing, 2011), was a game changer for the profession. Key messages of the report require that the profession look both out of the window to external forces that regulate the profession and in the mirror to identify the changes that nursing itself must make to stand as equal partners in the healthcare system and with credible voices in the healthcare policy conversations (see Exhibit 3.8). To ensure that the key messages are heard and the recommendations of the IOM report implemented, the RWJF and the AARP partnered to form the Center to Champion Nursing in America (CCNA). A major initiative that addresses developing nursing leadership and expanding nursing’s influence beyond the profession itself is the Nurses on Boards Coalition (NOBC, 2017). Organized in 2014 and composed of national nursing and other organizations, the NOBC is addresses one of the most challenging recommendations of the Report that nurses serve in critical decision-making roles on boards to improve health and patient care. The NOBC goal is to have 10,000 nurses serving on corporate and health-related boards, panels, and commissions by 2020. The coalition provides support to nurses seeking board positions. This support provides nurses with opportunities to influence healthcare beyond the profession and beyond healthcare venues by improving health and ­building healthier communities. Running for Office The ultimate influence on a system comes from within that system. Only three nurses have seats in the U.S. House of Representatives; there are no nurses serving in the U.S. Senate. Nurses do serve in their state legislatures. However, more nurses need to seek public office. Gale Adcock, FNP, has a long history of political office. More than 20 years

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EXHIBIT 3.8  KEY MESSAGES OF THE INSTITUTE FOR MEDICINE REPORT ON THE

FUTURE OF NURSING

• Nurses should practice to the full extent of their education and training. • Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. • Nurses should be full partners with physicians and other healthcare professionals in redesigning healthcare in the United States. • Effective workforce planning and policy making require better data collection and information infrastructure. Source: From Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press.

ago, she was a woman with a mission: to influence healthcare in her state through politics. She carefully planned her political career, engaged her community, and ultimately, sought and won office in local government (council member in Cary, North Carolina) and in state office as assemblywoman for the 41st North Carolina District. She is the only NP to have ever served in her state. Representative Adcock has introduced, sponsored, and cosponsored legislation running the gamut of the interests and needs of her constituency. Her very presence in the Assembly elevates nursing and gives voice to the possibilities that nurses offer the communities in which they live and work.

Contributing to a PAC PACs are groups that form around issues to support candidates who can represent those interests and influence legislation supportive of them (see Chapter 7). PACs provide financial support to candidates on both sides of the aisle who support issues important to nurses and patients. Campaigns are expensive. Advertisements, debates, and other strategies to reach out to a constituency cost money. When nurses contribute to a PAC, they are demonstrating their influence by providing financial support to candidates who support nursing.

OPPORTUNITIES TO INFLUENCE THE EXECUTIVE BRANCH OF GOVERNMENT The executive branches of federal and state governments are responsible for implementing laws and, consequently, oversee the agencies that are responsible for programs and services supported by legislation. Vast opportunities exist for nurses to influence the implementation of services and programs. All agencies need to hear from those with real infor­ mation, expertise, research, and stories about how it affects patients or their local areas.

Executive Orders Under the power granted in the U.S. Constitution, the president can issue executive orders to officials and federal agencies. Executive orders are instructions to government agencies and departments. Executive orders have the full authority under the law and may be made pursuant to certain congressional actions that explicitly delegate discretionary power to the agency and the president. Executive orders can significantly influence internal government operations and the focus of federal agencies, but they cannot

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reverse congressional legislation, and their scope is not as wide ranging as legislation; in essence, as an option, the president can issue executive orders that create policy where and when legislation fails or does not exist. Executive orders have been issued by every president since George Washington. Some presidents have been accused of abusing executive orders and using them to make laws without congressional approval or impacting existing laws from their original mandates. Like legislation and regulations, executive orders are subject to judicial review and may be struck down if deemed by the courts to be unsupported by statute or the Constitution. President Franklin D. Roosevelt had more than 3,500 executive orders, whereas recent presidents had fewer than 400 each. The entire listing of executive orders can be viewed online at the nonprofit, nonpartisan American Presidency Project (www.presidency.ucsb.edu).

Federal Agency Appointment Selection In any given presidential term, several thousand individuals are appointed. The United States Government Policy and Supporting Positions (2016) document, known as the Plum Book, lists more than 9,000 federal civil service support and leadership positions in the federal government that may be subject to noncompetitive appointment. Such positions include justices in federal courts, the presidential cabinet, members of boards, heads of agencies and their immediate subordinates, policy executives and advisors, and aides who report to these officials. As described in Chapter 11, the ANA and other nursing organizations can make recommendations for appointments to key policy positions in governmental agencies. As evident with recent presidents, nurses’ efforts were successful in lobbying for appointments. President Clinton appointed nurses to key senior leadership positions. Beverly Malone, PhD, RN, FAAN, was appointed to serve as a deputy assistant secretary for health within the U.S. Department of Health and Human Services (DHHS), whereas Virginia Trotter Betts, MSN, JD, RN, FAAN, was appointed a member of President Clinton’s HealthCare Reform Task Force, and senior advisor on Nursing and Policy to the secretary and assistant secretary in the DHHS. President Obama appointed Mary Wakefield, PhD, RN, FAAN, as administrator of the Health Resources & Services Administration (HRSA); Marilyn Tavenner, MHA, RN, as administrator of the CMS; and Linda S. Schwartz, PhD, RN, as Assistant Secretary of Veterans Affairs for Policy and Planning. At the state level, Karen Murphy, PhD, RN, for example, was Pennsylvania’s secretary of health. These individuals and other nurses who have been selected in presidential or gubernatorial appointment processes are in ideal positions to influence health policy.

OPPORTUNITIES TO INFLUENCE JUDICIAL ACTIONS The third governmental branch is the judicial system; it is less well known and less involved in the nursing profession’s policy efforts. Historically, the ANA has participated in U.S. Supreme Court proceedings with cases of broad implications and interest to the profession. Typically, these cases have dealt with nurses’ rights, workplace issues, and human rights issues involving individual patient rights and access to healthcare. At the federal judicial level, the Supreme Court is well known for its powers that include interpreting the Constitution and reviewing laws. Unlike the criminal court system, the Supreme Court usually does not hold trials but rather interprets the meaning of a law, decides whether a law is relevant to a set of facts, determines how a law

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should be applied, and most important, determines whether a law or regulation is ­permitted under the Constitution or is unconstitutional. The Supreme Court may hear an appeal from lower courts on any question of law, provided that it has jurisdiction. Once a decision is made, the lower courts are obligated to follow the precedent set by the Supreme Court when rendering decisions. The justices on the Supreme Court are appointed by the president of the United States and confirmed by the U.S. Senate. Justices in lower courts can be appointed or elected depending on the jurisdiction and purpose of the court. Unlike the legislative and executive branches, one’s ability to influence judicial decisions is greatly limited. The only opportunity to influence judicial decisions is prior to justices being elected or appointed. Many times, these elections or appointments do not receive the scrutiny that they deserve. Supporting and electing candidates running for judicial positions or judicial nominees is an acceptable mechanism to have potential justices that represent and align with your values and views. Lobbying justices or members of juries is considered inappropriate and would not be tolerated outside legal proceedings. It is critical that information advantageous to the situation be presented in testimony or legal briefs from the involved parties, as well as from amici curiae, or “friends of the court.” Amici curiae are most often advocacy groups, such as professional associations and unions, that file a brief known as an amicus brief to advocate for or against an interpretation of a law or regulation. Amicus briefs can introduce concerns or support about the broader implications and effects in the court rulings. Whether to admit the information is at the discretion of the court. In prominent cases, amicus briefs are generally provided by organizations with available content expertise, legal, and financial resources to produce strong documents that present convincing information and argument to support their position. Over the years, the ANA has filed several amicus briefs either as a single association or with others on common causes. For example, the ANA, American Association of Nurse Anesthetists, American Association of Nurse Practitioners, American College of Nurse-Midwives, National Association of Clinical Nurse Specialists, and Citizen Advocacy Center filed an amicus brief in support of the Federal Trade Commission’s rulings regarding restraint of trade and unfair competition (ANA, 2016). This brief was in support of nondentists’ provision of teeth-whitening services. The case is important because regulations related to other providers may set precedence for nursing practice. The Supreme Court ruling on the Federal Trade Commission (FTC) action in this case provides guidance on what constitutes a controlling number of decision makers who are active market participants for the occupation regulated by a board. The rulings were supportive of healthcare professionals’ ability to practice to the full extent of their professional education and training. The nature of the decision, in this instance, requires that nurses closely monitor state regulatory board actions. Although the judicial branch plays a significant role in making policy through the interpretation of laws and rules, they do not make the laws, nor do they have the power to enforce laws and rules. It is essential that legislation and rules that are clear, appropriate, constitutional, and respectful of rights be written up front to avoid long, lengthy legal challenges. An example is the situation in California, American Nurses Association v. Torlakson, which is further described along with other legal strategies in Chapter 6. This controversial ruling allows unlicensed personnel to administer insulin in the school system. Years later, the policy matter has not resolved. Various stakeholders with a complexity of interests remain engaged to find a better solution.

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OPTION FOR POLICY CHALLENGE: American Veterans’ Access to Care: Full Practice Authority for Nurse Practitioners, Clinical Nurse Specialists, and NurseMidwives in the Veterans Administration System Cindy Cooke Timing is everything. To maximize the potential of its nursing workforce to provide high-quality, accessible care, Kathy Rick, chief nurse of the Veterans Administration (VA), recognized the power of The Future of Nursing report (Committee on the RWJF Initiative on the Future of Nursing, 2011). Standardization of APRN practice through full practice authority (FPA) was identified as a strategy for improving care access. In 2013 Dr. Penny Kaye Jensen, DNP, FNP-BC, FAAN, FAANP, was detailed to the VA Office of Nursing Services in Washington, DC, to serve as the National Health Policy Liaison for the VHA and to the team from within the VA to mobilize this effort. A proposed rule was entered into the Federal Register on May 25, 2016, that invoked federal supremacy in the VA system to allow all APRNs to have FPA, regardless of the APRN’s state licensure. The nursing community and proponents and opponents of the rule responded. Organized nursing was ready for action and established relationships facilitated responses by organized nursing groups (e.g., ANA, American Association of Nurse Anesthetists [AANA], the American Association of Colleges of Nursing [AACN], and American Association of Nurse Practitioners [AANP]) facilitated rapid mobilization. These organizations met weekly, communicated daily, and focused all messaging on this issue during the 60-day response period. Communication was constant; unity was essential. Organized nursing, Dr. Jensen, and the IOM report were drivers in this initiative. Its success rested on the collective voices of individual nurses and those served: veterans and patients. The power of social media campaigns was leveraged and education was targeted to the public, veterans, Congress, and nurses, as the latter needed to hear and understand the message and the need for the rule. All were encouraged to call their legislators, and letter writing campaigns were established through nursing organization advocacy centers. Nurses were encouraged to attend town hall meetings and tele–town hall meetings were established to allow for increased numbers of voices to be heard on this issue. A public relations firm was retained to set up a website, “Veterans Deserve Care,” to reach out to veterans and people who care for them to provide information about the initiative. It was a 60-day media blitz. Over 65,000 letters were sent supporting this initiative. The final rule, published on December 14, 2016, allowed for FPA for nurse practitioners (NPs), certified nurse-midwives (CNMs), and clinical nurse specialists (CNSs) FPA within the VA system. As is often the case in policy making, even a win comes with disappointment. FPA for certified registered nurse anesthetists (CRNAs) was not changed. However, organized nursing remains unified in working to bring about FPA for CRNAs. Success depended on the (continued )

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implementation of a variety of strategies and engagement with almost all areas of government. Lessons learned included the following: • Professional unity is the lynchpin around which other efforts spin. • Frequent authentic communication is essential. • Partnerships within nursing are important but engaging patients and non-nurse stakeholders is even more important. • Education is essential because one cannot assume that stakeholders fully understand the initiative. • Timing is crucial. • Individual voices joined together strengthen and legitimize one strong message. It is all about the team; no one individual, organization, or societal sector can do it alone.

IMPLICATIONS FOR THE FUTURE Nurses cannot afford to be reticent about engagement in the political and policy-­making processes. Discussions and debates will continue to take place in our nation regarding the best way to implement healthcare that is high quality, affordable, and accessible to every citizen in our nation. Every decision made on Capitol Hill and in state legislatures throughout the nation touches the lives of nurses and our patients. As the single largest healthcare provider group in the world, it is nurses that must not only sit at the table where all healthcare conversations are held, but also lead the discussion. This cannot happen if nurses continue to profess to be apolitical or disinterested in politics. Nurses must be proactive to introduce new legislation or be at the table during the process of writing and revising regulations. Although nurses typically provide testimony on current issues pertinent to nursing practice, few nurses provide testimony reflecting the challenges faced by nurses in daily practice or on the larger issues related to healthcare policy. To be an influential voice in policy, more nurses must take on greater involvement in the political system. Nurses have multiple opportunities for involvement in policy and political action as debates about issues affecting health and healthcare come to the forefront of the public’s attention in the legislative and regulatory arena. The profession must embrace these opportunities to focus on issues such as the eliminating healthcare disparities, fostering a culture of health, providing care to the swelling ranks of veterans and the aging population, ensuring that children live lives as healthy or healthier than their parents, and pursuing the improvement of health through technology. Such opportunities are all central to the values of the profession of nursing. Legislative polarization at the national level, of necessity, drives legislative initiatives at the state level. This will create additional opportunities for savvy nurses to develop close relationships with their legislators to advance specific initiatives. Increasingly, consumer groups may take a judicial approach to advance policy, and these approaches may have an impact on health or how nursing is practiced. Consequently, nurses will need to partner with consumer groups and be aware of specific claims to provide their expertise in support or ­opposition to a particular issue.

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KEY CONCEPTS 1. There are numerous opportunities for nurses to be involved across a variety of policy strategies. 2. Passing legislation has many steps in which the nurses’ voice should and can be heard. 3. All types of legislation should be monitored, but any reauthorization can be an opportunity to improve existing legislation and implementation. 4. Nursing organizations play a significant role in promoting the voice of the profession of nursing at tables where healthcare is discussed. Membership in a professional association is crucial to the advancement of initiatives important to nurses and patients. 5. Rulemaking is a critical step after legislation has been passed and is an opportunity to influence legislation implementation. 6. Although not often recognized, action through judicial processes has been used by nurses associations. 7. The appointment and election of judges are crucial because the normal lobbying activities in the judicial processes would be considered inappropriate. 8. Executive orders and appointments can be effective mechanisms to create policies when legislation is not an option or likely to occur.

SUMMARY The range of contributions and impact that nurses can have in policy areas is limitless. Nurses have unique perspectives on the healthcare of individuals, families, and communities that are characterized by advocacy, trust, action, accountability, and authenticity. To fully actualize the voice of nurses, engagement with stakeholders and policy activity requires individual and organized action. Broadening policy action for nurses beyond letter writing include key strategies such as testimony at public hearings, legislative engagement with staff writing language for bills, and public comment on proposed technical rules following enactment of laws. These actions will amplify the nursing voice as an advocate for all.

LEARNING ACTIVITIES 1. Identify your local government leaders (e.g., mayor, councils, boards) and your legislative representatives at the state and federal governments. For three of these representatives, identify at least one position they have taken on a healthcare issue. 2. Identify one nursing issue that has been adjudicated in the state and federal court system. Discuss highlights of the decision and how it has impacted nursing. Are there ongoing efforts to appeal these decisions or refine legislation? 3. Locate testimony provided at the federal, state, or local level on an issue that is important to nurses or health in general. Critique the testimony. Identify what should be included to influence the opinions of the group holding the hearing. 4. Locate proposed rules and regulations pertaining to a nursing or health issue. Identify the appropriate mechanism for providing comments. Critique the proposed rules and regulations for their support of nursing and/or for the way that an important healthcare issue is addressed. 5. Plan strategies to successfully gain support for a policy proposal at a mock city council meeting.

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6. Prepare a 3-minute testimony that will be presented at a BON hearing regarding proposed nursing regulations that require an NCLEX® type of examination every 5 years for license renewal. 7. Develop a strategy for influencing an issue in a town hall or school board meeting. 8. Identify all departments and administrators in your state government that hold a responsibility and authority over matters of interest to the nursing profession. 9. Select one strategy identified in this chapter to influence politics. Identify how you can use that strategy within the next week to influence an issue important to nurses and patients. 10. Identify Executive Orders that impacted healthcare in the past 50 years and what was, or could have been, nursing responses

E-RESOURCES • American Nurses Association http://www.nursingworld.org • American Nurses Association. Congressional Testimony http://www.rnaction.org/site/PageNavigator/nstat_congressional_testimony • American Presidency Project www.americanpresidency.org • U.S. Congress https://congress.gov • Congressional Management Foundation http://www.congressfoundation.org • The U.S. Constitution https://www.whitehouse.gov/1600/constitution • Diffen: Federal vs. State Law https://www.diffen.com/difference/Federal_Law_vs_State_Law • Federal Register https://www.federalregister.gov • U.S. Government Accountability Office (GAO) http://www.gao.gov • Government Agencies and Elected Officials https://www.usa.gov • Government Publishing Office (GPO) https://www.gpo.gov • A Guide to the Rulemaking Process http://www.federalregister.gov/uploads/2011/01/the_rulemaking_process.pdf • Health Resources & Services Administration http://www.hrsa.gov • U.S. House of Representatives http://www.house.gov • How Our Laws Are Made How Our Laws Are Made—Learn about the Legislative Process https://www.congress.gov/resources/display/content/How+Our+Laws+Are+ Made+-+Learn+About+the+Legislative+Process • Judges as Policy-Makers http://www.youtube.com/watch?v=qhsO4L5LezU • The Legislative Process: Overview https://www.congress.gov/legislative-process

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• U.S. Library of Congress https://loc.gov • National Conference of State Legislatures http://www.ncsl.org • National Council of State Boards of Nursing: Contact Information https://www.ncsbn.org/contactbon.htm • U.S. Senate http://www.senate.gov • Tracking the United States Congress https://www.govtrack.us • U.S. Congress and Health Policy Tutorial http://kff.org/interactive/the-u-s-congress-and-health-policy-tutorial • White House http://www.whitehouse.gov

NOTE 1. Speaking truth to power refers to taking a stand and mobilizing societal action. It was a phrase popularized by Quakers in the 1950s with publication of their book with the same name. The phrase is also attributed to Bayard Rustin, a civil rights leader.

REFERENCES Almendrala, A. (2017, September 1). Nurses endure a shocking amount of violence on the job: Usually, though, it’s not at the hands of police officers. Huffington Post. Retrieved from https:// www.huffingtonpost.com/entry/nurses-violence-police_us_59a9c2f9e4b0dfaafcf07093 American Nurses Association. (n.d.) Agencies & regulations. Retrieved from https://www .­nursingworld.org/practice-policy/advocacy/federal/agencies-regulations/ American Nurses Association. (2010). Nursing’s social policy statement: The essence of the profession (2nd ed.). Silver Spring, MD: Author. American Nurses Association. (2012, February 7). ANA to Supreme Court: ‘Individual Mandate’ needed to make health care work. The American Nurse. Retrieved from http://www .­t heamericannurse.org/2012/02/07/ana-to-supreme-court-individual-mandate-needed-tomake-health-reform-work/ American Nurses Association. (2015). Issue Brief. North Carolina State Board of Dental Examiners v. FTC: Next steps for state action & for nurses. Retrieved from https://www.nursingworld .org/~4af030/globalassets/docs/ana/ethics/issue-brief-nc-db-v-ftc-2015-6-17--2.pdf Apold, S. (2008). The doctor of nursing practice: Looking back, moving forward. Journal for Nurse Practitioners, 4(2), 101–107. doi:10.1016/j.nurpra.2007.12.003 Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The Triple Aim: Care, health, and cost. Health Affairs, 27(3), 759–769. doi:10.1377/hlthaff.27.3.759 Bodenheimer, T., & Sinsky, C. (2014). From Triple to Quadruple Aim: Care of the patient requires care of the provider. Annals of Family of Medicine, 12(6), 573–576. doi:10.1370/afm.1713 Brenan, M. (2017, December 26). Nurses keep healthy lead as most honest, ethical profession. Gallup News. Retrieved from http://news.gallup.com/poll/224639/nurses-keep-healthy-lead-honestethical-profession.aspx Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Congress.gov. (n.d.). The legislative process. Retrieved from https://beta.congress.gov/content/­ legprocess/legislative-process-poster.jpg

100   UNIT I  MAKING THE CASE Des Jardin, K. (2001). Political involvement in nursing—Politics, ethics, and strategic action. AORN Journal, 74(5), 614–618, 621–622, 628–630. doi:10.1016/s0001-2092(06)61760-2 GovTrack. (n.d.). Statistics and historical comparisons. Retrieved from https://www.govtrack.us/ congress/bills/statistics Greiner, A. C., & Knebel, E. (Eds.). (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press. Kaiser Family Foundation. (2017, April). State health facts. Total number of professionally active nurses. Retrieved from https://www.kff.org/other/state-indicator/total-registered-nurses Khoury, C. M., Blizzard, R., Wright Moore, L., & Hassmiller, S. (2011). Nursing leadership from bedside to boardroom: A Gallup national survey of opinion leaders. Journal of Nursing Administration, 41(7–8), 299–305. doi:10.1097/NNA.0b013e3182250a0d Nurses on Boards Coalition. (2017). About: Our story. Retrieved from https://­nursesonboardscoalition .org/about Patzek, M. J. (2010). Understanding the DNP degree. American Nurse Today, 5(5), 49–50. Retrieved from https://www.americannursetoday.com/understanding-the-dnp-degree PEW Health Professions Commission. (1998). Competencies for the 21st century. San Francisco, CA: Author.

UNIT II

ANALYZING POLICY

FOUR

Identifying a Problem and Analyzing a Policy Issue Rebecca M. Patton Margarete L. Zalon Ruth Ludwick Problems are only opportunities in work clothes.—Henry J. Kaiser

OBJECTIVES 1. Discuss the critical nature of problem identification in the policy process. 2. Explore sources of problems for policy development in nursing. 3. Investigate resources that may be used to identify and refine policy problems. 4. Examine tools that can be used for the assessment of a nursing policy issue. 5. Demonstrate the use of a structured policy-analysis method to examine a policy issue in nursing or healthcare.

Reflect on the past week at work or school or on recent healthcare news at the local, state, or national level. Have you questioned a practice, were you with frustrated with a process that seemed cumbersome or out of date, or were you dismayed with a news about healthcare? Did any these seem to be at cross-purposes with the achievement of the Quadruple Aim of healthcare: (a) enhancing patient experience, (b) improving population health, (c) reducing costs, and (d) improving healthcare provider work life (Bodenheimer & Sinsky, 2014). Problems abound in today’s healthcare system. We, as nurses, observe and experience problems every day in our practice settings and communities. The problems we see most often relate to the patients under our care and the environments where we work and live. These problems, whether clinical, managerial, or environmental, require an alignment of the problem with a workable solution or solutions and favorable political conditions. This confluence of factors when aligned is often referred to as the opening of a window of opportunity (Kingdon, 2011). Solving challenging problems encountered in the healthcare arena requires an appreciation and recognition of the alignment of necessary variables that are prerequisite to opening a window of opportunity.

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Without this appreciation and skill, it is likely that any expenditure of time, resources, and energy may not yield the desired policy change. Not all problems are created equal and not all problems lend themselves to a policy solution. It is easy to become frustrated with problem identification and policy analysis. Once a problem is identified, the next step is to analyze the related policy issues to identify options and determine the best solution. However, beginning to make sustained contributions to improving healthcare requires the necessary skill of being able to define the problem. Once the problem is defined, the process to be pursued in tackling a policy issue can be determined (see Chapter 6), and frustration can move to activation. The Policy Challenge illustrates the importance of being careful with language as a very necessary beginning step in identifying a policy issue.

POLICY CHALLENGE: The Words We Use in Identifying a Policy Issue Words matter. As professionals, we exert extreme caution to use words, terminology that will have universal meaning and understanding. Nurse educators instruct students on proper terms to use to describe patients’ assessments and conditions. Subjective terms are vague and can be meaningless in the electronic healthcare record. “Respirations and heart rate were fast after the respiratory treatment.” What does that mean and what is the value knowing that the respirations and heart rate were fast? The word “fast” in this description will be interpreted differently by different people. The distinction between the best description and almost best can have life and death consequences. Similarly, words and language used when advocating and then writing policy can have multiple meanings and subsequent consequences. Words are interpreted through the prism of each person’s understanding, which often can be unique. The profession struggled to find quantifiable measures to capture crucial aspects of patient care demonstrating nursing’s impact. The American Nurses Association (ANA) in the 1990s provided leadership to define nurse-sensitive indicators that became the foundation for the National Database of Nurse Quality Indicators (NDNQI). The ANA conducted a multiphase project called Nursing’s Safety and Quality Initiative that initially established definitions to best describe nurse-sensitive indicators. Today, these indicators are used around the world in healthcare settings to measure the quality of patient care, the impact on patient safety, and nurses’ work environments. This work provides unique, significant value in evidence-based healthcare report cards and has been used to show how nursing interventions can be used to direct change and improve indicator scores. Without clear, consistent terms, NDNQI would not have had as much impact on patient care and safety. Words matter, and it is important to get them right. As a society, we are witnessing an assault on word usage. An issue in the ­discussion of “fake news” is the choice and interpretation of words. It was reported in multiple mainstream media sources that staff at the Centers for Disease Control and Prevention (CDC) were directed not to use the words: vulnerable, entitlement, (continued )

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diversity, transgender, fetus, evidence-based, and science-based in budget documents. The immediate public reaction was swift, loud, and united. These reactions highlighted the significance that these words have in healthcare and policy discussions. Some accused the administration of limiting words that have long been used and questioned the motivation behind such repeated action. Others within the healthcare and scientific community called the action dangerous and offensive to the science. Within days of the announcement and the evolving public outcry, CDC director Dr. Brenda Fitzgerald tweeted that no words were banned. Words can be life altering. Understanding words and their usage avoids confusion and delay in addressing issues. When drafting and implementing policies, how issues are described and framed is crucial. Misunderstood policy can be dysfunctional or can have unintended consequences. As a profession, our language and words have not always been clear and supportive of nurses’ unique roles and contributions. See Option for Policy Challenge

PROBLEM IDENTIFICATION: MORE THAN MEETS THE EYE Effectively addressing the most challenging problems in the strongest and most efficient manner requires thoughtful preparation that includes systematic examination of the problem and collection of relevant data (including policies, which can then be integrated into a policy analysis). Once this preparation is completed, it is then possible to think about the problem more clearly and determine the appropriate course of action. Patient falls, a common issue across all settings, illustrate how problem identification can unfold. If a patient falls on a cardiac unit, for example, it is considered as an adverse event. Responding by helping the patient back to bed is appropriate, but nothing has been done to prevent future patient falls. If a nurse attends to the fallen patient and then proceeds to collect data by studying the number of falls on the unit during the past month, the age of the patients who have fallen, and the time of day or night during which most falls have taken place, then data can be used to identify patterns. Patterns can be found when analyzing fall risk data. These data might reveal, for example, that more falls take place in the early evening, when staff are taking breaks. After examining the data, the schedule might be adjusted to provide better coverage during that time. On the other hand, the solution might end with the using a new fall risk assessment tool without exploring strategies to reduce falls or serious injuries from them. Instituting policies on breaks or using a new fall risk tool will not necessarily fix the problem. Many nurses have observed a problem being tackled like this and the resultant application of a wrong solution. Then nurses are frustrated because they have extra tasks that did not solve the problem. Now, suppose the lens is widened to examine what is happening in relation to falls on other units in the hospital and other settings. This requires examining existing patient safety standards and policies, the number of patient and family complaints, modifiable risk factors, and what other hospitals in the area are doing. The search may be expanded to include both national and international data (see Chapter 13) for b ­ enchmarking

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against other healthcare systems. These data provide more information about the size and impact of the problem and the data required for the next steps. An interprofessional task force could be formed to analyze the data, collect additional information, and make recommendations for possible short-term solutions, which could eventually be applied more globally. Follow-up evaluations may generate long-term solutions or may indicate that new patient safety policies need to be developed and implemented. Examining a particular problem beyond a single incident can offer a broader perspective that helps one see events, as well as patterns. Both help answer these critical questions: When does a problem become more than an isolated event, and when does solving a problem become a policy issue that requires time, effort, and resources necessary for a successful resolution? The example regarding the number of patient falls shows a common local organizational policy change, but healthcare policy occurs at all levels throughout the healthcare system. Seldom is a problem solved with a single policy solution. When examining a problem, the nurse should start at the local level with policies and regulations designed to meet goals and allocate resources to accomplish the work at the unit level or, more broadly, to meet the organization’s mission and purpose. There are also policies that govern healthcare at the community-wide level, at the state level, and, finally, at the national level, where policy decisions can impact large segments of the U.S. healthcare system. Introducing a new healthcare policy or modifying an existing policy is a challenging endeavor that does not happen in a vacuum and is not the work of one individual. It takes more than an idea to move a proposal through the policy process. It takes resources, energy, persistence, patience, time, and the ability to compromise to achieve the desired results. Policy changes at the national level to address problems typically begin with a vision. This vision may have its genesis in an individual or a group of dedicated individuals concerned about something observed or experienced in the environment. Trends identified in the larger healthcare environment may also generate ideas related to the anticipated need for increased resources to meet national healthcare goals. Rich complex exemplars of problems in nursing are found in the daily practice of frontline clinicians. Common sources of problems also include those related to practice barriers such as admitting privileges, credentialing, prescriptive authority, and reimbursement for advanced practice registered nurses (APRNs). Research is conducted from a need to address a problem, and its results can provide further understanding and direction for policy.

OPENING A WINDOW: ELEMENTS FOR SUCCESS The policy-making process is complex and cyclical and takes knowledge, relationships, human and fiscal resources, and a willingness to negotiate and compromise to reach one’s vision and goal. Changing policy at the macrolevel, or the big “P” level, requires one to understand that change is an incremental process requiring stamina and patience while always keeping the long-term goal in sight. Even at the little “p” level, the process can be slow because change is often hard work, no matter at what level it occurs (see Chapter 8). If the problem is within a hospital setting, it could be that a simple change can be made at the unit level, or perhaps a new hospital-wide policy must be implemented. At the big “P” level, the change might require drafting legislation with the goal of creating a new law or adding language to clarify an existing regulation. The eventual

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success or failure of any of these policies depends on the political environment in place at the time the change is proposed. Thus, within complex environments, how does an issue come to the forefront? How does one recognize that a problem exists? A problem often gets noted when it is repeated, identified as wicked, associated with uncertainty, creates discomfort, or has undesirable consequences. A strategy for success for dealing with the problem in policy making is capitalizing on the window of opportunity. Kingdon (2011), who is often cited for his work, identifies three streams that come together for capitalizing on a window of opportunity: (a) problem definition, (b) availability of realistic policy solutions, and (c) political motivation to create the movement necessary for action.

Problem Identification Problem identification is a crucial and basic, but often complex, stage of the policymaking process. It often not only involves clearly identifying the problem, as well as identifying related policies that are needed or existing policies that are problematic, but also involves determining how aware the public is of the problem and the surrounding issues, deciding who will participate in fixing it, and considering what means are available to accomplish a solution. The answer to these deliberations helps determine which, if any, policy changes are requisite to address the identified problem or if an existing policy needs to be changed or eliminated. Initially, the process for problem identification may involve discussions with key individuals, or it may be done as part of a group process. Identifying a problem and then clearly defining it are not only critical to making a problem known, but also essential to having the right people at the table (stakeholders) and to forming a policy solution. Problem identification is a necessary component for all policy work and is often embedded in agenda setting (see Chapter 6). It is not, however, a simple step. Although often discussed as part of agenda setting, problem identification is examined as a necessary skill in detail in this chapter because a poorly defined problem, at minimum, wastes time and resources. A poor definition can lead to innumerable harms such as disengaged nurses, loss of the window of opportunity, and/or failure to change policy. Albert Einstein captures the importance of clearly thinking about the problem and identifying it, “If I had an hour to solve a problem I’d spend 55 minutes thinking about the problem and 5 minutes thinking about solutions.” Nurses know firsthand that there are times when even defining a single patient problem or clearly stating an evidence-based question can be difficult. Problem identification in policy work is no less complex. As nurses working in a range of settings, problems in the little “p” arena can involve not only clinical problems, but also a variety of issues, depending on settings and/or roles (e.g., educational, managerial, and workplace problems). Policy problem identification, like in patient care work, may be further  complicated when intraprofessional and interprofessional collaboration are involved. To begin clarifying the problem, nurses should start by making a short statement about what the best situation is compared to what is current; nurses should also describe the consequences if the situation is not corrected. Clarity and conciseness are the watchwords of problem identification. Problem identification might start with writing down the current state (e.g., falls are increasing, restraint use has resulted in a complaint, and nurses are verbalizing that there is not enough time to

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complete tasks). It is not important at this juncture to worry about precise wording because clarification and refinement occur later in the process. The point is to ­commit to an issue and to get something in writing so that you and others can react to it. Sometimes, it is easier to start with the goal or a description of the best or ideal situation. Thus, another way to start may be to write that the ideal is “zero falls,” “a restraint-free environment,” “improved nurse satisfaction scores,” or “provision of access to care for a vulnerable population in a rural area.” Then the nurse lists the consequences that may result if the current situation is not changed. The current and possible future effects of the problem should be considered. Often, at the little “p” level, consequences impact patients, the nurses’ work environment, or both. The problem statement should be two or three sentences long. Once these components are drafted, it is easier to refine them and to get help and feedback. Policy is a team “sport” that requires input from a group of people. Nurses are crucial to identifying problems. Problems come to the attention of nurses in various ways. Every day, nurses have numerous opportunities to observe problems resulting from contact with patients while delivering care, experiences with  ­equipment, and the centrality of patient safety and quality to nurses’ work. Sometimes, the problem seems obvious. An event happens that has an impact on a clinician. The event may be at the little “p” level while caring for a patient or working with a colleague. A patient fall or a readmission of an elderly clinic patient might be an example of how a problem comes to one’s attention. Often, nurses are so embroiled in day-to-day work that they fail to see problems that have policy implications. For example, when nurses repeatedly work around established safety procedures, it is indicative of a process in the system of care that is not working. Sometimes, the ­problem is one that arises from the big “P” arena. Large-scale disasters are an e­ xample of one way that big “P” problems can come to attention. See Exhibit 4.1 for guidance in identifying policy problems. Once a problem is reasonably stated, it is important to carefully explore its nature and identify the right policy issue associated with it. A common mistake is to assume that the lack of adherence to established procedures requires an educational solution. Consider what can be done about the problem and who has the responsibility and authority to address the problem as a policy issue. For example, hand hygiene adherence is a perennial problem. Although strategies for increasing adherence to hand hygiene guidelines were tried for many years, it was not until the workflow (in relation to the existing guidelines and new research) was carefully examined by infection-­ control experts that the CDC guidelines were updated (CDC, 2002). Setting the agenda to focus on the right policy is discussed more thoroughly in Chapter 6 but deserves some caveats here. Although defining the problem is necessary to determine who has the responsibility and authority to address the problem and the policy that follows, not all problems require policy and not all policy needs input from nursing (see Chapters 8 and 11). The effort of moving a problem from its definition to determining what can be done about it and who is responsible is a dynamic iterative process. In analyzing the problem of postpartum depression, Selix et al. (2017) identified a number of issues: (a) lack of consistency in screening policies, (b) poor care coordination between primary care and mental health services, (c) inadequate community education, (d) stigma, and (e) inadequate use of research and technology. Each of these issues can be addressed through a variety of policy options that includes interdisciplinary collaboration of stakeholders from different practice settings.

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EXHIBIT 4.1  ACTIONS FOR IDENTIFYING LITTLE “p” PROBLEMS Reflect about the work environment: • • • • • • • •

Identify complaints about daily routines and procedures. Observe colleagues interacting with one another about an issue. Consider workflow breakdowns. Review and write about a work-related critical incident. Attend presentations about successful work changes. Review nurse satisfaction surveys. Examine exit interviews. Participate in meetings where issues related to the problem can be raised.

Reflect about a clinical issue: • Examine the most common patient complaints. • Observe patients and families affected by the problem and their responses. • Review the newest treatments for the most commonly encountered clinical problems. • Monitor for new accreditation requirements and recommendations. • Visualize going through patient experiences (e.g., admissions, treatments). • Review unusual and unplanned clinical events.

Often, many problems that are of concern to nurses and nursing can be framed in numerous ways. The nursing shortage may be cast as an issue of recruitment and retention, an aging workforce, job dissatisfaction, increased demand, faculty shortage, or a combination of these factors. APRNs may wish to frame issues in terms of access to care, quality, cost, or practice barriers. As the problem is refined and discussed more widely, words matter. As noted in this chapter’s Policy Challenge, language can be an issue of framing (e.g., whether nursing shortage or nurse shortage is used). How the problem is framed can be instrumental in providing direction for a policy solution. The Patient Protection and Affordable Care Act (ACA) of 2010 is a complex piece of legislation that will be debated for many years to come, much like Medicare legislation introduced in 1965 is still being debated. Policy solutions of this magnitude often result in debate from many perspectives, including the identification or definition of the problem at the time of the policy’s development. After enactment, questions will be raised about whether the definition of the problem remains relevant over time or was originally well identified. Medicare and the ACA are examples of legislation designed to address the problem of healthcare financing. Framing the problem of healthcare reform as an issue of healthcare financing is a less controversial or more neutral approach to opening the discussion of the problem. This is an example where the choice of words matters. Although analysis of healthcare financing legislation is beyond the scope of this chapter, it is relevant in demonstrating how nursing can play a role in problem identification. The American Nurses Association (ANA) backed both the enactment of Medicare legislation in 1965 and, more recently, the ACA. Since 1958, the ANA, in particular, has identified healthcare financing as an issue (Woods, 1996). The ANA website contains numerous resources related to healthcare financing. A problem becomes a policy issue when there is a lack of policy to address it or there is an existing policy that does not effectively address the problem. Developing or modifying

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a policy assumes that some collective good will result and that codifying actions will lead to better patterns of behavior or improved conditions; if not, then the problem is not likely to be “fixed” by policy. Unfortunately, the wrong policy solution may be applied to a particularly vexing problem, yielding unintended consequences. Being involved on the ground floor of problem identification can go a long way toward the development of more effective policy solutions. This is illustrated by the process used to enhance the ability of new graduates to recognize patient deterioration in Policy on the Scene in 4.1.

POLICY ON THE SCENE 4.1: Identifying and Quantifying Preparation for Practice Joan Kavanagh, MSN, RN, NEA-BC Associate Chief Nursing Officer, Nursing Education and Professional Development, Cleveland Clinic Health System, Cleveland, Ohio Christine Szweda, MS, BSN, RN Senior Director Operations, Nursing Education and Professional Development, Cleveland Clinic Health System, Cleveland, Ohio Nurses have a responsibility to serve as advocates for the health and well-being of our patients, but that effort is jeopardized by a growing preparation-to-practice gap (Kavanagh & Szweda, 2017). Amid an impending nursing shortage and calls to educate a more diverse nursing workforce representing the multicultural patient populations we serve, academic programs and service partners are increasingly under pressure to understand the variables impacting student success because, ultimately, those students become new graduate registered nurses (NGRNs) who provide essential patient care in the form of surveillance, education, and advocacy. During the past 8 years, our global health system continued to grow in capacity, as well as patient acuity. As a result, a large number of NGRNs had been hired annually for newly created positions or vacancies. High-volume aggregate data from assessments of NGRNs contributed to validating, quantifying, and piloting solutions to address the widely recognized problem of NGRN readiness in our system. In 2010, as the first step in problem identification/clarification, we advocated for and implemented a vendor product that assesses competencies associated with NRGN clinical judgement. These competencies included patient problem recognition and management of the patient problem, as well as differentiation of urgency. More than 6,000 assessments were completed between 2010 and 2017, with year-to-year consistency in the results. For example, 23% of NGRNs were unable to demonstrate recognition of a change in a patient condition or level of urgency a majority of the time; another 54% could recognize a change in patient condition and level of urgency but were unable to demonstrate problem management in its entirety (Kavanagh & Szweda, 2017). We used the data to stratify NGRNs by their unique opportunities for growth and developed programs that would target and support each nurse’s specific (continued )

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learning needs. This led to the launch of a competency-based nurse residency program and the development of a patient problem–identification workshop focused on recognizing change in patient conditions and levels of urgency. The 1-week immersive workshop fosters nurses’ ability to assess the bigger picture of patient history, patient presentation, and clinical data, as well as develop clinical judgment, so that the urgency of a patient situation is recognized and appropriately escalated. It includes clinical experience, simulation, and facilitated discussion and has an almost 99% success rate in teaching new graduates patterns of critical thinking that can serve as a guide to safe practice. Working side by side with our academic partners is crucial. We share NGRN competency information and our strategies to support NGRNs with our local nursing schools. Academic nursing faculty generously shares their expertise in teaching and facilitating learning. Together, we can mitigate the preparation-topractice gap and promote a more inclusive broader-based dialogue to support patient safety, quality outcomes, and the success of our NGRNs.

Problem identification takes refinement and, often, ongoing rework. Once preliminary ideas are committed to writing, the next step is seizing the window of opportunity for policy. A key action is the formation of a stakeholder work group (see Chapter 6). At first, these groups are often composed of interested individuals who can help you further refine the problem. In all likelihood, the formation of a working group will result in some modification of the problem definition. As with any problem solving, the process is not static or linear, and group efforts often lead to better outcomes.

Formation of a Core Working Group Who are the interested in parties willing and able to invest in the work of moving a problem/issue through the policy process? Who are the stakeholders or interested parties who will likely oppose your ideas? These are the stakeholders who may have their own solutions to propose, or they may be satisfied with the status quo (see Chapter 6). A working group facilitates progress on the three streams identified as part of the impetus to create windows of opportunity. It helps refine the identification of the problem, examine the practicalities of policy alternatives, and identify the political realities in creating a change. When dealing with changes in healthcare policy, representatives of nursing organizations, physician groups, employers, consumers, hospital organizations, and other coalition groups are all possible participants. These are the identifiable stakeholders who may or may not benefit from a change in the status quo. Formation of a core working group of supportive stakeholders typically takes place at the organization or the coalition level. Participation, commitment, and support by recognized organizations at this level add credibility, expertise, and resources as efforts move forward. At this early policy development stage, nurses associations need and frequently seek out member volunteers with appropriate expertise to serve on these types of policy groups. Opportunities for participation as part of this type of core group may be one of the most desirable direct benefits of membership because it provides unique opportunities for active engagement in the problem-identification and policy agenda–setting phase.

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Committees, councils, task forces, subcommittees, and boards are examples of groups wherein policy is often born (i.e., defined) and solutions identified. Membership in these groups can be voluntary, appointed, or elected. Some groups such as boards and/or policy committees are understood to have overt or frank policy r­ esponsibilities; in reality, however, most formal group efforts at the little “p” and the big “P” levels involve some policy work. A recent approach to involving patients as key stakeholders in their care is the development of patient advisory councils. These councils may serve a department or a hospital and provide feedback on services, programs, and policy. This type of a council can be instrumental in defining problems and then subsequently helping determine solutions. This is not unlike the approach used in participatory action research in which key stakeholders drawn from the community of interest participate and are actively engaged in advancing knowledge. As the core working group for any policy, the initial task is defining and clarifying the problem to be addressed. This step also includes accurate documentation of events surrounding the problem and patterns of occurrence. What is the history associated with this problem? Has it been addressed previously? What was the response? Does this problem meet the criteria for a policy solution? Then possible solutions are identified and the final projected desired outcomes determined. Have all alternative solutions been considered? Are all the internal stakeholders on the same page regarding perceptions of how the problem should be defined and what the desired outcomes are? Are there acceptable and agreeable compromises that could be negotiated? These types of answers often come from group work, especially for major problems. Numerous groups and panels have helped identify healthcare problems. One example is the report by Surgeon General Luther Terry, whose office issued the first Surgeon General Report on Smoking and Health in 1964 (U.S. Department of Health, Education, and Welfare, 1964). This example is mentioned not merely because of its longevity and because it demonstrates the level of formality that a work group can encompass. Since 1964, there have been more than 50 Surgeon General reports. About half were about smoking because the Public Health Cigarette Smoking Act of 1969 (a legislative response to the 1964 report) mandated an annual review of research on smoking. These formal work groups varied with the project and the surgeon general, but they illustrate the central role of a group work in policy processes. It also shows that it is often not the work of one group, but sometimes many groups, especially when the problem is so widespread and embedded in society. Although nurses were not consulted in the first Surgeon General report, this has changed over the years. April Roeseler, MSPH, RN, chief, California Tobacco Control Program of the California Department of Public health was a contributing author to the Surgeon General’s report, E-Cigarette Use Among Youth and Young Adults (U.S. Department of Health and Human Services, 2016). Many professional and specialty nursing associations have opportunities for group work on policy-related matters, as outlined in Chapter 7. These groups may have standing committees or task forces to work on policy matters. The ANA, for example, always revises its scope and nursing practice standards with members in a group format. The APRN Consensus Model is another example of group work in identifying a problem and proposing solutions that have far-reaching implications for removing practice barriers (APRN Consensus, 2008). The removal of scope-ofpractice barriers has the potential to increase primary care capacity, expand access

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to healthcare (particularly in rural and vulnerable populations), and facilitate the delivery of high-quality, c­ omprehensive healthcare that is efficient and cost-effective (Bosse et al., 2017; Xue, Ye, Brewer, & Spetz, 2016). Bringing key stakeholders together takes time and depends on having and sustaining long-standing relationships. A broad range of viewpoints is essential in identifying policy issues. Sometimes policy conferences are held to take advantage of a window of opportunity presented by heightened interest in an issue that has received increased publicity (e.g., disaster planning, violence). In the aftermath of Hurricane Katrina, it was widely recognized that more effective disaster planning was needed. The ANA hosted a policy conference on disaster planning, bringing together experts and clinicians, including those who had direct experience with responding to Hurricane Katrina. One outcome of the conference was a seminal national policy paper, Adapting Standards of Care Under Extreme Conditions (ANA, 2008).

TOOLS FOR ASSESSMENT To effectively plan for policy and fully take advantage of a window of opportunity requires data about the environment and the contextual factors impacting the situation. A variety of methods can be used for assessment of these factors: environmental scanning; a political, economic, sociocultural, technological (PEST) analysis; a strengths, weaknesses, opportunities, and threats (SWOT) analysis; and a scenario analysis to name a few. Often, an environmental scan is conducted through an analysis of the SWOT associated with an issue. It is a necessary step in identifying a problem.

Environmental Scan Part of the preparatory work essential in identifying a problem with a policy solution is conducting an environmental scan of external and internal factors related to a particular problem/issue. An environmental scan is a systematic way of examining an issue within the context of current events and situations. Environmental scans are commonplace in all planning across settings, from business to education to healthcare. The setting and purpose help define the environmental scan carried out. Environmental scans can be used for a variety of reasons: to assess clinical issues, the adoption of clinical guidelines, or the climate for legislative or regulatory policies. Such a scan was conducted to assess the climate for the implementation of early mobilization guidelines in intensive care units across the United States to determine readiness to adopt early mobilization, current practices, as well as barriers to early mobilization (Bakhru, Wiebe, McWilliams, Spuhler, & Schweikert, 2015). The National Council of State Boards of Nursing (2017) conducts an annual environmental scan that covers the current state of nursing, the regulatory environment, innovations in healthcare, technology, politics, and society, with a goal of outlining issues faced by regulators to address change and ensure safety. The American Hospital Association (AHA), also regularly publishes an annual environmental scan, which focuses on market forces impacting healthcare (AHA, 2018). The CDC conducts environmental scans for selected public health problems. as illustrated by a scan of initiatives that incorporate the social determinants in public health (Koo, O’Carroll, Harris, & DeSalvo, 2016).

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Healthcare policies do not exist in isolation, so taking the necessary time to ­conduct and analyze an environmental scan can pay off by identifying both positive and negative factors, that may impact the problem. The scan should also consider the following: the stakeholders involved and the resources available, which of these factors will or will not influence the successful outcome, which factors can be influenced, and which factors are outside your scope of influence. The results of the scan and analysis of those results should help identify important trends and events in the larger external environment, which provide a basis for developing strategies to move the issue toward the policy agenda. Environmental scanning is typically conducted through a group process. The stakeholder group proposing a legislative solution to an identified problem may form a small task force or an ad hoc committee to carry out the environmental scan or, depending on available resources, may hire an outside consultant to do this important work. There are no hard and fast rules for conducting an environmental scan, and it is only one component of an external analysis. The environmental scan can be informal and mainly observational and can consist of identifying and gathering existing information, or it can take on a more formal aspect in which new data are collected through surveys or other research methods. Information may be gathered through review of relevant publications; media resources; Internet sites; statements or opinions by social critics, experts, and activists’ and other existing data. Although determining what is important to scan or examine is usually specific to the problem being addressed, there are some common methods and considerations to help organize the environmental scan. It usually starts with an internal scan to identify the strengths within one’s own interest group or organization that can be leveraged to advantage efforts and also to identify any weaknesses associated with the group that will need adaptation or neutralization as the group moves the issue through the legislative process. This internal scan, discussed in more detail later in this chapter, is often examined using a SWOT analysis.

PEST Analysis One type of analysis that can be used for assessment focuses on the environment from the perspective of politics, economics, sociocultural changes, and technology, or a PEST analysis. The PEST analysis helps to more fully explore external factors. The following provides examples of things to be considered in conducting a PEST analysis for a policy issue: • Political environment: What is the current legislative climate? Is there political will to address the issue? Do major changes to laws and/or regulations impact the issue, the group, or the organization? Has the issue been successfully addressed in other jurisdictions? • Economic environment: What are the critical economic factors influencing the issue: costs, reimbursement, market influences? Will the general economic climate influence the policy direction for the issue? Are there legitimate financial constraints? • Sociocultural environment: Do unique demographic trends or changes affect the community of interest for the issue? How are underserved and/or vulnerable populations impacted by the policy? What are related ethical considerations for the issue?

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• Technological environment: Is there a technological component to the issue? How does technology impact delivery of care if it is a clinical issue or the knowledge, skills, and talents of nurses if it is a workforce issue? How might social media impact development and dissemination of information about the issue? In some circumstances, legal and environmental factors also need to be examined; hence, PEST is sometimes referred to as PESTLE. Understanding these dimensions in the environment is essential to anticipating opportunities, as well as constraints, and helps individuals and groups design more effective policies. Exhibit 4.2 provides some preliminary questions to consider when exploring the political environment in greater depth before executing a strategic plan to advance an issue. These questions are often thought to relate to public policy, but in reality, they have applicability to all policy. The political aspects of the environment quite often get the most attention when examining an issue in depth. After data collection for each of the selected environmental sectors, some analysis is necessary to assess the external opportunities and threats. Information gathered should be shared with the larger working group. Activities in some identified sectors may need to be tracked over time to monitor changes in the environment and to clarify

EXHIBIT 4.2  CONSIDERATIONS WHEN SCANNING THE POLITICAL ENVIRONMENT Determine leadership

• Assess who has the ability or desire to lead the policy change. • Recognize what individual or group has the capacity, expertise, reputation, and established relationships. • Determine if this is an interprofessional issue.

Consider • Anticipate how stakeholders will be impacted. relationships/ • Determine stakeholders’ engagement with each other. reputation • Determine stakeholders’ level of support and/or opposition for the issue. Identify possible stakeholders

• Assess what organizations or groups have a vested interest in the issue. • Identify who will be impacted whether status quo is maintained or a change is implemented. • Determine who supports, does not support or is noncommittal.

Examine relationships

• Assess whether a relationship exists between the groups and identified stakeholders. • Evaluate if the group leading the policy forward is viewed as credible and speaking for all involved. • Review groups with strong policy influence who may support or oppose the policy. • Determine if any group participates in a coalition that could be built upon. (continued )

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EXHIBIT 4.2  CONSIDERATIONS WHEN SCANNING THE POLITICAL ENVIRONMENT

(continued )

Define and assess adequacy of resources needed to advance an issue

• Identify resources needed to help clarify the problem, especially those who can or would “carry the water.” • Human: in terms of staff, contract lobbyist (if appropriate), and volunteers. • Financial: depending upon the campaign needed, do you have a political action committee (PAC)? • Physical: such as a grassroots system. If not, with what groups can the association partner?

Consider timing: determine if a history is associated with the issue/ initiative

• Investigate whether the issue had been addressed previously and by whom. • What was the response? • If not favorable, what were the barriers? • How much time has elapsed since last attempted? • Analyze unintended consequences of the timing. • Plan for the best time to act.

Identify bases • Which party dominates in the legislative/executive branch of power leadership or faction in little “p” efforts? • Are power changes expected, e.g., election year, new administration? • Are there powerful committee chairpersons acting as gatekeepers for the issue? Determine relevancy

• Anticipate if the issue will be reflected in an agenda, e.g., the legislature’s or regulatory agency’s agenda. • Determine the possible competing policy issues. • Identify the level of public awareness. Has the issue been in the news? • Identify what will influence relevancy. • Assess if this initiative costs money.

Source: Adapted from the American Nurses Association. (2013). Conducting a political environmental scan. Silver Spring, MD: Author. Retrieved from https://www.nursingworld.org/~4af159/ globalassets/docs/ana/ethics/conductingpoliticalenvironmentalscan.pdf

their importance for the proposed health policy change. Environmental scans are recognized as valuable tools in healthcare decision making because they can identify the problem, the affected population, and the responsibility for the problem. All these factors influence policy makers’ responses.

SWOT Analysis The SWOT analysis is a widely used tool for assessing the viability of a project. It is a logical means of strategically examining an issue to better identify a pathway to success. Online tools such as Mind Tools (n.d.) for a SWOT analysis are readily available. The SWOT analysis is different from the PEST or PESTLE in that it can be used to examine internal and external factors related to a policy issue. Exhibit 4.3 provides factors that

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EXHIBIT 4.3  FACTORS TO CONSIDER WHEN CONDUCTING A SWOT ANALYSIS INTERNAL

Strengths • Personal stories of patients, nurses, and/or healthcare workers regarding the consequences of not dealing with the problem • Prominent individuals willing to speak out publicly and push the issue to the forefront • Data available describing the extent and pervasiveness of the problem or its consequences • Data about costs of the problem to individuals, healthcare organizations, or government • Qualifications and name recognition of key individuals who are experts on the problem • Resources of stakeholder organizations with experience in developing issue campaigns

Weaknesses • Lack of media attention and lack of communication outlets and resources to share these stories of lifealtering consequences • Competing agendas for stakeholder and policy maker involvement; too many issues to address What is the priority issue? • Lack of sufficient association resources (staff, financial) to address the issue • Strong need to build an economic case on the issue to make a compelling message for those not familiar with the issue

EXTERNAL Opportunities • Nurses, nurses associations, unions, healthcare organizations, and consumer groups supportive of advancing a policy solution • Collaboration among important stakeholders • Increased calls for action because of the impact of the problem • New technologies and data analytics to address the problem • New communication strategies and social media platforms to get the word out about the problem • Multifaceted support from the public and private sectors, including professional associations representing different disciplines, healthcare organizations, industries, government, and consumer groups • Willingness of an organization to take the lead in addressing the issue • Endorsement of stakeholders for an organization to take the lead on an issue • Financial commitments from stakeholder groups

Threats • Costs of policy options • Opposition claiming that the burden of costs is prohibitive • Opposing organizations and the strength of their lobbying power • Compelling arguments put forth by opposing organizations • Lack of transparency about the extent of the problem • Lack of data or data being held and/or controlled by opposition groups • Reluctance to collect and disclose information related to the problem • Lack of consistency in proposed solutions offered by stakeholder groups

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may be included when conducting a SWOT analysis for a specific issue. Using both SWOT and PEST(LE) is thought to reflect a more encompassing analysis. A SWOT analysis clearly outlines strengths and weaknesses that could impact the ability to advance an issue. The ANA conducted a SWOT analysis to investigate whether federal legislation on needlestick safety was a viable option. Legislation related to needlestick injuries had been passed in 16 states, indicating that there was potential for momentum. The SWOT analysis indicated that focusing efforts at the national level was feasible. At times, a critical mass of states acting on an issue is needed to move an issue forward. This analysis of factors revealed that the time was right to move this issue from the state houses to Congress. This led ultimately led to the passage of federal needlestick safety legislation (Needlestick Safety and Prevention Act, 2000)

Scenario Analysis Scenario analysis, sometimes called scenario framing or planning, is a strategy used to identify potential future problems and policy solutions. It was first used in World War II to analyze the consequences of nuclear proliferation and then popularized by the Dutch Shell company and other businesses that used it for strategic planning (Swart, Raskin, & Robinson, 2004). Scenario analysis in healthcare has included both quantitative and qualitative methods designed to address a wide range of possible outcomes (Vollmer, Ostermann, & Radaèlli, 2015). A common use of scenario analysis in healthcare is for the identification of problems that may occur from public health policies or crisis situations. The process usually involves various stakeholders, who are presented with a futuristic but plausible scenario. The problem requires broad input from multiple constituencies. Those present are divided into small groups that analyze strategies to address the scenario, which are then presented to the larger group. Developing the scenario with realistic consequences of different decisions is of prime importance to the process. Discussion of the scenario by experts allows for the realistic exploration of alternatives. A scenario example in healthcare is an outbreak of pandemic flu with limited supplies for a vaccine. This policy problem was used throughout the Veterans Affairs system in their community planning process (Lurie et al., 2008). The ANA also used this scenario topic in preparation for discussions with stakeholders in the larger healthcare community. Challenges presented by this example are policies related to who should get scarce vaccine flu first to prevent the spread of disease and maintain essential public services. The topic selected for a scenario analysis is usually one that has high impact and differing opinions about options. This process helps identify problems with different versions of policy solutions. Scenarios can be developed for different purposes, with descriptive scenarios using what is known about a situation that leads to certain outcomes to examine intended and unintended consequences. The choice of a tool and the extent of preparatory work completed as part of a systematic analysis are dependent on the interplay of numerous factors and the current political environment, be it within an organization or the governmental arena. The selection and use of tools for the identification of a policy issue provides direction for subsequent steps in the policy-making process. Identifying and defining the problem is an important step that if not carried out with care, can lead to missteps in the analysis of options and the allocation of scarce resources for implementing a plan. Once the policy issue has been identified, the next step is policy analysis.

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Policy Analysis Refining the problem to develop workable solutions requires an analysis of both existing and proposed policy. A variety of methods can be used for policy analysis. Almost all methods start with the definition of the problem or issue, gathering information and then making choices among alternatives. Policy analysis methods usually include problem identification, development of alternatives, and then selection of a preferred strategy. Using one common model, we explore factors that should be taken into consideration when conducting a policy analysis. The eightfold path for policy analysis developed by Bardach and Patashnik (2016) includes (a) defining the problem, (b) assembling evidence, (c) developing alternatives, (d) selecting criteria by which to evaluate the alternatives, (e) projecting outcomes, (f) analyzing tradeoffs, (g), making decisions, and (h) communicating the results. As with any examination of an issue, at some point, the group or organization needs to move forward with a policy option. It should be recognized that one will never have all the information that might be needed, that the analysis is designed to come up with a viable policy direction, and that the exploration of options need not necessarily be an exhaustive process. Although examination of the environment, as discussed under Tools for Assessment, addresses the feasibility of moving forward with an issue, a number of steps must be taken to ensure that the best and/or most achievable policy options are selected. The best option might be a combination of what is reasonable and what is feasible for the context in which you are working. Assembling evidence about an issue requires both quantitative and qualitative approaches (see Chapter 5). For example, a research study, newly commissioned survey, or meta-analysis might be included. It is the quality of the information gathered that is important. The credibility of the sources needs to be examined using primary sources rather than secondhand information. If citing statistics, you need to go to the original source for that data rather than relying on someone else’s interpretation. This helps to verify assumptions about the problem. The issue would not have come to attention without someone having some knowledge about it and some beliefs about the best course of action. Here, you want to clarify the accuracy of your assumptions and gather meaningful comparative data. Ultimately, when decisions are being made, the facts about the issue are presented accurately and with a reasonable degree of completeness. Just like research, the nature of the policy issue determines the nature of approach to gathering evidence about the issue, as well as determining what specific evidence needs to be gathered. Qualitative approaches in gathering information for policy analysis might include analyzing key documents and interviewing key stakeholders. It is strategically wise to interview those who may be opposed to the change (Bardach & Patashnik, 2016) to gain their perspective and also include mention of their ideas in the analysis. Developing alternatives is a challenging component of a policy analysis. At the beginning, a preliminary solution might have been identified, but interaction with stakeholders and the analysis of the environment might point to solutions that go in a different direction. The preferred state of affairs or outcome regarding the policy issue also needs to be clarified. For example, a school nurse’s goal might be to have children in the school have access to healthcare through a school-based clinic; the outcome that gets the attention of stakeholders who have the power to make policy changes is improvement in the school’s educational outcomes.

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Generally speaking, alternatives may include keeping the status quo by doing nothing, tweaking the current system, applying an innovative or radical change, or possibly combining options. Alternatives may be used for different aspects of the problem. Sometimes, there may be evidence for an approach that has been successfully adopted elsewhere and that can be applied to the current environment. See Policy on the Scene 4.2 for an example of how this strategy was used to develop disaster case management services. However, in examining successes elsewhere, it is important to note the similarities or differences in the current context in the community of interest. Considerations for developing policy alternatives include (a) starting with a lengthy list of policy options, (b) using out-of-the-box thinking, (c) determining what could be done if the budget is unlimited, (d) asking why not, and (e) determining what trends impact the policy (Bardach & Patashnick, 2016). These considerations are designed to develop a comprehensive list that can then be narrowed down to explore two to three options in depth. Approaches for alternatives might include creating or modifying a program, addressing access to care, changing the workflow, providing education, changing financial incentives, and changing laws and/or regulations. The alternatives might not be mutually exclusive; they might all be highly desirable, but it is probably not

POLICY ON THE SCENE 4.2: Adapting Policy for Disaster Case Management Roberta Lavin, PhD, FNP-BC, FAAN Captain (retired, USPHS), Professor and Executive Associate Dean of Academic Affairs, College of Nursing, University of Tennessee at Knoxville, Knoxville, Tennessee Health policy is often closely linked to other policy and goals requiring coordination at the local, state, and national levels. Good policy can be adapted from a policy that has historically been effective. As the director of the Office of Human Services Emergency Preparedness & Response (OHSEPR) in the Administration for Children and Families (ACF), one recurring problem was the provision of disaster recovery services. A policy I worked on for years was the development of Disaster Case Management Program (DCMP). This federally funded program is administered by the Department of Homeland Security’s Federal Emergency Management Agency (FEMA) and is designed to provide immediate aid to disaster survivors. This program focusing on providing coordinated services to meet disaster-related needs such as healthcare, mental health services, and human services has a single point of contact to obtain assistance (e.g., food, shelter, clothing). Access to these resources can occur when a president declares an emergency, and then a governor requests enactment if the declared emergency included assistance for individuals. (continued )

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In analyzing policy needs, we examined programs that could serve as ­models for DCMP policies. This policy was based on the case management program used by the refugee resettlement program at the ACF a Department of Health and Human Services division. The DCMP is designed for U.S. citizens who are poor or underserved and are impacted by a disaster. The evidence for the policy was synthesized from in-depth discussions with key informants, a review of relevant documents, guided discussions at key partner stakeholder meetings, review of and abstraction from available government planning documents, and the survey of case management experts, followed by a pilot project and subsequent research to show effectiveness. Key stakeholders included faith-based organizations, and volunteer organizations active in disaster (VOAD), who would be involved in the implementation of DCMP, were included in our discussions. Such a grand effort required governmental, nongovernmental, and faith-based organizations to work together. A good policy should be built on mutually agreeable principles. DCMP was based on the principles of self-determination, self-sufficiency, federalism, flexibility and speed, and support to states, which were agreed on by our stakeholder group. More quickly linking victims of disaster to appropriate assistance reduces the likelihood that they will require more intensive healthcare and social service benefits. Thus, the potential impact on states and existing systems is reduced. When I started talking to stakeholders, one of the policy concerns identified was inclusion of access to healthcare services. I found that healthcare was largely excluded from the services currently offered by both VOADs and ­nongovernmental organizations (NGOs) and that case managers rarely had healthcare experience. Our agency’s research showed that medical issues barely made the top-10 needs. When we examined the issue more closely, a nurse case manager needed to be available to provide advice to lay case managers. Therefore, it was decided that a more effective approach was to use the RN as a consultant to lay case managers rather than as the provider. The DCMP became part of the national assets that could be deployed or requested by a state. The multipronged approach we used to identify essential DCMP needs created a strong foundation to justify a national policy. The DCMP that was adapted from the refugee resettlement program was accepted and remains policy to this day. For details, see www.acf.hhs.gov/ohsepr/response-recovery/disaster-case -management.

feasible or wise to tackle all of them. Therefore, a decision needs to be made about the best course of action. During discussions about the proposed ACA legislation, for example, nurse leaders considered whether to focus on reimbursement or other care access approaches delivered by nurse practitioners. They recognized that including reimbursement modifications for nurse practitioners in the legislation would not have been feasible at that time. The fourth and next step in policy analysis is determining the criteria that will be used to evaluate the policy alternatives. Clarifying the goals (i.e., specifying the desired

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outcomes) then helps in refining specific objectives and determining which measures are most appropriate for comparing the alternatives. Criteria for evaluating alternatives commonly include financial and political considerations, operational logistics, stakeholder perspectives, and the impact on the community to be served by the proposed policy. Financial considerations include direct and indirect costs to patients, providers, and the healthcare system. Political considerations are most often related to the feasibility of getting legislation or regulations passed or organizational dynamics. However, legislation sometimes needs to be introduced in several sessions before enough support can be garnered for its passage. Similarly, it may take months or years to make or alter organizational policy. Operational logistics includes changes to systems that might be needed for the implementation of the policy. Analyzing positions of key stakeholders who could influence the policy’s direction is important, as is examining the likelihood of being able to change a stakeholder’s position. It is helpful to think about adding stakeholders whose views are in alignment with the policy goals. Examination of the impact on the community of interest includes social justice issues of equity and access to care, effects on the outcomes of care (e.g., morbidity, mortality), and considerations related to the balance between individual rights and actions taken for the overall benefit of the community. Projecting outcomes, the next step in the model, involves identifying the impact (intended and unintended) of all of the alternatives (Bardach & Patashnick, 2016). This step is future oriented in that it is an attempt to figure out what will happen if the policy is implemented. At the big “P” level, proposed federal legislation is ­generally evaluated by the Congressional Budget Office, which provides estimates for costs and other metrics. The CDC has an office dedicated to the identification of highimpact policies (CDC, 2017). A Canadian government agency, Statistics Canada, uses microsimulation, the POpulation HEalth Model (POHEM) to project societal, socioeconomic, and demographic changes by simulating outcomes based on disease prevalence and incidence, costs, quality of life, and other factors (Hennessy et al., 2015). At the little “p” level, resources for making outcome projections might be more limited. In these cases, information may need to be drawn from multiple sources of publicly available information, such as community needs assessments and workforce boards. Once all the information has been gathered regarding the policy alternatives and projected outcomes, the process of evaluating trade-offs among the options begins. One strategy for this phase is the development of a matrix so that the options can be evaluated side by side. However, it is quite likely that the information developed for each of the alternatives may not be exactly comparable. The proposed alternatives may be based on different values about the policy issue. The policy team may need to consider whether using an incremental approach is better than making a dramatic change in policy. Sometimes, there are trade-offs on what is included in a particular law, regulation, or policy, and sometimes, new problems emerge because of changes in practice that move ahead of the policy process. At times, the evaluation of the alternatives is not directly quantifiable. In this case, ethical considerations may come  into the forefront of the discussion. This is where the collective wisdom of leaders and key experts come into play in making judgments about the best course of action. The next to the last step is making decisions about the policy direction. This may be done by a variety of means, a large group of stakeholders, or a small task force

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established by an organization, and everything in between. Regardless of the authority to move forward with the decision for a course of action, involving key people is integral to the success of the effort. Policies are not often perfected on the first attempt, but often involve years of painstaking work and effort to achieve the desired goal. Efforts to provide a safe working environment for nurses are ongoing, as are efforts to remove practice barriers and eliminate healthcare inequities and other policy issues in healthcare. These steps may be revisited multiple times as the process continues. The next steps in moving the policy forward, including communications about the decisions are described in subsequent chapters.

OPTION FOR POLICY CHALLENGE: The Words We Use in Identifying a Policy Issue Nurses advocating a policy solution need to clearly define the issue with ­appropriate words as a first step in problem identification. Defining the issue begins by appreciating which words are universally understood and which can be emotionally or politically charged. As a profession, our language and use of words has not always been clear and supportive of nurses’ unique roles and contributions. In fact, confusing terminology has hindered the profession from achieving success in its advocacy efforts. Therefore, strides have been made to use words that are reflective of the roles and responsibilities of practitioners without creating confusion for practitioners and the public. Consider the difference between an APRN and a mid-level practitioner. One title implies a limited role, whereas the other signals a role with advanced knowledge and skills. Consider also, the difference between APRNs and advanced practice nurses (APNs). Are they one and the same? The confusion of a public member at a policy table thinking that an APN was a licensed practical nurse with advanced education led to the consistent use of the term APRN (M. J. Schumann, personal communication, November 18, 2014). Likewise, different standards, regulations, and titling for APRNs led to the development of the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education (APRN Consensus, 2008). This collaborative effort among more than 40 nursing organizations resulted in agreement about key issues to make APRN practice better understood and more uniform. Collaborative efforts across the nation spearheaded by the Institute of Medicine (IOM), now the National Academy of Medicine, resulted in the landmark report, The Future of Nursing: Leading Change, Advancing Health (Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, 2011), with the recommendation that nurses should practice to the full extent of their education and training. In the 5-year ­follow-up report, it was noted that “independent practice” for APRNs might imply solo or competitive practice for some physician groups but that full practice authority refers to the use of one’s education and training and that for APRNs, it is “part of an organized collaborative system of care” (Altman, Butler, & Shern, 2016, p. 48). (continued )

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The use of words and terminology has even greater importance in legislation and regulation. The time it takes to change legislation and their accompanying regulations for implementation can be lengthy. There may only be one opportunity to get the language right. That is why it was important when the ACA was being discussed and language drafted for the bill that the words used were carefully considered. Historically, traditional titles such as medical doctor, physicians, RN, and healthcare provider were used in legislative proposals. For the ACA, these titles needed replacement when appropriate with the use of the term, licensed independent practitioner (LIP). Considerable effort was given to ensure that LIP was used in the proposed legislation over previous titles to provide the greatest role delineation for APRNs in the ACA. As nurses, we understand the significance and impact when unclear words are used in our practice. Appropriate word selection used in issue discussions and then solutions should provide the confidence and knowledge that the problem and potential solutions or policy will be understood. Clear terms used in problem identification, analysis, and solutions can go a long way toward a foundation for successful effort with minimal unintended consequences

IMPLICATIONS FOR THE FUTURE Nursing has to be vigilant in identifying problems and taking responsibility for ­creating favorable political circumstances by voting and electing individuals who share nursing’s philosophy. Nursing can no longer expect to exist in a silo using disparate voices to demand change. As the healthcare system moves toward models of care that require interprofessional education and practice environments, nursing will need to position itself so that, as a profession, it can be viable and integral to this changing healthcare system, as called for in The Future of Nursing: Leading Change, Advancing Health report (Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, 2011). This changing environment will become even more competitive as players vie to carve out their niche and protect their existing status while others try to enhance, expand, or control their roles. To be effective, nursing organizations need to be aware of the internal strengths and external opportunities that exist related to their advocacy initiatives, activities, or goals. Only then will nurses be able to determine their ability to move forward in identifying and tackling problems or issues in any system. Nurses need to cultivate allies to support and champion issues. Nursing can be a major stakeholder if we unite on common goals. Joining professional nurses associations enables us to build our diversity and strength in numbers to participate in advocacy activities, as well as shape favorable political circumstances. Nurses who become informed citizens engaged in the full participation of the electoral process can better position themselves in boardrooms, as well as political and administrative leadership positions at the local, state, and federal level. As you can see, opportunities for policy change occur at many levels, and nurses need to be ready to seize positions of power and influence to effect change. In those roles, we know nurses can work to realize more favorable circumstances to create change and advance their vision for nurses and patients, from the bedside to the boardroom.

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KEY CONCEPTS 1. Not every problem requires a legislative solution, and not every problem requires a policy solution. 2. Problem identification is a critical initial step in moving forward with the policy process. 3. Words matter when describing the policy problem to stakeholders and members of the external environment. 4. A confluence of aligned factors creates a window of opportunity for advancing a policy solution for an identified problem. 5. Identifying key stakeholders and understanding their positions is critical because policy work is most often carried out by groups. 6. Change is possible at every level, and changes at one level often impact other levels. 7. Careful preparation and the systematic examination of a problem from a broad perspective within the context of current events and situations are essential for the effective evaluation of policy direction. 8. An encompassing analysis of the internal and external environment can include using an environmental scan, the PEST(LE) or SWOT analysis. 9. Compromise is necessary to achieve results. 10. Persistence and patience are necessary components for success. 11. It is important to listen to and gather information from individuals impacted by the problem. 12. Policy analysis is a critical step in evaluating alternatives against established criteria and deciding about the direction for a policy. 13. Policy making is cyclical; nothing is perfect. 14. Modification and refinement are part of an iterative process in policy analysis. 15. Uniting on common goals and participating in the advocacy work of associations can shape favorable political outcomes. 16. Persistence and patience are necessary components for success.

SUMMARY Learning the steps necessary to identify and analyze problems, developing possible solutions, building stakeholder support, and evaluating the existing political circumstances are essential components in the process of identifying policies proposed for action. Examining the environment through a scan, PEST(LE) analysis, or scenario analysis and taking stock of the internal and external environment with SWOT provide valuable information about the feasibility of a policy direction. Movement through these often-nonlinear steps is preparatory for recognizing the confluence of factors that create a favorable window of opportunity. Policy analysis using a well-defined process serves as an objective but critical step in determining the best course of action. Involving key stakeholders at key junctures in the process increases the chances for success in making a decision to move forward with a policy option. The policy process is iterative and will, of necessity, involve revisiting the analysis steps as the healthcare environment evolves. Several key examples demonstrated the challenges encountered when one advances a vision through policy.

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LEARNING ACTIVITIES 1. Identify a healthcare issue that, in your opinion, is a problem that calls for a policy solution. Explain how you would begin to gather data about the issue and to develop a plan to address the problem. Discuss the tools that will help you in gathering the data. 2. Discuss some of the factors indicating that a window of opportunity is opening, making it possible to move a proposed problem solution forward in the policy process. Use an example from a policy at work, school, or the community where you live to illustrate when a window of opportunity might open. 3. The Robert Wood Johnson Foundation, Heritage Foundation, Urban Institute, Kaiser Family Foundation, and Commonwealth Fund are all examples of research/ policy organizations. Investigate the websites of at least three research/policy organizations to identify their organizational healthcare priorities. 4. Identify a health story in the news that has potential policy implications. List the political institutions that are germane to the discussion about this health news issue. Brainstorm some possible policies that address this issue and then identify one policy from the list in which a nursing voice can have the greatest impact. 5. Select one of the following e-resources to share with a work or school colleague or someone you supervise. Prepare a short summary of its purpose and applicability for policy that is tailored to the audience. 6. Link to C-SPAN at www.c-span.org and select a topic that has implications for nursing. Discuss the problem identified and what contributions nursing can make to the definition of the problem. 7. Investigate the use of an advisory council where you work or go to school. Summarize its purpose, when it was developed, and current problems and solutions for which the group is being asked to provide advice or investigate. 8. Develop measurable outcome criteria for the assessment of policy alternatives for a policy problem or issue. 9. Identify a practice barrier for an APN and identify two policy solutions to address the barrier. 10. Identify a policy change that did not achieve its intended goals. How might that policy be altered? What other options might be a better choice in addressing the problem?

E-RESOURCES • Agency for Healthcare Research and Quality (AHRQ): Innovations Exchange Learning Communities https://innovations.ahrq.gov/learning-communities • American Nurses Association. Advocacy https://www.nursingworld.org/practice-policy/advocacy • An environmental scan of self-direction in behavioral health: Summary of major findings. Chestnut Hill, MA: National Resource Center for Participant-Directed Services, 2013 http://www.bc.edu/content/dam/files/schools/gssw_sites/nrcpds/BH%20Scan/ Summary_Scan%20of%20SD%20in%20BH_May2013.pdf • Mathematica Policy Research https://www.mathematica-mpr.com

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• National Highway Traffic Safety Administration (NHTSA): Community How to Guide: Needs Assessment and Strategic Planning for Underage Drinking Prevention http://www.nhtsa.gov/people/injury/alcohol/Community%20Guides%20HTML/ Book2_NeedsAssess.html

REFERENCES Altman, S. H., Butler, A. S., & Shern, L. (Eds.). (2016). Assessing progress on the Institute of Medicine report The Future of Nursing. Washington, DC: National Academies Press. American Hospital Association. (2018). The 2018 environmental scan. Chicago, IL: Author. Retrieved from https://www.besmith.com/trends-and-insights/articles/2018-aha-environmental-scan American Nurses Association. (2008). Adapting standards of care under extreme conditions: Guidance for professionals during disaster, pandemics, and other extreme emergencies. Silver Spring, MD: Author. Retrieved from https://www.nursingworld.org/~4ade15/globalassets/ docs/ana/ascec_whitepaper031008final.pdf American Nurses Association. (2013). Conducting a political environmental scan. Silver Spring, MD: Author. Retrieved from https://www.nursingworld.org/~4af159/globalassets/docs/ana/ethics/ conductingpoliticalenvironmentalscan.pdf APRN Consensus Work Group, & National Council of State Boards of Nursing APRN Advisory Committee. (2008, July 7). Consensus model for APRN regulation: Licensure, accreditation, ­certification & education. Retrieved from https://www.ncsbn.org/aprn-consensus.htm Bakhru, R. N., Wiebe, D. J., McWilliams, D. J., Spuhler, V. J., & Schweikert, W. D. (2015). An environmental scan for early mobilization practices in U.S. ICUs. Critical Care Medicine, 43(11), 2360– 2369. doi:10.1097/CCM.0000000000001262 Bardach, E., & Patashnik, E. M. (2016). A practical guide for policy analysis: The eightfold path to more effective problem-solving (5th ed.). Thousand Oaks, CA: CQ Press. Bodenheimer, T., & Sinsky, C. (2014). From Triple to Quadruple Aim: Care of the patient requires care of provider. Annals of Family Medicine, 12(6), 573–576. doi:10.1370/afm.1713 Bosse, J., Simmonds, K., Hanson, C., Pulcini, J., Dunphy, L., Vanhook, P., & Pogoshyan, L. (2017). Position statement: Full practice authority for advanced practice registered nurses is necessary  to transform primary care. Nursing Outlook, 65(6), 761–765. doi:10.1016/j .outlook.2017.10.002 Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/DSA Hand Hygiene Task Force. Morbidity and Mortality Weekly Report, 51(RR-16), 1–56. Retrieved from https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf#page=19 Centers for Disease Control and Prevention. (2017). Health policy at CDC. Retrieved from https:// www.cdc.gov/policy Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Hennessy, D. A., Flanagan, W. M., Tanusepetro, P., Bennett, C., Tuna, M., Kopec, J., … Manuel, D. G. (2015). The Population Health Model (POHEM): An overview of rationale, methods and applications. Population Health Metrics, 13, 24. doi:10.1186/s12963-015-0057-x Kavanagh, J. M., & Szweda, C. (2017). A crisis in competency: The strategic and ethical imperative to assessing new graduate nurses’ clinical reasoning. Nursing Education Perspectives, 38(2), 57–62. doi:10.1097/01.NEP.0000000000000112 Kingdon, J. W. (2011). Agendas, alternatives, and public policies (Updated 2nd ed.). Glenview, IL: Pearson.

128   UNIT II  ANALYZING POLICY Koo, D., O’Carroll, P. W., Harris, A., & DeSalvo, K. B. (2016). An environmental scan of recent initiatives incorporating social determinants in public health. Preventing Chronic Disease, 13, E86. doi:10.5888/pcd13.160248 Lurie, N., Dausey, D. J., Knighton, T., Moore, M., Zakowski, S., & Deyton, L. (2008). Community planning for pandemic influenza: Lessons from the VA Health Care system. Disaster Medicine and Public Health Preparedness, 2(4), 251–257. doi:10.1097/DMP.0b013e31817dd143 Mind Tools. (n.d.). SWOT analysis. Retrieved from https://www.mindtools.com/pages/article/ newTMC_05.htm National Council of State Boards of Nursing. (2017). The 2017 Environmental Scan. Journal of Nursing Regulation, 7(4 Suppl), S1–S36. Retrieved from https://www.ncsbn.org/2017_Environmental_ Scan.pdf Needlestick Safety and Prevention Act of 2000. Pub. L. 106-430. Patient Protection and Affordable Care Act (ACA) of 2010. Pub. L. 111-148. 124 § 119-1025. (2010). Public Health Cigarette Smoking Act of 1969. Pub. L. 91-222. (1970). Selix, N., Henshaw, E., Barrera, A., Borcheva, L., Huie, E., & Kaufman, G. (2017). Interdisciplinary collaboration in maternal mental health. MCN, American Journal of Maternal Child Nursing, 42(4), 226–231. doi:10.1097/NMC.0000000000000343 Swart, R. J., Raskin, P., & Robinson, J. (2004). The problem of the future sustainability ­science and scenario analysis. Global Environmental Change, 14, 137–146. doi.org/10.1016/j.gloenvcha .2003.10.002 U.S. Department of Health, Education, and Welfare. (1964). Smoking and health. Report of the Advisory Committee of the Surgeon General of the Public Health Service. Official Report. Retrieved from http://profiles.nlm.nih.gov/ps/access/NNBBMQ.pdf U.S. Department of Health and Human Services. (2016). E-cigarette use among youth and young adults. A report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Retrieved from https://www.cdc.gov/tobacco/data_statistics/sgr/e-cigarettes/pdfs/2016_ sgr_entire_report_508.pdf Vollmer, H. C., Ostermann, T., & Redaèlli, M. (2015). Using the scenario method in the context of health and health care. BMC Research Methodology, 15, 89. doi:10.1186/s12874-015-0083-1 Woods, C. Q. (1996). Evolution of the American Nurses Association’s position on health insurance for the aged: 1933–1965. Nursing Research, 45(5), 304–310. Xue Y., Ye, Z., Brewer, C., & Spetz, J. (2016). Impact of state nurse practitioner scope-of-practice regulation on health delivery: Systematic review. Nursing Outlook, 64(1), 71–85. doi:10.1016/ j.outlook.2015.08.005

FIVE

Harnessing Evidence in the Policy Process Kathleen M. White Audra N. Rankin The acquisition of knowledge is the mission of research, the transmission of knowledge is the mission of teaching and the application of knowledge is the mission of public service.—James A. Perkins

OBJECTIVES 1. Describe issues and resources that impact the translation of evidence into policy. 2. Analyze the types of evidence that have the potential to influence health policy. 3. Compare and contrast how evidence can be used at both the local level and beyond to influence policy. 4. Advocate for the implementation of policy initiatives based on evidence at different levels of policy making.

The power of harnessing evidence for public policy can be easily traced in nursing from the data collected and analyzed by Florence Nightingale during the Crimean War and her advocacy efforts in the years that followed. Harnessing evidence, in this chapter, implies finding evidence and coupling it at the right times and places in the policymaking process. As illustrated in the lifelong work of Nightingale, the role of finding and using evidence to make policy change does not always follow a steady course in nursing or in healthcare generally. Shortly after Florence Nightingale began her work, President Abraham Lincoln established the National Academy of Sciences (NAS) in 1863 to gather scientific information. It was not until 1930 that the Ransdell Act formalized the establishment of the National Institute of Health (NIH) as a single agency whose research focus was biological and medical issues. In 1948, the singular NIH was renamed to the plural name, the National Institutes of Health that we recognize today (Harden, 1998).

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In 1986, the National Center for Nursing Research (NCNR) was created, and then, in 1993, the National Institute of Nursing Research (NINR) was transitioned to institute status, 130 years after the NAS was established. Institutionalization of research has not, however, ensured a clear path for using scientific evidence for policy making. Currently, there is much discussion on policies that were developed and are still operational; this discussion did not look at, or in some cases seemed to ignore, convincing evidence contrary to those policies. Phrases heard at the big “P” level such as “when policy trumps science” and at the little “p” level such as “putting sacred cows to pasture” are testimony in common vernacular that attest to the disputes about the use of evidence in policy making. The spectrum of policy making has myriad examples where evidence can be put to better use. At the big “P” level, policy makers often need help to make sense of evidence and its practical relevance to policy. A great source of synthesized evidence for current policy topics is found in Health Affairs Health Policy Briefs. These provide a synopsis of issues and relevant research related to healthcare improvement in the United States that are of concern to policy makers, healthcare professionals, the public, and journalists. Originally (from 2009 to 2016), the policy briefs were produced by Health Affairs through a grant from the Robert Wood Johnson Foundation (RWJF) and included topics such as Patient Engagement, Implementing the Medicare Access and CHIP Reauthorization Act (MACRA), and the Two Midnight Rule. In 2017, Health Affairs began producing the briefs in collaboration with a variety of other partners. A recent example is a brief produced in partnership with the Commonwealth Fund that is focused on pharmacy benefit managers, the brokers that negotiate formulary placement and rebates (Health Affairs, 2017). Professional associations, ­organizations and other groups also use research in the development of their policy briefs, testimony, and other dissemination venues (see Chapter 10). For example, the American Academy of Nursing’s policy briefs developed by its expert panels often appear in its journal Nursing Outlook, as is illustrated by a brief on RN s­ taffing in nursing homes (Mueller, Bowers, Burger, Cortes, & Expert Panel on Aging, 2016). Work at the little “p” level may not be as easy to see or synthesize because this work does not often make it to the published literature. Further complicating the dissemination of little “p” work is that so much work remains to be done to achieve the goal set by Institute of Medicine (IOM; now the National Academy of Medicine) that 90% of clinical choices be based on evidence (IOM, 2009). For example, Melnyk and colleagues (2016) found in a survey that more than 50% of chief and executive nurse officers stated that the practice of evidence-based care was “low.” There are, however, growing numbers of examples of how evidence is garnered and shared at the little “p” level that can be seen at websites, in books, and in best practice stories from Magnet® designated organizations like those available at Johns Hopkins (www.hopkinsmedicine .org/evidence-based-practice/ebp-spotlight.html). The policy challenge illustrates an example of a practice policy that was changed first at the little “p” level followed by advocacy and policy change at the big “P” level, both levels using evidence to make the practice policy change. Despite the policy problem, abusive head trauma, that would most surely have universal support, policy changes of this nature are not always “simple” and often require multiple steps for implementation and success in improving outcomes. As discussed in the next section, controversy often surrounds harnessing the evidence.

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POLICY CHALLENGE: From ICU to State Capital: Policy Change Starting at the Bedside Staff from North Children’s Hospital Just for Kids Pediatric Critical Care Center in Louisville, Kentucky, noticed an increase in the number of children being treated for nonaccidental abusive head trauma. Although the trend was noticed in the intensive care unit, these healthcare providers knew that significant change would occur only if they focused their efforts on educating the public on prevention strategies and warning signs of nonaccidental trauma. Justine O’Flynn, a nurse on the unit, contacted the hospital’s Public Relations and Child Advocacy departments by saying “I want to write a letter to the editor to every newspaper in the state of Kentucky” (J. O’Flynn, personal communication, October 9, 2017). The passion on the unit to educate others on preventing child abuse grew rapidly and resulted in an awareness campaign that greatly influenced the following actions: • Developing a multidisciplinary child abuse task force focused on research on pediatric abusive head trauma • Purchasing additional child abuse screening equipment within the hospital • Establishing a Department of Pediatric Forensic Medicine at the University of Louisville • Developing a “train the trainer” program, Preventing Shaken Baby Syndrome, in partnership with Prevent Child Abuse Kentucky • Creating an educational video on child abuse–prevention strategies to play to families on all birthing units in the hospital system This little “p” project that started at the bedside took root with these efforts. It was time, like many projects that have roots at the direct level, to be taken further. See Option for Policy Challenge.

CONTROVERSY Although much work remains to be done on full use of evidence, there is no doubt that its use to inform practice in healthcare has changed the practice environment. Increasingly, clinicians at all levels and points of care are held accountable to ensure that healthcare practices are based on the best available evidence. Those examining policy often question why the same attention has not been paid to using health services research to develop policies, with many articles written over the past 15 years on this question. The titles or phrases in some of those articles indicate the conundrum we face: “The Paradox of Health Services Research: If It Is Not Used, Why Do We Produce So Much of It?” (Lavis et al., 2002); “How Research Influences Policy Makers: Still Hazy After All These Years” (Lewis, 2011); Bridging the Gap Between Research, Policy and Practice (Waterson, 2016); and finally, a favorite, “Translation of Research to Practice: Why We Can’t Just Do It” (Green & Seifert, 2005). These articles and many others

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suggest that the challenge to evidence-based policy is the gap that exists among the research, policy, and practice worlds. Cairney and Oliver (2017) challenge researchers to consider that closing the gap requires a long view and recognition that this change goes beyond presenting evidence and is often value and belief driven. The notion of whether evidence-based policy is achievable has been questioned. There are numerous influences on policy, and evidence is not always the most definitive determinant of public health policy (Anderson et al., 2005). Hewison (2008) argues well that evidence-based practice (EBP) cannot and should not be the sole determinant of policy and that too much emphasis on EBP as a basis for policy may detract from nurses developing the full range of competencies needed for policy activism. Evidence-informed policy has gained considerable attention and the realm of evidence has been greatly expanded to include preferences, political contingencies, and behavioral theory (Lavis, Oxman, Lewin, & Fretheim, 2009; Lewis, 2011). The World Health Organization (WHO) formed an Evidence-Informed Policy Network (EVIPNet) in 2005 to promote the use of health research evidence for better decision making and health policy making, primarily focusing on low and middle-income countries. EVIPNet defines evidence-informed health policy making as an approach to policy decisions aiming to ensure that decision making is well informed by the best available research evidence (WHO, n. d., www.who.int/evidence/about/en). It is characterized by the systematic and transparent access to, and appraisal of, evidence as an input into the policy-making process. This assumes that once a policy problem is identified, evidence is obtained, and thus, the relationship between evidence and policy making is linear. Often, policy making is not linear (see Chapter 1). The complexity of the policy-making process was well observed and will be debated for years to come regarding the unfolding of the passage and implementation of the Patient Protection and Affordable Care Act (ACA).

CHALLENGES IN MOVING EVIDENCE INTO POLICY The important role that research, in particular, plays in improving healthcare and the development of healthcare policies has been recognized for some time. Brownson, Royer, Ewing, and McBride (2006) indicate researchers and policy makers are “travelers in parallel universes” (p. 164). Why are researchers and policy makers thought to be traveling in parallel universes? What are the issues? Policy makers, whether at the big “P” or little “p” level, and researchers often have conflicting roles and needs. Three major global resolutions, the Mexico Action Statement on Health Research, the related World Assembly resolution in support of health research and the development of health research capacity, and the Bamako Call to Action on Research for Health urged researchers, policy makers, and healthcare providers to bridge the practice and policy gap (Lavis et al., 2010). These resolutions support efforts for moving evidence into policy across the globe. As early as 1979, Caplan sought to explain the issue by suggesting that there are cultural differences between researchers and policy makers, noting these groups have different views of the world. Gaps exist between the two in values, language, reward systems, and professional affiliations; researchers are mainly concerned with pure science and esoteric issues, whereas policy makers are more interested in immediate relevance and have an action orientation. Another issue is where the responsibility lies for ensuring the use of or translation of new research into policy and practice. The difficulty in identifying or assigning responsibility is explained using the technology transfer theory. It is postulated that there

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is a unidirectional responsibility. There is either a science push or knowledge-driven model in which the information flows from researchers to policy makers, resulting in specific policy decisions, or a demand pull or problem-solving model whereby there is a commissioning of information from researchers by policy makers with the intent of addressing a well-defined policy problem. Researchers have tried to determine (a) what barriers make the gap so hard to bridge and (b) the most effective strategies that help close the gap. Published systematic reviews provide strong evidence of numerous barriers in translating research into policy. With a major issue being the role of communication between researchers and those using the research. (Innvaer, Vist, Trommald, & Oxman, 2002; Orton, Lloyd-Williams, Taylor-Robinson, O’Flaherty, & Capewell, 2011). Work examining the most effective strategies for translating evidence into policy is ongoing. Public health laws are often perceived to be a strategy for infusing research into policy. “Model” public health laws consist of statutory language recommended by at least one organization for adoption by government. Hartsfield, Moulton, and McKie (2007) identified 107 model public health laws, but in only 6.5% did the sponsors provide details demonstrating that the model law was based on scientific information (e.g., research-based guidelines). More recent public health laws include food policy laws for obesity prevention (Hawkes et al., 2015), as well as public health initiatives to reduce opioid overdose (Alexandridis et al., 2017). Despite these efforts, public health laws are perceived to be a missed opportunity, in part because there is no systematic method for categorizing them and examining their effectiveness in achieving the desired change (Attaran, Pang, Whitworth, Oxman, & McKee, 2012). Several initiatives have been developed to address the lack of evidence use in practice and policy making. In 2002, the NIH initiated a series of consultations with the research community to define major scientific trends that led to the development of the NIH Road Map for Medical Research (Zerhouni, 2003). A major theme that emerged from these consultations was the complaint that clinical research was becoming more difficult to conduct and less attractive to new investigators, and that clinician–­scientists were moving away from patient-oriented research. This led the NIH Road Map to include the theme, “Re-Engineering the Clinical Research Enterprise,” to initiate the funding of Clinical and Translational Science Awards (CTSAs) for the conduct of original clinical and translational research as part of a full-spectrum biomedical research enterprise (Zerhouni, 2005). In 2010, the ACA established the Patient-Centered Outcomes Research Institute (PCORI) to fund research that helps people make decisions about their healthcare (PCORI, n.d.). PCORI uses members of the public in the grant-review process to assess how the community of interest is involved in proposed projects. The results of research funded by the federal government, including NIH and PCORI are made available to the public in PubMed Central. Professional groups and patient advocacy groups are also working to translate evidence into practice. A private sector initiative is illustrated with the Research-to-Policy Collaboration (RPC) that uses a cost-effective model combining strategic legislative needs assessments and a rapid-response researcher network to facilitate the translation of research into criminal justice prevention into practice by (a) engaging scientists with legislators, (b) connecting legislative offices with prevention researchers, and (c) ­eliciting requests from legislators for evidence to support prevention efforts (Crowley, Scott, & Fishbein, 2017). This model has the potential to be replicated with other scientist groups. Advocacy organizations, often started and managed by patients and their families, frequently have scientific advisory boards and encourage members to become advisors to research studies through patient-powered registries and patient-powered

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research networks (Workman, 2013). Although each of these initiatives has a different focus, they illustrate the value of evidence, dissemination to the public and policy makers, and efforts to move research evidence into practice and policy.

TERMINOLOGY Another key piece in the puzzle to understanding the harnessing of evidence for policy making is the variation in the use of terminology. Different terms have been used to explain the complex process of moving evidence to both practice and policy, with perhaps more attention given to practice. Both practice and policy have their own barriers in using research, and some authors have used the term valley of death to illustrate how difficult it may be to cross these gaps between research and practice, as well as research and policy (Meslin, Blasimme, & Cambon-Thomsen, 2013). Translational research is a term originally designed for use in the medical world and emerged in response to concern over the long-time lag between scientific discoveries and changes in treatments, practices, and health policies that incorporate the new discoveries. Rubio and colleagues (2010), in a search of MEDLINE for an answer as to why research is not used to inform the development of policy practice, found that the term translational research appeared as early as 1993, but that there were few references to the term in the 1990s and most were in reference to research about cancer. However, translational research has different definitions, means different things to different people, and is interpreted differently, but it seems important to almost everyone (Levine, 2007; Naylor et al., 2013; Woolf, 2008). For instance, Woolf (2008) comments that some researchers define it as what occurs from bench to bedside in the development of new drugs, devices, and treatment options for patients, whereas others view it as “translating research into practice.” As seen in this one example, one definition is product driven and the other community and policy focused. Translational research is further explained in several ways: using new knowledge produced as part of the science of discovery and applying that knowledge to improve health and healthcare, applying new and unproven laboratory discoveries to improve health, or engaging in research that explores and develops potential treatments and tests the safety and efficacy of those treatments in randomized controlled trials (RCTs). These definitions of translational research are referred to as T1 translation (White, 2011; Woolf, 2008). Nursing has also developed definitions associated with translational work. In 2003, the University of Iowa held an invitational conference focused on translation science and nursing’s role in translation. A definition of translation research was generated that is widely used in nursing research today. Translation research is “the scientific investigation of methods, interventions, and variables that influence adoption of EBPs by individuals and organizations to improve clinical and operational decision making in healthcare. This includes testing the effect of interventions on promoting and sustaining the adoption of EBPs” (Titler, 2004, p. S1). Because the issue of translation is so important, the NIH established the National Center for Advancing Translational Sciences (NCATS) in 2011. NCATS is not disease or discipline focused. Its purpose, as implied in its name, is the translation of research. Of major interest to center is policy work. To that end, NCATS has developed the Office of Policy, Communications, and Education and the Office of Strategic Alliances (OPCSA; https://ncats.nih.gov/about/center/org), which has dedicated time and resources for this arena. This center and the research agencies mentioned in the chapter’s introduction are described in Exhibit 5.1.

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EXHIBIT 5.1  SELECTED U.S. HEALTH RESEARCH ENTITIES AGENCY AND YEAR ESTABLISHED

DESCRIPTION

Agency for Healthcare Research & Quality (AHRQ); 1999

An agency of the U.S. Department of Health and Human Services that oversees health services research. It is complementary to the research mission of the National Institutes of Health. Originally known and established as the Agency for Health Care Policy and Research, it was reauthorized as AHRQ in 1999.

National Academy of Medicine (NAM), formerly the Institute of Medicine (IOM); 1970

Last of four federally authorized independent, nonprofit institutions called the National Academies established to provide expert, unbiased scientific information for health decisions. The other agencies include the National Academy of Sciences, National Academy of Engineering, and the National Research Council.

National Institutes of Health (NIH); 1948

An agency of the U.S. Department of Health and Human Services that oversees 27 institutes and centers that conduct research to improve health and life, including length, and to decrease both illness and disability. Link to mission and goals: nih.gov/ about/mission.htm

National Institute of Nursing Research (NINR); 1993

Originally established as a center in 1986, the mission of this institute is specifically research that increases the health of individuals, families, communities, and populations across the life span.

National Center for Advancing Translational Sciences (NCATS); 2011

One of the six centers of the NIH. The center’s aims stress novel approaches and outcomes and the use of evidence and technology to advance, establish, and publicize improvements in translational science. Its work is meant to complement the research of other NIH institutes and centers.

Patient-Centered Outcomes Research Institute (PCORI); 2010

Established as an independent nonprofit organization to conduct research to help patients and their healthcare providers make decisions based on the best available evidence about prevention, treatment, and care options that is derived from research guided by patients, caregivers, and the broader healthcare community.

Further complicating the use of terminology is the confusion existing about the meaning of research, EBP, and quality improvement (QI), as well as the interplay among them. Many practitioners use these three terms incorrectly. Many nurses in practice today may have had little formal education in these processes, and nurses who have had such education may not have adequate opportunity to practice each of these separate but overlapping processes.

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Evidence-Based Practice The EBP approach is credited in medicine to Archie Cochrane in the early 1970s, so the term evidence-based medicine is often heard. The more generic term EBP is useful because it is not discipline specific. EBP is a problem-solving approach designed for practice that includes three major components: the incorporation of best evidence with clinical knowledge and patient preferences and values (Melnyk & Fineout-Overholt, 2005). To ensure a practice based upon evidence, healthcare providers are encouraged to use a framework or model to approach the search, critique, and translation of evidence for implementation into practice policy. Many nursing models of EBP are available for guiding practice. The Johns Hopkins Nursing EBP model is defined as a problem-solving approach to clinical decision-making within a healthcare ­organization that integrates the best available scientific evidence with the best available experiential (patient and practitioner) evidence, considers internal and external influences on practice, and encourages critical thinking in the judicious application of such evidence to care of the individual patient, patient population, or system. (Newhouse, Dearholt, Poe, Pugh, & White, 2007, pp. 3–4)

Three key goals in having an EBP are the following: (a) to ensure that the highest quality of care is provided to achieve the best outcomes for patients, (b) to support rational decision making (including structural changes) that reduces inappropriate variation in care, and (c) to create a culture of critical thinking and ongoing learning that grows a practice environment where evidence supports clinical and administrative decisions (Newhouse, Dearholt, Poe, Pugh, & White, 2005). The highest quality is often assumed to be the biggest and latest finding, but that might not necessarily be the case. And it is just as important to eliminate practices that are no longer valid as it is to institute new practices based on evidence. An EBP inquiry is performed for many reasons, but most often, it is because nurses are questioning their practices and are concerned about practice outcomes. Some typical reasons why an EBP inquiry is performed include the following: improvement is needed for a high-risk, high-cost, and/or high-volume patient problem; negative outcomes are being reported; variations in care are noticeable; policy reviews are being completed; and/or healthcare team members are aware of new evidence or that their practice is different from the professional or community standard. The EBP inquiry process, although designed for practice, can be used as an approach to policy making at both the big “P” and little “p” level. Some of the key steps in the EBP movement (searching, critiquing, appraising, and synthesizing evidence) may be helpful to policy makers who are faced with how to find, evaluate, use, or discard scientific information in areas foreign to their background such as healthcare. This problem is aptly called a “research glut and information famine” (Colby, Quinn, Williams, Bilheimer, & Goodell, 2008). Critical synthesis of evidence in relation to the scientific literature and making it relevant to policy makers are important steps in bridging the gap between the explosion of knowledge and the lack of information (Andermann, Pang, Newton, Davis, & Panisset, 2016). Nurses who are well acquainted with EBP could use its steps to provide policy makers with usable data to guide policy questions and subsequent policy development. Numerous professional associations provide their members with resources on EBP. See Policy on the Scene 5.1.

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POLICY ON THE SCENE 5.1: A Framework for EvidenceBased Practice Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN Director of Evidence-Based Perioperative Practice, Association of periOperative Registered Nurses, Denver, Colorado Evidence-based practice is essential to promoting high-quality healthcare and safety because it ensures that decisions are made based on the evidence rather than on the opinion of an individual provider. Clinical practice guidelines consist of recommendations developed from evidence, along with the evaluation of benefits and harms of various approaches to care. The Association of periOperative Registered Nurses (AORN) publishes national guidelines that are based on a comprehensive, systematic review of research and nonresearch evidence; the individual references are appraised and scored, and the recommendations are rated according to the strength and quality of the evidence supporting the recommendation (AORN, 2018). Guidelines such as these provide a foundation for implementing evidence-based recommendations into state and national policy decisions. AORN has created a framework for evidence-based practice that is used to appraise research and nonresearch studies and determine a recommendation for practice. These appraisal tools help evidence reviewers and authors who work on the AORN guidelines determine both the type and the quality of study used and the strength of the findings. The AORN research appraisal tools can be used to appraise research evidence, which includes systematic reviews; randomized controlled trials (RCTs); and quasiexperimental, nonexperimental, and qualitative studies. The AORN nonresearch appraisal tools can be used to appraise nonresearch evidence, which includes clinical practice guidelines, position or consensus statements, literature reviews, case reports, expert opinion articles, and quality or organizational experiences (Spruce, Van Wicklin, & Wood, 2016). After the evidence is individually appraised, the collective evidence supporting each intervention within a specific recommendation is rated using the AORN Evidence Rating Model. Factors considered when applying this model to the collective body of evidence are the quality of research, the quantity of similar studies on a given topic, and the consistency of results supporting a recommendation. The recommendations in each guideline are given a strength rating that helps guideline readers or policy makers quickly understand the collective level of evidence used to support the practice recommendation. Perioperative nurses and others can use these tools to evaluate research and nonresearch evidence from many disciplines, and the tools should be used by students who are interested in learning more about evidence-based practice. Perioperative nurses and policy makers can be confident in the AORN evidence (continued )

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review process and in knowing that the evidence supporting the AORN Guidelines for Perioperative Practice is the highest quality available and that the guidelines provide reliable guidance to inform perioperative practice. AORN appraisal tools and model are available at www.aorn.org.

Research Research is conducted to discover and generate evidence and knowledge. The need to conduct research can result from an EBP inquiry when the search has found poorquality evidence, conflicting evidence, or no evidence to support a practice change. Research, as defined by the Office for Human Research Protections (OHRP) at the U.S. Department of Health and Human Services (USDHHS, 2009), is a systematic investigation, including research development, testing, and evaluation, designed to develop new knowledge or contribute to generalizable knowledge (www.hhs.gov/ohrp/regulationsand-policy/regulations/45-cfr-46/index.html). Researchers must complete formal educational training to meet OHRP standards for the protection of human subjects and have their research protocols reviewed and approved by their organization’s institutional review board (IRB). Report of the research results must include specific protections for confidentiality. Generally, three types of research can influence policy: disciplinary research, policy research, and policy analysis (Hinshaw, 2011). Disciplinary research and policy research are particularly important to harnessing evidence. Each is discussed briefly here. Disciplinary research in nursing, which is often applied in nature, is the type of research most familiar to nurses. Disciplinary research is carried out to provide new knowledge specific to any number of healthcare fields, including, but not restricted to, nursing. Indeed, many times, nurses draw on other disciplinary research to inform their own work. A strong emphasis is placed nationally and often locally on collaborative research among disciplines. In the Policy Challenge and Option for Policy Challenge in this chapter, interdisciplinary work was necessary to move from the local to the state level policy. Policy research is conducted with the purpose of appraising policy translation and used in particular settings or situations to determine effectiveness and usefulness. Nursing policy research has not reached its potential. The body of policy research is small compared with applied disciplinary research. Policy research in nursing is often guided by priorities, especially from the nursing professional and specialty ­associations. In addition, NINR has laid out its strategic plan and the themes that will guide the projects they fund. Similarly, organizations such as the National Pressure Ulcer Advisory Panel (NPUAP) have made public their research priorities for pressure injury prevention, treatment, and policy. These can be found at www.npuap.org/ research-priorities-identified-for-pressure-ulcer-prevention-treatment-policy. Today, leading nurse researchers are having a profound effect on policy development. The research evidence provided by nurses in many arenas is being used to direct management solutions and policy development that benefit patients, nurses, and the employers of nurses (Ellenbecker & Edwards, 2016). Dorothy Brooten, PhD, RN, FAAN, as an early pioneer in policy research, examined the impact of advanced practice nurses (APNs) in providing transitional care for very-low-birth-weight (VLBW) infants. Her Quality Cost Model of Advanced Practice Nurses Transitional Care, developed in 1980,

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was expanded to include other high-risk and high-cost patient groups (e.g., women with unplanned cesarean births or high-risk pregnancies, patients undergoing hysterectomies, elders) to have their care managed by APNs (Brooten et al., 2002). Mary Naylor has continued to extend the transitional care work, and the research over time has led to the Transitional Care Model (TCM) using many of the principles in the work of Brooten and extending it to care with the elderly (Hirschman, Shaid, McCauley, Pauly, & Naylor, 2015). Policy analysis is carried out to determine how well a policy has realized its intended outcomes and whether it has resulted in unintended outcomes (see Chapter 13). Policy analysis is often carried out by staff or commissioned by government agencies, organizations, or associations. Policy analysis is a systematic and formal approach that includes using specific criteria to examine and evaluate a policy problem. It involves developing policy alternatives or options, assessing the potential outcomes of each, and selecting a preferred alternative from among the proposed choices. The policy analysis process includes specific steps quite familiar to nurses: Define the problem, establish evaluation criteria, identify policy choices among alternative solutions, formulate the chosen policy, implement the policy solution, and evaluate the policy. Policy analysis tends to be issue specific. An interprofessional approach, with nurses contributing to the process, is often effective. In Policy on the Scene 5.1, a research project was carried out in a community hospital that arose from an everyday clinical question. It involved a clinically based policy requiring research to determine the best direction for policy formulation. The example demonstrates where nurses returning to school for advanced degrees can use their new skills in leading teams investigating these little “p” issues. These little “p” initiatives are often carried out based on the immediacy of a clinical problem.

Quality Improvement QI is a process designed to evaluate systems and clinical processes with the primary purpose of improving healthcare quality and outcomes for a specific healthcare organization and its patient population. Evaluating these processes usually involves small tests of local changes to the organization’s healthcare delivery. The intent of QI work is to describe and share lessons learned rather than demonstrating a cause and effect to create generalizable knowledge. In QI efforts, the patient is expected to benefit directly (Newhouse, Pettit, Poe, & Rocco, 2006; Reinhardt & Ray, 2003; Shirey et al., 2011). One final comment should be made here. Some types of QI efforts are considered research and are subject to OHRP standards and regulations. When QI projects involve introducing an untested clinical intervention for the purposes of improving the quality of care or establishing scientific evidence about how well the intervention achieves its intended results, it may be considered research. There is considerable variation reported in literature about when specific QI projects require human subject review. Although there may be overlap or lack of clarity in what constitutes research, EBP, or QI, it is important that clinicians have human subjects’ protection training so that they are familiar with OHRP standards and their own organization’s policies. Furthermore, IRBs at different facilities may view protocols and the application of regulations differently. Therefore, it is best to address issues of human subjects’ protection early in the planning process, well in advance of any data-­collection procedures. This is particularly important when collaborating across several institutions.

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As can be seen in several of these definitions, the connection to policy is not overt, so the term implementation science has come into use. This is the study of approaches that support the incorporation of evidence and research findings into both healthcare policy and practice. Implementation science involves addressing the “complexity and systems of care, individual practitioners, senior leadership, and ultimately changing healthcare cultures to promote an evidence-based practice environment” (Titler, 2010, p. 35). It involves examining the factors and context for using knowledge in practice and policy, as well as interventions to promote its implementation (Titler, 2014). Implementing evidence-based policies involves understanding what strategies work and are most effective in a particular care setting.

EVERY NURSE’S ROLE IN TRANSLATING EVIDENCE INTO POLICY Translating evidence into policy (and practice) involves communicating new evidence to decision policy makers in a way that is both understandable and useful. Once again, differing terms are often encountered in describing the process of translation. The term knowledge transfer is defined as a systematic approach for capturing, collecting, and sharing tacit knowledge for it to become explicit knowledge so that individuals and/ or organizations can access and utilize essential information, which previously was known intrinsically to only one person or a small group of people (Graham et al., 2006). Another term, diffusion, refers to a broad process whereby knowledge or evidence is communicated throughout an organization or a larger system. Finally, the term dissemination, which is used frequently in the translation literature, refers to communicating knowledge or evidence in journals, at conferences, or through some other medium. The discussion of the nurses’ role in translation refers to multiple avenues of communication. The translation of evidence into healthcare practice and policy faces multiple challenges. Those challenges are found throughout the healthcare system, with individual providers or teams of providers at the organizational level and both public and private organizations at the local, state, and national levels, such as professional organizations and governmental agencies. See Exhibit 5.2 for a summary of key steps to enhance the use of evidence for policy. It is important for all healthcare professionals to use evidence to make informed decisions about practice and policy, and yet we know this does not happen consistently (Guerden, Adriaenessens, & Franck, 2014; Lockwood, Aromataris, & Munn, 2014, EXHIBIT 5.2 KEY STEPS TO ENHANCING THE USE OF EVIDENCE IN THE

FORMULATION AND IMPLEMENTATION OF POLICIES

1. Familiarize yourself with the evidence related to practice issues. 2. Understand the difference between research, EBP, and quality improvement. 3. Build relationships with policy makers at all levels (organizational, local, state, and national). 4. Raise questions about the evidence used in policies. 5. Lead the development of a research, EBP, or quality-improvement project. 6. Develop an action plan for the dissemination of evidence. 7. Disseminate evidence in a variety of outlets pertinent to the policy issue. 8. Use implementation science principles to carry out policy changes. EBP, evidence-based practice.

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Yost, et al., 2014). In many organizations (e.g., health departments, clinics, hospitals, educational programs), internal data and benchmarks are used only when data may be available at a regional, state, or national level. Using internal data may, however, result in false reassurance about the effectiveness of a program. Internal data from a project, although useful, may not necessarily be subject to the rigor of external peer review. Translating evidence to practice and policy requires that attention be directed toward decreasing barriers to evidence adoption and enhancing factors that facilitate adoption. For instance, consideration must focus on communicating evidence in a timely and relevant manner, responding to the needs of the healthcare profession or organization, and presenting findings in a user-friendly manner easily understandable to decision makers. Good examples of translating evidence into policy do exist. Seat-belt laws that have been proved to save lives have been enacted in 49 states, the District of Columbia, and many U.S. territories; New Hampshire is the only state without such legislation (Brownson, Chriqui, & Stamatakis, 2009). Convincing evidence exists for wearing motorcycle and bicycle helmets to decrease injuries from accidents. Legislation for motorcycle helmets has been passed in 47 states but not always with the same requirements. A total of 19 states require helmets for all riders, and the other 28 require helmets only for certain riders. Bicycle-helmet legislation has been passed only in 21 states; however, many localities have passed bicycle-helmet legislation for their communities. Tobacco-control legislation is similar in that legislation continues to be passed in many U.S. jurisdictions, but the uptake or passage of this legislation takes different formats due to local social, cultural, and economic factors. Nurses have made substantial contributions to the research evidence in many of these areas. Translation of injury-prevention guidelines for healthcare workers in the United States has also shown considerable uptake, most notably in organizations with better resources. Professional associations have also participated in the translation of evidence to policy through the promulgation of position statements and clinical practice guidelines (CPGs). Professional associations bring together panels of experts to review, appraise, and synthesize evidence about a professional issue or a disease or symptom management to make current practice recommendations to their membership and the healthcare community at large. These recommendations may be published in journals or posted on websites and have been adopted at all levels of policy making (organizational, state, and national). They may also be submitted to the National Guideline Clearinghouse, a searchable website hosted by the AHRQ (www.guideline.gov). Safe patient handling and mobility is an example of how organizations are promoting policies based on evidence (see Chapter 2). The identification of this problem started with professional associations and moved through other levels of policy development at the organizational, state, and national levels, involving both the private sector (e.g., businesses, nongovernmental organizations [NGOs]) and government agencies.

Federal Level A widely cited example of the translation of nursing research to policy can be found in the ACA. There is strong evidence showing that hospital readmissions can be significantly reduced and the quality of care for patients can be improved by implementing a program that targets transitions of care. The Community-Based Care Transitions Program (CCTP) under the auspices of the Centers for Medicare & Medicaid Service (CMS, n.d.), created by Section 3026 of the ACA, tests models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries.

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The  goals of the CCTP are to improve transitions of beneficiaries from the inpatient ­hospital setting to other care settings, improve quality of care, reduce readmissions for high-risk beneficiaries, and document measurable savings to the Medicare program (­innovation.cms.gov/initiatives/CCTP/?itemID=CMS1239313; Naylor et al., 2013). Nurse researcher Dr. Mary Naylor developed one of the CCTP models. Her TCM, a translation of an evidence-based strategy into a practice-delivery model, uses APRNs with specialized training to care for older adults with multiple chronic conditions and support their family caregivers (Naylor et al., 2013). Testing the TCM has demonstrated significant and sustained outcomes, including avoiding hospital readmissions and emergency room visits for primary and coexisting conditions, improving health outcomes after discharge, enhancing patient and family caregiver satisfaction, and reducing total healthcare costs (Naylor et al., 2013). The outcomes of transitional care interventions have been evaluated with the goal of providing guidance for the implementation of transitional care programs under the ACA (Naylor, Aiken, Kurtzman, Olds, & Hirschman, 2011). In addition to the TCM being included in the ACA, Aetna has adopted the TCM to achieve better outcomes for its older adult enrollees with multiple chronic problems, AARP has recommended expansion of the services of the TCM to its members, and the National Quality Forum endorsed deployment of evidence-based transitional care such as the TCM as one of 25 national preferred practices for care coordination.

State Level States are pursuing a variety of strategies for getting the research and analytical assistance they need (Coburn, 1998; Pew Charitable Trusts, 2017), including expanding their relationships with university-based health services research and policy analysis programs. A well-known and published translation of evidence to practice and policy at the state level was established by the Michigan Health and Hospital Association Keystone Center for Patient Safety and Quality. This Michigan statewide safety initiative is known as the Michigan Keystone ICU Project. Michigan hospitals with adult ICU beds were asked to implement an evidence-based intervention to reduce the incidence of catheter-related bloodstream infections (CRBSIs). Data were obtained from 67 hospitals, representing 1,625 beds or 85% of all ICU beds in Michigan. The statewide initiative resulted in a large and sustained reduction (up to 66%) in CRBSI rates that were maintained throughout the 18-month study period (Pronovost et al., 2006). Further work indicates that the reduction of central line–associated bloodstream infection (CLABSI) rates were sustained for 10 years with success attributed to active involvement of key leaders, ongoing monitoring, and performance feedback (Pronovost, Watson, Goeschel, Hyzy, & Berenholtz, 2016). The nation is facing an opioid epidemic, with overdose rates continuing to rise dramatically. A statewide intervention program, a collaborative of the North Carolina Medicaid authority, Community Care of North Carolina, and the Mountain Area Health Education Center began in 2013 by asking North Carolina counties to identify opioid overdose-reduction strategies relevant for their communities (Alexandridis et  al., 2017). These strategies included community education, provider education, emergency department policies requiring additional checks before prescribing opioids, diversion control, support programs for pain, policies for naloxone distribution, and addiction treatment. The implementation of this model in a pilot study in one county resulted in a 69% reduction in opioid overdoses. By 2014, 74 of 100 counties had implemented some intervention strategies, resulting in a reduction of overdose mortality rates (Alexandridis et al., 2017).

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Local Level On a local level and a public–private collaborative, the city of Baltimore has an ­initiative called B’more for Healthy Babies (BHB) that was designed to improve the quality of care provided by physicians, nurses, social workers, and others who work with pregnant and postpartum women and has helped all home visiting programs in Baltimore to transition to evidence-based models of care. The BHB Initiative is sponsored by the Office of the Mayor of Baltimore, the Baltimore City Health Department, and the Family League of Baltimore City, Inc., with catalytic funding from CareFirst BlueCross BlueShield and other donors. One major program is an evidence-based strategy called the BHB sleep initiative: Alone. Back. Crib. Don’t Smoke (www.healthybabiesbaltimore.com). The BHB sleep initiative has distributed culturally sensitive video materials to more than 120 sites to educate families on proper evidence to prevent crib deaths. Posters are used to target the message to different audiences to provide the evidence for the initiative to the public (see Figure 5.1 for one message).

FIGURE 5.1  Sleep safe. Alone. Back. Crib. Don’t Smoke. No exceptions. Source: Reprinted with permission from Baltimore City Health Department.

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Although a direct correlation between the initiation of BHB and the drop in the infant mortality rate (IMR) cannot be made, the Baltimore IMR has dropped 38% and sleep-related infant deaths in Baltimore City have decreased by more than 50% since implementation of the BHB sleep initiative in 2009. However, in 2015, an African American infant was almost two times more likely to die than a white infant, indicating that additional work needs to be done in this community (see Chapter 14). The BHB initiative has continued to expand its reach. The program also works to improve low-birth-weight delivery rates and maternal and infant outcomes. (Harvey et al., 2016) In addition, work that originated with the BHB program has expanded into the B’more Fit Coalition, a group of local partners that works to shape polices related to nutrition, fitness, and wellness in the Baltimore area (Truiett-Theodorson, Tuck, Bowie, Summers, & Kelber-Kaye, 2015).

Organizational Level At the organizational level, there are many examples of translation of evidence into practice and policy, and often these are different types of translations because of the origins of their evidence. Clear evidence exists on the health hazards of smoking. Translating that evidence in organizations has offered specific challenges and great opportunities to an organization. The University of Arkansas for Medical Sciences, Healthy Arkansas, and the Arkansas Department of Health developed an evidencebased approach to creating a Smoke-Free Workplace and a Smoke-Free Hospital Toolkit: A Guide for Implementing Smoke-Free Policies aimed at three audiences: employers, healthcare providers, and community members (Sheffer, n.d.). The toolkit recommends that a comprehensive smoke-free workplace implementation needs to include a policy, a timeline, training, a communication plan for a smoke-free message, assistance with smoking cessation for employees and patients, and a plan for ongoing support of the implementation (www.uams.edu/coph/reports/smokefree_toolkit/ Hospital%20Toolkit%20Text.pdf). The guide suggests that smoke-free policies should include purpose, definition, facilities and areas affected, use of those facilities by outside parties, patient and visitor smoking, tobacco sales on campus, progressive counseling and enforcement, available smoking-cessation programs, breaks, and smokeless tobacco use. Another example of an organization-wide translation, resulting from strong, highquality evidence, is the implementation of policies regarding the wearing of artificial nails for direct caregivers in the hospital setting. In 2002, the Centers for Disease Control and Prevention (CDC, 2002) published Guideline for Hand Hygiene in Healthcare Settings, recommending that healthcare workers not wear artificial fingernails or extenders when having direct contact with patients at high risk, such as in intensive care units, transplant units, or operating rooms. Elaine Larson, PhD, RN, FAAN, CIC, who has conducted extensive research on hand hygiene, was a member of the two major committees (CDC Hospital Infection Control Practices Advisory Committee and the Hand Hygiene Task Force) that authored the hand hygiene guidelines. Each year since 2007, The Joint Commission (TJC, 2014) has published the National Patient Safety Goals, which include a goal to reduce the risk of healthcare-associated infection and with specification that healthcare organizations must comply with current CDC or WHO hand hygiene guidelines. In addition, many nursing specialty associations have also endorsed the use and translation of evidence in the form of CPGs. For example, the Association of periOperative Registered Nurses (AORN) recommends that acrylic (artificial) nails should not be worn, providing rationale that numerous studies validate the increased

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number of bacteria cultured from the fingertips of persons wearing artificial nails, both before and after hand washing. Another opportunity for translation at the organizational level is to ensure that policies and procedures are based on the best available evidence. This opportunity to question current evidence or seek out new evidence arises frequently when there is a need to develop a new policy or procedure or during the annual review of current policies and procedures. Not all policies need to be reviewed with an extensive evidence-based protocol; it is necessary to consider other influencing factors, such as other initiatives that may be taking place, along with an assessment of the priority of the policy needing to be changed. This assessment may come from a number of sources (e.g., quality data, new knowledge, staffing issues in implementing a policy). Knowing how to find evidence is a vital skill set. It is important for nurses with advanced education to have these skills to guide and mentor others in finding evidence resources. Finding evidence can be a daunting experience regardless of one’s background. Although numerous resources are available, all policy issues do not have adequate data for informing policy, and access to resources may be limited. When working in a clinical agency with electronic health records, access to the evidence used for the clinical decision-making tools provided with the software may be available. A nursing program’s library resources may vary from those where you have been employed. Listing these resources is beyond the scope of this book, but a good overview of resources can be found at many academic and hospital library home pages. A health sciences librarian at either a nursing program or a hospital can be invaluable member of a team when searching for evidence. It is increasingly common for a librarian to be a team member for conducting systematic reviews. The library at the University of Rochester provides an example of resources and explanations of resources that can be found online and are available to the public (see Tools for Nursing Research–Finding the Evidence at www.urmc.rochester. edu/libraries/williams/electronic_resources/NursingResearchEBP.cfm). However, there are many other examples when healthcare practices are questioned in organizations and the quality, quantity, and consistency of evidence is not available to make a practice change. In these cases, and many others, it is necessary for the organization to generate its own evidence to support practice decisions in the form of QI or research. Policy on the Scene 5.2 illustrates interprofessional collaboration and how answering one question on policy may lead to another.

POLICY ON THE SCENE 5.2: When Opportunity Knocks, Answer the Door! Healthcare Services for Transgender Individuals: Position Statement Carol Sedlak, PhD, RN, ONC, FAAN Professor Emeritus, Kent State University, Kent, Ohio Often, an opportunity comes knocking at your door when least expected. This was an unplanned journey in a new area for this researcher who seized the opportunity to study transgender individuals, a marginalized population. The journey led to unexpected dissemination via policy development. (continued )

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How did my journey lead to conducting research with transgender i­ndividuals? My expertise is in orthopedic nursing with a focus on osteoporosis prevention. As a nurse researcher, I was one of the first nurse researchers to explore osteoporosis prevention in women and men long before osteoporosis became a public health concern. The journey began in a conversation with faculty colleague, Cyndi Roller, about her research on transgender individuals’ access to healthcare. She expressed interest in wanting to team up with a fellow researcher successful in obtaining research grant funding. My first thought was how could we possibly merge our interests—osteoporosis prevention with the transgender population?—Is there a connection? How could this be an opportunity for both of us? As we brainstormed and searched the literature, an idea was generated: transgender individuals’ bone health and the effect of using cross-sex hormones. There were no nursing studies on this topic. However, if I were going to pursue this research area, I needed to learn about the population. Since this was a population in whom I had no experience, I felt somewhat uncomfortable. Why would I want to pursue such an undertaking at this stage of my research career? Why not, I thought. As a nurse educator with a strong belief in the promotion of adult learning, I believe that educators, whether in the academic or clinical setting, need to practice what they preach. This means learning something new on a regular basis that takes you out of your comfort zone. This helps to develop an understanding of what students and patients experience when they are exposed to learning something new, whether it be a new class or some new aspect of their healthcare. First, I needed to immerse myself in the literature to explore what evidencebased practice existed for overall transgender health, and then explore bone health and use of cross-sex hormones. I planned meetings with leaders in the transgender community and learned about the life of transgender individuals: their challenges, frustrations, and healthcare needs. These interactions served in conducting an informal needs assessment for this marginalized population. In attending transgender support group meetings, I gained the trust of the community. The goal was to establish myself as a credible and knowledgeable healthcare professional who wanted to help. I became more comfortable and exhilarated in making a research contribution for this diverse group. To immerse myself in learning about the transgender population, I became a member of Dr. Roller’s newly established research team exploring how transgender individuals engage in healthcare. This was an invigorating opportunity and led to a publication on how transgender individuals navigate the healthcare system (Roller, Sedlak, & Draucker, 2015). Next, we developed a grant proposal addressing transgender individuals and osteoporosis prevention funded by the American Academy of Nursing (AAN) and Sigma Theta Tau International. The research was a success and the results were published (Sedlak et al., 2017). Something kept gnawing in me about the need to further disseminate the research and promote a greater awareness of the healthcare needs of transgender individuals. Then an unexpected opportunity came knocking at my door to lead (continued )

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policy development for transgender individuals’ health. On being inducted as a Fellow into the AAN, I expected to engage in service. I chose to accomplish this by volunteering to serve as a member of an AAN Expert Panel. However, there were many panels to choose from such as Aging, Health Behavior, and Women’s Health. Which one should I select? The purpose of the AAN Expert Panels is to promote knowledge development and collaboration and shape health policy and practice for addressing the health needs of populations, including diverse populations. This can be in a variety of formats such as policy proposals, policy briefs, and position statements. On talking with a colleague at an Academy conference and sharing my research endeavors addressing transgender individuals, I was encouraged to join the Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ) Health Expert Panel. I was welcomed to the panel; it was a good fit. As the strategic planning for the panel’s work evolved, one of the goals focused on transgender individuals’ healthcare. This was an opportunity for dissemination knocking on my door. I volunteered to lead the endeavor. This was a first-time experience for me. How do you go about doing this? I learned that the expert panel may develop either a position statement or a policy brief. A policy brief is two to four pages with a list of actionable positions and recommendations from the Academy. A position statement is generally a short one-page document that states the Academy’s overall position on a specific area. Our panel decided to pursue the development of a position statement on healthcare services for transgender individuals. It was a relief to learn that the AAN provides a format for the position statement, including a detailed plan for dissemination that would begin with publication in Nursing Outlook. We were to include names, emails, and website URLs of contacts in various organizations for press release and dissemination that included (a) all nursing organizations in the AAN database; (b) non-nursing f­ederal organizations, including the White House and pertinent offices (e.g., Office of Public Engagement, Congressional LGBTQ Equality Caucus, National Institutes of Health), (c) medical non-nursing organizations (e.g., American College of Physicians, The Joint Commission, Gay and Lesbian Medical Association: Health Professionals Advancing LGBT Equality), (d) nonmedical/non-nursing organizations (e.g., World Professional Association for Transgender Health) briefing events on Capitol Hill; (e) media outlets located in the AAN database; (f) press releases; and (g) social media LGBTQ contacts (e.g., Facebook, blogs, Twitter). The position statement was developed over several months, much quicker than anticipated, since the evidence had already been gathered and the research had been conducted. The document was approved by the AAN board, and published (Sedlak, Boyd, & AAN LGBTQ Health Expert Panel, 2016). In conclusion, when opportunity knocks, do not be afraid to open the door. You may not know exactly where the journey may take you, but take a risk and as you move forward, use your expertise and accomplishments. You will find that you can contribute by disseminating in a variety of formats that you may have not tried, including policy development.

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STRATEGIES FOR DISSEMINATION OF EVIDENCE Carrying out evidence-based research or QI is not complete if the work is not ­disseminated and the policy implications explicated. Often, however, dissemination is not given consideration, especially at the level of the little “p,” until someone outside of the project hears about it and encourages dissemination. Dissemination should be part of the early planning of projects. Seasoned researchers know the value of developing dissemination plans from the earliest planning of a project and being cognizant of dissemination opportunities that may develop as a project develops. To effectively harness evidence for policy, there must be some method of dissemination. Over time, authors have identified key determinants and strategies that can guide the translation of evidence to policy makers (Grimshaw, Eccles, Lavis, Hill, & Squires, 2012; Jacobson, Butterill, D., & Goering, 2003; Lavis, Posada, Haines, & Osei, 2004). Four major elements that are basic to messaging in general, and to researchers conveying messages about evidence they have harnessed, are knowing and selecting an audience, selecting dissemination techniques, understanding that context matters, and providing communication that is timely, relevant, understandable, and practical. Although listed as separate elements, there is overlap. The type of audience you select influences what method you use to communicate your evidence. The immediacy of the evidence to a problem at hand is likely to influence how quickly and widespread you will want to convey your work.

Know Your Audience Choosing dissemination strategies involves identifying and knowing the audience who needs to be involved in the translation. Identifying those with something to gain and something to lose is critical to the planning (Weston, White, & Peterson, 2013; also see Chapters 7 and 10). At a minimum, evidence from projects needs to be shared across an organization, and wider audiences should be routinely sought out. As you strategically plan for dissemination, consider who within your organization should be informed about the project: patients, professional colleagues, staff, managers, and/or administration. Outside the organization, consider if your audience is local, national, and/or international; you also need to consider who you should target. It may be that your results have bearing across a number of audiences, including lay audiences. Often, you choose to disseminate your evidence to predetermined stakeholders who are decision makers or who are strongly influential in the issue at hand. Clinicians, administrators, researchers, and lay audiences may all be important stakeholders. In policy analysis and, later, during the translation of evidence to policy, it is important to perform a stakeholder analysis. A stakeholder analysis identifies those who may positively or negatively influence the success of your project, allows you to anticipate their influence, and provides you the opportunity to get the most effective support for the project and address barriers to implementation early in the translation process. There are key steps in any stakeholder analysis (see Chapter 6). Early research into understanding audiences and targeting interventions to them focused on the appropriateness and efficacy of specific interventions and showed that there was considerable lack of knowledge about which strategies work best for different audiences. Research on the translation of research into practice initiatives funded by the AHRQ indicates that the most commonly used intervention to translate evidence to the relevant audience was educational (Farquhar, Stryer, & Slutsky, 2002).

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EXHIBIT 5.3 BLUEPRINT FOR EFFECTIVE STRATEGIES IN THE DISSEMINATION

OF EVIDENCE-BASED PRACTICE THROUGH A NATIONAL QUALITY CAMPAIGN Strategy 1: Highlight evidence base and relative simplicity of recommended practices. Strategy 2: Align the campaign with the strategic goals of the adopting organizations. Strategy 3: Increase recruitment by integrating opinion leaders into the enrollment process and employing a nodal organizational structure. Strategy 4: Form a coalition of credible campaign sponsors. Strategy 5: Generate a threshold of participating organizations that maximizes network exchanges. Strategy 6: Develop practical implementation tools and guides for key stakeholder groups. Strategy 7: Create networks to foster learning opportunities. Strategy 8: Incorporate monitoring and evaluation of milestones and goals.

Source: Reprinted with permission from Yuan, C. T., Nembhard, I. M., Stern, A. F., Brush, J. E. Jr., Krumholz, H. M., and Bradley, E. H. (2010). Blueprint for the dissemination of evidence-based practices in health care. Issue Brief (The Commonwealth Fund), 86, 1–16. Retrieved from https://www.commonwealthfund.org/publications/issue-briefs/2010/may/ blueprint-dissemination-evidence-based-practices-health-care

However,  educational materials (e.g., distribution of recommendations for clinical care, CPGs, audiovisual materials, electronic publications) and didactic educational meetings (e.g., lectures) have been shown to be the least effective ways to reach an audience (Bero et al., 1998). Yuan and colleagues (2010) reviewed four national campaigns designed to disseminate evidence for practice policy improvement and developed a "Blueprint for Effective Strategies in the Dissemination of Evidence-Based Practice Through a National Quality Campaign” (see Exhibit 5.3). In proposing these strategies, the authors stated that the existing literature was not able to evaluate which of these eight strategies are most important and whether any subset is sufficient. This supports previous work suggesting that dissemination strategies for the uptake of evidence should be multifaceted even when aimed at a single audience.

Select Dissemination Techniques Once you have determined who your audience is, then it is important to consider what method or methods of communication will be used to disseminate your evidence. The audience and purpose are vital to knowing how you disseminate your evidence. There are numerous other types of dissemination that should be considered, and several of these (e.g., press releases, white papers) are discussed in Chapter 10. Often, dissemination is not a singular act. If, for example, you have an article selected for a major publication or a premier research conference, you may want to consider submitting a press release to the local newsletter of an association or for work, as well as submitting the release to the local paper or even writing a letter to the congressional representative. Researchers may only think of journal articles and peer-reviewed presentations for purposes of dissemination. However, venues do not often reach policy makers and the policy implications are not often called for or discussed in articles. Thus, you can

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EXHIBIT 5.4  DISSEMINATION BEYOND ARTICLES • • • • • • • • • • • •

Classroom presentations Fact sheets Newsletters Pamphlets Posters Presentations Public meetings (e.g., school board meetings, support groups) Reports (technical or research) Social media sites Town halls Webpages Workshops

consider is how you can meaningfully discuss policy implications in the venue you have selected, using venues that routinely consider policy implications of research as a requirement for the work, or writing a policy article with the research findings providing the evidence. Finally, consider whether the professional dissemination you have planned (e.g., poster, article) lends itself to its own publicity. Consider working with your marketing department to highlight work that has received acclaim by being accepted or by being published in a major venue. To help in the consideration of avenues for disseminating one’s work, consider whether the evidence lends itself to the written or oral format or both. Often, a combination of dissemination modalities may be considered, and it is helpful to convey your findings. Besides formal posters at professional organizations, consider displaying a poster exhibited at a conference in a public spot at work so that colleagues and administrators, lay audiences, or students may be exposed to it. In addition, it is important to consider the use of social media platforms to disseminate work. Examples such as blogs, Twitter, Facebook, and other social networking programs may often reach a broader audience and augment traditional forms of publication. Exhibit 5.4 lists some examples of venues to consider for presenting evidence. Although we often think of dissemination as external process, it is a strategy that can and should be used more widely within work settings. Too often within a work setting, individuals are not aware of what others are working on, so efforts get duplicated and lost. Projects carried out on one unit have the potential to be incorporated across several others. The exposure to nurses and managers across units can help spread policy uptake. Dissemination internally can include the techniques included in Exhibit 5.3.

Context Matters It is critical to recognize and understand the social, political, economic, historical, ethical, and legal contexts and other forces in the environment, both facilitating and constraining, that are present in any effort to integrate evidence into policy and practice. How do we increase the use of evidence for policy making among healthcare professionals and nurses specifically? There are several strategies. First is attempting

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to understand how nurses and other health professionals receive, critique, and adopt evidence for practice and policy change. Research into how adoption occurs, known as diffusion of innovations, is manifested in different ways because of organizational and individual factors and the way that decisions to adopt are made. Researchers have identified five categories of adopters differentiated by their speed and acceptance of change: innovators, early adopters, early majority, late majority, and laggards (Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004; Rogers, 2003). Likewise, identification of which organizational factors play a role in facilitating translating evidence and innovations into practice and policy can be counted on to assist in the translation process. These factors include an organizational structure that facilitates communication and relationships; strong involvement by senior leadership; effective clinical leadership and interprofessional team practice; organizational culture supportive of learning and inquiry; and resources, expertise, and infrastructure to support evidence acquisition, appraisal, change implementation, and management. Another strategy for identifying the barriers for the uptake of evidence to change practice and create policies is based on evidence. Murthy and colleagues (2012) listed obstacles that health systems face when dealing with a large volume of research evidence and the difficulties they have adapting evidence to the local setting. They suggest that a practical intervention might be to develop an organization’s summaries of systematic reviews to improve the accessibility of findings. In addition, on the local level, organizations should consider employing a specialist to synthesize evidence to inform local decision making. The authors concluded that if the message is relatively clear and simple, passive dissemination of the evidence can work. Context also matters at the big “P” level. Policy makers want to know research findings that have policy implications for their constituents. When providing information about new evidence that supports a policy change, the communication should be in plain language and include the number of constituents may be affected by the change.

Communicating Research So That It Counts When asked what they needed for decision making, policy makers identified three needs for use of research evidence in the development of policy: a clear translation of the information that is relevant to their needs, information that is available and accessible when needed, and information that is presented in user-friendly format (Colby et al., 2008; Innvaer et al., 2002). Thus, like many of us in everyday life, we want material that tells us what we need to know and makes the information easy to obtain. Because the language of research itself can be complex and researchers talk among themselves using research language, it is easy to forget about other audiences and talk in research terms that are not well understood outside of research communities. A similar phenomenon can be seen in our overuse and complexity of “medical speak” with patients. The evidence message must be clearly stated, timely, relevant, and responsive. Frequently, when evidence is needed, it is not readily accessible or available to those who need it. If the information is available, the evidence message is not described in a way that resonates with those targeted to receive the message. Data supporting the importance of adopting new evidence into practice and policy can help propel decision makers to act (Bradley et al., 2004). Data points or “killer numbers” would be selected for use in the messaging as appropriate. Today’s dynamic environment

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requires that effectiveness data be included whenever possible. As many have ­experienced, if new evidence is going to be adopted, something else might have to be given up, such as an old way of doing things. Making the “business case” for the translation of evidence to practice and policy, such as any financial or administrative data to accompany the clinical evidence, might motivate an otherwise complacent decision maker. To convey the message, it is critical to have a well-thought-out and comprehensive communication plan that allows you to “tell your story.” What communication media will be used? Will there be different messages for different media presentations? To increase the success of the translation, you should know what is newsworthy in the environment (e.g., organizational, local, state, national; see Chapter 10). The plan should design messages that fit the audience or different audiences. For example, presentation to a large audience might include a PowerPoint presentation or a video. Equally important is the 30-second sound bite or elevator speech that is designed to be given in the 30 seconds that you have as you run into an essential stakeholder in the hallway or at a meeting. When considering development of the message, a challenge arises to identify the key messages for different audiences and to present them in the appropriate understandable format. Unfortunately, journal articles and research reports are written for researchers, not decision makers. However, there are several formats that are used to communicate evidence depending on the needs of the audience. As the message is crafted, it is important to inform, not inundate. Too often the dissemination of evidence into practice and policy is hampered by inadequate presentation of the new information. The goal of translating evidence into practice and policy requires first that the new evidence be synthesized into usable information in a readable format for decision makers. Several understandable and readerfriendly formats are used to communicate new research evidence to decision makers, healthcare practitioners, and the public. At a local level, one method that many across clinical systems are familiar with is situation, background, assessment, and recommendation (SBAR). The same approach can be used to show why a policy change is needed and what evidence exists for the change. Decision makers are often besieged with information and have very little time to stay abreast of changes in current research or emerging evidence that could be of great use. They are interested in short, easily skimmed, and policy-focused information that focuses on the evidence findings, rather than all the research methods. Up-to-date systematic reviews, or other syntheses of research findings, facilitate the communication of evidence to inform decision makers. A systematic review is used to identify, select, appraise, and synthesize existing research on a specific topic. Systematic reviews can be found in the peer-reviewed literature indexed in familiar databases such as the Cumulative Index to Nursing and Allied Health Literature (CINAHL) or MEDLINE or at repositories developed for evidence such as the Cochrane Library (2013) or the Joanna Briggs Institute. The purpose of writing a systematic review is to identify, judge, and synthesize all the observed evidence that meets prespecified criteria to answer a given research question. The author of the review uses explicit methods aimed at minimizing bias to produce more reliable findings that can be used to inform decision making. However, even systematic reviews are criticized because the content of evidence resources is often not enough for the needs of the decision makers, since many of these reviews focus on the strength and validity of evidence rather than its applicability. To be useful, the systematic review must clearly state its research question and not only describe the synthesis methods,

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but also include a discussion of the intervention and any recommendations made. However, in a systematic review on how to improve use of systematic reviews by policy makers, it was concluded from eight studies that there was no strong evidence to support using a singular best approach to develop awareness and knowledge of the new evidence (Murthy et al., 2012). Thus, although systematic reviews can play a role in policy making, their potential use needs further exploration and development for wider adoption by policy makers (Fox, 2017). A common dissemination tool specific to policy is a policy brief: a succinct presentation of an issue with policy options (usually including new evidence) geared to a specific audience. It is usually written for decision makers and is often referred to as a two-pager. The policy brief attempts to make the issue understandable by presenting information on the problem, delineating policy options, and making a recommendation for the best option. The details of a policy brief and an example can be found in Chapter 10. For some decision makers, a policy brief on the topic may be the first and only thing they read on the subject; for others, it may be the first effective compilation of evidence in a single accessible format, and for others, it may be entirely redundant.

OPTION FOR POLICY CHALLENGE: From the ICU to the State Capitol: Policy Change Starting at the Bedside The Take It to the Street campaign employed multiple strategies to roll out its message from a health system to the larger community and across the state. The staff of the Just for Kids Critical Care Unit created statewide public awareness on nonaccidental pediatric head trauma. Pamphlets on proper ways to handle a crying baby were delivered to primary care offices. Presentations on the scope of nonaccidental trauma were made across the state. In addition, the staff used evidence to support their policy efforts. In a retrospective study using their unit-level data, the team identified bruising patterns in nonaccidental trauma patients that were indicative of risk for future child abuse (Pierce, Kaczor, Aldridge, O’Flynn, & Lorenz, 2010). This evidence was used to improve daily practice, resulting in the creation of bruising screening tools with automatic referrals to Social Services and the Pediatric Forensics Department for positive findings. In 2010, Kentucky legislators introduced House Bill 285, that required mandatory education for pediatric abusive head trauma. The staff at Norton Children’s Hospital were instrumental in getting the bill passed, making weekly trips to meet with legislators to share both their patient stories and the evidence that supported the policy change. What started as a few passionate individuals in the Just for Kids Critical Care Unit resulted in a major policy change across Kentucky. The hospital has seen an increase in child abuse referrals and a decrease in morbidity and mortality. The state has dramatically decreased their number-one ranking in the United States for deaths of children from nonaccidental trauma. These individuals did an exceptional job of harnessing evidence in the policy process while ultimately saving lives (J. O’Flynn, personal communication, October 9, 2017).

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IMPLICATIONS FOR THE FUTURE While harnessing evidence is not without controversy, it is expected that evidence use for all levels of policy making will continue to be emphasized. As we move to the near future when more nurses are prepared with the skills to advance research and better understand the processes of quality and EBP, as well as the potential interplay among all three, nurses can produce better-quality evidence with the purpose of impacting policy. Involving all nurses, as well as healthcare teams, in monitoring evidence related to policy is essential. It is not sufficient for us to defer QI to the “quality nurses,” EBP to nurses who are members of an EBP internship or ­academy, or research to academics in nursing or to projects done while in school that are never applied to a real practice setting. A challenge that remains is to integrate and use the evidence from these three processes more effectively and efficiently. Harnessing evidence is also important at the big “P” level; therefore, nurses who are carrying out disciplinary or interprofessional research must consider the policy implications of research that they undertake as they design their work. We must be thoughtful and explicit when translating research for policy not only in how, but also to whom, we present the evidence. In the future, more attention will be given to the difficult job of eliminating longstanding policies based on outdated information that could potentially harm patients. Many policies are based on evidence that may not be synthesized, evidence that is ignored because of cultural beliefs, outdated evidence carried over from outdated education, or the competition’s adoption of a policy. Furthermore, we need to be poised with the range of policy skills to make use of evidence; research evidence alone will not change policy. Communicating and disseminating evidence more quickly and more efficiently are critical to moving good practice from isolated practices and organizations to systems and regions and beyond. Lag time from evidence to viable policy must be decreased.

KEY CONCEPTS 1. Harnessing evidence involves locating evidence and using it at the right times and places in the policy-making process. 2. Institutionalization of research does not create a clear path to policy making, as illustrated by the disconnect between research evidence and policies found in clinical settings. 3. Efforts have been instituted globally to ensure that decision making in policy is informed by evidence. 4. Cultural differences between researchers and policy makers create challenges in translating evidence into practice. 5. The responsibility for ensuring the transfer of new research into policy and practice tends to be viewed as a unidirectional flow from researchers to policy makers. 6. Communication between researchers and policy makers has an important role in translating research into policy. 7. Differences in the understanding and use of research, EBP, QI, and translation research illustrate the complexity of harnessing evidence for practice and policy. 8. Translating research into policy involves communicating information about research in a useful and understandable manner. 9. Challenges in translating evidence into policy include decreasing barriers and enhancing facilitators of evidence adoption.

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10. Translation of evidence into policy has been successful at the federal, state, local, and organizational levels. 11. Opportunities within organizations for translating evidence into policy include ensuring that current practices and policies are based on the best available evidence. 12. Carrying out research, EBP, or QI requires a comprehensive dissemination plan to harness evidence for policy. 13. Nurses need to be prepared in a wide range of skills to make use of data that have implications for policy.

SUMMARY The term evidence-based policy is used in the literature, yet generally relates to one type of evidence—that of scientific research. The literature and some organizations, including the WHO, are using the term evidence influenced or evidence informed to reflect the need to consider different types of evidence and use of the best available evidence when dealing with everyday problems and issues in the healthcare environment. Research and nonresearch evidence both play an important role in the translation of evidence to practice and policy. This chapter has presented the importance of context as critical to translation. When new evidence is generated or discovered, it is essential that not only the new evidence is evaluated on the quality and strength of that evidence, but also an organization must consider the “fit and feasibility” of the uptake and adoption of that evidence in that environment (organizational, professional, local, state, and national). The fit and feasibility test considers things in the environmental context such as values, beliefs, norms, history, resources, infrastructure, legislation and regulation, politics, and the competency, skills, and knowledge of those involved. Translation of evidence is not a linear process, and attention needs to be given to actively coordinating the dissemination to ensure that the evidence is implemented according to the plan.

LEARNING ACTIVITIES 1. Ask nurses employed in clinical positions in various settings about their knowledge and use of clinical guidelines available from specialty organizations and government agencies, such as the AHRQ or the CDC. 2. Locate resources for EBP at your place of employment and compare them to the resources for EBP at an academic institution. 3. Visit your specialty organization and review their process for standards/guideline creation and the level of evidence used in the process. 4. Visit the websites of your federal and state legislators and identify one bill that they support or do not support that has healthcare implications. Write a letter to a legislator citing evidence for support or lack of support of this piece of legislation. 5. Identify a policy in your organization (work or school) related to health or nursing education. Discuss the level of evidence that is available to support the change. 6. Locate three research articles on a topic of interest to you and your organization. Evaluate the degree to which policy implications are discussed in each article. For each, briefly summarize policy implications that need further explication. 7. Discuss two or three policies needing change in a healthcare organization. Describe the approach or combination of approaches (research, EBP, or QI) to change one of the identified policies.

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E-RESOURCES • AARP Public Policy Institute http://www.aarp.org/research/ppi • Academy Health http://www.academyhealth.org • Agency for Healthcare Research and Quality (AHRQ) http://www.ahrq.gov • Center for Economic and Policy Research (CEPR) http://www.cepr.net • Cochrane Collaboration http://www.cochrane.org • Commonwealth Fund http://www.commonwealthfund.org • Dartmouth Institute for Health Policy & Clinical Practice http://www.tdi.dartmouth.edu • Evidence-Informed Policy Network (EVIPNet) http://www.who.int/evidence/about/en • Office for Human Research Protections https://www.hhs.gov/ohrp/ • Health Research and Policy Systems http://www.health-policy-systems.com • Institute for Women’s Policy Research (IWPR) http://www.iwpr.org • Joanna Briggs Institute http://joannabriggs.org • Kaiser Family Foundation http://kff.org • Patient-Centered Outcomes Research Institute (PCORI) https://www.pcori.org • RAND Corporation http://www.rand.org/about/glance.html • Robert Wood Johnson Foundation (RWJF) http://www.rwjf.org • U.S. Department of Health and Human Services Office for Human Research Protections, Quality Improvement Activities FAQs https://www.hhs.gov/ohrp/regulations-and-policy/guidance/faq/quality -improvement-activities/

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Lavis, J. N., Ross, S. E., Hurley, J. E., Hohenadel, J. M., Stoddart, G. L., Woodward, C. A., & Abelson, J. (2002). Examining the role of health services research in public policymaking. Milbank Quarterly, 80(1), 125–154. doi:10.1111/1468-0009.00005 Levine, J. (2007). Lost in translation: Facing up to translational research. Diabetes, 56(12), 2841. doi:10.2337/db07-1371 Lewis, S. (2011). How research influences policy makers: Still hazy after all these years. Journal of the National Cancer Institute, 103(4), 286–287. doi:10.1093/jnci/djq543 Lockwood, C., Aromataris, E., & Munn, Z. (2014). Translating evidence into policy and practice. Nursing Clinics of North America, 49, 555–566. doi:10.1016/j.cnur.2014.08.010 Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and health care: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins. Melnyk, B. M., Gallagher-Ford, L., Thomas, B. K., Troseth, M., Wyngarden, K., & Szalacha, L. (2016). A study of chief nurse executives indicates low prioritization of evidence-based practice and shortcomings in hospital performance metrics across the United States. Worldviews on EvidenceBased Nursing, 13(1), 6–14. doi:10.1111/wvn.12133 Meslin, E. M., Blasimme, A., & Cambon-Thomsen, A. (2013). Mapping the translational science policy “valley of death.” Clinical and Translational Medicine, 2(1), 14. doi:10.1186/ 2001-1326-2-14 Mueller, C., Bowers, B., Burger, S. G., Cortes, T. A., & Expert Panel on Aging. (2016). Policy brief: Registered nurse staffing requirements in nursing homes. Nursing Outlook, 64(5), 507–509. doi:10.1016/j.outlook.2016.07.001 Murthy, L., Shepperd, S., Clarke, M. J., Garner, S. E., Lavis, J. N., Perrier, L., … Straus, S. E. (2012, September 12). Interventions to improve the use of systematic reviews in decision-making by health system managers, policy makers and clinicians. Cochrane Database of Systematic Reviews, 9, CD009401. doi:10.1002/14651858.cd009401.pub2 Naylor, M. D., Aiken, L. H., Kurtzman, E. T., Olds, D. M., & Hirschman, K. B. (2011). The care span: The importance of transitional care in achieving health outcomes. Health Affairs, 30(4), 746–754. doi:10.1377/hlthaff.2011.0041 Naylor, M. D., Bowles, K. H., McCauley, K, M., Maccoy, M. C., Maislin, G., Pauly, M. V., & Krakauer, R. (2013). High-value transitional care: Translation of research into practice. Journal of Evaluation in Clinical Practice, 19(5), 727–733. doi:10.1111/j.1365-2753.2011.01659.x Newhouse, R. P., Dearholt, S., Poe, S., Pugh, L. C., & White K. M. (2005). The Johns Hopkins nursing evidence-based practice model. Baltimore, MD: Johns Hopkins Hospital & Johns Hopkins University School of Nursing. Newhouse, R. P., Dearholt, S. L., Poe, S. S., Pugh, L. C., & White, K. M. (2007). Johns Hopkins nursing evidence-based practice model and guidelines. Indianapolis, IN: Sigma Theta Tau International. Newhouse, R. P., Pettit, J. C., Poe, S., & Rocco, L. (2006). The slippery slope: Differentiating between quality improvement and research. Journal of Nursing Administration, 36(4), 211–219. doi:10.1097/00005110-200604000-00011 Orton, L., Lloyd-Williams, F., Taylor-Robinson, D., O’Flaherty, M., & Capewell, S. (2011). The use of research evidence in public health decision making processes: Systematic review. PLoS One, 6(7), e21704. doi:10.1371/journal.pone.0021704 Patient-Centered Outcomes Research Institute. (n.d.). PCORI 101. Retrieved from http://www.pcori .org/assets/articulate_uploads/PCORI_1018/story.html Pew Charitable Trusts. (2017). How states engage in evidence-based policymaking: A national assessment. Washington, DC: The Pew Charitable Trusts. Retrieved from http://www.pewtrusts.org/en/ research-and-analysis/reports/2017/01/how-states-engage-in-evidence-based-policymaking Pierce, M. C., Kaczor, K., Aldridge, S., O’Flynn, J., & Lorenz, D. (2010). Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics, 125(1), 67–74. doi:10.1542/ peds.2008-3632

160   UNIT II  ANALYZING POLICY Pronovost, P., Needham, D., Berenholtz, S., Sinopoli, D., Chu, H., Cosgrove, S., … Goeschel, C. (2006). An intervention to decrease catheter-related bloodstream infections. New England Journal of Medicine, 355(26), 2725–2732. doi:10.1056/NEJMoa061115 Pronovost, P. J., Watson, S. R., Goeschel, C. A., Hyzy, R. C., & Berenholtz, S. M. (2016). Sustaining reductions in central line-associated bloodstream infections in Michigan intensive care units: A 10-year analysis. American Journal of Medical Quality, 31(3), 197–202. doi:10.1177/1062860614568647 Reinhardt, A. C., & Ray, L. N. (2003). Differentiating quality improvement from research. Applied Nursing Research, 16(1), 2–8. doi:10.1053/apnr.2003.50000 Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York, NY: Free Press. Roller, C., Sedlak, C., & Draucker, C. (2015). Navigating the system: How transgender individuals engage in healthcare. Journal of Nursing Scholarship, 47(5), 417–424. doi:10.1111/jnu.12160 Rubio, D. M., Schoenbaum, E. E., Lee, L. S., Schteingart, D. E., Marantz, P. R., Anderson, K. E., … Esposito, K. (2010). Defining translational research: Implications for training. Academic Medicine, 85(3), 470–475. doi:10.1097/ACM.0b013e3181ccd618 Sedlak, C. A., Boyd, C. J., & American Academy of Nursing Lesbian, Gay, Bisexual, Transgender, Queer Health Expert Panel. (2016). American Academy of Nursing on Policy Health care services for transgender individuals: Position Statement. Nursing Outlook, 64(5), 510–512. doi:10.1016/j. outlook.2016.07.002 Sedlak. C. A., Roller, C. G., van Dulmen, M., Alharbi, H., Sanata, J., Leifson, M., … Doheny, M. O. (2017). Transgender individuals and osteoporosis prevention. Orthopaedic Nursing, 36(4), ­259–268. doi:10.1097/NOR.0000000000000364 Sheffer, C. (n.d.). Smoke free hospital toolkit: A guide for implementing smoke-free policies. Retrieved from http://www.uams.edu/coph/reports/smokefree_toolkit/Hospital%20Toolkit%20Text.pdf Shirey, M. R., Hauck, S. L., Embree, J. L., Kinner, T. J., Schaar, G. L., Phillips, L. A., … McCool, I. A. (2011). Showcasing differences between quality improvement, evidence-based practice, and research. Journal of Continuing Education in Nursing, 42(2), 57–68; quiz 69–70. doi:10.3928/00220124-20100701-01 Spruce, L., Van Wicklin, S., & Wood, A. (2016). AORN’s revised model for evidence appraisal and rating. AORN Journal, 103(1), 60–72. doi:10.1016/j.aorn.2015.11.015 Titler, M. (2004). Overview of the U.S. Invitational Conference: Advancing quality care through on translational research. Worldviews on Evidence-Based Nursing, 1(Suppl. 1), S1–S5. doi:10.1111/j.1524-475X.2004.04053.x Titler, M. (2010). Translation science: Theory and context. Research and Theory for Nursing Practice, 24(1), 35–55. doi:10.1891/1541-6577.24.1.35 Titler, M. (2014). Overview of evidence-based practice and translation science. Nursing Clinics of North America, 49(3), 269–274. doi:10.1016/j.cnur.2014.05.001 Truiett-Theodorson, R., Tuck, S., Bowie, J. V., Summers, A. C., & Kelber-Kaye, J. (2015). Building effective partnerships to improve birth outcomes, by reducing obesity: The B’more Fit Healthy Babies Coalition of Baltimore. Evaluation and Program Planning, 51, 53–58. doi:10.1016/j. evalprogplan.2014.12.007 U.S. Department of Health and Human Services. (2009). CFR Title 45 Public Welfare Part 46 Protection of human subjects, subpart A. Basic HHS policy for protection of human research Subjects. Retrieved from http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.html Waterson, P. (2016). Bridging the gap between research, policy and practice in health and safety. Policy and Practice in Health and Safety, 14(2), 97–98. doi:10.1080/14773996.2016.1261814 Weston, M., White, K., & Peterson, C. (2013). Creating nursing’s future: Translating research into evidence-based policy. Communicating Nursing Research Conference proceedings: Creating a shared future of nursing. Research, Practice, and Education, 46, 47–54. White, K. M. (2011). Translational research. In J. F. Fitzpatrick & M. W. Kazer (Eds.), Encyclopedia of nursing research (3rd ed., pp. 517–520). New York, NY: Springer.

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Woolf, S. (2008). The meaning of translational research and why it matters. JAMA, 299(2), 211–213. doi:10.1001/jama.2007.26 Workman, T. A. (2013). Engaging patients in information sharing and data collection: The role of patientpowered registries and research networks. AHRQ Community Forum White Paper. Rockville, MD: Agency for Research Healthcare and Quality. AHRQ Publication No. AHRQ 13-EHC124-EF. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK164513 World Health Organization. (n.d.). Evidence-informed policy network. Retrieved from http://www .who.int/evidence/about/en/ Yost, J., Thompson, D., Ganann, R ., Aloweni, F., Newman, K., McKibbon, A., … Ciliska, D. (2014). Knowledge translation strategies for enhancing nurses’ evidence-informed decision making: A scoping review. Worldviews on Evidence-Based Nursing, 11(3), 156–167. doi:10.1111/wvn.12043 Yuan, C. T., Nembhard, I. M., Stern, A. F., Brush, J. E. Jr., Krumholz, H. M., & Bradley, E. H. (2010). Blueprint for the dissemination of evidence-based practices in health care. Issue Brief (Commonwealth Fund), 86, 1–16. Retrieved from https://www.commonwealthfund.org/publications/issue-briefs/2010/ may/blueprint-dissemination-evidence-based-practices-health-care Zerhouni, E. (2003). Medicine: The NIH road map. Science, 302, 63–72. Zerhouni, E. (2005). Translational and clinical sciences—Time for a new vision. New England Journal of Medicine, 353(15), 1621–1623. doi:10.1056/NEJMsb053723

SIX

Setting the Agenda Linda K. Groah Amy L. Hader Things do not happen. Things are made to happen.—John F. Kennedy (1963)

OBJECTIVES 1. Explain the importance of effective agenda setting in the policy process. 2. Discuss critical components of agenda setting. 3. Analyze effective strategies for advancing a policy agenda. 4. Describe methods for overcoming barriers to advancing a policy agenda. 5. Compare and contrast options for agenda setting at the organizational, local, state, and national levels. 6. Identify nonlegislative strategies to move an organizational, local, state, or national agenda forward.

Agenda setting is the first step, and some would argue the most important step, in the policy process. It is your navigation tool in your policy journey. It is an extension of the problem identification and prerequisite to successful policy development at all levels. Agenda setting is critical whether you are working on big “P” or little “p” issues. Agenda setting can seem a straightforward process; however, if you consider setting an agenda for a meeting and reflect on meetings that have gone in less than desirable directions, you can start to envision that agenda setting is an iceberg and only the tip is visible. Consider the complexities of agenda setting related to healthcare reform at the national and state levels in the United States. Thus, once you have identified a policy issue (see Chapter 4) and evaluated the available research (Chapter 5), it is time to set the agenda. This chapter discusses the importance of policy agendas and strategies for controlling and influencing the agenda-setting process. You are guided through the processes of agenda setting and the pivotal role that nursing plays in agenda setting. Consideration is given to variations in the agendas. The agenda-setting process is based on a variety of intersecting factors such as the policy problem, scope of the issue, stakeholders, timing, personal agendas, and public agendas. Agenda setting at the federal level, within key nursing organizations, and for key clinical issues are highlighted to showcase the critical role nurses must play in this process. Nurses’ full understanding and control 163

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of agenda setting are foundational to the achievement of sustained power in policy. Knowing the basic concepts related to agenda setting is prerequisite to appreciating its power. The Policy Challenge illustrates a turning point for agenda setting for advancing baccalaureate education.

POLICY CHALLENGE: Advancing Nursing Education— The New York Experience Barbara Zittel, PhD, RN, Delmar, New York On Friday, December 8, 2003, the New York State Board of Nursing (the Board) had an extensive discussion of the following motion: Statutory change be sought permitting future RN applicants who have completed an associate degree or diploma in nursing to continue to receive licensure as an RN, but requiring such persons to obtain a baccalaureate degree in nursing within 10 years of initial licensure.

The motion was unanimously approved by Board’s membership, amid moans from several of the observers at the public meeting. Within 2 days, letters of opposition began to arrive primarily from community college presidents. Although the Board countered the opposition with twice as many letters, they did not have the same political impact. As the executive secretary to the Board, I was summoned to the deputy commissioner’s office to justify the Board’s position. I persisted in strategizing ways to decrease opposition and increase support. Our initial emphasis focused on garnering support from nursing faculty, primarily from associate degree programs. Meetings commenced in 2004 with Board and nurse faculty using a collaborative, constructive decision-making process. The goals were to clarify the intent of the recommendation, clarify misunderstandings, and obtain input and recommendations. The New York State Associate Degree Nursing Council notified us about a position change to support the proposed legislation. This letter was decisive, demonstrating that opinions could be changed with respectful collaborative discussion. Revitalized, the Board reached out to the New York Organization of Nurse Executives and Leaders (NYONEL). A second major collaborator was the New York State Nurses Association (NYSNA), who provided support, guidance, and expertise in the legislative process. By the end of 2005, bill language was developed and legislative sponsors were identified. Through persistent outreach, ­in-state and national nursing groups and groups exterior to nursing began to voice their support; these included the American Nurses Association (ANA); the Black Nurses Association of Manhattan; the Indian American Nurses Association; the Philippine Nurses Association of New York, Inc.; the New York Chapter of the Association of Hispanic Nurses; and the Pharmacists Society of the State of New York. However, opposition remained (e.g., Local 1199 Service Employees International Union, NYS Public Employees Federation, the NYS Union of Teachers, Healthcare Association of New York). Nonetheless, advocacy continued. Through our lobbying efforts, the ­number of legislators sponsoring the bill increased steadily each legislative session. NYONEL (continued )

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developed an executive summary that focused on the economic benefits to increasing the number of BS-prepared RNs. Support strengthened, and opposition dampened when the American Nurses Credentialing Center’s Magnet® Recognition Program emphasized the need to increase the number of staff nurses with baccalaureate nursing degrees in acute care facilities. The predicted nursing shortage did not materialize. Large healthcare systems preferentially hired RNs with a BS degree. In 2010, the prestigious Institute of Medicine (IOM; now the National Academy of Medicine) report, The Future of Nursing: Leading Change, Advancing Health, included among its recommendations that, to meet the future healthcare needs in the United States, the proportion of nurses with a BS needed to increase to 80% by 2020 (Committee on the Robert Wood Johnson Foundation [RWJF] Initiative on the Future of Nursing, 2011). Based on expert analysis, we concluded that this target was not achievable without passage of this bill. The Health Association of New York State (HANYS) voted to support the legislation in 2013. Hopes were high. Our first legislative victory occurred at the end of the 2014 session. Joseph Morelle, the majority leader of the Assembly, an allyand the main sponsor of the bill, quickly learned the intricacies of nursing education and the added value of a BSN. With his guidance, the bill was voted out of the Assembly’s Higher Education Committee, through the Ways and Means Committee, and on to the Assembly floor. With an overwhelming vote of 126 in favor and eight against, we could not have done better. Unfortunately, the bill stalled in the Senate’s Higher Education Committee. That committee’s chair publicly stated, “Once a woman is an RN she should not have to leave her husband and family to continue her education!” Despite intense work, this senator refused all bargaining or compromise attempts. Legislative victory would not happen until a change in Senate leadership occurred. Even an attempt to get the governor’s staff to consider including the bill’s content into the governor’s budget bill failed despite the work of a loose collaboration referred to as the Coalition to Advance Nursing Education (CANE). Although there was general acceptance of the bill’s intent, time was insufficient for pursuing this alternative strategy. The year ended with some progress toward the goal and with a strategizing meeting for working around the chair of the Senate’s Higher Education Committee. Under Assemblyman Morelle’s continued leadership, the bill was again passed by the Assembly by a vote of 126 to eight. In the meantime, we recruited Senator John Flanagan, the majority leader, to serve as the Senate’s primary sponsor. Under his guidance, the bill was moved out of the Higher Education Committee. Regrettably, the session ended while the bill was in the Ways and Means Committee before it could be voted on by the full Senate. See Option for Policy Challenge.

AGENDA IDENTIFICATION A problem or issue must get the attention of those who want to help make a change before the policy process starts. On any given day, numerous problems command and compete for attention. The repetition of a problem (e.g., frequency of nurse musculoskeletal injuries, number of patient falls with injuries) or the magnitude of a problem

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(e.g., number of Americans without health insurance) are often seen as instrumental in shaping the agenda-setting process, but repetition and magnitude are not guarantees that an issue will make it to the top of an agenda. Understanding the definition of an agenda, the importance of an agenda, those who set and define an agenda, and levels of agendas are interrelated, but key, concepts that are basic to getting an issue for an agenda identified.

What Is an Agenda? An agenda is a complex process that involves laying out issues and solutions: “An agenda is a collection of problems: understandings of causes, symbols, solutions, and other elements of public problems that come to the attention of members of the public and their governmental officials” (Birkland, 2016, p. 201). This definition can be reworked more generically to encompass both the big “P” and the little “p” of policy: An agenda is a collection of difficulties or issues and their causes, representations (privately and publicly), and suggested resolutions that get the attention and consideration of policy makers locally, nationally, or internationally and within or across institutions, organizations, or governments. Thus, agenda setting is not solely applicable to government policy. In fact, nurses can and must be active in policy where they work, in their communities, and in their profession. The purpose of an agenda is to influence events, news, and understanding. An agenda can be as simple as an identified issue and the proposed solution, or as comprehensive as a descriptive series of problems that require solutions from varying vested individuals or groups (e.g., stakeholders in government, private sector, individuals, communities). For example, for a state nurses association, an agenda might include a list of legislation that has been introduced that has an impact on nursing. It could also include a more comprehensive analysis of legislative and regulatory changes that need to take place within a state to remove barriers to advanced nursing practice. Kingdon (2011) conducted hundreds of interviews with government officials and policy makers, yielding a comprehensive review of research on agenda setting. His findings indicated that context was important—timing, political climate, and other political realities—in the policy-making and agenda-setting process. For nurses considering or already engaged in policy work, it is important to know that our current context includes a strong focus and continuing national attention to the healthcare needs of the population.

Importance of the Agenda Many writers and speakers intent on urging readers and listeners to become more involved in the political process have used the saying, “If you are not at the table, you’re on the menu.” This old saying in Washington, DC, bears repeating here. Individuals and organizations whose priority issues are not on the agenda stand little chance of influencing policy regarding their priorities; at worst, they may experience backward progress and lose ground on their issues. Agenda setting is about power. Power is exercised by determining what gets on the agenda and what is blocked from getting on the agenda. A number of theories describe how power and its influence on activities such as agenda setting develop. Some researchers in the policy arena have adopted an “elite theory” perspective, suggesting that relatively few individuals in key positions in government, industry, academia, the media, and other powerful institutions control a disproportionate share of the economic

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and political resources (Birkland, 2016, p. 199). However, the interest group theory alternately posits that competition among interest groups, with their own agendas, help keep in check the balance among groups. Within interest groups, grassroot efforts are often very effective (see Chapter 7). Nursing issues at the big “P” level almost always lie within the policy issue category of healthcare. Your goals and action plan may vary from seeking legislative or regulatory changes to increased public awareness of a public health issue or even incremental policy changes within your healthcare facility. The national political climate, as well as interest groups and individual connections, all coalesce to inform your policy agenda and action plan. “Agenda setting is crucial because if an issue cannot be placed on the agenda, it cannot be considered, and nothing can possibly happen in government” (Peters, 2016, p. 60).

Those Who Set and Define Agendas All organizations and state and federal agencies and their subdivisions have mission statements and strategic plans that are routinely reviewed and updated. The partisan balance of Congress and other legislative bodies also influences the policies on an organization’s agenda. The mission and strategic plans guide agenda setting at all levels and determine priorities for action. If an agenda is not linked to the mission and strategic plan, it is difficult, if not impossible, for the agenda to gain traction among key stakeholders. Understanding these connections among missions, strategic plans, and agendas is vital for nurses to move an agenda forward. Too often, the assumption is made that money, media, and power control agendas. Acceptance of this assumption can feed a sense of powerlessness that often leads to nurses’ disillusionment about their ability to change policies, legislation, and regulation that have an impact on their practice environment. Rather, it is important to recognize who controls the agenda so that change efforts are directed in the appropriate direction. One example of a government institution’s role in leading policy changes can be seen in the approach to safe patient handling taken by the U.S. Department of Veterans Affairs (VA). VA health facilities use the latest specialized devices and proven methods to keep patients and healthcare workers safe when moving patients. Many health systems look to the VA model for guidance on safe patient handling when seeking to implement best practices at their facilities. The VA’s continued close attention to the issue lends weight to its importance and can be referenced as an example by unit peer leaders looking to implement best practices or to purchase new devices and equipment. Nurses associations have well-established procedures for formulating their agendas. Some associations routinely seek and include members’ ideas and concerns when developing their agendas. As membership organizations, they follow a democratic process that includes mechanisms to collect suggestions or mandates from the membership. The annual meetings of many associations include a process in where topics are debated and voted on to determine resource priorities for future actions. These topics often end up in policy agendas. Exhibit 6.1 provides links to the policy agendas of several professional associations. Agendas may focus on a specific policy. Sometimes. organizations may have a separate research agenda to address priorities for research. Sometimes, landmark reports serve an agenda-setting function. This is illustrated by two seminal reports, (a) To Err Is Human (Kohn, Corrigan,  &  Donaldson,  2000) from the IOM

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EXHIBIT 6.1  POLICY AGENDAS OF SELECTED SPECIALTY NURSES ASSOCIATIONS ORGANIZATION

TYPE OF AGENDA

WEBSITE

American Association of Colleges of Nursing (AACN)

Federal policy agenda

www.aacnnursing .org/Policy -Advocacy/About -Government-Affairs -and-Policy/Federal -Policy-Agenda

American Association of Nurse Practitioners (AANP)

Advocacy center

www.aanp.org/ legislation -regulation/ advocacy-center

American College of Nurse-Midwives (ACNM)

ACNM policy agenda

www.midwife.org/ ACNM-Policy -Agenda

Association of periOperative Registered Nurses (AORN)

Policy agenda

www.aorn.org/ government-affairs/ policy-agenda

Emergency Nurses Association (ENA)

Public policy agenda

www.ena.org/ government/ Federal/Pages/ Default.aspx

National Association of Clinical Nurse Specialists (NACNS)

2016–2018 public policy agenda

nacns.org/ advocacy-policy/ public-policy-agenda

National Association of Pediatric Nurse Practitioners (NAPNAP)

Health policy agenda

www.napnap.org/ health-policy-agenda

Oncology Nursing Society (ONS)

Policy priorities

www.ons.org/ advocacy-policy/ priorities

(now the National Academy of Medicine), which brought focus to the problem of safety by publicizing the statistic of 98,000 annual deaths due to medical errors; and (b) the IOM/RWJF report on The Future of Nursing (Committee on the RWJF Initiative on the Future of Nursing, 2011). Similarly, the Consensus Model for APRN Regulation serves an agenda-setting function for standardization of advanced practice licensure, accreditation, certification, and education across the states (APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee, 2008).

Levels of the Agenda Prior to Kingdon’s (2011) extensive examination of political agendas and the ­policy-making process, Cobb and Elder (1972) examined the importance of the

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political agenda. Their work showcased the difference between issues or problems under discussion in society—which can be thought of as a systemic agenda or ­public problems—and institutional or organizational agendas. Birkland (2016) expands this concept to include four levels of increasing specificity: agenda universe, systemic agenda, institutional or organizational agenda, and decision agenda. The agenda universe consists of all ideas that could possibly be brought up and discussed in a society or a political system. The systemic agenda or public problems are those worthy of consideration and within the scope of authority of a government. The list of issues from the systemic agenda that are being considered become the institutional agenda. Finally, the decision agenda includes items that are about to be acted on; for government actors, these are often bills, court cases, and regulations. Without prominence on the institutional or organizational agenda, an issue is unlikely to make any meaningful headway through the political system (see Figure 6.1). Although any number of issues may be the important components of a nurses association agenda, the goal is to move an issue closer to the decision agenda so that desirable actions can be taken. Often not discussed is the importance of an agenda in one’s local environment and, in particular, the importance of nurses owning the policy agenda for their practice. For example, rather than becoming frustrated with the failure to move forward with a policy that implements an evidence-based practice (e.g., fasting times before surgery, prevention strategies for postoperative urinary retention, meal tray delivery, insulin

Groups seeking policy change seek to advance issues closer to the decision agenda

Agenda Universe

Systemic Agenda

Institutional Agenda

Decision Agenda Groups that oppose change seek to block issues from advancing on the agenda

FIGURE 6.1  Levels of the agenda. Source: Reprinted with permission from Birkland, T. A. (2016). An introduction to the policy process: Theories, concepts, and models of public policy making (4th ed.). New York, NY: M. E. Sharpe.

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administration times), nurses need to examine how to get their issue on the policy agenda of the group or groups that can best help implement the practice. It is vital to show how the practice issue fits with the mission or strategic plan related to safety and/ or cost. This is illustrated by the efforts to implement practices designed to improve physical activity in school children (see Policy on Scene 6.1). Regardless of whether an issue requires attention at the legislative or regulatory level, within your healthcare institution, or even within a municipality or local civic group, an issue’s prominence often directly correlates to the level of attention it receives from decision makers and stakeholders. Identifying the systemic and, more important, the institutional agendas of the decision makers you are trying to influence provides the foundation for the development and refinement of your agenda so that your issue can rise to the decision agenda.

POLICY ON THE SCENE 6.1: From Passion to a Policy Agenda Brea Loewit, MSN, RN, FNP, IBCLC Lactation Consultant and Childbirth Educator, University Hospitals Portage Medical Center, Portage, Ohio Health policy is used to achieve specific health goals within a population on a local, state, or national level. Health policy gives clarity and direction to a specific p ­ roblem with the goal of improving health outcomes. One public health issue that I feel passionate about is physical activity in school children. Remaining physically active has immense social, physical, and cognitive benefits for children (American Academy of Pediatrics [AAP], 2013). I am a parent of two elementary school children, and I know that their remaining physically active gives balance to the demands of a school environment oriented to standardized testing, meeting core curriculum goals, and completing homework after school. I realized the issue became more acute in recent winter, with many inclement days that prevented children from going outside for recess. When I started talking to stakeholders, I found there were no established physical activity time recommendations in the local school district and no contingency plans to provide physical activity alternatives during inclement weather. But I did identify opportunities for schools to meet physical activity guidelines within the existing policy, as well as areas for growth. I presented my findings and suggestions to the school board. My four recommendations were: • Have an indoor recess plan in place for each elementary school building. • Implement the recommended 30 minutes of daily exercise as provided in Ohio’s 2010 Healthy Choices for Healthy Children Act. • Develop a task force of Parent Teacher Association (PTA) members in each elementary school to help facilitate indoor recess. • Revise and update the existing health and wellness policy. (continued )

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These recommendations became the foundation for my policy agenda that was fueled by my passion. It provided me a vehicle for advancing my agenda to the school system. My presentation was well received and resulted in being invited to be on the planning committee for a new school in our district, where I could continue looking for opportunities to improve the health of children.

DEVELOPING AN AGENDA Agenda development includes defining the problem and establishing the agenda. These are two intertwined and evolving processes. Articulating the problem provides the launching pad for establishing the agenda.

Defining the Problem A problem clearly stated is a problem half solved.—Dorothea Brande

Conditions and problems can become agenda items, but there is a difference between them. Weather, illnesses, and poverty are conditions. Conditions become problems when someone decides to do something about them (Kingdon, 2011). Agenda setting is a process. Issues gain and lose attention in the spotlight every day. In addition to healthcare, widely accepted policy agenda items in the United States are the problem of poverty, the quality of our public education system, and gun safety. Environmental concerns, drug enforcement issues, and civil rights movements have had enthusiastic and then waning interest in recent years. Many issues pass through an “issue attention cycle” in which they are of high public concern for a brief period, and then the enthusiasm wanes as the costs and difficulties of implementing real policy change emerge (Peters, 2016). A large part of agenda setting is defining the problem. For example, after the mass tragedies of September 11, 2001, in the United States, security for airline travel became a pressing issue. Everyone agreed on the importance of the issue of airline travel security. However, the finer points of how to increase travelers’ security while balancing travelers’ privacy were the subject of much disagreement. Whether to allow body scans, pat downs, profiling, and even liquids on airplanes became the subject of national debate. The next steps on the nation’s agenda were framed largely by perceptions of the root of the problem. Did the problem lie in a failure to enforce existing rules, or were additional rules necessary to ensure nothing like September 11 could ever happen again to U.S. citizens? Should existing or new security measures for airline travel now be applied to other mass transit such as trains, subway systems, and buses? A person’s reaction to and support for the agenda would depend in large part on the answer to these questions. Another example of defining the problem can be seen in drug-enforcement policy. Drug abuse is part of the national systemic agenda, but whether one views it as an education, public health, or poverty-related problem influences the remedies likely to be chosen (Peters, 2016). More recent problems still in the forefront of the minds of many Americans are the continued health of the economy after the 2008 economic downturn, terrorist acts in the Middle East and other regions, and the

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uncertain impact of the Obama-era health reforms (Birkland, 2016). Group competition to set the agenda is intense because no one agency or individual has the capacity or power to address all problems at any one time (Hilgartner & Bosk, 1988 as cited in Birkland, 2016). A group must articulate its problem with the objective of swaying the right policy makers at the right time in the group’s favor. Thus, it is important to have the right problem on the agenda. Individual and organizational or institutional stakeholders, including government agencies, are affected differently, depending on how a problem is defined. For example, a state nurses association may be successful in getting a legislator to introduce a bill on nurse title protection so that non-nurses are not allowed to call themselves nurses. However, the ultimate passage of the bill depends on the committee to which it has been referred (see Chapter 3). Some committees may provide a more favorable context for the passage of a particular piece of legislation than others. An example of an ongoing policy problem for nurses and other healthcare providers is healthcare-associated infections (HAIs). The Association for Professionals in Infection Control and Epidemiology (APIC) reported that there were an estimated 722,000 HAI in U.S. acute care hospitals in 2014 and that approximately 75,000 patients with HAIs died during their hospitalizations (APIC, 2016). APIC has a policy agenda paper designed to both educate about the problem and to persuade healthcare providers to work toward attainable solutions. To move more fully toward HAI elimination, APIC (2016) recommends: • Aligning monetary incentives and continuing proven strategies. Payment policies that do not incentivize elimination of HAIs work against the public goal. Prevention-oriented payment systems based on population results will catalyze systems of care, which emphasize HAI avoidance. • Using data to formulate prevention strategies. Analysis of trend data locally, regionally, and internationally facilitates the prioritization of preventive initiatives and assessment of their impact. • Implementing evidence-based practices. Proven strategies for HAIs exist, yet clinicians do not always adhere to scientifically proven methods, especially in noncritical care hospital settings and nonhealthcare settings. • Focusing on gaps in knowledge. Clinicians need help in understanding the mechanisms of HAI occurrence and transmission to develop prevention strategies and promote adherence to best practices. The APIC (2016) policy brief provides a great working example of how a policy interest group such as a membership organization of professionals can work to define a problem for policy makers and then showcase how the group’s proposed solutions would solve the problem. Nurses can also work on identifying similar problems at the state and local levels. Strategically, agenda setting evaluates the best approach and in what venue the issue should be first attempted. Some problems get addressed on a state-by-state basis first, before their impact is recognized at the national level. The support of an issue at the local and state levels is often strategically planned before introduction at the federal level. The process can vary significantly, however. Sometimes a problem is identified by numerous organizations within and beyond nursing. Sometimes problems repeatedly fail to gain traction at the state level only to be recognized at the federal level.

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Establishing the Agenda There will always be competition among groups for policy makers’ attention to their problem. Issues with ramifications for greater numbers of people or important institutions may take precedence over issues with lessened societal impact, but not necessarily and not as often as the public might like. Issues that may seem perfectly rational to some may not resonate as clearly with others. Immigration and gun control may be important one year, only to slide off the radar the next year without any solution to the problems that thrust them onto the agenda in the first place. The Gallup company has been routinely surveying Americans on the “most important problem facing this country today” for years. In 2009, a substantial majority of respondents (86%) cited economic problems, such as unemployment, the deficit, and taxes, as the most important problem (Gallup, n.d.). In 2017, 20% of respondents thought that government was the most important problem, and 17% thought healthcare was the most important problem (Gallup, 2017). Such polls can lend insight into groups looking to launch their issue onto policy makers’ agendas. At any given time, people may be more or less receptive to proposed policy changes, depending on the nation’s and policy makers’ mood and preoccupation with other issues perceived to be more pressing. Solutions should be framed with the national mood in mind. In a time when government dissatisfaction is high, talking points for a bill that highlight the government’s role in solving a nursing practice issue are less persuasive than talking points emphasizing how a bill authorizes and enables a profession to accomplish its stated goals. Key influencers can work in favor of a policy issue gaining prominence on the agenda, but they can also work against it. For example, a president’s role in agenda setting is interesting because the president and the executive administration are typically more involved in agenda setting than developing the policy alternatives and solutions to the raised issues and problems (Birkland, 2016). A new government administration, new nursing leadership on your unit or at your healthcare facility, and even a planned accreditation visit can create new opportunities for issues to be presented to the decision makers and potentially be placed on the agenda. Unpredictable events such as weather-related disasters, a mass accident, or another local or regional tragedy may also focus the public and decision makers’ attention on or off an issue without warning. Natural disasters have elevated America’s concern for preparedness and response to catastrophes (Peters, 2016). After Hurricane Katrina, the ANA (2008) significantly engaged the nursing profession in policy development, resulting in the policy document, Adapting Standards of Care Under Extreme Conditions: Guidance for Professionals During Disasters, Pandemics, and Other Extreme Emergencies. Healthcare institutions are focusing on the need for disaster response plans after mass tragedy events such as the Boston marathon bombing and mass shootings in American workplaces, schools, and hospitals, as well as natural disasters. Nurse researchers have shed light on the need for reformulating disaster-preparedness agendas to address balancing nurses’ personal needs and professional obligations in the face of disasters (VanDevanter, Raveis, Kovner, McCollum, & Keller, 2017), as well as the need for the advancement of disaster nursing education. Implementing public policies requires a budget and institutional infrastructure (Peters, 2016). Some issues of seemingly public importance may not rise on the agenda for a variety of reasons: cost, public or stakeholder acceptance, or opposition. It is common to have many issues of national importance in our country, or even many issues in our own communities, to take a backseat as budgets wax and wane.

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At the federal level, resources are allocated among competing federal agencies for their programs, the decisions of which are necessarily informed by the president’s economic beliefs and policy goals (Peters, 2016). At the institutional level, budgets and financial constraints are similarly a leverage point with key executives and decision makers. Obtaining funding for quality improvement projects within a healthcare institution can be as long and complex a process as seeking policy changes at the state and federal levels. At the local level, nurses’ agendas are expected to address cost-effectiveness with their practice and policy development. One strategy in helping overcome this potential challenge is to provide data with sound cost–benefit ratio rationales when working for policies that have financial implications. Although it may not be readily apparent, most policies and agendas have financial implications. For example, in creating an agenda to begin work on improving patient flow in the ED, you must consider not only the financial impact of the changes, but also patient, employee, and physician satisfaction in offsetting costs.

STAKEHOLDERS Careful consideration is necessary to determine whose interests and welfare should be considered in the agenda-setting process. Identification and inclusion of stakeholders are crucial in advancing a policy agenda. Stakeholders can be for an issue, against it, and even neutral. Inclusion of all stakeholders, regardless of their position, facilitates the broadest discussion and development of policy solutions. Stakeholders are the people, groups, and/or entities that are vested in the issue you are exploring or promulgating. Knowing the stakeholders is essential in helping define the problem and in setting the agenda. Stakeholders may include political parties, interest groups, the media, and the public and vary depending on the issue itself, the level, and the timing of the issue. An example of stakeholders can be seen in the 2013 California Supreme Court decision, American Nurses Association v. Tom Torlakson (2013). The ANA filed an amicus brief in support of California school nurses (Balestra, 2012). This controversial ruling allows trained school personnel to administer insulin in the California school system, which in turn had an impact on the policy agendas of key stakeholders. Strategies surrounding this issue are being refocused on how to promote safety for children under this ruling. Exhibit 6.2 illustrates the diversity and complexity of interests of various stakeholders related to this policy agenda. As seen earlier, identifying the list of stakeholders can be a lengthy process. A complete analysis of all the stakeholders and their positions are necessary for setting effective policy agendas. Identifying the stakeholders is about not only knowing who your allies and opponents are, but also strategizing about effective ways to capitalize on both. In the following pages, we describe how to use interest groups to advance your agenda and how to assess your opposition to overcome the obstacles they may present. The inclusion of stakeholders can be strategic in terms of advancing the agenda. Sometimes, key stakeholders are included in the initial development of an agenda. Initially, for more controversial issues, groups may choose to start by including those who are primarily supportive of an agenda direction. This provides the group with the opportunity to examine its strategies, refine its arguments, and gain support for an issue and to be sure that “everyone is on the same page.” Subsequently, others may be invited to join when the initial group has gained a core sense of direction. This might

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EXHIBIT 6.2  STAKEHOLDERS AND INSULIN ADMINISTRATION IN SCHOOLS STAKEHOLDER

INTEREST

Children with diabetes and their parents

Strong interest to have their healthcare needs addressed

Nurses in the school district

Interest by school nurses affected but lack of desire by some to become involved

Teachers and staff in each school

Great interest in those with new duties but less interest in those whose duties remain the same

Principal and administrative staff in each school

Strong interest having been told to implement the plan with some potential ability to give input to the plan; interest in hiring fewer school nurses

State Department of Education

Strong interest to resolve issues to reduce costs to school districts

National Association of School Nurses

Strong interest and expertise

American Nurses Association

Strong interest and concern about implications for other practice arenas

American Diabetes Association

Strong interest to address their focused special interest

Local community

Strong interest but not a formed, cohesive group prepared to be involved

Local and state media

Not much interest, but if given the right information at the right time, could be very interested

Local politician

Indifferent but may change in an election year

be illustrated with any of a number of the regional action coalitions (RACs) established around the country in support of The Future of Nursing recommendations (IOM, 2008). The leaders of an RAC might believe that its region would be best served by clarifying the focus and direction of their agenda before inviting potential supporters and funders to join in the process. Although some need to be in on the development from the ground up, others do not want to expend their resources unless there is a clear expectation and direction. Each RAC needs to determine what is best, depending on its unique circumstances and political landscape.

Importance of Interest Groups Interest groups are often formed for common interests or purposes and to promote a cause. They may at some point decide that their mission and their needs will be met by influencing policy. Research has demonstrated that interest groups “often play a central role in setting the government agenda, defining options, influencing decisions and

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directing implementation” (Grossman, 2012, p. 172). Interest groups are credited with policy accomplishments in all three branches of government, influencing not only legislative changes, but also court rulings, executive orders, and agency administrative decisions. Nurses can become part of an interest group by joining one. Types of interest groups include advocacy groups, consumer groups, community groups, business interest groups (e.g., chambers of commerce, corporations), academic groups, professional associations, unions, think tanks, and foundations. Groups may need to form coalitions to get a place on an agenda.

Interest Groups Aligned With Your Agenda State nurses’ and specialty nurses associations are professional interest groups typically open to RNs and occasionally to other healthcare providers who support the association’s mission. These associations can be a wise choice for enlisting support of a policy agenda. Partnering with your state nurses’ and specialty associations is an important

POLICY ON THE SCENE 6.2: Partnering to Advance a Policy Agenda Mary K. Weis, MSN, RN, CNOR, CRNFA In the fall of 1993, registered nurse first assistants (RNFAs) in Minnesota began discussing strategies for passing legislation for RNFA reimbursement in our state. We were encouraged to seek the assistance of our state nurses association and other partners. By spring 1994, we were holding regular statewide RNFA meetings. We continued developing communications with key interest groups, including legislators, hospital medical directors, and medical and nursing associations. A key strategy was educating these stakeholders about the RNFA role. We collected examples of how and why RNFAs are the best surgical assistants for providing total patient care. Included were stories of barriers to RNFA employment and cost-effectiveness of RNFA services. Our team implemented a campaign to educate Minnesota Nurses Association (MNA) members about the RNFA role that included attendance at district meetings, the statewide meeting, and the distribution of fact sheets, brochures, and cost comparisons. The culmination of our efforts resulted in RNFA reimbursement being placed on the multiple stakeholders’ agendas, including the MNA’s legislative agenda. This action meant that we would have additional resources available. The MNA helped craft our bill, broaden our language, lobby, and shepherd it through the legislative process. A legislative stakeholder, who subsequently became lieutenant governor, advanced our agenda by holding discussions with the state health committee. We engaged in traditional lobbying tactics of correspondence, phone calls and meetings with legislators; a Lobby Day; and provision of testimony. Our legislative success in achieving state-mandated reimbursement for RNs assisting in surgery was clearly attributable to the involvement of multiple stakeholders. Source: Adapted with permission from Association of periOperative Registered Nurses. (2007). RN first assistant guide to practice (3rd ed.). Denver, CO: Author.

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initial step in becoming an active and effective participant in setting the policy agenda. See Policy on the Scene 6.2, which illustrates how registered nurse first assistants (RNFAs) in Minnesota partnered with their state nurses association in establishing reimbursement for RNFAs as a component of the Minnesota Nurses Association (MNA) policy agenda. Partnering with state nurses associations provides specialty nurses with a number of advantages, as well as challenges that must be overcome in setting their policy agenda. The RNFA story highlights the importance of the involvement of a state nurses association in legislative movements initiated by a smaller and informal specialty nurse group and individual nurses. The RNFA’s success was facilitated by a number of strategic decisions. The RNFA recognized that to achieve greater political clout, they needed to partner with an organization (MNA) that had visibility and credibility in their statehouse. With MNA’s mission to represent all nurses, the partnership would appear to be logical to external constituencies, such as legislative bodies. Diversity in interest group support, along with the traditional grassroots strategies, demonstrates the success of this approach. Expanding interest group support for your policy agenda involves not only determining who would naturally be aligned with your position, but also identifying the advantages for interest groups with seemingly divergent goals. However, as we have seen with the RNFA and MNA experience, keeping the issue on the agenda involves building and sustaining the relationship to keep the agenda item from stalling and to realize success. Since Minnesota passed the RNFA-reimbursement bill in 1996, legislation has been introduced in 23 states and has been enacted in 17, most recently in New York in 2016. That only 17 states have passed this legislation in contrast with 42 states that passed legislation related to violence against nurses (see Chapter 1) illustrates how other issues can come to the forefront and how continued work is sometimes needed in moving an agenda forward. New and different strategies or agenda modifications are needed to engage stakeholders in the changing political climate. Professional associations can bring credibility and prominence to an agenda and enhance the potential for a policy agenda’s success. Other kinds of interest groups in which nurses can find synergy and have an impact include business and industry groups. For example, a nurse responsible for directing an ambulatory surgery center might join, as a representative of the center, her local chamber of commerce to elevate the center’s opportunity to have a voice in local business regulations that might affect it. Nurses in certain areas and specialties may also join other groups such as unions to advance their policy agendas. Consumer groups may also have an impact on policy agendas. Consumer groups are often formed to champion causes framed as “in the public interest,” such as consumer protection groups and “good government” organizations. Other examples of public interest groups include groups formed to speak for populations that cannot speak for themselves, such as children. These kinds of groups are often called on to respond to others’ agendas on behalf of their constituents and intended beneficiaries. Consumer groups are often portrayed as counterpoints to the self-interested business, labor, and professional groups, but consumer groups do not exist solely to respond to the agendas of others. At times, consumer groups may have their own issue agendas. Sometimes a group calling attention to an issue may not be an organized “group” at all. For example, on the day after the presidential inauguration in 2017, approximately half a million people took part in the Women’s March in Washington, DC, with hundreds of thousands of others participating in their home cities, totaling 3.3 to 4.6 ­million nationwide (Waddell, 2017).

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EXHIBIT 6.3  ASSESSMENT OF THE OPPOSITION • • • • • • • • • •

What is the nature of the opposition (e.g., finances, values, stereotypes)? Is the opposition proposing an alternative? Is the opposition from within your organization? Is the opposition coming from an individual or a group of individuals? Can you identify common ground with the opposition? Does the opposition answer to a constituency? How does the public view the opposition? Will swaying the opposition to a neutral position help your agenda? What are the financial resources of the opposition? To what extent is your agenda item important to the opposition?

Knowing the Opposition Knowing groups that may be aligned with your policy agenda is not enough. It is equally important to consider your possible opposition as you advance your policy agenda. It is vital to try to understand early on what obstacles your group faces or may face in response to your policy initiatives. Early identification of barriers helps determine how best to work toward your objectives and keep your goals realistically attainable. Knowing the opposition involves identifying those who would oppose your agenda, as well as the specifics of their positions. Points to consider in determining the opposition and their positions are illustrated in Exhibit 6.3. Knowing and understanding the opposition allows you to identify competing interests. The information allows you to frame the issue, develop your arguments, and formulate strategies (see Chapter 10). Unaligned Interest Groups Some stakeholder or special interest groups may be unaligned with your policy agenda. It is just as important to identify groups that may have an interest in your policy agenda, but that either are uninvolved or have taken a neutral position, as it is to identify the opposition. Key decision makers are interested in the positions of other organizations in relation to your agenda. When visiting a legislator, a nurse may be asked about the position of other groups. A legislator may want to gauge constituent interest in the issue. Although nurses cannot answer for other groups, nor should they, they should be aware of these positions to be prepared. In fact, it is generally wise to avoid answering questions about the positions of other organizations. Unaligned groups may be indicative (a) of internal disagreement about an issue, (b) of private support for an issue when public expression of support may be politically incorrect for the organization, or (c) of a belief that the issue is too far removed from the mission or focus of the group. Just because a stakeholder group is unaligned does not necessarily mean the group will stay unaligned. Likewise, it may be considered a victory when a stakeholder group moves from a position of active opposition to neutrality. Sometimes, large coalitions encourage a member organization that cannot fully support the focus of a coalition’s policy initiative to remain silent on the issue.

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Networking and Coalition Building Influence is basic to agenda setting and should be taken into consideration, whether you are trying to influence others or others are trying to influence you. A number of factors are associated with success and/or failure of influence when setting an agenda. A person’s status, for example, may play a role in others granting unconditional support and following; a well-respected nurse leader may get more support for an idea based on status. Three ways to build influence in support of your agenda are networking, building coalitions, and raising awareness of your issue.

Networking Nurses seeking to advance a policy agenda should use a network. Building relationships is important so that they are in place when they are needed. You want to involve your network early in helping to create an agenda, foster engagement, and plan for the resources needed. Nurses can practice the art of networking every day in many ways—at work, at their children’s schools and sporting events, at church, and even at the gym. Networking takes practice. Many nurses may have entered the profession when many employment choices were available. That reality has changed for new nurse graduates who are being quickly thrust into the realities of today’s job market, where networking might be the only strategy for securing an interview. As a result, networking may be uncomfortable initially, but it really is just transferring communication skills into action. Networking certainly includes connecting with your legislators. Effective networking begins with simple steps. For example, legislators and their staff appreciate brief communications. This may include a note of thanks for a legislative position or a success attributable to their office. Legislators and their staff also may appreciate informational notes. For example, the Association of periOperative Registered Nurses (AORN) and other organizations similarly dedicated to advancing safety and quality agendas in our nation’s operating rooms promote a National Time-Out Day annually to highlight the importance of the “time-out” in preventing wrong site, wrong side, wrong patient, and wrong procedure surgeries. As part of this campaign, the AORN asks its nurse members to write letters to the editor of their local newspapers explaining the key role perioperative nurses play in implementing the time-out and advancing patient safety in the operating room. When a letter is published, the AORN urges the nurse to send a clipping of it to legislators with a personal note, as shown in Exhibit 6.4. Even simple notes like this are remembered, thus increasing the EXHIBIT 6.4  SAMPLE LETTER TO LEGISLATOR OFFERING EXPERTISE Dear [Senator or Representative name], I thought you might be interested in this letter to the editor of [newspaper name] as an example of how complex healthcare has become and what perioperative nurses in your district are doing to improve patient safety in our surgical invasive environments such as operating rooms, ambulatory surgery centers, and catheterization laboratories. As an RN with many years of experience, I am available to assist and offer my expertise in these times of complex healthcare issues. I look forward to working with you and having ongoing conversations. Thank you for your service to our district and our country. Sincerely, NAME, CREDENTIALS, CONTACT INFORMATION

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likelihood that a legislator and staff will remember an individual’s name when that constituent later asks the legislator for support. Persistence is often the key to success in networking with all contacts. Success does not happen with only one email or phone call. Networking needs to be a habit, a way of interacting with people and using opportunities for putting forward an agenda. Having a wider network allows you to share your policy agenda with more people. A network takes time to build, but the reward is the expansion of your influence. Networking involves not only legislators, but also nurses, community leaders, and members of the business community, as well as members of other professions (see Exhibit 6.5 for tips on networking and see Chapter 11).

Coalition Building Coalition building can be an effective tool for setting an agenda to influence a target audience. Coalitions can be official (formal) or unofficial (informal). Coalitions are alliances of organizations supporting a common policy goal, such as the Future of Nursing State Action Coalitions that have formed to advance nursing issues. Coalitions marshal the energy of large numbers of people through organizations. The impact is greater when a coalition of several organizations supports a formal agenda than when separate organizations work alone. This partnership demonstrates that the organizations are not speaking from a narrow position of self-interest (Smith, Bucklin, & Associates, Inc., 2000). The Future of Nursing Campaign for Action (2012) has evidence-based indicators of success for building successful coalitions; these were developed by the California Endowment and are available at campaignforaction.org/ effective-coalition-tcc. Nurse groups looking for other stakeholders not only should look to other nursing groups such as state nurses associations and other specialty nurses associations, but also can look to business groups, patient safety groups, and other groups in the community whose agendas align. Nurses need to reach beyond the usual partners to

EXHIBIT 6.5  TIPS ON NETWORKING 1. Learn the person’s name and repeat it later in the conversation. 2. Listen to the concerns of the individual and learn what is important to him or her. 3. Arrive early and stay late for meetings. 4. Volunteer for community or charitable events and legislative days. 5. Supplement your networking with an online professional network. 6. Introduce people to others who have common interests. 7. Follow up with a note, email, or phone call. 8. Keep messages about your policy agenda brief and to the point. 9. Share why your issue is important from your networking contact’s perspective. 10. Be prepared with a description of your organization and its accomplishments. 11. Demonstrate knowledge and enthusiasm for your issue. 12. As appropriate, thank the individual for the meeting.

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develop coalitions. Just because a group has opposed a nursing initiative in the past does not mean that same group may not support a different initiative proposed by your nursing group. Credible organizations take policy positions by issue, less often by “group.” As consensus builds on your agenda, the merits of your solution should spread through the policy community (see Chapter 7 for more details).

Raising Awareness of the Agenda Creating public awareness can also increase your group’s chances of getting on a legislative agenda. Increasing public understanding of the scope of a problem increases your group’s chances of regulatory, legislative, and other success. Numerous junctures and outlets exist for raising awareness of your agenda. Research studies, posters, protests, media campaigns, fundraising events, educational speeches, and informational flyers are all tactics that can be used to raise awareness of your interest group’s policy agenda. More recently, social media has become an effective way to raise awareness of an issue. Social media has facilitated the contributions of individuals in influencing agendas, which was a component missing in traditional constructions of agenda-setting models (Albalawi & Sixsmith, 2015). Social media differs from traditional media in that any individual or organization can be part of the communication dynamic. With social media’s potential for vast reach stemming from one individual or one interest group, individuals and groups with traditionally less power can stimulate the awareness of people, with the greater societal interest in turn pressuring powerful stakeholders to pay attention to an otherwise ignored issue. Raising awareness of your identified policy agenda and your proposed solution can motivate people to support your cause or to actively join your interest group. This can cause a ripple effect so that others contact policy makers on your behalf and spread the word, creating an even greater awareness and in turn increasing the likelihood that your agenda will receive support from key policy makers (see Chapter 10). Although your organization may wish to increase the visibility of an issue, the level of attention that is received by an issue depends on a number of factors, including the issue’s political attractiveness with regard to vote-seeking (Green-Pederson & Wilkerson, 2006). Similarly, the strategies used at any given time for agenda setting depend on the issue’s stage of development, as well as the extent to which key stakeholders have knowledge and understanding of an issue (Kozel et al., 2006). Highlighting how your group’s solution fits within the existing healthcare policy agendas to improve quality and safety while increasing access and cost-efficiencies is another media tip. Nurses who are formulating issues, defining problems, and preparing their agendas must also remember to promote and capitalize on the nursing profession’s high esteem in America per the Gallup poll (Brenan, 2017). As the most trusted health profession, when presented thoughtfully and with an eye toward the nation’s current temperature and healthcare priorities, nursing’s voice should be clearly heard in the offices of legislators and administrators. An important caveat about raising awareness is the need to speak with one unified voice. Cohesion among the group provides a distinct advantage in getting buy-in for an agenda. With numerous associations representing nurses, it is vital to speak with one voice to convince policy makers that an issue has support. An often-heard lament in the past is that nurses did not always speak with one voice. It does not take much to imagine the importance and power of over three million nurses speaking with a single, united voice.

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FOCUSING THE AGENDA An important step in agenda setting is focusing the agenda to maximize the influence of policy decisions. This includes assessing the most appropriate jurisdiction and determining whether legislative, regulatory, or judicial approaches would be most beneficial in advancing the agenda.

Jurisdiction An important concrete step is determining who has jurisdiction over your identified issue. In other words, who is the decision-making body with power to implement your agenda? Is legislative action necessary, or can the issue be remedied more expeditiously through a rule-making process at an agency level? At the state level, health policy issues may fall within the purview of the state’s department of health. Issues relating to hospitals, ambulatory surgery centers, and other healthcare facilities often fall within the state agency responsible for licensing, certification, and/or oversight of such facilities. Scope of practice issues and other issues specific to licensed healthcare professionals fall under the state board with licensing authority, such as the board of nursing (BON) for RNs and APRNs and the board of medicine for physicians and, often, physician assistants. An effective way for nurses to influence healthcare policy and delivery in their state is to get to know their state BON. Many state boards rely on practicing nurses as clinical experts; when an issue comes before a board that relates to a certain specialty, board members reach out to their nursing friends and colleagues in that field for advice and guidance. Some nurses may find that they want to influence policy more directly by serving as a member of the BON or a state agency’s advisory committee. Because state health departments tend to regulate hospitals and ambulatory surgery centers (ASCs), another way for nurses to influence healthcare policy in their state is to get to know the department staff responsible for the agency’s policy decisions in their area of practice. Although we generally think of jurisdiction in relation to government entities, it is just as important to consider jurisdiction in relation to a healthcare organization, community group, or association. The goal is the same: to advance the agenda with the individuals or groups who have the power to make the decision. For example, nurses may complain to the materials management department about the ineffectiveness of a product rather than taking the issue to a nurse practice council, which might examine policy and safety related to the product’s use and gather relevant data and evidence to make a change. Sometimes nurses, in frustration and without investigation of available channels and resources, ask a favorite physician or involve a patient to “complain” and hopefully get the intended change, as well as to champion an issue when the nursing department clearly has the primary jurisdiction. This “work-around” may create anger, stall progress on the agenda item, foster the status quo, and create significant unintended consequences. Going through others who do not have authority to handle the problem may backfire and is not often recommended. Once you understand the jurisdictional issue for your agenda, the next step in the process is venue shopping. “Venue shopping refers to the activities of advocacy groups and policymakers who seek out a decision setting where they can air their grievances with current policy and present alternative policy proposals” (Pralle, 2003, p. 233). Venue shopping is a legitimate strategy for ensuring success as groups seek the level of government or institution in which they are likely to gain the most favorable hearing (Birkland, 2016). For example, for nearly 25 years, nurse practitioners (NPs) in

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Pennsylvania fought to obtain prescriptive privileges. When the first regulations were passed, they only applied to NPs collaborating with medical physicians, not osteopaths. This created a separate set of practice requirements based on which type of physician the NP was working with in a practice setting; very often, it was both in the same setting. The NPs were gearing up to go through the entire rule-making process again with the osteopathic board, but instead a legal ruling was made also applying the regulations to collaboration with osteopaths. In this instance, changing the focus from creating the regulation to interpreting the regulation resulted in success for the NPs, allowing the agenda to shift to removing other practice barriers and gaining full practice authority for NPs; the most effective venue for this would be legislation.

Legislation The first assumption that typically comes to mind when people think of policy and advocacy work by an interest group is that the group is working to pass a new law. Not all agendas involve legislative activities. Legislation is often viewed as an ideal solution to a problem, and passage of laws can be a very effective way to achieve the group’s goals for the agenda. Legislation is often preferred because once a proposed solution is passed into law, it is less likely that the legislature or administration will later act to reverse the action, particularly as individuals and stakeholders begin their compliance efforts and the effect of the law becomes visible to society. Other decisions that need to be made are determining which legislative body is the most appropriate for advancing your agenda. Consideration needs to be given to the likelihood of success in one legislative arena or another and the long-term implications for success. A critical mass of successes at the local or state level may be necessary before other jurisdictions will consider an agenda item. Cigarette smoke–free environments began with success in county and municipal jurisdictions before success could be achieved at the state level. For example, Chicago adopted a smoke-free policy before it was adopted by Illinois. Likewise, when working with national organizations, deciding where to advance an agenda first can be strategic in terms of subsequent successes.

Regulation Regulations made by state and federal agencies with rule-making authority present opportunities for policy gains for interest groups. Agencies with directors who are appointed by the president or a governor are more accountable to the current executive administration’s policy agenda, whereas agencies created by statute with staffing decisions made further outside the purview of a current administration might be more likely to attend to an issue not prominently on the current administration’s agenda. The political leanings of an agency’s leadership inevitably sways the agency’s direction on rules, regulations, and other guidance. Elections have a direct influence on broad policy agendas and can, because of the appointment process, determine the partisan composition of agencies and Congress, which must approve many of a president’s appointments (Birkland, 2016). These appointed positions can be opportunities for nurses. For example, Mary Wakefield, PhD, RN, FAAN, who has a long history as a health policy activist, was named administrator of the Health Resources & Services Administration (HRSA) by President Barack Obama on February 20, 2009. HRSA is a critical agency of the U.S. Department of Health and Human Services (DHHS). In this position, Dr. Wakefield’s expertise was instrumental in expanding the use of RNs and improving services for

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the uninsured or underserved population while addressing severe provider shortages across the country. The nursing community supported Dr. Wakefield for the HRSA position and was pleased to see this major milestone for nursing. In 2015, Dr. Wakefield was appointed acting deputy secretary of the DHHS, becoming one of the highestranking nurses in the federal government, a post she held until the next administration took office. It is the general practice for political appointees at the federal and state level to be replaced when the administration changes. Some legislation designates an agency to implement regulations to enforce the law. Laws governing nursing (e.g., state nurse practice acts) designate the state board of nursing in most states as the implementing authority. Often, laws governing hospitals and other healthcare facilities designate the state department of health or another licensing body as the regulatory authority. The DHHS, within which the Centers for Medicare & Medicaid Services, the Agency for Healthcare Research and Quality, the Food and Drug Administration, and the Centers for Disease Control and Prevention reside, is often the federal regulatory authority for implementing federal healthcare laws. The regulatory process is intended as a way for agencies with more expertise than legislators to add specificity to laws by providing implementation, interpretations, definitions, and compliance and enforcement provisions. For example, a nurse overtime law in a state may generally prohibit mandatory nurse overtime in hospitals. Further explanation of the prohibition and important definitions, such as definitions of “overtime” or “on call,” might then be provided by the state agency charged with oversight responsibilities for hospitals. Such rules and regulations can be adopted only by state agencies after a specific rule-making process, typically set forth in a state’s administrative procedure law. The specifics vary by state but, generally, state that agencies are required to publish proposed rules in advance and allow a specified period for public comment and possibly a hearing. Agencies are to consider all comments before issuing final regulations or rules. Agencies can also take action that falls shy of regulation but still may have enormous impact. Some agencies have the power to issue advisory opinions, reports, and other guidance that is outside of the rule-making process. For example, state boards of nursing offer position statements, advisory opinions, and other guidance for the RNs licensed under their nurse practice acts. This guidance is less formal than regulation but is nevertheless intended to guide the practice of nursing in a particular state and often does have the same effect as regulation. Another example is when a state agency is charged with studying an issue and then publishing a report, either for the legislature or for another government body. For example, after a failed legislative initiative to mandate certification for surgical technologists in hospitals and ambulatory surgery centers, the Washington State Department of Health was asked to conduct a thorough review to examine the public policy impact of changing the surgical technology profession’s scope of practice. In September 2012, after collecting written comments and holding a 4-hour hearing on the issue of requiring surgical technologists working in Washington hospitals and ambulatory surgery centers to hold and maintain national certification, the health department issued a 216page comprehensive report that included the presentations from those who submitted comments and testified at the hearing. The report recommended against mandatory certification of surgical technologists with a detailed recommendation and its rationale for the Washington legislature (Washington State Department of Health, 2012). This report does not have the force of law or even regulation, and legislators are not bound to follow it. However, given the breadth of the research and the deference traditionally

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given by lawmakers to agency expertise, it is unlikely that the Washington legislature will pass a law requiring certification of surgical technologists without the support of the Washington State Department of Health. Much healthcare policy also happens at the institutional level. How a hospital interprets and implements a practice, a state regulation, or standard from The Joint Commission can vary. Nurses must establish channels to provide their expertise as institutions adopt and revise healthcare policies and directives. Even items such as continuing education programs, hospital newsletters, and staff development initiatives offer opportunities for nurses to shape and influence healthcare delivery within their institutions. One example of hospitals leading policy changes is in the area of healthy and sustainable food. Many hospitals across the nation are taking part in the healthy food initiatives focusing on both nutrition and food sustainability in response to a Healthy Food in Health Care program, an initiative of the Health Care Without Harm organization (Knudson, 2013). Hospitals are leading changes in communities by using their enormous purchasing power to favor local organic fruits and vegetables and healthy food from sustainable sources. Some healthcare systems have developed initiatives to reduce food insecurity in their communities. Examples of baseline policy actions facilities in the program might initially include taking a pledge or formally adopting a policy. Hospitals that have been successful in implementing change have used interprofessional teams, with nurses heavily involved and often leading the efforts.

Litigation The legal system is another policy strategy used by interest groups to advance a cause or seek an intended outcome. In addition to resolving claims and disputes between individuals and corporations and adjudicating the innocence or guilt of persons accused of violating criminal laws, our American judicial system is used to establish, affirm, or clarify constitutional and statutory rights. Litigation initiated to accomplish policy outcomes is known as impact litigation. For example, in June 2012, in response to a challenge brought by many states’ attorneys general, the U.S. Supreme Court upheld President Barack Obama’s landmark healthcare reform legislation, the Affordable Care Act (National Federation of Independent Business v. Sebelius, 2012). Brown v. Board of Education, the landmark 1954 case declaring state laws establishing that separate schools for black and white students are unconstitutional, was a result of impact litigation. However, using litigation to enforce existing legislation or regulations can be very expensive. The American Civil Liberties Union (ACLU) is a well-known example of a funded interest group that uses impact litigation to accomplish its policy goals. The ACLU has over one million members who financially support its work; its litigation efforts are paid for by member dues, contributions from individuals, and grants from private foundations. The ANA and state and national specialty associations have impacted litigation that is important to the profession’s agenda while protecting RNs and patients’ rights and well-being. Another way to use the legal system is to file amicus briefs in cases of interest to the group but in which the group is not actually a party. Amicus curiae means “friend of the court” in Latin. Interest groups may file amicus briefs with a court to provide information on the possible legal effects of a court decision and its potential impact on others who are not party to the litigation. For example, the ANA, Louisiana State

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Nurses Association (LSNA), and Louisiana Alliance of Nursing Organizations (LANO) filed an amicus brief to support the full scope of practice for certified registered nurse anesthetists (CRNAs). The focus of the brief was specific to CRNAs’ interventional pain management (e.g., injection of local anesthetics). Although the options for venues may vary with the issue and the particular locale, agenda setting is an important part of the policy process. The Option for Policy Challenge illustrates one route taken in New York for advancing baccalaureate education. Other options or combinations of options may work better in other settings and may include different groups of stakeholders. It is to our advantage to think outside of the box in considering possibilities for setting the agenda.

OPTION FOR POLICY CHALLENGE: Advancing Nursing Education: The New York Experience Barbara Zittel A new legislative session began in 2017 with both bills needing introduction and sponsorship again. Both Assemblyman Joseph Morelle and Senator John Flanagan sponsored the bill again. On June 19, 2017, each of the bills was passed in their respective house. After a 6-month anxious wait, the governor signed the bill into law on December 18, 2017. One of my heroines is Elizabeth Cady Stanton, a New York social activist and leading figure of the 19th-century women’s rights movement. She worked unceasingly for 50 years and died before passage of the 19th amendment; her story is now overshadowed by the contributions of Susan B. Anthony, her lifelong friend. Stanton writes, “I never forget that we are sowing winter wheat which the coming spring will see sprout and other hands than ours will reap and enjoy.” To move this legislation, an alliance of like-minded folks (i.e., a group of nursing and healthcare organizations, educational leaders, and the public) was needed. That group, noted earlier, is the Coalition to Advance Nursing Education (CANE), a collaborative of interested members who are willing to meet or write their legislators and other parties to lobby for the bill. Members were connected through the web and did not have a face-to-face meeting other that once a year for a Lobby Day in Albany. To maintain interest and enthusiasm, a group email, Friday’s Update, was sent out to relay information about progress and actions to take, clarify questions, and make suggestions. This was sent weekly for each week of the legislative session to over 700 members for 9 years. As the end of 2017 approached when it seemed that our efforts to get the bill passed would be lost, we ramped up our efforts to get the word out that nurses and our friends needed to contact the governor to push the bill over the finish line. We found the following: 1. Compromise on accepting a 10-year time frame garnered the support of associate degree nurse educators, a key group. 2. Multiple requests were required to obtain organizational letters of support. (continued )

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3. Economic benefits of the bill changed minds more than most other points. 4. Employing a lobbyist made a significant difference in having our positions and presence felt by legislators. 5. Educating majority leaders and their staff in the Senate and Assembly and recruiting the leaders as sponsors was the major variable in moving the bill forward. Nurses in other states expressed interest in the process and bill. While we celebrate its passage in New York, these nurses are determining a course of action in their own jurisdiction.

IMPLICATIONS FOR THE FUTURE As you take steps to implement your agenda, you will begin to see political ramifications and responses. Nurses should capitalize on their unique professional talents to establish and advance their agenda. Nurses are excellent negotiators, communicators, problem solvers, and team players (Boswell, Cannon, & Miller, 2005). These skills are used by nurses every day to manage conflict, cope with challenging personalities, and diffuse potentially explosive situations, all in the name of patient care and safety. It is well established that teamwork is essential for patient safety (Kalisch, Weaver, & Salas, 2009). Nurse advocates must draw on these same talents and skills as they engage in policy discussions at both individual and institutional levels. “Once a nurse is motivated to try to change or develop policy, and becomes engaged in the process, many of the basic approaches to work and problem solving developed in nursing education and practice prove useful” (Gebbie, Wakefield, & Kerfoot, 2000, p. 314).

KEY CONCEPTS 1. Agenda setting is a complex process involving the laying out of problems and solutions so that the issue comes to the attention of the public and governmental officials. 2. Agendas are designed to influence events, news, and understandings. 3. The context of an agenda, timing, political climate, and political realities are important in the agenda-setting process. 4. Organizations, or groups within an organization, work to get their priority issue on the agenda to influence policy. 5. An organization’s agenda needs to be linked to its mission and strategic plan to gain traction with key stakeholders. 6. Agendas have levels of increasing specificity: agenda universe, systemic agenda, institutional or organizational agenda, and decision agenda. Issues need to reach the institutional agenda to achieve progress toward a decision. 7. Nurses need to own the agenda for their practice, within their organizations, and within the profession. 8. Agenda development includes defining the problem and establishing the agenda. 9. Numerous internal and external factors influence whether an issue gains prominence on the agenda; these include a new administration, new leadership, unpredictable events, finances, public acceptance, opposition of powerful interests, or competing issues.

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10. Knowing the numerous stakeholders and their varying degrees of support are invaluable in planning strategies for moving an agenda forward. 11. Interest groups, including associations, corporations, and consumer groups, may be supportive, neutral, or opposed to an agenda. 12. Understanding obstacles to an agenda facilitates designing a strategy to move an agenda forward. 13. Networking provides opportunities to build relationships with legislators, regulators, and key organizational and community leaders. 14. Coalitions provide an opportunity to expand influence in support of a common policy goal. 15. Raising awareness of an agenda either in the public arena or within an organization increases the chance of moving the agenda forward. 16. Speaking with a unified voice is important to the success of an agenda. 17. Focusing an agenda on a specific venue, such as legislative, regulatory, or judicial, can be strategic in maximizing successes. 18. Agenda setting is a process that can be used both in the public arena and within organizations to achieve important policy goals.

SUMMARY Setting the agenda is a process that is in constant flux, and strategies need to change to reflect the dynamics of the situation. Policy changes rarely happen quickly. Advocates must be prepared, persistent, and patient in their approach to changes. Windows of opportunity may open and close over years or an even shorter time. Just when your group is about to close in on a regulatory success, a key agency personnel or elected official change may derail your efforts. Maintaining a long view is helpful and healthy. During times when your legislature is not in session or executives sensitive to your issue are not in office, do not sit idle. Remain focused and monitor your policy makers’ agenda. Seize opportunities to raise your issue on that agenda. Keep your group and grassroots advocates engaged and prepared. Review and refine your messaging. Meet with public officials and legislators and their staff to educate them about your issue, even if you know this is not the year your issue will advance on the policy agenda. Stay committed to your group’s mission and goals while continuing to redefine your policy issue as needed. Work to identify a solution in ways that stand the best chance of resonating with the largest number of policy makers and stakeholders.

LEARNING ACTIVITIES 1. Determine the policy issues important to the governor in your state, your local representative, and one professional nursing organization. Describe the methods you used to obtain the information and critique the ease of access among the three sources. 2. Talk to a nurse leader or identify for yourself how a new agenda in management or in shared governance has been successfully or unsuccessfully introduced. 3. Identify the details of your state governor’s agenda items that relate to healthcare. Compare those agenda items with the agenda of the nursing organizations with which you are involved and describe how you could frame your nursing organization’s issues within the state executive’s agenda.

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4. Find fact sheets from various organizations, including a national organization, a state organization, and a consumer group, and identify strengths and weaknesses. Try to find fact sheets from opposing groups on the same issue and compare how the groups define the problem. 5. Find examples of press releases and other materials designed to increase public awareness of an issue. For example, the Coalition for Patients’ Rights issues press releases and media stories designed to educate the public about the importance of the patient’s right to choose providers. Can you find others? 6. Which groups make up the IOM state action coalition in your state? What groups could be included in your state’s action coalition? In your state and others, can you find examples of successes and policy changes accomplished by the IOM state action coalitions? 7. Locate a health policy stakeholder’s mission statement and/or strategic plan and identify how a practice issue that you believe needs to be on the agenda fits with the statement or plan.

E-RESOURCES • Agency for Healthcare Research and Quality: Setting the agenda for research on cultural competence in health care http://www.ahrq.gov/research/findings/factsheets/literacy/cultural/index.html • American Nurses Association http://www.nursingworld.org • American Nurses Association: Health system reform agenda https://www.nursingworld.org/practice-policy/health-policy/health-systemreform/ • Canadian Nurses Association: Nursing and the political agenda http://www.cna-aiic.ca/en/advocacy/nursing-and-the-political-agenda • National Council for Research on Women https://www.2020wob.com/affiliate/national-council-research-women-ncrw • Oncology Nursing Society: Research Agenda https://www.ons.org/sites/default/files/2014-2018%20ONS%20Research%20 Agenda.pdf • World Health Organization. Health service planning and policy-making: A toolkit for nurses and midwives, WHO Module 2: Identifying and analyzing the stakeholders and establishing networks http://www.wpro.who.int/publications/docs/hsp_mod2_BB2D.pdf?ua=1

REFERENCES Albalawi, Y., & Sixsmith, J. (2015). Agenda setting for health promotion: Exploring an adapted model for the social media era. JMIR Public Health Surveillance, 1(2), e21. doi:10.2196/publichealth.5014 American Academy of Pediatrics. (2013). Policy statement—The crucial role of recess in school. Pediatrics, 131(1), 183–188. doi:10.1542/peds.2012-2993 American Nurses Association. (2008). Adapting standards of care under extreme conditions: Guidance for professionals during disasters, pandemics, and other extreme emergencies. Retrieved from https://www.nursingworld.org/~4ade15/globalassets/docs/ana/ascec_whitepaper031008final.pdf

190   UNIT II  ANALYZING POLICY American Nurses Association v. Tom Torlakson. 2013, s184583 Ct. App C061150 Sacramento County Super. Ct. No. 07AS04631. Retrieved from http://www.cde.ca.gov/ls/he/hn/documents/anavtorlakson2013.pdf APRN Consensus Work Group, & National Council of State Boards of Nursing APRN Advisory Committee. (2008, July 7). Consensus model for APRN regulation: Licensure, accreditation, certification & education. Retrieved from https://www.ncsbn.org/Consensus_Model_for_APRN_ Regulation_July_2008.pdf Association for Professionals in Infection Control and Epidemiology. (2016, November 15). APIC Policy Agenda: Moving toward elimination of HAIs. Retrieved from https://apic.org/Resource_/ TinyMceFileManager/Government_Affairs/APIC_Policy_Agenda_-_Elimination_of_HAIs.pdf Association of periOperative Registered Nurses. (2007). RN first assistant guide to practice (3rd ed.). Denver, CO: Author. Balestra, M. (2012). Amicus brief supports administration of insulin to students only by licensed nurses. Journal of Nursing Law, 15(1), 27–32. Birkland, T. A. (2016). An introduction to the policy process: Theories, concepts, and models of public policy making (4th ed.). New York, NY: ME Sharpe. Brown v. Board of Education of Topeka, 347 U.S. 483 (1954). Retrieved from https://supreme.justia. com/cases/federal/us/347/483/ Boswell, C., Cannon, S., & Miller, J. (2005). Nurses’ political involvement: Responsibility versus privilege. Journal of Professional Nursing, 21(1), 5–8. doi:10.1016/j.profnurs.2004.11.005 Brenan, M. (2017, December 26). Nurses keep health lead as most honest, ethical profession. Gallup News. Retrieved from http://news.gallup.com/poll/224639/nurses-keep-healthy-lead-honestethical-profession.aspx?g_source=&g_medium=search&g_campaign=tiles Cobb, R. W., & Elder, C. D. (1972). Participation in American politics: The dynamics of agenda-­building. Boston, MA: Allyn & Bacon. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Future of Nursing Campaign for Action. (2012). What makes an effective coalition? Retrieved from http://campaignforaction.org/effective-coalition-tcc Gallup. (n.d.). Most important problem. Retrieved from http://www.gallup.com/poll/1675/most -important-problem.aspx Gallup. (2017, August 10). Government, healthcare most important problems in the U.S. Retrieved from http://news.gallup.com/poll/215645/government-healthcare-important-problems.aspx Gebbie, K. M., Wakefield, M., & Kerfoot, K. (2000). Nursing and health policy. Journal of Nursing Scholarship, 32(3), 307–315. doi:10.1111/j.1547-5069.2000.00307.x Green-Pederson, C., & Wilkerson, J. (2006). How agenda-setting attributes shape politics; basic dilemmas, problem attention and health politics developments in Denmark and the US. Journal of European Public Policy, 13(7), 1039–1052. doi:10.1080/13501760600924092 Grossman, M. (2012). Interest group influence on US policy change: An assessment based on policy history. Interest Groups & Advocacy, 1(2), 171–192. doi:10.1057/iga.2012.9 Healthy Choices for Healthy Children Act. (2010). Ohio General Assembly SB 210. Retrieved from http://archives.legislature.state.oh.us/bills.cfm?ID=128_SB_210 Kalisch, B. J., Weaver, S. J., & Salas, E. (2009). What does nursing teamwork look like? A qualitative study. Journal of Nursing Care Quality, 24(4), 298–307. doi:10.1097/NCQ.0b013e3181a001c0 Kingdon, J. W. (2011). Agendas, alternatives, and public policies (2nd ed.). Glenview, IL: Pearson. Knudson, L. (2013). Healthier hospital food can affect health of patients and the planet. AORN Journal, 97(6), C1, C9–C10. doi:10.1016/S0001-2092(13)00474-2 Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. Washington, DC: National Academies Press.

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Kozel, C. T., Kane, W. M., Hatcher, M. T., Hubbell, A, P., Dearing, J. W., Forster-Cox, S., … Goodman, M. (2006). Introducing health promotion agenda-setting for health education practitioners. Californian Journal of Health Promotion, 4(1), 32–40. Retrieved from http://www.cjhp.org/Volume4_2006/ Issue1/32-40-kozel.pdf National Federation of Independent Business v. Sebelius. 567 U.S.; 132 S.Ct. 2566 (2012). Retrieved from http://www.scotusblog.com/case-files/cases/national-federation-of-independent-businessv-sebelius Peters, B. G. (2016). American public policy: Promise and performance (10th ed.). Thousand Oaks, CA: CQ Press. Pralle, S. B. (2003). Venue shopping as political strategy: The internationalization of Canadian Forest Advocacy. Journal of Public Policy, 23,(3), 233-260. doi:0.1017/S0143814X03003118 Smith, Bucklin & Associates, Inc. (2000). The complete guide to nonprofit management (2nd ed.). New York, NY: John Wiley & Sons. VanDevanter, N., Raveis, V. H., Kovner, C. T., McCollum, M., & Keller, R. (2017). Challenges and resources for nurses participating in a Hurricane Sandy hospital evacuation. Journal of Nursing Scholarship, 49(6), 635–643. doi:10.1111/jnu.12329 Waddell, K. (2017, January 23). The exhausting work of tallying America’s largest protest. The Atlantic. Retrieved from https://www.theatlantic.com/technology/archive/2017/01/ womens-march-protest-count/514166/ Washington State Department of Health. (2012). Surgical technologist certification. Retrieved from http://www.doh.wa.gov/Portals/1/Documents/2000/SurgTechCert.pdf

UNIT III

STRATEGIZING AND CREATING CHANGE

SEVEN

Building Capital: Intellectual, Social, Political, and Financial Lauren Inouye Colleen Leners Suzanne Miyamoto We in America do not have government by the majority. We have government by the majority who participate.—Thomas Jefferson

OBJECTIVES 1. Compare and contrast the types of capital used in policy and advocacy. 2. Relate the concept of capital to its policy impacts. 3. Explore competencies to successfully build capital, given an advocate’s resources. 4. Examine the contributions and challenges of coalitions in developing political capital. 5. Discuss the critical role of lobbying and its impact for nursing. 6. Compare the phenomena of the “free rider syndrome” and grassroots in relation to the impact to the nursing profession.

What does building capital truly mean, how does it shape policy, and to what extent is it important for nurses to engage in developing capital? At its core, capital is a necessary tool that can shape status, power, and reputation—in other words, influence. Capital can be developed in intellectual, social, political, and financial forms. For the individual, capital has ramifications on personal and professional life. For example, capital could be used to win the school board election or secure the promotion at work. Capital is necessary for state and national organizations to be effective in their mission. National organizations seeking to be leaders in health policy development and implementation may use all forms of capital to their advantage. Essentially, the more capital an individual, group, or institution controls, the more effective it is in influencing and shaping policy. It is critical to understand not only how important it is to build capital, but also how to amplify the resources necessary to do so. Therefore, this chapter explores the

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• Build Financial Capital to engage at a higher level in the process. Consider becoming a Grasstop.

• Build Intellectual Capital to establish credibility as the expert in both content and process. Investigage the issue from all angles.

Intellectual

Financial

Politically Active Nurse

Political • Build Political Capital to make nursing’s voice heard and influence the process. Don’t be a “free rider.” Respond to nursing’s call to action.

Social

• Build Social Capital to create a network of supporters. Make friends by coming early and often, and as well as by being a resource.

FIGURE 7.1  Creating capital for nurses’ political engagement.

i­ndividual nurse’s role in developing personal capital, as well as how the individual nurse supports the growth of the profession’s resources. Figure 7.1 illustrates the ­centrality of the nurse to the policy-making process. Each type of capital will be examined for its role in policy making at the big “P” (e.g., congressional agenda) and little “p” (e.g., policies where you work and live) levels. Nurses and the nursing profession have all the essential resources for maximizing the forms of capital to engage policy makers at the local, state, and national levels. The Policy Challenge highlighted here demonstrates the use of capital at the national level.

POLICY CHALLENGE: Gaining Political Capital by Being Part of a Team Colleen Leners, DNP, APRN, FAANP Director of Policy, American Association of Colleges of Nursing, Washington, DC The routes to gaining political capital are varied. This Policy Challenge illustrates how one’s professional experiences can be strategically used to develop political capital. I am a daughter of a nurse and grew up in family in which (continued )

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politics was not discussed. My parents had differing political opinions and party affiliations, which taught me that there were two sides to every story. I obtained an associate degree in nursing and launched my career in the emergency department of a California hospital. I joined the U.S. Navy Reserves and became a nurse practitioner (NP) while still working in the civilian sector. My reserve duty varied as an NP from physical examinations to the care of mothers and children. A turning point in my career came when I decided to join the U.S. Army so that I could apply my trauma and family medicine knowledge and expertise (my intellectual capital) to those serving on the front lines in Iraq. Leaving three children in the care of my mother, I deployed in 2005, worked in Tikrit, a battered city some 80 miles north of Baghdad, the Iraqi capital. The conditions were trying to say the least, even living in tents for short times. My responsibility was outpatient care in a combat support hospital, a role that included care and triage of mass casualties with oversight of a team of nurses, physicians, and other personnel. Working as a team was all important. One day a surgeon said to me, “I forgot you were a nurse.” I responded that I forgot that he was a surgeon. I also worked off the base teaching emergency medical care. While off base, I provided care to people in those areas. Informally, I provided advice and counsel to younger nurses, brand new nurses, and personnel who were put in combat zones. These efforts resulted in my being awarded a Bronze  Star.  But  in  my heart, the real heroes are the ones that do not come home. On returning to the United States, I had a persistent bad cough and was subsequently diagnosed with follicular lymphoma, most likely attributable to breathing air from open burning pits while in Iraq. I received a medical retirement. It was difficult to navigate the system and receive consistent treatment. Electronic health record interoperability between the health records of the Department of Defense and Veterans Affairs did not exist. If I was having difficulty with the system, how were enlisted personnel with no arms or legs and maybe a high school education going to manage? It upset me as a provider, a wounded warrior, and a veteran. This fueled my passion to make a difference for our soldiers and our veterans. It led me to apply for a Robert Wood Johnson Fellowship. I thought that my placement would be working directly with the Veterans Affairs Committee, but that was not to be. See Option for Policy Challenge

As we see in this Policy Challenge, nurses have multiple time points in their careers to maximize their capital to influence policies that would ultimately impact nursing and healthcare. This chapter explores the four types of capital (i.e., intellectual, social, political, and financial), their interdependency, and ways that they can be maximized to advance healthcare policy. The introductory Policy Challenge and subsequent Option for Policy Challenge demonstrate how gaining political capital can accumulate from experience and challenging yourself to take opportunities when they arise.

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INTELLECTUAL CAPITAL Intellectual capital for nursing is the knowledge of an individual or the collective knowledge of a group that can be expended to influence policy makers to use or adopt suggestions, viewpoints, and solutions about healthcare and the healthcare environment. Nurses have the brainpower to effectively influence policy at both the big “P” and little “p” levels. They can also draw on a large body of research from nursing and other disciplines to support their policy initiatives (see Chapter 5). Nurses in every type of position have intellectual capital that can be used to inform, communicate, and advance nursing and healthcare agendas. Nurses may not realize the extent of their intellectual capital when communicating with federal, state, and local officials, very few of whom have a healthcare background. These officials may have no practical context for what it is like to provide care to a patient, run a nurse-managed health clinic, or educate the next generation of nurses. Only nurses have this expertise. Legislation may be necessary to improve access to care for individuals who use community clinics. For example, legislation designed to reimburse clinics for diabetes education, might also include considerations related to the social determinants of health. Barriers may involve health literacy and accessible transportation that prevent patients from being able to self-manage their care. Nurses working with patients can provide these valuable insights to officials who oversee policy at the big “P” and little “p” levels in a variety of organizations. Policy makers rely on their expert constituents to provide them with the background across a broad spectrum of healthcare policies. Most of the time, officials and elected leaders do not reach out to an individual constituent for advice unless they have an established relationship (see Social Capital). Social media is an important communication channel of constituents. According to a Congressional Management Foundation (CMF, 2015) report that asked federal legislative staff on the role of social media and advocacy, 76% responded they “agree” or “strongly agree” that “social media enabled us to have more meaningful interactions with constituents.” In addition, 63% of respondents reported that they believe constituent communications will come in social media form more than email, phone, or other means in the next 5 to 10 years (CMF, 2015). Twitter, Facebook, Instagram, and other social media platforms are a few examples of how everyday constituents message their legislators. Members of Congress typically have staff who handle communications for the office and who track and respond to social media; however, many legislators respond directly to their constituents. In this age, communication that is instant and easily digestible (“bite-sized”) appeals to the masses, and social media outlets provide the means to message in this manner (see Chapter 10).

The Big “P” In 2010, the Robert Wood Johnson Foundation (RWJF), in collaboration with Gallup, conducted a survey of over 1,500 healthcare thought leaders (e.g., from government and the healthcare sector) to ask their opinions about the role that nurses play and can play in policy. The large majority reported that nurses should have a greater part in policy. Few nurses, however, would argue that nursing’s full intellectual power has been capitalized on in the policy arena. In fact, the thought leaders were asked to state how they believed that nursing could take on more leadership in the healthcare delivery system. The top response was to increase their input and make their voices heard (Khoury, Blizzard, Wright Moore, & Hassmiller, 2011).

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Nurses and other leaders across the country believe that the science, experience, and skills unique to the nursing profession can drive positive transformations. However, policy can seem an elusive process to many individual nurses. As a result, this section first discusses some ways that individual nurses have capitalized on their unique skills at the level of the federal government. The nursing profession is not in short supply of experts. From nationally and internationally renowned nurse researchers to the nurse practicing at the bedside, every nurse is an expert and can drive change from personal knowledge. A textbook example of a nurse using intellectual capital to inform policy change is Mary Naylor, PhD, RN, FAAN, professor and director of the New Courtland Center for Transitions and Health at the University of Pennsylvania. For years, Dr. Naylor demonstrated the successful use of advanced practice registered nurses (APRNs) to reduce readmission rates, known as the Transitional Care Model. A similar model was adopted at the federal level. According to the Centers for Medicare & Medicaid Services Innovation Center (CMS Innovation Center), this program, the Community-Based Care Transitions Program, “tests models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries” (CMS Innovation Center, 2013). This example illustrates how a nurse’s expertise was used to shape national policy, but it may not be clear that vital to her success was her understanding of the policy process. Earlier in her career, Naylor had a W. K. Kellogg Foundation leadership fellowship with the Senate Committee on Aging. Many nurses carry out research, but they fail to tie their work to policy or are not savvy about the political process; thus, their research and expertise never bears full fruition. Therefore, it is important to understand that although expertise in an area is necessary, intellectual capital also refers to understanding the policy process and keeping abreast of policy issues. Congressional staff, nurse lobbyists, and medical lobbyists as groups have identified an understanding of the process as an essential strategy for moving an issue forward (Begeny, 2009). Understanding the intricacies of policy making, like timing of an issue, is vital to success. For example, if an intended goal is to increase funding for nursing education, knowing when to ask for increased funding or knowing when to support a request that has been made is vital. For example, requesting funding for federal programs must come during the time when Congress is developing its spending bills. A strong place to start learning this process and what is happening on the national agenda is through nurses associations (e.g., see Exhibit 7.1). EXHIBIT 7.1  SELECTED RESOURCES FOR BUILDING INTELLECTUAL CAPITAL Policy News From Nurses Associations American Association of Colleges of Nursing’s Washington Weekly: www .aacnnursing.org/Policy-Advocacy/About-Government-Affairs-and-Policy/ Newsletters American Nurses Association’s Capital Beat: www.anacapitolbeat.org Federal Agencies Department of Health and Human Services Patient Protection and Affordable Care Act (ACA): www.healthcare.gov Department of Health and Human Services: www.hhs.gov (continued )

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EXHIBIT 7.1  S  ELECTED RESOURCES FOR BUILDING INTELLECTUAL CAPITAL

(continued ) Agency for Healthcare Research and Quality: www.ahrq.gov Centers for Medicare & Medicaid Services: www.cms.gov Health Resources & Services Administration: www.hrsa.gov/index.html National Institutes of Health: www.nih.gov National Journals, Nonprofit Organizations, and Think Tanks Center for American Progress: www.americanprogress.org Health Affairs: www.healthaffairs.org Henry J. Kaiser Family Foundation: www.kff.org Heritage Foundation: www.heritage.org Robert Wood Johnson Foundation: www.rwjf.org National Governors Association: www.nga.org/cms/home.html Political Newspapers Politico: www.politico.com The Hill: thehill.com Association Toolkits American Association of Colleges of Nursing August Recess Toolkit: www .aacnnursing.org/Policy-Advocacy/Advocacy-Tool-Kit American Association of Nurse Practitioners Federal Policy Toolkit: www.aanp .org/legislation-regulation/policy-toolkit American Nurses Association Activist Toolkit: www.rnaction.org/site/ PageServer?pagename=nstat_take_action_activist_tool_kit&ct=1&ct=1 Association of periOperative Registered Nurses Take Action Tools: www.aorn .org/community/government-affairs/advocacy-tools-and-resources National Association of Clinical Nurse Specialist Legislative and Regulatory Toolkit: www.nacns.org/professional-resources/toolkits-and-reports/ legislative-and-regulatory-toolkit National Association of Neonatal Nurses Legislative Advocacy 101: www.nann .org/uploads/Advocacy_Fact_Sheets/Legislative_Advocacy_101.pdf

Nurses associations are rich with resources such as policy factsheets, newsletters, and web pages. Many associations send out monthly policy electronic newsletters that provide the most current actions occurring at the state and federal levels. Federal agencies, national journals, think tanks, and policy newspapers are

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all resources a nurse can use to build intellectual capital. These organizations and media sources report on what Congress is addressing and what healthcare topics are gaining or losing support. To better hone both your intellectual and political capital, consider getting help from lobbyists that nurses associations, universities, or healthcare systems can provide. Both types of lobbyists have an understanding about intellectual capital often have relationships with congressional staff members and can help arrange a meeting to discuss the issue at hand. They can assist in putting the research, data, and statistics into context for the legislator. Furthermore, when nurses’ expertise is shared with their national or state associations, those organizations may use them as expert witnesses for a congressional or state legislative hearing. Many state and specialty nurses associations also offer workshops in conjunction with what are referred to as advocacy days to learn the policy process. Advocacy days are events, usually a day long, held in a state or federal capitol and sponsored by nurses associations. The event is educational and incorporates meetings with legislators and/ or members of the governor’s office. The goal is helping nurses understand the legislative process and providing them with proactive steps for advocating for their patients and practice. These events are open to nurses and nursing students and provide nurses associations the opportunity to brief their members and nursing students on the political climate and legislative requests. Short-term programs are available for nurses and nursing students to develop their policy skills (see Exhibit 7.2). These programs are focused on helping nurses become stronger political leaders and expanding the grassroots capacity for the nursing profession by providing comprehensive health policy education and experiences. Attending these policy and advocacy programs opens the doors to endless possibilities. Aside from gaining information about the legislative processes that drive our federal government, the chance to network with other nurses and healthcare leaders is invaluable (social capital). It is important for nurses and nursing students wanting to become further involved in policy and advocacy to participate in opportunities that help build their knowledge base and professional experience because nurses are the best experts for their profession and can make a true and lasting impact. EXHIBIT 7.2  OPPORTUNITIES TO BUILD INTELLECTUAL CAPITAL For Registered Nurses American Nurses Advocacy Institute (ANAI) The ANA created the ANAI, a year-long mentored program designed to develop nurses into stronger political leaders and expand grassroots capacity for the nursing profession and healthcare. To be considered, the nurse must belong to both the ANA and a state nurses association (SNA). On completion, each Fellow counsels the SNA in establishing legislative/regulatory priorities, recommends strategies for execution of the advancement of a policy issue, and educates members about political realities, as well as assists in advancing the ANA’s agenda. https://www.nursingworld.org/practice-policy/advocacy (continued )

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EXHIBIT 7.2  OPPORTUNITIES TO BUILD INTELLECTUAL CAPITAL (continued ) The Alliance: Nursing Organization Alliance Nurse in Washington Internship (NIWI) Open to any RN or nursing student (all levels of education) who is interested in learning about current issues in nursing and the legislative process. Each participant spends time meeting with his or her members of Congress while participating in the NIWI Annual Advocacy Days (see Figure 7.2). www.nursing-alliance.org/Events/NIWI-Nurse-in-Washington-Internship For Advanced Practice Registered Nurses American Association of Nurse Practitioners (AANP) Health Policy Fellowship The AANP Health Policy Fellowship program provides AANP members with a comprehensive fellowship experience at the center of health policy and politics in Washington, DC. It is an outstanding opportunity for members with an interest in healthcare policy to promote the health of the nation and the advancement of NPs’ ability to work within their full scope of practice. www.aanp.org/legislation-regulation/federal-legislation/ health-policy-fellowship For Nursing Students American Association of Colleges of Nursing (AACN) Student Policy Summit (SPS) The SPS is a 3-day conference held in Washington, DC, and is open to baccalaureate and graduate nursing students enrolled at an AACN member institution. It is a didactic immersion program focused on the nurse’s role in professional advocacy and the federal policy process (see Figure 7.3). www.aacnnursing.org/Policy-Advocacy/Get-Involved/Student-Policy-Summit For Nurse Faculty AACN’s Faculty Policy Intensive (FPI) The FPI is a 3-day immersion program designed for faculty of AACN member schools interested in actively pursuing a healthcare and nursing policy role. It offers the opportunity to enhance existing knowledge of policy and advocacy by strengthening understanding of the legislative process and the dynamic relationships between federal departments and agencies, national nursing associations, and the individual advocate. www.aacnnursing.org/Policy-Advocacy/Get-Involved/Faculty-Policy-Intensive

The Little “p” A nurse’s individual expertise is vital to shaping policy change at every level, but nurses must be diligent to share this expertise. From the unit level to the hospital system level, the observation of one nurse could improve quality of care, save the healthcare system hundreds of thousands of dollars, improve the efficiency of care delivery, or develop a national policy standard. Yet, an exceptional idea never comes to fruition if it is not heard. Empowered nurses can use their expertise to enact change in their organization (Bradbury-Jones, Sambrook, & Irvine, 2008). On the contrary, if nurses do not feel empowered, feelings of frustration and failure emerge (Laschinger & Havens, 1996;

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FIGURE 7.2  Nurses participating in the Nurses in Washington Internship in 2017.

FIGURE 7.3  American Association of Colleges of Nursing Student Policy Summit attendees, taking part in the association’s advocacy day, are featured with cochair of the House Nursing Caucus, Representative David Joyce (R-OH; center).

Manojlovich, 2007). A thorough literature review conducted by Rao (2012) examined the concept of nurse empowerment over time. This analysis revealed that nurses have viewed empowerment through a lens that focuses on organizational structure. According to Rao (2012), nurses rely “too heavily on rigid bureaucratic structures rather than their own professional power to guide practice. Limiting nurses in this way denies the professional power their role affords them and constrains their ability to achieve extraordinary outcomes” (p. 401). According to Des Jardin (2001), nurses may not believe that they have a role to “challenge the structure of the health care system or the rules guiding that system” (p. 614). Because policy is change, this can cause tension for nurses (Des Jardin, 2001). Therefore, the first steps in many cases are recognizing one’s intellectual capital and then overcoming the inertia and speaking out. At work, this process starts by regularly attending meetings and bringing forth issues that have policy implications, and nursing expertise can help guide these steps. Substantive policy changes often start when people see problems as they carry out their jobs. The policy may relate to an array of practice or clinical issues. Policy on the Scene 7.1 provides examples of how nurses in adult and pediatric settings made change using intellectual capital.

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POLICY ON THE SCENE 7.1: Using Intellectual Capital to Change Practice APRNs have a unique opportunity to use intellectual capital to help change practice. The work of Dianna Copley, MSN, APRN, ACCNS-AG, CCRN, at the Cleveland Clinic and Sue Nicholas MSN, RN-BC, WHNP-BC, CCCTM at Akron Children’s Hospital are used here to illustrate capital to change practice policy. In her first few months in practice as a new clinical nurse specialist (CNS), Dianna Copley observed inconsistency in care for hospitalized patients who needed a wearable cardiac defibrillator. As a new CNS, it was on her list of problems to tackle, along with preparing for an upcoming presentation she had at the National Association of Clinical Nurse Specialists annual conference. She was presenting on her recent transition from clinical nurse to CNS. While at the conference, she attended a presentation describing an interprofessional approach to the care of patients wearing cardiac defibrillators. She also learned that this low-volume, high-risk device has inadvertently shocked healthcare providers. The CNS collaborated with CNS colleagues, clinical nurses, and nurse leaders to create guidelines for caring for patients with such defibrillators. The guideline was identified as having implications across the entire healthcare system and span of adult care, including emergency services, critical care, and medical– surgical nursing. What started as one CNS wanting to improve care in her own unit became a new policy supporting care provided by over 22,000 nurses in the system (Dianna Copley, personal communication, November 9, 2017). In the second example, Sue Nichols, made her change when she participated in her hospital’s evidence-based practice (EBP) learning community. Her work led to a revised policy for taking family histories in a maternal–fetal medicine (MFM) practice. As part of her EBP project, Ms. Nicholas collaborated with a team that found a self-report of family history might improve the comprehensiveness of the ­history, result in a timelier completion of the history, and facilitate opportunities for earlier and more comprehensive genetic counseling. Using the Rosswurm-Larrabee Model for planned change, Ms. Nicholas and the team synthesized evidence for analysis by linking the problem, interventions, and outcomes. They found that a self-report using a standardized pregnancy health tool increased identification of families at risk for inheritable disease and women at risk for pregnancy difficulties. The tool was easy for patients to use and understand, and it was free of charge. After institutional review board approval, the project was trialed for 6 months, with the results showing a dramatic increase in genetic counseling from 7% to 71% after the implementation of the self-report process. Subsequently, the completion of the pregnancy health tool became a standard policy in the completion of family histories for the MFM practice (Meghan Weese, MSN, RN, CPN, NEA-BC, Magnet® coordinator, personal communication, November 6, 2017).

SOCIAL CAPITAL The second interdependent component is social capital. As noted, intellectual capital must be expended to be of benefit; it needs to be shared. Developing social capital is essentially relationship building. More specifically, relationships are built and

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nurtured with key decision makers at the state and national levels to influence policy change. For the nursing profession, social capital should be the most basic, intuitive, and strongest form of capital. Nurses create relationships with their patients, their patients’ families, fellow nurses, managers, and so on. Contextually, it relates to the key elements that are necessary for a positive relationship, namely, honesty and trust. As is often repeated in this book, but not capitalized on by nurses, the nursing profession consistently ranks highest among all others as being the most honest profession (Brenan, 2017).

The Big “P” Social capital at the big “P” level involves the development of relationships with appointed and elected officials. Members of Congress listen to the voices of their constituents. This is a reality that every lobbyist inherently knows well. It is constituents, not the registered lobbyists, who reelect legislators to serve another term. Therefore, opinions of constituents are tremendously more relevant than any political wonk in the nation’s capital. Even though many believe that and there is evidence that wealth plays an influential role in swaying policy, the value of constituents’ opinions and support cannot be dismissed; however, constituents must make their opinions known. To simply be a nurse constituent in the district of a member of Congress does not mean your voice will be heard among the other hundreds of thousands of constituents. You must be savvy. One of the best ways to accomplish this is to gain guidance from national or state nurses associations. If a nurse has an opportunity to directly communicate with a member of Congress, a nurses association’s lobbyist could provide background on the member’s political positions, information about what Congress is currently debating and what message would be most relevant, and talking points to help prepare for an interaction (see Chapter 10) This is the job of registered lobbyists: to prepare their members to be politically savvy through relationships or social capital. In relation to the big “P” political scientists have described these as grasstops. Essentially, nursing needs to develop more grasstops. Grasstops are defined as leaders, such as those within an industry or field, who “usually know who within their sphere shares their interests and what other prominent leaders may be interested” (Gibson, 2010, p. 91). They also embody the social capital necessary to influence a member of Congress. “The member may listen to that person and no one else on a particular issue” (Gibson, 2010, p. 91). Many times, the grasstops are constituents who have supported members of Congress either politically (worked on a campaign) or financially (provided an individual donation to a campaign) or who are leaders in their industry (Goldstein, 1999). To summarize, nursing can build its social capital by having individuals who are savvy (intellectual capital) and who have developed relationships with their elected representatives or staff: in other words, grasstops. The goal is to develop a meaningful relationship. That relationship helps the individual nurse be a valued and trusted resource to that member of Congress. At the core of social capital is developing a longstanding relationship. Meaningful relationships can be nurtured through financial or personal volunteerism. If financially contributing to the campaign of a member of Congress is not feasible, consider volunteering to work on the campaign. If your political views do not align with your current members of Congress, work on the campaign of their

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opponent. Also consider being an ever-present voice in your legislators’ offices, no matter their views or party affiliations. This activity can and has led to nurses becoming a major resource and influence on a legislator, a governor, or staff member. Offering time and expertise is a significant determinant in one’s ability to influence a member of Congress and staff. These relationships do not form overnight. Do not give up even when you are told “no.” Even when you have differing political leanings than the member of Congress, you can have the opportunity to educate the legislator or staff about issues that are important. Relationship building takes tenacity, particularly when you are working with a congressional office that might not have the same viewpoint and may never support the issue at hand. This should never be a reason not to visit a member of Congress and staff and pass on the opportunity to educate them about the issue and the importance to their constituency. “No” does not always mean never. Grasstop relationships are important in nursing, as exemplified in the Policy Challenge and Option for Policy Challenge in this chapter. The type of social capital that a high-level professional position in leadership or in politics provides is important in not only opening doors to the discussion of issues, but also providing support that can sway support of or defeat a project or legislation. Although discussed under the big “P” here, there are grasstop advocates at the little “p” level. As a chair of a local political party or a local board, you may have access to influencing to influence other opinion leaders.

The Little “p” Social capital can ensure policy change at the little “p” level in many of the same ways as at the big “P.” The goal is developing relationships with individuals making the policy decisions and with individuals who have intellectual and social capital themselves. It is critical to identify who those individuals are and how you can connect with them. Often, at the big “P” level, the individuals with whom you want to develop relationships may be obvious, and at the little “p” level, it is sometimes less clear. At first, one may think of only the organizational hierarchy where you work as important in building social capital. Those relationships are vital. However, a good strategy is starting with your existing base of relationships and then broadening those relationships and networks. Consider all your acquaintances as potential opportunities to extend your social capital. As your network grows, it extends to people who do not necessarily think like you or do the same job as you. You will become less insulated in your views, friendships, and networks. As discussed in the section Political Capital, there is power in numbers. Building a network of colleagues (nurses and non-nurses) who agree with the premise of the policy change can better solidify the chances of its implementation. Demonstrating that more than one individual supports the policy change can influence the decision. Establishing this network can sometimes be done easily. Talking during a shift or during an after-hour socialization are some ways. Oprah Winfrey popularized her “book club,” and thousands began discussing literature. Take a cue from Oprah to create a “policy club,” a network that can offer information and assistance. Building social capital at the local level can be accomplished in many ways: ­attending continuing education programs provided by your employer, participating in district nurses associations or other nurses’ groups, serving as a moderator for educational sessions, joining or participating in local organizations’ social events or journal clubs,

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using break times to socialize with key leaders in your organization, or v­ olunteering for your organization’s community events. For example, one new graduate built social capital when she was asked by her nurse manager to volunteer for her hospital’s ­community health fair a week before her employment start date because one of the volunteers had an emergency. The graduate had experience in organizing community events. She fulfilled an important need in making the event a success while building important social capital. A particularly effective way of learning about social capital is from a mentor. Mentors can, formally or informally, help you by advising you through stories and exemplars of how they were successful and not so successful in relationship building. Nurse leaders, such as committee chairs, managers, or nurse executives, can serve as mentors. Successful nurse leaders embrace helping nurses with less experience; they often tell you they owe their success to a mentor or mentors. They believe in paying it forward. Whether social capital is built at the state, national, or local level, the key is not necessarily quantity, but quality. As your network grows, it is important to monitor and continually scan for changes in opinions, relationships, and opportunities to advance your social capital. Just as in building any relationship, it takes time and commitment to establish a trusted long-term relationship. A visit or phone call once a year is not enough. Consistent, regular communication is necessary. At the big “P” level, consistently taking the time to send your legislators a new study or simply checking in and offering assistance establishes that necessary connection. Moreover, creating opportunities to connect with your network at the little “p” level is also accomplished through consistent purposeful communications. Simple measures for maintaining a relationship yield great return on the social capital investment and can ultimately assist in creating policy changes.

POLITICAL CAPITAL Political capital is influence. It can take multiple forms: financial, social, and intellectual. For the context of this section, political capital is described as advocacy and “lobbying” efforts undertaken by nurses and the nursing profession. Often when the term lobbying is heard, it may carry a negative connotation, depending on an individual’s experience with the political process. Lobbying used in the general sense is promoting an agenda to influence specific decisions. However, there are precise definitions and regulations for lobbying at the federal and state levels that govern practices. The education of policy makers (e.g., providing information) and advocacy on an issue (see Chapter 2) are closely related but often misunderstood. The concepts of grassroots, free riders, and coalitions are introduced and clarified in relation to lobbying (see the section Financial Capital for the financial aspects of lobbying).

The Big “P” At the federal level, the Lobbying Disclosure Act (LDA) defines lobbying contact as any oral, written, or electronic communication to a federal official that is made on behalf of a client as specified in the LDA (Office of the Clerk, 2017). Moreover, lobbying activities include “any efforts in support of such contacts, including preparation

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or planning activities, research, and other background work that is intended, at the time of its preparation, for use in [lobbying] contacts” (Office of the Clerk, 2017, p. 5). Basically, any attempt to influence an official is considered lobbying. State laws also dictate what is considered lobbying (see E-Resources for the report by the National Conference of State Legislatures). Lobbying is protected under the First Amendment because it allows for the right to “petition the government for redress of grievances” (Lobbying Institute, 2017). Not all attempts by nurses to contact their representatives should be considered lobbying, nor should these nurses be considered lobbyists. Since most nurses are not paid to lobby, they technically are not considered registered lobbyists; however, they are advocates and can share their intellectual capital with legislators. Lobbyists work for a cause or, often, an association or firm, and are paid to “lobby” members of Congress. These individuals must file lobbying disclosure forms to legally engage in this process and are deemed registered lobbyists. There is also variation on what lobbyists can and cannot do under the LDA, depending on where they work. For example, the American Nurses Association (ANA) is a 501c(6) organization (trade association, defined under the tax code) that can lobby, have a political action committee (PAC),1 and endorse candidates (see E-Resources, Internal Revenue Service). Many other nurses associations are considered a 501c(3) organization (nonprofit); because of this status, they can spend only a certain portion of their annual revenue on lobbying, and it cannot be a major component of the association’s work; nor can they have a PAC or endorse candidates. Policy on the Scene 7.2 illustrates an example of how nurses associations can come together and lobby successfully for best practice for those we serve and for fair reimbursement for the care provided. The 2010 Supreme Court decision created controversy and confusion regarding the use of donated monies for political influence and the “Super-PAC” (Citizens United v. Federal Election Commission, 2010). Former chair of the ANA-PAC, Faith M. Jones, MSN, RN, NEA-BC, stated, “A PAC is not a PAC is not a PAC.” The ANA-PAC is not a Super-PAC; it is a trade association PAC. The ANA-PAC is composed of nurses who are ANA members. Through their contributions to the ANA-PAC, these nurses participate in the political process and support candidates at the federal level who support ANA’s legislative agenda. The ANA-PAC is bipartisan and supports candidates based on the candidates’ stand related to issues important to nurses, regardless of party affiliation. This PAC provides the avenue needed to stay abreast of issues, to be educated on a personal level, and to become an informed educator of patients and communities related to healthcare policy (F. M. Jones, personal communication, July 14, 2013). Unique to a professional nurses association is the ANA-PAC’s presidential endorsement process. When endorsed presidential candidates win, it has resulted in ANA members being appointed to key federal agencies and ANA leaders being invited to engage in policy discussions at the White House. For example, under the Obama administration Mary Wakefield, PhD, RN, FAAN (Interim Deputy Secretary of Health and Human Services); Marilyn Tavenner, MHA, RN, FAAN (Administrator, Centers of Medicare & Medicaid Services); and Linda Schwartz, DrPH, MSN, RN, FAAN (Veterans Administration Secretary for Policy and Planning) were appointed to key positions. Endorsements create opportunities for ANA leaders to engage in high-level policy discussions. For example, former ANA presidents, Rebecca M. Patton, DNP, RN, CNOR, FAAN, and Karen Daley, PhD, RN, FAAN, participated in White House forums, some of which

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POLICY ON THE SCENE 7.2: Are Nurses Influencing New Healthcare Payment Policies? In April of 2016, Medicare and CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015 (MACRA) passed with overwhelming bipartisan support. However, during the rule-making process, there was trepidation among many nursing stakeholder organizations that APRNs would not be recognized as eligible clinicians in Physician-Focused Payment Models. This payment model comprises two tracks for participation the Merit-Based Incentive Payment Systems (MIPS) and Advanced Payment Models (APMs). In the final rule, which was published on October 14, 2016, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists were acknowledged as providers in the Quality Payment Program (QPP) (Federal Register, 2016). National nurses associations came together with other stakeholders that recognize the value of rallying around a common set of recommendations for the Centers for Medicare & Medicaid Services (CMS). There were 4,377 comments submitted about the Medicare QPP, MIPS and APM incentives under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models (CMS-5517-P). Nurses associations collaborated again, presenting a unified voice to APRN groups by using social media platforms, encouraging comments that incorporated data on their patient populations to emphasize their points. Strategies for APRN recognition in the Medicare QPP are encompassed in the list below. Often recognized but inconsistently used, the nursing profession came together and remained focused on achieving results. Whether working at the big “P” or little “p” level, the following strategies, while complex and interrelated, can be used by nurses to achieve policy change: • • • • • •

Collaborating among stakeholders Presenting a unified nursing voice Establishing a common set of goals Determining a single set of priorities Developing a framework for the group’s actions Instituting a clear communication process

resulted in key provisions of the Patient Protection and Affordable Care Act (ACA) that were favorable to nurses and nursing.

Grassroots For the nursing profession, the single most powerful form of political capital is its grassroots. Using grassroots is powerful no matter the issue at hand. In grassroots efforts, numbers matter; this is why the RN workforce size is so important. There were 2,955,200,000 RN jobs in 2016 (Bureau of Labor Statistics [BLS], 2017a) as opposed to

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713,800 physician jobs (BLS, 2017b). The RN workforce outnumbered the physician workforce by 314%. Consider the impact that nurses could make in their advocacy efforts compared with physicians. Political capital for nursing could be summarized in the long-standing adage: “power in numbers.” The premise underlying this assertion suggests that numbers mean nothing if they are not maximized. In other words, the choice of the individual nurse plays a substantial role in building the profession’s political capital. Engaging nurses as grassroots members can achieve this. Moreover, each of the nurses’ organizations sent out multiple calls to action to their memberships to ramp up grassroots advocacy. When the Veterans Affairs (VA) department put out a request for public comment on whether to grant APRNs full practice in May and December 2016, nursing’s response was swift. The first call for comments yielded 223,623 comments, of which a significant portion came from those in favor of granting full practice. The second call for comments yielded 38,831 comments, clearly, showing the public’s interest in this proposed policy change. The department ultimately decided that nurse practitioners (NPs), certified nursemidwives (CNMs), and clinical nurse specialists (CNSs) could practice to their full scope. Certified Registered Nurse Anesthetists (CRNAs) were not included in the final policy change, with the Department citing a lack of evidence regarding anesthesia service needs. It should be noted that CRNAs faced heavy lobbying efforts stemming from the anesthesiology community, who did not want their professional counterpart to be granted full scope. The VA sites across the country are in various stages of adopting full scope for the other three APRN roles. Grassroot efforts involve “using interest group members (or the general public) to pressure congressional lawmakers to support a group’s agenda” (Wilcox & Kim, 2005, p. 136). Grassroots can be in the form of letters/emails or social media campaigns, coordinated calls to Capitol Hill, or face-to-face meetings with members of Congress or their staff (Wilcox & Kim, 2005). Many larger organizations use electronic databases to manage their grassroots advocacy communications. These platforms can be quite sophisticated and allow government affairs staff to target constituents based on a number of factors, such as whether their member of Congress sits on a particular Committee of Jurisdiction or supports a particular bill. RNs who belong to national nurses associations benefit when their associations use these platforms to send messages to their memberships, often alerting them to take action. It is critical that memberships respond in a timely manner because these issues are often time-sensitive. Congressional offices take note of how many correspondences are sent on a certain issue and flag the issue if several constituents weigh in. This is another example of grassroots advocacy in the age of electronic communications. Title VIII Nursing Workforce Development programs, administrated by the Health Resources & Services Administration for over 50 years, provide essential support for maintaining a strong nursing workforce. Each year, Congress must determine how much funding, if any, these programs receive (also known as the appropriations process). Title VIII is the largest dedicated source of federal funding specifically for nursing education. Even though this funding is modest compared with other health professions, from 2006 to 2013, over 500,000 nursing students and nurses received support from the bill. The bill requires ongoing grassroots advocacy. At the grasstop level, national nurse leaders such as ANA president Pam Cipriano often provide testimony, as seen in Figure 7.4, about the need for this ongoing support for nursing;

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FIGURE 7.4  American Nurses Association president Pam Cipriano providing testimony in 2017.

at the grassroots level, individual nurses are called to action to speak as nurse constituents to their representatives about the critical need for this bill in person and in writing. As Goldstein (1999) suggests, “Grassroots communications demonstrate to legislators that traceability has been established” (p. 39). Traceability suggests that a large constituent voice has been registered with the member of Congress through calls, emails, or other methods such as visits. The effectiveness of grassroots is often measured by the quality and quantity of output by the constituents (Kollman, 1998; Thrall, 2006; Wilcox & Kim, 2005). This is where nursing can excel and demonstrate its power in numbers.

Free Rider Syndrome With so much at risk, it is important to explore the reasons why nurses do not engage. Some may suggest time constraints, other competing priorities, or lack of interest in policy work as factors. However, for nearly five decades, the political science community has described this as what Olson (1965) originally defined as the “free rider syndrome.” Free riders are individuals who avoid bearing any of the costs or burdens associated with the actions required to get a benefit. This is common, particularly in large groups. With over three million practicing nurses, the free rider syndrome is not as easy to spot as in smaller groups. In small groups, it is easy to see when only a few individuals are doing the work and financially supporting the cause. As the group gets larger, members of the group do not notice if some are doing the work while others gain the benefits of that work. As an example, a nurses association sends an email action alert to its 10,000 members requesting them to tell their member of Congress to increase funding for nursing education. Normally, 100 responses would be considered robust. However, there are 100 U.S. senators and 435 members of the U.S. House of Representatives.

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With 100 letters, it is likely that some congressional offices did not receive a letter, some offices may have received only one or two, and others may have received 25. With 1% participating in this call to action, nursing education funds may not be increased as requested. The explanation for this lack of participation is the free rider syndrome: the fact that nurses rely on the large group to do their work and have excuses for their nonparticipation. Regardless of the explanation, lack of participation hurts the profession and ultimately hurts patients. For years, scholars have suggested the importance of an implied cost. Tversky and Kahneman (1981) proposed that to elicit a more intense response, one must impress on the individual constituent that he or she would suffer a personal cost. In addition, some researchers suggest that to elicit greater grassroots intensity, interest groups must raise the cost of not participating (Goldstein, 1999; Rosenstone & Hansen, 1993). Nurses, for example, may have finished all the degrees that they set out to acquire. However, they may work in a setting that has a nursing shortage. They may experience the added stressors that come from working in a facility with a shortage of nurses: increased emotional distress and job dissatisfaction (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002). While the issue may not be directly relevant, there is the benefit to those nurses if they help ensure that more colleagues join the care-delivery setting. That is why nurses associations often craft a message to show how their members could be personally affected. To achieve the desired outcome, quantity is necessary for grassroots advocacy. Numbers matter. and the only way to increase nursing’s numbers are for the individual nurse to respond. The voice of each nurse does in fact make a difference; when nurses come together in coalitions, the impact intensifies.

Power of Coalition Building For decades, coalitions have been an effective strategy for building political capital. Although the makeup, structure, and longevity of coalitions may vary, they demonstrate power in numbers. Coalitions are usually created to address an immediate issue (Nownes, 2001; e.g., passage of the ACA). Most nurses associations at the national and state levels are involved with some coalitions to advance policy agendas. Coalitions provide credibility for the needs of organized interests. Credibility can be developed in two ways. First, organizations with a similar membership can form a coalition. For example, a coalition of all nursing associations could advocate for federal nursing appropriations or a piece of legislation. This demonstrates credibility because nurses are speaking with a unified voice. The RWJF and Gallup study (Khoury et al., 2011) pointed out that healthcare opinion leaders felt that one of the ways for the profession to make its voice heard was to speak with a unified message. Often, policy makers may become weary if only one organization promotes an issue (Nownes, 2001). Second, coalitions can reduce the level of conflict associated with an issue (Nownes, 2001). When conflict is minimal, an issue stands a better chance of being recognized and successfully moving through the policy process. As Price (1978) points out in his seminal work, an issue has a better chance of appearing on the congressional agenda if the degree of conflict among groups is low and public salience (or interest) is high.

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Second, coalitions are extremely efficient because they allow organizations to pool their resources (Nownes, 2001). Pooling of resources allows organizations to spend less than if they were advocating for the issue on their own (Hula, 1995). This is critically important to the nursing profession. As discussed in the section Financial Capital, nurses associations often do not have the same level of funding as other health professions associations. One of the advantages in creating coalitions is that they allow organizations to share resources in the forms of financial resources, lobbyists, expertise, and time. Although coalitions may be effective, it is important to know that they do not always work. Olson (1965) warns that the assumption that groups of individuals with common interests usually work to further those interests is false and based on flawed logic. Just as in the case of grassroots efforts, coalitions can also fall victim to the “free rider syndrome.” As organizations convene to work on an issue and as that group grows, members of the coalition quickly decide if the benefits outweigh the necessary contributions. In a coalition of 50 organizations, only five to 10 may do the work while the others benefit. If incentives are not in place for the five to 10 that do the work, they may not be willing to share their political capital. Although Olson points out that altruism is sometimes the case, it is not the norm. Knowing that Congress places significant weight on coalitions and their ability to speak with one voice, many organizations are actively pursuing coalitions. Coalition work is an opportunity to network (build social capital) with others who share similar views on an issue. However, a coalition must be strong enough to have members that become engaged and find value in its work. See Figure 7.5 for key components in coalition building based on lessons learned by the author. One example of a strong collaboration within nursing is the Nursing Community Coalition (2017). Started circa 2002, the Nursing Community Coalition was a group of national nurses associations that came together once a year to discuss the unified funding request for the Nursing Workforce Development programs (Title VIII of the Public Health Service Act [1944]). For more than 15 years, the Nursing Community Coalition has determined the funding request level for nursing education and advocated in a cohesive fashion to move this number forward. This forum has strengthened its power from a loosely affiliated group that came together once a year to a coalition that drafts letters to congressional appropriations; hosts virtual Lobby Days, receptions, and briefings on Capitol Hill; and visits with members of Congress who sit on the House and Senate Appropriations Committees. The coalition has, in recent years, become a more formalized structure that includes a Steering Committee and various ad hoc w ­ orking groups. This has been done, in part, to address free rider behavior. Currently, 60 national organizations belong to the Nursing Community Coalition, having grown from approximately 35 organizations. Coalitions offer a prime opportunity to build political capital. However, not all coalitions are easily established or maintained. The common theme that has surfaced throughout this chapter is that all forms of capital are needed. When working in coalitions, trust (social capital) needs to be established and a common good must be identified. The ability of nurses to build coalitions as a form of political capital transcends across big “P” and little “p.” Coalitions can be effective tools for creating policy change at the unit, local, or state level. At the heart of coalitions is power in numbers.

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Facilitation Someone who can provide the coalition with leadership over the determined activities and guide the dialogue. This individual must be trusted.

Flexibility

Engagement

In policy, time frames for action can be tight. Flexibility helps a coalition react when timing is crucial and a change in direction is necessary.

It is important to ensure all members of the coalition support the group’s activities and mission.

Lessons Learned From the Nursing Community These necessary traits are not linear in nature. Framework

Trust

It must be defined how the group functions. Consensus must be determined and agreed on.

All members of the coalition must trust each other, in addition to the facilitator.

Partnership Coalition members must feel their voices are heard or will be heard equal to that of other members.

FIGURE 7.5  Keys to building an effective coalition.

The Little “p” In many respects, building political capital starts at the local level. It is not uncommon for elected officials to work their way through a number of appointed or elected positions before reaching the state or national level. The processes of big “P” and little “p” can and, by necessity, often do overlap. Grassroots work by its very definition starts at the local level. In addition, free riders exist across all settings. They do not attend meetings, are often critical of discussions and decisions, and seldom offer solutions or get involved to resolve issues. Just as coalitions are important at the big “P” level, they are equally important at the little “p” level. An experienced nurse working to improve patient flow illustrates a little “p” example of political capital. This issue is problematic for many units (e.g., emergency departments, ICUs, postanesthesia care units). Each year, during the flu season, the need for timely discharges and transfers intensifies and becomes a major throughput issue. In anticipation of the flu season, a well-respected

Chapter Seven  BUILDING CAPITAL  215

nurse convened a meeting with representatives from each unit. All agreed there was a need to recommend solutions to improve patient flow and formed a coalition, including staff from other departments. This group quickly assembled solutions that were implemented system-wide and in each department that improved patient flow and patient satisfaction. Political capital is influence, which is essential for having an impact on policy. Nursing must be strategic. Significant healthcare policy issues can benefit from the nursing perspective. When policy issues are identified, coalitions must be established, experts found, and resources pooled to achieve success.

FINANCIAL CAPITAL Financial capital is often exemplified in the golden rule: He who has the money, makes the rules (Nownes, 2001). Nurses may be quick to point out that, compared with other industries and professions in healthcare, nurses do not have the “gold” that would allow the profession’s voice to resonate loudest. In many cases, this is true. According to the BLS (2017a, 2017b), in 2016, physicians made approximately two times more money than RNs. This is clearly an important factor in the amount a nurse can contribute to a PAC or donate to candidates or causes. Nevertheless, financial resources are, without a doubt, a significant factor to organized advocacy and allow for a specific interest to be advanced.

The Big “P” At the federal level, it is believed that money is the driving force in achieving space on the congressional agenda. As Berry (1999, p. 85) points out, “Space on the Congressional agenda is a precious commodity.” Nursing’s financial capital has not measured up to the capital of other healthcare professionals. Organizations’ financial capital supports services such as professional registered lobbyists and provides resources to promote their agendas, such as studies to support an issue, expert analysis, and advocacy materials. Money also comes in the form of a PAC and individual contributions to members of Congress. Two forms of financial capital are lobbying and PACs.

Lobbying As indicated earlier, lobbying serves to advocate, educate, and influence members of Congress. There are 10,461 registered federal lobbyists in the United States working on issues from gun control to healthcare (Open Secrets, 2016a). In 2016, the “health professions” organizations spent $85,061,148 on their lobbying efforts (Open Secrets, 2016b). Comparatively, total healthcare industry spending in 2016 equaled $507,480,504. More than half of this was contributed by the pharmaceutical and health products sector (Open Secrets, 2016b) In Policy on the Scene 7.2, the American Association of Nurse Anesthetists (AANA) spent a total of $1,059,100 in contributions to political activity in 2015 and 2016, whereas and their physician counterparts (American Society of Anesthesiologists [ASA]), while the ASA spent $3,189,550 (Open Secrets, 2016c, 2016d). The ASA spent 338% more on lobbying than the AANA (see Exhibit 7.3). This trend is not uncommon when comparing physicians’ political spending with nurses’.

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EXHIBIT 7.3 LOBBYING DOLLARS SPENT IN 2016a: TOP THREE NURSE AND

PHYSICIAN ORGANIZATIONS LOBBYING DOLLARS SPENT

BILLS LOBBIED

NURSE ORGANIZATIONS

American Nurses Associationb

$1,743,635

25

American Association of Nurse Anesthetists

$890,000

16

American Association of Nurse Practitioners

$554,808

38

Total

$34,188,443

79c

American Medical Association

$19,410,000

108

American College of Radiology

$3,222,764

3

American Academy of Family Physicians

$2,787,620

42

Total

$25,420,384

153c

PHYSICIANS ASSOCIATONS

Data compiled after every 2-year election cycle.

a

Includes lobbying firms but not state associations.

b

May be overlapping bills.

c

Source: Open Secrets (2016a). Lobbying. Retrieved from https://www.opensecrets.org/lobby

Political Action Committees Some would argue that PACs hold much weight as a form of capital in helping secure space on the congressional agenda. Exchange theories suggest that lobbyists and legislators engage in unspoken agreements or trades (Austen-Smith, 1997; Morton & Cameron, 1992). As the theory suggests, the trade between a member of Congress and a lobbyist is an implicit trade that mutually benefits both parties and is typically identified as a political campaign or PAC contributions to a member of Congress for their vote on an issue. Exchange theories have been described as “vote buying,” whereas others view this as “buying” a member of Congress’s time (Stratmann, 1998). This suggests that PAC contributions are made so that lobbyists can discuss a specific issue with the hope of gaining “votes.” Some may question the level of effectiveness between PAC contributions and the actions of congressional members, but there is evidence that PACs provide some level of access to legislators and their staff (Wright, 1990). As Berry (1999, p. 151) states, “Interest group leaders believe that PAC donations are well worth it because the money is converted into more face time with legislators and key aides, and they think that this interaction increases the chances that these congressional offices will do something on the group’s behalf.” For the context of this discussion, the assumption is that PACs, to a certain level, influence and build financial capital. More important, it is a quantifiable data piece

Chapter Seven  BUILDING CAPITAL  217

that clearly illustrates the gap in nursing’s political expenditures. Nursing has PACs at both the national and the state levels. In total, 220 PACs are considered “health professions,” and four originate within national nurses’ organizations. Compare this with the more than 50 national physician PACs. Many state physician PACs and ­private companies lobby at the national level (Open Secrets, 2016b). Not only do physicians have more PACs, but they also significantly outspend the existing nurse PACs. In comparing lobbying contributions among the top three nurses’ organizations and physician’s organizations in the last presidential-election cycle, it is clear to see that the physician organizations are raising and spending more (see Exhibit 7.4). The path for nursing to overcome the financial resources dilemma is clear. Organizations pay for lobbying activities through their membership dues and other sources of revenue generated by the support of their membership (i.e., conferences, publications). Numbers matter in achieving financial capital. Membership in national nurses associations is paramount. Individual nurses must determine where their money will be best spent, matching personal values and priorities. It should also be noted that although the aforementioned information concerning PACs and lobbying relates to federal activity, trends are similar at the state level. At the state level, most nurse PACs and lobbying are done by state nurses associations. Unions representing nurses may also lobby at the state level. Therefore, should nurses consider joining not only national organizations, but also state associations. This is important for APRNs for whom a unified voice at the state level is so critical to removing practice barriers. It is important for all nurses when unlicensed persons seek to represent themselves as “nurses” in states that do not protect the title “nurse” or “RN.” There are numerous issues addressed at the state level that require an ongoing and vigilant presence at the statehouse that benefits from the use of PACs and lobbying efforts. These same principles can be applied at the local level such as in the case of a school board, city council, or township board.

The Little “p” Money speaks at all levels. Although financial capital at the big “P” level receives a lot of attention, the financial impact at the little “p” level is often not fully r­ ealized. Contributions locally are just as important as at the national and state levels. Your personal contribution of time or money will be acknowledged and may lead to opportunities for influencing policy within your community. Personal donations are strategic and can lead to future board appointments. Often there is the expectation for board members to support foundations and special events, causes, and programs. However, financial capital is not just about what you contribute. It is important to realize the opportunities that exist to fund and support your cause or policy. Foundations, hospital auxiliary boards, and alumni groups can be solicited for financial support. The first essential step a nurse can take to maximize the profession’s political capital is joining the organizations that advance the voice of nursing at the national and state levels. Second, knowing the importance and significant gap in nurses’ financial political capital, nurses should consider contributing to a PAC, to a member of Congress, or to both.

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EXHIBIT 7.4  NATIONAL NURSE AND PHYSICIAN ASSOCIATIONS: 2016 ELECTION

CYCLE PAC SUMMARY

RAISED

NUMBER CONTRIBUTIONS % TO % TO OF TO FEDERAL DEMOCRATS REPUBLICANS DONORSa CANDIDATES

NURSES ASSOCIATIONS

American Association of Nurse Anesthetists

$1,342,328

$1,150,972

48

52

1,922

American Nurses Association

$489,687

$458,218

82

18

332

American Association of Nurse Practitioners

$451,259

$380,690

57

43

188

American College of Nurse-Midwives

$156,725

$89,402

61

39

132

Totals

$2,439,999

$2,079,282

2,574

PHYSICIANS ASSOCIATIONS

American Society of Anesthesiologists

$3,962,647

$4,119,006

37

63

5,026

American Medical Association

$2,114,478

$2,047,840

38

62

2,031

American Congress $1,194,076 of Obstetricians and Gynecologists

$1,092,417

53

47

1,353

American Academy of Family Physicians

$921,028

$1,042,658

59

41

1,215

$8,192,229

$8,301,921

Total

9,625

PAC, political action committee. Gave over $200.

a

Source: Open Secrets (2016b). Top Industries. Retrieved from https://www.opensecrets.org/lobby/indusclient .php?id=H01&year=2016

Chapter Seven  BUILDING CAPITAL  219

OPTION FOR POLICY CHALLENGE: Gaining Political Capital by Being Part of a Team Colleen Leners The military taught me to be part of a team, as well as it was the mission that was most important. Now, one of the first things that I learned in my Robert Wood Johnson Fellowship is that people on Capitol Hill were not interested in my neutrality. I was very pointedly advised that I needed to declare my political affiliation. My placement was with Senator John Thune (R-SD). It was the year that Senate flipped to Republican control. Senator Thune was a member of the Finance Committee, which has jurisdiction over Medicare, Medicaid, and other health programs. I had the opportunity to work on issues related to the healthcare needs of not only veterans, but also communities. Since the senator was from South Dakota, we worked particularly hard to address the needs of the Indian communities. I learned that we could not just make changes to improve life for one segment of the population, without making changes for everyone. I had come from a single-payer healthcare system in the military and was thrust into examining policy in a much more complex environment. I wrote memoranda based on current research, took calls from veterans, and during peak times, worked many 12-hour days. A highlight of the year was taking a week-long tour of South Dakota reservations and talking with community leaders to gain insights about their special needs. We worked very hard to get bipartisan bills passed; I learned that in the Senate, it is not as bipartisan as it appears. My policy work reached into new arenas. As was true in the military, I saw the importance of working together to achieve a common goal. I took advantage of opportunities to advance nursing’s positions. For example, when full practice authority for certified registered nurse anesthetists (CRNAs) was being debated, questions were raised about the quality of CRNAs’ outcomes. I pointed out the inconsistencies of the arguments to restrict CRNA practice and related that I had worked with CRNAs deployed to Iraq who practiced when their patients had no blood pressures and that their education and training would certainly prepare them for whatever they had to do stateside. I also learned to pay attention to economic evaluations. Although a nursing lens is valuable, nurses need to use an economic lens on a much more regular basis and speak specifically to the economic impact of our work. One area where nurses can benefit is paying attention to “reach back” amendments. These new paragraphs are inserted at the end of a bill change funding amounts that were specified earlier. In addition, associations can provide economic data to legislators. For example, the AACN has provided such data for nurse education funding. My advice to nurses beginning to develop political capital is that the very first thing you must do is to vote. We are all working as team members and that the best work is accomplished when we are focused on how to achieve our goals and work as a team. When we address a specific need, it is the right thing to do to address it in all populations. My passion for working with wounded warriors (continued )

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enhanced the work I did in my fellowship year and that in turn prepared me to continue my policy and advocacy work at the American Association of Colleges of Nursing. Do not hesitate to take a stance on an issue. Our patients, our friends, our neighbors, those who have fought for our country, and our communities deserve nothing less from us.

IMPLICATIONS FOR THE FUTURE Nursing has remarkable potential to build and expand its capital. This is true of each individual nurse, as well as state and national nurses associations. However, the cornerstone of achieving this potential is the ability of individual nurses to understand that their voices and resources (i.e., money, time, expertise) are necessary for the greater good of the profession, as well as patients, families, and communities. Although many of the themes outlined in this chapter relate to capital focused on national advocacy, they translate to the work of each nurse. If one’s goal is to change a standard in the hospital setting, how can relationships, coalitions, resources, and expertise be maximized? Over the decades, nursing has made epic strides as a profession. Nurses are trusted and respected by the public, but they must make their voices heard, and heard in unison. It was evident in the Financial Capital discussion that significant work is essential for nursing to be comparable with the lobbying efforts of other national health professions. This is within our reach by using our expertise and dedication to the patient.

KEY CONCEPTS 1. Nursing’s capital must be grown and cultivated. 2. Nurses must value and appreciate the importance of the individual voice in building capital. 3. At the heart of the profession is patient advocacy. This innate trait should be used to improve the health of the nation at every level. 4. Nurses must not be intimidated or hesitant to offer their valued contribution to those in power. Nursing’s expertise is a commanding form of capital. 5. Nurses must view political advocacy as a professional value, not something that is “dirty.” 6. Whether social capital is built at the state, national, or local level, the key is not necessarily quantity, but quality. 7. For nursing, coalitions offer prime opportunities for building political capital. How­ever, not all coalitions are easily established or maintained. 8. Nurses must invest in their nurses associations to ensure that they have the resources to build the profession’s capital. 9. Building capital is obtainable and necessary for every nurse because all politics are local. 10. Nurses must understand that policy change occurs without the profession’s insight if nurses do not build all forms of capital.

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SUMMARY If nursing wants a seat at the table when healthcare policy decisions are being debated and made, then it must invest in the efforts to obtain that seat. As the opening quote from Thomas Jefferson points out, “We in America do not have government by the majority. We have government by the majority who participate.” To participate, nurses must maximize the four types of capital to the best interest of the profession and their patients. Nurses and the nursing profession must get strategic and build capital through education and engagement of nurses. It cannot be left to a few to attempt the massive change that the profession wishes to achieve to truly impact health and wellness nationally and globally. Nursing can excel in this realm; however, nurses must first overcome any lingering stereotypes and historic sentiments that politics and policy are not appropriate for the profession. At the heart of the profession is patient advocacy, so why can this not be replicated at the local, state, and national levels? Nurses must establish a pathway that will create their own capital. In the end, it is power in numbers.

LEARNING ACTIVITIES 1. Identify your local, state, and federal legislators. Select one whom you want to visit. Identify the key points that you will discuss at the visit. Plan for a 10-minute visit and for a 20-minute visit. Consider how your visit will vary if you talk to a staffer or the legislator. Then make a visit to the office and report on the highlights of the visit. 2. Determine when your state and national nurses associations are hosting their advocacy days and the process to register. Be sure to familiarize yourself with the advocacy materials before attending. 3. In your work environment consider inviting a leader to coffee. Ask for recommendations and advice for becoming politically active. Specifically inquire about their pathways in policy and mentors. 4. Follow your legislators on social media, such as Twitter, for an easy way to stay up to date on their issues. Challenge yourself to connect with them. 5. Develop a list of strategies for convincing classmates of the importance of supporting a nurses association and its PACs at the state or national level. 6. Reread the sections on “free riders” and “grasstops.” Consider whether you know people in either category. Develop talking points to challenge one “free rider” to join an advocacy effort with you. 7. Investigate the funding received by your state from the Title VIII Nursing Workforce Reauthorization Act.

E-RESOURCES • Coalition for Patients’ Rights http://www.patientsrightscoalition.org • Internal Revenue Service: Lobbying http://www.irs.gov/Charities-&-Non-Profits/Lobbying • National Conference of State Legislatures http://www.ncsl.org/research/ethics/50-state-chart-lobbyist-report-requirements.aspx

*

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• Nursing Community Coalition http://www.thenursingcommunity.org • Open Secrets http://www.opensecrets.org/pacs/pacfaq.php • RWJF and AARP’s Future of Nursing Campaign for Action. https://www.campaignforaction.org • Public Affairs Council http://pac.org

NOTES 1. A political action committee is “an organization set up solely to collect and spend money on electoral campaigns. A type of organized interest” (Nownes, 2001, p. 231). 2. The Senate Finance Committee has jurisdiction over Medicare and Medicaid, whereas in the House, the jurisdiction falls to the Ways and Means Committee.

REFERENCES Aiken, L., Clarke, S., Sloane, D., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association, 288(16), 1987–1993. Retrieved from https://jamanetwork.com/journals/jama/fullarticle/195438 Austen-Smith, D. (1997). Interest groups: Money, information and influence. In D. C. Mueller (Ed.). Perspectives on public choice (pp. 296–321). Cambridge, UK: Cambridge University Press. Begeny, S. M. (2009). Lobbying strategies for federal appropriations: Nursing versus medical ­education. (Doctoral dissertation, University of Michigan).Retrieved from http://hdl.handle.net/2027 .42/64641 Berry, J. M. (1999). The new liberalism: The rising power of citizen groups. Washington, DC: Brookings Institute Press. Bradbury-Jones, C., Sambrook, S., & Irvine, F. (2008). Power and empowerment in nursing: A fourth theoretical approach. Journal of Advanced Nursing, 62(2), 258–266. doi: 10.1111/j.1365-2648. 2008.04598.x Brenan, M. (2017, December 17). Nurses keep healthy lead as most trusted, honest profession. Gallup News. Retrieved from http://news.gallup.com/poll/224639/nurses-keep-healthy-lead-honest -ethical-profession.aspx?g_s ource=CATEGORY_SO CIAL_POLICY_ISSUES&g_ medium=topic&g_campaign=tiles Bureau of Labor Statistics. (2017a). Occupational outlook handbook: Registered nurses. Retrieved from https://www.bls.gov/ooh/healthcare/registered-nurses.htm Bureau of Labor Statistics. (2017b). Occupational outlook handbook: Physicians and surgeons. Retrieved from https://www.bls.gov/ooh/healthcare/physicians-and-surgeons.htm Centers for Medicare and Medicaid Innovation. (2013). Community-based care transitions program. Retrieved from http://innovation.cms.gov/initiatives/CCTP Citizens United v. Federal Election Commission, 558 US 310. (2010). Retrieved from http://en.wikipedia .org/wiki/Citizens_United_v._Federal_Election_Commission Congressional Management Foundation. (2015). # Social Congress 2015. Retrieved from: http://www .congressfoundation.org/projects/communicating-with-congress/social-congress-2015 Des Jardin, K. (2001). Political involvement in nursing: Politics, ethics, and strategic action. Association of Operating Room Nurses Journal, 74 (5), 614–622. doi:10.1016/S0001-2092(06)61760-2

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Federal Register. (2016). Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models. Retrieved from https://www.federalregister.gov/­ documents/2016/11/04/2016-25240/medicare-program-merit-based-incentive-payment-systemmips-and-alternative-payment-model-apm Gibson, J. (2010). How to spend less and get more from Congress: Candid advice for executives. Alexandria, VA: TheCapitol.Net. Goldstein, K. M. (1999). Interest groups, lobbying, and participation in America. New York, NY: Cambridge University Press. Hula, K. W. (1995). Rounding up the usual suspects: Forging interest group coalitions in Washington. In A. J. Cigler & B. A. Loomis (Eds.), Interest group politics (4th ed., pp. 239–258). Washington, DC: CQ Press. Khoury, C. M., Blizzard, R., Wright Moore, L., & Hassmiller, S. (2011). Nursing leadership from bedside to boardroom: A Gallup national survey of opinion leaders. Journal of Nursing Administration, 41(7–8), 299–305. doi:10.1097/NNA.0b013e3182250a0d Kollman, K. (1998). Outside lobbying. Princeton, NJ: Princeton University Press. Laschinger, H. K. S., & Havens, D. S. (1996). Staff nurse work empowerment and perceived control over nursing practice: Conditions for work effectiveness. Journal of Nursing Administration, 26(9), 27–35. https://www.nursingcenter.com/journalarticle?Article_ID= 102772&Journal_ID=54024&Issue_ID=54728 Manojlovich, M. (2007). Power and empowerment in nursing: Looking backward to inform the future. Online Journal of Issues in Nursing, 12(1). doi:10.3912/OJIN.Vol12No01Man0 Morton, R., & Cameron, C. (1992). Elections and the theory of campaign contributions: A survey and critical analysis. Economics and Politics, 4, 79–108. doi: 10.1111/j.1468-0343.1992.tb00056.x The National Institute for Lobbying & Ethics. (2017). What is lobbying. Retrieved from https://­ lobbyinginstitute.com/what-is-lobbying Nownes, A. J. (2001). Pressure and power: Organized interest in American politics. Boston, MA: Houghton Mifflin. Nursing Community Coalition. (2017). Core .­thenursingcommunity.org/core-principles

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Office of the Clerk, U.S. House of Representatives. (2017). Lobbying disclosure act guidance. Retrieved from https://lobbyingdisclosure.house.gov/ldaguidance.pdf Olson, M. (1965). The logic of collective action: Public goods and the theory of groups. Cambridge, MA: Harvard University Press. Open Secrets. (2016a). Lobbying. Retrieved from https://www.opensecrets.org/lobby Open Secrets. (2016b). Top industries. Retrieved from https://www.opensecrets.org/lobby/­ indusclient.php?id=H01&year=2016 Open Secrets. (2016c). American Assn of Nurse Anesthetists. Retrieved from https://www .opensecrets.org/orgs/summary.php?id=D000000349 Open Secrets. (2016d). American Society of Anesthesiologists. Retrieved from https://www .­opensecrets.org/orgs/summary.php?id=D000000199 Patient Protection and Affordable Care Act of 2010, Pub. L. No. 111-148. 124 § 119-1025. (2010). Price, D. E. (1978). Policy making in Congressional Committees: The impact of “environmental” factors. American Political Science Review, 72(2), 548–574. doi:10.2307/1954110 Public Health Service Act of 1944, Pub. L. 78-410, Title VIII. (1944). Rao, A. (2012). The contemporary construction of nurse empowerment. Journal of Nursing Scholarship, 44(4), 396–402. doi: 10.1111/j.1547-5069.2012.01473.x

224   UNIT III  STRATEGIZING AND CREATING CHANGE Rosenstone, S., & Hansen, M. (1993). Mobilization, participation, and democracy in America. New York, NY: Macmillan. Stratmann, T. (1998). The market for congressional votes: Is timing of contributions everything? Journal of Law and Economics, 41, 85–113. doi:10.1086/467385 Thrall, A. T. (2006). The myth of outside strategy: Mass media news coverage of interest groups. Political Communications, 23, 407–420. Retrieved from https://www.tandfonline.com/doi/abs/10 .1080/10584600600976989?journalCode=upcp20 Tversky, A., & Kahneman, D. (1981). The framing decisions and the psychology of choice. Science, 211, 453–458. doi:10.1126/science.7455683 Wilcox, C., & Kim, D. (2005). Continuity and change in the congressional connection. In P. S. Herrnson, R. G. Shaiko, & C. Wilcox (Eds.), The interest group connection: Electioneering, lobbying, and policymaking in Washington (2nd ed.). Washington, DC: CQ Press. Wright, J. R. (1990). Contributions, lobbying, and committee voting in the U.S. House of Representatives. American Political Science Review, 84, 417–438. doi:10.2307/1963527

EIGHT

Changing Organizations, Institutions, and Government Tim Porter-O’Grady Kathy Malloch Ingrid Johnson The natural instinct is to think that innovation has to do with invention. That’s the smallest part & the real essence of innovation is fresh thinking that connects with value creation.—Vijay Vaitheeswaran

OBJECTIVES 1. Compare and contrast the differences between change and innovation and their relationship to policy advancement. 2. Explain the barriers and facilitators to policy development and implementation in the work of healthcare. 3. Examine the significance of team building and teamwork among healthcare stakeholders and the relationship to effective policy formulation. 4. Differentiate concepts necessary for translational policy formulation in both small- and large-scale change. 5. Evaluate lessons learned in the creation of healthcare policies. 6. Plan one’s own future actions as a nursing leader in the continuing journey of effective healthcare policy participation, creation, and revision.

The work of change is inherent in making policy. Although change is often challenging, there is no avoiding it. Understanding change is essential to healthcare policy because many policies evolve from the ever-emergent nature of healthcare. Shifts in knowledge, relationships, economics, technology, and the environment are normative now and are projected to only increase in the future. Healthcare policies need to be current and appropriate to support safe and effective healthcare with the numerous changes that are ongoing. As nurses, the essence of our work is about change, innovation, and creation of policies to support the expected work of patient care excellence. Nurses work with patients to change and improve their state of health on a continual basis. When, for example, a new technology or treatment is initiated, it is often the nurse in direct care who is the first to see the unforeseen impact on patients and nurses as they carry out new work and recognize the need for policy change. The numerous redesign of workflow that occurs when moving from paper to electronic documentation is one example 225

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of how policy with a little “p” is implemented. In this chapter, theories of change, team building, translational policy formulation, barriers and facilitators to change, turning of the work of failed attempts and lessons learned into success, and a brief discussion of future opportunities are presented. The National Licensure Compact (NLC) implementation over time provides many policy process lessons that directly impact nursing practice (National Council of State Boards of Nursing [NCSBN], n.d.-b). In this chapter’s Policy Challenge, the original NLC innovation process, including gaps in support, successes, and lessons learned, that facilitated course correction in the creation of the enhanced Nurse Licensure Compact (eNLC) are highlighted. These principles and concepts are discussed in more detail throughout the chapter.

POLICY CHALLENGE: Enhancing the Multistate Nurse Licensure Compact The characteristics of this planned, teleological change are described as an innovation that can used by large groups at the state and national levels. From the outset, the proposed compact focused heavily on improved patient outcomes. Often, a policy is doomed for failure at the outset, driven by primary process failure in the establishment of inappropriate objectives (Richtermeyer, 2010). Focusing a policy on service provision directed to specific populations rather than to clearly defined and well-articulated health outcomes, expectations, or impact is a mistake often replicated in healthcare but avoided in this situation. Early collaborative work was critical in gaining support for the state-based model. At the start, key National Council of State Boards of Nursing (NCSBN) leaders sought to involve and educate others about the National Licensure Compact (NLC) and anticipated outcomes. The NCSBN was successful in adding states to the enhanced Nurse Licensure Compact (eNLC) through ongoing collaboration and modification and largely using the original strategy of focusing heavily on improved patient outcomes and adding a stronger emphasis on background checks. The Nine Essential Phases of Policy Team Work guidelines were used in the original NLC process with a similar change structure used for the eNLC process. These proceeded in the following manner: 1. Determining the foundational need for change: Three drivers supported this licensure change: telehealth, multiple shared borders among states, and the burdensome maintenance of multiple licenses (Dorsey & Schowalter, 2008). The intent of the NLC was to provide a nationally recognized licensure system in which licensure is state based and state enforced. The eNLC addressed the concerns of states related to the alignment of state licensing procedures and background checks (NCSBN, n.d.a.). 2. Setting the table: Representatives from NCSBN member boards met with the president of the American Nurses Association (ANA), representatives of the American Nurses Credentialing Center (ANCC), numerous other nurses associations, and state boards of nursing. 3. Defining expectations: Expectations for the NLC were simplification of governmental processes, removing regulatory barriers, and increasing (continued )

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4.

5. 6. 7. 8. 9.

access to safe nursing care. Standardizing state regulations facilitates complaint and investigative information sharing and impacts patient safety in a timely manner. The eNLC included the same expectations, with modifications to meet the needs of more states, with the aim of full implementation in 50 states. Context, timeline, powers, and deliverables: Context for stakeholders was provided by educating state boards, professional associations, citizen groups, and individual nurses over time. The full implementation ­timeline was dependent on state boards of nursing obtaining backing for the NLC, including legislative support to enact the appropriate statutes. The eNLC timeline was set at 6 months after the first 26 states adopted the eNLC, or December 2018. Each board had the power to determine whether to move forward with the NLC. The deliverables or outcome was successful implementation of legislation and the creation of ­administrative policies for multistate processes. Methods and terms of engagement: Each board of nursing determines the appropriate time to advance the eNLC. Team tools and dynamics fit: Strategies and dynamics included informational documents and local and national representation, with open dialogue for understanding the issues surrounding the process. Outcome agreement: The outcome was the participation of all the boards of nursing to achieve the identified goals for the NLC and is included in moving the eNLC forward. Completion of work: Work will be completed when legislation is enacted in all 50 states and implemented by each board of nursing. Hand off mechanisms for closure: Once legislation is enacted, the oversight of compact processes is handed off to the NLC administrators.

See Option for Policy Challenge.

THEORIES OF CHANGE Every day, new evidence and innovative approaches in providing patient care are introduced with the expectation that these ideas are considered and implemented when appropriate. Nurses continually assess current work processes and explore new research and information to find and deliver the highest value patient care for the lowest cost— and this requires change as a basic competency for professional nursing practice. The implementation of new policies, adjustments to existing policies, or elimination of current policies should be grounded in evidence. Nurse work requires that we become experts in advancing both change and innovation in the delivery of patient care services and the environment in which the care is delivered. Nurses must also be mindful that standing still, the opposite of change and innovation, is the beginning of the dying process, a process that is final and reflects the absence of life. For example, many hospitals implemented 12-hour shifts to retain nurses and provide more days off. However, research now indicates that longer shifts are associated with worse job outcomes and lower quality and safety

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(Bae & Fabry, 2014; Trinkoff et  al., 2011). Research indicates planned naps taken during night shifts are beneficial in improving alertness (Geiger-Brown et al., 2016). The question that is raised is whether employers of nurses will modify their policies and practices as they learn about the evidence regarding fatigue and its relationship to safety and patient outcomes. Standing still on evidence has the potential to jeopardize patient safety and quality. It raises the question about at what point the body of evidence is sufficient for implementing change within an organization and beyond through legislation and/or regulation. Interestingly, despite the seemingly positive nature of change, much time and effort are spent in working to harness and minimize change, given its often disruptive and uncertain nature. Learning to embrace both change and innovation is necessary to successfully navigate events and, ultimately, thrive in our ever-changing world. Successful advocates have mastered the competencies of embracing change and innovation. Numerous strategies, templates, and theories of both change and innovation are available to assist nurses in understanding and advancing new ideas, specifically advancements in healthcare policy. Some theories are linear and devoid of the influences of the context, whereas others are more robust and include the multiple forces and interactions impacting the change or innovation process. Having an appreciation of the nature of theories of change and innovation provides a foundation for nurses to assume an active role in the policy process. What is also important to understand is that the multifaceted nature of change and innovation makes it nearly impossible to focus EXHIBIT 8.1  COMMON DESCRIPTIONS FOR CHANGE AND INNOVATION • To make different; to undergo a transformation or modification (Change, 2018) • The implementation of new or altered products, services, processes, systems, organizational structures, or business models as a means of improving one or more domains of healthcare quality (Agency for Healthcare Research and Quality, 2013a) • Anything that creates new resources, processes, or values or improves a company’s existing resources, processes, or values (Christensen, Anthony, & Roth, 2004, p. 293) • The power to redefine the industry; the effort to create purposeful focused change in an enterprise’s economic or social potential (Drucker, 1985) • A new patterning of our experiences of being together as new meaning emerges from ordinary, everyday work conversations (Fonseca, 2001) • The first, practical, concrete implementation of an idea done in a way that brings broad-based, extrinsic recognition to an individual or organization (Plsek, 1997) • A historic and irreversible change in the way of doing things; creative destruction (Schumpeter, 1943) • Emergent continuity and transformation of patterns of human interactions understood as ongoing ordinary complex responsive processes of human relating in local situations in the living present (Stacey & Griffin, 2008) • Fresh thinking that leads to value creation (Vaitheeswaran, 2007) • Something new, or perceived new by the population experiencing the innovation, that has the potential to drive change, as well as redefine healthcare’s economic and/or social potential (Weberg, 2009)

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on all aspects of change simultaneously. Thus, our attempts to understand change and innovation are necessarily limited and incomplete—but necessary in the evolution of effective change and healthcare policy creation. To be sure, the change expert will integrate multiple facets of change to increase understanding of the concepts and processes involved in change and innovation. An overview of the multiple descriptions and definitions specific to change and innovation is presented here to assist the reader in differentiating the concepts, as well as to provide frameworks for readers to examine and consider their own change and innovation attributions when involved in this work. Descriptions of common terms related to change and innovation are presented in Exhibit 8.1 (Porter-O’Grady & Malloch, 2015). Change is more commonly referred to as a simple alteration of something, whereas innovation is considered a qualified type of change in which the alteration positively impacts future processes. A brief overview of selected traditional theories of change is presented in Exhibit 8.2; Exhibit 8.3 contains brief descriptions of selected theories of innovation and strategies for facilitating change and innovation. As indicated in Exhibit 8.2, innovation theories extend theories of change and add qualifiers to the type, space, and timing of change processes. Most of the traditional change theories tend to simplify the processes of change. The addition of theories of innovation in Exhibit 8.3 provides a more robust understanding of the complexities of change and innovation and may, in fact, assist nurses in more eagerly embracing new ideas. Selected strategies for implementation are illustrated in Exhibit 8.4.

EXHIBIT 8.2   TRADITIONAL CHANGE THEORIES Lewin (1947)—A common change theory using a force-field model in which behaviors of driving and restraining forces push individuals in a particular direction. This model describes the change process as one of, first, unfreezing current behaviors; second, moving to a new position; and third, refreezing the new behaviors. For change to occur, there must be a shift in the balance between driving and restraining forces. Lippitt, Watson, and Westley (1958)—Extends Lewin’s model and emphasizes the role of the change agent, participation of those involved, communication, and problem solving. Reddin (1970)—A seven-step technique with a participatory element that can be used by nurses to bring about change. The steps are diagnosis, mutual setting of goals, group emphasis, maximum information, discussion of implementation, use of ceremony and ritual, and resistance interpretation. Havelock (1973)—Modifies Lewin’s model and emphasizes the participative approach to effecting the desired change. Spradley (1979)—Theory of change based on Lewin’s theory; Spradley emphasizes constant monitoring of the change project. Rogers (2003)—Extends Lewin’s, Lippitt’s, and Havelock’s theories emphasizing the iterative nature of the decision-making process specific to change; change can be reversed or discontinued on the basis of interest and commitment to the new expectations.

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EXHIBIT 8.3   SELECTED THEORIES OF INNOVATION • Disruptive Innovation: Helps create a new market and value network and eventually disrupts an existing market and value network (over a few years or decades); displaces earlier technology; describes innovations that improve a product or service in ways that the market does not expect, typically first by designing for a different set of consumers in the new market and later by lowering prices in the existing market (Poole & Van de Ven, 2004). • Punctuated Equilibrium: Depicts organizations as evolving through relatively long periods of stability–equilibrium or convergent periods— in their basic patterns of activity that are punctuated by relatively short periods of fundamental change—revolutionary periods (Tushman & Romanelli, 1985). • Organizational Logics: Logic can be understood as the underlying cognition or mental model that configures a coherent thought, orders an argument, or arranges a system; dominant logic is defined as the way in which managers conceptualize the business and make critical resource allocation decisions, be it technologies, product development, distribution, advertising, or human resource management (Drazin, Glynn, & Kazanjian, 2004). • Diffusion of Innovations: Seeks to explain how, why, and at what rate new ideas and technology spread through cultures (Rogers, 2003). • Complex Adaptive Systems: Teleological in nature and portrays constructive change brought about by individual agents pursuing improvement in their individual fitness level, although fitness can also have global, aggregate components (Dooley, 2004). • Dynamics of Organizational Culture: Built on Schein’s theory, using artifacts, assumptions, and values, Hatch focused on the processes linking these elements, processes of stability and change, symbols, and the environment (Hatch, 2004).

Regardless of the specific theory examined, there are common characteristics (see Exhibit 8.5) across all the theories that nurses will want to consider when planning and implementing policy change and innovation (Poole & Van de Ven, 2004). EXHIBIT 8.4   SELECTED STRATEGIES FOR CHANGE IMPLEMENTATION • The Deep Dive: An area is selected for observation in multiple ways; workflows, photos, interviews, and observations are gathered by a team to analyze current processes and brainstorm new ways of doing the current work processes (Kelley, 2005). • Directed Creativity: Situation is proposed to encourage and advance new ideas. For example, stakeholders are asked how to design a wound clinic if resources such as staff, space, and finances are unlimited (Plsek, 1997). • Mind Mapping: Tool for collecting, organizing, and synthesizing large amounts of data in layers with complex relationships; useful for documenting connectivity, interdependencies, and emerging phenomena in healthcare • Scenario Planning: Disciplined approach considering multiple conditions in various orders; a strategic planning method used to make flexible, (continued )

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EXHIBIT 8.4  SELECTED STRATEGIES FOR CHANGE IMPLEMENTATION (continued ) long-term plans; allows inclusion of factors difficult to formalize, such as novel insights about the future, deep shifts in values, and unprecedented regulations or inventions (Schoemaker, 1995). • Innovation Space: Place or laboratory where inquiring minds collaborate to create a more livable and sustainable world focused on developing products that create market value while serving real societal needs; products that are progressive, possible, and profitable; the focus is often on biomimicry (Boradkar, 2010). • Prototyping: Model built to test a concept or process or to act as a thing to be replicated or learned from; designed to test and trial a new design to enhance precision by system analysts and users; prototyping serves to provide specifications for a real, working system rather than a theoretical one (Endsley, 2010). • Brainstorming: Process to generate ideas as a collective exercise; a good exercise generates 100 ideas; focuses on suspending judgment and criticism, freewheeling thinking, quantity of ideas, and building on the ideas of others (Endsley, 2010).

These include: • An alteration. Both change and innovation involve an alteration of the present way of doing things. Change can be an event of moving an item from one position to another. Innovation adds qualifiers of the movement and includes benefits, irreversibility, and nuance. • Human agency. Individuals or groups (human agency) range from one individual to groups to organizations. • Time parameters. These include the rate of change, when change will occur, and the extent of the change. Change can be episodic or continuous depending on the drivers or mechanisms of change. Continuous change is ongoing, evolving, and cumulative and episodic. Episodic change is infrequent, discontinuous, and intentional. EXHIBIT 8.5   COMMON CHARACTERISTICS OF CHANGE AND INNOVATION • • • • • •

An alteration Human agency Time parameters Levels of change Predictability Driver

Sources: From Poole, M. S., & Van de Ven, A. H. (Eds.). (2004). Handbook of organizational change and innovation. New York, NY: Oxford University Press; Porter-O’Grady, T., & Malloch, K. (2015). Leadership in nursing practice: Changing the landscape of healthcare (2nd ed.). Sudbury, MA: Jones & Bartlett.

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• Levels of change. This refers to the size of the units of change and innovation and range from a unit of similar individuals to units of differing foci to organizations composed of multiple levels of groups. • Predictability of the change or innovation. Some changes are planned, and other changes are unplanned. The range of planning includes the degree to which change can be choreographed, scripted, or controlled. Planned change is consciously conceived and implemented by knowledgeable individuals. There are attempts to improve a situation with targeted end points for the desired state. In contrast, unplanned change may or may not be driven by human choice or purposefully conceived, and it moves an organization in either a desirable or undesirable direction. Natural disasters, such as floods or hurricanes, can be the drivers of unplanned changes in resource allocations. Such events often force the reprioritization of resources and planned change processes. For example, changes may include funding priorities when federal funds designated for roads may be diverted to flood or hurricane relief. Or, as in the case with Hurricane Sandy in 2012, if a hospital with an obstetrical service closes, it impacts patients, nurses, physicians, and other staff. Patients may have to deliver their babies in a different facility. Displaced nurses need to be oriented to new facilities to provide for expanded capacity needs. Physicians may not have practice privileges at the facilities taking their patients. Finally, expectations and processes for implementing practice standards may differ when professionals from different facilities work together to meet patient needs. Both planned and unplanned changes can occur simultaneously at differing levels of an organization. Leadership teams can be strategically implementing a new electronic medical record using a project plan while the larger community in which the organization exists can be experiencing unplanned economic-, cultural-, or nature-driven change from an unplanned perspective. • Driver of the change or innovation. Four drivers of change have been identified: life cycle, teleological, dialectical, and evolutionary. Life cycle change and innovation occur in sequenced stages much like the stages of life, from birth to death. The change has a clearly defined beginning and end. Teleological drivers emphasize social construction and the cycle of goal formation, implementation, and modification of actions of goals. Dialectical drivers involve a thesis and antithesis. This change process is iterative and emphasizes discussions and actions to confront conflict and determine the best option. The evolutionary change process is one of repetitive sequences of variation, selection, and finally retention. The emphasis is on competition for scarce resources (Poole & Van de Ven, 2004). These essential characteristics of a change or innovation process—alteration type, human agency type, time parameters, levels of impact, predictability, and driver— should be determined for any anticipated policy change or innovation. Clarification of these characteristics provides critical insight into the anticipated trajectory of the process, as well as potential barriers to the process. For example, if a dialectical or goal-driven change such as the funding for healthcare is framed as a life cycle change with a beginning and an end, significant frustration would occur each time a new iteration for funding is proposed—when in fact it is part of the change and innovation process.

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Four exemplars using the drivers or motors of change and innovation are presented to enhance further understanding of these complex processes (Poole & Van de Ven, 2004). The first exemplar is life cycle change and innovation. Consider the election or reelection of candidates to office. Using the five characteristics discussed previously, the change model would include: Alteration: An expectation for either new or sustained leadership as the current individual is re-elected or the challenger is elected. Minimally, there would be a change in the elected official with potential for innovation of new policies. Human agency: The focus is on the candidate or incumbent; a single entity or individual. There are also multiple groups involved in an election, including those very active in the campaign and election processes and those able to vote for candidates. Time parameters: Clearly defined by election guidelines and election dates. Some extended time might be required for vote counting in close elections. Levels of change: Change is expected at multiple levels across the specific district or legislative area and will impact all the parties involved in an election. Predictability: In general, elections are planned changes and occur at legislatively defined times. There are unplanned circumstances when an incumbent leaves office at a time outside of the established election times, thereby requiring the appointment of an individual to complete the elected person’s responsibilities until the next election. The second exemplar is based on a change or innovation known as the teleological driver. In this exemplar, the area of interest is support for abortion. Goals are determined by selected groups to advance a position. Specific groups create initiatives and work to gain support for them. Alteration: The intent is a change in acceptable behaviors and procedures. Innovation is most likely not considered. Human agency: The focus is a single entity or individual with an unwanted pregnancy. There are also multiple groups involved in supporting or opposing the proposed position. Time parameters: These are determined by position advocates based on support and resources to advance the position. Start time could be when resources and support are available, and stop time is when the goal is achieved or support and resources are exhausted. Levels of change: Change is expected at multiple levels at either the state or federal level. Predictability: Typically, this is a planned change that evolves based on the support and resources for the initiative. The third exemplar is dialectical change and innovation. This process is one of iterative discussions and actions to confront conflict and determine the best option. Development of healthcare policy specific to access, funding, and coverage is a dialectical change process.

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Alteration: Both change and innovation may be included in this process, and new and creative ideas to support healthcare services emerge from debates and discussions. Human agency: Large-scale change involving national groups as well as state-based groups. Time parameters: These are determined based on support and resources to advance the position. Start time could be when resources and support are available and stop time is when the goal is achieved or support and resources are exhausted. Levels of change: Change is expected at multiple levels across state and national groups, including groups representing providers, payers, and numerous other constituencies. Predictability: Planned change is the backdrop for this initiative on the larger scale. At times, unplanned change may occur as smaller interest groups may emerge and facilitate or obstruct the progress in determining whether or a healthcare policy will be supported at a national level. Dialectical change is illustrated by the process used to develop the nursing community’s request for federal funding for nursing workforce programs under Title VIII (see Chapter 7). For many years, nursing organizations would ask congressional leaders for different funding levels. Eventually, a process was put into place that resulted in a unified request that was championed by more than 50 nursing organizations, resulting in greater success in achieving the desired funding levels. The fourth exemplar is an evolutionary change or innovation and can be identified in the processes to fund healthcare over time. Medicare was enacted into law in 1965 as amendments to the Social Security Act (U.S. Social Security Administration, 2012). In 1983, the Social Security Act was again amended to add Diagnosis-Related Groups, a prospective payment system, to control costs for Medicare patients. Most recently, healthcare reform legislation, the Patient Protection and Affordable Care Act (more commonly known as the Affordable Care Act [ACA]) created a national payment system to cover all citizens from a value-driven perspective. An evolutionary driver is one in which a repetitive sequence of variation, selection, and finally, retention occurs. This process is focused on the competition for scarce resources. Alteration: Both change and innovation may be included in this process, and new and creative ideas to support healthcare services or decrease costs emerge. Human agency: Large-scale change involving national and state-based groups. Time parameters: These are determined based on the needs of the citizens and the available support from the federal government. Levels of change: Change is expected at multiple levels across the specific district or legislative area and impact all parties involved in an election. Also, providers, funder groups, and vendors influence the process. Predictability: This process is both planned and unplanned as needs change in the health status of citizens or changes in available resources. These exemplars can greatly assist policy makers in determining the elements for consideration in a complex change or innovation process. The determination of the characteristics of the change or innovation provides essential information and strategies to advance the desired position with specific target actions and measures.

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Although each driver or motor of change is presented as a discrete event, it is highly likely that more than one driver is involved in complex change. A change can begin as a life cycle change and quickly become a teleological or evolutionary change.

SUCCESSFUL TEAM PROCESSES IN POLICY FORMULATION In the era of recalibrating health reform policy and practices, building a foundation in collective wisdom is essential to both engaging stakeholders and ensuring that concerted collective action operates in a way that demonstrates mutual understanding, commitment, and coordinated action (Nickerson, 2013). Often, development and initiation of new policies and collaborative action are waylaid from the outset simply because critical relational and communication requisites necessary to the successful design and implementation of policy are not successfully addressed (Nohria & Khurana, 2010). The details of good team dynamics are critical to the collective ability to establish effective principles, set good direction, and implement concerted action (Finkelman, 2015). A number of components of policy team dynamics are essential to the effective formulation, translation, and implementation of good policy (Matheson, 2009). From initial formative stages of group development to the definitive phases of policy implementation, each of the elements necessary to good group process must be effectively addressed if related processes are to come to fruition. Each stage of the policy team process depends on the previous phase in a way that exemplifies the cascade of related elements in the building of a successful trajectory toward effective policy application and implementation (Bodenheimer & Gumbach, 2016; see Exhibit 8.6, which highlights the critical cascade of stages essential to establishing a good policy process).

Determining the Foundational Need Policy should not be lightly undertaken or superficially addressed. Policy has serious implications regarding organizational constructs, political variables, social trajectory, and individual life. Because much legal, regulatory, and administrative direction and discipline is grounded in the fulfillment of a specific policy, the use of policy for making change at any level must be carefully considered and well developed. Whether the

EXHIBIT 8.6   ESSENTIAL PHASES OF POLICY TEAMWORK • • • • • • • • •

Determining the foundational need Setting the table with the right stakeholders Defining clear expectations Enumerating context, timeline, powers, and deliverables Effectively delineating methods and terms of engagement Ensuring a good fit between team tools and dynamics Agreeing collectively about the product of teamwork Determining when the team’s work is done Establishing good mechanisms for handoff and bringing closure to the work

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policy covers a broad range of society or a narrower population or group, it has the potential to impact action and behavior in a disciplined and definitive manner, with the hope of creating an effective and consistent response to an overarching need. Policy assumes that some aggregated good will be advanced and that the action based on the policy will lead to more appropriate or effective patterns, conditions, or behaviors. In the absence of these essential improvements or enhancements, the development of policy as a mechanism for codifying action should be avoided. It is preferable that a protocol for administration of a specific drug be authorized by the involved clinicians rather than have a universal policy that would require more prescribed processes and/or a time requirement. For example, some facilities require that pain medication orders specify different dosages for mild, moderate, and severe pain intensity ratings in the absence of any empirical evidence that a specific dose is effective for pain levels within a certain range. This removes the expectation for nurses to use professional judgment in assessing pain and is potentially unsafe. The ability to shift a protocol when evidence demands is easier and more focused than making a policy change, which has broader implications for both time and resources. An entire range of other approaches to establishing consistency and patterns of practice through use of protocols, standards, quality metrics, or evidentiary dynamics are available (Hayes, 2006). The lack of careful consideration about the use of policy, its general overuse, and its inappropriate use ultimately creates diminishing value, adherence, and ownership. The larger the number of policies that are created, the less value each policy represents. While policy can certainly be viewed as foundational, it should also be seen as critical. Policy should not be easily or superficially conceived and applied. Good policy reflects sound principles and establishes a floor for systematic and universal applications and actions in each set of circumstances. The point to establishing policy is to generate a firm set of principles on which process and action scaffolding can be constructed in a way that ensures a consistent response to principle-related issues, yet provides sufficient individual flexibility to render critical judgment that adapts action to inherent circumstantial vagaries (see Policy on the Scene 8.1). Every policy has an intended consequence designed to meet a defined and foundational need. Every policy also has an unintended consequence, which may be harder to identify. Unintended consequences can be compared to a side effect of a drug. Sometimes, the side effects are helpful, and sometimes, they are not. Policy should not be rote, inflexible, pedantic, or unchanging. Policy works best when it represents a principle or a set of principles that inform human judgment and that use the policy that flows from it to guide effective related human action (Bardach & Patashnik, 2016). Policy formation should be rare and few in number. Policy sets general rules for action within which standards, protocols, and processes can be more clearly and specifically designed to guide human action. A policy statement such as “the ANA Code of Ethics for Nurses forms the foundation for all ethical decision making made within the nursing ethics committee of this organization” and provides an example of the simplicity, clarity, and directness of a good policy statement. Policies need to be briefly stated, succinct, specific, and clear. The rationale for a policy should be generally understandable, acceptable, and reflective of a rational basis for subsequent action. The reason for the policy should be evident, clear, and logical in a way that could be found generally acceptable to most persons. The need for it should be obvious and understandable to all those to whom the policy relates.

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POLICY ON THE SCENE 8.1: APRN Practice and the Veterans Health Administration Recognizing the need to transition healthcare delivery in an outcomes-driven equation challenged the Veterans Health Administration (VHA) to recognize that essential health reform policy changes would ultimately require institutional, structural, and practice changes in its health system nationally. Policy foundations at the center of this change responded to ongoing concerns surrounding healthcare provider access for the nation’s veterans. This policy foundation provided a framework for the convergence of strategic organizational and delivery efforts to transform the service model into a collaborative care system that more fully used all providers within that system. The collaborative care partnership resulting from this new policy and strategic focus is designed to allow advanced practice registered nurses (APRNs) to practice at the top of the scope of their education and experience without requiring the added oversight of a physician (Department of Veterans Affairs, 2016). Initially, the proposal to allow full practice authority for APRNs at the Veterans Affairs (VA) was met with strong opposition from physician groups, arguing that this policy would create an unsafe environment for veterans seeking care. However, using data analytics to assess healthcare models that indicated an impending severe health provider shortage, the VA opted to closely look at APRNs to mitigate that challenge. Again, data analytics were used to assess all available outcomes measures surrounding APRN practice. National outcomes evidence identified in the data clearly showed APRNs as having both the expertise and the quality outcomes expected of providers. It became evident that a policy shift and system change would be necessary to ensure that all veteran’s seeking care would have timely access to a safe, quality provider. This information provided the foundation for creating a broad system change for three of the four APRN specialty groups. The VA did not allow for full practice authority for the certified registered nurse anesthetists (CRNAs) but did indicate that there would be requests for stakeholder input on the possibility of CRNA full practice authority in the future (Department of Veterans Affairs, 2016). The impact of the VHA’s policy shift represents the following key elements: 1. Policy must reflect environmental shifts, which recalibrate and reconfigure demand for a shift within the system. Systems policy response should tightly reflect environmental demands and translate them into action and performance in the organization. 2. Changing policy must affect the life of the organization at all levels: (a)  strategic decisions that drive systems changes; (b) operational decisions that address structure, process, finance, resource management, and leadership; and (c) practice decisions that affect clinical protocols, care partnership, care practices, evaluation of impact, and changes that advance patient care. 3. Policy informs practice when it changes patterns of interaction, role expectations, personal behavior, interprofessional interaction and relationship, and the role of the patient in day-to-day decision making.

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Setting the Table With the Right Stakeholders No policy should be formed that reflects or impacts the processes or actions of ­individuals without their representation or participation in its formation. Good policy assumes a measure of ownership, engagement, and investment. If a policy is to have significant impact on the action of individuals or groups and they do not share a role in its consideration and formulation, the price paid is no commitment or buy-in. It is at this point that many leaders and organizations pay a significant price in nonadherence or noncompliance with appropriate and well-thought-out policy that lacked only the engagement and investment of those on whom it had an impact (Schuman, 2006). Setting the policy table involves a good fit between policy and policy makers. The leader setting the table must know how deliberation and formation need to be informed and what varieties of capacity are necessary to adequately serve the process. Those with knowledge related to the policy arena and others with understanding regarding the structural, organizational, and contextual impact considerations influencing effective policy design must be carefully incorporated into the process. Although there may be a core group of team members at the policy table who need to be consistently present by virtue of their stake, there are other members at the policy table who may be either situationally or influentially present depending on the breadth or significance of contribution the policy formation requires. The policy leader must also be aware of the design process, knowing just when representation or interface needs to occur in the decisional flow and who best needs to play a decisive role at a particular point in the process that helps facilitate the policy dialogue and decision making. Group membership is a fluid and dynamic circumstance requiring good group management and continual recalibration of the players in the process in a way that best fits the circumstances and needs of the process at any given moment in time. Recognizing this strong need for fit between process and player alerts the group leader to the need for constant assessment of dialogue, decisions, and the good fit with participants and contributors to the group dynamic (Taylor, 2011). This is illustrated by the Agency for Healthcare Research and Quality (AHRQ) On-Time Quality Improvement Program for Long-Term Care involving the use of design teams composed of core members to provide expertise and ad hoc members who provide expertise related to specific aspects of care processes. This model has been used successfully to reduce falls, prevent pressure injuries, promote pressure injury healing, and avoid hospital transfers (AHRQ, 2013b).

Enumerating Context, Timeline, Powers, and Deliverables Important to policy group dynamics and team behavior is the establishment of clarity regarding the premises and purposes driving the work of the team. Although this is common to all group processes, what is especially important to policy groups is a deep and clear understanding of the drivers, circumstances, and conditions necessitating the establishment of principle and the formation of policy. Understanding contextual issues and policy drivers provides the umbrella that serves to frame dialogue and deliberation and to formulate a backdrop for intent, which serves to provide a rational basis for the formation of policy. The conditions and circumstances that create the need for principle and consistency and underpin policy formation help participants clarify whether and how the use of policy results in desirable outcomes. If, on the one hand, the dialogue demonstrates that a less directive or interventional set of choices could better address the issues of concern, the need for policy is abrogated and less intensive methods can be applied. If, on the other hand, the contextual realities point to a specific

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need for policy formation, providing the backdrop helps more strongly elucidate the appropriateness of this choice. Ensuring clarity of purpose and laying the foundations for deliberation rest in the hands of planning leaders. Creating team agreement among the stakeholders at the outset can provide clarity regarding expected behavior among the team members. This can be important as, often, stakeholders may agree to a common goal for different reasons. Providing clear guidelines on group behavior can help mitigate challenges related to competing priorities that team members may encounter from other sources. Clarifying expectations and roles provides the opportunity to build trust by eliminating the uncertainty of roles and holding the team to those agreements (Sinek, 2014). Much of this activity is initially generated prior to the formation of the policy team and establishes the basis for the initial dialogue with team members to further refine and clarify the purpose and direction of the work. Some of the early elements and issues that need to be addressed and that establish the foundations for dialogue and deliberation are: • General summary of the issues and concerns, which provide both reason and purpose for undertaking a policy initiative • Level of specificity regarding the mandate, charge, and powers for setting policy and direction established within the group’s purview • Brief but clear indication of organizational leadership support for the work, deliberation, decisions, and actions of the policy group as a part of the clear charge to the group • Some primary establishment of the parameters within which the policy team operates that provides the contextual framework within which policy teamwork expectations are located • Clear and precise delineation of the time parameters within which the policy team works with some clear delineation of the termination date for its work • General indication of the performance expectations and products anticipated from the work of the policy team that narrowly articulates the expectations for change and the anticipated positive impact or consequence of the policy work • Clear vision of expected outcomes for the policy work • Identification of strategic messaging focused on the vision and expected outcomes Rather than narrowly constricting the ability of the policy team to undertake as a wide range of actions as necessary to inform and guide policy, an original charge from leadership establishes the floor on which team construction, membership, and initial discourse are based. Establishing as much specificity and clarity as possible at the outset of the purpose and work of the policy team ensures that its members are clear about the thinking of current leadership and the depth of their reflection and intention in response to the need underpinning the formation of the team (Cheung, Mirzaei, & Leeder, 2010). It should be understood that, while this floor is established, it is not a fixed position. Subsequent discussion by the policy team, further informing its deliberation and introducing new realities impacting policy formation, ultimately alters the way that issues and concerns are perceived and addressed by the team. Creating a clear and intentional message can help the team stay on task, even as unexpected challenges arise. This can be best accomplished by first identifying a common vision for the team of stakeholders to work toward. The message should be based on the grand vision and throughout the process can be used to ensure all actions focus on achieving the defined vision, regardless of the unforeseen barriers (Lencioni, 2012).

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Effectively Delineating Methods and Terms of Engagement Once the issues and drivers are clarified, stakeholders are identified, members are selected, and the table is set for policy deliberation, it becomes important to focus on methodology and process rules. In many cases, team dynamics around policy formation are liberally sprinkled with strong feelings, bias, preexisting positions, and definitive points of view. The goal of all teamwork is to find points of reference that lead to opportunities for consensus and agreement in a way that moves the team through the course of its work (Dunin-Keplicz & Verbrugge, 2010). Successfully doing so is not accidental, serendipitous, or simply emergent. Rather, the products of innovation and creativity in thought, dialogue, and serious deliberation emerge from well-thought-out methodology and processes that provide discipline for the dialogue and accelerate the opportunity for the emergence of the seeds of innovation. Team leaders must be as deliberate about methods and approaches as they are about the selection and inclusion of participants. Balancing the team with those who have much to contribute to its work requires that there be participants with widely variable styles of reflection and communication. Team leaders must be aware of the personality characteristics and vagaries of the participants they have pulled together and adapt methods and approaches that maximize the contribution of each, yet facilitate the synergy of ideas through use of the disciplines and methods of good discourse and distributive decision making. At the same time, policy team leaders must also use techniques that help the team work through deliberative conflicts, contrasting ideas, group confabulation, heading off course, process dead space, and relational crisis. Although there is much contemporary discussion concerning emergent leadership and team innovation and creativity, much of the current evidence suggests that formal team leadership is best determined in advance of team process (Gratton & Erickson, 2007). Who these individuals should be must be balanced against organizational concerns, strategic imperatives, role locus of control, team facilitation competence, and team trust. Much of the work of team leadership occurs before and beyond team interaction and involves intensive processes of facilitating teamwork, assessing/evaluating effective team processes, anticipating and planning team dynamics and processes, and developing useful and productive team methodologies. Certainly, there must be a goodness of fit between the policy team methodologies, work efforts, process, and progress. As to whether those dynamics interface well and produce a satisfactory product often depends on the effectiveness of the leadership activities. See Exhibit 8.7 for guidance in developing an effective team. EXHIBIT 8.7  THE DISCIPLINED TEAM All members need to take ownership and accountability for the team’s performance and functioning. Some considerations for the policy team to ensure good structure and effective process include: • • • • • •

Is everyone clear on the purpose and the charge to the team? Are the terms of interaction specific and clear? Are members clear of their obligations for participation? Are the time parameters for the team process clearly outlined? Are methods and processes for the team’s work understood and useful? Are the mechanisms for measuring progress specific and effective?

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Ensuring a Good Fit Between Team Tools and Dynamics Managing highly creative and strongly motivated team members provides a set of challenges that requires rigorous group process skills. The effectiveness of teamwork can be significantly diminished or extended if those designated to facilitate such processes do not have the requisite skills to move the group successfully through the vagaries of group dynamics. Good process relates to not only facilitating the progress of the group’s work but also helping create synthesis of effort, strong and creative bonds of reflection and deliberation, useful methodologies and techniques for problem solving, crisis management, and solution seeking. Policy groups are especially challenging because of the high degree of personal interest issues, political bias, and individual values investment. In the policy-setting process, leaders often confront issues and concerns that make sense to some individuals but alienate or challenge other group members. Values differences often create the most intractable positions and require sensitive and delicate maneuvering to keep participants fully invested and on track toward problem resolution (Deleuran, 2011). Policy team leaders cannot expect to be universally skilled in all arenas of group process and problem solving. Some flexibility must be applied to the inclusion of content and process experts who are from outside the core group and who periodically provide unique skills that help move the team past potential logjams and critical barriers to effective deliberation. In addition, access to and adaptation of a wide variety of communication and deliberative techniques, as well as process tools and innovations, help keep the group dynamic focused, yet sufficiently innovative to avail themselves of the most useful supports that consistently move the team toward achieving the positive products of its work. Policy development reflects a continuum of stages before full implementation can be achieved. For example, the ACA (2010) was originally seen as a single-payer approach. Through political process, the act is instead a compromise that expands access and establishes a foundation (a “policy door”) that subsequent policy and legislative deliberation will refine and adapt.

Collective Agreement Regarding Teamwork Product Although the purpose, mission, and drivers of the formation of the policy team are often determined prior to its formation, the team does have an obligation both at the outset and during the process of deliberation to ensure that the goals and anticipated results of the work are legitimate, are viable, and fulfill the purpose for which they were formed (Fitz-enz, 2009). Often, the purpose for which a policy team is formed appears clear at the outset and provides a definitive foundation on which that work builds. At the same time, the work and processes of deliberation, interaction, knowledge generation, work processes, and development yield new facts, insights, and clarity that alter original notions and substantially affect the original purpose for which the team was formed. In the interests of transparency and truth, policy teams often determine that the initial insights used to establish their work may not accurately reflect the theory of the case or adequately represent the full range of issues, which influences appropriate decision-making and subsequent solutions differently. The policy imperative originally perceived may no longer be accurately reflected after deeper and more intensive assessment, subsequently changing both the premises and the terms of engagement. If this occurs, the policy team leadership may need to temporarily halt the work process to provide an opportunity for interaction and recalibration with senior leadership.

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Process always shifts the initial design. Whatever the originating charge for a team’s work, its progress ultimately adjusts the initial design for it and creates opportunities to rethink the relationship between original design and implementation. Flexibility and fluidity between purpose and deliberation do not mean the loss of purpose. Progress may help reinform purpose in a way that both refines and adjusts it to better reflect emergent reality. This ability to trust the process means that leaders must develop a foundational understanding that the risk of implementing a policy change using team dynamics can often be best represented by conclusions not originally conceived by those driving the policy change. The result may either be a recognition that there is no justifiable need for the policy itself or an entire shift in the character and content of the policy resulting from the policy team’s work. Within the team is the continual obligation to periodically but regularly review its progress against its charge. Here again, the team’s deliberation and progress may alter key elements of the policy process and determine significant enough factors to shift original expectations, creating the demand for new insights and the high possibility of a shift in strategy and approach.

Determine When the Team’s Work Is Done Policy decisions and developments unfold along a continuum. It is incumbent on policy team leadership to clearly monitor the team’s progress and help its members delineate, along the way, what progress has been made and at what stage they are in achieving their policy goals. All policy team activities must be moderated and measured against the team’s initial charge. Whether the policy is local, institutional, or broad based, the same parameters of measuring progress and satisfying intent operate for all team leaders. An often-seen detriment or deficit in policy development is the continuing and sometimes endless wrangling over whether policy goals have been met. Often, driving such conflicting views is the uncertainty around whether the points of policy decision making have fulfilled the policy intent and hopes of those who initiated the process. One of the characteristics of negotiation and compromise in deliberation and decision making relates to the personal acknowledgment of the difference between the ending point of policy discussion and decision making from the perceptions present at the beginning. As the policy process becomes increasingly informed by the team’s deliberation, data gathering, and new knowledge generation, original insights, notions, and directives become differently informed and call the policy team to recalibrate its charge, inform leadership, and, ultimately, make the most correct policy decision (Tunis, 2007). Harnessing the policy team around final decision making is the role of team leadership. It is the obligation of the team’s leader to direct and manage its members’ work and to help members discern when that work has reached a critical juncture. The leader must determine whether its original charge has been substantially addressed. The leader asks whether deliberations have led to a point of demarcation where further work would lead the team away from the contextual framework for the policy or where their work has obtained substantial value or impact as a reflection of the issue that it was intended to address. The team leader must always work to keep dialogue and decision making clearly within the parameters of the policy charge and validate that concluding decisions and impact demonstrate a fulfillment of the original purpose and intent. As with all such directed and time-limited work, the policy team terminates its function after this final decision making and with its report to the systems leadership who gave it its charge.

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Establishing Good Mechanisms for Handoff and Bringing Closure to the Work The importance of clinical handoffs is well described in the literature (Bennett, Probst, Vyavaharkar, & Glover, 2012; Clarke et al., 2012; Maxson, Derby, Wrobleski, & Foss, 2012; Staggers & Blaz, 2012). In policy teamwork, the link to handoff is just as critical. Good policy affects values, actions, and outcomes and therefore should never be lightly addressed. Policy also represents the principal foundation on which it is grounded and challenges organizations and people to be continuously aware of the principles that guide thought and action and inform correct choices. At the same time, policy is not fixed. If it is, it is as much an impediment to growth, development, and transformation as any other structural and behavioral element in an organization. For example, some state nursing boards have regulations that specify the number of clinical hours in nursing programs. The introduction of high-fidelity simulation has changed the nature of laboratory instruction in nursing. Having great specificity in laboratory requirements may be a hindrance to programs seeking to substitute some of their clinical hours with simulation. Policy should never be looked at as finite or rigid or even unchanging. These insights alone create pushback and reaction from those who see policy as inflexible, finite, and fixed. When policy is used as a weapon rather than a tool, it becomes an impediment to engagement, advancement, and appropriate meaningful change (Cooperrider, Whitney, & Stavros, 2008). This is illustrated by policies related to medication error reporting in the past that focused on individual blame and efforts to shift to a more reasoned approach that examines the nature of the error in the context of the system and the riskiness of the behavior that may have led to it (Vogelsmeier, Scott-Cawiezell, Miller, & Griffith, 2010). Similarly, zero-tolerance and punitive policies result in an atmosphere where nurses with substance abuse problems are reluctant to ask for help (Monroe & Kenaga, 2011). Handoffs in the case of policy development relate specifically to follow-up occurring after the work of the policy team and after the decisions they have made regarding specific policy. There is no value in establishing policy if it does not directly influence decisions and behaviors. The intent of policy formation is ultimately to establish principled foundations that drive decisions and actions. Policy team leadership and executive leadership should undertake the following steps to ensure a good link between the decisions of the policy team and the actions of organizational leadership: 1. A clear presentation and delineation of the policy team’s work and decisions collectively shared with involved organizational leadership in a way that best articulates the considerations, value, and meaning of both deliberation and decision making on the policy team. 2. A specific delineation of next steps of the organizational leadership and the subsequent decisions and actions related to their role, which follow up or advance the policy team’s work and decisions. 3. Development of a follow-up and/or implementation process that translates policy decisions or directives into an organizational initiative that establishes the foundations, principles, and drivers that make the policy a part of the organization’s operating milieu. 4. Identify and outline metrics that serve as the frame for measuring performance and compliance with policy and principle in all the places to which the policy is

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directed. Measures should reflect real-time progress associated with inculcating the policy in the practices and behaviors of the organization and people to which it is directed. 5. Establish a long-term mechanism for measuring the value and effectiveness of the policy and determining both the need and time for alteration and change; note that both the organizational dynamics and practice shifts create a demand for policy change. Whether a national or local work unit policy, the processes associated with its planning and implementation are consistent. The implications of policy represent the same set of characteristics regardless of how broadly their impact is experienced. It is simply a matter of degree, not of process. Those establishing national health policy are driven by the same rules of engagement as those attempting to lay the foundations for a practice policy. Reflection on the need for policy and the implementation of policy must always be carefully considered. Policy should not be developed as a vehicle for codifying, controlling, and circumscribing every single element of human behavior. In the guidance and governing of the work of professions, precedence must always be given to the role of critical thinking and judgment moderated by the circumstances and conditions driving a certain response. Policy should always be more strongly related to the establishment and/or codification of principle rather than to the formation of directives. In the contemporary age, policy has all too often been used as a vehicle for establishing behavioral strictures and as a reaction to personal or process error that would be better addressed by enhancing critical thinking skills and good judgment than by constructing rigid policy boundaries eliminating the capacity to think, adjust, and adapt. Policy has often been used in place of accountability and effective discipline; in doing so, it has acted as a poor substitute for managing human behavior. The work of the policy team should reflect this understanding, validate the principal foundation of policy, and limit the use of policy as a unilateral mechanism for control and discipline (Stone, 2011). For example, some facilities still restrict the use of smartphones and the Internet while nurses are on duty, resulting in nurses being unable to access current information for clinical treatments and medications to provide safe care. Keep in mind that policy gives direction to action; it is not the action itself. As indicated in this chapter, action refers to the processes and mechanics of translating policy into protocols, practices, and processes. Examples of simple policy statements are illustrated in Exhibit 8.8. EXHIBIT 8.8   EXAMPLES OF SIMPLE POLICY STATEMENTS A member’s eligibility and benefits must be verified each time he or she receives hospital services. The hospital’s Voice Response Unit is always available 24 hours a day, 7 days a week. The community health service requires that all services performed on behalf of its members be provided in a culturally sensitive manner, including to those with limited English proficiency or reading skills, diverse cultural and ethnic backgrounds, and physical or mental impairment. All decisions about practice standards, policies, and protocols related to orthopedic nursing care are made by the orthopedic unit practice council. (continued )

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EXHIBIT 8.8  EXAMPLES OF SIMPLE POLICY STATEMENTS (continued ) All members of the professional nursing staff must be credentialed annually through the Credentials Committee of the Nursing Quality Council. All nursing clinical policies, protocols, and practices must be based on the appropriate specialty nursing standards of practice and specifically enumerated and/or referenced in the body of the text. The Affordable Care Act requires that the value case be made for all episodes of care and includes the contribution made to desirable outcomes by all members of the healthcare team.

Note that each policy statement is declarative, simple, and directive. Not included in the policy statement itself are the rationales, procedures/methodologies, definitions, responsible persons, and so forth. Each of these elements is a subset to the policy and serves to provide an expanded explanatory and methodological foundation for acting on and implementing the policy; they are not themselves the policy.

TRANSLATING POLICY INTO ACTION AND IMPACT Much effort and resources are used to plan, change, and initiate policy. Federal legislation such as the 2010 ACA demonstrates both the significance and the breadth of social impact of significant policy efforts. The time and resources associated with harnessing social, political, and economic forces and converging them around particular policy initiatives are not only considerable but also personally demanding at every level of society (Hartley, 2012). The economic and social capital invested in such efforts concentrate change forces and marshal societal responses that represent considerable expenditure of intellectual, emotional, and political noise. Intellectual noise is characterized by conflicting ideologies regarding a particular policy, emotional noise relates to how people feel about a position or a policy, and political noise relates to the variety of power positions people take to influence the content and exercise of a policy. Healthcare change at every level of consideration is a hot-button issue. Because of both the personal and social issues implicated in healthcare services, all people have a vested interest in the translation and application of health to their own personal experience. Everyone has a viewpoint on some element or consideration of healthcare. Complicating this view are individuals’ social and political perspectives, which inform their personal expectations related to the healthcare system in general and health service at the more personal level. Even if people judge a health policy change as appropriate or even essential, their capacity to understand or embrace the change may be moderated by their view of its personal demand or impact without awareness of unintended consequences of potential policies. The social good is always viewed through the lens of personal value. Therefore, translation and implementation of shifts in policy at every level of consideration must incorporate a deep and abiding understanding of the vagaries of health policy as it is translated into personal experience (see Policy on the Scene 8.2). This is just as true for a point-of-service practice change as it is for a transformative federal health policy change. Although each represents a different level of social intensity, both demonstrate the same human characteristics in response to the requisites for a modification or adjustment in existing patterns of behavior.

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POLICY ON THE SCENE 8.2: Motorcycle Helmet Legislation—Pros and Cons A policy stating that, because of the potential for devastating head injury, helmets are always required for manual or motorized cycles is a stronger and more deterministic policy than one that simply relates to treatment availability for head injuries in general. There must be a clear cause-and-effect relationship in policy formation (no helmet leads to inevitable head injury) that goes beyond the root cause. Nurses may see this discussion from a very practical standpoint because teaching prevention is considered an important part of nursing practice. However, in policy, building on an intention of improving public safety may not be enough to move policy makers to create a statute requiring helmets, regardless of the evidence supporting the public safety outcomes or clear intent to prevent brain injury. There will be opposition to such a policy. This issue is often defined as an individual choice. Many policy makers believe adults have the right to risky behavior as their body is their own, as long as the behavior is not harmful to others. The question therefore lands on the cost of risky behavior in the public realm. If a person who understands the risks chooses not to wear a helmet and sustains a life-changing head injury requiring lifelong care, who is responsible for the costs of that care? Some states with large outdoor recreation areas, such as snow skiing resorts and hiking and biking trails, have created tough laws around personal choice issues. For example, if a person purposefully skis, bikes, or hikes in an area marked as out of bounds or restricted and is injured, emergency personnel will be deployed to save the injured person; however, the heavy cost of those emergency services will be billed to the injured person who chose to ignore the restriction. It is unlikely that policy makers would create a law that limits public assistance to someone who has sustained a severe and debilitating brain injury, and some may see this outcome as its own consequence. However, there is a steep public monetary cost that is incurred with long-term disabilities. In addition, is personal choice an option for children when public safety is involved? Some municipalities require anyone younger than the age of 16 to wear a helmet when on a motorized or a manually driven cycle. Children are not treated the same under law as adults, but there are still people who believe it is not the role of the government to legislate how to keep children safe. Many feel that this is solely the role of the parent and thus argue against requiring helmets. However, if a child sustains a head injury because a parent did not require a helmet, who is responsible for the long-term costs of that child’s care? Unless the family is very wealthy, if the child is severely injured, it is likely that at some point the state will be needed to support the care as that child grows to adulthood. Policy is never simple. In addition, requiring a helmet may provide a long-term cost benefit to the public at a time when many state budgets are stretched. Prevention is often much less costly than a cure. For the change agent at any level of policy change, there are some basic considerations that should almost always be incorporated into the processes and dynamics of any policy shift:

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1. No matter the breadth, depth, or complexity of a policy change, the policy maker must always be prepared to translate it into the simplest elements of description that will satisfy the most basic level of understanding of those it will impact. If owners of a response to any policy change cannot describe it in personal terms, they cannot engage its implementation. 2. Clarity is a fundamental companion to understanding. If the policy can be presented in component parts or as a cascade of action and impact, understanding can be more easily obtained. Here again, clarity is best informed through simple terms of personal impact. 3. Understanding and acceptance of a policy change is best obtained when individuals can judge that it has value and meaning at the personal level. The more effectively the policy can be applied to a net aggregated improvement in personal experience and the more the policy is in a language that articulates positive personal impact, the easier it is to embrace. 4. Ultimately, all policy is local, regardless of where it originates or its breadth. Suggesting how good a policy is for the country is not nearly as effective as demonstrating how valuable the policy is for the individual. All policy is seen through the lens of each individual and is best when reflective of personal values and perspective. 5. In addition to suggesting what a policy means, it is vital to define what a policy does. Clearly, policy change alters experience and behavior in a specific and defined manner. This alteration is of concern to the individuals and groups around whom these actions and responses must coalesce. Individuals need to know what they must do and how they must change to act congruently with the requisites of the policy. 6. Individuals and groups need to sense a generalized awareness that they will be better because of the policy change. Suggesting that things will be better represents a generalized amorphism, which will keep people disengaged and suspicious of the real value of the suggested change. Any policy change that requires personal energy but does not attain some level of personal benefit or that threatens the safe status quo will have a short tenure. 7. All individuals associated with any policy change need to express and play some part in the design and initiation of policy that directly impacts their lives. Good policy formation is generative, is engaging, and invests stakeholders in the processes associated with its formation. Suggesting to stakeholders impacted by a policy that they can only be involved in its implementation creates late-stage engagement and delays their capacity to incorporate it as part of their personal values and behavior. The closer a policy can be formulated to where it will have impact, the more likely it will be both embraced and successfully initiated. Over the past decade, the growing understanding of the essential “locality” of policy formation and implementation has challenged historical notions of centralized approaches to policy management (Winowiecki, Smulder, Shirley, & Remans, 2011). Much of the devolution to regions and states of policy decision making regarding national healthcare and Medicaid reforms is an example of the shift. In addition, the Centers for Medicare & Medicaid Services (CMS) Center for Innovation best demonstrates this point-of-service approach to model building and policy formation through the generation of innovation initiatives in a wide variety of local settings.

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Models such as accountable care organizations, medical home delivery systems, community care delivery models, and nurse navigator continuum-of-care approaches all demonstrate point-of-service approaches. Through its Patient-Centered Outcomes Research Institute (PCORI) funding for comparative effectiveness, the CMS gives patients and those who care for them the ability to make better-informed health decisions (PCORI, 2014). These models demonstrate an approach that permits the aggregation of local efforts to be evaluated in a way that helps define common elements and characteristics. This effort better defines the policies and practices that converge to inform appropriate policy formation and to more effectively suggest that the policies and practices can be best replicated across a larger number of settings. Organizational efforts have suggested that this less top-down and more centerout approach yields better engagement and ownership suggested by crucial policy change.

FACILITATORS AND BARRIERS TO CHANGE AND INNOVATION The barriers and facilitators noted in the successful team processes in policy formulation section of this chapter are joined by both subtle and overt barriers and facilitators that can render the policy process either effective and impactful or dismantling. Gaining an appreciation of the significance of both facilitators and barriers to change and innovation further supports the advancement of new ideas. Facilitation of change results from multiple factors, including knowledge and understanding of the intended change, personal or professional investment in the intended change, and active involvement in creating the intended change. Facilitation of change results when goals and values are mutually supported and the personal impact of the change or innovation is acceptable to the individual. There is nothing more frustrating than learning about a change that will impact your work after it has already been formulated and proposed. When key stakeholders are involved in creating the rationale, processes, and expected outcomes of new or revised policies, support for the proposed change is more likely to be facilitated. An exemplar is the work done in Colorado by nurses associations in supporting legislative agendas and collaborating outside of direct nursing organizations to pass legislation. Rural hospitals in the state were encountering extreme challenges in recruiting anesthesiologists. Much of the anesthesia was being done by certified registered nurse anesthetists (CRNAs); however, the law continued to require supervision from an anesthesiologist, even though there was rarely one nearby. The state hospital association was integral in writing and supporting legislation, with the support of nursing, to increase the scope of practice for CRNAs, with a goal of better supporting rural hospitals. Involvement of key stakeholders has been essential in clarifying the scope of practice of CRNAs across the country, and Colorado provides a strong example of how this can be effectively accomplished. In this example, key stakeholders did not represent nurses directly, but, because the rural hospitals they represented were unable to recruit anesthesiologists, they found that this was the most efficient manner of serving their membership. Collaboration is an essential step in facilitating the change process, and the potential for problems later can be mitigated if organizations outside of nursing and other healthcare professions are included in the discussion of the changes and language of a bill. It is also important to note that this type of scope of practice documentation in the legislative process typically requires more

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time than anticipated. The Colorado Supreme Court was pushed by anesthesiologists to assess the ­constitutionality of the legislation allowing CRNAs full practice authority. Although the courts upheld the legislation, there is a loophole that could allow it to be overturned, if a future governor decides to do so. Therefore, maintaining a strong collaboration with non-nursing organizations that see the importance of CRNA practice is imperative. The role of CRNAs continues to be strongly contested by anesthesiologists, which continues to create full practice authority limitations for CRNAs across the country. See Policy on the Scene 8.1. Consider the length of the actual times in which legislative bodies are in session and the available time frames for which changes can be submitted. Fitting change processes into legislative schedules requires significant collaboration and teamwork before the start of the session; being strategic and timely in this work is essential. Ensuring that key stakeholders are knowledgeable and able to support the proposed change cannot be accelerated without some anticipation of loss of support. A second factor that generates support for change is one in which personal or professional practice is supported or enhanced. Change and innovation often arouse emotions and passionate pleading for one choice or another. When one’s choice is sustaining the current reality, barriers to considering and adopting new ways are quickly raised. Fear of the result of the change, as well as avoidance of risk-taking, contributes to resistance. These barriers to change and innovation are most often related to personal comfort with the current situation. Our personal baggage includes everything from once-valid beliefs and practices that have outlived their usefulness to misinformation and misconceptions that we have accepted or even embraced without much examination or thought or evidence. Consider the implementation of regulations specific to the need for a collaborative relationship with nurse practitioners. Each state varies in its requirements for such collaboration. Some states do not recognize clinical nurse specialists in their nurse practice acts or regulations. Similar to the work in clarifying the role of CRNAs, developing practical and safe practices from the policy perspective requires the collaboration of physicians, nurses, payers, and insurers. Achieving the goal of decreasing the level of supervision requires support and facilitation from multiple stakeholders. Consideration specific to individual practitioners, groups of practitioners, organizations using the services, and payers reimbursing for the services all needed to be included. Regardless of the best preparation and planning, resistance to change and innovation occurs. As noted in Exhibit 8.9, resistance to change occurs in many formats, from outspoken, verbal reactions to subtle, nonverbal, and indirect avoidance of the issue. Generally, individuals resist change when there is a perceived threat to their safety and security or position. The culture of an organization or the leadership style can also impede change and innovation (Schein, 2016). Some barriers or resistors to change and innovation are covert and difficult to uncover. Resistance can result from subtle competing commitments (Kagan & Lahey, 2001). Consider the situation in which individuals say that they are team players, but feedback from others indicates that they dismiss anyone else’s ideas and input and seldom ask for assistance. According to Kagan and Lahey (2001), the competing commitment for these individuals is that they are internally committed to getting the credit for work and avoiding the frustration or conflict that comes with working with others. What is even more important is the assumption that these individuals believe no one will appreciate them unless they are seen as the source of success. Also consider the

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EXHIBIT 8.9  RESISTANCE TO CHANGE: UNCOVERING COMPETING

COMMITMENTS

Individuals often state that they are supportive and want to participate in change or changing; however, the change does not happen. Consider the following underlying assumptions that get in the way of individuals moving forward with change. • Stated commitment: I want to be a team player, but I am struggling with making this happen because I know I do not collaborate enough. I make unilateral decisions too often, and I really do not take people’s ideas and input into account. • Competing commitment: I am committed to being the one who gets the credit and to avoiding the frustration or conflict that comes with collaboration. • Big underlying assumption: I assume that no one will appreciate me if I am not seen as the source of success. I assume nothing good will come of me being frustrated or in conflict. Using your understanding of change and innovation, the process and dynamics, the strategies to manage resistance, and the tools of innovation, how would you and your team address these types of resistance and, more important, how could the team be proactive in minimizing this resistance in the planning phase for a new policy?

potential competing values involved in supporting pro-life or pro-choice beliefs. Professionally, nurses might be pro-choice; however, from a personal faith perspective, their alignment of values is pro-life, thus creating a very challenging situation. As people, these nurses may have been raised in a religion strongly supportive of life, whereas the challenges of teenage and unintended pregnancy that they have seen as professional nurses have garnered their support. These competing values often make it difficult to understand which side of the policy debate an individual will e­ ventually choose. Finally, resistance can emerge because of outdated systems or information that obstructs one from considering a different alternative. If individuals believe that electronic communication is unreliable and a violation of privacy, they will resist it until secure electronic line information is fully disseminated. Sometimes the most challenging aspect is determining the source of the resistance, be personal knowledge to levels of trust to skills in managing conflict and negotiation. Being able to differentiate personal knowledge and professional resistance provides information to move from jaded nostalgia about the past or knowledge deficits to increasing engagement in the change and innovation processes. Exploring resistance is a critical part of the change and innovation process. Interestingly, resistance to change and innovation often occurs when there is little stakeholder engagement, sharing of knowledge and ideas, and team building. Strategies for decreasing resistance include sound principles of team building, work to understand the rationale, and competing commitment that results in resistance and the allowance of adequate time for discussion and collaboration.

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LESSONS LEARNED Given its complexity, it is not surprising that creating and sustaining policy change specific to nursing practice are not always successful on the first attempt. Often, policy failures represent an inadequate application of the processes, the terms of engagement, and the cautions briefly pointed out in this chapter. Policy most often fails because some process associated with its formation was in some way flawed (Latin, 2012). While the challenges of policy implementation can be daunting, adherence to good process from the outset can facilitate implementation and reduce both the intensity and vagaries associated with making policy work (see Exhibit 8.10). Numerous lessons can be learned from both successful and unsuccessful attempts at change. The importance of collaboration and the allowance of chaos and noise during the dialogue allows all voices to be heard. Equally important is the recognition that additional information emerges during the process and that the new information needs to be considered in the process to achieve the desired goals. This is the opportunity to learn from mistakes and build on successes.

CONFRONTING FAILED POLICY AND RE-ENERGIZING ENGAGEMENT Policies often fail for specific reasons. Often, a policy is doomed for failure at the outset, driven by the primary process failure in the establishment of inappropriate objectives (Richtermeyer, 2010). Directing a policy on service provision to specific populations rather than to clearly defined and well-articulated health outcomes, expectations, or impact is a mistake often replicated in healthcare. Establishing strong helmet laws to reduce accidental head injury is not nearly as specific a policy objective as the establishment of such laws to reduce crippling and costly brain damage. In addition, health laws that focus on cause or prevention are more effectively defined than those emphasizing treatment. A second leading failure for policy initiatives is the provision of asymmetrical information to those who are impacted by the policy. The classic example in the United States is the duplicity shown by drug companies when recommending the use of their drugs to the general population. Although this information may be objectively correct, EXHIBIT 8.10   ESSENTIAL ELEMENTS IN THE POLICY PROCESS Policy teams can enhance the success of their proposed policy through the use of a brief checklist that focuses on policy progress. Some important items on the checklist include: • • • • • • • •

Specificity and clarity of the policy General understanding of the policy and its implications Appropriateness of the policy to the issue it is attempting to address Significance of the policy and its impact Strategic and systemic commitment to the policy Perceived fairness and value of the policy Evaluation of effectiveness of the policy Flexibility of the policy to change, when necessitated

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its accuracy and veracity are particularly limited when viewed through the lens of individual patient conditions, circumstances, and drug interactions. One of the most prescribed powerful psychotropics is prescribed by primary care providers because of patient demand rather than carefully delineated clinical need. One notable erectile dysfunction drug is generally prescribed for those who want it but who present little evidence of actual erectile dysfunction; advertising a side effect of prolonged action led to a boon in demand. Both are examples of information asymmetry resulting in behaviors that have little relationship to purpose or intent. An important threat to the integrity of policy formation is the issue of moral hazard. In many cases in the United States, drugs approved by the Food and Drug Administration (FDA) have been used for off-label purposes, or the data supporting the use of drugs for specific purposes have been inadequate or inaccurate. Often, the interest in generating a large volume of sales or the exciting potential effects of one of these drugs overwhelm careful judgment with regard to appropriateness, safety, and efficacy. Problems lie both in policy, which governs the approval process, and in issues in which the effectiveness related to countering “opportunity enthusiasm,” elements of groupthink, or inadequacies in review or process lead to a negative impact or outcome. Often driving policy failure are issues of adverse selection regarding who, how, and where policy is managed and executed. The formation of policy often portends a legitimate response to a public need. That good intention is sometimes lost in the dynamics of politics, competition, lowest bidder vendor selection, hidden agendas, and other issues. Policy can be implemented and applied through clear management, budgetary parameters, and precise metrics, which validate the relationship among intent, impact, and outcome expectations (see Exhibit 8.11). A classic example of the conflict between policy and resources is that which relates to the wide variety of nursing staffing mechanisms and approaches. Frequently, policies related to staff-to-patient ratios do not include valid measures of preparation, competence, intensity, and demand, resulting in generalized staff-to-patient ratios that may not best fit the clinical conditions or requirements of patients or populations. As a result, wide variation exists in the appropriate use of resources and a good fit with patient needs. Some of the most challenging circumstances to the successful implementation of policy are related to failure to effectively communicate and failure to monitor policy performance effectiveness. The relationship between design and implementation is

EXHIBIT 8.11   SUGGESTIONS FOR AVOIDING POLICY FAILURE • Make sure the use of policy to address the behavior is necessary. • Define objectives in a way that clearly relates to policy outcomes. • Make sure there is a tightly related interaction between cause and effect in policy formation. • Define a clear relationship among cost–benefit, outcome efficacy, and effectiveness. • Invest and engage stakeholders in policy design and construction. • Ensure that there is an effective communication model that affirms a strong relationship between intent and implementation. • Establish a continuous and ongoing mechanism for monitoring policy effectiveness and relevance.

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critical. Often, the breakdown in effective handoffs and the thorough and complete generation of relevant information related to the character, content, and intent of the policy gets lost or altered in the transition and communication process. In effect, the policy being implemented is frequently not the policy designed, and either the structure of implementation leads to a perversion of the policy or the processes of application implement a policy format that looks little like its origination. In addition, as policies move into the rituals and routines of organizational systems and human practices, they often devolve into patterns of behavior and action that little resemble the purpose, intent, or origination that drove policy formation. A structured, regular, consistent review of individual policy is an essential corollary for effectively managing policy that can serve to determine its continuing value and relevance as it is applied. Some institutions may bar nurses from using cellphones while on duty. Yet nurses are now using their personal smartphones to access online information about medications, diseases, and laboratory tests, as well as applications to help patients manage their illness. An unintended consequence of limiting access to such resources is that it could have a negative impact on the quality of care received by patients. Policy is as dynamic as the circumstances it addresses; when circumstances change and policy fails to change along with them, people become cynical, lax, and noncompliant, and their action becomes increasingly situational (Scott, 2004). Clear communication processes are necessary to ensure that policies are efficient, appropriately applied, and impactful.

OPTION FOR POLICY CHALLENGE: Enhancing the Multistate Nurse Licensure Compact The enhanced Nurse Licensure Compact (eNLC) was adopted by the National Council of State Boards of Nursing (NCSBN) in 2015, using both positive and negative feedback from the adopting and nonadopting states, with an aim at increasing state participation. By July 2017, 26 states adopted the eNLC, making its implementation date January 2018. The lessons learned are both positive and negative. Successful enactments resulted from collaborative work among constituencies, sensitivity to legislative timelines, and the work of champions for the eNLC. In contrast, many lessons related to unexpected competing commitments were learned and are still being learned. Unexpected resistance to this work was quickly evident from labor organizations representing nurses in states with high union membership because increasing nurse mobility was perceived as having the unintended consequence of facilitating strike breaking. This is a good example of how competing commitments can impact policy outcomes. On the other hand, a broader unintended consequence of not passing this legislation might be that nurses would be challenged in crossing state lines to provide disaster relief because of a lack of reciprocity. Weighing the broader impact of the potential for unintended consequences and defining what those might be are important when prioritizing policy decisions. Another lesson is related to the context and intent of the eNLC. Some states’ attorneys general believed that the eNLC implementation would be abandonment of states’ rights; therefore, an illegal action would be committed by joining a compact. Concern was also raised about the loss of revenue to boards of nursing from nurses being licensed in multiple states and the negative impact on their (continued )

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budgets and their ability to effectively discipline nurses. Some states simply feel the verbiage of the eNLC does not adequately protect nurses' right to privacy regarding their own healthcare diagnoses. These lessons and sources of resistance, very often founded in local concerns, provide valuable input into the enactment of this complex legislation. They also illustrate why competing commitments among stakeholders can and often do end in failure. Identifying the opposition and the reasons for opposition to policy change allows the team to mediate more effectively for the success of future initiatives. Competing commitments for union membership, preservation of state funds, and states’ rights issues need to be examined and mediated for more states to enact the eNLC.

There are now many options for evaluating nursing licensure policy models. You can begin the process by using strategic team processes to define the type of change or innovation that is needed for advance practice registered nurses to work seamlessly across state borders. Most likely, this work would be driven by teleological or goal formation and dialectical forces. In this early formation process, recognizing whether this work is an expectation or is still open for both rejection and acceptance is an important step, given the strong feelings of current supporters and opponents. In this case, either a change or an innovation could be possible. Change would be appropriate if the current licensure model is merely translated to a national model; an innovation model would be appropriate if the model for licensure was reinvented in a new, different way. In examining the case of the eNLC, think about the nature of the change if all states signed on to the compact. Think about how the change process would be different if we moved to a model of national licensure, not only for registered nurses and advanced practice registered nurses, but also for healthcare professionals. The nature of this complex change requires time parameters in a planned process, the levels of participation from local to state to national collaboration. Could a national licensure model provide the foundation for global credentialing? As the infrastructure and teams are formed and the processes are selected, the translation of policy formulation is a critical step in gaining maximal engagement of stakeholders. The stakeholder process is illustrated by the Future of Nursing Campaign to ensure that all nurses are practicing to the full extent of their education and training (Campaign for Action, n.d.) and differences in opinion about the location of one’s practice (ANA, n.d.). Key stakeholders would want to be aware of the lessons learned in the current processes engaged by 26 states in forming the eNLC. Barriers and facilitators would also be identified and recognized by stakeholders in this complex work.

IMPLICATIONS FOR THE FUTURE Policy formation and policy changes are rarely the result of linear approaches or even sequential dynamics in which the stages of policy are logically determined. Although true policy formation is a discipline, the generation of policy and the machinations influencing its formation are often surreptitious and tangential. Looking through the

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“windows” of social dynamics, it is often easy to see the emergent character of demand for policy because of changes in conditions, circumstances, scenarios, or interactions (see Option for Policy Challenge). Leaders must be available during such occurrences and recognize when the forces they represent aggregate sufficiently to challenge current policy and practice. The changing digital landscape will play a key role in the future of policy formation and change. Nothing could be more clearly indicative of a changing social milieu and technological context for policy formation than social media and the innovative and dynamic opportunities for connection it represents. Throughout the globe, overwhelming political, social, and economic circumstances have been both challenged and reacted to through predominantly online media mechanisms. The emergence of digital reality has created a whole new set of challenges and opportunities for democratic action, decision making, discourse, cooperation convergence, and social revolution. The breadth of connections and interaction provided by a universal medium such as the Internet creates an entirely different social construct, diminishing the two-dimensional value of borders, boundaries, limited access, and human communities. The universality of the human condition and human interaction has emerged as the critical centerpiece of these digital tools whose most widely used purposes are connection, communication, linkage, networking, convergence, and relationship. Dialogue and discussion related to existing policy circumstances and conditions, policy efficacy, legality, appropriateness, and legitimacy now have a broad constituency with mutual access to information and resources in a way that more broadly informs policy discussion and decision making. At every level of communion from international to regional to local, policy implications can be explored over a large constituency of stakeholders, providing a medium for enhanced engagement with a more vigorous interaction and collective convergence achieving a higher level of veracity of fact and truth. Not only does the digital reality create increasing opportunities, but it also ultimately creates an accelerating demand for connection, participation, and stakeholder engagement. Because of the access and opportunity for interaction, the mechanisms of policy formation can now be more functionally refined as policy makers become more aware of the multifocal streams of interacting forces that inform, discipline, and direct the processes of policy formation. Advocacy for certain approaches and views becomes more transparent as information is more available to all the stakeholders. As data provide increasing clarity around implications and choices, solutions become more emergent and visible across stakeholder groups, creating a greater potential for agreement and ratification. At every level of policy deliberation and formation, the use of the digital infrastructure and digital tools provides a more dependable and sustainable format for establishing principles and more strongly universalizing policy, protocols, and best practices. Whether it is an international conflict over the management of immigration, citizen flow across national boundaries, or a very local decision around a patient care practice, policy can now be more universalized. Then the evidence and rationale for supporting and sustaining it can be more generally promulgated and accepted. Furthermore, when evidence suggests the need for refinement or change in a policy, the digital environment makes it possible to make such adjustments just in time so that they can be immediately reconfigured and applied (Tucker, 2010).

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KEY CONCEPTS 1. Change is an alteration of something, whereas innovation is a type of qualified change that impacts future processes and includes benefits and nuances. 2. Important features to identify in the change process include knowing supporters and obstacles, the extent of the change, time parameters, drivers, levels of change, and its predictability. 3. Types of drivers of change include life cycle change and innovation (e.g., election cycle), teleological change (e.g., advancement of a position), dialectical change (e.g., iterative development), and evolutionary change (e.g., repetition of variation, selection, and retention). 4. Successful team processes in policy formulation include determining the foundational need; setting the table with the right stakeholders; enumerating context, timelines, power, and deliverables; effectively delineating methods and terms of engagement; ensuring a good fit between team tools and dynamics; collectively agreeing on teamwork products; determining when the work is done; and bringing closure to the work. 5. Translating policy into action and impact requires simplicity, clarity, illustration of how the policy impacts individuals, illustration of the policy’s value for individuals, description of exactly what will happen as a result of its implementation, indication that the policy will make things better, and involvement of stakeholders at the outset. 6. Change is facilitated by understanding of the intended change, personal and professional investment, and active involvement. 7. Resistance to change takes many forms, may be difficult to uncover, and may result from competing commitments. 8. There is value in sharing lessons learned from policy implementation at the local, state, and national levels. 9. Policy failures most commonly result from an inadequate application of processes, inappropriate objectives, asymmetrical information, poor communication, poor implementation, or failure to monitor policy effectiveness. 10. The changing digital landscape will impact how policy is formulated and implemented in the future.

SUMMARY Healthcare policy is an essential societal component and requires stakeholders knowledgeable in the basic processes of change and innovation. Nurses are critical stakeholders in facilitating effective team building to ensure that the best interests of all community members are served. To be sure, effective teams are best able to translate policy formulation while understanding the barriers, facilitators, and historical lessons learned from policy processes. As the nation moves to a reformed model of healthcare, the future is filled with opportunities for nurses to create the essential healthcare policies and avoid the creation of non-value-added policies.

LEARNING ACTIVITIES 1. Select an issue of personal importance to you that can be addressed with a change in policy. Describe the intellectual, emotional, and political noise associated with the implementation of a policy change related to this issue.

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2. Describe a potential policy change for the selected issue: (a) the actual change or alteration, (b) human agencies (individual or organizational), (c) time parameters, (d) level of change, (e) predictability, and (f) drivers of change (life cycle, dialectical, teleological, or evolutionary). 3. With the selected issue, identify all the potential stakeholders or stakeholder groups who have an interest in the outcome of such a policy change, describe their position on the issue, and explain the rationale for their position. For each stakeholder, determine whether the issue is a serious one, as well as if the stakeholder is for, against, or neutral regarding the policy change. 4. Debate whether a national licensure model could provide a foundation for global credentialing.

E-RESOURCES • Change Management. Mind Tools https://www.mindtools.com/pages/article/newPPM_87.htm • Helena Temkin-Greener on Teams and Teamwork in Health Care: Using Evidence to Inform Policy. University of California Irvine Open Courseware http://www.youtube.com/watch?v=FhMWh2qU7WY • Managing Change in the NHS: Making Informed Decisions on Change http://www.who.int/management/makinginformeddecisions.pdf • National Council of State Boards of Nursing: Enhanced Nurse Licensure Compact (eNLC) https://www.ncsbn.org/enhanced-nlc-implementation.htm • Team Effectiveness Assessment: How Good Is Your Team? http://www.mindtools.com/pages/article/newTMM_84.htm

REFERENCES Agency for Healthcare Research and Quality. (2013a). About the AHRQ health care innovations exchange. Retrieved from https://innovations.ahrq.gov/about-us Agency for Healthcare Research and Quality. (2013b). AHRQ’s safety program for nursing homes: On-time prevention. Retrieved from http://www.ahrq.gov/professionals/systems/long-term -care/resources/ontime/index.html American Nurses Association. (n.d.). Interstate nurse licensure compact. Retrieved from https:// www.nursingworld.org/practice-policy/advocacy/state/interstate-nurse-compact2 Bae, S., & Fabry, D. (2014). Assessing the relationship between nurse work hours/overtime and nurse and patient outcomes: Systematic literature review. Nursing Outlook, 62(2), 138–156. doi:10.1016/j.outlook.2013.10.009 Bardach, E., & Patashnik, E. M. (2016). A practical guide to policy analysis: The eightfold path to more effective problem-solving (5th ed.). Washington, DC: CQ Press College. Bennett, K. J., Probst, J. C., Vyavaharkar, M., & Glover, S. (2012). Missing the handoff: Posthospitalization follow-up care among rural Medicare beneficiaries with diabetes. Rural and Remote Health, 12, 2097. Retrieved from http://www.rrh.org.au/articles/showarticlenew .asp?ArticleID=2097 Bodenheimer, T., & Gumbach, K. (2016). Understanding health policy (7th ed.). New York, NY: McGraw-Hill. Boradkar, P. (2010). Transdisciplinary design and innovation in the classroom. In T. Porter-O’Grady & K. Malloch (Eds.), Innovation leadership: Creating the landscape of health care (pp. 109–134). Sudbury, MA: Jones & Bartlett. Campaign for Action (n.d.). Our story. Retrieved from https://campaignforaction.org/about/our-story

258   UNIT III  STRATEGIZING AND CREATING CHANGE Change. (2018). Merriam-Webster dictionary. Retrieved from http://www.merriam-webster.com/ dictionary/change Cheung, K. M., Mirzaei, M., & Leeder, S. (2010). Health policy analysis: A tool to evaluate in policy documents the alignment between policy statements and intended outcomes. Australian Health Review, 34(4), 405–413. doi:10.1071/ah09767 Christensen, C. M., Anthony, S. D., & Roth, E. A. (2004). Seeing what’s next: Using the theories of innovation to predict industry change. Boston, MA: Harvard Business School Press. Clarke, D., Werestiuk, K., Schoffner, A., Gerard, J., Swan, K., Jackson, B., & Probizanski, S. (2012). Achieving the “perfect handoff ” in patient transfers: Building teamwork and trust. Journal of Nursing Management, 20(5), 592–598. doi:10.1111/j.1365-2834.2012.01400.x Cooperrider, D. L., Whitney, D. K., & Stavros, J. M. (2008). The appreciative inquiry handbook: For leaders of change (2nd ed.). San Francisco, CA: Barrett-Koehler. Deleuran, P. (Ed.). (2011). Conflict management in the family field and in other close relationships: Mediation as a way forward. Portland, OR: International Specialized Book Services. Department of Veterans Affairs. (2016, December 14). VA grants full practice authority to advanced practice registered nurses [Press release]. Retrieved from https://www.va.gov/opa/pressrel/ pressrelease.cfm?id=2847 Dooley, K. J. (2004). Complexity science models of organizational change and innovation. In M. S. Poole & A. H. Van de Ven (Eds.), Handbook of organizational change and innovation (pp. 354–373). New York, NY: Oxford University Press. Dorsey, C. F., & Schowalter, J. M. (2008). The first 25 years: 1978–2003. Retrieved from https://www .ncsbn.org/25Years_13.pdf Drazin, R., Glynn, M. A., & Kazanjian, R. K. (2004). Dynamics of structural change. In M. S. Poole & A. H. Van de Van (Eds.), Handbook of organizational change and innovation (pp. 161–189). New York, NY: Oxford University Press. Drucker, P. (1985). The discipline of innovation. Harvard Business Review, 63(3), 67–72. Dunin-Keplicz, B., & Verbrugge, R. (2010). Teamwork in multi-agent systems: A formal approach. Hoboken, NJ: John Wiley & Sons. Endsley, S. (2010). Innovation in action: A practical system for results. In T. Porter-O’Grady & K. Malloch (Eds.), Innovation leadership: Creating the landscape of health care (pp. 59–86). Sudbury, MA: Jones & Bartlett. Finkelman, A. W. (2015). Leadership and management for nurses: Core competencies for quality care (3rd ed.). Boston, MA: Pearson. Fitz-enz, J. (2009). The ROI of human capital: Measuring the economic value of employee performance (2nd ed.). New York, NY: AMACOM. Fonseca, J. (2001). Complexity and innovation in organizations. London, UK: Routledge. Geiger-Brown, J., Sagherian, K., Zhu, S., Wieronjey, M. A., Blair, L., Warren, J., … & Szeles, R. (2016). CE: Original research: Napping on the night shift: A two-hospital implementation project. American Journal of Nursing, 116(5), 26–33. doi:10.1097/01.NAJ.0000482953.88608.80 Gratton, L., & Erickson, T. (2007). Eight ways to build collaborative teams. Harvard Business Review, 85(11), 100–111. Retrieved from https://hbr.org/2007/11/eight-ways-to-build-collaborative-teams Hartley, D. (2012). Social policy (2nd ed.). London, UK: Polity Press. Hatch, J. J. (2004). Dynamics in organizational culture. In M. S. Poole & A. H. Van de Van (Eds.), Handbook of organizational change and innovation (pp. 190–211). New York, NY: Oxford University Press. Havelock, R. G. (1973). The change agent’s guide to innovation in education. Englewood Cliffs, NJ: Educational Technology Publications. Hayes, M. T. (2006). Incrementalism and public policy. Lanham, MD: University Press of America. Kagan, R., & Lahey, L. L. (2001). The real reason people won’t change. Harvard Business Review, 78(10), 85–92. Retrieved from https://hbr.org/2001/11/the-real-reason-people-wont-change

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Kelley, T. (2005). The ten faces of innovation. New York, NY: Doubleday. Latin, H. (2012). Climate change policy failures: Why conventional mitigation approaches cannot succeed. Hackensack, NJ: World Scientific. Lencioni, P. (2012). The advantage: Why organizational health trumps everything else in business. San Francisco, CA: John Wiley and Sons. Lewin, K. (1947). Frontiers in group dynamics: Concept, method, and reality in social science, social equilibria and social change. Human Relations, 1(1), 5–41. doi:10.1177/001872674700100103 Lippitt, R., Watson, J., & Westley, B. (1958). The dynamics of planned change. New York, NY: Harcourt Brace. Matheson, C. (2009). Understanding the policy process: The work of Henry Mintzberg. Public Administration Review, 69(6), 1148–1161. doi:10.1111/j.1540-6210.2009.02072.x Maxson, P. M., Derby, K. M., Wrobleski, D. M., & Foss, D. M. (2012). Bedside nurse-to-nurse handoff promotes patient safety. Medsurg Nursing, 21(3), 140–144, quiz 145. Retrieved from http://www .medsurgnursing.net Monroe, T., & Kenaga, H. (2011). Don’t ask don’t tell: Substance abuse and addition among nurses. Journal of Clinical Nursing, 20(3–4), 504–509. doi:10.1111/j.1365-2702.2010.03518.x National Council of State Boards of Nursing. (n.d.-a). Enhanced Nurse Licensure Compact (eNLC) implementation. Retrieved from https://www.ncsbn.org/enhanced-nlc-implementation.htm National Council of State Boards of Nursing. (n.d.-b). Original nurse licensure compact. Retrieved from https://www.ncsbn.org/nlc.htm Nickerson, J. A. (2013). Leading change in a Web 2.1 world: How ChangeCasting builds trust, creates understanding, and accelerates organizational change. Washington, DC: Brookings Institution Press. Nohria, N., & Khurana, R. (Eds.). (2010). Handbook of leadership theory and practice: An HBS centennial colloquium on advancing leadership. Boston, MA: Harvard Business Press. Patient-Centered Outcomes Research Institute. (2014). National priorities and research agenda. Retrieved from http://www.pcori.org/research-we-support/priorities-agenda Patient Protection and Affordable Care Act of 2010. Pub. L. 111–148, 124 §§ 119–124. Plsek, P. E. (1997). Creativity, innovation and quality. Milwaukee, WI: ASQC Quality Press. Poole, M. S., & Van de Ven, A. H. (Eds.). (2004). Handbook of organizational change and innovation. New York, NY: Oxford University Press. Porter-O’Grady, T., & Malloch, K. (2015). Leadership in nursing practice: Changing the landscape of healthcare (2nd ed.). Sudbury, MA: Jones & Bartlett. Reddin, W. J. (1970). Managerial effectiveness. New York, NY: McGraw-Hill. Richtermeyer, S. B. (2010, February 8). Top 5 reasons why strategic initiatives fail. Industry Week, 1, 1. Retrieved from http://www.industryweek.com/change-management/top-five-reasons-why -strategic-initiatives-fail Rogers, E. M. (2003). Diffusion of innovation (5th ed.). New York, NY: Free Press. Schein, E. (2016). Organizational culture and leadership (5th ed.). San Francisco, CA: Jossey-Bass. Schoemaker, P. J. H. (1995). Scenario planning: A tool for strategic thinking. Sloan Management Review, 36(2), 25–40. doi:10.1016/0024-6301(95)91604-0 Schuman, S. (2006). Creating a culture of collaboration: The International Association of Facilitators handbook. San Francisco, CA: Jossey-Bass. Schumpeter, J. A. (1943). Capitalism, socialism, and democracy (6th ed.). London, UK: Routledge. Scott, G. (2004). Public policy failure in health care. Journal of the American Academy of Business, 5(1/2), 88–94. Retrieved from http://www.jaabc.com/jaabcv5n2preview.html Sinek, S. (2014). Leaders eat last: Why some teams pull together and others don’t. New York, NY: Penguin Group. Spradley, J. P. (1979). Spradley’s theory of change. In L. A. Roussel & R. C. Swansburg (Eds.), Management and leadership for nursing administrators (7th ed.). Sudbury, MA: Jones & Bartlett. Stacey, R., & Griffin, D. (Eds.). (2008). Complexity and the experience of values, conflict and compromise in organizations. New York, NY: Routledge.

260   UNIT III  STRATEGIZING AND CREATING CHANGE Staggers, N., & Blaz, J. W. (2012). Research on nursing handoffs for medical and surgical settings: An ­integrative review. Journal of Advanced Nursing, 69(2), 246–262. doi:10.1111/j.1365-2648.2012.06087.x Stone, D. (2011). Policy paradox: The art of political decision-making. New York, NY: W. W. Norton & Company. Taylor, J. (2011). Decision management systems. Philadelphia, PA: IBM Press. Trinkoff, A. M., Johantgen, M., Storr, C. L., Gurses, A. P., Liang, Y., & Han, K. (2011). Nurses’ work schedule characteristics, nurse staffing, and patient mortality. Nursing Research 60(1), 1–8. doi:10.1097/NNR.0b013e3181fff15d Tucker, P. (2010). Remaking education for a new century. The Futurist, 44(1), 22–25. Retrieved from https://www.questia.com/magazine/1G1-214547851/remaking-education-for-a-new-century -communications Tunis, S. (2007). Reflections on science, judgment, and value in evidence-based decision making: A conversation with David Eddy. Health Affairs, 26(4), 500–515. doi:10.1377/hlthaff.26.4.w500 Tushman, M. L., & Romanelli, E. (1985). Organizational evolution: A metamorphosis model of convergence and reorientation. In L. L. Cummings & B. M. Staw (Eds.), Research in organizational behavior (Vol. 7, pp. 171–222). Greenwich, CT: JAI Press. U.S. Social Security Administration. (2012). The history of Medicare. Retrieved from http://www.ssa .gov/history/corning.html Vaitheeswaran, V. (2007). An interview with Vijay Vaitheeswaran. The Economist. Retrieved from http://www.economist.com/node/9934754 Vogelsmeier, A., Scott-Cawiezell, J., Miller, B., & Griffith, S. (2010). Influencing leadership perceptions of patient safety through just culture training. Journal of Nursing Care Quality, 25(4), 288–294. doi:10.1097/ncq.0b013e3181d8e0f2 Weberg, D. (2009). Innovation in healthcare: A concept analysis. Nursing Administration Quarterly, 33(3), 227–237. doi:10.1097/naq.0b013e3181accaf5 Winowiecki, L., Smulder, S., Shirley, K., & Remans, R. (2011). Tools for enhancing interdisciplinary communication. Sustainability: Science, Practice & Policy, 7(1), 74–83. doi:10.1080/15487733 .2011.11908067

NINE

Implementing the Plan Rebecca M. Patton Margarete L. Zalon Ruth Ludwick There are those who look at things the way they are, and ask why.…I dream of things that never were, and ask why not?—Robert Kennedy

OBJECTIVES 1. Assess the leadership necessary for implementing the plan. 2. Appraise the resources needed in implementing the plan. 3. Review and refine the strategies for carrying the plan forward. 4. Analyze collaborative strategies for the plan. 5. Carry out steps of an action plan that will impact policy processes and outcomes. 6. Recognize the ebb and flow of implementing any plan.

Implementing a plan is a pivotal step in the policy process. Having a plan and giving careful thought to the phases of the plan, as well as to who the key s­ takeholders will be at each phase, are integral to the success of the plan. The plan and the details depend on the particular policy issue and the environment for bringing that policy issue forward in either the big “P” or the little “p” arena. This chapter is designed to help you develop the knowledge and competencies necessary to successfully activate an advocacy plan. This chapter particularly builds on the lessons learned when setting the agenda (see Chapter 6) and then implementing the change process (see Chapter 8). Implementing a plan is an iterative process that often requires continuous monitoring, shifting, and balancing to be responsive to changes that can derail or stall the plan. Involving others along the policy journey and implementing detailed preparation are essential to maximizing success. The phases of implementing the advocacy plan both at the big “P” and the little “p” levels are natural extensions of nursing knowledge and skills. Firsthand knowledge acquired from day-to-day practice, such as developing new models of care delivery, obtaining resources within an organization, speaking to the public, and negotiating and conflict 261

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resolution, help position nurses effectively to carry out advocacy plans. In this chapter’s Policy Challenge, the firsthand experiences of emergency nurses involved a mass shooting led to implementation of a plan to enhance emergency nurses’ disaster preparedness. The dramatic events related to violence show how nursing know-how is necessary for effective advocacy and policy implementation. This chapter describes a practical approach for implementing an advocacy plan. implementing the plan involves many substeps and often re-examining previous steps, such as clarifying the problem or examining the adequacy and currency of existing policy and evidence. The stakeholder and group work discussed in previous chapters help identify the policy alternatives to be consider and to verify the level of policy work (i.e., little “p” or big “P”) needed. Will the

POLICY CHALLENGE: Casualty Nursing in the Emergency Department Nancy Bonalumi, DNP, RN, CEN, FAEN President, NMB Global Leadership, LLC, Lancaster, Pennsylvania; Past President, Emergency Nurses Association October 1, 2017, one of the worst mass shootings in the United States, ended, with 58 dead and more than 500 wounded at a Las Vegas music concert. Local emergency departments (EDs) were once again on the frontline of saving lives and worked tirelessly through the night doing what they know best, triaging and treating the wounded. Unfortunately, mass casualty events are happening with increasing frequency in the United States and around the world. Violent attacks by individuals, civil unrest, terrorist acts, natural disasters, and weather extremes are taxing EDs and challenging the staff that work under these conditions. As the largest component of the healthcare workforce, nurses represent the citizens of their communities and advocate for them as patients. Disaster management policies and programs from the federal to the community level need the input of emergency nurses at the planning level. They possess a unique understanding of both hospital operations and the communities where they function; therefore, they should be involved at the outset, not only when the plan needs implementation. In an advocacy role, emergency nurses can build links among stakeholder entities when planning for disaster policy and management, ensuring that high-quality, evidence-based practice guides decisions and protocols. To ensure that nurses are prepared for the unimaginable, the Emergency Nurses Association (ENA) and its Emergency Management and Preparedness Committee began holding a mass casualty drill at its annual education and networking conference. In 2017, the drill was live-streamed to an audience of 2,500 attendees. The drill leaders created a realistic environment and narrated the efforts of the incident commander taking control of the scene and rescuers implementing disaster protocols while treating the victims in moulage. Adding to this realism, a frustrated family member looking for a loved one became agitated and fired a gun, providing a vital lesson that amid the unexpected, more chaos can erupt. Preparedness is crucial, and every emergency nurse should be able to function in such an event. See Option for Policy Challenge.

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work involve writing a new policy or altering or finessing new p ­ olicies? Are you faced with implementing a policy that you have little say in d ­ eveloping? We discuss leadership and empowerment, resource assessment, activation strategies, presentation of the plan, unexpected events, and maintenance of the plan.

LEADERSHIP FOR IMPLEMENTING THE PLAN Leadership and empowerment are important factors in the success of an advocacy plan. Regardless of the setting, leadership is a critical driver for tailoring the plan, which capitalizes on the strengths of the setting and influences a particular course of action. Each setting has unique considerations that can be harnessed in the implementation of the advocacy plan. In some settings, you may have access to leaders with a wide variety of expertise, whereas in other settings, access may be limited. In some settings, team leadership (discussed in Chapter 8) is strong and cohesive, but it may be less so in other settings. No matter the setting, leadership is vital to change, and it is not solely the job of those who hold titles, such as “president” or “unit manager.” Leadership belongs to us all. All of us at times demonstrate leadership that influences and empowers o ­ thers. Leadership is a key facilitator of the advocacy process (Richardson & Storr, 2010). Empowerment is an interpersonal process in which adequate information, support, resources, and environment exist, enabling the formulation of increased personal ability and effectiveness to set and achieve organizational goals (Hawks, 1992). In the context of patient care, this is translated as the extent to which nurses possess the power to influence those around them to deliver safe, effective care. This empowerment should be the standard and not a luxury (Linnen & Rowley, 2014). A collaborative governance structure is the umbrella for the decision-making process. The structure makes clinicians central to patient care and to cross-disciplinary decisions and can thus result in significantly higher empowerment and can foster self-growth and organizational development (Ives Erickson, Hamilton, Jones, & Ditomassi, 2003). Research examining Magnet® hospital outcomes has demonstrated the value of creating empowering social structures that enhance nurses’ abilities to take ownership and leadership for enhanced practice. Nurses empowered in this manner feel free to question policy, investigate problems, offer solutions, participate in decisions, and enable others to do the same. By engaging other nurses in the work of an organization, nurses can further hone their problem-solving skills to address and implement important unit and organizational policy changes related to patient care and nurses’ work. Nurses, empowered in organizations, use research to close the gap between evidence and practice by raising awareness of the importance of problems (e.g., sleep and rest, falls, nurse fatigue) and then finding solutions to change unit (hospital) policies and practices. The success of a little “p” initiatives then feeds the cycle of leadership, empowerment, and policy change. In Chapter 5, in the Policy Challenge and subsequent Option for Policy Challenge, one can see how success at the little “p” level led to a state law that required mandatory education for the diagnosis of pediatric head trauma due to abuse. Most important, the state saw fewer deaths of children from nonaccidental trauma.

Professional Associations Provide Leadership Professional and specialty associations can provide indispensable leadership when advocating issues, especially when it comes to implementing the plan. They may, for example, be a source for (a) practice guidelines or (b) support and staff assistance for

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pursuing a policy issue. Professional associations enable nurses to articulate values, integrity, practice recommendations and standards, and social policy and to demonstrate advocacy and self-regulation (Matthews, 2012). Since its beginning, the American Nurses Association (ANA) has led and coordinated the development of position statements and the documents that express those ideas and beliefs, facilitate stakeholder meetings, analyze issues, and develop potential solutions to help with advocacy. It is just as important to understand that the ANA uses a deliberative and democratic process to develop the documents advocating its positions. This democratic process allows nurses a voice in the development of guiding the policy documents so vital to advocacy. Publications such as the Code of Ethics for Nurses (ANA, 2015a), Nursing’s Social Policy Statement (ANA, 2010), and Nursing: Scope and Standards of Practice (ANA, 2015b), as discussed in Chapter 2, not only provide a wealth of information to its members, the nursing community, and the public, but also can provide direction when implementing a plan and can help validate why a policy is needed. Reflecting on this commitment, the ANA designated 2018 as the Year of Advocacy. The education and publications that they offered throughout 2018 focused on differing aspects of nurse advocacy, such as advocating locally, influencing officials, getting out the vote, and impacting globally. Using the link, www.RNAction.org, nurses can stay informed to get engaged and to get political updates from the ANA. The ANA is unique as a nurses association because it has an affiliate partnership in every state. Each partnership aligns with ANA to carry out legislative advocacy efforts. The ANA focuses on national issues, whereas the constituent (e.g., Virgin Islands) and state nurses associations and their respective districts provide leadership for nurses working on projects at the state or community level. The state nurses associations often work to change state laws and local issues specific to their members. The majority of these constituents or partnerships have websites, linked from the ANA (https://www.nursingworld .org/membership/find-my-state), where current advocacy of a group can be found. Nurses’ policy engagement can be enhanced with education supported by partnerships among leaders of nurses’ organizations, academia, and practice settings (Perry & Emory, 2017). Some nurses’ organizations also provide leadership opportunities and member services, such as specialty-specific standards, education and/or annual conferences, and membership meetings, that can help determine policy. Some dedicate resources to formulate position statements, develop formal policy agendas, engage their members in advocacy, and provide specific resources to enable members to take action on specific issues. Larger organizations may have staff members in various roles related to lobbying or government relations. Increasingly, many provide members with toolkits with actionable items that enable members to easily participate in the implementation of an advocacy plan. Four such examples are found in Exhibit 9.1. These toolkits show a small but diverse sampling of the available resources. These toolkits demonstrate just some of work done by nurses associations. The American Association of Nurse Anesthetists (AANA) has a sustained position of advocacy for nurses related to substance abuse. Policy on the Scene 9.1 shows the evolution of the unrelenting work of this organization on a major nursing problem. Beyond advocacy support and help to individuals or groups, active involvement in an association or a professional organization can help empower nurses and the organizations that employ them. Healthcare organizations benefit from supporting nurse manager and staff nurse involvement in professional organizations. Nurses can develop leadership competencies, which in turn can be very productive for the organization. Involvement in organizations, boards, and committees is a strategy for i­ nfluencing their direction and implementing plans to address issues pertinent to the mission of the group.

Chapter Nine  IMPLEMENTING THE PLAN  265

EXHIBIT 9.1   SPECIFIC ISSUE ADVOCACY TOOLKITS ORGANIZATION

NAME OF KIT

LINK

American Association of Critical-Care Nurses

Alarm Fatigue

www.aacn.org/clinical-resources/ clinical-toolkits/strategies-for -managing-alarm-fatigue

National League for Nursing

Public Policy Advocacy Toolkit

www.nln.org/professional -development-programs/ teaching-resources/toolkits/ advocacy-teaching/toolkit-home

National Association of School Nurses

Naloxone in Schools Toolkit

www.pathlms.com/nasn/ courses/3353

National Association of Clinical Nurse Specialists

Cost Analysis Toolkit Alarm fatigue Toolkit

www.nacns.org/professional -resources/toolkits-and-reports/ cost-analysis-toolkit www.nacns.org/professional -resources/toolkits-and-reports/ alarm-fatigue-toolkit

Empowerment Through Coalition and Alliances Professional associations also can help unite individuals to create power and influence in the political arena. Coalitions and alliances may be created for an advocacy plan when there is a specialized need to bring together representatives from diverse constituencies. One example can be found in helping the over 43 million family caregivers, who provide daily unpaid help to adults and children; the majority of that help is given to adults older than age 50 (National Alliance of Caregiving [NAC] & AARP Public Policy Institute, 2015). The Caregiver Advise, Record, Enable (CARE) Act has been passed in most states and requires hospitals to help with care transition from hospital to home, with an emphasis on medical caregiver tasks such as medication administration. As often happens, legislation and regulation alone are not enough for a successful policy. Often, additional support is necessary for effective implantation of a policy and, to that end, a new organization, The Home Alone AllianceSM was created (Reinhard & Young, 2017). This private–public and not-for-profit organization is working to increase the education of nurses, who often are responsible for teaching caregivers and may be unpaid caregivers themselves. Thus, late in 2017, the Home Alone Alliance worked to partner with the American Journal of Nursing to launch videos and articles to educate nurses about common caregiver questions. As you read and hear more about caregiving, remember that as a nurse you can contribute to the work of this coalition. See Exhibit 9.2 for some action strategies for involvement in this legislation. Large-scale coalitions, can cross state lines, as exemplified by the Center to Champion Nursing in America (CCNA), an initiative supported by AARP, the AARP Foundation, and the Robert Wood Johnson Foundation (RWJF). The goal is to ensure that all Americans have access to high-quality care, with nurses contributing to the full extent of their capabilities. The coalition structure is set so that each state and Washington, DC, has an action coalition that can strategically work with policy representatives, the

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POLICY ON THE SCENE 9.1: The Long View of Implementing a Policy Plan for Substance Use Disorder Linda Stone, DNP, CRNA, Assistant Program Director, Raleigh School of Nurse Anesthesia/UNCG, Raleigh, North Carolina Julie Rice, BA, Manager, AANA Health & Wellness and Peer Assistance Programs, Chicago, Illinois Substance use disorder (SUD), a chronic brain disease characterized by relapsing use of alcohol and/or drugs leading to clinically significant impairment, is a major public health challenge in the United States (Office of the Surgeon General, 2016). Anesthesia professionals are at greater risk for SUD than other healthcare specialists (Bozimowski, Groh, Rouen, & Dosch, 2014; Stone, Quinlan, Rice, & Wright, 2016). Recognizing this risk, the American Association of Nurse Anesthetists (AANA) was one of the early leaders in developing a peer support network for certified registered nurse anesthetists (CRNAs) and student registered nurse anesthetists (SRNAs) with SUD. In 1983, the Peer Assistance Advisors Committee (PAAC) was established with two members; within the next decade, the committee grew and a national helpline and a support network of state peer advisors (SPAs) were added. The committee faced challenges related to the variety of disciplinary SUD license actions by state boards of nursing (BONs) and a general lack of recognition of the special occupational risks for CRNAs (due to exposure and access to drugs of abuse). To address these, in the late 1990s, PAAC organized a seminar with key nursing groups such as the American Nurses Association (ANA), the International Nurses Society on Addiction (IntNSA), and the National Council of State Boards of Nursing (NCSBN) to discuss the lack of nonpublic disciplinary alternative for licensees. From that effort came the 2002 ANA resolution for affording nurses nonpunitive options for early recognition and treatment without loss of career, as well as the eventual development of the National Organization of Alternative Programs (Quinlan, 2009). This collaboration is also seen in the recent AANA and ANA endorsement of the Emergency Nurses Association (ENA) and IntNSA position statement, Substance Use Among Nurses and Nursing Students, calling for an alternative to disciplinary approaches (Strobbe & Crowley, 2016). To promote overall well-being, in 2004 SUD efforts were broadened with the addition of the AANA wellness initiative facilitated by the Health & Wellness committee to provide proactive education and supportive resources focused on ways to stay healthy, addressing personal and professional wellness (www .aanawellness.com). The PAAC has grown to six volunteer CRNAs and one advanced practice nursing professional, who advocate, inform, promote, and provide peer support to CRNAS and SRNAs with this disease. Committee members answer helpline calls and lead the SPAs, providing confidential assistance and sharing AANA resources and recommendations for intervention, treatment, long-term recovery, and appropriate re-entry (www.AANAPeerAssistance.com). PAAC’s work is committed to educational endeavors, aggressive promotion of (continued )

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awareness and prevention modalities, and development of facility SUD policy resources to include education for awareness, random drug testing, drug diversion prevention, processes for reporting and managing impairment with a safe intervention, and transition to evaluation for treatment (www.aana.com/ addressingSUD). AANA online content includes a wealth of resources for the journey that goes beyond preventing and treating SUD, such as the toolkits Workplace Resources for Substance Use Disorder, Wellness and Substance Use Disorder Education and Research, Resources to Build a Healthy Work Environment, and State Health and Wellness Ideas for State Association (see section E-Resources).

business community, and educators to ensure the goal. Each group has a different internal structure and operating principles and thus is at different levels of progress. The Nebraska State Coalition has made significant progress publishing guidance on the use of models to oversee the development of partnerships and coalition building, as well as a framework for data collection and analysis to identify challenges and opportunities (Cramer, Lazure, Morris, Valerio, & Morris, 2013). Nurses, other healthcare professionals, and consumer groups may form temporary or informal coalitions or groups to advance an issue. A council or ad hoc task force might band together to address a specialized issue. An example might be a parent– teacher–nurse group to support healthy food choices in a school cafeteria. Other specific nursing coalitions relate to advocacy for the environment. Examples include the Environmental Health Committee of the Pennsylvania State Nurses Association and the Nurses Environmental Advocacy Team for Ohio (NEATO).

STRATEGIES FOR IMPLEMENTING THE PLAN An advocacy plan can take many forms, depending on the desired goals, whether it is a public policy or a policy change within an organization. Universal to all plans are goal refinement, application of influence, strategic issue framing, and targeting of the EXHIBIT 9.2   ADOPTION AND IMPLEMENTATION STRATEGIES FOR THE CARE ACT • Stay up to date about legislation in your state on the CARE Act. • Establish an awareness event in local or statewide healthcare settings to highlight the work of caregivers and the status of the CARE Act This open day could be part of a massive statewide public education campaign. • Use social media applications (e.g., Facebook, Twitter, Instagram) to increase community awareness. • Work with legislators to visit caregivers in their homes to see issues of caregiving firsthand. • Become active in organizations supporting caregiver advocacy (e.g., AARP, National Alliance for Caregiving) to learn ways that you can volunteer on initiatives. CARE, Caregiver Advise, Record, Enable. Source: Adapted from Glazer, G., & Ali, A. A. (2017). Legislative: Family Caregiving Act: Healthcare impact and nurses’ role. Online Journal of Issues in Nursing, 23(1). doi:10.3912/ OJIN.Vol23No01LegCol01

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message to an audience. In each of these endeavors, nurses are strategic in ­implementing the plan. Nurses advocating for a policy are going to need to make who, what, when, and where decisions to make the best use of strategy to move an issue forward. Exhibit 9.3 compares strategic and nonstrategic methods of advancing an issue.

Goal Refinement As an ongoing process, goal refinement involves specifying the “what” as illustrated in Exhibit 9.3. Although initial problem identification and agenda setting might be more laborious and intense, it is essential to continue to modify and refine advocacy goals. You need to determine what and to what extent you want to change a particular policy goal while considering the context of the environment. For example, during 2009 White House discussions on healthcare reform, it was apparent to Rebecca M. Patton, ANA president at the time, that both the expansion opportunities for advanced practice registered nurses (APRNs; e.g., demonstration projects with the nurse-managed health centers and school-based health centers) and inequities in reimbursement for nurse practitioners could not be accomplished in a single piece of legislation. Hence, efforts focused on expanding opportunities for advance practice nurses’ recognition and role in a reformed healthcare delivery system. There is always uncertainty with policy, but at some point, you need to make the decision to move forward or wait strategically for another time. There is no perfect time, even when a window of opportunity exists. As new information becomes available or as the circumstances change, the plan may need refinement. Implementing the plan should be based on the best available evidence, and consideration needs to be given to the fact that you may need to change course and revise strategies

EXHIBIT 9.3   COMPARISON OF APPROACHES FOR ADVANCING AN ISSUE STRATEGIC

NONSTRATEGIC

Who

Shared governance nursing council or nurse manager

Complaints to the chief surgeon or chief of medicine

What

Targeted issue focused on a doable solution or discrete problem

Huge laundry list of all the ills associated with the problem

When

A time when related reports indicate the issue is a problem that, when solved, could improve outcomes or when a precipitating event occurs

Same time as when a major change initiative, such as an electronic medical record is introduced, or 3 months after national publicity on a topic

Where

Privately, or in a small group

In front of other staff members or the person’s supervisor

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and/or goals. Barkhorn, Huttner, and Blau (2013) developed a framework for assessing an advocacy plan that includes conditions for a successful policy campaign. These framework conditions include considering (a) what route your ­advocacy plan will take (e.g., legal, legislation), (b) whether there is a window of opportunity, (c) what solutions and benefits are possible, (d) if you have a flexible master plan that is readily communicated, (e) if advocates can deliver on the resources needed, (f) if and when allies can help win over policy makers, (g) whether the relevant community will support the policy, (h) how you can employ champions to overcome any opposition, and (i) if the way is clear from the organization behind you to implement the solution.

Strategic Framing of an Issue Success in implementing health policy is contingent on the development and activation of a plan that is specifically targeted using proven strategies. Some of these strategies may be the culmination of years of efforts to achieve the desired change. For example, efforts to reduce tobacco use include (a) policies and funds to promote education about the hazards of smoking in schools, (b) workplace smoking-cessation programs, and (c) smoke-free environments. Each of these requires the support of different constituencies and strategies tailored to achieve the policy action. Framing the issue is an important step in considering the needs and desires of stakeholders and/or constituencies impacted. Once you have identified goals, the ideal path to solutions, and the potential opposition, it is time to frame your issue in a way that provides the greatest likelihood of advancing your targeted agenda and attaining your goals. The policy issue should be framed within the context of existing policy agendas when possible. Framing the issue is not just for legislative audiences. Regulators, executive agency staff, judges, potential jurors, executives, and the public are not listening only to the problems and solutions on policy makers’ agendas; many may have their own policy agendas, or they might be more receptive to the agendas of others, depending on how they understand the problems as described. How we construe the problem is “linked to the existing social, political and ideological structures at the time” (Birkland, 2011, p. 71). Not only must advocates remain mindful of the prominent and broader issues already on the “agenda,” such as the White House’s attention in 2017 to reduce governmental regulations to positively impact the economy and bring jobs back to the United States. Advocates must frame their issue to maximize the likelihood that it will be important to stakeholders and within the context of their values to motivate people to action. For example, Americans have generally and historically valued individualism, freedom, and free enterprise over socialism and, some would say, community. Nurses seeking to define an issue that requires public attention should not only highlight how their solution advances patient safety, improves access to care, and/ or achieves cost efficiencies in delivering healthcare, but might also take heed of how the traditional American values may or may not be consistent with your group’s proposed solution. For example, given political changes in traditionally strong labor states, such as Wisconsin, Michigan, and Ohio, a proposal for staffing legislation might resonate with legislators and the public if it is framed from a patient safety perspective rather than as a labor issue. Influencing which committee receives a bill or a policy proposal might be important in determining whether it ever gets out of committee or sees a vote.

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Framing an issue is an ongoing process. Although consistency in messaging is needed, one needs to be mindful of the changing context for an issue. Framing an issue involves focusing on a specific aspect of it to highlight a particular feature. Framing within an existing issue strengthens the priority for it within a given political context. This was witnessed during the drafting and implementation of the provisions of the Affordable Care Act (ACA). Policy solutions designed to improve patient safety, access to care, and cost-effectiveness are received more positively than initiatives that do not address any of these goals. See Exhibit 9.4 for examples of how an issue can be framed. Although framing is designed to have issues resonate with key policy makers, it is necessary to ensure that members of the team advancing a policy agenda are prepared with key facts. This important strategy is accomplished with the creation of talking points to provide easily remembered and succinct information about the proposed policy change. Talking points may be made on an informal basis when preparing for a meeting, or they may be more formal, such as when preparing nurses to visit legislators. Organizations and associations may prepare talking points for general distribution to the public and legislators, with more detailed backgrounders so that individual nurses can quickly learn the salient facts and answer potential questions (see Chapter 10). EXHIBIT 9.4   FRAMING AN ISSUE BROAD TOPIC

IMPACT ON HEALTH

STRATEGIC FRAMING

Climate change

Health consequences of global warming

Weather-related disasters, emerging infectious diseases

APRN scope of practice and full practice authority

Access to care

Uninsured in a local community, antitrust issues impacting APRNs; removal of collaborative agreements and provider neutral language

Nurse shortage

Reduced musculoskeletal injuries

Cost of worker’s compensation

School nurse– pupil ratios

Healthy children, reduced number of teen pregnancies

Higher educational attainment of school children

“Nurse” title protection

Prevention of public confusion about the qualifications of nurses

Protecting the public from unsafe practitioners

CRNAs as sole providers

Access to obstetrical, surgical, interventional diagnostic, trauma stabilization, and pain services

Closure of rural hospitals

APRN, advanced practice registered nurse; CRNAs, certified registered nurse anesthetists.

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Targeting an Audience Identifying the best audience for a policy issue goes hand in hand with framing an issue and is the “who” of being strategic. Although framing an issue is designed to make the policy goal resonate with the audience, targeting the audience is a careful and strategic analysis of the key decision makers and those in a position to influence the key decision makers. Thus, targeting the audience involves strategizing to highlight an issue for a particular constituency in a way that motivates decision makers to take action. In a hospital setting, it might be a chairperson of a committee, a department head, or a board member. In the regulatory arena, it might be an administrator of an agency. In Congress, a state legislature, or a city council, it might be the chairperson of a committee for a bill. In the community, the target audience might be members of key agencies or community boards. Framing an issue for a group means individualizing approaches, just as one shoe does not fit everyone. Federal legislators may be different from state. Legislators collectively may have different demographic characteristics than their constituents. In a study of state legislators’ priorities, the top-rated factor in determining health issues of importance was constituents’ needs, followed by evidence of scientific effectiveness (Dodson et al., 2013). In this particular sample, 63% of state legislators were aged 55 years and older, and 76% were male. Thus, implementing a policy plan should include considerations for targeting decision makers, the nurse community, and the general public for support for the desired policy. Nurses seeking policy changes locally or within their healthcare organizations also need to be mindful of the ideologies and biases of the decision makers. Kingdon (2011) indicates that policy solutions must be “acceptable in the light of the values held by members of the policy community” (p. 143). Acknowledging the impact on patient quality and safety helps advance strategies. When seeking adoption by staff, nurse leaders need to frame the policy as advantageous to them and patients. For example, a new handwashing policy needs to include support from leadership, a facility-wide campaign, knowledge of staff traffic patterns, availability of sinks, and education for multidisciplinary teams and patients so that it will more likely be implemented by members of the team. The Policy on the Scene 9.2 shows how strategies for implementing a plan can come together quickly when there is a concerted effort among decision makers and the policy community, in this case a hospital. When selling the need for a new policy designed to improve patient safety to the chief financial officer of a healthcare facility, nurse leaders need to speak to the financial impact, including the bottom line that can be realized from the new policy (e.g., reduced readmissions, which are not paid for by Medicare; fewer costly medication errors). Targeting an audience involves learning about its characteristics and being strategic about the location and timing for a presentation. This information can be obtained through direct interaction, such as when making visits to a legislator’s office, and consultation with colleagues and policy makers. Examination of websites and other publicly available information about the decision maker provides information about positions and values. For example, a legislator’s website can provide information about legislative committee memberships and expertise. Other sites can provide information on specific votes cast for certain bills. Very often, legislators have had contact with health professionals and nurses through their own illnesses or experiences with family members. This information can be used to develop messages that take advantage of these important details. The when and where of targeting an audience depends on the current milieu for the issue and other issues on policy makers’ agendas. For example,

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POLICY ON THE SCENE 9.2: An Advocacy Journey Aniko Kukla, DNP, CPNP, Quality Manager, and Lea Woodrow MSN, RN, CPHQ, CPSO, CPSP, Senior Director, Quality Management Services, Salinas Valley Memorial Hospital, Salinas, California In the spring of 2016, the newly appointed senior director of quality ­management set a goal of updating the clinical care polices with evidence-based practice guidelines. In addition, bedside nurses were advocating for patient safety in sedation and were tracking their near misses for quality purposes. The sedation policy was due for review, and it did not reflect the current recommendations from the American Society of Anesthesiologists Sedation and the Association of ­periOperative Registered Nurses. An interprofessional team was formed with wide range of ­stakeholders including, but not limited to, representatives from the emergency department (ED), Surgical Services, Pharmacy, and Clinical Informatics. The subsequent diverse team reviewed the sedation procedures, roles, competencies needed, documentation practices, and data on patient outcomes. This initial phase led to the determination that a change was needed in how sedation data were collected, entered, and analyzed, beginning with data-entry method because documentation was done on paper in some departments and in the electronic medical record in others. The initial goal of updating the policy with current literature was refined, and like many times with policy, we found that we also needed to assess the knowledge and competencies of the staff, as well as data-collection goals and their measures. The entire team met on three more occasions before the work was parsed out to team leaders and work groups who met, in some cases, initially on a daily basis. We advocated for a faster approval of policy updates, which often took up to 6 months, and were able to get the approval in 2 months. All did their share. Anesthesia and nursing staff reviewed the policy and made suggestions for updates. The quality department defined the data elements with the help of bedside staff and managers and refined the collection tools and data-entry dashboards. Pharmacy, with the help of the clinical informatics team, created reports to capture the number and name of reversal agents used. When roadblocks appeared in proposed process changes, the team leader (senior director of ­quality) used her influence and bargained with departments to make sure that their needs were met and that the proposed processes would be accepted. The team created an education and roll-out plan (an online module, newsletter, in-services) for staff involved in providing sedation. Regular reports were provided to the hospital leadership teams in quality meetings, and the results were disseminated to the frontline staff. something seemingly simple might be the placement of an issue on an agenda for a meeting, whether it is part of another agenda item or whether it stands alone. Location ­factors might include whether members of an audience are on their home turf or whether a meeting is public or private.

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Applying Influence Nurses who have become active policy advocates and who have significant ­accomplishments have learned to recognize that they can effectively influence policy development and implementation. We have discussed how a number of steps (Chapter 5) and substeps (Framing an Issue, as previously discussed) can influence policy. A myriad of factors impact policy. To make sense of the complexity of influence that pervades the policy process, one can look at how the development of advocacy skills can be enhanced with the development of leadership and an understanding of the process of influence. Influence is the ability of an individual to sway or affect another person or group (Adams & Ives Erickson, 2011). The Adams Influence Model (AIM) provides a framework for understanding how various factors, attributes, and processes support nurses to influence and impact individuals and/or groups (Adams, 2009) and thus can be used to inform implementing policy (Adams & Natarajan, 2016). The AIM highlights the relationship between two parties. The first party is the influence agent (e.g., the nurse with knowledge and skill of healthcare) who seeks to influence a decision. The second party is the influence target, likely the policy maker (including legislators, staff, or other political leaders or groups), who is the focus of the effort and has a role in setting the ultimate policy. Both the agent and the target possess the same influence factors and attributes, although these may be titrated in different amounts for the agent and target depending on the issue. As Exhibit 9.5 illustrates, five factors are in play in any effort to influence policy: (a) authority, (b) communication traits, (c) knowledge-based competence, (d) status, and (e) use of time and timing. By considering these elements, nurses can develop a well-organized plan for working on and implementing a plan to form a policy. It amounts to finding the right spokesperson with the appropriate knowledge and authority, who communicates clearly, consistently, and effectively at the right moment(s) in time. Very often, nurses do not believe that they have the power to use influence, but as shown in Exhibit 9.5, nurses’ attributes do align to influence policy. As a result of this alignment, nurses are in an ideal position to use influence in policy development and to be successful at it. Ultimately, it is the entire social system and the organizational culture that need to be considered in developing strategies to influence policy direction. If you reflect on your day, both personally and professionally, you can think of many times when you were both successful and unsuccessful in using your influence. Using Exhibit 9.5, consider which factors and attributes you used successfully or unsuccessfully. Further consider how these same factors and attributes worked in some situations and not others or even evolved over time. The power to influence is a key tool in the policy process and is more detailed in Chapter 7.

ASSESSING RESOURCES The ability to implement policy depends on the resources and support available for carrying it out. Regardless of the environment, whether it be a healthcare association, a professional association, an informal group, or a community setting, it is necessary to assess resources. This includes identifying resources that are readily available, as well as those that need to be acquired. The assessment of resources includes people and manpower, data, finances, and communication capabilities.

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EXHIBIT 9.5   AIM INFLUENCE FACTORS AND ATTRIBUTES

FACTOR

ASSOCIATED INFLUENCE ATTRIBUTES

ALIGNED NURSE ATTRIBUTES FOR INFLUENCING POLICY

Authority

Access to resources Accountability Responsibility

Extended education Understanding of patient experience Accountability for care delivery

Communication traits

Confidence Emotional involvement Message articulation Persistence Physical appeal environment Physical appeal self Presence

Experience in communication in challenging situations involving patients and their families

Knowledgebased competence

Aesthetic knowledge Empirical knowledge Ethical knowledge Personal knowledge Sociopolitical knowledge

Empirical knowledge (science, nursing) Personal experience Capacity to envision needed improvements Commitment to ethical and moral judgment Understand of role of socioeconomic status in access to healthcare

Status

Hierarchical position Informal position Key supportive relationships Reputation

High respected and trust Expertise in relationship building

Time and timing

Amount of time to sell an issue Timing to deliver the issue

Experience in selecting actions based on competing priorities

AIM, Adams Influence Model.

People and Manpower Although the power of one person can never be underestimated, the availability of people as resources and the sheer manpower to implement an advocacy plan is a primary determination of the level that your policy can be implemented (i.e., little “p” or big “P”) and the success of that implementation. Manpower can be paid or unpaid, and the assessment of that manpower needs to include an examination of the expertise of volunteers, staff members of organizations, and any other individuals who could ­contribute to the plan.

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Volunteer expertise includes determining who is interested in the issue and ­potential sources of volunteers. A state, for example, may have several nurse practitioner groups, based either on region or on specialization, as well as a state-wide practitioner organization. When an issue involves prescriptive privileges, individuals from all of these groups are key to success. Other APRNs may wish to join because advancing a cause for one advanced practice group may benefit all advanced practice groups in terms of political capital (see Chapter 7). Having quick access to volunteers for quick response and help is often critical. The ANA, for example, has an RN Action Center with information about issues and mechanisms to notify nurse activists of pending issues and votes so that they can contact their legislators in a timely and strategic manner. The site can be reached at ana.aristotle.com/ SitePages/issues.aspx. Social media is often a key avenue for communication, as described in Chapter 10. Consider becoming a volunteer that the ANA, your state nurses association, or your specialty organization can call on for advocacy efforts when quick turnaround is needed. Included in assessing volunteer expertise is ensuring that individuals understand the dynamics of the policy issue being advanced for the action plan. For example, if an organization wants to take responsibility for systematically evaluating proposed legislation (e.g., endorsement, opposition) then members need education and guidance for making those decisions. To facilitate the process, the group might create talking points or a backgrounder document for the issue, or they might also organize regional town halls to raise awareness of an issue. The strategies used to assess volunteer expertise depend on the information that is available to an organization, which might include a member database, a speaker’s bureau, or some other systematic way of gathering information. Larger organizations have the capacity to conduct member surveys or obtain systematic feedback on an issue. Smaller groups, of necessity, use more informal means such as networking, e-mail, or media outlets (e.g., Facebook, Twitter) to obtain information. It is important that the volunteer activities are a match with the organization’s mission, as well as the volunteer’s interests. Manpower can also include staff employed by organizations or associations. Staff members may include nurses who have direct experience with the issue or ancillary staff such as secretaries or administrative assistants who can be released to devote time to an issue. In addition, some workplaces employing RNs may want nurse management or staff with direct care responsibilities related to an issue to help with a community or state or even national policy. That involvement then requires consideration of the need to have protected time for such activities. Advancing a policy issue, for example, might be a component of a clinical nurse specialist’s regular job duties, but obtaining input, particularly on a substantive level, may require further provision of time for activities. Many agencies have guidelines for staff involvement in volunteer activities that are tied to their work role. Consideration should be given to marshaling the forces of other types of volunteers who are willing or have the capacity to support the activation of a plan. This might include family members who have connections to media outlets, students, family members of volunteers with computer or webpage skills, or people who might be willing to provide short-term service for the plan. Individuals who teach at universities and colleges may be able to provide introductions to faculty members who place students in internships or externships in fields such as communications, computer science, business, and media. Universities and colleges may have volunteer offices that serve as a clearinghouse for students desirous of being involved in community service.

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Data Data are important in any policy endeavor. Data may take the form of findings from research, evidence-based projects, or quality improvement processes in providing the foundation for a policy position or background information that can support the plan. Data can be used to help with the issue itself as emphasized in Chapter 5, or data can be used for implementing the plan as described here. Data sources can include research on priorities, demographic characteristics, and other details in support of implementing an issue. Demographic data are important, for example, in explaining, analyzing, and predicting nursing workforce needs. Big data sets are needed to fully understand the nature of the nursing workforce. This need and gaps in availability of nursing workforce data were identified with the Institute of Medicine (IOM), now the National Academy of Medicine (NAM), report, The Future of Nursing: Leading Change, Advancing Health, recommendation that nursing workforce data collection be improved (Committee on the RWJF Initiative on the Future of Nursing, 2011). The subsequent progress report indicates that data regarding the makeup of the ­workforce is an ongoing need (NAM, 2016). For many years, the National Sample Survey of Registered Nurses (NSSRN) provided demographic data about RNs every 4  years from 1980 to 2008. However, that survey is no longer being conducted. Data are needed at both the state and the national levels. Data sources for studying the nursing workforce include state data on RN licensure and renewals. Using state data, Fraher (2017) relates how state data were used to “tell stories” about the nursing workforce that helped inform policy discussions with legislators. The state data provided information about care access, the proportion of nurses with baccalaureate degrees, workforce diversity (and match to the state’s population), and career trajectories of RNs and licensed practical nurses (LPNs; Fraher, 2017). Data can also be obtained from the National Nursing Workforce Study and U.S. Census Bureau’s American Community Survey (ACS). The former is conducted every 2 years and is funded through a partnership between the National Council of State Boards of Nursing (NCSBN) and the National Forum of State Nursing Workforce Centers (NCSBN, n. d.). The ACS is conducted continuously, thus providing constantly updated social, economic, housing, and demographic data that can be used for policy decisions by communities (Spetz, 2013; U.S. Census Bureau, 2017). Data may include not only characteristics about nurses, but also information about the impact of an issue or the number of people affected, often a key to policy ­implementation. Ensuring that one has the right and the latest data can facilitate the development of information and other support materials in implementing the advocacy plan. A hospital, for example, may examine its own pressure injury rate compared with national benchmark data from the National Database of Nursing Quality Indicators (NDNQI) or may consult its own workers’ compensation cases for nurses with back injuries to make the case for purchasing ceiling lift equipment. At the c­ ommunity level, hospitals are required to complete community assessments every 3 years as part of their federal reporting requirements. These documents, which are usually available online, provide rich information about the community, which can be used for making the case for implementing a specific program and/or policy change.

Economic Resources Economic resources require a realistic appraisal of what will be needed for implementation of the advocacy plan. This includes supplies, materials, and personnel time, both

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paid and unpaid. Organizations typically budget financial resources to ­implement advocacy programming, and when additional resources are needed, they can ­ some times divert resources from other priorities or seek external funds. Healthcare organizations may have resources to finance a policy initiative. Some organizations, such as a professional association or a nonprofit organization, may not have significant financial assets. However, they may be able to obtain financial assistance through community organizations designed to assist nonprofits with their business processes or join a coalition that will have greater combined resources. Although large foundations such as the RWJF or the Kellogg Foundation may fund major initiatives, smaller foundations may be a resource for policy initiatives or pilot projects that have policy implications in their own communities. Local affiliates of national organizations (e.g., March of Dimes, Susan G. Komen for the Cure, American Heart Association) and hospital foundation or auxiliaries are some resources to consider. Equally important to finding funding for policies, is determining the economic costs of implementing the policy plan given the competing funding for and rising costs of healthcare. Economic evaluations of interventions associated with policy should always be addressed. A variety of tools can be used for this evaluation and can include one or more of the following: cost–benefit analyses, cost-effectiveness analyses, cost-utility analyses, or cost avoidance (Zalon & Ludwick, 2018).

Communication Communication is essential throughout the process of implementing the plan. It was discussed briefly in the AIM Model (see Applying Influence) and also discussed in the Creating Narratives and in greater detail in Chapter 10. The ability to deliver a clear and consistent message is important in all settings and circumstances and is especially important for a nurse who is advocating for policy. The goal of communication as discussed here is to emphasize its role is in mobilizing staff, members of organizations, and the public to carry out all phases of the activation step. Communication includes the management of internal and external relationships, as well as messaging. Free or inexpensive resources, such as community bulletin boards, radio or television talk shows, mail list servers, and public service announcements, can be used to get your message out. A town hall or well-publicized event can also be used to communicate important messages about a policy issue. Town halls are open forums that are an opportunity to provide information about an issue to the community while allowing for dialogue with key stakeholders. The degree of formality of a town hall depends on the overall goal and the way that it is being used to advance a particular policy. Often, the forum is a panel discussion, followed by questions from the audience. With advertising savvy, a town hall or workplace forum draws additional supporters who are interested in and supportive of your positions or proposed policy.

Readiness The assessment of readiness for implementing the plan includes a number of c­ omponents that help determine the capacity of the group to take action. Understanding the ­organization or group’s knowledge, skills, and resources is essential for implementing the plan, whether it is a little “p” bedside policy change or a big “P” policy that involves ­proposing legislation. The Alliance for Justice has developed resources for advocacy, ­including an Advocacy Capacity Tool (Bolder Advocacy, n. d.). This organization focuses on using its expertise on equity in the federal judiciary but provides resources for advocacy

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capacity assessment, as well as understanding the laws and regulations impacting the advocacy work of nonprofit organizations at the community, national, and i­nternational levels. In assessing readiness, you should ensure that all team members can speak clearly, simply, and effectively about the proposed policy and its implementation. Everyone needs to be on the same page. The message about the policy needs to include its basic elements so that it can be understood by those impacted. This may require practice and coaching for some. The assessment of readiness includes ongoing activities to ensure that you have the latest intelligence on the issue and to create a mechanism for ongoing environmental scanning (see Chapter 4). Understanding the available and needed resources and assessing readiness can be used to empower and support individuals involved in implementing the advocacy plan. Knowing your resources and monitoring them throughout the plan is critical for maximizing your effort and not squandering resources that can often be limited.

PRESENTATION OF THE PLAN Once the details of the plan have been developed, it is time to enact the actions and procedures to put the policy into practice. To roll out the plan, it is necessary to build momentum, create stories and education that can be taken on the road so that the plan is understood, and continue networking with key decision makers.

Building Momentum Building momentum pushes an issue into the policy limelight, much like the tipping point described by Gladwell (2000). For example, needlestick prevention passed in a critical number of states before it was possible to achieve passage at the federal level. On the other hand, North Dakota had baccalaureate entry for nursing practice from 1986 through 2003 (Smith, 2009). Nurses in Oregon, Montana, and Maine initiated efforts for baccalaureate entry but were unsuccessful. The failure to create an action plan to accompany the ANA 1965 position statement on baccalaureate entry (Elliott, 2010) and the lack of momentum with other states adopting baccalaureate entry contributed to failure in these implementation efforts and the ultimate demise of baccalaureate entry in North Dakota. Another way to build momentum is to capitalize on current events and news stories that relate to the policy. News and events can help draw attention to problems and sometimes can be used as tipping points for some action, but they cannot be counted on to sustain momentum of a plan.

CREATING NARRATIVES Any advocacy plan includes enhancing the visibility of an issue. Nurses can bring their real-world experiences to bear in the discussions through the creation of narratives. Although media strategies are critically important, nurses need to be adept at developing narratives that make issues real and understandable across a spectrum of audiences (see Chapter 10). Encouraging nurses to share their stories about their clinical practice and its impact are effective means of empowering nurses to become advocates for their patients and for the profession at all levels of policy.

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A clinical narrative is a first-person story that describes a specific situation. Narratives help us understand practice through reflection by making it visible; by uncovering hidden aspects of the practice; and by sharing with the larger community clinical knowledge, caring practices, and the complex environment in which we practice. In healthcare organizations, narratives can be used to strengthen nurses’ abilities to voice their concerns and to speak up about extraordinary situations. They are used to make the case for a policy initiative by serving to inform and influence colleagues, members of other disciplines, management, board members, and the public. As it happens, the way in which a nurse communicates through a narrative is also an extremely effective way of communicating in the policy arena—by telling an important first-person story in a clear and concise way that the uninitiated can easily understand. Narratives can be used external to a health organization, as when talking with a reporter, visiting a legislator, or framing testimony for a legislative hearing. We are increasingly seeing the use of narratives in books about clinical practice in nursing, medicine, and other healthcare disciplines. The prestigious health policy journal, Health Affairs, has a long-running column, “Narrative Matters,” designed to capture the stories of patients, families, and their caregivers, and nurses have shared their narratives in this column. Putney (2015) shares one example by providing poignant insights about the complexities and challenges of our healthcare system in managing the care of a child with complex healthcare needs. Characteristics of situations that make good clinical narratives and that may be included in advocacy plans are listed in Exhibit 9.6. These characteristics, derived from the work of Benner, Hooper-Kyriakidis, and Stannard (2011) in selecting narratives, can be used to select compelling narratives for policy makers. As you write the narrative, provide background for the reader; this can include time of day, the setting where it took place, and the detail of what occurred. The focus should be on what you were thinking, using “I” rather than “we.” The narrative gives the reader insight into the practice, and it also provides the opportunity to reflect on practice— what the nurse did and why. The story that is told is the right one for that person at that time. For many nurses, the idea of writing a narrative is paralyzing. They worry that their story is not enough: It is not extraordinary enough, it is not long enough, and it is not perfect. Presentation skills can be learned. Education and practice help participants understand how to organize clear messages and hone their delivery skills Nurse leaders can create an environment that is not judgmental, that values and respects practice at all levels, and that offers encouragement and support as nurses share their narratives. Encouragement and support from managers and administrators EXHIBIT 9.6  ELEMENTS OF GOOD NARRATIVES • • • • • •

Portray excellence in nursing Describe practice breakdowns, errors, or moral dilemmas Raise issues and problems Illustrate differences made by nurses Provide opportunities for learning new perspectives Etch into memory

Source: Benner, P., Hooper-Kyriakidis, P., and Stannard, D. (2011). Clinical wisdom and interventions in acute and critical care: A thinking-action approach (2nd ed.). New York, NY: Springer Publishing.

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for the voice of nurses is critical. Giving this support individually, in public, and verbally and in writing is vital. Not only does it reassure nurses, but also it may help inspire others to help or to work on narratives for their own projects. See Chapter 5, as many of the same techniques discussed there can be used for disseminating narratives. Telling one’s story is not without its caveats. Suzanne Gordon and Bernice Buresh, both journalists who have written extensively about issues in nursing, indicate that nurses need to be more vocal and visible by telling their stories in a way that represents nurses as knowledgeable and competent. In their classic book, From Silence to Voice, Buresh and Gordon (2013) take nurses through a step-by-step process of developing and refining narratives to more effectively capture the realities of nurses’ work.

Networking Policy-Maker Allies We need to take the time to strategically identify where to focus efforts and how to choose issues that are important to the profession and for which a nurse would be a respected, knowledgeable advocate. Consider who potential allies are, ask why the policy you advocate for (or would like to prevent) has not been adopted, and decide whether you have the interest and stamina to see the issue through to its conclusion. Integral to any plan are opportunities to have direct interaction with lawmakers, policy makers, and key decision makers. Key strategies are visiting with leaders in your workplace or legislators or having them visit your unit or facility to see the real people (e.g., patients, nurses) impacted by the problem. Visiting legislators and providing testimony can be one component of implementing a plan. Since building new relationships takes time, capitalizing on existing relationships is key, just as it is in delivering patient care. As part of this process, it is important to identify any existing personal connections with important opinion leaders and public policy decision makers; a nurse who is active in her town government, worked on a campaign, or went to school with a legislator’s child has an entrée that can add credibility. Getting to know the decision makers, educating them about issues, solving the inevitable constituent patient care and employment questions that arise, and alerting them to breaking news—good and bad—at your institution are excellent ways to foster these relationships. Invitations to visit and see your unit or institution can also be extremely effective. Extending invitations, for outside visitors often is a routine responsibility of the  chief executive officer (CEO) and/or chief nurse officer (CNO). Finding ways to showcase and highlight advocacy work might include invitations to shadow a nurse on an inpatient unit, explanations on how patient acuity is calculated for staffing, observation of surgical procedures, or tour services that are unique to your organization (e.g., an interprofessional approach to a particular disease, a specialized cancer treatment, or cutting-edge technology). Another aspect of strategically building allies is attending meetings or special events that are held by those you want to enlist in your plan. In public policy this might mean attending events held by a policy maker in their home office, in public meetings, or at the state or national level. You can attend as individual, but more political influence can be gained as part of an organized group that attends the event (see Chapter 7). The obvious advantage of these events is efficiency; it is an opportunity to highlight your plan in your policy maker’s turf. The visit also helps convey a consistent message, and the common experience creates some accountability among the leaders who attend. An event can also help with communication because often, public events are great ­opportunities for publicity.

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THE WORK IS NEVER DONE Once a policy is in place, do take time to celebrate but remember that the work is often never fully realized. In Chapter 6, the Policy Challenge and Option for Policy Challenge were about the success of requiring the BSN at entry into practice in New York. The work is not done, especially when one recognizes that this is the only state to have requirement and that now the inaugural regulations must be drafted and approved. There were many ups and downs because New York nurses maintained the long view and championed this issue for many years. See the Policy on the Scene 9.3 for the little “p” issue that evolved into a state-level issue that remains unfinished. Another issue lies in that policy can be rescinded or even just ignored intentionally or unintentionally. In Chapter 13, the ongoing monitoring of policies is discussed, but a few caveats are noteworthy in this chapter.

Dealing With the Unexpected Often, policy work is ongoing. Any number of examples throughout the book point out the need for the long view for policy and advocacy. In any advocacy plan, there may be an unexpected turn of events or unintended consequences. For hospitals, these may be sentinel events; for APRNs, it may be a report of less-than-desired outcomes; for anesthesia providers, it may be a lapse in infection-control practices, leading to potential widespread outbreak of disease; or for nurse educators, it may be a loss of accreditation status. These events require an immediate response and transparency. The public wants and needs to be assured that something is being done about the situation and that your organization’s staff will provide safe care. Transparency provides information and helps restore trust. An organization’s commitment to transparency and continuous improvement is critical in times of turmoil and uncertainty. In the legislative or regulation process, there are often many ups and downs. Even when a plan successfully ends in legislation, the passage of a law is only the beginning of the regulatory process, and then there is evaluation of the law’s outcomes. In the legislative process, a bill may be passed but not funded, or the regulations may fall short of the full vision of the policy planners. Certainly, the many twists and turns that led to the passage of the ACA and the subsequent twists and turns that have followed its passage clearly illustrate how the unexpected can occur. Passage of the ACA shows the importance of the long view, no matter whether you supported or opposed the law. Equally important to the long view is appreciating what can be gained by looking historically at legislation, a point made in the important work on the topic of unintended consequences in 2001 by the IOM. The discussion of consequences broadly focused on several general policy areas: “Medicaid, Assessing Risks and Regulating Benefits, Delivery System Restructuring” (IOM, 2001, p. 2). Several reasons for unintended consequences were identified. Time was the first lesson learned. How long a bill takes to pass and to be written into regulation is one example of how timing can impact consequences. Sometimes, it is just a matter of time before the unintended consequences can be learned. A second lesson was that policy is born of politics; that is, factors such as reelection and the need to act can lead to unintentional outcomes such as imperfect legislation. The third and last lesson was that politics often overrides science, an important lesson that is receiving much attention today. Staffing is a common but complex problem across healthcare settings today and has been the subject of much debate, study, and policy work. It serves as a good example of

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POLICY ON THE SCENE 9.3: When a Policy Task Becomes a Challenge Linda Griggs, MSN, RN-BC, ACNS-BC Specialized Senior Services/NICHE Coordinator Aultman Hospital, Canton, Ohio It is important for nurses to be involved in policy writing, but at times it can be challenging. Several years ago, I was assigned a policy revision regarding Pap smears, and I shared my experience in the first edition of this book (Griggs, 2015). The policy stated that all women aged 18 and older should be offered a Pap smear. I started a long process of investigation, finding that the policy mirrored Ohio law; most patients refused it anyway due to lack of insurance coverage. Further checking revealed that the policy and law did not follow the current practice recommendations outlined in the American College of Obstetricians and Gynecologists (ACOG) guidelines and the Report of the U.S. Preventive Services Task Force, Guide to Clinical Preventive Services. Cervical screenings were recommended starting at age 21 and ending at age 65. I sat at my desk with an overdue policy mirroring Ohio law, which did not follow current practice guidelines and thought “Is it my responsibility to contact a local government representative to get the law updated? Really?? Whose job is it anyway?” The hospital Policy and Procedure Committee approved the policy reflecting current law, but I just could not let this matter go. After several months, I decided to attempt to get the law changed. I strategically sought out a female state representative for two reasons. First, I did not want a government official giving an excuse to not get involved because it was a women’s health issue, and second, she had presented a lecture for my husband’s government class a few years prior, so I thought she might recognize my last name. After a brief introduction, my letter described the current situation of our hospital policy mirroring the outdated state legislation. I stated the importance of providing care that is evidence based and in alignment with current practice standards. Second, I addressed how, despite being offered, most inpatients refused the examination because their insurance would not cover the cost if it were unrelated to their admitting diagnosis. Preventive screenings work and can reduce healthcare costs and improve care when they are appropriately offered. Attached in the letter were supporting documents with pertinent areas highlighted. Finally, I requested her assistance in changing the current regulations. A week later, I received an email from the representative’s aide and then a follow-up phone call from the state representative herself asking clarifying questions. The representative acknowledged that the original law was written in the 1970s and that she was going to attempt to have it updated. Three months later, I was notified that the changes submitted by the representative were accepted in the House version of the bill. I was one step closer to conquering this policy. With disappointment, I was later notified by the representative’s office that the Senate did not support the changes, so I should contact a state senator to request consideration. As often (continued )

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happens, other responsibilities took priority. So here I am, 3 years later, sitting at the same desk knowing the state regulations are still outdated and do not follow current practice guidelines. I realize it is within my ability and my responsibility to take action, so I will contact my senator, seeking assistance from other stakeholders, including my state nurses association, in another attempt to get the law changed. unintended consequences. In a study by Chen and Grabowski (2015) of nursing home minimum staffing in California and Ohio, the researchers found that adopting minimum staffing standards led to some improvements but also unintended consequences. In these staffing regulations, all direct-care staff (e.g., RNs, LPNs, certified nursing assistants [CNAs]) were treated the same and the indirect-care staff (e.g., housekeeping, activity workers) were overlooked. Thus, the state changes had the unintended impact of (a) dropping the direct skill mix of nursing care so that there was a lower ratio of professional nurses to CNAs and (b) decreasing the total level of indirect care staff.

Sustainability of the Advocacy Plan The leaders responsible for implementing a plan need to give careful thought to the sustainability of interest and effort in the plan and the adjustments needed to achieve the desired goals throughout this process. With many issues and efforts to move forward, it usually takes years of effort and success to achieve policy goals. The path may be circuitous or not very direct, but persistence is important. A single policy achievement is only one step of the process. Incrementalism is a credible strategy for achieving sustainable results. At times, achieving only small steps is possible. Today, full practice authority is a reality for APRNs, a situation that was not a possibility when these roles were first conceived years ago. When implementing a plan, there is constant consideration of the pros and cons for possible solutions or compromises. Often, the implementation of a policy provides the first opportunity to learn if it will be effective in the manner it was conceived. Sustaining interest involves creating an interest among key legislators, stakeholders, and decision makers. These strategies can include maintaining contacts with key leaders, sending newsletters or updates, and developing press releases on the topic (see  Chapters 7 and 10). In general, you can work on expanding your influence by meeting new people and building coalitions. Networking never ends. Keeping interest involves having the supporters of your plan engaged in continuing the work. Transparency in sharing information and providing your team members with progress updates is essential. As with any issue, some individuals who were once leaders will drop out, and new leaders will emerge. It is important that your plan includes consideration to succession planning and ongoing leadership development to ensure that the policy agenda continues. Knowing the challenges to achieving success in changing policy can make the task appear quite daunting. One strategy for strengthening your position and increasing the likelihood of success is to propose a pilot project with the suggested policy change. This would allow you to collect data. More realistically, a pilot would provide you with preliminary information about the policy and challenges, foreseen and unforeseen, in implementing a policy. This information may lead to a revision in the policy or to a strategy for getting it implemented.

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Finally, any advocacy plan needs periodic revision and regrouping through an evaluation process. This may be accomplished formally, with an evaluation tool, or informally, depending on the nature of the plan. This provides necessary information about your stakeholders, your organization, the external environment, and the impact of your plan. Having new information and the latest information empowers you and your team members as your plan is refined and implemented. Although it is important to deliver a consistent and preferably unified message, the plan may need revision, depending on new circumstances. Being strategic at the big “P” or little “p” level is constantly shifting and gauging, being aware of the environment, being aware of the concerns of your patients and colleagues, and being aware of the concerns and challenges faced by key policy decision makers. It is an iterative process and most successful when the people who are most affected by the issue are involved.

OPTION FOR POLICY CHALLENGE: Casualty Nursing in the Emergency Department Nancy Bonalumi Education and policy development and evaluation go hand in hand. Emergency nurse leaders should ensure and staff should advocate for the opportunity to participate in a true-to-life drill for the practical reason of preparation, but participation also provides experiences valuable to policy. As nurses go through the education, they can gain insights that can help them appreciate and evaluate some of policy issues that can and should be addressed. Deconstructing the actions in the drills allows attendees to understand the steps being taken during the event, providing insight to the decision making required when responding to a mass casualty incident and some of the issues that may require further policy work. In the Policy Challenge, the drill became complicated when someone got a gun into the emergency department (ED). How did someone with a gun get into the ED? Protocols to screen for weapons at entrances to hospitals are often in place, but are they robust enough during implementation in an emergency when the ED becomes overwhelmed with victims and distraught families and friends? Another policy implication is developing communication and transportation protocols with emergency responders during mass casualty events to ensure that patients are evenly distributed and dispatched to hospitals offering the appropriate level of care to efficiently maximize limited resources. Advocacy is also necessary for funding educational activities. Nurses need to advocate for adequate funding from the Federal Emergency Management Agency (FEMA) and state counterparts that support disaster planning and education, response, and mitigation efforts. Advocacy begins with the individual, and emergency nurses need to develop competency in this distinctive aspect of our role in the healthcare system. Taking advantage of education is one step. Participating as a volunteer in a drill and serving on a committee for hospital- or community-based emergency preparedness are examples of local efforts that can impact policy.

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IMPLICATIONS FOR THE FUTURE Nurses have unique professional skills for implementing an advocacy plan. Therefore, greater involvement by nurses at the grassroots level is needed. Resources are increasingly limited, and plans need to be creative, strategic, and well thought out, anticipating desired and unintended consequences. In some instances, establishing or joining coalitions certainly adds resources, support, and credibility, particularly when the coalitions include other healthcare professional and consumer groups. State nurses associations have greater visibility with efforts to advance The Future of Nursing recommendations (Committee on the RWJF Initiative on the Future of Nursing, 2011) because their established networks and partnerships provide an ideal infrastructure for supporting these initiatives. State-based affiliates of specialty nurses associations also have greater opportunities for visibility through partnerships and coalitions. Greater emphasis will be placed on mentoring recent graduates, involving them in policy through (a) shared governance at their place of employment, (b) professional associations, and (c) community organizations to lead advocacy plan efforts. Many recent graduates have been involved in service learning. This means that they are accustomed to providing service. However, nurses who have had service learning experiences may not have necessarily thought about service as a means to influence policy. In addition, many recent graduates of undergraduate, graduate, and doctoral programs have been involved in projects related to policy change, but on graduation, this enthusiasm was not marshaled for further engagement in the policy process. These graduates are an ideal resource when organizations seek to vitalize their advocacy efforts. Advocacy plans in an increasingly wired society will involve greater use of technology and social media. However, attention will need focus on how to include individuals living in remote areas and those who do not have Internet access. Data analytics will increasingly become part of advocacy plans. Therefore, strategies need to be designed for seamless data collection when plans are developed, initiated, and evaluated. The implementation of many policies important for nursing and health policy will be implemented at the state level. Often, laws and regulations must be enacted in a critical number of states before they capture the attention of policy makers at the national level. As organizations make improvements in certain policies, it may take time for the value of these improvements to achieve widespread recognition and then be adopted, as we saw with the Magnet® Recognition Program. Likewise, when new programs, laws, or regulations are established, it may take years for related policies and procedures to be implemented. For example, the implementation of many policies related to the ACA is at the state level. Nurses are a crucial link in helping the public understand how the ACA is applied, promoting the shift in emphasis to preventive care and advocating for policies to achieve the goals of a transformed health system. Nurses are needed to improve access and quality, control costs, and enhance the work environment. The contributions of nurses need to be maximized but so do their roles in implementing and sustaining advocacy plans to enhance nursing practice and promote the health of the public.

KEY CONCEPTS 1. Implementing a plan is a pivotal step in the policy process. 2. The environment for implementing a plan can be a healthcare organization, a professional association, or an entirely new structure developed for the specific policy issue; each has unique features to be considered in plan activation.

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3. Shared governance provides opportunities to address policies and serve as a vehicle for implementation of a plan. 4. Participation in a professional association enables nurses to activate plans in an organized and systematic manner and provide resources, toolkits, and an infrastructure for activities. 5. New structures and/or coalitions may be created to energize support for an advocacy plan. 6. Resources that need to be assessed for an advocacy plan include people and manpower, data, economic resources, and communication abilities, as well as the overall readiness or capacity for action. 7. Implementing the advocacy plan involves the use of multiple strategies, including refining goals, applying influence, framing an issue, and targeting an audience. 8. The AIM involves the assessment and understanding of the interplay of authority, communication traits, knowledge-based competencies, status, and timing to effectively advance an advocacy plan. 9. Rolling out the plan includes creating narratives and building momentum. 10. Strategies to build momentum include marshaling forces to advance a policy position, visiting legislators or key policy makers, seeking out organizational leaders, attending policy maker's events, and bringing policy makers to your organization. 11. Dealing with the unexpected, such as unanticipated adverse events or an unintended consequence, requires superb communication, an immediate response, and transparency to restore trust. 12. Sustaining an advocacy plan may take years and include numerous refinements and reiterations as implementation of the policy or related policies unfolds. 13. Incrementalism may be a strategic choice that allows a plan to move forward and slowly build momentum. 14. The use of technology and new media for communication helps nurses garner support from a wider audience when implementing the advocacy plan. 15. Future initiatives will require greater involvement by nurses at the grassroots level, including new graduates who can offer unique experiences and competencies that can be harnessed to enhance the success of an advocacy plan.

SUMMARY Nurses, long champions for their patients, must now become champions and indeed experts in implementing plans for advocacy. Consistently involving nurses and widening the circle of involved nurses are key to implementing an advocacy plan. Each environment—workplace, professional associations, or the larger community at the state, national, or international level—has its own unique circumstances and challenges in implementing an advocacy plan. The establishment of a new policy, law, or regulation may only represent the initial phases of a plan that addresses a critical issue. Consistently articulating the importance of advocacy from within the profession and equipping nurses with practical tools facilitate the activation of an advocacy plan. The AIM provides a useful framework for understanding, articulating, and using influence to help nurses gain the knowledge needed to advance healthcare policy issues and successfully persuade key decision makers. Involvement in professional organizations and advocacy groups provides nurses with the additional competencies and confidence to advance policy goals. Understanding the environment, assessing resources, and being strategic and systematic in the rollout are all critical to an advocacy plan’s success. Activation of a plan

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is not a single activity but is an ongoing process that needs to be sustained through constant refinement, involving those directly impacted by a policy and engaging decision makers. It involves ongoing work, an ability to respond to the unexpected, and a tolerance for ambiguity as policies are moved forward.

LEARNING ACTIVITIES 1. Write a personal narrative to use to support a policy at your work, locally in your community, or for a state or federal legislative action. Include it in your portfolio. 2. Identify an issue you support at the big “P” level, identify the target audience, and then examine websites and other publicly available information to determine information about the decision maker’s positions and values. 3. Examine one of the toolkits listed in Exhibit 9.1, identify personal talking points that you can speak to, and review them with a colleague where you work. 4. Select an issue at the big “P” level and identify groups that would be good strategic partners or members of coalitions to advance a policy position and explain why these groups should be involved. 5. Select an issue at the little “p” level and determine how the members of the task force should be selected to oversee the issue. Identify the people who should be on the task force and what roles need to be represented, and provide the rationale for your selections. 6. Describe the strategies you would use for implementing a plan to implement a policy change for the issues selected in activities 4 and 5. Include who, what, when, and where (see Exhibit 9.3). 7. Visit the CCNA website (www.campaignforaction.org/our-network/state-actioncoalitions) and find the link to your state to familiarize yourself with its work. If you are involved already, consider sharing your work and activities with classmates.

E-RESOURCES • American Association of Nurse Anesthetists: Substance Use Disorder Workplace Resources www.aana.com/sudworkplaceresources • American Association of Nurse Anesthetists: State Health and Wellness www.aana.com/statewellness • American Association of Nurse Anesthetists: Wellness and Substance Use Disorder Education and Research www.aana.com/hweducation • American Association of Nurse Anesthetists: Wellness in the Workplace www.aana.com/workplacewellness • American Heart Association: How to Schedule and Conduct a Successful Meeting With Your Elected Officials http://www.youtube.com/watch?v=Q320LHS847w • American Nurses Association Action Center http://www.rnaction.org • American Nurses Association: Policy and Advocacy http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy • Frameworks Institute http://www.frameworksinstitute.org

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• Campaign for Action http://campaignforaction.org • Illinois Education Association: Tips for Talking to Legislators http://www.youtube.com/watch?v=8TtAe-_rs5U • National Association of Clinical Nurse Specialists (NACNS): Coalitions http://nacns.org/advocacy-policy/coalitions • Prevention Institute: Prevention and Equity at the Center of Community Well-Being http://www.preventioninstitute.org • Rising Voices: Featured Guide: Social Advocacy Toolkit for Activists and Non-Profits http://rising.globalvoicesonline.org/blog/2012/05/28/featured-guide-social -advocacy-toolkit-for-activists-and-non-profits • Robert Wood Johnson Foundation: Nurses & Nursing http://www.rwjf.org/en/topics/rwjf-topic-areas/nursing.html • UNICEF. Advocacy Toolkit: A Guide to Influencing Decisions That Improve Children’s Lives http://www.unicef.org/evaluation/files/Advocacy_Toolkit.pdf • Video for Change Toolkit http://toolkit.witness.org

REFERENCES Adams, J. M. (2009). The Adams Influence Model (AIM): Understanding the factors attributes and process of achieving influence. Saarbrüken, Germany: VDM Verlag. Adams, J. M., & Ives Erickson, J. (2011). Understanding influence: An exemplar applying the Adams Influence Model (AIM) in nurse executive practice. Journal of Nursing Administration, 41(4), 186–192. doi:10.1097/NNA.0b013e3182118736 Adams, J. M., & Natarajan, S. (2016). Understanding influence within the context of nursing: Development of the Adams Influence Model using practice, research, and theory. Advances in Nursing Science, 39(3), E40–E56. doi:10.1097/ANS.0000000000000134 American Nurses Association. (2010). Nursing’s social policy statement: The essence of the profession. Silver Spring, MD: Author. American Nurses Association. (2015a). Code of Ethics for nurses with interpretive statements. Silver Spring, MD: Author. American Nurses Association. (2015b). Nursing: Scope and standards of practice (3rd ed.). Silver Spring, MD: Author. Barkhorn, I., Huttner, N., & Blau, J. (2013, Spring). Assessing advocacy. Stanford Social Innovation Review. Retrieved from http://www.redstonestrategy.com/wp-content/uploads/2013/02/ Spring_2013_Assessing_Advocacy_No_Links.pdf Benner, P., Hooper-Kyriakidis, P., & Stannard, D. (2011). Clinical wisdom and interventions in acute and critical care: A thinking-action approach (2nd ed.). New York, NY: Springer Publishing. Birkland, T. A. (2011). An introduction to the policy process: Theories, concepts, and models of public policy making (3rd ed.). Armonk, NY: ME Sharpe. Bolder Advocacy. (n.d.). Tools for effective advocacy. Retrieved from http://bolderadvocacy.org/ tools-for-effective-advocacy Bozimowski, G., Groh, C., Rouen, P., & Dosch, M. (2014). The prevalence and patterns of substance abuse among nurse anesthesia students. AANA Journal, 82(4), 277–283. Retrieved from https:// www.aana.com/docs/default-source/aana-journal-web-documents-1/prevalence-patterns -0814-pp277-283.pdf?sfvrsn=73cd48b1_4 Buresh, B., & Gordon, S. (2013). From silence to voice: What nurses know and must communicate to the public (3rd ed.). Ithaca, NY: ILR Press.

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Chen, M. M., & Grabowski, D. C. (2015). Intended and unintended consequences of minimum staffing standards for nursing homes. Health Economics, 24(7), 822–839. doi:10.1002/hec.3063 Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Cramer, M. E., Lazure, L., Morris, K. J., Valerio, M., & Morris, R. (2013). Conceptual models to guide best practices in organization and development of state action coalitions. Nursing Outlook, 61(2), 70–77. doi:10.1016/j.outlook.2012.06.022 Dodson, E. A., Stamatakis, K. A., Chalifour, S., Haire-Joshu, D., McBride, T., & Brownson, R. C. (2013). State legislators’ work on public health-related issues: What influences priorities? Journal of Public Health Management and Practice, 19(1), 25–29. doi:10.1097/PHH.0b013e318246475c Elliott, J. E. (2010, June). ANA Past presidents panel discussion. American Nurses Association House of Delegates. Washington, DC: American Nurses Association. Fraher, E. P. (2017). The value of workforce data in shaping nursing workforce policy: A case study from North Carolina. Nursing Outlook, 65(2), 154–161. doi:10.1016/j.outlook.2016.10.003 Gladwell, M. (2000). The tipping point. Boston, MA: Little, Brown. Glazer, G., & Ali, A. A. (2017) Legislative: Family Caregiving Act: Healthcare impact and nurses’ role. Online Journal of Issues in Nursing, 23(1). doi:10.3912/OJIN.Vol23No01LegCol01 Griggs, L. (2015). Policy on the scene 15.1. Whose job is it anyway? In R. M. Patton, M. L. Zalon, & R. Ludwick (Eds.). Nurses making policy from bedside to boardroom. New York, NY: Springer Publishing; Silver Spring, MD: American Nurses Association. Hawks, H. J. (1992). Empowerment in nursing education: Concept analysis and application to philosophy, learning and instruction. Journal of Advanced Nursing, 17(5), 609–618. doi:10.1111/j.1365-2648.1992.tb02840.x Institute of Medicine. (2001). Unintended consequences of health policy programs and policies: Workshop summary. (US) Robert Wood Johnson Health Policy Fellowships Program. Washington, DC: National Academies Press. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK223665 Ives Erickson, J., Hamilton, G., Jones, D., & Ditomassi, M. (2003). The value of collaborative ­governance/staff empowerment. Journal of Nursing Administration, 33(2), 96-104. Retrieved from https://journals.www.com/jonajournal/Abstract/2003/02000/The_Value_of_Collaborative_ Governance_Staff.6.aspx Kingdon, J. W. (2011). Agendas, alternatives, and public policies (Updated 2nd ed.). Glenview, IL: Pearson Education. Linnen, D., & Rowley, A. (2014). Encouraging clinical nurse empowerment. Nursing Management, 45(2), 44–47. doi:10.1097/01.NUMA.0000442640.70829.d1 Matthews, J. H. (2012, January 31). Role of professional organizations in advocating for the nursing profession. Online Journal of Issues in Nursing, 17(1), Manuscript 3. doi:10.3912/OJIN .Vol17No01Man0 National Academies of Science, Engineering, and Medicine. (2016). Assessing progress on the Institute of Medicine Report on The Future of Nursing. Washington, DC: National Academies Press. Retrieved from https://www.nap.edu/catalog/21838/assessing-progress-on-the-institute-of-medicine-report -the-future-of-nursing National Alliance of Caregiving, & AARP Public Policy Institute. (2015). 2015 report: Caregiving in the U.S. 2015. Bethesda, MD: Author; Washington, DC: Author. Retrieved from https://www .aarp.org/content/dam/aarp/ppi/2015/caregiving-in-the-united-states-2015-report-revised.pdf National Council of State Boards of Nursing. (n. d.). National Nursing Workforce Study. Retrieved from https://www.ncsbn.org/workforce.htm Office of the Surgeon General. (2016, November). Facing addiction in America: The Surgeon General's report on alcohol, drugs, and health. Washington, DC: U.S. Department of Health and Human Services. Retrieved from http://addiction.surgeongeneral.gov Perry, C., & Emory, J. (2017). Advocacy through education. Policy, Politics & Nursing Practice, Advance 18(3), 158-165. doi:10.1177/1527154417734382

290   UNIT III  STRATEGIZING AND CREATING CHANGE Putney, A. (2015). Across state lines, a family navigates complexity and Medicaid hurdles. Health Affairs, 34(7), 1241–1244. doi:10.1377/hlthaff.2015.0431 Quinlan, D. (2009). Peer assistance reaches its 25th year. AANA Journal, 77(4), 254–258. Retrieved from https://www.aana.com/publications/aana-journal/all-issues Reinhard, S. C., & Young, H. M. (2017). Nurses supporting family caregivers. American Journal of Nursing, 117(5), 58–60. doi:10.1097/01.NAJ.0000516385.05140.b0 Richardson, A., & Storr, J. (2010). Patient safety: A literature review on the impact of nursing empowerment, leadership and collaboration. International Nursing Review, 57, 12–21. doi:10.1111/j.1466-7657.2009.00757.x Smith, T. G. (2009, October 5). A policy perspective on the entry to practice issue. Online Journal of Issues in Nursing, 15(1). doi:10.3912/OJIN.Vol15No01PPT01 Spetz, J. (2013). The research and policy importance of nursing sample surveys and minimum data sets. Policy, Politics & Nursing Practice, 14(1), 33–40. doi:10.1177/1527154413491149 Stone, L., Quinlan, D., Rice, J. A., & Wright, E. L. (2016). The evolution of a peer assistance network for nurse anesthetists' substance use disorder. Journal of Addictions Nursing, 27(3), 218–220. doi:10.1097/JAN.0000000000000138 Strobbe, S., & Crowley, M. (2016). Emergency Nurses Association & International Nurses Society on Addictions Position Statement. Substance use among nurses and nursing students. Retrieved from http://www.intnsa.org/resources/Documents/IntnsaEnaPositionPaper.pdf U.S. Census Bureau. (2017, October). American Community Survey: Information guide. Retrieved from https://www.census.gov/content/dam/Census/programs-surveys/acs/about/ACS_Information_ Guide.pdf Zalon, M. L., & Ludwick, R. (2018). Health economics. In J. J. Fitzpatrick, C. Alfes, & R. Hickman (Eds.). Encyclopedia of clinical nursing. New York, NY: Springer Publishing.

TEN

Influencing Public Opinion and Health Policy Through Media Engagement Pamela F. Cipriano Jessica Keim-Malpass If you don’t exist in the media, for all practical purposes, you don’t exist.—Daniel Schorr, commentator, National Public Radio

OBJECTIVES 1. Design a media strategy to advance a current policy issue. 2. Develop effective written communication (e.g., letters, press releases, op-eds, blogs, social media ­engagement, policy briefs) to convey a message to the public and policy makers. 3. Adopt at least one form of social media to track, initiate, or influence opinion on a current policy issue. 4. Prepare for engagement with radio, television, and print media sources. 5. Understand how the use of social media can portray public health messaging for the public or can be tailored to specific populations of interest. 6. Use options for converged media to accelerate and amplify a media message.

The media, love them or hate them. This commonly heard phrase aptly describes the reaction to the strong influence the media exerts in shaping public opinion. The media can rapidly build support or swiftly derail well-intentioned ideas. Society relies on traditional media to inform us by exposing the truth and reporting news and events. The media landscape has dramatically changed over the past decade and rather than the predominance of traditional media sources (i.e., print, television, radio), there has been a convergence of traditional and social media outlets. Prior to the turn of the 21st century the favored approach in communications and public engagement was the broadcast model, in which a single broadcast was cultivated for a mass audience and there was a delay in public response and reaction. Historically, within the broadcast model of communication, there were fewer media outlets, so traditional media sources could be leveraged to deliver health-promotion campaigns and reach mass audiences (Institute of Medicine [IOM], 2002). Even though larger audiences could be reached, the downfall with the broadcast model was that the approach was r­ elatively ineffective with targeted high-risk populations and there was very limited engagement of the audience (IOM, 2002). 291

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Now, social media, used alongside traditional communication outlets, have given rise to the concept of converged media, or the merging of traditional broadcast models with newer social media and networking platforms to garner fast responses to ongoing events. Social media and other types of user-generated content are instruments of influence and have a broad reach to various audiences with the ability to facilitate real-time feedback and inputs from the users. Social media is unbridled by traditional reporting ethics, as well as the rigor and formalities of publishing and scripting. With instantaneous dissemination channels, social media can trigger a tsunami of interest in a subject, which in turn can compel traditional media to cover an issue. The rise and ubiquitous nature of digital media and increased access to smartphone technology has dramatically changed the everyday interactions people have with the media and has further facilitated media convergence (Bird, 2011). The transformation to a digital world has shifted the user as a media consumer to user as an engaged consumer with a variety of media platforms. Digital media and media convergence have allowed multidirectional user-generated content, allowing citizens the opportunity to also be producers, hence representing the merging of user-generated content and consumers of media in the same environment (Bird, 2011). Digital media sources have also become an increasingly popular platform for public health interventions and clinician crowdsourcing, or participatory networking in healthcare (McCartney, 2013). This chapter explains how to use various digital and conventional communication methods and to develop the tools for communicating effectively to various audiences, along with pointers to ensure that actions lead to the intended results. It also provides timeless approaches and tactics for leveraging the power of traditional media. Using proven techniques to work with the media helps nurses in all settings think critically and strategically about establishing and maintaining relationships with the media. To influence public opinion and drive policy, nurses must look for, as well as create, opportunities to broadcast messages important to the public welfare and advancement of the profession. Nurses can take advantage of digital communication and social media platforms to reach a broad audience and establish a greater presence than ever before. The process for establishing presence is illustrated in the Policy Challenge.

POLICY CHALLENGE: Force-Feeding at Guantanamo Bay—Protecting a Nurse’s Right to Conscientious Objection Journalists began reporting about conditions at the U.S. military prison at Guantanamo Bay Naval Base in 2013. In July 2014, the Miami Herald broke the story about a Navy medical officer who had been reassigned to alternative duties after refusing to continue providing enteral feedings to hunger-striking detainees at the prison (Rosenberg, 2014). That officer was an RN with 18 years of service who had been carrying out orders to force-feed detainees but then decided he could no longer participate in this activity because it challenged his ethical obligation to the detainees as his patients. The nurse’s actions were brought to light when one of the detainees reported the courageous act of this nurse to his attorney. (continued )

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Weighing in with an effort to enlighten the public about the procedure, a rapper aired a graphic video simulating the force-feeding technique; the military disputed the video as not representative of the actual procedure. The impact was clear, however, dramatizing the potential for pain and humiliation. It also rekindled strong emotions evoked from a first-person account published in the New York Times (al Hasan Moqbel, 2013) a year earlier by a prisoner who detailed being force-fed as a hunger striker protesting his prolonged detainment. At one point, legal counsel for three detainees appealed unsuccessfully to a U.S. District Court to stop the feedings. The Pentagon’s belief that the treatment was humane and would prevent starvation and death was starkly pitted against public opinion, ethical opinion, and the views of the human rights activist community. On learning about the nurse’s refusal to participate in the force-feedings, the American Nurses Association (ANA) sent a letter to the chief of the Navy Nurse Corps and spoke to her about the situation, emphasizing the right of the nurse to conscientiously object without retaliation. The ANA Code of Ethics for Nurses with Interpretive Statements (ANA, 2015) clearly supports the ethical right of a professional nurse to make an independent judgment about whether to participate in this or any other such activity. This right must be protected and exercised without concern for retaliation. Furthermore, the Code calls for respect for the inherent worth, dignity, and human rights of every individual. Several months later, as the case advanced, the ANA learned that the Navy was considering discharging the nurse from active duty, so a similar letter was sent to the Secretary of Defense, urging that no adverse action be taken against this nurse, but rather that his right to conscientious objection be honored without retaliation. The ANA, together with the nurse’s attorney (the nurse chose to remain anonymous), a retired captain from the Navy War College who had served as a physician at Guantanamo Bay, and Physicians for Human Rights, held a media event to appraise the media of support for this nurse and to uphold the ethical right to objection, as well as to urge the military to review and revise its practices. The press received talking points, asked questions after formal remarks, and were able to conduct follow-up interviews. Throughout 2015, the ANA highlighted the ongoing case in its print publications and social media as part of the “Year of Ethics” activities. Other nursing organizations, journals, and advocacy groups also continued to follow this issue, publish opinion editorials, and encourage ongoing conversation about the ethical issues and professional self-determination. This threat to professional practice, juxtaposed against the duty to military command, served as a pressing example of the importance of professional policy intersecting with public policy and the importance of informing the nation about an issue that had been cloaked in secrecy. The fate of this officer’s career was in the hands of the military, but many eyes watched and many voices weighed in on the complex issues and advocated for a fair and just outcome. See Option for Policy Challenge.

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THE MEDIA AND HEALTH POLICY Nurses have always embraced advocating for patients (see Chapter 2). The time has come to advocate for healthcare policy with the same vigor and tenacity to realize the vision for an improved healthcare system in which nurses are leading change. Nurses need to be knowledgeable about the media and know how to use it to advocate for their issues. Strategies for using the media include a variety of written and digital approaches such as news releases, letters to the editor, opinion editorials, interviews, a media events, and Internet options such as social media feeds, blogs, videos, and podcasts.

The Media and Nursing Why is it essential for nurses to engage the media? Starting with grassroots efforts to initiate changes in our communities, nurses can exert influence to achieve little “p” and big “P” policy changes by using the media to spread their messages, thereby ­influencing as many people as possible. We want to shape the continuing development of nursing and health policy. We have a responsibility to convey our current thinking and opinions and stimulate action to effect better health policy to serve our communities and the nation. Public policy advocacy means speaking up. An essential focus throughout this book is creating or changing laws and policies to advance nursing, promote health, and improve healthcare. One of nursing’s greatest role models, Florence Nightingale, was viewed as an astute political actor (McDonald, 2006). She was credible, determined, well connected, and deliberate, and she did not shy away from controversy. She was able to influence social changes not only in healthcare delivery, but also in working conditions. Her approach included obtaining information from reliable sources, discussing the content with experts, and then writing her views and recommendations. From her prolific letter writing to her issuing meticulous reports she had vetted with colleagues and by using statistics and developing innovative visual representations of data, she was able to influence opinion leaders and politicians despite her lack of formal degrees and her station as a woman. She knew the importance of garnering support and tapped her extensive network of friends and colleagues to accomplish her agenda for change. In Nightingale’s time, it was the power of the pen. Today, it is the power of the Internet. We can use her strategies with our modern methods of communication to achieve our goals.

Media Advocacy Working with the media to have your message heard, advance opinions about issues, and influence policy decision makers is considered media advocacy. When we promote a nursing or healthcare issue, we seek to educate the public, influence policy makers, and steer public viewpoints. Media advocacy combines mass communication with community advocacy. By using a range of media with purposeful strategies, groups can evolve episodic news stories into reframed public health issues. When children were dying from drunk-driving accidents, a far-reaching media advocacy campaign shined a spotlight on the dreadful effects of drunk driving, eventually resulting in stiff laws and long prison sentences for offenders. Effective media advocacy addresses gaps in power and resources to effect changes that improve health and healthcare (Dorfman & Krasnow, 2014). Media advocacy requires building skills for using the media as a tool to pursue social change and shift power within a community.

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Planning your approach to media advocacy involves a number of steps and s­ trategies to get the desired outcome. One approach is to follow the steps of “Got Me” (goal, objectives, target audience, message, and evaluation), as outlined in Exhibit 10.1 (Wallack & Dorfman, 1996). These steps are complementary and aim to inform the media in a clear and concise manner so that your message is understood and amplified. Spreading information about issues no longer relies on only one-way mass communication via the traditional media of radio, television, film, and books, newspapers, and other print media. Instead, consumer-generated messages flood the Internet. Individual content experts can use new digital distribution channels to court public opinion. A multitude of opportunities exists to use print, audio, and video in traditional presentations, along with various newer technologies such as webpages, podcasts, online conferencing, blogs, smartphone applications, and posts on social networking sites. The media is a powerful messenger to policy makers, as well as to the public. Mainstream news media publicizes issues to policy makers and non-news entertainment media, particularly through television and newspapers. Coverage of issues creates awareness and exerts major influence over public sentiment. Politicians are attentive to the media because they know their constituent voters pay attention and are influenced by what they see and hear (Ensign, 2011). The presidential election of 2016 and its aftermath, however, caused a shift in public and lawmaker confidence in the mainstream media, with partisan divides and general concern that some news is “fake” with no way to decipher truth from fiction (Easley, 2017). Media outlets, many of which align exclusively with liberal or conservative ideologies, choose to cover issues and related opinions as a means of shaping the public policy agenda. Media campaigns are used to spread a message quickly to a large audience. Campaign messages may include providing public health information and advisories, announcing event promotions, asserting viewpoints, or declaring pro or con positions to current issues. Social media may also be used to generate immediate attention to raise issue EXHIBIT 10.1  “GOT ME” APPROACH TO MEDIA ADVOCACY Goal

Establish common ground among the group that describes what you plan to accomplish

Objective

Define the set of actions that will achieve the goal

Target audience

Tailor the message to the audience: • Those with power to change policy • Influential interest groups • General public

Message

Help the media get an accurate message: • Clearly state the concern • Identify impact or threat and frame as the value to the community • Propose the policy solution(s)

Evaluation

Assess the success of your media advocacy approach to advancing your message

Source: Adapted from Wallack, L., and Dorfman, L. (1996). Media advocacy: A strategy for advancing policy and promoting health. Health Education Quarterly, 23(3), 293–317. doi:10.1177/109019819602300303

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awareness, announce a short-term gathering (virtual or physical), or garner support for a cause or policy. Simple techniques such as having a letter or editorial published can capture media attention. The more coverage secured in the media, the more potential influence is gained. Targeting multiple means of exposure for media coverage garners the attention of policy makers from local to nationally elected officials. For local or state issues, media can help publicize opinions, information, or events. Maintaining contact with local reporters, as well as radio and television personalities, helps familiarize them with your expertise and content and can lead to coverage of your issues on a regular basis. Media advocacy involves not only planned activities to initiate a policy change, but also activities that arise as a result of current events. A multipronged approach can garner widespread publicity and support. Media advocacy can be used for different types of situations or health policy initiatives. Media advocacy combines mass communication with community advocacy (see Policy on the Scene 10.1).

MESSAGING AND MEDIA ENGAGEMENT IN THE DIGITAL WORLD Internet and Social Media Electronic media have changed how we communicate with one another. Media provide numerous channels of communication and connectedness with our family, friends, peers, and communities. Each format has unique advantages and disadvantages. Each can be key in the policy process.

Internet and Websites The Internet provides rapid access to an endless source of information. It is the core structure that supports the World Wide Web (WWW or W3), the window to millions of sites across the globe. The WWW is an application supported by the Internet. WEB 2.0 is the current version of the interactive WWW with access to a myriad of remote software. Also referred to as a social web, people are interacting through sites such as blogs, social networks, social news, and wikis. These social media tools are evolving, and new ones are constantly being developed. They enable human interaction and are a place to tell your story, often on your own terms. Your website address on the Internet serves as the anchor for information about you and your organization. Maintaining current information in various formats, including stories, news updates, videos, photographs, and links to other resources, secures your position as a source of information. Reporters, policy makers, other colleagues, rival organizations, and the public use the Internet to gather insights and critique what your organization represents and has to offer in terms of expertise and influential opinions. Many organizations have online communities that provide not only information, but also interaction through message boards, surveys, blogs, and links to other resources. NurseSpace, from the American Nurses Association (ANA, 2017), is an example of a community with both open and members-only content. The Internet has become a mainstay for accessing health information for patients, healthcare professionals, and public health officials. Upwards of 59% of U.S. adults have looked online for health information within the past year, and that number rises among those who are managing a chronic health condition (Center, 2013; Fox & Purcell, 2010).

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Although many consider access to health information a positive force for public health and disease knowledge/management, not all websites and not all website searches are created equally. Dunne et al. (2013) note that websites containing inaccurate or biased information may precipitate the unintended consequences of misinformation and that most Internet search engine strategies rely on the number of hits a website receives and the readability of content but do not account for accuracy of the information presented. The authors further note that search engine optimization, or providing guidance in tailoring results, can be a critical factor in delivering trusted health resources and that such search practices should be considered by professionals or groups to deliver quality information to the general public. The ubiquitous nature of the information available on the Internet and the proliferation of social media have accelerated the importance of media literacy, which used to be focused primarily on recognizing bias. More developed critical thinking skills are required to recognize bias and satire, discern real news from news that is fabricated or distorted, and evaluate reliable sources (Kiley & Robertson, 2016). Political friction over alternative facts and accusations of fake news has further fueled concerns because fabricated information can spread in a matter of seconds over social media before it is corrected. Nurses can help provide legitimate information when the public may be at risk from misleading reports intended to fool readers by expressing extreme views as fact. Tactics may include reiteration of positions that have been debunked, presenting partial truths with a spin to appeal to a specific audience, and designing sources of information to look legitimate when they are not. The best advice is if a story seems shocking, be sure to read carefully past the headline, investigate the sources, and look for other corroboration of the information from credible sources. A growing number of organizations such as FactCheck.org and Snopes.com provide fact-checking. Mikkelson (2016) expresses greater concern for the volume of bad news, which includes the category of fake news.

Social Media Tools The Internet has made possible rapid communication, collaboration, and connections with others on a real-time basis. The digital communication platform of Web 2.0 offers tools to participate in active dialogue through user-generated content and sharing of personal and professional information. More and more organizations are finding engagement in social media an important adjunct to the more static website-based information for the distribution of professional content. Given the diverse preferences for communication among generations, social media helps reach segments of audiences that may not follow traditional sources such as print materials. Social media has changed the entre landscape of communicating and is an essential component of public relations (PR). Whereas PR used to be the vehicle to manage a message, it is now the means to facilitate an ongoing conversation in a 24/7 world. The use of social media tools by healthcare organizations has grown rapidly. Just 10 hospitals were using social media in 2006 compared with 762 in 2010 (Ressler & Glazer, 2010). Hospitals, associations, consumer groups, and many healthcare businesses have started using popular social media accounts such as Facebook and Twitter, placing icons on their web pages to link readers to their sites. Businesses may also use LinkedIn, a professional networking site, to provide news and updates about their work as well as encourage ongoing connections. For many of these sites, push emails direct readers or followers to visit the sites often to stay informed.

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The media convergence revolution is taking hold. Multiple platforms are being used with a shift to user-engagement and user-generated content. Current and emerging tools are making information and interactive communication available from single sites where video, live streaming, the ability to toggle to social media links, chats, messaging, and more traditional static information will reside together on a single site. Already, social media sites have formed partnerships to provide live streaming from traditional television sites, impacting immediate access to news that reaches a mobile multigenerational audience. Rapidly evolving technology makes information portable and its device agnostic, allowing the public to choose how and when they receive information, whether from their smartphones while on the go or from the comfort of watching television in their homes. The possibilities for policy applications are endless. Nurses can use these converged techniques to reach coworkers, student groups, public gatherings, or association members. When planning strategies to promote a policy, nurses are challenged to consider new methods that increase the reach to target audiences locally, nationally, and even globally. Nurses looking to the future will consider technology changes an essential component. Facebook, Twitter, blogs, Instagram, video-streaming sites, and quick response (QR) codes are some of the current popular free tools that have revolutionized real-time information sharing with the public. An example of the power of social media is demonstrated in the backlash to disparaging comments made by televisions hosts in Policy on the Scene 10.1.

POLICY ON THE SCENE 10.1: Miss Colorado and “Show Me Your Stethoscope”—The Power of Social Media and Professional Advocacy In 2015, Miss Colorado, RN Kelley Johnson, performed a monologue during the Miss America pageant’s talent competition in which she wore scrubs and her stethoscope and described a moving patient narrative in her own spoken word. The next morning, commentators from the TV show The View expressed the following: “She came out in a nurse’s uniform and basically read her emails out loud and shockingly did not win.”—Michelle Collins “Why does she have a doctor’s stethoscope on?”—Joy Behar “She helps patients with Alzheimer’s, which I know is not funny, but I swear you had to see it.”—Michelle Collins

Facebook and Twitter lit up immediately with tremendous backlash to the hosts of The View, for their disrespectful mocking of Miss Colorado, which also showed a profound lack of understanding about the work nurses do every day. Nurses around the world, as well as physicians, patients, and families, spoke out in response to the outlandish sentiment about a “doctor’s stethoscope.” On Twitter, nurses were quick to share vignettes about their critical work and uses of their stethoscope, and hashtags included #NursesShareYourStetho­ scopes, #NursingIsMyTalent, #ThisIsNotACostume, #ShowMeYourStethoscope, #NursesUnite, #RespectNurses, and #NursesMatter. The ANA and their constituent and state nurses associations (continued )

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asked that nurses tweet at The View, sending their stethoscope selfies using the hashtag #NursesShareYourStethoscopes. On Facebook alone, ANA’s post reached more than 4.7 million, and on Twitter, the hashtags had a reach of well over 2 million memes quickly circulated as nurses posted pictures in their “doctor’s stethoscope.” The Facebook group grew to over 600,000 members; after the backlash, commentators from The View were forced to make a public, on-air apology. Because social media pressure remained high, more than a dozen companies paused their advertising, with some issuing passionate statements about their respect, admiration, and support for nurses, praising their knowledge and skill and thanking them for the critical role they play in healthcare and their work to improve the lives of patients and families. The president of ABC News called the ANA president to offer his personal apology, promising to work with the ANA to help educate the public on the heroic work of nurses. Ultimately, five million people viewed ANA’s campaign on Facebook, and more than 38 million individuals around the world connected with media coverage of the story through Twitter or other social media sites.

Facebook Started in 2004, Facebook connects people with other individuals or businesses (Facebook, 2014). Boasting more than 1 billion users, Facebook businesses are sharing news, photos, and promotions with their followers. The primary use of Facebook in healthcare is for casual connection and information sharing because it makes posting of messages, photos, and videos easy. However, an example of using Facebook to change policy was the Obesity Action Coalition’s (OAC, 2013) efforts to remove the restriction on obese Boy Scouts from participating in the 2013 National Jamboree. As previously noted, it is also useful to advertise events. However, many hospitals, as well as nursing organizations, have Facebook and use it to engage with their communities. Twitter Twitter, considered a microblogging service, is a vehicle for connecting with other people and sharing timely news, opinions, and updates. The focus of Twitter is on the message. Opinion containing as many as 140 characters and posted as blast communication, photos, and links can be sent via this medium. Regular media sources use Twitter as an additional means of drawing attention to stories and people and connecting with audiences on the go. When you sign up to access a Twitter account, you become a “follower.” Twitter posts are sourced in major search engines, allowing access to real-time information, and can be data mined with stored searches through use of either search terms or hashtags. As is true with other blogs, one must consider the value of the source. Some popular nursing Twitter feeds include the ANA Government Affairs, NursingWorld Twitter feeds (Twitter.com/nursingworld), and American Nurse Today (Twitter.com/AmerNurse2day). International and national nursing and health conferences have started to disseminate specific hashtags that attendees can use on Twitter while at the conference to network with other health professionals and disseminate research findings. The use of Twitter among scholars and clinicians has been shown to promote research and engage with other professionals (Salzmann-Erikson, 2017). Twitter has had a growing user pool, with an estimated 218 million active monthly users, and many uses such as updating followers on an ongoing event or issue (Gomes & Coustasse, 2015). Rapidly sharing information on critical issues (e.g., drug safety alerts,

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potential epidemic developments, emerging disasters) is another benefit. Healthcare providers can also tweet to their patients and other followers about new developments in care or reminders about self-care. The use of Twitter for health policy is burgeoning, as are the applications for using Twitter in health-related research (Keim-Malpass, Mitchell, Sun, & Kennedy, 2017). Twitter is an ideal place for understanding the sentiment (overall negative or positive stance) of various communication strategies and messaging tactics. Even with the advantages of the social media tool, Twitter has been a largely untapped resource in hospital settings and among clinicians in terms of direct engagement with various patient populations (Gomes & Coustasse, 2015).

Blogs Blogs may have a broad or narrow topic focus or may be issue specific. Blogs mirror the historic model of one voice, one view on an issue. You can either pitch a blogger to cover your content or offer your own blog. The author/writer, or blogger, can do a deeper dive on issues and needs to be ready as the content expert to answer tough questions. Although most bloggers usually have expertise on a subject, nothing requires a blogger to be an expert; the follower needs to differentiate the credible expert from an individual who proliferates a dialogue with only opinion and not verified facts. The number of blogs is growing exponentially. Bloggers want to attract interest to their topics and opinions on a regular basis, bringing loyal followers to a website. They can also repurpose content, adding their own perspectives. Frequent updating is expected to attract new visitors and maintain repeat visitors to a blog website. Bloggers must heed the caution not to rant or face loss of credibility and interest among readers. With reliable facts, blogs can be a trusted source of information about nursing and healthcare. Blogs also offer a unique opportunity to understand various illness perspectives and treatment experiences beyond the traditional clinic walls and can be used to drive nursing science (Keim-Malpass, Steeves, & Kennedy, 2014). Instagram Instagram is a social networking platform that allows users to connect and share photographs and short videos, either publicly or privately and, like Twitter, uses hashtags to identify subject material and specific topics. In the United States alone, more than 78 million actively used Instagram in 2016, and the application continues to be one of the fastest growing social media platforms (DMR Business Statistics, 2018). Within the health realm, Instagram has been used to document patient experiences, engage in disease advocacy, advertise fundraising events, and connect users who may be impacted by the same disease (Braunberger, Mounessa, Rudningen, Dunnick, & Dellavalle, 2017; Demiris, 2016). Video Streaming YouTube and Vimeo are two examples of websites that host user-generated videos that can be either publicly or privately accessed on the web or through mobile applications. Video streaming is beginning to emerge as an embedded modality within Facebook and Twitter that users can experience in their home feeds and easily share through sharing the video (Facebook) and retweeting (Twitter). The use of video streaming in nursing has emerged in the context of education as a learning process aid, dissemination of nurse-led interventions, and understanding of the illness experience through study of patient-created videos (Harrison et al., 2017; Keim-Malpass et al., 2013; Wright & Abell, 2011).

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QR Codes A QR code is a type of two-dimensional barcode read with a special application on smartphones and some tablets. Originally developed for marketing, QR codes have become a tool that can connect people in ways that have not been fully explored. The code can provide access to prewritten text, connect to a website, send an email or a text message, and receive a telephone number or make a call. The codes have a characteristic square pattern arrangement of modules. Codes can appear anywhere a user might want to seek more information such as magazines, signs, giveaways at meetings, flyers, and any print material. Providing QR codes on your organization’s materials that link to information important to policy makers is one way to take advantage of this technology. As they prepare briefs, backgrounders, and policy briefs, organizations can create their own QR codes to link back to more issue-specific information on their websites. Another easy way to provide a link for policy makers to information about you and your organization is to provide a QR code on the back of your business card.

Special Uses of Social Media Social media (e.g., Facebook, Twitter, Instagram, video-streaming sites, QR codes) can be used for many special applications within the realm of public health, social marketing, research and understanding of public responses to worldwide health events. Individuals rely on media, and social media as important sources of health information, and before engaging in a social media platform for health, nurses must take into account cultural norms, developmental considerations, and the way that opinions and sentiments may be shared through social media (Krieger et al., 2013; Zhang, Gotsis, & Jordan-Marsh, 2013).

Social Marketing and Public Health Some researchers have suggested the need to have innovative public health paradigms and social media involvement to initiate and sustain public health campaigns, including innovations in health communication through media convergence (Niccolai & Hansen, 2015). One such modality is understanding the context of public health communication and promotion as a social marketing entity and the importance of delivering reliable health information to the public. Social marketing is the “activity, set of institutions, and processes for creating, communicating, delivering, and exchanging offerings that have value for customers, clients, partners, and society at large” (Nowak, Gellin, Macdonald, Butler, & Group, 2015). Social marketing can be used as a public health framework for developing interventions for the greater public health good and involves techniques from commercial marketing concerning the four ps: product, price, place, and promotion (Roncancio et al., 2016). To date, social marketing has been applied to interventions focused on eating healthy diets, increasing physical activity, and breastfeeding (Roncancio et al., 2016) and only recently has been conceptualized as a public health framework to decrease vaccine hesitancy (Cates, Shafer, Diehl, & Deal, 2011; Hull et al., 2014; Nowak et al., 2015; Roncancio et al., 2016). Along with traditional text-based dissemination, the use of infographics is becoming increasingly common to spread health messaging through social marketing. Infographics are an engaging method of visually communicating information in a colorful and concise manner and enhances our ability to visualize and interact with pertinent data (McCrorie, Donnelly,

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& McGlade, 2016). Infographics can be designed for mass communication through social or print media outlets or can be a means of tailoring communication with the public on a smaller scale (e.g., poster on a college campus; McCrorie et al., 2016).

Disaster and Disease Response Previous research has demonstrated that social media can be used as a proxy for disease activity (particularly infectious diseases) and responsiveness to public health intervention (Sinnenberg et al., 2017; van Lent, Sungur, Kunneman, van de Velde, & Das, 2017). Content embedded within social media can be extracted for tracking or even forecasting disease events if used in a specific manner and can be used to indicate specific outbreaks of disease (Signorini, Segre, & Polgreen, 2011). In addition, it has been used to analyze the public response and fear related to certain diseases, such as Ebola and the Zika virus (van Lent et al., 2017). In 2014 when the world was startled by the epidemic of Ebola in Guinea, Sierra Leone, and Liberia, researchers noted that the general public converged media engagement, and responses made the epidemic feel psychologically close due to several people being treated in the United States (van Lent et al., 2017). Researchers have indicated that the upswing in the use of social media has decreased our perceptions of social distance, making it easier to give public attention to worldwide crises such as epidemics (van Lent et al., 2017). In addition, many believe that the social media response to certain tragic events and disasters, such as the Boston Marathon bombing in April 2013, have strengthened the disaster preparedness infrastructure and allowed public health professionals to more easily communicate needs and response strategies in real time (Cote & Hearn, 2016). Crowdsourcing Crowdsourcing originated in the business realm but has increasingly been recognized as an essential activity within the realm of participatory networking (McCartney, 2013). Within healthcare, crowdsourcing has generally been described as a social media model for enabling public involvement in the process and can be viewed through the lens of patient- or clinician-initiated crowdsourcing. Generally, crowdsourcing can be used to engage large, diverse groups of people to participate in research, study digital strategies, respond to emergencies, and even gather opinions regarding difficult diagnoses or treatment-related questions (Rumsfeld et al., 2016; Schemmann, Herrmann, Chappin, & Heimeriks, 2016). Increasingly, there has been momentum to involve patients through every phase in the research process through the advent of crowdsourced research protocols and participatory design (Franzoni & Sauermann, 2014; Schemmann et al., 2016). Nearly any social media platform can be used to pose a crowdsourced question and elicit targeted responses. Even so, there must be an acknowledgement that the use of digital engagement strategies can have unintended consequences and a lack of quality control of information delivery (Rumsfeld et al., 2016).

Social Media and Political Activism The Future of Nursing report (Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, 2011) calls for nurses to directly engage in health policy and lead the transformation of the U.S. healthcare system. Nursing has consistently been ranked among the most honest professions and represents a significant percentage of the U.S. workforce; however, this does not always translate into direct policy influence (Waddell, Audette, DeLong, & Brostoff, 2016). Nurses have a unique on-the-ground

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perspective, should be viewed as a critical policy-promotion resource, and should have the opportunity to engage in civic discourse and advocacy (Waddell et al., 2016). Nurses are actively finding better ways to convey civic engagement and political messages in a turbulent political environment, and often their engagement is enhanced through social media platforms (Matthews, Burris, Ledford, Gunderson, & Baker, 2017). Mobilizing nurses to engage in policy advocacy was a critical approach to influencing action on a Veterans Affairs rule to secure full practice authority for three categories of advanced practice registered nurses (APRNs) as described in Policy on the Scene 10.2. In early 2017, nurses were engaged in advocating for patients through the uncertainty of the repeal of the Patient Protection and Affordable Care Act (ACA). They mobilized through professional organizations (e.g., ANA) or used social media sites such as Facebook and Twitter to engage in political messages and urge others to contact their local representatives.

POLICY ON THE SCENE 10.2: APRN Scope of Practice Within the Veterans Affairs System In 2016, the Department of Veterans Affairs (or the Veterans Administration [VA]) proposed an amendment to its regulations to grant full practice authority to advanced practice registered nurses (APRNs) when they are acting within the scope of their VA employment (Lambert-Kerzner et al., 2016; VA, 2016). The VA is the nation’s largest employer of nurses, with approximately 93,500 RNs and nearly 6,000 APRNs. A major impetus for the regulation change was the need for full practice authority for APRNs to improve access and enhance quality care for our nation’s veterans and their families. The recommendation was preceded by an extensive evidence-based synthesis that described no differences between APRN and physician care in affecting the following outcomes: health status, quality of life, mortality, or hospitalizations (McCleery, Christensen, Peterson, & Humphrey, 2014). Scope of practice is of great importance to the VA system because the use and employment of APRNs have increased since the mid1990s (McCleery et al., 2014). Following the VA draft rule announcement, there was significant policy engagement through social media among professional organizations (including the ANA) and APRN advocates. The VA stated that this rule making would increase veterans’ access to VA healthcare by expanding the pool of qualified healthcare professionals who are authorized to provide primary healthcare and other related healthcare services to the full extent of their education, training, and certification, without the clinical supervision of physicians. (Federal Register, 2016)

Numerous online petitions were circulated, and there was an opening for public comment. An unprecedented response yielded more than 200,000 comments. Although the final rule included nurse practitioners, certified nursemidwives, and clinical nurse specialists, it excluded certified registered nurse anesthetists (CRNAs) from the scope of practice expansion, and significant advocacy efforts continue to urge the VA for full implementation (VA, 2016). The VA claimed that there was no access problem related to anesthesia care, which was refuted by evidence gathered through independent, congressionally (continued )

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mandated assessments of VHA facilities confirming that veterans experience surgical delays due to lack of anesthesia support and are sometimes diverted to other facilities for care (Nimmo, 2017). Cheryl Nimmo, U.S. Army Reserve veteran and president of the American Association of Nurse Anesthetists, suggested that including CRNAs in the scope of practice enhancement would align with the U.S. Department of Defense policy that already allows CRNAs to work as full practice providers in other military service branches and that appropriately using CRNAs within their full practice authority would increase access to surgical care services without additional funding (Nimmo, 2017). Continued advocacy engagement is needed for this critical APRN issue, and there is a role for social media in continuing to mobilize the CRNA workforce and APRN advocates.

Challenges for Using Social Media in the Workplace Many organizations have adopted policies to direct the appropriate use of social media to protect the patients, staff, and institution. Protecting patient confidentiality, adhering to laws governing privacy, and maintaining appropriate patient–professional boundaries are typical areas addressed in policy. Numerous organizations around the world have issued guidelines about the use of social media, stressing how to avoid problems (ANA, 2011; Barry & Hardiker, 2012; National Council of State Boards of Nursing [NCSBN], 2011). Organizations have invoked policies to protect patients, staff, and their reputations. As with any new medium, a few individuals have abused it, and some have used social media without understanding its implications. As a result, some policies have been overly restrictive and have not allowed people to explore the potential positive uses of social media. Following accepted guidelines and etiquette for proper communication, as well as being tech savvy, will lead to effective use of social media such as Facebook and Twitter.

TRIED AND TRUE: GUIDELINES FOR WORKING WITH THE MEDIA Whether you want to contact the media as an individual or as a representative of a group, first become familiar with the type of media you believe will help convey your message. For local issues, knowing the interest and track record of the print and broadcast media coverage of public health issues is important. Become acquainted with the reporters and, if possible, cultivate relationships that can lead to more longitudinal coverage of an issue. If your reach is to Congress, contacting papers and media outlets that cover politics and access a broader audience is necessary. Organizations should maintain an updated media contact list. If you hold events, maintain a sign-in list and follow up with media representatives to thank them for attending. National directories are available for a fee to locate media outlets. Media directories are available by state, which can be easily found by typing media directory and the state into a search engine. Professional associations can also be a resource. For example, the National League for Nursing’s (2017) Legislative Action Center has an interactive search page to locate local and national media organizations. It is also important to seek resources in your community and establish relationships before a pressing issue becomes news. Traditional (e.g., newspapers, radio, television)

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and nontraditional (e.g., Internet, electronic bulletin boards, blogs, corporate and community organization newsletters) media reach different audiences and help replicate your message. Get to know your local newspaper editorial staff, talk radio personalities, and television broadcasters. Healthcare organization PR and marketing staffs may be less familiar with how to promote nursing stories, so it is important for you to familiarize them with issues important to nurses, as well as nursing interest stories. For example, invite your organization’s PR staff to attend events such as nursing research presentations, awards ceremonies, advancement celebrations, and community service days. Request that a consistent person be assigned to cover nursing events to avoid a repetitive learning curve. PR staff members make excellent partners, are familiar with writing guidelines, and usually have already established relationships with local media representatives. Since it is their job to make an organization look good in the public eye, you can help make their job easier by being a resource and alerting them to newsworthy stories. As you work with the media, it is essential to make yourself available in a timely manner to reporters seeking information, interviews, or quotes; this helps journalists respond to tight deadlines. These stories do not always have much lead time. Remember, you are responding on the record, so your comments can be used and quoted. Being prepared when a hot issue breaks allows for immediate coverage and premier positioning of nursing’s response. If you initiate the media contact, your message must be clear and concise. Using personal experiences makes examples more compelling and easily understood.

Message Development Your message is a value proposition, so you must explain why an issue is important, what is at risk, and why one should care, as well as why someone should act. The more closely you can align the message with others who share your values and concerns, the more support you will engender. Being prepared with a plan is the starting point for advocating an issue. Professional associations provide a wealth of background information for their members such as fact sheets, issue briefs, policy analysis, and talking points. These may be combined into a comprehensive resource, allowing one to be prepared when planning outlining goals and objectives, and crafting an effective message. Knowing the overall goal of the actions you are taking on an issue allows you to identify appropriate audiences and the most effective types of media to reach them. Your goal may be to introduce a new issue and ask others to join in action. Or you may want to express a position or opinion about a current issue in your community or on a state or national agenda. Your plan to develop a clear and simple message includes the steps in Exhibit 10.2.

Developing a Case Statement: Tell Your Story A simple compelling story often captures attention. Telling your story starts with the facts and builds on what your audience knows and believes. Case statements are often used in fundraising circles and involve a simple compelling story that captures the essence of your values, as well as what you are trying to address with policy. Try to establish a personal connection, one that inspires an emotional attachment on the part of the audience. Often issues are depicted as having a threat, a victim, good guys and bad guys, and a real or potential solution. Drawing the lines and explaining your side helps define what is at stake. Define the actions you want to take that will solve a problem. Linking solutions to problems, and explaining how the audience can help, advances an action agenda.

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EXHIBIT 10.2  STEPS TO DELIVERING A SUCCESSFUL MESSAGE 1. State your goal clearly. 2. Identify your audiences. 3. Define your issue—the issue must draw attention and be considered “newsworthy.” 4. Include only one main message with no more than three underlying themes of support. 5. Confine your message to 30 seconds or less so that it is memorable. 6. Frame your statements so that your message connects to the greater public’s interest. 7. Be strategic when proposing a solution. 8. State the support sought. 9. Compel the audience to be concerned about your issue. 10. Use humanizing examples and/or analogies. 11. Match your message and language to the audience. 12. Repeat your message frequently and consistently in all communications. 13. Evaluate your message effectiveness.

Talking Points Talking points are a useful tool for focusing a message on facts, which will in turn educate media sources, internal and external stakeholders, and the public. Talking points are a short list of arguments that succinctly summarize your arguments for or against an issue. Advocating for pending or new legislation routinely calls for concise communication to express opinion to lawmakers and to educate the media and the public. Many nursing organizations equip their members with talking points on current issues, particularly when there is a planned lobbying event. Examples are the issues highlighted by the American Organization of Nurse Executives (2018) for talking with congressional representatives addressing important legislation (Title VIII funding for Nursing Workforce Development Programs and the National Institute of Nursing Research, the Home HealthCare Planning Improvement Act of 2017, the 2018 budget proposal, preservation of healthcare coverage, Medicare Access and CHIP Reauthorization Act quality payment program, and expansion of nurse-managed clinics and advanced practice demonstration programs). The “Pitch”: Getting Your Story Heard Getting your story heard can be achieved with a succinct, powerful, 25- to 35-word description of your subject and position, answering what your issue is about, who is the target of your issue, why anyone should care, why your position is different, and what your qualifications are for making the pitch. Otherwise known as an elevator speech, it is an ideal way to pitch newsworthy information (see Chapter 2). The message includes the concise wording one would use in a theoretical encounter with a captive audience when you have less than a minute to make a lasting impression (Pagana, 2013). Brevity is key to getting your message across. The pitch can be made in writing, in person, or via telephone. When pitching your story, follow these five rules: (a) Introduce yourself, your credentials, and your affiliations; (b) inform them of your story idea; (c) ask if it is a good time to talk; (d) offer your brief description of what, who, and why; and (e) confirm follow-up plans. Avoid healthcare jargon to enhance clarity.

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Written pitches by letter or email should be no more than one page. Present the issue in a concise manner and establish relevance and timeliness to the audience. Include a simple description of your story and provide names of contacts, resources, and appropriate contact information. Other preparations include compiling supporting documents, developing talking points, and determining who is available to be interviewed. However, when working with television stations, plan on no more than 15 to 30 seconds of coverage and prepare recommendations for video coverage that support your story. You must be clear about identifying who you are, what your credentials are, and in what capacity you are speaking. Identify whether you are acting as an individual, as a concerned citizen, or as an official spokesperson of an organization or group. It may be useful to have personal calling cards prepared for use when business cards with your employer’s name are inappropriate.

Reporter Calls When a local issue breaks or if your organization is on the critical path of a story line, being prepared for reporter calls puts you in a prime position to respond. Reporters are looking for access and information, not an adversarial relationship. Some due diligence is essential to preparing your ideas and being sure you will be able to anticipate the request of the reporter and the timeline for responding. Understanding the reporter’s interest and familiarity with the subject, as well as the priority for the story, provides clues about the amount of information you need to provide. Information to gather from the reporter is reviewed in Exhibit 10.3. Ask clarifying questions before providing answers. Never argue, but stick to your message. If it is a negative story, additional preparation may be necessary, but in general, take some time to prepare thoughtful responses. Indicate that you will get back to the reporter within the designated time frame. Do not repeat a negative statement or question because it may inadvertently get associated with you or your organization. Sound Bites A short 10- to 20-second statement comprises a sound bite that you may develop or that the media may distill from longer stories. Sound bites should support your proposition. You can promulgate them as short quotes and use them repeatedly in conversations, in interviews, or on social media. Anticipating what might be used in a negative perspective is helpful as well; try to avoid providing ammunition for your opposition. Sound bites can also be pulled from written statements with a memorable phrase that creates an emotional connection between your issue to your audience. Shorter social media messages are prime vehicles for conveying poignant and pithy phrases. EXHIBIT 10.3  THINGS TO KNOW BEFORE RESPONDING TO A REPORTER • • • • • • •

Topic of interest Type of information you are being asked to provide Type of information the reporter has already gathered Importance of the story Who has the expertise and experience to give the best interview What background information is available and can be shared publicly Deadline for the story

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Press Releases and Advisories Press or news releases are intended to convince reporters to cover a story. Reporters scan news releases to gauge interest in potential stories. Bloggers, policy experts, and the public also pay attention to press releases for basic information on issues. This section includes techniques for writing releases and provides examples of press releases that can provide additional and correct misinformation.

Inverted Pyramid Widely used for more than a century, many news writers use the inverted pyramid guide as depicted in Figure 10.1 in response to readers’ desire for fast-paced delivery of information that holds their interest. In this style, the most important information is provided up front. The content covers the five Ws and H: who, what, where, when, why, and how. The amount of content diminishes as do the sizes of the three areas of the pyramid. Alternatively, presenting a story that is idea-driven or reported in chronological order may be appropriate for more human-interest stories rather than breaking news. Writing a Press Release The standard format for a press release provides quick access to all the information a reporter needs and indicates how to get in touch with the author. To grab a reporter’s attention, start with one or two strong leading sentences to convince the reporter that the issue has news value. Address who and what in the first sentence. Throughout the story, address when, where, why, and how. Follow the introductory paragraph with one that begins to communicate feeling; using a quote helps personalize the message. The concluding paragraph typically includes a quote. Above all, the information must be credible and defensible. Once the entire release is written, devise an eye-catching headline. It can have up to 10 words, and subheadlines are acceptable. Purposeful inclusion of positive or negative words can shape the reader’s opinion of the story. A sample list of positive and negative words in Exhibit 10.4 illustrates the power of adjectives; the same impact applies to oral presentations. Important items to consider when issuing a press release are displayed in Exhibit 10.5. Nursing organizations actively disseminate press releases on a variety of topics throughout the year to address issues from responses to tragic events; notable events and funding awards; congratulatory accolades; expressions of positions on issues of major import at the local, state, or national level depending on the scope and reach of the organization; and recognition of major legislative victories.

Who, What, When, Where, Why, How

Important facts, quotes, details

Background, least important details

FIGURE 10.1  Journalism inverted pyramid.

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EXHIBIT 10.4  POSITIVE AND NEGATIVE OPINION WORDS POSITIVE WORDS

Acclaimed Appealing Beneficial Courageous Distinguished Effective Flourishing Generous Impressive Knowledgeable Quality Respected Successful Transformative

NEGATIVE WORDS

Abysmal Angry Callous Despicable Difficult Disastrous Dishonest Expensive Ill-conceived Terrible Tired Unhappy Unpleasant Weak

In response to the growing concerns about the rising opioid crisis in the United States and the legislation paving the way for nurse practitioners to prescribe medication-assisted treatment (MAT), the American Psychiatric Nurses Association (2017) issued a press release announcing the offering of two free online courses to prepare EXHIBIT 10.5  SAMPLE PRESS RELEASE CONTENTS • Organization’s name • Use of letterhead if possible • Contact information • Contact person • Company name • Phone and fax numbers • Email address • Website address • Catchy headline • Release date • City, state, followed by lead sentence • Body of message • Powerful introductory paragraph • Quotes • Organization “tag” (standard paragraph that describes organization or goals highlighted in the release and that may be in italics) • For more than one page, use of “—more—” at the bottom of the page and abbreviated headline at the top of the second page; repeated contact information at the end • At the conclusion, use of “END” or “###” to indicate end of content

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APRNs to be able to meet requirements to prescribe MAT for opioid disorders, desperately needed care in communities across the country. An important initiative for curbing the overuse of care is the Choosing Wisely® campaign of the ABIM (American Board of Internal Medicine) Foundation. The American Academy of Nursing (AAN) is an active partner in this initiative and, in turn, has engaged other nurses associations to identify evidence-based recommendations to help patients make the best decisions about their care. In 2017, the AAN announced their fourth set of specialty recommendations in collaboration with the American Association of Neuroscience Nurses in a press release building the Academy’s list to “Twenty Things Nurses and Patients Should Question.” In the first half of 2017, the ANA issued 22 press releases covering national policy topics such as the opposition to efforts to repeal and replace the ACA by both the U.S. House of Representatives and the Senate, opposition to the president’s executive order on immigration, and the proposed 2018 national budget. Press releases targeted for a nursing audience included an announcement of work with the Centers for Disease Control and Prevention (CDC) on infection prevention; and announcement of the launch of ANA’s Healthy Nurse, Healthy Nation Grand Challenge; a revised statement opposing capital punishment; and statement of support for nurses to lead and transform palliative care in all settings. Recent releases can be viewed on NursingWorld (https://www.nursingworld.org/news/news-releases), a site that is updated regularly.

Press Advisories Press advisories alert the media to a pending event. For example, an organization may want to invite the press to cover an upcoming conference. A hospital or nursing school may want to alert the press to a release of research findings or innovations important to improving care. The announcement should be brief but arouse interest without exposing the whole story. Be sure to include the sponsor (who), subject (what), time (when), place (where), and relevance (why), as well as contact information. A press advisory may also ask media representatives to respond if they are planning to cover the event. If you have provided more than a week’s advance notice, plan to send a follow-up message 1 or 2 days before your event. Email transmission is common for both press releases and advisories. When sending information to media sources via email, limit the text to 500 words, or approximately five paragraphs. Expert sources accept longer releases of one or two pages. Avoid sending the key information only in an attachment. Place a short headline in the subject line of the email using the most important attention-grabbing words. Include URL links to additional information sources. Mirror the format of a press release. Both the advisory and the email should begin with contact information followed by the headline and then body of the release. Do a test of your email because formats may change with transmission. When sending to multiple media representatives, place the names as blind copies so that addresses are not shared without permission. Releases and advisories sent at slower business times receiver greater attention. Aim for late morning. Nurses rarely have difficulty establishing credibility. Despite the portrayal of inaccurate stereotypes on television and other entertainment, the mainstream media recognizes and respects nurses’ expertise. Academic degrees, certifications, and job titles convey a certain status and should be used when contacting the media. When representing an organization, pick an appropriate leader or spokesperson.

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MESSAGE DELIVERY Effective message delivery includes knowing your audience and their interest in your story, as well as ways to deliver a message using a specific medium. Each of these media—written, voice, or visual—requires specific strategies to enhance policy impact.

Knowing Your Audience and When Your Story Is of Interest Knowing the right medium for reaching the target audience guides media strategies. If you are taking your message to a broad audience, it may need to be tailored in several different ways to reach different groups. Questions to bear in mind for any audience include What is important about this issue that should make others care? Of what interest is this to the targeted audience? What will capture the attention of this audience? Is it a friendly audience or one that bears convincing? What actions can I expect or request the audience to pursue? Is the timing right? The reporter’s or your target’s response to a conversation with you can reveal if or when you have piqued their interest. According to Fitch and Holt (2012), immediate silence is not a good sign, but an initial response of “Really?” means the reporter wants to hear more, and a “Wow” is promising for a print story and is your cue to get ready to respond with an interview or additional materials; “Holy s--t” is a top-drawer response that is almost a guarantee of a print coverage.

Policy Makers Reaching local policy makers may require tracking down someone at a home or a work address because they often fulfill public duties as a part-time responsibility. Reaching state and national policy makers usually requires initial contact with their staff. Response times may vary. Federal officials have a chief of communication and dedicated communications staff, as well as issue-specific staff. Many have someone assigned to cover healthcare issues. The more potent your message, the greater likelihood policy makers will take note and listen. Successfully getting on the public’s agenda also almost guarantees getting on a policy maker’s agenda. The messages are synergistic for focusing attention on health issues and concerns that affect large constituencies. The typical vehicles for delivering your message to policy makers include letters, emails, opinion editorials, background papers, blogs, press releases, and published articles, all of which can be made available to the individual and staff. General Public Broadcast media (both television [news and non-news] and radio), newsletters, newspapers, bulletin boards, and social media will reach the public. Offering nursing’s response to time-sensitive current events or weighing in to a larger debate, can bring attention to nursing’s interest in and viewpoints about public health issues, as well as the welfare of the general public and nurses. Although most consumers have interest in nursing’s message, it may be only situational and, thus, calls for aiming the message for broad appeal. Nurses should also weigh in on current events that relate to the public health and well-being to solidify nursing’s role of advocacy in the eyes of the public. Issues such as obesity, opioid addiction and substance use disorders, gun violence, and legalization of marijuana have struck a chord, and nurses, as opinion leaders, can provide a viewpoint that shapes local

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sentiment and brings the perspective of a trusted professional. The mass shootings targeting the gay community at the Pulse Nightclub in Orlando in June 2016, where 49 people lost their lives, sparked outrage in the healthcare community and the public at large. The ANA’s Membership Assembly joined the public outcry by issuing a declaration in support of meaningful gun-control legislation to protect society, including repeal of the legislation that blocks CDC research on gun violence and encouraging dialogue to stop hate and violence (ANA, 2016). Public service announcements (PSAs) are also an effective way to spread your message at no cost to your organization. The announcement must benefit the community; most often, it is used to announce a nonprofit community event or service. The announcement can be in written form or presented in audio or visual format. If transmitted electronically, radio or television coverage is typically a short spot less than 1 minute in length. Like press releases, the PSA includes the typical who, what, where, when, and why.

Journalists Most of the exposure we seek for delivering our message is through journalists. Press releases, letters to the editor, opinion editorials, email communications, interviews, and media events target the health and general interest media with the intent to have our story published or broadcast. Multiple channels increase the odds of successfully disseminating your issue and opinions. Journalists are also relying more on social media as a source of information. Despite a plethora of criticism of mainstream media from public officials, journalists remain the top vehicle for coverage of our issues and enable message delivery across a variety of platforms.

Delivering Your Message—Put It in Writing! As previously discussed, communication about an issue written in your words or expressing the position of an organization is a simple tool that can deliver a powerful message. Written formats provide asynchronous contact and can be sent to multiple media sources at the same time to maximize coverage.

Letters to the Editor Newspapers and journals accept letters that offer commentary on other published articles or issues of current interest. Letters are also used to respond to criticism, offer a different view on a recently covered topic, correct inaccuracies, or add interesting content to a recent story. A letter to the editor is simple and focuses on one key point. Plan on a short letter of approximately 150 words that succinctly describes your ideas; check the editorial specifications because the limit may vary. If referencing a previous article, include a brief explanation so that readers connect your letter with the original source. Send letters quickly and in close proximity to the event or article you are addressing. Include your name, address, telephone numbers, and email address for follow-up information. When nurses and other groups across the country were involved in advocacy for APRNs to gain full practice authority within the VA, the ANA secured a letter to the editor in the Washington Post (Cipriano, 2016), as seen in Exhibit 10.6. The use of a high-profile letter to the editor on this issue (highlighted in Policy on the Scene 10.1) is an example of social media and political activism, which also reflects the power of converged media using multiple vehicles for message delivery.

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EXHIBIT 10.6 AMERICAN NURSES ASSOCIATION PRESIDENT’S LETTER TO THE

EDITOR IN THE WASHINGTON POST SUPPORTING FULL PRACTICE AUTHORITY FOR APRNs IN VETERANS AFFAIRS

Proposed VA rule is about providing better care to veterans, July 22, 2016 The July 19 Washington Post article “Battle Over VA Plan for Veterans’ Care Builds” framed nurses’ efforts to provide our nation’s veterans with direct access to high-quality patient care as a turf battle between physicians and nurses. This is not about doctors versus nurses but about how we can work together to meet the pressing care needs of veterans. The proposed Veterans Affairs (VA) rule that would grant APRNs full practice authority states that “APRNs would not be authorized to replace or act as physicians or to provide any healthcare services that are beyond their clinical education, training, and national certification.” Veterans service organizations, consumer groups, and more than 80 members of Congress support this change because the research is clear: Nurses consistently deliver exceptional care with high patient satisfaction when allowed to work to the full extent of their education and training. To provide quality care to veterans, all healthcare professionals must work together as a team. Pamela F. Cipriano Silver Spring, Maryland The writer is president of the American Nurses Association.

Opinion Editorials Opinion editorials (op-eds) appear opposite the editorial page in a newspaper and aim to evoke an emotional response from the reader. The targeted opinion piece opens with a strong statement or argument and offers a clear point of view. Op-eds can be used to persuade public sentiment or to defend a policy position. They are more successful when they are written about current issues that appeal to readers with an urgency for understanding and action. In March 2017, Mary Wakefield, former acting deputy secretary of the U.S. Department of Health and Human Services, sent an op-ed to five newspapers across North Dakota as the U.S. House of Representatives was preparing to vote on their American Health Care Act (AHCA). The Grand Forks Herald (Wakefield, 2017) and others published her editorial, which highlighted facts about the AHCA that revealed stark contrasts in benefits provided under the ACA. Most notable was her clear articulation of the facts and emphasis on her perspectives as a nurse. Because of her stature as a highly regarded policy expert, others took notice, spawning dialogue on the issues she raised. Tips for a successful op-ed are displayed in Exhibit 10.7. Be sure to check the policies and submission guidelines for your chosen publication. Contacting the editor to introduce yourself and your topic in advance may increase the likelihood of publication. For local publications, a strong association with a local angle increases your editorial appeal. See the sample letter to editor excerpts in Chapter 1’s, Healthcare Reform. Organizational Policy-Oriented Newsletters and Electronic Communications Many different types of nursing groups use newsletters and email blasts to list-serves as effective vehicles for reaching a specific target audience. Hardcopy newsletters are becoming less common, giving way to electronic ones that arrive quickly and at a lower

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EXHIBIT 10.7  KEY POINTS FOR GETTING AN OP-ED PUBLISHED • • • • • • •

Provide author’s credentials and expertise. Develop a catchy title. Incorporate data/statistics, expert testimony, or other resources. Describe a personal story or analogy. Create an engaging flow of ideas. Close with a strong final sentence culminating the argument/position. Limit reading time to under 5 minutes; 700 to 800 words.

cost, with links to additional information. Newsletters, in general, can be read asynchronously at someone’s leisure, making them more effective than media such as radio, television, and some websites, where content is updated and older coverage may be available for only a brief period. The content must match the target audience’s interests and include items that are newsworthy. Newsletter contents should also follow the inverted pyramid style of an effective headline followed by the five Ws and H and then the supporting information in descending order from most to least important. Newsletter articles and email update designs should focus on a primary issue with a persuasive argument or point of view that creates interest. Ensure the accuracy of the content to earn the trust of your audience. Content delivered electronically requires some additional preparation, including addressing visual display differences for electronic in-box formats, offering other versions such as HTML, and offering an opt-in process for receiving the newsletter. Sending frequent electronic editions can increase your reputation as a top-of-mind source of information. The same format can be used to send special messages highlighting a release of distinct urgent information. The ANA SmartBrief is an excellent example of an opt-in electronic newsletter for members; it addresses newsworthy items with URL links so that readers can retrieve in-depth information. It offers an optimized mobile version of the newsletter, as well as an ­in-box email version. ANA members can sign up (http://www2.smartbrief.com/ getLast.action?mode=sample&b=ANA) to receive this daily collection of handpicked news sources for current trends and issues; it is also offered to non-nurses for a small annual subscription fee (www.smartbrief.com/signupSystem/subscribe.action?pageSe quence=1&briefName=ana&campaign=in_brief_signup_link&utm_source=brief).

Policy Briefs, Backgrounders, and Tip Sheets A policy brief succinctly states a position. The target audience is policy makers who seek facts and arguments about an issue from trusted sources. A brief, as its name implies, is concise and quickly conveys the important policy facts and implications, poses questions for policy makers to consider, and proposes arguments substantiating one’s position on the issue. An effective policy brief is persuasive and well organized. The contents of a policy brief are addressed in Exhibit 10.8. Issuing a policy brief on an emerging or a critical issue positions your organization as an opinion leader on a subject. One of the recurring issues plaguing nursing is periodic workforce shortages. In its policy brief, the American Association of Colleges of Nursing (2017) lays out the facts, contributing factors, impact, and strategies for

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EXHIBIT 10.8  CONTENTS OF A POLICY BRIEF • • • • • • • • • • • • • •

Introduction Overview Statement of the problem or objective Argument or thesis Clear statement of position Recommendations (placed at the beginning) History and relevant background Analysis Critique of arguments, alternate viewpoints, and quality of evidence Citation of evidence that supports your thesis and recommendations Conclusion Argument Call for action Summary statement

addressing the problem. With links to other pertinent documents and supporting information, it serves as resource to nurses, the media, and others interested in understanding this complex issue. A media backgrounder addresses one topic and is written without bias. It usually includes a fact sheet with statistics, timeline of related events, contact information, and description of sources. Backgrounders should be no more than three or four pages, with facts appearing in an easily identifiable format such as bulleted notes so that a reporter can easily identify salient points. Longer papers such as white papers, reports, or analyses are not expected to generate a rapid response. Tip sheets that provide either facts at a glance or an exhibit that expands on the contents of a policy brief are helpful materials that add depth to other formal statements. Consistent updating of media backgrounders, tip sheets, and fact sheets advances an ongoing agenda by having information at the ready when new developments occur or when an organization wants to refresh coverage of their position.

Delivering Your Message—Voice and Visuals Live presentations provide the opportunity for powerful message delivery. With videography and use of podcasts, the message can be rebroadcast and quickly made available to remote audiences.

Images Visual images can help transmit a message that words alone cannot convey. Availability of portable high-quality still and video cameras has made the use of visual images an integral part of messaging today. Photographs are commonly used in newsletters, on websites, and in social media, as well as supplied to print media outlets. In the absence of live footage, television stations may also use still photos. Obtaining permission with a signed photography/videography release form is essential for using pictures of individuals not associated with your organization. A professional photographer owns the copyright to photos and must grant

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permission for you or your organization to place the image on a website or reuse a photo. In addition to any required fees, the site or publication gives attribution to the photographer.

Speeches Speeches at scheduled meetings may get the attention of a reporter with advance promotion of a well-known or important presenter or the announcement of breaking news. Reporting controversial expert knowledge or revealing important findings also helps guarantee coverage. As with press conferences, advance materials enable the reporter to judge the importance of covering your meeting. Typically, nursing media representatives cover a limited number of national meetings, but regional, state, and local meetings draw fewer reporters in the absence of a highprofile speaker or topic. You may want to request a brief podcast recording with your speaker to archive for later use. Also, arranging time after a presentation for an invited speaker to grant interviews to the press can provide a personal angle and more in-depth content for a reporter. Seasoned speakers may or may not have honed their interview skills, so you want to work with the interviewer to limit the subject matter to what was presented at the meeting and a specific area of expertise. Having your own spokesperson in attendance also allows for an additional perspective to represent your organization in the event that there is a discrepancy between the speaker’s comments and the organization’s; it is important to provide distinction between the two. Organizations want to have experts at the ready for interviews of all types (live or taped, radio or television, print coverage). When a hot topic emerges, have your most articulate spokesperson available and prepared for impromptu or scheduled interviews. Many organizations maintain a speaker or media contact list or advertise a speaker’s bureau. Consider signing up with your availability dates and times. Remember to keep your expertise and contact information up to date. Interviews The fastest way to circulate your information is on the radio. Not surprising, the best times are during the morning and evening commutes (6–10 a.m. and 4–7 p.m.). The morning audience tends to be almost three times larger than afternoon. Radio interviews, often done over the phone, are usually short, less than 5 minutes; questions are direct and predictable; you can help shape them by talking with the radio show host in advance or sending in questions that address the topic you will discuss (Fitch & Holt, 2012). Television and the use of video add emotional intensity. Television is part show and part content. Like radio, interviews can be live or taped. If live, being prepared to respond to an emerging issue that is critical. If taped, there is typically more time to prepare and stage the interaction. Timely topics include connections to a current news story or a new development in healthcare or your organization. Maintaining readiness and being available are critical to getting radio or television coverage as new topics and changes emerge. Scheduling appearances on live talk shows can reach a broad audience. Always remember to research your host so that you can know the style of questioning and the audience. Different media offer different approaches for transmitting your message. The most rapid form of traditional media dissemination is radio, followed by television and print. Converged media using the power of the Internet allows for combining the speed of broad transmission with inclusion of visual and print messages.

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Preparing for an Interview Securing a coveted interview carries the responsibility of keen preparation. Do your homework. Determine the reporter’s questions in advance and understand the key areas of interest. Know what type of work your reporter has recently covered. For radio and television, know the name of the host, show, station, and any other guests who may be appearing with you. Listen in advance to anticipate the style of the interviewer, pace, format of the show, audience or call-in questions, and length of the segment. Print journalists often request permission to tape the conversation to retrieve details at a later time. Before the interview, review previous statements and talking points on your topic, be clear on positions, and rehearse your messages, including sound bites, personal stories, anecdotes, and answers to anticipated questions. Remember, anything you say can be repeated on television, radio, or the newspaper, so you want to be well prepared. Offer a fact sheet with your sound bites and have additional background information prepared. When working with a reporter, know the deadline. Offer a list of questions that you would like to have covered, and ask if the reporter will also provide you with a set of anticipated questions. It may be beneficial to establish the setting and time frame that works best so that your spokesperson is prepared and relaxed, taking into consideration any deadlines or schedule constraints. Advice for successful message delivery in an interview is presented in Exhibit 10.9. Appearing on Camera Television adds the dynamic of managing your appearance, voice, and overall impression with your audience. A successful on-camera interview appearance requires attention to appearance and actions. Standard rules of dress include keeping clothing simple and professional. Clinical attire such as scrub suits and laboratory coats are worn only in settings reflecting patient contact or in settings that are in immediate proximity to the event you are covering, such as a disaster response or in-hospital press event. For example, the more than 50 nurses invited to appear with their stethoscopes on The View in the aftermath of the public outcry about mocking Miss Colorado (see Policy on the Scene 10.1) made a striking appearance in scrubs, reflecting the daily attire for hard-working clinical nurses (Corinthios & Beard, 2015). EXHIBIT 10.9  IN THE HOT SEAT: POINTERS FOR A SUCCESSFUL INTERVIEW • Keep your responses short, clear, and crisp. • State your main message as succinctly as possible and follow it with supporting points. • Use simple language and no jargon or acronyms. • Remain calm. • Never get defensive or angry. • Be comfortable with pauses between questions. • Resist urges to fill the silence. • Don’t be afraid to say, “I don’t know.” • Politely correct any inaccuracies on the part of a reporter/interviewer. • Redirect the focus of a negative question by saying something like, “The real question is…” and return to your main message on the issue.

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When appearing on television, show energy and enthusiasm, make purposeful eye contact, maintain good posture, use gestures appropriately, and speak clearly. More detailed pointers are available online from sources such as Resource Media (2017). Practice your interviewing skills by getting a colleague to videotape you or use your own smartphone or camera. As you watch your practice performance, look for positive motions, animation, comfortable posture, and good eye contact. Be sure you are not speaking too quickly and listen for clear enunciation of each word.

Press Conferences and Briefings Press conferences, also called news conferences, are planned for the release of a significant story or development. The more prestigious the organizer or the more compelling the issue, the greater response from media. Nursing and healthcare delivery organizations, schools, and other groups may be tapped to participate in press events organized by lawmakers or others to address key issues. When the U.S. Senate was facing the initial introduction of the Better Care Reconciliation Act, Senators Debbie Stabenow, Jeff Merkeley, and Maggie Hassan worked with the ANA and provided a press event that was livestreamed from the Capitol. The ANA president and two other ANA nurse leaders presented statements humanizing the effects of the proposed bill that would decimate health benefits and put healthcare and insurance out of reach once again for many Americans. An Associated Press photo of the ANA president holding a placard with the ACA’s Essential Health Benefits was circulated widely in print media and Internet reports the following day. The press event was recorded on YouTube and can be viewed at www.youtube.com/watch?v=k84KkcZuZiw. Press conferences are not always complex, but all require a compelling story and careful planning. In addition to respected speakers, audiovisuals can be used not only to help tell the story, but also to seize the attention and emotions of the audience. Both positive and negative visuals can evoke a response. The palm-sized preterm infant, the injured accident patient saved from the clutches of death, and the handcuffed perpetrator of a crime are powerful symbols of the human condition. When possible, include other participants such as children, heroes, or favorite personalities in the press conference to draw in your audience. The selected venue must support space for video cameras and reporters, adequate sound and lighting, access to electrical outlets, and open space at the rear of the room for additional cameras. A podium and front table to accommodate all speakers sets the stage for the conference. Be careful that the venue is not so large that chairs remain empty because empty chairs send an inaccurate message of lack of interest. Popular venues include press clubs, hotels, public buildings, and settings that highlight or complement the topic, such as a clinic, hospital, neighborhood, or other location within easy access of media offices. Schedule the event to avoid any major national, state, or religious holidays or conflicting popular local or regional events. The same schedule restraints affecting reporters apply to press conferences. The best times are late morning (10 a.m.–12:00 p.m.); Tuesdays, Wednesdays, and Thursdays are less busy. Several days prior to your event, email or fax a media advisory to secure greater participation. Be sure to have extra printed materials available. Preparing your presenters is fundamental to any public speaking. Maximize coverage of your own events by quickly posting video or audio and pictures on your website and reuse materials in other publications. Specially planned briefings give journalists background information on an issue you want them to cover and establish your role as a trusted source of information on an

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issue that captures the public’s attention. The content can be used to identify an emerging issue, update any key developments on an issue, or present organizational policies and positions. Briefings are usually informal and offer the chance to build relationships and rapport with media representatives. Keeping a briefing small allows reporters to ask questions meaningful to their media outlet. Briefings can also be held virtually to allow more convenient participation of nationwide press representatives. Press conferences and briefings require careful planning, execution, and follow-up. Whether you are a seasoned PR professional or volunteer, following the tips in Exhibit 10.10 helps ensure a successful event. EXHIBIT 10.10  TIPS FOR A SUCCESSFUL PRESS CONFERENCE Initial planning • Identify target media outlets/individuals. • Choose a strategic date and time. • Write the press advisory. • Select an accessible, familiar location. • Identify and secure speakers. • Schedule speaker lineup. Groundwork • Pitch the event; send press advisory 1 to 2 weeks in advance. • Contact media outlets to determine attendance. • Prepare media kit materials: • Press release • Background information • Speaker biographies • Prepare on-site visuals (charts, photos, and slides) and precheck all equipment. • Confirm event venue setup. The event • Record the list of press in attendance. • Collect information from press representatives for postevent needs. • Distribute press release and/or full media kits on arrival. Same-day follow-up • Post press release and related material on website. • Post video and provide links. • Follow up with response to reporters’ additional needs. • Summarize coverage for future reference. • Provide appropriate written and verbal acknowledgments. Tracking • Collect inventory of all media coverage. • Prepare final summary for archives. Source: Adapted from Fitch, B., and Holt, C. J. (Eds.). (2012). Media relations handbook for government, associations, nonprofits and elected officials (2nd ed.). Alexandria, VA: TheCapitol.Net.

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Disaster Recovery—When Bad News Happens Tragedy, macabre events, and wrongdoing all capture media attention. It is disheartening when the story implicates one of our own. The darker side of nursing becomes newsworthy when, for example, a nurse strays from the contract with society and intentionally inflicts harm or when negligence or human error results in a sentinel event or near miss. All too often, reporters use the generic term nurse without more accurate identification of the qualifications of a person believed to have done harm or acted in a way unbecoming to a law-abiding professional. When bad news happens, organizations must tell the truth, admit to mistakes, and express remorse. Aim for full disclosure. The public and the organization want to get the facts straight and move on to repair and healing. Most negative stories are 1-day events. If prolonged, the multiday event or the one spanning months and years can be trying for any organization and requires effective PR management. Handling negative stories is part of the skill set held by PR professionals. It is unpleasant and embarrassing to have to deal with patient abuse or harm, safety violations, or illegal behavior. If surprised by a negative issue raised by a reporter, remain calm and suggest that you need time to check out the facts before you respond. As you gather facts, plan your strategy, which may include a brief written statement or an interview. Sometimes, an independent third party is effective as a spokesperson who can defend the organization. If your group is truly in crisis management mode, a communication plan is essential and varies based on the magnitude of the blunder.

OPTION FOR POLICY CHALLENGE: Force-Feeding at Guantanamo Bay—Protecting a Nurse’s Right to Conscientious Objection In the 6 months following the media event and letters to the Secretary of Defense, very little public coverage of the nurse’s situation was aired. Then the commanding officer of the Navy Personnel Command announced that the Navy would not institute discharge proceedings against the nurse. There were some lingering concerns, however, about the nurse’s status to resume full duties. Several months later, the military announced a revision of official policy surrounding treatment of hunger-striking detainees and prisoners, which reflected the understanding that prior policies violated international law and medical ethics. This cleared the way for removing any concern about the nurse’s conduct and potential conflict of duty between professional ethics and military command. Once again, we returned to the airwaves with a virtual press conference to applaud the decision and restate unequivocally the importance of protecting human rights and professional and ethical conduct, including the right to conscientiously object without retaliation. In April 2016, this nurse resumed full military duties without any further pending concerns. It was a victory for ethics, the people, and the profession, which would not have been possible without the media advocacy that brought the issue to light and maintained pressure to exhaust the review and analysis of practices and policies being questioned by many.

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When your organization experiences a crisis, leaders must inform their internal constituents, as well as keep an open channel to the media. It is important to generate a response quickly and be prepared to define the event, say what you are doing to address the situation, and let others know whether you need their help. Top leaders must be visible. In addition, identify a team of individuals capable of interacting with the media. Anticipate questions and prepare talking points. Integrate social media into your plan to keep a variety of constituents informed with frequent updates. Remember, your organization’s values and ethics are judged by your response. In 2014 when Texas Health Presbyterian Hospital in Dallas was ground zero for the first diagnosed case of Ebola virus disease in the United States, leading to the death of a patient and infection of two nurses, crisis loomed. Flawed communication had resulted in lack of identification of a critical factor about the patient’s recent travel to an affected area with Ebola. Subsequently, protective measures failed to adequately prevent transmission of the virus to staff despite following what was believed to be the most current information from the CDC. The hospital issued public apologies in major newspapers, brought in a PR firm to assist with crisis management, and spent months dissecting the situation with their staff and local and national stakeholders, doing damage control to earn back trust while maintaining operations and helping the nation learn how to avoid the same problems (Fieldstadt, 2014; Shlachter, 2014).

IMPLICATIONS FOR THE FUTURE Without question, the use of media has changed how people behave, how we communicate about health, and how we can advocate on the behalf of the patients we serve and our own profession. A large component of the nursing profession involves improving environmental, societal, and physical conditions that inhibit our patients from maintaining optimal health status. Improving these conditions is an inherently political process because there is a finite amount of resources. We must continue to craft messages that resonate with not only their audience, but also stakeholders involved in political and decision-making processes. In addition, we need to create more opportunities for nurses to be the stakeholders contributing to this process. Media advocacy is one modality that can help accomplish these diverse tasks. What is critical for the future is taking advantage of media advocacy to influence not only individual behaviors and beliefs, but also public policy that creates change. Studies about social media have focused primarily on increased use and less on effect. Nurses and others can study the implications of using media to influence public opinion, health policy, and legislation. Further work is needed by nurses to use new media channels to promote policy and advance their roles in advocacy. It is essential that nurses acquire basic skills and move to mastery of social media and traditional methods of media engagement so that they can be players in the world of converged media. In perusing the Internet for illustrations of nurses in the media, there is a noticeable presence of union activity, feel-good congratulatory stories, and notices of new educational programs but with little coverage of public policy issues or nurses involved in political advocacy movements. Nurses also have a responsibility to proliferate stories, photos, videos, and electronic links to content describing the expertise and efforts of nurses to advance health policy issues. Every letter, background paper, policy brief, and presentation that addresses a current issue should be converted into media that are shared, archived, and repurposed. Social media interests, on the other hand, are

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almost without limits, and reflect a consistent presence of engagement by nurses and nursing organizations. Taking advantage of all forms of media means greater exposure of nursing’s views and builds support for nursing’s role in advancing healthcare policy. Understanding how to advocate for individual patients and populations of interest, how to communicate about health policy, and how to apply advocacy to the role of the nurse must be a sustained component of our professional development.

KEY CONCEPTS 1. Nurses can use the media to reach a broader audience and establish a presence in the community. 2. Nurses have a responsibility to convey their vision, current thinking, and opinions to stimulate actions to effect better policies that serve our communities and nation. 3. Media advocacy combines mass communication with community advocacy. 4. Media advocacy includes working with the media to have your message heard, advance opinions about issues, and influence policy decision makers. 5. Effective use of social media has the potential to maximize influence on policy makers. 6. Use of multiple media modalities can maximize the impact of media advocacy efforts, which has the potential to change the power differential in communities. 7. Nurses’ use of media advocacy has the potential to change the power differential in communities. 8. Working with the media includes cultivating long-term relationships with their representatives. 9. The “Got Me” approach (goal, objective, target, audience, message, and e­ valuation) can be used to guide media advocacy. 10. Message content needs to be short and concise, provide key details, and define the main issue by using no more than three themes of underlying support. 11. Responding to media representatives includes preparing the who, what, when, where, why, and how of the story and preparing key facts and background using a format known as the journalism inverted pyramid. 12. Messages should be specifically crafted for a target audience, which may include policy makers, the public, and journalists. 13. Letters to the editors, opinion editorials, organizational policy-oriented newsletters, policy briefs, backgrounders, tip sheets, letters to policy makers, and announcements can all be used to garner support for an issue. 14. Careful orchestration of events such as press conferences can maximize their impact. 15. An effective disaster recovery plan can help mitigate the impact of a negative event.

SUMMARY Media advocacy is a vital tool that can change the power differential for nursing and health in our communities and across the national landscape. Nurses, more than ever before, are recognizing the importance of working with the media to advance their messages and positions and are stepping up efforts to use traditional and nontraditional forms of media. A comprehensive plan is critical for bringing an issue to the public’s attention, shaping opinion, and then shepherding the crusade to drive desired policy outcomes through systematic efforts using all types of media communications.

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Nurse leaders, together with their employers, professional associations, academic partners, and community organizations, can advance their views and positions through organized efforts to reach out to the media on a consistent basis. It is important to cultivate relationships with media representatives, make periodic contact to raise issues, provide background information, stand ready to address emerging issues, and give advance notice of developments related to nursing and healthcare and important to the community. The same strategies for cultivating relationships with media representatives can be used to develop relationships with PR staff within one’s organization. Responsible use of social media by individuals as thought leaders and organizations is an essential component of media advocacy. A planned strategy for integrating social media enables an organization to initiate or reinforce messaging and capture interests quickly on dynamic issues. Nurse leaders have a responsibility to learn the skill set needed for working with the media. Combining knowledge of media advocacy, ability to express ideas in writing and oral presentations, and use of current and emerging Internet and other social networking resources can have a profound impact on influencing local policies, as well as more comprehensive national policy and politics.

LEARNING ACTIVITIES 1. Retrieve a set of talking points, or fact sheets, on a current policy issue from a nursing organization. Assess the ways the media has covered the topic and critique the impact of the information on the current state of the issue. 2. Analyze a current issue for different media coverage (e.g., op-ed, press release, social media, press event, letters) What venue produced the most uptake? What organization or individual was cited most frequently? Did one form of media dominate? 3. Identify nursing leaders you admire and analyze their use of social media. Do they have a following? Are their entries timely? Do they capture your attention? Are they amplified by others? What changes to their use of social media do you believe would enhance their messaging? 4. Retrieve an electronic health policy–oriented newsletter or single story. Critique the contents to assess: Is the story newsworthy? Do the authors use the inverted pyramid or another writing style? 5. Using Exhibit 10.8, critique a recent policy brief. What are its strengths? How could it have been improved? 6. Select a previously published issue or current healthcare concern and submit a letter to the editor to a newspaper of your choice. Indicate the rationale for your selected paper. 7. Write an elevator speech about why you believe nurses should engage in policy advocacy for a general or specific issue. 8. Select a recent healthcare issue known to be controversial (e.g., side effects of childhood vaccines, efficacy and risks of statin drugs, safety of outpatient abortion facilities) and critique the Internet and social media coverage to determine whether there is any bad or fake news related to the issue by establishing the following: a. Accuracy of claim(s) made by the author(s) b. Corroboration by other sources c. Reliability and legitimacy of the source (check URLs, confirm that source houses cited information) d. Analysis of related social media posts on the issue (explain how the post might or might not be a useful source of information).

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E-RESOURCES • American Association of Colleges of Nursing Media Relations Fact Sheets http://www2.smartbrief.com/getLast.action?mode=sample&b=ANA • American Association of Nurse Practitioners Media Tools for the NP https://www.aanp.org/press-room/media-tools-for-nps • American Nurses Association Capitol Beat Blog http://anacapitolbeat.org • American Nurses Association Media Backgrounders https://www.nursingworld.org/news/media-resources/media-backgrounders • American Nurses Association Media Resources https://www.nursingworld.org/news/media-resources • American Nurses Association NurseSpace http://www.ananursespace.org/ANANURSESPACE/BlogsMain/Blogs • American Nurses Association Social Networking Principles Toolkit https://www.nursingworld.org/practice-policy/nursing-excellence/social -networking-Principles • Berkeley Media Studies Group Resources: Media Advocacy 101 http://www.bmsg.org/resources/media-advocacy-101 • Health Affairs Blog https://www.healthaffairs.org/blog • Kaiser Family Foundation: Health Policy Communications http://www.kaiseredu.org/Tutorials-and-Presentations/Health-Policy-and -Communications.aspx • Nurse.com https://www.nurse.com/blog • On the Spot Media Training and Coaching http://www.onthespotmediatraining.com

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American Psychiatric Nurses Association. (2017). Nurses expand access to needed treatment for opioid use disorder with complimentary MAT waiver training. Retrieved from https://www.apna .org/i4a/pages/index.cfm?pageID=6260 Barry, J., & Hardiker, N. (2012, September 30). Advancing nursing practice through social media: A global perspective. Online Journal of Issues in Nursing, 17(3), Manuscript 5. doi:10.3912/OJIN. Vol17No03Man05 Bird, S. E. (2011). Are we all producers now? Cultural Studies, 25(4–5), 502–516. doi:10.1080/09502 386.2011.600532 Braunberger, T., Mounessa, J., Rudningen, K., Dunnick, C. A., & Dellavalle, R. P. (2017). Global skin diseases on Instagram hashtags. Dermatology Online Journal, 23(5), 8. Retrieved from https:// escholarship.org/uc/item/7sk410j3 Cates, J. R., Shafer, A., Diehl, S. J., & Deal, A. M. (2011). Evaluating a county-sponsored social marketing campaign to increase mothers’ initiation of HPV vaccine for their pre-teen daughters in a primarily rural area. Social Marketing Quarterly, 17(1), 4–26. doi:10.1080/15245004.2010.546943 Center, P. R. (2013). The internet and health. Retrieved from http://www.pewinternet.org/2013/02/12/ the-internet-and-health Cipriano, P. (2016). Proposed VA rule is about providing better care to veterans. The Washington Post. Retrieved from https://www.washingtonpost.com/opinions/proposed-va-rule-is-about -providing-better-care-to-veterans/2016/07/22/c5a50df4-4eb1-11e6-bf27-405106836f96_story .html?utm_term=.87e7b8946669 Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Corinthios, A., & Beard, L. (2015). The View celebrates nurses after losing advertisers for mocking Miss America monologue. People TV Watch. Retrieved from http://people.com/article/ the-view-celebrates-nurses-after-losing-advertisers-following-controversy Cote, E., & Hearn, R. (2016). The medical response to the Boston Marathon bombings: An analysis of social media commentary and professional opinion. Perspectives in Public Health, 136(6), 339–344. doi:10.1177/1757913916644480 Demiris, G. (2016). Consumer health informatics: Past, present, and future of a rapidly evolving domain. IMIA Yearbook, 25(Suppl. 1), S42–S47. doi:10.15265/IYS-2016-s005 DMR Business Statistics. (2018). 250 amazing Instagram stats. Retrieved from https://expandedramblings .com/index.php/important-instagram-stats/ Dorfman, L., & Krasnow, I. D. (2014). Public health and media advocacy. Annual Review of Public Health, 35(1), 293–306. doi:10.1146/annurev-publhealth-032013-182503 Dunne, S., Cummins, N. M., Hannigan, A., Shannon, B., Dunne, C., & Cullen, W. (2013). A method for the design and development of medical or health care information websites to optimize search engine results page rankings on Google. Journal of Medical Internet Research, 15(8), 1–8. doi:10.2196/jmir.2632 Easley, J. (2017, May 24). Poll: Majority says mainstream media publishes fake news. Retrieved from http://thehill.com/homenews/campaign/334897-poll-majority-says-mainstream-media -­publishes-fake-news Ensign, J. (2011, July 10). Nurses and advocacy: Working with the media [Web blog post]. Retrieved from http://josephineensign.wordpress.com/2011/07/10/nurses-and-advocacy-working-with -the-media Facebook. (2014). Homepage. Retrieved from https://www.Facebook.com Federal Register. (2016, May 25). Advanced practice registered nurses. Retrieved from https://www .federalregister.gov/documents/2016/05/25/2016-12338/advanced-practice-registered-nurses Fieldstadt, E. (2014, October 19). Texas hospital apologizes for ‘mistakes’ in Ebola treatment in full-page ad. Retrieved from https://www.nbcnews.com/storyline/ebola-virus-outbreak/texas -hospital-apologizes-mistakes-ebola-treatment-full-page-ad-n229196

326   UNIT III  STRATEGIZING AND CREATING CHANGE Fitch, B., & Holt, C. J. (Eds.). (2012). Media relations handbook for government, associations, nonprofits and elected officials (2nd ed.). Alexandria, VA: TheCapitol.Net. Fox, S., & Purcell, K. (2010). Chronic disease and the internet. Pew Research Center. Retrieved from http://www.pewinternet.org/2010/03/24/chronic-disease-and-the-internet Franzoni, C., & Sauermann, H. (2014). Crowd science: The organization of scientific research in open collaborative projects. Research Policy, 43(1), 1–20. doi:10.1016/j.respol.2013.07.005 Gomes, C., & Coustasse, A. (2015). Tweeting and treating. Health Care Manager, 34(3), 203–214. doi:10.1097/HCM.0000000000000063 Harrison, D., Reszel, J., Dagg, B., Aubertin, C., Bueno, M., Dunn, S., … Sampson, M. (2017). Pain management during newborn screening: Using YouTube to disseminate effective pain management strategies. Journal of Perinatal & Neonatal Nursing, 31(2), 172. doi:10.1097/ JPN.0000000000000255 Hull, P. C., Williams, E. A., Khabele, D., Dean, C., Bond, B., & Sanderson, M. (2014). HPV vaccine use among African American girls: Qualitative formative research using a participatory social marketing approach. Gynecologic Oncology, 132(Suppl. 1), S13–S20. doi:10.1016/ j.ygyno.2014.01.046 Institute of Medicine. (2002). Speaking of health: Assessing health communication strategies for diverse populations. Washington, DC: National Academies Press. Keim-Malpass, J., Baernholdt, M., Erickson, J. M., Ropka, M. E., Schroen, A. T., & Steeves, R. H. (2013). Blogging through cancer: Young women’s persistent problems shared online. Cancer Nursing, 36(2), 163–172. doi:10.1097/NCC.0b013e31824eb879 Keim-Malpass, J., Mitchell, E. M., Sun, E., & Kennedy, C. (2017). Using Twitter to understand public perceptions regarding the #HPV vaccine: Opportunities for public health nurses to engage in social marketing. Public Health Nursing, 34(4), 316–323. doi:10.1111/phn.12318 Keim-Malpass, J., Steeves, R. H., & Kennedy, C. (2014). Internet ethnography: A review of methodological considerations for studying online illness blogs. International Journal of Nursing Studies, 51(12), 1686–1692. doi:10.1016/j.ijnurstu.2014.06.003 Kiley, E., & Robertson, L. (2016, November 18). How to spot fake news. Retrieved from http://www .factcheck.org/2016/11/how-to-spot-fake-news/ Krieger, J. L., Katz, M. L., Eisenberg, D., Heaner, S., Sarge, M., & Jain, P. (2013). Media coverage of cervical cancer and the HPV vaccine: Implications for geographic health inequities. Health Expectations, 16(3), e1–e12. doi:10.1111/j.1369-7625.2011.00721.x Lambert-Kerzner, A., Lucatorto, M., McCreight, M., Williams, K. M., Fehling, K. B., Peterson, J., … Battaglia, C. (2016). The Veterans Health Administration’s proposal for APRN full-practice authority. Nurse Practitioner, 41(11), 16–24. doi:10.1097/01.NPR.0000502792.43113.73 Matthews, G., Burris, S., Ledford, S. L., Gunderson, G., & Baker, E. L. (2017). Crafting richer public health messages for a turbulent political environment. Journal of Public Health Management and Practice, 23(4), 420–423. doi:10.1097/PHH.0000000000000610 McCartney, P. (2013). Crowdsourcing in healthcare. Maternal and Child Health Journal, 38(1), 392. doi:10.2196/jmir.1988 McCleery, E., Christensen, V., Peterson, K., Humphrey, L., & Helfand, M. (2014). Evidence brief: The quality of care provided by advanced practice nurses. In VA evidence-based synthesis program evidence briefs. Washington, DC: Department of Veterans Affairs. Retrieved from https://www .ncbi.nlm.nih.gov/books/NBK384613/ McCrorie, A. D., Donnelly, C., & McGlade, K. J. (2016). Infographics: Healthcare communication for the digital age. Ulster Medical Journal, 85(2), 71–75. https://www.ums.ac.uk/umj085/085(2)071.pdf McDonald, L. (2006). Florence Nightingale and public health policy: Theory, activism and public administration. Retrieved from http://www.uoguelph.ca/~cwfn/nursing/theory.htm Mikkelson, D. (2016, November 17). We have a bad news problem, not a fake news problem. Retrieved from http://www.snopes.com/2016/11/17/we-have-a-bad-news-problem-not-a-fake-news-problem

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National Council of State Boards of Nursing. (2011). White paper: A nurse’s guide to the use of social media. Retrieved from https://www.ncsbn.org/Social_Media.pdf National League for Nursing. (2017). Legislative action center. Retrieved from http://www.capwiz .com/nln/dbq/media Niccolai, L. M., & Hansen, C. E. (2015). Practice- and community-based interventions to increase human papillomavirus vaccine coverage: A systematic review. JAMA Pediatrics, 6520(7), 1–7. doi:10.1001/jamapediatrics.2015.0310 Nimmo, C. (2017). VA Ignores CRNA evidence as veterans wait for timely anesthesia care. Forbes. Retrieved from https://www.forbes.com/sites/realspin/2017/01/12/va-ignores-crna-evidence-as -veterans-wait-for-timely-anesthesia-care/#3c794ba322c7 Nowak, G. J., Gellin, B. G., Macdonald, N. E., Butler, R., & Group, W. (2015). Addressing vaccine hesitancy: The potential value of commercial and social marketing principles and practices. Vaccine, 33(2015), 4204–4211. doi:10.1016/j.vaccine.2015.04.039 Obesity Action Coalition. (2013). Obesity action coalition is on Facebook. Retrieved from https:// www.Facebook.com/ObesityActionCoalition Pagana, K. D. (2013). Ride to the top with a good elevator speech. American Nurse Today, 8(3), 14–16. Retrieved from https://www.americannursetoday.com/ride-to-the-top-with-a-good-elevator-speech/ Resource Media. (2017). Broadcast interview tips. Retrieved from http://www.resource-media.org/ broadcast-interview-tips-2 Ressler, P., & Glazer, G. (2010, October 22). Legislative: Nursing’s engagement in health policy and healthcare through social media. Online Journal of Issues in Nursing, 16(1), 11. doi:10.3912/OJIN. Vol16No01LegCol01 Roncancio, A. M., Ward, K. K., Carmack, C. C., Muñoz, B. T., Cano, M. A., & Cribbs, F. (2016). Using social marketing theory as a framework for understanding and increasing HPV vaccine series completion among Hispanic adolescents: A qualitative study. Journal of Community Health, 42(1), 169–178. doi:10.1007/s10900-016-0244-0 Rosenberg, C. (2014, July 15). Navy nurse refuses to force feed Guantanamo captives. Retrieved from http://www.miamiherald.com/news/nation-world/world/americas/article1975643.html Rumsfeld, J. S., Brooks, S. C., Aufderheide, T. P., Leary, M., Bradley, S. M., Nkonde-Price, C., … Merchant, R. M. (2016). Use of mobile devices, social media, and crowdsourcing as digital strategies to improve emergency cardiovascular care. Circulation, 134(8), e87–e108. doi:10.1161/ CIR.0000000000000428 Salzmann-Erikson, M. (2017). Mental health nurses’ use of Twitter for professional purposes during conference participation using #acmhn2016. International Journal of Mental Health Nursing, 27(2):804–813. doi:10.1111/inm.12367 Schemmann, B., Herrmann, A. M., Chappin, M. M. H., & Heimeriks, G. J. (2016). Crowdsourcing ideas: Involving ordinary users in the ideation phase of new product development. Research Policy, 45(6), 1145–1154. doi:10.1016/j.respol.2016.02.003 Shlachter, B. (2014, October 21). Texas health resources faces public fallout from Ebola crisis. Retrieved from http://www.star-telegram.com/news/business/article3884433.html Signorini, A., Segre, A. M., & Polgreen, P. M. (2011). The use of Twitter to track levels of disease activity and public concern in the U.S. during the influenza A H1N1 pandemic. PLoS ONE, 6(5), e19467. doi:10.1371/journal.pone.0019467 Sinnenberg, L., Buttenheim, A. M., Padrez, K., Mancheno, C., Ungar, L., & Merchant, R. M. (2017). Twitter as a tool for health research: A systematic review. American Journal of Public Health, 107(1), e1–e8. doi:10.2105/AJPH.2016.303512 van Lent, L. G., Sungur, H., Kunneman, F. A., van de Velde, B., & Das, E. (2017). Too far to care? Measuring public attention and fear for Ebola using Twitter. Journal of Medical Internet Research, 19(6), e193. doi:10.2196/jmir.7219

328   UNIT III  STRATEGIZING AND CREATING CHANGE Veterans Administration, Office of Public and Intergovernmental Affairs. (2016, December 14). VA grants full practice authority to advanced practice registered nurse. Retrieved from https://www .va.gov/opa/pressrel/pressrelease.cfm?id=2847 Waddell, A., Audette, K., DeLong, A., & Brostoff, M. (2016). A hospital-based interdisciplinary model for increasing nurses’ engagement in legislative advocacy. Policy, Politics, & Nursing Practice, 17(1), 15–23. doi:10.1177/1527154416630638 Wallack, L., & Dorfman, L. (1996). Media advocacy: A strategy for advancing policy and promoting health. Health Education Quarterly, 23(3), 293–317. doi:10.1177/109019819602300303 Wakefield, M. (2017). Affordable care act needs mending not ending. Affordable care act needs mending not ending. Grand Forks Herald. Retrieved from https://www.grandforksherald.com/ opinion/columns/4240594-mary-wakefield-former-health-and-human-services-executive -affordable-care Wright, D. G., & Abell, C. H. (2011). Using YouTube to bridge the gap between baby boomers and millennials. Journal of Nursing Education, 50(5), 299–300. doi:10.3928/01484834-20110419-03 Zhang, C., Gotsis, M., & Jordan-Marsh, M. (2013, November). Social media microblogs as an HPV vaccination forum. Human Vaccines and Immunotherapeutics, 9, 2483–2489. doi:10.4161/ hv.25599

ELEVEN

Applying a Nursing Lens to Shape Policy Joanne Disch Health reform will only be achieved if nurses are unrelenting in pursuing their rightful place in policy leadership in partnership with others who are also committed to accessible, safe, effective, and equitable health care.—Donna Shalala

OBJECTIVES 1. Examine how the intersection among policy, politics, and nursing impacts practice. 2. Analyze the essential features of a nursing lens as applied to policy. 3. Identify ways a nursing perspective can aid policy development and implementation. 4. Describe skills essential for formal and informal policy involvement.

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, 2011. p. 6). Policies exist at unit (microsystem), organizational, and societal levels. They are developed through processes that are individually driven or collectively based. They can address social issues, organizational effectiveness, or health. Up to this point, the role of nurses in policy development and implementation at all three of these levels has been inconsistent. This was not always the case. In early days, nurse leaders advocated for better healthcare for the public and established policies for the effective running of healthcare systems, whether they were in field hospitals or community centers. Florence Nightingale created change through administrative leadership and skillful persuasion through her correspondence with influential people. Nurse leaders who followed, such as Katharine Densford (1890–1978), advised presidents on expanding nursing capacity (the Cadet Nurse Corps), created innovative programs of education for nurses in universities, and worked to advance professional nursing through her presidency of the American Nurses Association (ANA) as it voted to support collective bargaining and to integrate Black nurses into its membership. There is growing evidence of nursing influence on public policy, as reflected by nurses leading national organizations and advancing public policy in state and national legislatures. In addition, nurses are increasingly assuming positions as senior leaders within their own organizations. Yet there are many 329

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POLICY CHALLENGE: Tackling a Patient Care Threat, Which Had Seemed Normal Susan Sendelbach, PhD, APRN, CNS, FAAN (Former) Director of Nursing Research, Abbott Northwestern Hospital, Minneapolis, Minnesota Alarm fatigue, defined as being overwhelmed by false alarms, has been ­identified as the cause of several patient deaths. In a survey study by Funk, Clark, Bauld, Ott, and Coss (2014), 18% of respondents said they knew of harm caused to patients by false alarms. As a critical care nurse, I had always just accepted that false alarms were a “normal” part of the job. However, when asked to write an article on alarm fatigue and delved into the literature, I realized that not only accepting these alarms as a part of the job was harmful to patients, but also there was an opportunity to decrease, if not eliminate, these false alarms. The combination of publishing a critical review of the literature and being a member of the American Heart Association provided access to Dr. Marjorie Funk, who is a nursing expert on ECG monitoring, including alarm fatigue. This combination provided a foundation to address the issue of false alarms at Abbott Northwestern Hospital. Because there were a very limited number of research studies on how to decrease false alarms, we relied on published quality-­ improvement projects, with Graham and Cvach (2010) providing an approach on how to decrease false alarms. See Option for Policy Challenge.

more opportunities for nurses to be more actively involved, and their absence not only diminishes nursing’s impact, but also results in suboptimal policy outcomes. The purpose of this chapter is to examine the intersection among policy, politics, and nursing and to identify ways that a nursing perspective can enrich policy development and implementation. The concept of “the nursing lens” is used as a framework throughout the chapter, and numerous examples of the impact of this lens are provided. The Policy Challenge illustrates how a nurse used her nursing lens to work with others within her organization and at the national level to deal with a significant threat to patient safety.

POWER TO INFLUENCE: POLITICS The story in the Policy Challenge shows how a practicing nurse, armed with data and a common goal, can exert sizable influence by tackling a patient care issue within her care area, extending the impact throughout her organization and, ultimately, shaping national policy and becoming a highly regarded content expert in the process. All nurses have this potential power. “Powerless nurses are ineffective nurses …” (Manojlovich, 2007, para 1). Studies have shown that powerlessness is associated with several poor outcomes for nurses and patients alike. Power is essential for politics. Indeed, in its broadest and most informal definition politics “the way a democratic society resolves differences...arising from

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conflicting ideas, interests, values, and information on public-policy issues” (Anderson, 2011, p. 5). Politics is a word derived from the Greek word politikos (of, for, or relating to citizens) (Politics, n.d.). This term began to be used in English in the mid-15th century. In our current environment, it has become synonymous with bipartisanship, finger pointing, distortion of facts, and gridlock. However, more precisely and formally defined, politics simply refers to the skills and techniques used to run government. Both definitions of politics are applicable to nursing—and politics can be applied at every level and within all types of organizations. In this chapter, understanding the nurse’s role both informally and formally is highlighted. The work of “influence” is a necessary political skill that can be cultivated and honed much like the skills used in working with patients, students, and employees. Every day, nurses work to influence individuals. Talking with patients who have a poor prognosis, students who are struggling in class, or employees who are receiving negative feedback are just a few examples of the complex conversations in which nurses exert influence. The skill sets to intervene in these work situations are learned and honed throughout our nursing careers. Yet these skills are often perceived as easier and more familiar compared with skills related to putting oneself into an uncomfortable or unfamiliar setting (e.g., sitting down to dinner with an executive, garnering support from a team of surgeons for a practice change). Less recognized by many nurses is the potential of political power where nurses work and live. Informal politics are carried out when we encourage colleagues to support a policy change at work, give an elevator speech to the chief of staff about an initiative we are undertaking, or sit with a board member at a luncheon. There are numerous opportunities to carry out politics at an informal level (see Exhibit 11.1).

EXHIBIT 11.1  TIPS TO EXPAND YOUR INFLUENCE CREATE ONE-ON-ONE OPPORTUNITIES TO MEET PEOPLE; GET TO KNOW SOMEONE BETTER

1. Attend a nursing forum or staff meeting at work and talk with someone you do not know. 2. Invite a colleague to coffee to gain perspective on a key organizational issue. 3. Invite an adversary to lunch, as Disch (2014) suggests. Although you might not end up agreeing on issues, you will have a better sense of the person’s point of view. 4. Send a note to the department head, giving positive feedback for something done well or suggesting an improvement for a problem. 5. Make an appointment with a senior administrator to better understand a controversial decision and offer your perspective. 6. Take a new employee to coffee during the first week of work. 7. Sit down with the clinical preceptor in your area and ask to better understand the curriculum and how nursing student experiences can be improved. 8. Ask what ideas a physician colleague has for improving care on the unit. (continued )

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EXHIBIT 11.1  TIPS TO EXPAND YOUR INFLUENCE (continued ) DEMONSTRATE YOUR SUPPORT

9. Join a professional nursing organization separate from your organization. 10. Volunteer to help with a recruitment event or nursing program. 11. Invite a coworker to join you in helping at a community project. 12. Write a thank-you note to a nurse colleague who effectively handled a difficult patient situation. 13. Write a note complimenting a supervisor on handling a difficult personnel issue. 14. Offer to cover for a nurse colleague who wants to attend a nursing meeting. 15. Volunteer to be a nursing student preceptor. 16. Tell people that they have done a good job. 17. Offer to help someone who is struggling. EXPAND YOUR KNOWLEDGE

18. Attend nursing or organizational information sessions. 19. Familiarize yourself with the organization’s mission, vision, values, and strategic plan. 20. Invite a colleague who is in a nursing program to share what is being learned. 21. Subscribe to two professional nursing journals and read each issue monthly.

Being skillful in engaging in the formal political process often starts with, and is strengthened by, engaging in acts of informal politics. In her book, Becoming Influential, Eleanor Sullivan, PhD, RN, FAAN (2012, p. 94), describes the power of small talk, which she points out is “neither small nor unimportant.” Rather, it is an opportunity for equally sharing between two people, for exchanging ideas and making connections, and for possibly laying the groundwork for future, more important conversations. To get started, simple questions of interest (e.g., “How long have you been in nursing?” or “What intrigued you about becoming a physician?”) can be used. At a conference with relative strangers, you could ask, “Is this the first time you’re attending this meeting?” Follow-up comments or questions can be used to elicit more information and allow the conversation to evolve on its own. Small talk is about finding mutual connections and not indicating how important one is or how much one knows. Before attending a key meeting or event, it is a good idea to anticipate who might be there and generate a few comments to make or questions to ask. Nurses also must be formally and informally involved in politics. In the current era of healthcare reform, there is no better time for nurses to pursue politics. “The fact is, nurses who pursue politics offer something that candidates without their experience simply cannot: a firsthand and accurate accounting of what happens on site in medical institutions, in private practice, and in-home healthcare environments” (Lyttle, 2011, p. 19). Despite the importance of and the stories in this book that highlight nurses who hold elected or appointed positions, the fact remains that not enough nurses are involved in politics. Adding to the complexity of the issue is that men are underrepresented in

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nursing and women traditionally are underrepresented in politics. In the United States, less than 1% of the 535 members of the 115th Congress are nurses, and no nurses are senators (see Exhibit 11.2). An exciting possibility in the United States are the candidacies of Erin Murphy for governor of Minnesota and Diane Black for governor in Tennessee. Black has served in the U.S. House of Representatives, and Murphy has served in the Minnesota House of Representatives, with a term as House majority leader. Policy on the Scene 11.1 outlines her philosophy and the value that nursing has played in her career All nurses need to understand politics, work locally to influence their practice, and participate in formal politics at least at the level of being informed of local (community and work), state, and national issues and voting at all levels. Then they can seek progressive roles as time and expertise dictate. These roles can range from volunteering for political campaigns to seeking appointments for positions to running for office. Advanced practice registered nurses (APRNs) are uniquely positioned not only to be proactive in politics because of the constant challenges faced in being able EXHIBIT 11.2  NURSES IN THE 115th CONGRESS CONGRESSWOMAN KAREN BASS (D-CA-37)

Karen Bass was sworn in as a member of the 112th Congress in January 2011. She is the former speaker of the California Assembly and was the first African American woman to lead the California Assembly. She serves on the prestigious Steering and Policy Committee, which sets policy direction for the Democratic Caucus. She was appointed as assistant Democratic whip for the 115th Congress. Congresswoman Bass became an RN and then a physician’s assistant. She was the first African American woman to serve as a state assembly speaker. Current committees can be viewed at www.bass .house.gov/about/committees-and-caucuses. CONGRESSWOMAN DIANE BLACK (R-TN-06)

Diane Black was sworn in as a member of the 112th Congress in January 2011. She is a former member of the Tennessee State House and State Senate. From 1971 to 1998, Congresswoman Black worked as an RN, beginning her career in the emergency department, and then moving to long-term care and out-patient surgery. She is a former educator and also started two family-owned businesses. In 1998, Congresswoman Black was elected to Tennessee’s legislature. She chairs the House Budget Committee. Current committees can be viewed at www.black.house.gov/about-me/ committees CONGRESSWOMAN EDDIE BERNICE JOHNSON (D-TX-30)

Eddie Bernice Johnson was sworn in as a member of the 103rd Congress in January 1993. She is the first RN elected to the U.S. Congress and is the first African American and female ranking member of the House Committee on Science, Space, and Technology. In 2013, she chaired the Congressional Black Caucus. An RN since 1956, Congresswoman Johnson worked as chief psychiatric nurse at the Dallas Veterans Administration Hospital (the first African American to hold that position). After 16 years, she entered public life. She was first nurse to serve in the Texas State House and then the Texas State Senate. Current information can be viewed at www.en.wikipedia.org/ wiki/Eddie_Bernice_Johnson

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to practice using the full extent of their education and training, but also to mentor, teach, and role model the value of the nursing perspective to nurses, administrators, and the public across the spectrum of settings.

POLICY ON THE SCENE 11.1: Gubernatorial Candidate Erin Murphy, MA, RN, FAAN, Minnesota House of Representatives, District 64 A Erin Murphy has been actively involved in politics for years. A former executive director of the Minnesota Nurses Association, she was first elected to the Minnesota House of Representatives in 2006 and eventually worked her way up the ranks to become Majority Leader in 2012. She has served five terms in the House and was reelected to her sixth. She has turned her sights toward becoming the first woman governor in Minnesota. Here are some excerpts from her website on how nursing has shaped her thinking and her career. One of the things you learn right away as a nurse is that every problem, big or small, matters. You can’t brush the big ones off and wait for another nurse to handle them, you can’t cut corners and you can’t just deal with the easy stuff. People’s lives depend on your work and your decisions. Your patients need you to dig in, to make tough calls and grind out challenging work. I went into nursing to help people. I became a surgical nurse and worked at a big hospital in rural Wisconsin. I moved to St. Paul to work at the University of Minnesota Hospital as a part of a transplant team. At our core, nurses work to care for people, without judgement, until they can care for themselves again. I experienced things that challenged me, seeing the hardness of disease. I learned to manage a crisis and to work through conflict while keeping a cool head. I eventually went to work for my union, the Minnesota Nurses Association, and worked for them in a variety of capacities, including as executive director. As the chief executive, I managed our budget, engaged in difficult negotiations and ultimately made decisions about how to move our organization forward, no matter how difficult. While I’m no longer in surgery, I’m still a licensed nurse, and I’m still good in a crisis, ready to help if any of my colleagues in the house feels short of breath after a long-winded speech. In addition to my work at the Capitol I also teach a nursing class at St. Kate’s, helping the next generation of nurses and caregivers prepare for their important work ahead. Reminding them that their work to bring care to those who need it extends outside the hospital doors. At the end of the day the work we do, all of us, matters. It’s part of who we are and what we bring to the world. It may sound cliché but too often I feel like the leaders in our state are willing to leave the problems for the next ­session or the next generation. It hurts us as a state and it is time we do better. The opportunity and decision to become a nurse had a huge impact on my life and on the work I do now. It’s one of the best decisions I ever made. Source: Reprinted with permission from www.murphyformn.com/about

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Although we tend to think of power as being wielded by practicing nurses, even undergraduate nursing students can advance policy. This can be due to the increasing number of second-career students who already have a rich background in policy work in their original work settings and are ready to tackle healthcare ­challenges or due to the growing activism of students in traditional nursing programs who want to make a difference. A good example is Mathew Keller, BSN, RN, JD. During his undergraduate nursing program, Keller had been selected as a Densford Undergraduate Scholar (DUGS), which was an enriched leadership experience. Each scholar was invited to select a project to explore and tackle. Keller felt that the gender dichotomy in the nursing profession was truly underexplored and underaddressed. Policy on the Scene 11.2 outlines the work that Keller spearheaded to address this problem in his school.

POLICY ON THE SCENE 11.2: Getting an Early Start in Creating Change Mat Keller, BSN, JD, RN, Senior Policy Advisor American Nurses Association, Silver Spring, Maryland “If you look at efforts to get more women involved in STEM professions, you see that it is a huge, multi-pronged effort … government/industry partnerships, scholarships, mentorship programs, major advertising campaigns. But it’s a disservice to both men and women in the nursing profession that such a huge lack of diversity isn’t being tackled in a similar way.” Mat’s initial intent was to bring people together to talk about the issues that men encounter in this traditionally female-dominated profession: What are the things we see that might be different? How might we support each other? How might we encourage others to get involved in this wonderful profession without the stigma of being a nurse? His first steps were to secure buy-in from the director of the Densford Center; to schedule the meetings; and to invite students via a variety of mechanisms. A male faculty member volunteered to be the advisor. And M.E.N. (Men Enjoying Nursing) was launched. Mat was thrilled with the response: “I thought it was kind of a crazy idea that probably wouldn't come to pass. I was also surprised at the support of my peers and classmates. I was expecting to encounter some pushback in the general student populace, but in fact it was overwhelmingly ­supportive—in fact, we had several female students join us from time to time, which was  great.” What helped this succeed? Mat identified several things: a passionate leader, support from faculty sponsors, the recognition of an issue that was of concern to a broad cross-section, the willingness of some students to be active early, and achievement of some early wins. What would he do differently? “I would have tried to start the group on more of a wider basis, rather than limited to our nursing students. It would have helped with the initiative being sustainable and have more staying power and a wider appeal”—all good learnings that fit with effective policy formation and politicsat any level.

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THE NURSING LENS What differentiates nurses from others when engaging in the political process are the insights and experiences about health, illness, resiliency, and the human condition gained through their nursing careers. Disch (2012, p. 170) calls this the nursing lens, or a “viewpoint from which someone sees things holistically, considering the person, population or community in the larger context.” With this perspective, nurses seek personalized solutions that are pragmatic and realistic. Nurses can also readily size up situations and people. The nursing lens also enables nurses to be particularly effective in establishing effective interpersonal relationships that help people achieve their goals and do their very best work. With this lens, nurses understand the human condition with all its intricacies and complexities. Finally, nurses can devise solutions or access resources where none seem to exist. Examples of nurses using their nursing lens abound. Over the past few years, a growing number of leaders with a nursing background have stepped forward to make significant contributions in highly visible senior leadership roles, taking a big “P” role in national organizations beyond nursing, in government, and in industries outside of healthcare (see Exhibit 11.3). Each of these leaders would affirm that one of the strengths of his or her success is rooted in the foundation of the nursing profession, the way nurses view the world, and the skills and attitudes they have developed over the years based on that perspective. Claire Fagin provides a thoughtful reflection on the nursing lens and the unique perspective that women and nurses bring to leadership situations. In Policy Scene 11.3, she responds to a question posed to her after completing her term as interim

EXHIBIT 11.3  NURSE LEADERS IN PROMINENT POSITIONS Nancy Agee, MN, RN, President and CEO of Carilion Clinic, Roanoke Virginia Patricia Flatley Brennan, PhD, RN, FACMI, FAAN, Director of the National Library of Medicine Sophia Chan, PhD, MPH, MEd, RN, RSCN, FFPH, FAAN, Under Secretary for Food and Health in Hong Kong Karen Cox, PhD, RN, FACHE, FAAN, President of Chamberlain University Regina Cunningham, PhD, RN, FAAN, President and CEO of the Hospital of the University of Pennsylvania Joanne Disch, PhD, RN, FAAN, Chair of the Board of Directors, Advocate Aurora Health Alicia Georges, PhD, RN, FAAN, President-Elect of AARP David Graebner, MBA, RN, FACHE, Senior Vice-President/CEO, Greater Milwaukee North and Sheboygan/Calumet Hospitals, Advocate Aurora Health Marilyn Tavenner, RN, President and CEO, America’s Health Insurance Plans Sylvia Trent-Adams, PhD, RN, FAAN, Acting Surgeon General, U.S. Public Health Service Commissioned Corps Rita Wray, MBA, RN, BC, FAAN, Vice-Chairperson, Personal Services Contract Review Board, State of Mississippi

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POLICY ON THE SCENE 11.3: On Nurses, Women, and Leadership Claire Fagin, PhD, RN, FAAN, Dean Emeritus, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania Some aspects of the woman as administrator and leader were similar to my experiences as a successful nurse. All too often, after nurses have performed lifesaving or life-improving, functions during a patient’s hospitalization, the comment made by patient and family is, “The nurses were so nice.” Well, the nurse’s niceness was lucky for everyone, but it was not niceness that facilitated what appeared to be their effortless acts. What mattered most in the person’s hospitalization was that these nice nurses were using knowledge, skill, experience, and smarts in a graceful and smooth way that often prevented their being noticed for what they were. … What seems to be misunderstood or not understood is how we use our personality attributes within the context of carefully designed strategies for accomplishing goals. The strategies in my case had to do with opening communication internally and externally, building responsibility and accountability, establishing relationships with Penn’s wide public, healing the “open” wounds that were apparent, and identifying and dealing with more covert problems. Humanity, warmth, empathy, and other expressionistic characteristics undoubtedly helped and, in some cases, were essential to the strategies I chose. However, these qualities alone do not do the job. Strategic planning … included setting goals, steps, and timetables for their accomplishment and sharing information about their achievement. … Nothing was left to chance or hope. Source: Reprinted with permission from Fagin, C. M. (2000). Essays on nursing leadership. New York, NY: Springer Publishing.

president of the University of Pennsylvania, the first woman—and nurse—to hold this position. In fact, she was the first woman and nurse to be president of any Ivy League university. In addition, the nursing lens is a way to characterize nursing’s unique contributions, but it also describes the invaluable input that nurses bring to policy work. Because of the way that nurses think, view situations holistically, engage diverse stakeholders, craft pragmatic yet innovative solutions and understand the human condition, our input and this perspective is vitally needed in boardrooms, at policy tables and in senior leadership positions. (Disch, 2012, p. 170)

Nurses acquire this perspective because of their interface with patients, knowledge of technology, and central role they play in the day-to-day and often minute-to-minute safety of not one but literally millions of people every day worldwide. These experiences and our holistic approach to care facilitate and influence our perception and understanding of problems and help us determine and evaluate solutions. It is not simply a sum of nursing’s expert knowledge. Compare this with Intellectual Capital in Chapter 7.

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Jennie Chin Hansen is a nurse leader who possesses abundant intellectual capital and a strong nursing lens. In Policy on the Scene 11.4, she describes her journey from a nursing background through influential leadership positions in a number of consumer and healthcare organizations.

POLICY ON THE SCENE 11.4: A Senior Leader in Several Organizations Jennie Chin Hansen, MSN, RN, FAAN, Director of the Scan Foundation, SCAN Health Plan Jennie Chin Hansen recalled the early days of her career and the factors “impacting her psychic DNA”: attending a baccalaureate program at a Jesuit University at a time when women only had two options, nursing or education; being the sole Asian female undergraduate or graduate student on campus; the assassinations of Dr. Martin Luther King and Bobby Kennedy; Vietnam War protests and the women’s movement. “I recall being torn by rules that told me I couldn’t tell my patient her blood pressure, was unprepared for the death of my patient who was so isolated in his dying by his protective gown and my masks and gowns, shocked at how rude and insensitive many physicians were to both patients and myself due to the ‘power’ they wielded and saddened by how registered nurses treated others in the workforce who did not have comparable education. I resolved to not solely ‘doing things right’ but doing, what I felt were the ‘right things.’ “Right after graduate school, I decided to work in the community rather than in a hospital. Working in people’s homes, in their environments, without my uniform, was what I treasured. When that person didn’t need to be in the ED or in an ICU, I learned to listen, appreciate and understand in ways that were very different from within an institution. I realized I was interested in changing systems that allowed us to care for more than a few people at a time in a way that was respectful and effective and ensured that life could be better. “What did I learn? That all my book knowledge, research and charts by themselves did not amount to effective change. I experienced failure even though I had the ‘right data.’ I learned to slow down, listen, engage, and enable others to see the need and value of change. I went behind the scenes to facilitate and catalyze. It worked, and I learned a humbling lesson: It’s not about me. Over the decades, I have become involved in large system change, such as modifying Medicare and Medicaid laws to advance the Programs of All Inclusive Care (PACE); working with the AARP as a board member and then president, being engaged in analysis and advocacy at the national level; serving as a commissioner of the Medicare Payment Advisory Commission; leading and replicating the award-winning PACE program for nearly 25 years; and serving as CEO of the American Geriatrics Society. “I also learned that it is our ‘work’ to use our tools (i.e., education, experience, discernment and courage) to make health and healthcare better. I have had opportunities to develop and emerge rather than plan for and pursue. I have been fascinated by how decisions are fluid, requiring revisiting and reframing. And possibly most important: Everyone is different in what resonates for him or her, so how you go about your journey in leadership and growth will be your way.”

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BEYOND ELECTED POSITIONS Many roads lead to advocacy and politics. However, many visualize one road when they think of politics, and they assume that road is a straight path for running for and getting elected to a public office. In reality, elected positions reflect only a small number of political opportunities. Many political roles are less visible but are vital to nursing and to healthcare policy development. Nurses do, and many more can, hold appointed positions or volunteer for positions. One can be appointed to an office or a committee, but in many situations, especially at the little “p” level, one can volunteer for m ­ embership on boards, committees, and task forces. Whether contemplating or seeking an appointment or a staff position or volunteering for an advocacy position, nurses must take steps to develop their skill set and position themselves to be ready to move forward as they become aware of opportunities (see Exhibit 11.4). EXHIBIT 11.4  READINESS TIPS FOR SEEKING APPOINTMENTS OR NOMINATIONS • Learn the process that the organization uses to select its members: • Identify specific eligibility requirements (e.g., education, experience, political affiliation). • Review disqualifiers and conflicts of interest. • Have others review any written responses. • Consider professional consultation for advice when applying for prominent positions.

• Increase the visibility of your expertise or experience that relates to the organization’s mission and goals: • Attend organization’s functions. • Participate in meetings and other processes. • Introduce yourself to organizational leaders.

• Know the organization and review relevant documents, including the following: • • • •

Website and printed materials Current structure and organization chart Mission and goals Current and sensitive issues under consideration

• Demonstrate your interest by attending and supporting events,

programs, and fundraisers. • Network with individuals who have influence on or knowledge of the

selection process: current board members, organization leaders, and community or legislative leaders. • Review other considerations for selection such as money or time donations. • Prepare thoroughly if invited for an interview: • Get information on the organization’s history, priorities, and culture. • Write several drafts of the application and have it critiqued. • Conduct mock interviews if part of the process. • Anticipate interview questions. • Prepare informative, relaxed answers. • Develop two to three questions for the interviewer/interview team.

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Political Appointments Some of the nurse leaders listed in Exhibit 11.3 (e.g., Patti Brennan, Sylvia T ­ rent-Adams, Rita Wray) have held or hold appointed positions. Numerous federal, state, and local appointments would benefit from the nursing lens, and some positions can be filled only by an RN. State boards of nursing, for example, are filled primarily by gubernatorial appointment. Each state has regulations that specify the number of RNs and APRNs necessary for the full board complement. States differ slightly in the process of appointments, and the rules may vary for how APRNs are appointed, if at all, to the state board.

Volunteer and Staff The work of nurses associations has been instrumental in the policy strides made in nursing and healthcare. Essential to association successes are the countless staff members and volunteers committed to the mission and goals. There is strong conviction in what the association stands for and accomplishes. Associations provide numerous opportunities for political activism and visibility. Without the time, resources, and money of associations, the collective work on policy and advocacy could not be accomplished. It is the values of the members that propel ideas into actions to achieve policy goals. Therefore, engagement as an association member is an effective means of developing your nursing lens. Although much of our discussion has focused on nurses presenting a nursing lens to a wider circle beyond nursing, there  is considerable policy work to be done in influencing the public’s ­understanding of a nursing lens through the policies and positions of nursing organizations. For example, the American Nurses Association uses Professional Issues Panels to inform the decisions on practice and policy issues made by its board of directors. Each panel is led by a steering committee that is informed by a larger advisory committee. This facilitates widespread input, as well as a rigorous process to ensure quality of the recommended positions or actions. Numerous similar opportunities exist within specialty nurses associations to shape policy agendas. Many associations have legislative committees in which volunteers play a critical role. Although the legislative and practice committees are directly aligned with policy issues, other association activities provide opportunities to influence policy. For example, nominations to select leadership, bylaws to describe essential operations and functions, conference planning to showcase new ideas, and selection of liaisons to legislators and policy tables all provide opportunities to use the nursing lens. Staff members within associations are often equally committed to the purposes and mission of the association. They serve in multiple capacities and are essential to the operation and continuity of the association. Staff can be an invaluable resource. Staff members who are RNs bring the added value by incorporating their nursing lens to their role. One new collaborative effort to increase the number of nurses on boards is the Nurses on Boards Coalition (NOBC), which has a goal ensuring that there are 10,000 nurses on boards by 2020. The Coalition includes national nursing and other organizations that are focused on placing nurses on all types of boards and commissions (e.g., corporations, health-related organizations, commissions). Launched in response to the Institute of Medicine (IOM; now the National Academy of Medicine) The

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Future of Nursing (Committee on the RWJF Initiative on the Future of Nursing, 2011), NOBC organizational members assert that because nursing is the largest health profession and most respected, nurses’ voices should be heard at board tables at all levels of governance and government. As of 2017, there were 29 member organizations, mostly nursing-related, but a growing number reflect broader constituencies, such as the Robert Wood Johnson Foundation and AARP (www.nursesonboardscoalition .org/about).

Work and Community Often the best place to start down the path toward the roles just described is local committee work in the work setting and the community. Many of the nurses who tell their stories in this chapter relate how they began their involvement by serving on committees. Whether the career path is in practice, education, administration, research, or a combination of these, the pathway to leadership is often found in committee work within the work setting, such as on a practice committee or staff nurse council. Local communities also offer opportunities for committee work, such as through faith-based organizations, community centers, advocacy groups, and ­parent–teacher associations. Committee work not only provides opportunities to build political skills but also helps develop necessary networking skills, strengthen existing networks, and offer opportunities for mentorship. Organizations are often looking for members and chairs to lead committees or task forces, both in the work environment and within the local communities. Often committee work can seem daunting; finding a mentor and getting familiar with fulfilling expectations is critical. Without guidance, committee members can lose sight of the work of the committee or valuable time can be lost while members try to gather a sense of the committee. Both veterans and new members can benefit from formalizing the committee orientation process and in bringing clarity to the policy-making and review process. The first step is expressing interest—and often just showing up.

The Road Less Traveled President, health sciences dean, and business owner are just a few of the titles that reflect the diversity of roles that nurses hold that often are overlooked when advocacy and politics are discussed. These nontraditional, entrepreneurial, and executive roles are often overlooked because individuals mistakenly think that nurses in these roles have left the nursing lens behind. These nurses often hear from nurses in more traditional roles who state they could not consider such atypical roles because it would mean “giving up nursing” and the opportunities to advance nursing. Yet leaders like these find that they indeed have many opportunities to have a positive impact on patients and nurses in their roles, even though the roles may be less traditional. Jeannine Rivet is an excellent example of this. See Policy on the Scene 11.5, where she describes how her nursing background has served as a foundation for her work in the world’s largest health plan, UnitedHealth Group (UHG). In a similar vein, Terry Fulmer found herself in a role far beyond what she had imagined early in her career and yet found that her nursing background prepared her exquisitely for success in this broader sphere.

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POLICY ON THE SCENE 11.5: A Senior Executive at the Highest Level Jeannine Rivet, BSN, MPH, RN, FAAN, Executive Vice President UnitedHealth Group, Minnetonka, Minnesota My nursing background has been the foundation for a health career as a pediatric hospital nurse, public health nurse, clinic supervisor/director, chief operating officer, health plan CEO, and CEO of several health businesses. I’ve worked for seven different organizations, with 16 roles, eight of those at UnitedHealth Group (UHG). UHG is a diversified health and well-being company with $184 billion in revenues and 230,000 employees and serves more than 130 million individuals worldwide. At UHG, I have had the privilege of expanding our businesses, running operations, leading businesses, and developing new programs such as Military and Veterans Health Services, Office of Social Responsibility, and the Center for Nursing Advancement. In my current corporate role, I am engaged in customer relations, culture leadership, mentoring/coaching, boards (both for profit and non-profit), many advisory boards and women leadership groups, and the expansion of the Center for Nursing Advancement, which I initiated in 2008 to recruit, retain, and develop nurses in both clinical and leadership skills. The Center is now the Center for Clinician Advancement for our 35,000 (nonphysician) clinicians. In my 50-year career in healthcare, nursing has been my grounding. Nursing provides a consumer/patient lens: an approach that encompasses compassion, relationships, innovation, integrity, and performance. Nursing skills adapt very well to business and policy environments. Furthermore, nurses engage in real-life experiences that have impact and outcomes, and they understand the challenges and barriers to quality care and the opportunities to improve service and health outcomes. This can positively influence patients, families, diverse stakeholders, decision makers, and legislatures. I am humbled to be able to pay it forward to others personally and professionally. I am grateful for my nursing and leadership opportunities and am proud of what I have been able to accomplish helping people live healthier lives and working to simplify their experiences.

POLICY ON THE SCENE 11.6: Extending Nursing Expertise to Serve the Frail Elderly Terri Fulmer, PhD, RN, FAAN, President, the John A. Hartford Foundation, New York, New York Reflecting on my career path and my current role as the President of the John A.  Hartford Foundation in New York City, a non-profit, philanthropic leader dedicated to improving the care of older adults, it seems obvious that I would (continued )

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end up in this role. I smile as I recall this because, of course, it does not seem ­obvious when one considers my career as an academic nurse. However, my first job as a staff nurse at the Beth Israel Hospital in Boston, Massachusetts, under the leadership of Joyce Clifford as CNO with Trish Gibbons as her assistant director, was transformative for me. Joyce and Trish saw the possibilities of our discipline as endless and unique, and I believed them and embraced the philosophy that every role is one that a nurse can step into and lead. They taught us that the staff nurse was an extraordinarily powerful role when practiced with evidence and responsibility. In that role, I immediately gravitated to care for the very frail elderly patients on our unit. I found an enormous autonomy in my nursing practice because although the admitting diagnosis might be heart failure, all of the concomitant problems that might occur or needed prevention more squarely fell in the domain of nursing practice. I began evolving my ideas related to geriatric assessment and coined SPICES as an acronym for sleep disorders, problems with eating or feeding, incontinence, confusion, evidence of falls, and skin breakdown. As I transitioned to my position as faculty at the Yale School of Nursing with a joint appointment at Yale New Haven Hospital, I could further my work and had the good fortune to be included in a project called Hospital Outcomes Project for the Elderly (HOPE) funded by the John A. Hartford Foundation. In this project, I was able to develop the Geriatric Resource Nurse (GRN) Model, a mainstay of the Nurses Improving Care for Healthsystem Elders (NICHE) program. More important, I could form a lasting relationship with the John A. Hartford Foundation, which is evidenced by the progress accomplished at the New York University Hartford Institute for Geriatric Nursing. I was honored to be the first nurse to be funded as a principal investigator by the Foundation, and that initial planning grant led to the ultimate success of both NICHE and the Hartford Institute. The Foundation has stayed the course, championing the care of older adults, and I have done the same. My leadership in the care of older adults, and ongoing passion throughout my career has lead me to this moment. I could not be more thrilled and would say to those aspiring to leadership roles: Your commitment to the issue you care most about and your willingness to stay the course and invest the effort to distinguish yourself is a path to success.

SERVING ON BOARDS Serving on a non-profit or for-profit board is one way that nurses can exert significant influence over an organization’s performance and achieve tremendous personal satisfaction. It also affords opportunities for nurses to demonstrate the value that the nursing lens brings to a wide array of situations and issues.

Getting on Boards Although the adage was that “who you know” is crucial for getting on boards, what has become apparent is that, “It’s not who you know—but who knows YOU that matters.” For the most part, nurses are invited to serve on boards for reasons similar for others (i.e., who knows them and believes that they could bring value added to a board). Relationships are key and can stem from either a personal connection with the person(s) populating the slate of nominees or a referral from an intermediate party. As it relates

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to this chapter, the nursing lens is a perspective that is holistic, relationship based, and insightful; ­understands both the human condition and the way that systems (particularly in healthcare) do or do not work; and is innovative in thinking of creative options or solutions. Thinking back on my own career, most of my leadership and governance opportunities arose from someone needing an individual, sometimes specifically with a nursing background, and remembering that we had worked well together earlier in some capacity. It is important to note, however, that nurses are not always in proximity to decision makers who are inviting nominees to serve. This may be due to class differences, occupational silos, or other factors. There are also biases as to what many individuals may see as a nurse’s skill set. Also at work is gender bias, as well as outdated perspectives that nurses cannot be leaders or that nurses are too parochial and tied to narrow interests. Conversely, other may think nurses are too focused on only the needs of the nursing profession. Interestingly, system leaders themselves may focus too narrowly on the bottom line and not appreciate the impact of safety and quality on the bottom line, so a nursing presence is exactly what is needed to describe how quality impacts the finances and what might be feasible options for improving quality and reducing cost. Finally, search firms are not always the best vehicle for bringing forward diverse slates of candidates for consideration. They often have a well-developed pool of candidates with whom they have worked for years and, not surprisingly, embody traditional skill sets and profiles. This is not unique to nursing. According to the most recent survey, women hold 10.6% of the total 6,081 board seats on Fortune 500 companies, and 84% of these companies have no women board directors at all. Internationally, there is great variation of board participation for women, ranging from 0% in Saudi Arabia to 46.7% in Norway (Credit Suisse, 2016). Norway has a higher participation rate because it introduced a 40% quota system for corporate boards several years ago. Figure 11.1 displays the percentage of women’s share of board seats at stock index companies by selected countries. Norway France Sweden UK Canada Australia UNITED STATES Thailand India China South Korea Japan 0

10

20

30

40

FIGURE 11.1  Percentage of women on boards by country (2015). Source: Data from Credit Suisse Research Institute. (2016). The CS Gender 3000: The reward for change. p. 8. Retrieved from http://publications.credit-suisse.com/tasks/render/file/index .cfm?fileid=5A7755E1-EFDD-1973-A0B5C54AFF3FB0AE

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POLICY ON THE SCENE 11.7: A CEO’s Reflections on Nurses on Boards Nick Turkal, MD, President and CEO, Aurora Health Care Milwaukee, Wisconsin For most healthcare systems, nurses represent the largest single group of ­employees and deliver the majority of frontline clinical care to our patients. Given that, it would seem irresponsible to think about governing a healthcare system without appropriate input from nursing. While that input may be delivered in a variety of ways, our experience has been that someone with a nursing and leadership background should be a member of the board of directors. Nursing leaders provide a unique view of what it is like for our patients to experience healthcare; they provide valuable input into research priorities; and they are uniquely qualified to strategize about how to make our health system more consumer friendly for the future. Like other trustees, though, it is critical that nurses on boards do not simply represent their “constituency”; rather, they are uniquely positioned to fulfill their fiduciary duty because they understand all aspects of healthcare systems. Given that, it is important that nurses serve on nonclinical board committees (such as Finance and Audit), and that they be considered for officer positions on boards.

One key stakeholder who is critically important in supporting nurses getting on a board—and in describing how they can best contribute—is the CEO or president of an organization. Although it is interesting for nurses to opine on what we think, it is vital that the voices of organizational leaders are actively sought. As an example, several years ago, I was invited to serve on the Aurora Health Care board, which is a 15-hospital, $5 billion health system based in Milwaukee, Wisconsin. Interestingly, the invitation to serve was prompted by a physician leader who said, “We need a nurse on the board.” As they sought a nursing leader to join the board, two nursing leaders from within the organization gave my name (a great example of “It’s not who you know but who knows you that counts”) and I was interviewed by the CEO and president, Dr. Nick Turkal. Policy on the Scene 11.7 reflects his thoughts on nurses on boards. As a follow-up, after serving as a board member for 8 years, I was invited to serve as chair of the board for a 3-year term.

Being an Effective Board Member Once on a board or policy-setting committee, you can still face challenges. Some of these are beyond the direct impact of the nurse, such as state regulations that limit the scope and practice of nurses, reimbursement restrictions, policy statements from organizations opposed to nurses’ gaining greater influence, and restrictive credentialing policies of health systems. Working collaboratively with other nurses and stakeholders beyond nursing who share common goals is a critically important strategy. Sabo Chesney, Tracy, and Sendelbach (2017) describe the years-long effort to get APRN prescriptive privileges in Minnesota. Some barriers are more nurse-related, such as inadequate data gathering to support a particular position or innovation, designing implementation plans that are cumbersome or impractical, failing to keep colleagues and key stakeholders informed, and

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losing sight of the original goal(s). Marshall (2011) has observed that, even before getting to this stage, “Too many nurses opt out of policy discussions” (p. 254). This may be due to inadequate educational preparation in policy work, and/or nurses being involved so heavily in clinical practice that little time is available. Some nurses do not see the value in policy work, believing it is for others to do. Once on a board or major policy body, nurses must learn the ropes and culture of the organization they are serving, keeping in mind that the focus of the role is on stewardship of the organization and not representation of nursing. Strategies for success include (a) focusing on the good of the organization, (b) coming to meetings prepared, (c) listening carefully, (d) carrying out assignments promptly, and (e) contributing to the success of the board or team. Issues and questions should be framed in terms of what is good for the organization and what is consistent with its strategic plan and objectives. Although each member has particular agendas or viewpoints, do not become the “nurse board member” who brings every issue back to nursing or the “small town board member” who relates everything to the home town. Although nurses are not alone in this behavior, the result is that such contributions, and the board member herself, can be tuned out. Joy Deupree, PhD, RN, WHNP-BC, senior advisor for policy for the Nurse Practitioner Alliance of Alabama (NPAA), the professional association she co-founded in 2006, echoes this philosophy: “… avoid making a case based on how a decision for change will impact nursing [but] … develop a reputation for making decisions based on quality patient outcomes while containing or reducing costs…” (Adams, 2017). Claire Fagin, highlighted in Policy on the Scene 11.3, who has vast experience in board work at all levels, suggests that, in any interprofessional or business group, a nurse should first make at least two or three comments from a broad perspective before making one even remotely related to nursing (C. Fagin, personal communication, July 2013). Listen carefully to what your fellow board members are saying in discussions and seek to understand their points of view. The goal is not to talk the most but be the individual who adds a new comment or strategy to advance the cause. Finally, if you have made your point, you have made your point. Think through what you want to say before you say it, and then say it once. Those who bring up the same points, particularly advancing their own agendas, alienate their colleagues and, again, diminish their effectiveness. Madeline Albright, the former Secretary of State under Bill Clinton, made an interesting observation that could apply to most nurses and women: “Women are really good at making friends and not good at networking” (Shellenbarger, 2012). This suggests that purposeful interactions and intentional messaging with a goal in mind will be of more help than casual conversations. It should be acknowledged that sometimes nurses—who are mostly women—speak up but are ignored. James Turley, CEO of Ernst & Young from 2001 to 2013, recalled an experience he had at a meeting several years ago—“three or four women said something I wasn’t paying attention to. Then a guy said something similar and I said, ‘That’s a really good point.’” He was grateful when a female executive later took him aside and pointed out his behavior. He believes he has not made the same mistake since (Shellenbarger, 2012).

PROGRAMS THAT REFLECT THE NURSING LENS Programs providing care delivery and reflecting the nursing lens have been in existence since Florence Nightingale’s time. One of the earliest in this country is the Visiting Nurse Service of New York. Its roots go back to 1893, when Lillian Wald, after a care experience

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with a young mother, worked with a colleague to receive financial and ­governmental support to establish a community-based care center. Wald and her colleagues provided a foundation for public health nursing by caring for poor immigrants in the Lower East Side of New York, caring for the sick and assisting with births and deaths (Visiting Nurse Service of New York, 2018). Realizing that individual health and community health are inseparable, she addressed issues related to women’s health and their working conditions, children’s health, child labor, and emergency responsiveness. Another well-known program developed by a nurse that reflects the nursing lens is the 11th Street Family Health Services Center (2010) in Philadelphia, Pennsylvania. This program, led by Patty Gerrity, PhD, RN, FAAN, and colleagues, is affiliated with Drexel University and dates back to 1996, when the College of Nursing at MCP/ Hahnemann University entered into an agreement with the Philadelphia Housing Authority to address health issues of residents in Philadelphia’s 11th Street Corridor. The 11th Street Corridor encompasses several public housing tracts and has historically been underserved regarding affordable, accessible, and quality healthcare services. The first services from the 11th Street Health Center focused on health promotion and disease prevention. At present, diabetes education, self-efficacy programs, nutrition education, fitness, cooking classes, and behavioral health group support are the core program ­elements of the Healthy Living Center. The center also provides a venue for the education of nurses and other health professionals in culturally competent, ­community-based care. These and many other examples are included in the Raise the Voice campaign, spearheaded by the American Academy of Nursing (AAN). According to the AAN website: Health care in America today is inaccessible to many, expensive for most and fragmented for all. Enabling the system to deliver the best possible care at an acceptable cost requires not just reformation but transformation—moving American health care away from its current hospital-based, acuity-oriented, physician-dependent paradigm toward a patient-centered, convenient, helpful and affordable system. America needs a system that keeps people as healthy as possible, treats the patient promptly, comprehensively and effectively. (AAN, n.d., para. 1)

Out of this belief came the Raise the Voice campaign to educate the public and policy makers about innovative programs that nurses are implementing to provide holistic, personalized, effective, pragmatic, and accessible care delivery options, often to the individuals, families, and communities in greatest need. The campaign profiles Edge Runners, or nurses who are practical innovators using new thinking to create innovative models of healthcare delivery. The campaign not only provides evidence-based examples of creative care-delivery models that are making a difference in communities across the country, but also highlights the instrumental role that nurses can and must play in developing new policies for care delivery.

OPPORTUNITIES AND SUPPORT FOR A NURSING LENS IN POLICY For many years, the Gallup Poll has identified nurses as having the highest honesty and ethical standards. In the most recent survey, 82% of respondents rated nurses as very high or high, compared with the next highest group, military officers, at 71% and the next to the lowest group, members of Congress, at 11% (Brenan, 2017). This is a remarkable accomplishment, yet nurses are not correspondingly included in relevant policy-making

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circles. In 2011, the Robert Wood Johnson Foundation (RWJF) ­commissioned a Gallup Poll of over 1,500 policy leaders to assess their view of nursing’s role in policy (Khoury, Blizzard, Wright Moore, & Hassmiller, 2011). Of the respondents, a large majority indicated that nurses have a great deal of influence on components of a quality healthcare system such as medical error reduction, patient safety, and patient care quality. Yet the leaders identified a major barrier to nurses’ influence because nurses were not perceived as key healthcare decision makers, which means that they have the least amount of influence on healthcare reform over the next 10 years. From a different source—The Future of Nursing: Leading Change, Advancing Health (Committee on the RWJF Initiative on the Future of Nursing, 2011, p. 223)—the comment was made that perhaps the public views nurses as “functional doers” rather than “thoughtful strategists.” Ever so slowly, this perception is changing. Numerous national organizations have called for and supported an increasing nurse presence in policy development. Within organizations, nurses are needed to develop processes and push for changes that will improve patient care, help the organization run smoothly, and create supportive environments within which people want to work. This call for nurses to be involved is not an issue of parity (i.e., bringing in nurses’ voices as an act of generosity) or equity but rather is one of perspective. Nurses’ viewpoints are essential if workable solutions for healthcare problems are to be developed, implemented, and successful. Nurses’ viewpoints are used to influence policy by lobbying, persuading legislators, and working in coalitions to get legislation passed. However, this is only part of the policy-making process. What remains is turning policy into practice. As healthcare reform is implemented in whatever fashion and healthcare organizations change their internal policies and procedures to comply with new laws, there will be a need for nurses to participate in decision making to ensure that the appropriate changes are being designed and implemented.

Support for Nurses Being Involved A gradual groundswell of support has been building over the past 10 years to ensure that nurses are adequately involved, again not an issue of parity but of a needed perspective. In 2005, Don Berwick, MD, and former president and CEO of the Institute for Healthcare Improvement, noted, “It is key that nurses be as involved as physicians, and I think boards should understand that the performance of the organization depends as much on the well-being, engagement, and capabilities of nursing and nursing leaders as it does on physicians. I would encourage much closer relationships between nursing and the board” (Berwick, 2005). In the ensuing years, several national organizations have joined the chorus, advocating for greater nursing representation on healthcare boards. In 2007, the American Hospital Association (AHA) issued a report from a Blue Ribbon Panel on Health Care Governance, urging that boards “include physicians, nurses and other clinicians on the board. Their clinical competence and viewpoints are valuable to board members and will help the board better understand the needs and concerns of several of the organization’s stakeholders” (Blue Ribbon Panel, 2007, p. 13). The RWJF launched its Pipeline to Placement initiative to highlight and disseminate information on the important contributions that nurses make in policy issues and to encourage organizations to include more nurses as board members (RWJF, 2012). “Because nurses have the most contact with patients, families, and physicians, nurses have in-depth knowledge of healthcare delivery that could prove valuable to a board of trustees on relevant issues” (Totten, 2010, p. 84).

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Perhaps one of the most forceful mandates for nurses being actively involved in ­ olicy matters comes from the landmark work sponsored by the Robert Wood Johnson p Foundation and the IOM: The Future of Nursing: Leading Change: Advancing Health (Committee on the RWJF Initiative on the Future of Nursing, 2011). Among a number of strong statements of support is the following, one of the four key messages of this report: “Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States” (p. 32). Strong leadership is critical if the vision of a transformed healthcare system is to be realized. Yet not all nurses begin their career with thoughts of becoming a leader. The nursing profession must produce leaders throughout the healthcare system, from the bedside to the boardroom, who can serve as full partners with other health professionals and be accountable for their own contributions to delivering high-quality care while working collaboratively with leaders from other health professions (Committee on the RWJF Initiative on the Future of Nursing, 2011).

More Work To Be Done However, progress has been slow and efforts must continue: Nurses are still not frequently present at policy tables. A comprehensive review by Prybil et al. (2012) of the results of several studies conducted over the years indicated that nurses constitute 6% of voting board members versus earlier studies that indicated around 2%. This varies a bit as to whether the board is associated with a faith-based system (where the percentage is 9%) or a secular system (2%). (Interestingly, this disparity between faith-based systems and secular systems persists when considering the percentage of women on these boards: 40% vs. 21%.) Part of this inequity in the inclusion of nurses on boards may be due to misconceptions. A major one is that the physician can speak for all providers on healthcare issues. However, nurses and physicians have different responsibilities to and relationships with patients and families and spend very different periods of time with them. Mary Chesney, PhD, CRNP, RN, past president of the National Association of Pediatric Nurse Practitioners, describes her theory of this major barrier as being the “slice of the apple” phenomenon: “The public and legislators tend to see the physician as the big apple of healthcare, able to do all things and, thus, if a board or policy group has a physician in the group, this person is authorized to speak for all other health professional groups. The physician is the whole apple and every other profession is just a slice of the apple. What we need to do is to help legislators and the public see that the physician can be the apple, but the nurse is an orange. Different perspectives, some unique and some overlapping skill sets, different areas of expertise yet both are important and are needed for a full complement of services” (M. Chesney, personal communication, October 4, 2010). A second misperception may be that nurses do not have the requisite skills to serve effectively in governance roles. Exhibit 11.5 outlines the set of competencies that have been developed from work by the American Hospital Association’s Center for Healthcare Governance and the National Center for Healthcare Leadership (Hassmiller, 2012). It is clear that many nursing leaders have extensive experience and expertise in these areas. Furthermore, nurses understand the context of healthcare delivery in every type of facility, 365 days a year, 7 days a week, and 24 hours a day. Finally, sometimes nurses themselves do not believe that they have the skills or the responsibility to influence the greater system. Jane Barnsteiner, PhD, RN, FAAN,

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EXHIBIT 11.5  RECOMMENDED COMPETENCIES OF BOARD MEMBERS KNOWLEDGE AND SKILLS

• Healthcare delivery and performance • Business and finance • Human resources PERSONAL CAPABILITIES

• • • • • •

Achievement orientation Collaboration Community orientation Innovative thinking Organizational awareness Team leadership

Editor, Translational Research and Quality Improvement for the American Journal of Nursing, and coeditor of Quality and Safety in Nursing, contends that nurses today must accept responsibility for delivering high-quality patient care and for identifying and addressing system issues that threaten patient care.

GETTING STARTED Whether serving on a board or working with colleagues to change a policy, as Sue Sendelbach did with inappropriate alarms in the ICU, or to tackle the lack of gender diversity in nursing, as Mat Keller did as an undergraduate nursing student, there are certain steps that work well in pulling a group together to create needed change: 1. Bring together a diverse group of stakeholders to address the issue. 2. Appoint leaders who can reflect different perspectives (e.g., strong nurse and ­physician leadership). 3. Keep the focus on what is best for the patient, as well as support for those providing care. 4. Provide data to underscore the importance of the problem and evidence to support the legitimacy of the proposed solution. 5. Identify champions within the group who can speak to various constituencies. 6. Garner senior leadership support. Be explicit about what “support” means. 7. When approaching a person whose support is crucial to the acceptance of the policy, send the person who has the closest relationship with and greatest influence on the person to garner this support. 8. Anticipate needing to approach each discussion with a new person as one that should start at the beginning (i.e., what is the problem, why is it a problem, what can be done, what is the proposed policy change, and why do we believe this is the best approach?). Those close to the change assume that others are at the same point of embracing the policy change. Often, they are not and have to be brought along.

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OPTION FOR POLICY CHALLENGE: Next Steps in Tackling a Patient Care Threat Susan Sendelbach I convened an interprofessional team, including nurses, physicians, monitor technicians, and biomedical engineers, to conduct a rapid cycle quality improvement. By implementing a bundled approach that included daily ECG changes, eliminating duplicative ECG alarms, and customizing alarms, we decreased false alarms in the cardiovascular surgical intensive care unit by 88.5% (Sendelbach, Wahl, Anthony, & Shotts, 2015). Based on our work on alarm management at Abbott Northwestern, I was asked to lead the American Association of Critical-Care Nurses’ Practice Alert on Alarm Management. This Practice Alert helped provide evidence-based guidance to practicing clinicians on how to decrease the occurrence of false alarms. In addition, I was asked to participate on the Association of the Advancement of Medical Instrumentation (AAMI) Foundation workgroup on alarm management. This workgroup included practicing clinicians, academicians, representatives from the Food and Drug Administration, The Joint Commission (TJC), and industry and focuses on how to best manage alarms and eliminate false alarms. Three opportunities emerged because of my involvement with AAMI: (a) being asked to participate in a webinar for the AAMI Foundation Healthcare Technology Safety Institute that included Pat Adamski from TJC and Rikah Shah from the ECRI Institute; (b) being able to interact with persons in regulatory and industry roles to help them understand the clinical perspective and, in turn, learn the regulatory and industry perspectives; and (c) working on the American Heart Association ECG Practice Standards section on alarm management. In 2016, TJC updated its national patient safety goals related to alarm safety. Improvements are being seen in alarm management, but it continues to be a problem, requiring additional policy work with a nursing perspective. What started as writing one article on alarm management ended up shaping much of my clinical practice and, ultimately, improving patient care not only at a local but also at a national level.

IMPLICATIONS FOR THE FUTURE Nurses can influence the development, implementation, and evaluation of policies at the local, organizational, and national levels in many ways. Every nurse has the opportunity to influence policy, whether it is from a formal or an informal position. More than that, as nurses, they have a unique skill set that well suits them to achieve meaningful change in every setting. Nurses are particularly skilled in listening to people from all backgrounds, translating complex topics into coherent messages, listening to what is being asked as well as what is not being said, helping people deal with monumental change and disappointment, and identifying sources of optimism and hope. This reflects a skill set that is congruent with an approach that is holistic, people-oriented, realistic, big picture, and yet attuned to the small details of the human experiences. This is the nursing lens.

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For nurses who see the world through nursing’s unique prism and are willing to act, this is their time and the future is theirs to write. To further these efforts, nurses must see policy engagement as something that starts from the time they are in school and continues into employment, not something that is begun when they have time, when established in their work, or when they have seniority. For far too long nurses have encouraged the next generation of nurses to get established before furthering their education, experience, or involvement in policy. Last, nurses must set goals and develop strategies for increasing the number of elected officials who articulate the nursing lens, much as the goal has been set to increase the number of nurses on boards. Donna Diers in 1992 wrote that nurses must discard the “I am only a nurse” mentality when talking about why they chose their nursing role. It is time to argue that nurses must now also discard the “Policy is to be done by someone else” mentality and embrace the belief that “I can make a difference—and it’s part of my professional role to do so.”

KEY CONCEPTS 1. Nurses need to assume their rightful place in policy leadership and in partnership with others in shaping our healthcare system. 2. The absence of a nursing lens in policy development results in suboptimal policy outcomes. 3. A nursing lens can be brought to bear on high-profile health issues through unity and solid data. 4. Nurses, and women, are underrepresented in formal political structures both in the United States and globally. 5. The nursing lens differentiates nurses from others engaged in the political process through insights about health, illness, resiliency, and the human condition. 6. The nursing lens brings a whole-person/whole-systems perspective that informs the promotion of health, as well as the creation of effective systems and pragmatic solutions. 7. Political opportunities exist within formal political structures, and membership on boards, committees, and task forces in associations, at work, and in communities. 8. Board service, particularly in healthcare organizations and organizations that have a connection to the healthcare industry, is a key strategy for expanding nursing’s influence. 9. Strategies for being a successful board member include focusing on the good of the organization, listening well, and carrying out assignments promptly and effectively. 10. The Edge Runner program of the AAN offers exemplars of how nurses have influenced policy to improve health outcomes and use resources responsibly. 11. Support for including more nurses on relevant boards, commissions and councils comes from prominent national leaders and organizations. 12. Acting to influence policy is a responsibility of all nurses in all roles.

SUMMARY This chapter introduced the concept of the nursing lens and described how this perspective can enrich policy and politics, citing several examples of nurses whose careers were shaped by a view of the world through this nursing lens—and the differences that can make in improving health and healthcare through policy work.

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Nurses are the largest group of healthcare providers in the world and the group with the closest connection to patients, their families, communities, and individuals wanting to stay healthy. The current healthcare crisis can and should be addressed in part through solutions supplied by the largest healthcare profession: nursing. Policy development and implementation require the active and ongoing engagement of nurses using their nursing background and expertise. There are several ways in which nurses can use their nursing background and ­expertise—their nursing lens—when serving in key decision-making roles. Nurses can take complex topics and craft messages that enable stakeholders, employees, or members to understand them and see how they apply to their particular situations. Nurses know to even ask, “What are the implications for stakeholders and frontline workers when changes, such as reductions in benefits, elimination of services, or closing of facilities, are being considered.” Nurses are holistic in their thinking so that, when policies are developed, they know to ask about the implications for the family, the patient in the home, or the community. Nurses are inclusive in their language so that policies promoting “physicians” as provider offer more options when the phrase “healthcare provider” is used or that “at the patient’s side” is preferable to “bedside.” Nurses know that implementation of exciting new technology does not come without significant investment in orientation and ongoing training, as with electronic health records (EHRs) or medication-dispensing systems. Nurses know that what works at 2 p.m. on a weekday does not always work at 10 p.m. on a Saturday night. Policies have to reflect the realities of practice and patient care in all settings, at all times, with all combinations of providers. Finally, nurses know where threats to patient safety and quality exist, such as failure to invest in adequate resources, staff support, and training.

LEARNING ACTIVITIES 1. Examine the legislative agenda of the ANA or your specialty organization. What ­elements do you agree with? Where do you see room for change? 2. Interview a chairperson for a committee or task force where you work. How did they become chair? What recommendations would they make for becoming more involved? 3. Think of a policy change you would like to see implemented in your organization. Who else would be interested in seeing this change occur? What could be a workable solution? What kinds of information would you need to support your recommendation? 4. How many nurses serve on your state board of nursing? How many are nonnurses?  What are the requirements for serving? For what responsibilities are they accountable? 5. Participate in a committee meeting at work or in your community. Assess the leader’s behaviors and pay special attention to those that advance the work. What is he or she doing or saying that makes a difference? 6. Select a community organization whose mission you support. Who serves on their community board? How are those people selected? What requirements must they demonstrate? 7. Select a leader within your organization who you believe is particularly effective. Invite this person to coffee and ask the following: What have been key milestones in your career? Who has been particularly helpful? What has been the best piece of advice you’ve received? What suggestions would you make to help me get more active? 8. If you are on a board, commission, or other external policy-making group, sign up at the Nurses on Boards website.

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E-RESOURCES • 2020 Women on Boards http://www.2020wob.com • Advancing Women in the Workplace http://www.catalyst.org • American Academy of Nursing: Institute for Nursing Leadership: Appointments that Matter Essay Series http://www.aannet.org/initiatives/institute-for-nursing-leadership • Degrees of Impact: An Overall Strategy for Thinking about Board Appointments (Angela Barron McBride, PhD, RN, FAAN) • The Process of Getting Appointed to Boards (Catherine L. Gilliss, PhD, RN, FAAN) • Board Roles and Responsibilities: Before you say yes…. ASK (Rita Wray, MBA, RNC, FAAN) • The Importance of Personal Relationships (Patrick DeLeon, PhD, JD, MPH) • Targeting a Board (Louise Woerner, MBA, FAAN) • Policy Opportunities in a Presidential Election Year (Darlene J. Curley, MS, RN, FAAN) • Attaining a Seat at the Table (Rita Wray, MBA, RNC, FAAN) • What’s the Difference between For-Profit and Non-Profit Boards? (Catherine L. Gilliss, PhD, RN, FAAN) • Finding a Mentor to Guide You in Your Appointment (Diana J. Mason, PhD, RN, FAAN) • Turning a Deficit into an Advantage (Joanne Disch, PhD, RN, FAAN) • Sharpening Your Financial Skills (Louise Woerner, MBA, FAAN) • Fundamental Steps to Take to be Nominated/Elected to a Board (Randy A. Jones, PhD, RN, FAAN) • Board Vetting 101: The Process (Rita Wray, MBA, RN, BC, FAAN) • American Association of Colleges of Nursing: From Patient Advocacy to Political Activism: AACN’s Guide to Understanding Healthcare Policy and Politics http://www.aacnnursing.org/Portals/42/Policy/PDF/AACNPolicyHandbook_2010 .pdf • American Organization of Nurse Executives (AONE): Nurse Leader Competencies http://www.aone.org/resources/nurse-leader-competencies.shtml • Best on Board https://bestonboard.org • Good Governance (Victorian Local Governance Association) http://www.goodgovernance.org.au/about-good-governance/what-is-good -governance • Nurses on Boards Coalition https://www.nursesonboardscoalition.org

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Anderson, J. (2011). Public policymaking: An introduction (7th ed.). Boston, MA: Wadsworth. Berwick, D. (2005). Great boards ask tough questions. What to expect from management on ­quality. The Governance Institute. Retrieved from http://www.ihi.org/resources/Pages/Publications/ GreatBoardsAskToughQuestions.aspx Blue Ribbon Panel Health Care Governance. (2007). Building an exceptional board: Effective practices for health care governance: Report of the Blue Ribbon Panel on Health Care Governance. Retrieved from http://hscrc.maryland.gov/documents/public-interest/HospitalGovernance/ CtrHlthCareGovernance_2007.pdf Brenan, M. (2017, December 26). Nurses keep healthy lead as most honest, ethical profession. Gallup News. http://news.gallup.com/poll/224639/nurses-keep-healthy-lead-honest-ethical-profession .aspx Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Credit Suisse Research Institute. (2016). The CS Gender 3000: The reward for change. Retrieved from http://publications.credit-suisse.com/tasks/render/file/index.cfm?fileid=5A7755E1-EFDD-1973 -A0B5C54AFF3FB0AE Diers, D. (1992). One-liners. Image: Journal of Nursing Scholarship, 24(1), 75–77. doi:10.1111/ j.1547-5069.1992.tb00703.x Disch, J. (2012). The nursing lens. Nursing Outlook, 60, 170–171. doi:10.1016/j.outlook.2012.05.004 Disch, J. (2014). Invite an adversary to lunch. American Journal of Nursing, 114(5), 8. doi:10.1097/01 .NAJ.0000446753.16556.ca 11th Street Family Health Services: History. (2010). Retrieved from http://www.drexel.edu/11thstreet/ history.asp Fagin, C. M. (2000). Essays on nursing leadership. New York, NY: Springer Publishing. Funk, M., Clark, J. T., Bauld, T. J., Ott, J. C., & Coss, P. (2014). Attitudes and practices related to clinical alarms. American Journal of Critical Care, 23(3), 39–318. doi:10.4037/ajcc2014315 Graham, K. C., & Cvach, M. (2010). Monitor alarm fatigue: standardizing use of physiological monitors and decreasing nuisance alarms. American Journal of Critical Care, 199(1), 28–35. doi:10.4037/ajcc2010651 Hassmiller, S., (2012). Nurses on boards: Competencies required for leadership. American Journal of Nursing, 112(3), 61-66. doi:10.1097/01.NAJ.0000412641.93516.99 The Joint Commission. (2016). Hospital national patient safety goals. Retrieved from http://www .jointcommission.org/assets/1/6/2016_NPSG_HAP_ER.pdf Khoury, C. M., Blizzard, R., Wright Moore, L., & Hassmiller, S. (2011). Nursing leadership from bedside to boardroom: A Gallup national survey of opinion leaders. Journal of Nursing Administration, 41(7–8), 299–305. doi:10.1097/NNA.0b013e3182250a0d Lyttle, B. (2011). Politics: A natural next step for nurses. American Journal of Nursing, 111(5), 19–20. doi:10.1097/01.NAJ.0000398042.54557.0b Manojlovich, M. (2007, January 31). Power and empowerment in nursing: Looking backward to inform the future. Online Journal of Issues in Nursing, 12(1), 2. doi:10.3912/OJIN.Vol12No01Man01 Marshall, E. S. (2011). Transformational leadership in nursing. New York, NY: Springer Publishing. Murphy, E. (n.d.). About. Retrieved from www.murphyformn.com Prybil, L., Levey, S., Killian, R., Fardo, D., Chait, R., Bardach, D., & Roach, W. (2012). Governance in large, nonprofit health systems: Current profile and emerging patterns. Lexington, KY: Commonwealth Center for Governance Studies. Robert Wood Johnson Foundation. (2012). Nursing: Where the jobs are. Retrieved from https://www .rwjf.org/en/library/articles-and-news/2012/03/nursing-where-the-jobs-are.html Sabo, J. A., Chesney, M., Tracy, M. F., & Sendelbach, S. (2017). APRN consensus model implementation: The Minnesota experience. Journal of Nursing Regulation, 8(2), 10–16. doi:10.1016/ S2155-8256(17)30093-5

356   UNIT III  STRATEGIZING AND CREATING CHANGE Sendelbach, S., Wahl, S., Anthony, A., & Shotts, P. (2015). Stop the noise: A quality improvement project to decrease electrocardiographic nuisance alarms. Critical Care Nurse, 35(4), 15–22. doi:10.4037/ccn2015858 Shellenbarger, S. (2012, May). The XX factor: What’s holding women back? The Journal Report— Women in the Economy, B7, B9–B10. Retrieved from www.womeninecon.wsj.com/special -report-2012.pdf Sullivan, E. (2012). Becoming influential (2nd ed.). Saddle River, NJ: Prentice Hall. Totten, M. K. (2010). Nurses on healthcare boards: A smart and logical move to make. Center for Healthcare Governance. Healthcare Executive, 25(3), 84, 86, 87. Retrieved from http://www.ache .org/HEOnline/heonline_index.cfm Visiting Nurse Service of New York. (2018.). History: VNSNY begins with Lillian Wald. Retrieved from https://www.vnsny.org/who-we-are/about-us/history

UNIT IV

JUDGING WORTH AND ADVANCING THE CAUSE

TWELVE

Evaluating Policy: Structures, Processes, and Outcomes Sean P. Clarke Pamela B. Linzer One of the great mistakes is to judge policies and programs by their intentions rather than their results.—Milton Friedman

OBJECTIVES 1. Identify the place of research and evaluation in the policy cycle. 2. Explain the process of evaluating policy using a structure, process, and outcome framework. 3. Describe the use of outcomes research as an influence on policy. 4. Compare and contrast program evaluation and outcome evaluation. 5. Analyze proposed policies for intended and unintended consequences.

This chapter focuses on tracking outcomes for ongoing monitoring and evaluation of policies—and expands on the centrality of the use of evidence highlighted in previous chapters. Assessing anticipated and unanticipated outcomes of enacted policies is examined using a structure, process, and outcome framework. Evaluation data can form the basis for discontinuing, amending, or expanding policy or assist in advocating for greater investments for a strategy or wider uptake of a specific initiative. The evaluation process is fundamental in the policy making cycle, no matter whether one is involved in high-level (big “P”: national and state) or local (little “p”: local or organizational) service delivery policy. In clinical practice, evaluation often involves using the nursing process to assess a patient’s health status after an intervention. On a more abstract and aggregate level, clinical trials of drugs and equipment, performance appraisals, or institutional accreditation from bodies such as The Joint Commission are also evaluations. In more general terms and in the context of programs or policies, evaluation refers to examining the end results or consequences of a project, a program, or a package of services for one or more stakeholder groups. Evaluators ask a common set of questions and take similar steps when gathering and interpreting data to determine the effectiveness of policy. These questions and steps apply across all levels of policy making (i.e., big “P” or little “p”) and 359

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typically incorporate the perspectives of both the recipients of a program and its providers. The heart of evaluation is collecting and reviewing evidence regarding inputs and outputs of a program or policy to determine whether a policy or program meets its intended goals. It involves taking stock of the structures, processes, and outcomes of an activity. Evaluation may look at interventions or programs as a whole, examining the impacts of a policy on various individuals, or on society at large. An important example of how evaluation has informed advocacy relevant to both nurse and patient safety relates to sharps injuries. The following Policy Challenge illustrates some successes realized to date and highlights the ongoing evolution of policy.

POLICY CHALLENGE: Charting a Wider Path for Workplace Safety and Advocacy Increased emphasis has been placed on workplace safety and advocacy with many rules and regulations having been put in place in the 20th century. The early focus of these initiatives was often on jobs that were viewed as highly dangerous such as mining and manufacturing, but since the early 1970s and the establishment of the Occupational Safety and Health Administration (OSHA), safety efforts increasingly are applied across all work arenas. OSHA and numerous partners, including individuals and groups, have affected awareness and prevention of workplace injuries. The American Nurses Association (ANA) and specialty nurse organizations such as the Association of periOperative Registered Nurses (AORN) are examples of the influence that nurses can have and have had at the highest levels for safety advocacy in relation to sharps injuries. Nursing’s frontline work, with patients and the public, requires ongoing vigilance for nurse workplace safety and advocacy. Issues such as exposure to infection, violence, and chemicals, coupled with activities such as moving and lifting patients and equipment and working under conditions that may mean working alone or in high-crime areas, are just some of the safety issues nurses face. Nurses may be hindered in their ongoing vigilance for their own workplace safety and advocacy because of their own altruism. The addition of a fourth aim to healthcare’s Triple Aim of improving the experience of care, improving health and reducing costs—that of improving the work life of providers (Bodenheimer & Sinsky, 2014)—makes it increasingly important to prevent workplace injuries. One area that has realized significant improvements in workplace safety is sharps injuries. Policies, such as discouraging recapping of needles, ensuring widespread access to disposal containers, and using hands-free techniques (HFT) in the operating room have done much to contribute to improved safety (see Chapter 1). Sharps injury is also a good example of where much remains to be done in workplace safety. According to Daley, Laramie, and Mitchell (2017), complacency eroded the gains made in sharps safety. Are policies related to sharps injuries where you work adequate and are safe practices embedded in workflows? See Option for Policy Challenge.

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LANGUAGE OF POLICY EVALUATION The evaluation of policy has many facets that incorporate similar and/or overlapping concepts such as evaluation, research, policy analysis, quality improvement, and benchmarking. Evidence is important in all types in the policy-making process and all types of evidence are used.

Evaluation The purpose of evaluation in the policy-making cycle is to understand systems of services or policies that are assembled to address various issues or problems. Evaluation is necessary to make judgments about a policy’s effectiveness and decide whether it is sufficient, needs modification, or should be discarded. The primary audiences for evaluation findings are people in charge of planning, implementing, and making decisions about services. In direct care nursing, policies often relate to health, safety, quality patient care, and/or provider effectiveness. Evaluation is practically oriented. Evaluators are most concerned with the practicalities of getting sound data at the most reasonable cost and in the timeliest manner because they need to know, often quickly, how well a policy or program is achieving its intended outcomes. Some features academic researchers might consider important in a research design are not always seen as critical by managers and policy makers in the evaluation process.

Research Research, simply put, is the discovery of new knowledge, including descriptions and explorations of the nature of phenomena and the relationship of variables to one another. Researchers have a toolkit of techniques, including carefully collecting and analyzing data, to uncover patterns that offer answers to larger questions in a scientific field by using different strategies depending on the methods tradition of which they are a part (i.e., qualitative, quantitative, mixed methods). In the end, there are many similarities between research and evaluation, even if the end goals are different. Nurses engaged in evaluation use many of the same data-collection sources as conventional researchers, including interviews, observations, and surveys, depending on the nature of the policy and the best method for obtaining outcome data and evidence evaluation. Evidence is important in the policy-making process, and all types of qualitative and quantitative evidence from both highly formalized and informal data collection are used; as indicated in previous chapters (see, for example, Chapter 5). Many researchers engage in evaluation projects as part of their portfolio of activities. Sometimes, carefully designed evaluation projects using the approaches discussed in this chapter are considered to have broader applicability and scientific value and are disseminated in the same venues as more conventional and less practically oriented research.

Policy Analysis Policy analysis and its close cousin, policy analysis research, examine the context in which a policy might be introduced. They provide information about the likelihood of a policy’s successful implementation. After implementation, they are used examine how well the policy achieved its intended outcomes and determine whether there have been unintended consequences. Analysis of government-level policies is often seen

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as the domain of social scientists and sometimes more specifically of political scientists and economists, but some nurse scholars also engage in this work. However, policy does not occur only at the state or country levels. Policies at the local (or little “p”) level have extensive impacts on most nurses’ work and work environments. Therefore, nurses and nurse leaders in practice settings must also be able to carry out policy analyses (Hewison, 2007). Initiation of new local policies or modification of existing ones often results when problems arise in practice settings or when circumstances emerge that are thought to require an accompanying policy. From an organizational standpoint, policies are best examined from a multidisciplinary approach. Often, this process involves contacting colleagues at other organizations or searching the literature and the Internet for current best practices and guidelines, as well as information about their effectiveness. Nurses can also be informed by these self-administered practices, and they can also seek guidance offered by experts and professional groups. Policy analysis examines specific criteria to evaluate a policy and includes developing policy alternatives, assessing the possible outcomes of each alternative, and selecting an alternative from the projected choices. An often-cited practical process for policy analysis can be found in Bardach and Patashnik (2016), who developed an eight-fold path for policy analysis for public policy advocacy purposes that includes the following steps: (a) defining the problem, (b) assembling evidence, (c) constructing alternatives, (d) selecting criteria, (e) projecting outcomes, (f) confronting trade-offs, (g) deciding, and (h) telling the story. Some of these steps involve gathering data from the literature and other expert sources regarding a problem or issue, using best practices in addressing the challenge elsewhere and information specific to the location or site where one hopes to initiate the policy, whereas others involve analyzing this information and framing for communicating it to various decision-makers or stakeholders (see Chapter 4). Policy evaluation is often not as formal as research, and the sequencing of its steps is more flexible. It is often iterative with backward and forward movement in varying phases. These steps may seem familiar to nurses because the nursing process, the research process, and policy analysis have clear similarities.

Quality Improvement and Benchmarking Two other terms that are important to consider in the context of a discussion of outcomes and evaluation are quality improvement and benchmarking. Batalden and Davidoff (2007) define quality improvement as concerted efforts over time by all the stakeholders in healthcare to improve the health status of the population, care system functioning, and professional development or learning. We usually think of quality improvement as the work of managers or specifically designated work units within healthcare organizations charged with measuring and improving care system functioning, but Batalden and Davidoff ’s definition encompasses broader activities and could even be thought of as encompassing the policy realm. Quality improvement draws on ideas from research methodology and evaluation but is yet another data-driven pursuit demanding high-quality outcomes data—it is another practical activity that many different disciplines can participate in. Benchmarking is an activity comparing an object, an organization, or even a society against some sort of standard on a measure or measures. In healthcare contexts, benchmarks are used to describe a healthcare system (or a subset of the system, such as a clinic or nursing unit) in relation to others like it. The standard can be national or international norms for staffing or patient outcomes or a “best in class” performance level.

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Organizations can even benchmark their performance against themselves over time. Benchmarks are obviously a major part of quality improvement, highlighting the items on which managers need to act. They also provide a stimulus for higher-level policy makers to confront and address reasons why their organizations may not be performing well and spur leaders to match or better the performance of peer organizations or even healthcare systems internationally. A good international-level example is work comparing Organization for Economic Cooperation and Development (OECD) data on numerous topics across countries. For example, Squires (2013) compares a range of countries on measures touching on healthcare expenditures, mortality, and quality. Numerous databases allow benchmarking of healthcare facilities and subunits (such as clinics or units). Some common examples that nurses in hospital and home care encounter on a regular basis include the National Database of Nursing Quality Indicators (NDNQI) and the Outcome and Assessment Information Set (OASIS). Indicators are the specific measurements that are compared in a benchmarking process. Nurses in all settings and across all roles use and are often judged on some ­indicators (e.g., examination scores, numbers of publications, clinical practice benchmarks). Indicators related to quality and safety in clinical care areas are very familiar to nurses working in hospitals, clinics, and home healthcare. Patient fall rates, for example, are often measured and then benchmarked against those of similar units or institutions. NDNQI specifically measures nursing quality and provides nurses with unit- and hospital-level measurement for benchmarking across state, regional, and national data. It should be noted, however, that finding indicators and benchmarks capturing nursing safety-related factors such as occupational injuries can be challenging (see Policy on the Scene 12.1).

POLICY ON THE SCENE 12.1: Quadruple Aim: Benchmarking for Healthcare Worker Safety Establishing and comparing your institution,s data to local, state, and national benchmarks is one way to document progress and set-backs within an organization. After several years of mandatory reporting requirements for acute care hospitals to obtain full Centers for Medicare & Medicaid Services (CMS) reimbursement, benchmarks for patient safety outcomes such as surgical site infections and hospital-associated infections is readily available for those wanting to compare their own facility against other like facilities (i.e., bed size, geographic location, teaching status). However, benchmarking data of healthcare worker occupational harm and injury rates are not readily available. Therefore, it is often difficult for organizations to assess progress in performance-improvement initiatives in this area. With the increased emphasis on healthcare worker safety, including revising the Triple Aim to the Quadruple Aim (Bodenheimer & Sinsky, 2014) to include improving the work life of healthcare workers, there is an increased demand for benchmarking data of healthcare worker harm. Healthcare workers are faced with unique risks given the unpredictability and rapid pace of the environment. These injuries include bloodborne pathogen exposures, workplace violence incidents, (continued )

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and musculoskeletal disease related to patient handling. Performance improvement leaders are faced with challenges to compare their healthcare worker injury rates against other like facilities. On January 1, 2017, a final rule took effect requiring annual electronic submission of the injury and illness log to the Occupational Safety and Health Administration (OSHA, 2016), whereas previously, it was required to be maintained only at the organization. OSHA hoped this new rule for electronic submissions would encourage a “competitive spirit” among employers to increase their safety efforts and improve the work life of workers in high-risk settings such as healthcare. It also will enable researchers to examine and create benchmarking data for comparison and improvement.

EVALUATING STRUCTURE, PROCESS, AND OUTCOME A variety of models of program and policy evaluation have emerged over the years. A structure, process, and outcome approach was first described by Avedis Donabedian, a health services research scholar who wrote highly influential papers and books on health service quality. This model has been popular in healthcare circles for decades. Donabedian’s framework pushes clinicians, managers, and researchers to think about the services provided by professionals or the interactions with them that affect patients and communities and figure out raw materials use in terms of people, time, facilities, and equipment needed to deliver the services and the impacts they have on patients, providers, or society (Donabedian, 1980, 1988). His structure, process, and outcome evaluation model is classic and remains current and applicable today. Although by no means the only evaluation framework available, Donabedian’s ­structure, process, and outcomes framework, makes intuitive sense to healthcare managers, practitioners, direct care providers, and program designers and by extension is useful for thinking about health policy. The framework can be used to study outcomes in healthcare settings and to examine the environment, as well as the personnel and work processes in those environments. One example is when a public health nursing team providing community outreach visits (structure) does various types of teaching and connects at-risk families with resources (process), intending to facilitate coping, and teaches healthy behaviors and parenting skills to at-risk families (outcome), with the end goal of enhancing child development and long-term family functioning (higher level, long-range outcomes). Another example is when a population health nursing team works with legislators to introduce regulation (structure) to reduce secondhand smoke exposure (process) with the intent of preventing downstream illness (outcome). Donabedian’s framework breaks down the components of a service or program into the observable and measurable: structures, processes, and outcomes. Exhibit 12.1 illustrates how these may be applied in terms of high-level policy (big “P”), as well as local service delivery (little “p”).

Structure The “structure” in Donabedian’s framework is the “raw material” of healthcare (i.e., people and supplies), as well as the conditions or contexts of care provision. Structure encompasses human resources (the individuals who work to provide care and those

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EXHIBIT 12.1  EXAMPLES OF STRUCTURE, PROCESS, AND OUTCOME IN POLICY COMPONENT

DEFINITION

LITTLE “p” EXAMPLE

BIG “P” EXAMPLE

Structure

Attributes of settings in which healthcare is delivered: material resources and human resources, organizational structure

Hospital unit staffing, policies, procedures

Financial, space, and structural resources to establish statewide emergency response systems

Process

Processes and actions of care delivery

Method of falls screening implementation; falls prevention methods

Method of recording and transmitting patient falls with injury data to NDNQI

Outcome

Effects of care on health status of patients and communities

Healthcareassociated pressure injury prevalence per 1,000 patientdays for a specific unit

Community mortality and morbidity measures

NDNQI, National Database of Nursing Quality Indicators.

who support this work), as well as the way healthcare workers are selected, trained, organized, and managed. Structures can also include physical resources (e.g., equipment, supplies, physical space where care is provided). Finally, structure can also include management supports for care: the organizational structure and ­decision-making mechanisms in a setting, the selection and support of managers, and management practices. Several examples of structure cutting across both big “P” and little “p” in terms of ­policy was highlighted in The Future of Nursing report (Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, 2011). At a broad level, the report recommended that the proportion of nurses with baccalaureate degrees be increased to 80% by 2020 and that at a local level, residency programs be implemented for new nurses, new advanced practice nurses, and nurses transitioning to new practice areas.

Process Processes are the elements of the care or services provided to a patient population—the services intended to improve health and quality measures. The activities of healthcare workers, the order in which they are carried out, and their quality or content are normally included. At the simplest level, processes might include whether sterile technique was followed for a dressing change. Over the years, there have been some departures

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and popular reframings of structure, process, and outcomes from Donabedian’s original writings. Some also would include management practices under the banner of “processes,” but in the Donabedian’s original formulation, management approaches would normally fall under “structures.” Using the example of local and national approaches to attain the 80% baccalaureate preparation of nursing staff mentioned earlier, a process evaluation might include an evaluation of the routes to the bachelor of science in nursing (BSN) degree among RN staff and the barriers and facilitators of achieving a bachelor’s degree. In a hospital setting, the evaluation of the processes surrounding the initiation of a rapid response team is another example of process evaluation.

Outcome Outcomes are downstream results or endpoints of care. Donabedian’s work considers these primarily from a clinical point of view. Outcomes include “objective” health outcomes such as the incidence of illness, illness severity, complications, and mortality. However, it is also important to consider “subjective” patients’ and families’ perspectives on health situations. The notion of quality of life is an important subjective measure. It allows for individually interpreted ratings of health states and their impacts, as well as the patient’s perceptions of the quality of the care they have received and their satisfaction with their experiences. Outcomes can be considered proximal or distal. Proximal outcomes are direct indicators of the impacts of treatment on visible manifestations of the phenomena (e.g., symptom levels, tumor size, blood pressure, scores on knowledge tests). Distal outcomes are reflections of the way a treatment or program effects a higher level of or more abstract functioning of individuals or systems (e.g., life satisfaction, job performance; Brenner, Curbow, & Legro, 1995). It is often easier to demonstrate an impact of a program on a proximal outcome and more difficult to show its impact on a distal outcome, even though the public (and decision-makers at higher levels of systems) are often more concerned about distal outcomes that have clearer importance to patients and society. Quality can be considered in terms of the degree to which the package of services is in line with what are thought of as best practices (frequently the clinical point of view); this is more in line with Donabedian’s notion of process, but it may also be thought of in terms of the positive or desirable end points that are achieved (e.g., recovery of function, return home, enhanced long-term survival) or negative end points (e.g., complications) that are avoided in the delivery of a service. A number of important health system outcomes can also be considered through the perspectives of various stakeholders. These take on different forms for the consumer, for the organization, and for a health system or a wider society. Access and cost effectiveness are outcomes of healthcare that can be examined from various positions in the healthcare system, with consumers being more concerned about their personal experiences of care and managers and policy makers tending to look at experiences of many measured across a whole clientele or community. Access can refer to “theoretical access” or the availability of personnel and facilities in the community with or without examining whether there are enough “spaces” to meet demand. It can also refer to “practical access,” affordable services available within reasonable travel distances (Roberts, Hsiao, Berman, & Reich, 2008). A service can also be analyzed in terms of the resources consumed to bring a patient to a certain health state. Financial outcomes, seen from the perspective of a healthcare consumer (patients and families), usually relate to costs of their insurance coverage (through taxes, insurance premiums, or both), as well as any out-of-pocket costs

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that are not covered by insurance, such as additional copayments or bills above and beyond what their insurance plan covers, and expenditures, such as travel expenses and lost income. Through the eyes of a healthcare provider and organization, outcomes relate to the expenses sustained in delivering services relative to the reimbursements they receive and whether there are deficits that must be compensated for by other ­revenue-generating activities (e.g., other healthcare services). For a government or insurance payer, financial outcomes are a balance between the outlays relative to the end points that they are responsible for producing for their patients or citizens.

Interconnectedness The connections between structures, processes, and outcomes are very important. Altering processes of care that have limited or highly indirect connections to desired outcomes is highly unlikely to produce improvements. Likewise, hoping to improve processes of care without ensuring that a critical mass of structures is in place to allow sound practices to be consistently carried out is equally misguided. Some experts believe the first step in planning and evaluating a service or an initiative is to construct a diagram (one such type of diagram is called a logic model) that lays out the various components of an intervention or a policy and the preconditions for the outputs in terms of actions of the participants and then to identify the basic resources needed to make these actions possible. See Figure 12.1 for a comparison of the language used in Donabedian’s framework and a simple logic model for a hypothetical program involving teaching self-care to individuals with diabetes. Some also call such a series of relationships that connects structures, processes, and outcomes a program theory. A program theory or logic model not only is a convenient tool for explaining the reasoning behind an intervention or policy, but also provides a road map for evaluating implemented interventions and policies.

Elements of Donabedian’s Framework Structures

Processes

Proximal outcomes

Distal outcomes

Activities

Short-term outputs

Long-term outputs

Logic Model Inputs Physical space in clinic/ community to deliver intervention Appropriately trained staff assigned to program Culturally appropriate teaching materials

Patient and family teaching regarding key elements of diabetic self-care

Patients’ improved compliance with diabetic self-care regimens

Improved shortterm and longterm measures of diabetic control Decreased healthcare use Improved quality of life for patients and families

FIGURE 12.1  A comparison of Donabedian’s framework and a logic model in a scenario of teaching self-care to individuals with diabetes.

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Health is a complicated phenomenon with many facets that can be studied at many different levels from an individual level through the community and society levels; it is influenced by a multitude of factors such as genetics, developmental and life history, the social and physical environment, and, of course, healthcare. In health policy, the aim is often to use government powers to improve population health, usually, but not always, by influencing what happens in health service delivery. The Patient Protection and Affordable Care Act (ACA), commonly referred to as Obamacare, a legislative intervention signed into law in 2010, was intended to influence financing (structure), increase the use of appropriate services (process), and improve health (outcome) in the U.S. system. This complex law, from its inception, stimulated a great deal of controversy and after enactment received much attention from researchers and policy analysts. Opinions regarding the legislation were very strong and varied markedly, but many in organized nursing have advocated for these reforms, especially the elements of the law that touched on expanding access to health insurance and the lesser discussed, but still important, provisions related to quality and cost of care and the nurse workforce. At the time of its development and its debate through the legislative process, structures to make purchasing health insurance coverage more affordable and simpler were intended to promote processes for the public and insurers to increase the health insurance coverage of individuals across age groups, with the goal of improving quality of care and health outcomes. The proponents and detractors of the ACA clearly embraced or dismissed the argument for that legislation within their assumptions and political contexts/constraints. As of this writing, the impact of the ACA to date, as well as its future, are still in debate. Interestingly, few results from evaluation research (and indeed little economic theory) has informed the public debate or the legislative activity and tug of war over the act. However, many evaluation studies and analysts have reviewed the ACA as a policy in much detail. There have also been many studies of public opinion about the impacts of the legislation, consumer experiences, and insurance carrier and healthcare provider responses to it. Changing political winds from many different directions have clearly influenced legislators’ plans to repeal and replace the ACA with an alternative plan aimed at reducing expenses and improving access. Another example of the interconnectedness of structures, processes, and outcomes originates from research on nurse staffing and patient falls. In some studies, higher nurse-staffing ratios in acute care settings have been linked to decreased patient falls. In a study by Kalisch, Tschannen, and Lee (2012), guided by a model involving “missed nursing care,” they posited that certain nursing interventions being left unperformed would lead to more patient falls. Staffing was the structural variable, missed nursing care was the process variable, and falls was the outcome measure. The team found that lower levels of nurse staffing and missed care were statistically linked to in-patient falls. In cases in which care delivery is not the direct focus of attention, government-level health policy may be aimed at improving one of the other social determinants of health (i.e., income, social and physical environments, health-related behaviors). Most public health and social policy interventions fall into this category (see also Chapter 13). In either case, staff time, basic resources, or raw materials (structures) are transformed into services or contacts with a clientele that is expected to impact changes in their circumstances and then ultimately influence health-related outcomes. Policies of local agencies (processes) usually target narrower aspects of office, unit, or service functioning but relate to the way structures are used to accomplish the day-to-day work of an organization; the outcomes often relate to smooth organizational function or movement toward an organizational goal. In this case of local policies, the health status of the population is a tacit, or implied, downstream goal.

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MEASURING CHANGE Investigating whether there has been movement in outcomes because of the implementation of a program or policy, the goal of evaluation, can be thought of as the search for differences in a phenomenon of interest over a period that spans a change in contexts or activities in a system. The evaluation of a policy involves assessing changes in structures or processes (or both) that are related to policy implementation, along with possible changes in outcomes in the individuals targeted by a program or policy. Evaluation approaches can be summative, formative, or a combination. Summative evaluation involves collecting data after policies have implemented or at the end of a program. Formative evaluations collect data while a policy or program is implemented, sometimes with the explicit purpose of providing feedback that can be used to tweak the program along the way, and other times it is undertaken to understand how systems change over time. Users of both formative and summative evaluation approaches understand that changes in outcomes unfold over time. Policy on the Scene 12.2 provides a further illustration of how structure, process, and outcome data are being used to measure change at the local and national levels. Another distinction in evaluation methods (borrowed from research traditions) relates to prospective data collection (in which subjects are identified prior to implementation and followed forward in time) versus retrospective data collection (in which subjects are identified and information is gathered after the fact). When resources are scarce and policies are rapidly implemented, it is not uncommon for evaluation of policy, specifically at the little “p” level, to be examined cumulatively and retrospectively (i.e., after implementation) and may be quite informal.

POLICY ON THE SCENE 12.2: Policy Evaluation to Improve Quality and Patient Safety Under current policies, hospitals seeking to receive maximum reimbursement from Centers for Medicare & Medicaid Services (CMS) for their Medicare patients have a significant incentive to focus on improving quality outcomes for patients. In the years since value-based purchasing initiatives were instituted, hospitals have made significant changes to structures and processes, such as care bundles, in efforts to reduce these harm events to patients. Care bundles are a grouping of evidence-based structures and processes that, when implemented together, result in significantly better outcomes in certain preventable harm events than when implemented individually (Resar, Griffin, Haraden, & Nolan, 2012). Evaluating the impact of these changes is integral to future policy work. In one example of policy evaluation, Waters et al. (2015) studied whether a 2008 CMS policy to deny payment for certain hospital-acquired conditions (HACs) improved outcomes in four of the eight HACs: hospital-associated pressure injuries (HAPIs), injurious falls, central line–associated bloodstream infections (CLABSIs), and catheter-associated urinary tract infections (CAUTIs). Combining data from the American Hospital Association, Medicare Cost Report, and National Database for Nursing Quality Indicators (NDNQI), researchers (continued )

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found the HACs initiative was associated with decreased rates of CAUTIs and CLABSIs. However, the HACs initiative was not found to be associated with a reduction in HAPIs and injurious falls. Authors hypothesized that these two harm outcomes may not have had the same evidence-based care bundles of structures and processes that had been developed for CLABSIs and CAUTIs (Waters et al., 2015). The use of meaningful data to evaluate policies intended to improve structures, processes, and outcomes to reduce harmful events to patients is integral to future policy work both at the local and national level.

Understanding Change Over Time The heart of all research design is measuring differences in variables over time or across conditions; that is an element that research and evaluation share. For instance, a research study could ask whether mortality changes when a specific drug or treatment protocol is given to patients. Other variables (sometimes called secondary outcomes), such as blood pressure measurements, may also change alongside differences in the main variable of interest, the primary outcome. Perhaps the impact of the treatment on mortality moves in different ways after treatment is received, depending on the sex or age of the patient; in such a case, it would be wise to incorporate sex and age measures as biological variables. We also might be interested in a research study that examines how hospital length of stay or inpatient mortality varies across patients, hospitals, regions, or time. The Agency for Healthcare Research and Quality’s (AHRQ) Healthcare Cost and Utilization Project (HCUP; www.ahrq.gov/research/data/hcup/index.html) is a nationwide longitudinal U.S. database containing a range of state-by-state hospital care indicators that can be used to track changes over several years. In addition, national patient registries can provide ­population-specific data for use in tracking outcomes over time (Taha, Ballou, & Lama, 2014). The aim of a specific policy initiative involving the implementation of home visits by community nurses after the arrival of new babies in socially and economically vulnerable families (Olds et al., 2010) might be to improve short- and long-term child development. In this case, development of the children in targeted families would be measured before and after their participation in the program. When outcomes change after implementation, the policy or program appears to have also affected the structures or processes in a system, and evaluators have used various strategies to exclude competing explanations for outcomes improvements (e.g., mere passage of time, other changes in the environment that were independent from the interventions); evaluators can make statements that the initiative was responsible for the change with relative confidence. Data over time are very important to determining whether a policy or program is effective. In the home visit example, if the families receiving the intervention had considerable contact with nurses and the content of those interactions was closely aligned with providing information about optimal parenting techniques, anticipatory guidance, and timely referrals, this would strengthen confidence that any improvements seen were due to the policy. To take the example further, showing that the improved outcomes were seen only when nurses and not lay community workers conducted the intervention would suggest that it was relationship building with nurses that led to the improved outcomes for families and children (Bornstein, 2012).

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Using Quantitative and Qualitative Approaches to Evaluation In many cases, evaluators and policy makers want to understand what would happen without an intervention or initiative but are unwilling or unable to conduct a formal experiment. In situations when randomized trials and other forms of experimentation are not possible, researchers in the social and health sciences have assembled many approaches that attempt to answer the question of what would have happened without a specific initiative in place. This has sometimes included finding groups or situations that provide a possible “control” or “comparison” group outside the research or evaluation initiative to gauge the outcomes of those targeted by a policy or an initiative. It could involve examining outcomes for a comparable group of vulnerable families in other areas of the same region who did not participate in the home visit program or examining outcomes for families in the same area but in the years before the program was implemented. To the greatest extent possible, the comparison group is constructed to be similar in all important respects to the intervention group. In addition to having a control or comparison group, preferably one that individuals are assigned to randomly, the ideal quantitative evaluation approach involves a pretest before policy implementation, followed by a post-test after policy implementation. Posttest evaluation designs that involve measurements only after enactment of a policy or program are extremely common. The likelihood of many competing explanations for any patterns seen complicates the drawing of conclusions from the data obtained from such designs. As discussed previously, lack of planning and resources, both human and financial, contributes to the common use of post-test–only designs for evaluating policy. It is important and perhaps not surprising to realize that in most evaluations, the main outcome of interest fails to change or show differences. There are several likely explanations for this. First, most outcomes are the product of complex and often interrelated factors. Second, interventions or initiatives can only hope to address a small handful of the factors involved, and we may not understand the mechanisms as well as we think. Third, available outcome measures may simply not be as reliable as we might like. This situation is sometimes found in large, pre-existing data sets or when data can be accessed only after a policy has been implemented. Examples of proxy data would include using educational level for health literacy or using self-rated health status for disease state. Fourth, sometimes data are collected and theoretically available for use in evaluation, but access to them is greatly restricted to protect the privacy of patients or providers. This often leads to policy evaluators being unable to access and analyze the data. Many compromises have been made, including using proxy data to evaluate programs, but with compromises come debates about data quality that can render evaluations open to critique. These approaches to evaluation are based on measurement and the quantitative paradigm. A growing contingent of researchers and evaluators, as well as policy makers, recognize that quantitative approaches are not always the best or only methods for understanding the implementation and impacts of programs. Instead, they apply methods from qualitative research, including content analysis of various types of documents, interviews, focus groups, and field observation, to gain insights into the experiences of participants and stakeholders. Donabedian’s framework and the elements of structures, processes, and outcomes are equally relevant—addressing quality of the structures, evaluating changes in processes (or behavior changes of providers or patients), and understanding the outcomes perceived and lived by all involved. Although some see that quantitative evaluations using well-structured quasiexperimental designs provide more robust evidence for policy analysis, most are agreed that multiple types of data are needed for guiding policy.

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In addition to outcome data collected by the evaluator explicitly for the purpose of assessing program function, existing data sources and outcomes data can also be identified and accessed during the evaluation process. Both methods of data sources for policy evaluation around collecting outcomes data result in two interconnected sets of issues: logistical and methodological. Logistical issues involve energy and the human and financial resources that must be invested, as well as access barriers that must be overcome. Also, methodological issues include ensuring that the data collected are of consistent quality and are reliable and measure what they are intended to track. For data to be collected, stakeholder interests in gathering information must outweigh the costs and potential risks involved. These issues have been alluded to in the previous section, but they hold particular meaning for nursing because, in many cases, the impacts of policies involving nursing and nursing care are difficult to track. It is not uncommon that all the types of data needed to evaluate a program or a policy initiative are known or can even be collected. Often, there is a lack of measures, or assessments of key variables (structures, processes, or outcomes) from the time before a policy is implemented. Regardless of the design, data necessary for policy evaluation require resources in the form of money, energy, and time. This is a basic reality of all research and makes using existing data sources in policy evaluation particularly salient.

EXISTING DATA SOURCES Analyzing existing data sources, as opposed to gathering new data, helps alleviate many of the resource constraints evaluators face related to original data collection. State and federal public policies have for some time attempted to ensure that the numbers and types of nursing personnel are sufficient to meet regions’ and the nation’s needs. For over two decades, the National Sample Survey of Registered Nurses, a federally sponsored, carefully planned representative survey of licensed RNs across the United States, was conducted every 4 years. It had a strikingly high response rate and was considered the authoritative source for understanding trends in entry to and exit from the profession, as well as educational and career paths of nurses. Thus, it was a key tool in planning state and national workforce policy (Spetz, 2010). The survey was defunded by the Health Resources & Services Administration after the 2008 data-collection cycle, and until very recently, there are no immediate plans to restart it (Spetz, 2013). However, other researchers have been able to use U.S. Census datasets on employment across communities to get a sense of workforce trends (Auerbach, Buerhaus, & Staiger, 2015; Buerhaus, Skinner, Auerbach, & Staiger, 2017). Although the career paths of nurses are now more difficult to track, researchers are still finding ways to justify and evaluate investments in the nurse workforce. Evaluation of policies affecting the quality of nursing care has been impeded by a lack of systematic data collection about the trajectories of patients through the healthcare system and patients’ experiences of health. To complicate matters, nursing is often “invisible” in data sets in that variables that represent the factors that nursing directly influences have not been routinely collected. As a partial answer to that issue, nursesensitive indicators that are distinct from medical indicators have been developed and reflect the outcomes that nursing care can prevent or change. These measures are found in NDNQI, established by the ANA in 1998 and now owned by Press Ganey. It is the largest global quality nursing database available to assist nurses and hospitals to improve the quality of care and evaluate outcomes, and it helps make nursing’s impact much more visible. Over 2,000 hospitals participate domestically and internationally.

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Donabedian’s structure, process, and outcome quality framework is used in the database. See Exhibit 12.2 for a list of commonly used structure, process, and outcome measures and their relationship to the Donabedian framework. Using existing data sources, if they can be identified and accessed, saves time and resources. These data sources provide for robust comparison for policy evaluation. EXHIBIT 12.2  EXAMPLES OF STRUCTURE, PROCESSES, AND OUTCOME MEASURES STRUCTURES

Certified lactation consultant hours per 1,000 live births Nurse turnover Nursing care hour per patient day Nursing care hours per patient visit Nursing care minutes per surgical minute Patient volume and flow RN education Skill mix PROCESSES

Care coordination HAI (e.g., strategies to prevent urinary infections) Pediatric pain management Physical restraints Pressure injuries prevention techniques OUTCOMES

Assaults on nursing personnel CAUTIs Central line–associated bloodstream infection Patient falls Pediatric peripheral intravenous infiltrations Physical/sexual assault Pressure injuries VAE, including pneumonias CAUTIs, catheter-associated urinary tract infections; HAI, healthcare-associated infection; VAE, ventilator-associated events.

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ACCOUNTABILITY AND TRANSPARENCY IN EVALUATION Healthcare systems are stunningly complex webs of providers, organizations, and programs. The resources invested are huge, and the stakes are high for all involved. However, consumers/citizens often feel that they have limited choices about how and where they seek care and have limited inputs into the decisions around the design and payment of services. In addition to incorporating the voices of the consumers at the local level, such as having patient and family councils and inviting community members to serve on boards, a number of approaches have emerged to address such concerns. An accountability and transparency movement has emerged that emphasizes freer exchange of information about operational details and outcomes of policies in the hands of consumers. This movement is not unique to healthcare by any means; it has well-known forms in elementary and secondary education (i.e., standardized testing to evaluate schools and teachers) and is coming of age in many other areas of public and social services, including policing and the justice system (i.e., police body cameras to document whether the use of force by officers is consistent with regulations in jurisdictions). The accountability movement is intended to hold local managers and system policy makers responsible for the results generated. Accountability for outcomes of policy makers and executives/managers is part of a broader move toward “transparency”—a willingness to share information openly to permit outside examination of the operations of complicated organizations. Public reporting of healthcare structures, processes, and outcomes is increasingly common. Review or reporting of staffing levels in healthcare facilities; accreditation processes that focus on the verifiable presence of various types of equipment, supplies, and operating procedures; training and management practices; review of patient records and even inspection of care practice; and public reporting of outcomes are all examples of measurement of structures, processes, and outcomes and their publication or diffusion to various audiences either in the form of individual measures or in summarized form. Data, for example, are routinely made public that compare the price of comparative surgeries across a state, a region, a country, or even the world.

Government Accountability Programs Data are available from a large number of hospitals on the deadliest hospital-acquired complications. The Centers for Medicare & Medicaid Services (CMS) routinely publishes results that compare data on each of the following settings: nursing homes, Medicare-certified hospitals, and home care (www.medicare.gov/hospitalcompare/ search.html). There is a move toward providing managers and clinicians with additional incentives for meeting targeted standards or attaining certain outcomes by tying performance to some portion of remuneration or agency funding. This movement, known as “pay for performance,” exists in various forms in healthcare. In October 2012, reimbursement based on performance under the Medicare Hospital Value-Based Purchasing (HVBP) program began for acute care hospitals throughout the United States (Ryan, Krinsky, Maurer, & Dimick, 2017). HVBP can be traced to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and the Deficit Reduction Act of 2005 that started with voluntary public reporting of measures. With the passage of the ACA in 2010, HVBP was mandated providing rewards for how well hospitals meet selected quality measures. The program incentives have

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increased from 1% of diagnosis-related group revenue to 2% starting in October of 2016 (Ryan et al., 2017). Since inception, incentives were expanded from clinical process and patient experience measures to spending measure outcomes such as 30-day mortality rates for specific diagnoses (Ryan et al., 2017).

Considerations for Transparency Several issues surround high-stakes measurement used for public reporting or payment to providers or workers’ compensation. The first relates to differences in the clienteles served by various healthcare agencies that may make a challenge to interpret variability in outcomes. Should healthcare providers serving patients with more complex or challenging conditions be compared with those serving patients with less complicated conditions on their outcomes or financial performance? Performing statistical adjustments to outcomes that take patient or institutional characteristics into account and that soften the impact of treatment “failures” on the indicators is called risk adjustment. For instance, it is arguably important to consider the age and disability status of patients or their clinical stability and backgrounds before drawing conclusions about the possible significance of healthcare-associated pressure injury or infection data as an indicator of the quality of nursing care. The debates are not simple ones—arguably more challenging cases deserve tailored care, and patients and their communities often experience negative events as failures, whether some cases are inherently “harder” than others. Preliminary data after the first year of HVBP show that financial impact on hospitals caring for more disadvantaged patients was worse (Ryan, 2013). These results indicate that processes for reviewing the data and determining payments need further refinement. The second issue relates to understanding meaningful differences across healthcare providers or in the same healthcare providers over time. Much can be made of very small differences that may be trivial, the result of minor fluctuations, or the result of relatively small numbers of cases going into the calculation of event rates. Practical details of ensuring accurate and consistent data across agencies must be confronted. Intraorganizational differences in personnel, data-collection procedures without extensive external validation raises concerns for the rigor and quality of data. Criteria for determining incidence and rates of hospital-acquired conditions, especially when case definitions are constantly being revised, could lead to different interpretations by different providers and organizations collecting and analyzing the data. This leads to discrepancies and problems with comparing intraorganizational differences, especially when there is organizational motivation to report no adverse events. Underlying all these issues is the tension among the professional organizations, consumers, and healthcare agencies about the public availability of data. As healthcare reform pushes for data transparency, it is believed that consumers, if they can easily access and understand the outcome data, will choose providers with good track records on quality and who offer lower prices. In a study done of almost 1,500 employees, it was found that cost was a major factor in choosing providers (Hibbard, Greene, Sofaer, Firminger, & Hirsch, 2012). Many in the Hibbard study avoided providers who were less expensive because there seemed to be a perception that high cost equated with high quality. However, when the employees were presented with cost data and easy-tounderstand information about provider and service quality, more consumers indicated they would choose quality rather than basing decisions on cost.

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Implications for Nursing of the Accountability and Transparency Movement Accountability and transparency are arguably forces that work in favor of increased investments in nursing. However, in many organizations, nursing services are considered overhead, costs of doing business, and areas for possible cost cutting. Relying on financial accounting approaches with a misunderstanding of what are truly equivalent care structures and processes and without considering care outcomes can lead to decisions that cut staffing and other nursing resources but ultimately increase service costs. Widening the indicators tracked and reported/used to drive reimbursement to include more process and outcomes measures influenced by nursing care could support investments or reinvestments in structures of care. What is needed is a paradigm shift such that the financial bottom line is not the only outcome that should determine action. In the case of nursing, we need to analyze the ways that nursing offers value to the public in terms of keeping citizens healthier, including helping individuals enjoy greater quality of life and health within the context of illness. This involves identifying how outcomes for the public can be made tangible through measurement, exploring how nurses produce these outputs and what types of structures and processes are needed to achieve the outcomes, and considering whether and how measurement of structure and process should be undertaken. It also involves helping the public demand and interpret outcome data. Nursing can also influence how data are tabulated or graphed and what media are used to transmit the messages. Although structures, processes, and outcomes and their relationships to one another are all important, many stakeholders beyond clinicians and managers are almost exclusively interested in “hard” patient and financial outcomes. Structure and process data seem to be much more important to the architects of policy and the managers of services than to many other stakeholder groups. This is perhaps why transitional care interventions by advanced practice nurses that facilitate coordination of services between community and institutional settings were fully embraced only when their impacts on outcomes such as hospitalizations and overall service use were demonstrated (see Chapter 7). Another example highlighting the work of nurses beyond cost can be found in care coordination, the value of which has been well demonstrated (Camicia et al., 2013). The ANA (2013) has published a framework identifying the structural components and measurement context for nurses’ contributions to care coordination. The latter includes system, institutional, and individual/population contributors, impacting the ability of nurses to deliver highquality care. Historically, because the types of data that are most easily extracted from secondary data have involved negative outcomes assumed to be preventable with more nursing staff and investments in nursing care structures, such as falls and pressure injuries, such measures have been emphasized in data-collection schemes to date. However, many researchers and leaders are working to develop and refine measures that cover more areas and domains of nursing practice and assess what nurses do to facilitate positive outcomes, rather than only examining a narrow range of negative outcomes. Down the line, we can only hope for more nursing-relevant measures that can inform resource allocation decisions by suggesting where investments in healthcare settings should be increased to improve outcomes. Despite the promise of the accountability movement to provide leverage for the nursing profession by helping it assert its value and argue for investments in nursing services, special emphasis on indicators, especially outcome measures alone, can

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be a double-edged sword and can result in unintended consequences, as will be discussed briefly here and in more depth later in this chapter. Boiling down the outputs of systems for delivering care to single measures or a collection of indicators, even if only for the sake of clarity, starts to draw lines between important and less important aspects of system performance. This division can distract individuals from aspects of care activities that are “unpaid.” These activities, if seen as expected by management but not affecting reimbursement, can create ambiguity for staff. Furthermore, emphasizing grades or scores can force healthcare workers in direct care, as well as managers, to reallocate efforts without improving patient outcomes. For instance, increasing the burden on healthcare providers to maintain certain types of records can increase costs and divert attention from important work. Chasing favorable outcomes can persuade individuals and organizations to pursue any number of strategies that involve steering outcomes to even potentially to committing fraud. The public may not realize that the result may be steering attention and other resources away from aspects of care influencing their well-being or experience of care and playing up activities toward practices not of benefit to them. Accountability programs have much popular appeal even if their implementation is complicated and raises many concerns. Speaking out against accountability is risky because professionals and agencies can construe it as an avoidance tactic, a ploy to protect themselves and dodge responsibility for results. It may be risky even if it is intended to warn consumers and policy makers about the unintended consequences of using poor measures. Within healthcare, rating schemes developed by organizations such as the Leapfrog Group, which distills a great deal of data regarding patient safety down to a single, easily interpreted letter grade, generate similar anxiety in leaders and clinicians—and some of their criticisms seem warranted (Castillo, 2012). Arguably, nursing as a profession needs to take on a greater role in developing outcomes science. Developing meaningful measures, cost-effective means for tracking data, and an understanding of the web of factors influencing the components of evaluation are necessary to ensure the public’s safety.

DOCUMENTING THE IMPACT OF POLICIES RELATED TO NURSING Documenting how various policies affect the nursing profession is important first and foremost because patient well-being is influenced by nurses’ actions. Policies can influence the structures under which nurses practice and thereby alter what nurses are able to do for their patients. It has been argued for some time that what is “good for nurses” is also in patients’ best interest; this includes work satisfaction and other aspects of their work lives that influence their mental or physical health. Research on the Magnet® Recognition Program, which identifies institutions applying best practices in managing nursing workplaces, provides support for this idea. A growing body of literature shows more favorable outcomes for hospitals that have achieved Magnet status compared with those who have not (Barnes, Rearden, & McHugh, 2016; Kelly, McHugh, & Aiken, 2011; Stimpfel, Sloane, McHugh, & Aiken, 2016). Several researchers make a compelling business case for the Magnet program (Drenkard, 2010; Stimpfel et al., 2016). This work continues to be important at a time of profound change and cost awareness in the healthcare system when it is becoming increasingly common to hear questions and concerns about the return on investments in single professions such as nursing.

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Economic Evaluation: Costs in Relation to Outcomes As costs of healthcare have increased, consumer expectations have risen, and payers, government agencies, legislators, and advocacy groups are debating whether healthcare expenditures can continue to increase at current rates. Economic evaluation, or the assessment of options in healthcare in terms of their costs and consequences, has therefore become increasingly important. Care delivered by RNs and advanced practice nurses is often thought of as offering particularly high value for money, but relatively few nurses are accustomed to demonstrating this using data in this way. The steps in an economic evaluation are relatively simple, but the resources required for accomplishing them and the technical considerations involved can be considerable. First, an attempt is made to measure all relevant benefits or to assign values to health states, and then all relevant costs are measured. Next, how that costs vary across treatment options or situations in which a program exists and one does not is determined. Then the ratio between outcomes and costs is calculated, and finally an attempt is made to see how much this ratio is affected by assumptions made about the way that services are delivered, the most important elements of the costs and benefits, and the items that could be ignored. The last step is quite important; good economic evaluations always provide a sense of how the conclusions might be affected by making different assumptions. There are a number of different types of economic evaluation. The two most common approaches are (a) cost-effectiveness analysis (CEA), in which ratios of the total costs to the same measurable health outcomes obtained—lives saved, infections prevented, unit drops in blood pressure, or quality-adjusted life years—are calculated and compared for different treatment/care options, and (b) cost–benefit analysis (CBA), in which monetary values are assigned to the different health states resulting from various healthcare approaches and the costs of treatments are then considered alongside these treatments (Glick, Polsky, & Shulman, 2010; Stone, Bakken, Curran, & Walker, 2002). A few examples may help understanding of the distinction between these two strategies and the application of these methods to policy-relevant questions. A CEA of a community-based intervention run by nurse practitioners and community health workers for patients at high risk of cardiovascular disease that drew on a randomized controlled trial found that relative to usual care, the intervention was able to reduce systolic and diastolic blood pressures and lipid levels for approximately $40 to $200 per percent drop in these measures (Allen, Dennison Himmelfarb, Szanton, & Frick, 2014). In another CEA, it was determined through computer simulations that providing for anesthesia needs of a 12-bed/station operating room using only nurse anesthetists would yield revenues of $3.3 million, whereas using only physician anesthesiologists would yield revenues of $1.3 million and 1:6 supervision would yield revenues of $1.5 million (Hogan, Seifert, Moore, & Simonson, 2010). Wang et al. (2014) reported a CBA of school nurses in Massachusetts public schools, suggesting that every dollar spent on nursing services saved $2.20 in lost teacher productivity when they dealt with health-related tasks, as well as on preventable healthcare costs and lost parental productivity. In a second example of a CBA, Trepanier, Early, Ulrich, and Cherry (2012), found that by reducing nurse turnover and the need for contingent/temporary staff, new graduate nurse residency programs appeared to save between $10 and $50 per patient day relative to institutions that use more conventional onboarding programs. Economic evaluation is complicated by a number of features. Economic analysis always involves comparison of different approaches to care or investments in services to each other. Selecting which conditions to put side by side can be both methodologically and politically challenging, particularly if there is no obvious comparison or the

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comparison involves treatment approaches using very different health professionals. Another issue is finding consistent and accurate means of tracking all relevant costs and outcomes, rather than restricting attention to the costs and outcomes for which data are most readily available. For instance, even though what hospitals are billing for their services can be learned, charges or billings by healthcare providers have only a weak connection to the real costs of providing the services, with charges being notoriously much higher than what providers actually collect. Given uncertainties surrounding health outcomes, as well as differences across individuals in what outcomes or health states are desirable, it is often also difficult to assign values to different health states. Deciding on the frame of reference for analysis in terms of whose costs and benefits and over what time frames, given both the plurality of stakeholders and the long-time horizons for many benefits of healthcare, is a further challenge. Economic analyses are technical and costly in time and expertise, and incorrectly conducted analyzes can reach unhelpful and even damaging conclusions. Economic a­ nalyses, with insufficient attention to time horizons and the positions of the stakeholders, can reach counterintuitive conclusions. For instance, in accounting for the added costs of hospitalization for individuals who experience adverse outcomes, it can appear more cost-­effective to make choices that lead to death (and death early in patients’ hospital stays) than create conditions that allow for situations that require prolonged hospital stays to treat. Conclusions about costs and benefits are also often meaningfully different for different stakeholders. Cost savings or value added for a provider of healthcare or insurer may not be value added by a patient’s reckoning. One analysis concluded that the net benefits of improved nurse staffing on patient outcomes may really accrue to patients and society rather than to individual hospitals (Twigg, Myers, Duffield, Giles, & Evans, 2015). This suggests that policy strategies for improving nurse staffing may need to consider where motivations can be leveraged (i.e., at the societal level). The literature linking nurse staffing with patient safety outcomes in acute care hospitals has been at the heart of more than 15 years of advocacy work on the part of many, including nurses’ professional associations in a number of countries, trying to fend off dramatic cuts in funding for nurse staffing and increases in nurse–patient workloads. These efforts have led to more explicit examination of the unintended consequence of changes in nurse staffing whether due to nurse shortages or hospital cost-cutting. One such unintended consequence receiving increasing scrutiny is nurse rationing of care. Policy on the Scene 12.3 presents data from several recent nursing studies that examine the links between decreased nurse staffing hours and the rationing of patient care.

POLICY ON THE SCENE 12.3: Rationing of Nursing Care—An Emerging Concept in Staffing Plans and Ratios Nurses in direct care report that they do not have enough time to get patient care done and that they go home at the end of their work day worrying about what did not get done. Although much attention has been given in the past 15 years to staffing, the notion of bedside rationing because of staffing and time resources is relatively new. “Bedside rationing in nursing care refers to withholding or failure to carry out certain aspects of care because of limited resources such as time, staffing or skill mix” (Papastavrou, Andreou, & Efstathiou, 2014, p. 3). Studies on (continued )

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staffing and skill mix have most often focused on safety issues and quantifiable negative outcomes such as medication and treatment errors and adverse clinical incidents, including patient falls, pressure injuries (ulcers), unplanned patient readmissions, restraint use, and nurse injury. As early as 2001, evidence emerged that nurses were not getting all their work done. Canadian, U.S., and German nurses reported that basic tasks such as skin care were not being performed for lack of time. Although there were differences among the countries, at least 34% of the surveyed nurses reported that two tasks—comforting patients and care-plan updating—were being left undone when necessary (Aiken et al., 2001). More recently, a systematic review of 17 quantitative studies on rationing of care and nurse–patient outcomes revealed areas where some patterns were seen: features of the care that were rationed, reasons for the rationing, and nurse and patient outcomes affected by rationing (Papastavrou et al., 2014). Staffing ratios and staffing policies are continuing to unfold as research evidence continues to inform policy. Since California adopted the first state-level legislation related to staffing, a number of states have developed laws or regulations on staffing. The variation in approaches reflects the complexity of policy makers’ interpretation of these outcomes in the context of their political climate. The ANA maintains a webpage on the status of staffing legislation and regulation across the country (www.nursingworld.org/MainMenuCategories/ Policy-Advocacy/State/Legislative-Agenda-Reports/State-StaffingPlansRatios).

Understanding Failures to Observe Unanticipated Change and Analyzing Unintended Consequences Policies may fail to achieve the outcomes targeted by their originators in many ways. Policy initiatives may be based on incomplete or misinformed ideas about the factors that influence the outcomes being targeted. Various political forces may lead to the policies that are adopted not being the ones most likely to produce desired responses. Downstream, implementation of measures may also be incomplete or inconsistent; that is, structures are not being put in place or are failing to influence processes in the manner expected. Furthermore, attempting to engineer complex social systems with multiple actors can produce any number of reactions as stakeholders attempt to maximize or maintain their benefits and minimize their costs or inconveniences. Obamacare was designed to increase coverage of working-age adults by requiring employers of 50 or more employees to offer health insurance coverage to all employees working 30 or more hours per week. Some observers claimed that this provision would end up creating a disincentive to employers to create new jobs and to give more weekly hours to employees scheduled at the 30-hour per week threshold. This of course is bad news in a time of economic challenges when workers need hours and jobs and society needs job creation (McVeigh, 2013). It is not yet clear whether this is in danger of happening on a large scale (Kiely, 2013). However, it is clear that this concept played a role in the current repeal and replace of Obamacare that is currently underway. As a general principle, stakeholders can and do shift their energies or resources into alternative behaviors that can undermine the original intent of a policy or program. As a result, the consequences of implementing a policy may fall well short of the expected or intended ones and the possibility of new desirable and undesirable effects that were never foreseen must be kept in mind.

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A central concept in policy analysis is the notion of unintended consequences: changes that were not foreseen or intended by the creators of an intervention or a ­policy. Unintended consequences are not always bad, however. One example of a positive unintended consequence is found in examining health information exchanges (HIEs). HIEs, electronic-based exchanges that allow organizations, systems, and providers to share health information, are a direct result of the American Recovery and Reinvestment Act (ARRA) of 2009. Although benefits were anticipated in terms of enhanced quality of patient care and cost savings, concerns were raised about privacy invasions. At least one positive unintended consequence emerged: new possibilities for detection of disease outbreaks. Clinicians, officials, and researchers using syndromic surveillance can identify patterns of conditions and diseases that might point to a developing public health problem sooner, providing the opportunity for earlier response and intervention (McGowan, Kuperman, Olinger, & Russell, 2012). A full evaluation of a policy tracks and tallies both costs and benefits and attempts not only to identify whether expected changes are observed in targeted outcomes, but also to track what other related factors may be affected by the intervention. Commonly intended consequences of policies and programs include improved service quality, cost efficiencies, and health outcomes; increased and expanded access to services; and enhanced quality of life. Unintended consequences can be found by recognizing their potential to emerge when developing policy and examining a policy once it is in place for both positive and negative outcomes. See Exhibit 12.3 for a list of unintended consequences based on the work of Smith (1995) and Rambur, Vallett, Cohen, and Tarule (2013). Their work was designed specifically for use in examining performance metrics but has been reworked to what we call “traps” to missing unintended consequences. These traps can provide a cautionary note when both evaluating and planning for policies. Involving those directly impacted by the policies helps in anticipating potential consequences. EXHIBIT 12.3  MINDSETS THAT LEAD TO MISSING UNINTENDED CONSEQUENCES

AND EXAMPLES

Tunnel vision: Evaluating effectiveness based primarily on financial benefits Measure fixation: Focusing on a metric such as 30-day readmission without full consideration of the patient’s illness experience Acontextual actions: Choosing patients for an evaluation who will likely experience the best results Misrepresentation: Presenting only a subset of measured results or measured outcomes, either positive or negative or either expected or unexpected that supports conclusions Gaming: Inadvertently encouraging clinicians to work to influence the measures without affecting the targeted outcomes (e.g., patients are told how to respond on satisfaction surveys) Myopia: Focusing only on short-term results Suboptimization: Pursuing a limited number of outcomes and selecting only those that are likely to show the greatest improvements Ossification: Deterring innovation by overemphasizing strengths of existing approaches

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Deep knowledge of the targeted health problem or care-delivery issue with an understanding of the community and critical unbiased eyes is needed to draw up a complete list of consequences and select variables to include in an evaluation. Evaluations that leave out important consequences may sell the successes of a policy short or overestimate its benefits. Equally critical, evaluations perceived as omitting important considerations are particularly vulnerable to claims of bias. By virtue of their roles, nurses are well positioned to anticipate unintended consequences and think about how to place unintended consequences in context (Rambur et al., 2013).

DETERMINING SUSTAINABILITY Sustainability refers to the ability of a change in conditions, after an intervention, to continue after an initial investment of resources. As we noted earlier in this chapter,  many program or policy evaluations fail to identify the hoped-for improvement in the main outcome of interest. Even fewer evaluations can demonstrate sustained improvement in outcomes over time. People tire of messages and fail to be motivated by inducements or penalties; overall, systems tend to revert to their original states over time (Swerissen & Crisp, 2004). At the little “p” level in hospitals, the incidence of falls, restraint use, lack of hand hygiene, and inattention to alarms are examples in which old habits tend to recur and complacency is common. Whether the resources normally available in a system are sufficient to cover the ongoing costs or expenses of a policy initiative is a recurring question. Can a regulation be enforced to a sufficient extent over time? Will behavior become widespread enough, or will people in various roles have enough knowledge and intrinsic motivation over time to continue proceeding in a certain way? Could the benefits of an initiative balance the costs and eventually lead to it “paying for itself ”? If regulation is used as a means of influencing patients, providers, and healthcare payers and systems, will resources for inspection and enforcement of these regulations be available in the long term? Will the benefits of the policy, whatever it is, be sufficiently clear to maintain a critical mass of support over time? Obviously, careful evaluation of a policy initiative can provide important information for making a case that an intervention is sustainable. Thinking about sustainability is critical from the moment a policy is developed. If the structures needed to implement a policy are not thought through or are incompletely measured, the long-term costs and benefits of the intervention will be underestimated. Because of this problem, evidence-based practice (EBP) models include a final step of ongoing monitoring and/ or evaluation. Without ongoing monitoring and evaluation, initial improvements often fade away.

OUTCOMES DATA AS GUIDES TO NEXT STEPS IN POLICY The policy process is a cycle, as others have alluded to in earlier chapters: from problem identification, through agenda setting, policy formulation, selection, and implementation, and back to agenda setting after policies are selected and implemented. Some type of evaluation often takes place, even if it is on an informal basis and involves stakeholders gathering impressions and drawing conclusions about whether their aims were met and beginning the cycle anew. In terms of strategizing next steps, a number of basic options are available: Do nothing (i.e., to cease interventions and to let “natural” conditions take or retake hold), maintain the current course, increase investments or expand

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the scope of a policy, change course by withdrawing financial support or repealing regulations, introduce new policies that proceed in a different direction, or let others do something that takes the policy in a different direction. All of these options appear to be on the table with respect to the debate about repealing and replacing the ACA. The situation with the ACA is notable for the extent to which evaluation and research data have not had much to do with the options proposed. People seeking to influence the policy process must decide which of the previous options they wish policy makers to address. Formal analysis of a policy, including indicating the extent to which a policy measure has achieved its intended ends and determining what its other consequences have been, can be useful tools in figuring out how to move forward and as supports for arguments. Many argue that evaluation is a fundamentally political process and that data will nearly always be seen as the tool of one side or another in a policy debate. Perhaps this is true, but in the long run, using data in a principled way and avoiding intentionally overstating or misstating facts is the best strategy for ensuring that data are seen as a potentially credible means of informing policy.

DEVELOPING POLICY SCHOLARSHIP IN NURSING The future of healthcare increasingly requires health professionals to confront dilemmas about how to offer high-quality services that are accessible to the public at a reasonable cost. The pace of change in terms of social and economic forces hitting healthcare shows no sign of abating. Nurses and others must understand and attempt to influence the direction of policy for it to have greater benefit for their work. Most health professionals and researchers still have an uncomfortable relationship with policy and politics. They consider it, at best, a distraction from “higher yield” direct service to patients and, at worst, a convoluted and often distasteful process of manipulation and strategizing. However, many are now realizing that keeping our distance from policy is no longer a viable option. Beyond becoming informed about the policy process in general, it is important to learn about specific policies at various levels and eventually to share our experiences in advocacy, implementation, and evaluation. Relatively few academic policy evaluations specialize in healthcare issues, and even fewer nurse researchers are involved in this area. There are some notable examples, however, at a few major centers across the country. If we turn our attention briefly to local policy initiatives, many are never formally evaluated at all; among those where some data are collected and/or analyzed, few are ever formally reported in any consistent or retrievable manner. Given the understandable emphasis in the nursing literature on updating clinicians on clinical matters and publishing reports of research studies, it is easy to see how policy-focused articles are less often written or sought. As a result, there is mostly an informal method of passing along information about what has worked in local policies and programs and certainly around nursing involvement in policy and its results. Contexts and history are important for anyone who would seek to generalize approaches used in other communities or around other policy issues to new settings, but data of some sort—preferably health outcomes data—tend to be quite influential. Articles about political involvement, state and national policy issues affecting nursing, and policy advocacy efforts involving nursing appear in publications such as the American Journal of Nursing, American Nurse, American Nurse Today, Online Journal of Issues in Nursing, and Politics, Policy, and Nursing Practice, but

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OPTION FOR POLICY CHALLENGE: Charting a Wider Path for Workplace Safety and Advocacy Within healthcare delivery, sharps injuries can occur in any setting where care is provided, and in some settings, such as hospitals, there can be variation in exposure risk because of the nature of the care provided. Ongoing monitoring and evaluation of injuries, research, and policies is basic to safety advocacy. More work is needed to reduce sharps injuries by fully integrating policies and best practices into the work setting and expanding these initiatives to outpatient, home care, and nontraditional settings, as well as settings with fewer resources. Ongoing efforts at the big “P” and little “p” levels remain crucial. Continuing active research and sharing research results and practice and policy changes at all levels are vital to preventing the complacency that often sets in once new policies are in place. An example of how research is an option to consider when compliance with safety is stagnant or falls below established benchmarks is illustrated by our recent work (Linzer & Clarke, 2017). We conducted an integrative review of hands-free techniques (HFTs) in 14 studies and found 11 revealed compliance with HFT that was related to the following broad categories of factors, each representing a different structure or process that influences the outcome of sharps injuries: • • • • • • • •

Perceived risk of infectiousness Manager support Awareness of evidence regarding effectiveness of HFT Presence of policies and procedures regarding the HFT HFT education and training Amount of time personnel scrubbed Procedure characteristics Profession

Many of these factors are opportunities for the development of additional policies and or interventions to impact structure and process. These, in turn, have the potential to decrease the number of sharps injuries and increase the likelihood that healthcare professionals will report sharps injuries. Thus, policy implementation provides the opportunity for evaluation at multiple intersecting points. This type of research illustrates that policy work continues and that there is opportunity for the development of policy regardless of one’s role or practice setting. It is up to each nurse to examine the research or conduct and share it; in other cases, it may mean nurses need to help ensure that policies are followed or rewritten. Key to integration of policies into work settings is the sustained engagement of nurses who may be directly impacted by sharps injuries. although anecdotal experiences with implementing policies and programs are dotted throughout the management and clinical literatures, it is time to think of new ways to report these kinds of experiences. A number of scholars and journal editors developed the Standards for Quality Improvement Reporting Excellence (SQUIRE;

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www.squire-statement.org) to assist groups in reporting local experiences of ­implementing and evaluating programs in a complete and rigorous manner, keeping in mind that there is likely to be a fair degree of variation in the nature of programs and content of evaluations. Perhaps nurses, nurse scientists, and leaders need more encouragement to write their experiences and more recognition needs to be given to those who share their experiences in local and higher level policies with broad professional audiences. Developing the science of measurement of nursing’s structures, processes, and outcomes, and developing and maintaining data sources, is a second major challenge. A major challenge for nurses and the profession in the next years will be ensuring that mandates and funding for collecting key types of data highlight the impacts of policies on nurses and nursing care. It will require careful planning. If unsuccessful, a long history of nursing being largely invisible in policy circles will continue, evaluation of nursing-related policy and policies that impact nurses will be hampered, and advocacy for nursing-related health policy will be rendered more difficult.

IMPLICATIONS FOR THE FUTURE Outcomes and evaluation research are important tools in policy development and advocacy. Increasing debates about the role of government and of regulation in ensuring healthcare quality will mean that arguments for new health policies (or that justify existing programs) will increasingly need support with data. Nurse’s familiarity with the policy evaluation process will be critical to future policy evaluation efforts. In addition, educating the public about outcomes and their role as empowered consumers will also be more and more important. Of course, many have become increasingly cynical about the shaping of political messages and the selective reporting or overt misrepresentation of facts, including research and evaluation data, in the fight for public opinion. In the past decades, there have been massive investments in research projects, and the conclusions that can be drawn from these have often been somewhat softer or nuanced than many would like. The next years will probably see many stakeholders being more realistic in their expectations of program evaluations to guiding policy and more understanding that the synthesis or summarizing of evidence may need to proceed in a different direction rather than expecting a small handful of studies to provide “the” answers to complex and often very polarizing health policy debates and challenges.

KEY CONCEPTS 1. Evaluation of outcomes is an integral component of accountable policy making at all levels. 2. Evaluation takes many forms from the examination of specific clinical interventions to the impact of a policy on society. 3. Evaluation uses many of the same techniques of conventional researchers (e.g., quantitative and qualitative methods, prospective and retrospective approaches). 4. The purpose of evaluation is to understand systems and services or policies that address various issues or problems. 5. Policy analysis research assesses how well a policy has achieved its intended outcomes. 6. Benchmarking is a comparison against a standard of performance or level of quality. 7. Indicators are specific measurements that are benchmarked. 8. Nurse-sensitive indicators are outcomes that are believed to be particularly influenced by nursing.

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9. Structure, process, and outcome is a frequently used framework for evaluation that takes into consideration people, facilities, equipment, and the delivery of services. 10. Evaluation may be summative (after a policy is implemented) or formative (while a policy is implemented). 11. Demonstrating differences in outcomes is difficult because of the complexity of factors and their relationships, lack of complete understanding of involved factors, imprecise measurement, and data access restrictions. 12. Outcome measurement may have both positive and negative unintended consequences that impact the direction of policy. 13. Pay-for-performance schemes and public reporting are examples of high-stakes outcome measurement initiatives. 14. Economic evaluation focuses on the comparison of different approaches to investments in care or services and the way that the results vary based on different assumptions. 15. The sustainability of outcomes needs to be included in the initial development of policy. 16. Development of the science of measuring structures, processes, and outcomes and developing and maintaining data sources is critical to enhancing visibility in policy circles.

SUMMARY Sound data have enormous potential to influence the creation of worthwhile policies, as well as to assist stakeholders in evaluating the impacts of policies on key outcomes. Frameworks that describe how outcomes influence structures and processes for providing services are critical for designing outcomes; determining whether the connections between various elements of a policy or program are logical tends to be time well spent. Obtaining data that assists in policy or program planning is often costly and complicated, but possibilities almost always exist to leverage at least one of the major strategies. Documenting and presenting the contribution of nursing services to the public’s well-being is a challenging but worthwhile pursuit. Economic analyses of policies and programs are becoming more common, and an awareness of concepts such as sustainability and unintended consequences is certainly key to using evaluation data for policies. Future challenges for nursing relate to developing a tradition of nursing scholarship around how we know successful policies and to ensuring that data sources are available to guide our efforts.

LEARNING ACTIVITIES 1. Identify a little “p” or a big “P” health policy related to an issue of interest to you. List the intended and unintended consequences. 2. Obtain a policy evaluation report or a research study and compare and contrast the elements of the policy evaluation with the elements described in this chapter. Describe the stated conclusion about the effectiveness of the policy in the report and the recommendations for next steps proposed by the authors. Identify why you support or do not support the conclusions of the report based on the data presented. 3. Select a little “p” policy at work or in your educational program and discuss how outcomes for the policy are being formally measured. Discuss how the measures are reported and what changes for maintaining or modifying the measures and their reporting you would make and why.

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4. Re-examine Exhibit 12.2. Select a policy you would like to change related to one of the issues. Make a list of four or five questions that you would ask to determine whether the unintended consequences have not been fully explored because of the potential traps identified in the table. 5. Create a logic model illustrating the interconnectedness of structure, process, and outcome using a current health policy. 6. Identify two research or EBP questions in your practice setting that would yield relevant data and information to evaluate and direct future policy work.

E-RESOURCES • Agency on Healthcare Research and Quality: Healthcare Cost and Utilization Project (HCUP) http://www.ahrq.gov/research/data/hcup/index.html • Agency on Healthcare Research and Quality: Patient Safety and Quality: An Evidence-Based Handbook for Nurses http://www.ahrq.gov/professionals/clinicians-providers/resources/nursing/ resources/nurseshdbk/index.html • Centers for Disease Control and Prevention: Developing an Effective Evaluation Report http://www.cdc.gov/eval/materials/Developing-An-Effective-Evaluation-Report_ TAG508.pdf • Centers for Medicare & Medicaid Services https://data.medicare.gov • Centers for Medicare & Medicaid Services: Hospital Value-Based Purchasing Program https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment -Instruments/HospitalQualityInits/Hospital-Value-Based-Purchasing-.html • Needlestick Safety and Prevention Act of 2000, Pub. L. 106-430 https://www.govtrack.us/congress/bills/106/hr5178 • National Database of Nursing Quality Indicators (NDNQI) Quality Improvement Solutions from Press Ganey http://www.pressganey.com/solutions/clinical-quality/nursing-quality • Outcome and Assessment Information Set (OASIS) http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ OASIS/index.html • Standards for Quality Improvement Reporting Excellence (SQUIRE) http://squire-statement.org

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Kalisch, B. J., Tschannen, D., & Lee, K. H. (2012). Missed nursing care, staffing, and patient falls. Journal of Nursing Care Quality, 27(1), 6–12. doi:10.1097/NCQ.0b013e318225aa23 Kelly, L. A., McHugh, M. D., & Aiken, L. H. (2011). Nurse outcomes in Magnet® and non-Magnet hospitals. Journal of Nursing Administration, 41(10), 428–433. doi:10.1097/NNA.0b013e31822eddbc Linzer, P. B., & Clarke, S. P. (2017). An integrative review of hands-free technique in the OR. AORN Journal, 106(3), 211–218.e6. doi:10.1016/j.aorn.2017.07.004 McGowan, J. J., Kuperman, G. J., Olinger, L., & Russell, C. (2012). Strengthening health information exchange: Final report HIE Unintended Consequences Work Group. Retrieved from http://www .healthit.gov/sites/default/files/hie_uc_workgroup_final_report.pdf McVeigh, K. (2013, September 30). US employers slashing worker hours to avoid Obamacare insurance mandate. Retrieved from http://www.theguardian.com/world/2013/sep/30/ us-employers-slash-hours-avoid-obamacare Medicare Prescription Drug, Improvement, and Modernization Act of 2003. (2003). Pub. L. No. 108-173. Olds, D. L., Kitzman, H. J., Cole, R. E., Hanks, C. A., Arcoleo, K. J., Anson, E. A., … Stevenson, A. J. (2010). Enduring effects of prenatal and infancy home visiting by nurses on maternal life course and government spending: A follow-up of a randomized trial among children at age 12 years. Archives of Pediatric & Adolescent Medicine, 164(5), 419–424. doi:10.1001/archpediatrics.2010.49 Occupational Safety and Health Administration. (2016, May 12). Improve tracking of workplace injuries and illnesses a rule by the Occupational Safety and Health Administration. Federal Register, 81(92), 29623. Retrieved from https://www.gpo.gov/fdsys/pkg/FR-2016-05-12/pdf/2016-10443.pdf Papastavrou, E., Andreou, P., & Efstathiou, G. (2014). Rationing of nursing care and nurse-patient outcomes: A systematic review of quantitative studies. International Journal of Health Planning and Management, 29(1), 3–25. doi:10.1002/hpm.2160 Patient Protection and Affordable Care Act of 2010, Pub. L. No. 111-148. 124 § 119-1025 (2010). Rambur, B., Vallett, C., Cohen, J. A., & Tarule, J. M. (2013). Metric-driven harm: An exploration of unintended consequences of performance measurement. Applied Nursing Research, 26(4), 269– 272. doi:10.1016/j.apnr.2013.09.001 Resar, R., Griffin, F. A., Haraden, C., & Nolan, T. W. (2012). Using care bundles to improve health care quality. IHI Innovation Series White Paper. Cambridge, MA: Institute for Healthcare Improvement.  Retrieved from http://www.ihi.org/resources/Pages/IHIWhitePapers/UsingCare Bundles.aspx Roberts, M. J., Hsiao, W., Berman, P., & Reich, M. R. (2008). Getting health reform right: A guide to improving performance and equity. New York, NY: Oxford University Press. Ryan, A. M. (2013). Will valued-based purchasing increase disparities in care? New England Journal of Medicine, 369(26), 2472–2474. doi:10.1056/NEJMp1312654 Ryan, A. M., Krinsky, S., Maurer, K. A., & Dimick, J. B. (2017). Changes in hospital quality associated with hospital value-based purchasing. New England Journal of Medicine, 376(24), 2358–2366. doi:10.1056/NEJMsa1613412 Smith, P. (1995). On the unintended consequences of publishing performance data in the public sector. International Journal of Public Administration, 18(23), 277–310. doi:10.1080/01900699508525011 Spetz, J. (2010). The importance of good data: How the National Sample Survey of Registered Nurses has been used to improve knowledge and policy. Annual Review of Nursing Research, 28, 1–18. Retrieved from http://www.springerpub.com/annual-review-of-nursing-research.html Spetz, J. (2013). The research and policy importance of nursing sample surveys and minimum data sets. Policy, Politics & Nursing Practice, 14(1), 33–40. doi:10.1177/1527154413491149 Squires, D. A. (2013). Multinational comparisons of health systems data, 2012. New York, NY: The Commonwealth Fund. Retrieved from http://www.commonwealthfund.org/Publications/ Chartbooks/2013/Mar/Multinational-Comparisons-of-Health-Data-2012.aspx Stimpfel, A. W., Sloane, D. M., McHugh, M. D., & Aiken, L. H. (2016). Hospitals known for nursing excellence associated with better hospital experience for patients. Health Services Research, 51(3), 1120–1134. doi:10.1111/1475-6773.12357

390   UNIT IV  JUDGING WORTH AND ADVANCING THE CAUSE Stone, P. W., Bakken, S., Curran, C. R., & Walker, P. H. (2002). Evaluation of studies of health ­economics. Evidence-Based Nursing, 5(4), 100–104. doi:10.1136/ebn.5.4.100 Swerissen, H., & Crisp, B. R. (2004). The sustainability of health promotion interventions for different levels of social organization. Health Promotion International, 19(1), 123–130. doi:10.1093/ heapro/dah113 Taha, A., Ballou, M. M., & Lama, A. E. (2014). Utilization of national patient registries by clinical nurse specialist: Opportunities and implications. Clinical Nurse Specialist, 28(10), 56–62. doi:10.1097/ NUR.0000000000000018 Trepanier, S., Early, S., Ulrich, B., & Cherry, B. (2012). New graduate nurse residency program: A costbenefit analysis based on turnover and contract labor usage. Nursing Economic$, 30(4), 207–214. Retrieved from http://www.nursingeconomics.net/cgi-bin/WebObjects/NECJournal.woa Twigg, D. E., Myers, H., Duffield, C., Giles, M., & Evans, G. (2015). Is there an economic case for investing in nursing care—what does the literature tell us? Journal of Advanced Nursing, 71(5), 975–990. doi:10.1111/jan.12577 Wang, L. Y., Vernon-Smiley, M., Gapinski, M. A., Desisto, M., Maughan, E., & Sheetz, A. (2014). Cost-benefit study of school nursing services. JAMA Pediatrics, 168(7), 642–648. doi:10.1001/ jamapediatrics.2013.5441 Waters, T. M., Daniels, M. J., Bazzoli, G. J., Perencevich, E., Dunton, N., Staggs, V. S., … & Shorr, R. I. (2015). Effect of Medicare’s nonpayment for hospital-acquired conditions: Lessons for future ­policy. JAMA Internal Medicine, 175(3), 347–354. doi:10.1001/jamainternmed.2014.5486

THIRTEEN

Eliminating Health Inequities Through National and Global Policy Shanita D. Williams Janice M. Phillips Health inequities arise because of a toxic combination of poor social policies, unfair economic arrangements and bad politics. These, in turn, affect the circumstances in which people are born, grow, live, work and age.—Sir Michael Marmot (2008)

OBJECTIVES 1. Explain the link between social and economic conditions and population health inequity in the United States and globally. 2. Describe U.S. inequities and present the global context in which health inequities exist. 3. Analyze the health impact of the social determinants of health. 4. Evaluate the social, structural, economic, and health policy determinants of health inequities. 5. Recommend potential policy solutions for health inequities in the United States and globally. 6. Identify evidence-based policy strategies to address social and economic conditions that shape health inequities.

Health is a human right, and social inequities are indeed a matter of economics and social justice. Yet persistent social and economic inequities in health and healthcare exist both in the United States and on a global scale. Throughout the world, health inequities are inextricably linked to the unequal distribution of social and economic resources. Socially and economically disadvantaged groups are less likely to be in good health, less likely to have access to quality healthcare services, and more likely to die prematurely compared with the socially and economically advantaged. In the United States, those who live in poverty, the uninsured, the disabled, and people of color bear the brunt of the health inequities burden. Registered nurses (RNs) comprise the largest segment of the U.S. professional healthcare workforce, with 2.96 million employed in 2016 (U.S. Department of Labor, Bureau of Labor Statistics [BLS], 2017). Nurses are at the heart of the interface between health systems and patients, families, and communities and are strategically positioned to serve as key actors to advocate for the health and well-being of the nation. Therefore, championing the elimination of health and healthcare inequities through political advocacy and a commitment to policy development is an essential element of professional nursing practice. 391

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When people learn about healthcare inequities, they may assume that issues related to inequities do not exist in their own communities. However, one need not travel very far to observe the adverse impact of inequities on health and policies that perpetuate the status quo. Addressing national and global health inequities requires upstream, long-range approaches at the big “P” level to address their underlying causes. However, there are numerous opportunities in which nurses advocating for better health outcomes can address inequities in their local communities at the little “p” level to make a more immediate impact on the health of people in need. This chapter presents a broad overview of the link between social and economic policy and health inequities and highlights the health impact of social determinants on populations in the United States and across the globe. In the United States, the nature of health inequities has traditionally focused on racial, ethnic, and socioeconomic status (SES)/class inequities regarding healthcare access and health outcomes. This chapter aims to extend the health inequities discussion beyond U.S. borders to include a global context that allows description of the social, structural, economic, and health policy determinants underlying health inequities both within the United States and among nations. We conclude with a discussion of potential policy approaches that may contribute to the elimination of health inequities in the United States. The Policy Challenge in the following section vividly illustrates how early childhood exposures to toxic and unhealthy environments contribute to health inequities that extend both into adulthood and across generations. In the United States, childhood obesity is at epidemic proportions, and its contributions to lifelong comorbidities, poor health and reduced quality of life, and length of life is well documented (Centers for Disease Control and Prevention [CDC], 2017a; Fryar, Carroll, & Ogden, 2014; Pulgaron & Delamater, 2014). The Policy Challenge captures 9-year-old Marie’s story and is emblematic of social disadvantage and the childhood obesity epidemic in the United States. Marie’s life circumstances offer a lesson on how being born into a legacy of intergenerational poverty, fueled by a lack of the critical material and social resources that are necessary to ensure health and well-being, is at the very root of most chronic diseases and other health inequities. However, Marie’s story does not have to end in such a predictable way. The right policies and appropriate interventions can interrupt the cycle of poverty and disease. Evidencebased policies can ensure healthier environments and communities and address the lack of access to healthy fresh foods, safe places to play, and exercise environments that are often the root cause of childhood obesity. The key question for nurses then becomes what implications does Marie’s story have for U.S. and global policies on health and healthcare inequities? What can nurses do as a profession and in collaboration with other stakeholders to eliminate healthcare inequities and ultimately achieve health equity?

POLICY CHALLENGE: The Case of Marie: An Illustration of How Childhood Exposures to Toxic Environments Equals a Lifetime of Health Disadvantage Six-year-old Marie and her two younger siblings are all obese and failing in school. Marie’s 29-year-old mother, recently diagnosed with hypertension and type 2 diabetes, is currently receiving state disability benefits along with food subsidies to supplement her disability income. Marie’s high-carbohydrate diet consists (continued )

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primarily of frozen, microwavable, and fast foods and sugar-sweetened beverages. The three-room apartment where the family lives is infested with roaches and located in a resource-poor community. Marie’s mother and her live-in boyfriend smoke cigarettes in the home. There are no books, no Internet connection, and no safe place to go outside and play. The social and physical environment in which Marie and her two younger siblings live, grow, and play is toxic. A toxic environment, coupled with a lack of social and material resources, is a recipe for family poverty that will endure for generations. See Option for Policy Challenge.

HEALTH DISPARITIES VERSUS HEALTH INEQUITIES Healthy People 2020 (U.S. Department of Health and Human Services [USDHHS], 2014) defines a health disparity as a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.

The assumption that health differences are unjust or unfair more closely aligns with the World Health Organization (WHO) “health inequity” language as seen in their 2017 definition of health inequities: “systematic differences in the health status of different population groups. These inequities have significant social and economic costs both to individuals and societies.” Health inequalities refer to population health summary measures associated with group- or individual-level attributes such as income, education, or race and ethnicity (Braveman, 2014).

National and Global Health Inequities Researchers are consistently uncovering the deleterious effects that childhood poverty, stress, and social characteristics such as race and ethnicity have on genes and biology (Gopnik, 2014; Lam et al., 2012; Noble et al., 2015; World Bank, 2014). Those who have increased access to material and social resources—the educated, employed, socially connected—in almost every society on the globe consistently experience better health and longer life. Furthermore, this health advantage is patterned along a social and economic gradient whereby as one’s status on the social and economic hierarchy increases, health progressively improves. Gender and environment are two areas important for nurses advocating for the elimination of national and global health inequities. Clearly, there are inequities in health for children in the United States and around the globe. For example, obesity has immediate and long-term impacts on a child’s physical, social, and emotional health. In fact, children who are obese are at higher risk for having other chronic health conditions and diseases later in life such as asthma, sleep apnea, bone and joint problems, type 2 diabetes, metabolic syndrome, heart disease, and several types of cancer (CDC, 2017a; WHO, 2012). As an obese child grows into adulthood, childhood obesity’s legacy results in a lower quality and length of life (CDC, 2017a).

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In the United States, there are concerted efforts among multiple stakeholders at the local, national, private, and federal levels to solve the childhood obesity problem. For example, the U.S. Surgeon General in 2015 issued a Call to Action to promote walking and walkable communities to achieve increased physical activity as a way of reducing obesity (CDC, 2017b). The Surgeon General’s office collaborated with multiple private organizations and communities to shape its physical activity goals. Internationally, global organizations have made efforts to improve the health of children by providing access to safe food and drinkable water as a means to reduce disease burden and improve the overall health of families and communities. The WHO proposed population-based policies and programs that direct approaches focused on nutrition and physical activity to prevent childhood obesity (WHO, 2012). See Policy on the Scene 13.1 later in this chapter, to review the impact of a multistakeholder, evidence-based strategy to address childhood obesity and other threats to healthy and safe environments for children and their families. The environment is also receiving much more attention globally. What is often not included in the discussion is health inequities associated with environmental exposures. For example, in some instances, there is a fivefold increase in exposure for the disadvantaged compared with the advantaged (WHO, 2012; World Bank, 2014). These include exposures associated with secondhand smoke, inadequate housing, injuries, noise, sanitation, and water supply. These problems are not limited to developing countries but can be found in our communities.

Race, Ethnicity, and U.S. Health Inequities Social, economic, and class inequities that are pervasive and systemic across nations are frequently articulated in the United States as racial and ethnic disparities. Race and ethnicity in the United States historically have served as a proxy (or substitute) for SES and class primarily because racial and ethnic minority groups in the United States are consistently overrepresented among the poor and disenfranchised. The United States has traditionally collected data on ethnic and racial groupings, which has facilitated tracking disparities by these categories rather than by social class (Panel on the DHHS Collection of Race and Ethnic Data, 2004). Yet race and ethnicity are complex social phenomena in the United States that have been consistently shown to have real health impacts not fully explained by biological, genetic, or environmental determinants. Take, for example, the case of Hispanic/Latino ethnicity and health outcomes in the United States. Researchers have shown that generally Whites in the United States experience improved health outcomes compared with racial and ethnic minorities. Jones and colleagues (2008) further explored this consistent finding in a study that examined discordance between self-identified race and ethnicity (What race or ethnicity do you consider yourself?), socially assigned race and ethnicity (What race or ethnicity do others classify you?), and self-rated health outcomes (Do you rate your health as poor, fair, good, or excellent?). They found that Hispanics/Latinos who were socially assigned as “White,” although they classified themselves as Hispanics/Latinos, experienced large and statistically significant advantages in health status relative to self-­identified Hispanics/Latinos, who were also socially classified as Hispanics/Latinos (Jones et al., 2008). Furthermore, the socially assigned “White” Hispanics/Latinos experienced health outcomes that were statistically the same as U.S. Whites. The author’s major conclusion was that socially assigned categories of ethnicity had a significant and measurable impact on an individual’s self-rating of health status.

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The significant point about the findings of Jones and colleagues (2008) is that s­ elf-rated health has been consistently shown throughout the literature to be a good proxy indicator of physical health outcomes, including morbidity and mortality (Harris, Cormack, Stanley, & Rameka, 2015; Schnittker & Bacak, 2014; Wennberg, et al., 2012). This example of self-identified versus socially assigned ethnicity is also important in that it reveals one mechanism by which socially assigned race and ethnicity in the United States can impact the physical health outcomes of members of a social group. In the United States, it is the complex meaning of race and ethnicity, and the way it is used to assign value and life opportunities in society, that poses the greatest challenge to eliminating health inequities, particularly those driven by race, ethnicity, and s­ ocioeconomic/class differences among populations. However, the global context allows us to understand more fully that in the United States, health inequities are not simply about race and ethnicity. A global assessment of s­ ocioeconomic/class patterns of health inequities confirms the role of broader societal-level ­factors, such as human development, gender inequality, gross national product, income inequality, and healthcare system infrastructures, as the fundamental determinants of health ­inequities among populations and among nations (World Bank, 2014).

SOCIAL DETERMINANTS OF HEALTH INEQUITIES The moral test of government is how that government treats those who are in the dawn of life—the children; those who are in the twilight of life—the elderly; those who are in the shadows of life—the sick, the [poor], and the [disabled].—Hubert H. Humphrey (1977)

There is consensus among social and public health researchers that widespread health inequities experienced by social groups in the United States and throughout the world cannot be solely explained by individual-level determinants such as health-related behaviors. Consequently, there have been increased efforts to better understand factors that lie outside of an individual’s control such as social-, economic-, and policy-related factors that contribute to persistent and inequitable health outcomes. Social determinants of health (SDOH) can be understood as the conditions in which people are born, grow, live, work, and age—including the health system—and are shaped by the distribution of money, power, and resources at global, national, and local levels, which are themselves influenced by policy choices (WHO, 2012). Research on SDOH and their contribution to population health disparities emphasizes the complex role that social structures and economic systems play in the health of populations. The WHO confirmed in its landmark 2008 Commission on the Social Determinants of Health report (CSDH, 2008) that SDOH are indeed mostly responsible for health inequities—the unfair and avoidable factors in health status—within and among countries. By examining the individual factors that collectively form the composite measure of SES—income and employment, education, and access to care and health insurance—we can illustrate the potential health impacts of social determinants on populations in the United States.

Income and Employment Income and employment opportunities are critical to achieving and maintaining optimal health and accessing healthcare services (LEAD Center, 2015; Robert Wood Johnson Foundation [RWJF], 2013). Income and employment are directly related to

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morbidity and mortality outcomes in almost every health outcome. Health-related diabetes, ­cardiovascular ­disease (CVD), cancer, and infectious disease outcomes follow a consistent income and employment gradient, as income and employment increase, mortality and morbidity decrease. Subramanian and Kawachi state, “Income poverty is a risk factor for premature mortality and increased morbidity” (2004, p. 78). Take, for example, the well-established association between income and CVD and its associated risk factors such as hypertension, cholesterol, smoking, diabetes, and physical inactivity. Quarells, Liu, and Davis (2012) examined the impact of education, employment, income, and stress on CVD clinical risk factors in rural and urban men older than the age of 18. Quarells and colleagues reported that lower education, unemployment, lower income, and general stress were each significantly correlated with the presence of two or more CVD risk factors. In an earlier study of CVD risk and late career involuntary unemployment, researchers found that displaced workers who lost their jobs late in their careers were more than twice as likely to have a myocardial infarction and stroke compared with employed persons (Gallo et al., 2006). The investigators recommended that healthcare providers consider involuntary unemployment a significant risk factor for CVD. One of the challenges in income and employment is the lack of intergenerational income mobility or movement into the middle class. Disadvantaged groups are not able to rise out of poverty and mitigate its attendant health risks. A recent study examined the degree to which children can rise out of poverty. Factors having a positive impact on increasing income mobility included (a) greater geographical dispersion of the middle class, (b) betterthan-average schools, (c) higher proportion of two-parent households, and (d) engagement with community and religious organizations (Chetty, Hendren, Kline, & Saez, 2013).

Education Educational attainment is closely aligned with income and employment and reliably influences future earning potential and employment opportunities. Disadvantaged groups typically receive poor quality education exposures and often fail to graduate high school. For example, nearly twice as many adults with disabilities do not complete high school and subsequently live below the poverty level compared with the U.S. adult population (CDC, 2011). Level of education is also closely linked to population health outcomes in the United States and globally. There is a common expression, “when you educate a girl, you educate a family.” Extensive national and international data show that women who are educated and can obtain meaningful work are more likely to delay childbirth and to increase spacing between births and are less likely to deliver low-birth-weight (LBW) infants. Hence, educated women are more likely to experience healthy maternal and childbirth outcomes (MacDorman, Hoyert, & Mathews, 2013; MacDorman, Mathews, Mahangoo, & Zeitlin, 2014; Matijasevich et al., 2012). Infant mortality rate (IMR) is an important indicator of a nation’s health (CDC, 2016; MacDorman et al., 2013; Mathews & Driscoll, 2017). The IMR is tracked and measured throughout the world, providing local and global comparative healthcare outcome data for nations. In the United States, IMRs are highest among racial and ethnic minorities, the poor, and women living in the South. As with maternal outcomes, infant mortality is also closely linked to education. Researchers have shown that education status and race and ethnicity interact and result in cumulative disadvantage such that racial and ethnic minority women with low educational attainment experience the highest IMR among all women in the United States (Li & Keith, 2011; Singh & Kogan, 2007). In fact, there is a clear inverse association between educational attainment and IMR;

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as  a  woman’s educational attainment increases, IMRs decrease. The IMR among mothers with less than a high school diploma is more than the IMR of mothers with a bachelor’s or higher degree (Mathews, MacDorman, & Thoma, 2015; see Figure 13.1). There is also mounting evidence that links lower education, poverty, and childhood obesity. Data from the CDC show that obese children miss more days of school compared with children with normal weights. More missed days at school is linked to poor academic performance, and poor academic performance is correlated with reduced employment opportunities and increased likelihood of poverty in adulthood (CDC, 2017a).

Access to Care and Health Insurance Health insurance in general, and private, employer-based insurance specifically, is the gateway to accessing health and healthcare services in the United States. Higher status occupations and jobs are correlated with employer-based insurance, which is associated with increased access to health providers. Yet private, employer-based insurance, although considered the preferred method of payment by healthcare systems and its providers, can frequently lack key coverage provisions that require additional co-pays and deductible and other out-of-pocket costs. Furthermore, private insurance plans that are not employer based have even greater out-of-pocket expenses. In the United States, 62% of women with private insurance that was not employer based lacked maternity coverage (Assistant Secretary for Planning and Evaluation [ASPE],  2011). Consequently, women in the United States with private health ­insurance average $3,400 in out-of-pocket pregnancy expenses (Rosenthal, 2013). 2010 2013

14

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10 8.28 8

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5.25

5 4.27 4.07

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Non-Hispanic Non-Hispanic Whites Blacks

Hispanic

American Asian/Pacific Indian/Native Islander Alaskan

FIGURE 13.1  U.S. infant mortality rate by race and ethnicity, 2008 and 2013. Source: From Mathews, T. J., MacDorman, M. F., and Thoma, M. E. (2015). Infant mortality statistics from the 2013 period linked birth/infant death data set. National Vital Statistics Reports, 64(9). Retrieved from https://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_09.pdf

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Often, persons in lower status occupations often lack employer-based health insurance and frequently do not have the resources available to pay for private insurance. Consequently, low-status occupations such as service-oriented, trade, and labor sectors populate the ranks of the uninsured in the United States. The type of health insurance is a key indicator of SES and class status in the United States. Type of health insurance status is also strongly correlated with race, ethnicity, and SES. See Figure 13.2 for comparisons in relation to the federal poverty level (FPL). Public insurance or Medicaid is the primary source of health insurance for racial and ethnic minorities and the poor, primarily because they are unemployed or hold part-time or full-time, lower sector occupations that frequently do not offer health insurance to their employees (Mead et al., 2008). Several studies have shown that persons with public insurance or Medicaid experience decreased access to care and poor health outcomes comparable with outcomes for the uninsured population in the United States. In essence, having public health insurance or Medicaid offers no health advantages over having no insurance coverage (LaPar et al., 2010). Healthcare workers are not immune from these effects. Approximately 11% of this workforce lacks health insurance, with ambulatory care workers being 3.1 times more likely and residential workers 4.3 times more likely to be uninsured; service workers are 50% more likely to lack insurance than workers involved in diagnosing and treating illness (Chou, Johnson, Ward, & Blewett, 2009). Similar results were found in an earlier study, with 23.8% of health aides, 14.5% of licensed practical nurses, and 5% of RNs uninsured; for employment setting, 20% of nursing home workers, 8.2% of medical office workers, and 8.7% of hospital workers were uninsured (Case, Himmelstein, & Woolhandler, 2002). Very often, per-diem nurses and adjunct nurse faculty have several part-time positions and thus do not have health insurance. In terms of impact on health outcomes, older health service workers have 19 times the rate of severe obesity

70

59

60

55 40

50 Percentage

57

34 40 30 20

23 27

24

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16

13 10 12

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White

Black

Not Poor (201% + FPL)

Hispanic

Insured

Near Poor (101%–200% FPL)

Uninsured Poor (0%–100% FPL)

FIGURE 13.2  No regular source of healthcare among adults aged 18–64 by race/ ethnicity and insurance coverage by poverty status, 2013–2014. FPL, federal poverty level. Source: From Centers for Disease Control and Prevention. National Center for Health Statistics. (2016). Health, United States, 2015: With Special Feature on Racial and Ethnic Health Disparities. Retrieved from https://www.cdc.gov/nchs/data/hus/2015/062.pdf

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as younger health-service workers, indicating these trends are like those for the U.S. health workforce in general (Lee et al., 2012). Cancer survival is another example of health insurance status and health inequities. Niu, Roche, Pawlish, and Henry (2013) found that for breast, colorectal, lung, nonHodgkin lymphoma (NHL), bladder, and prostate cancers, uninsured and Medicaidinsured patients had significantly higher risks of death than privately insured patients. Similarly, Robbins and colleagues (2010) reported in a study of patients with rectal cancer in which those with Medicaid insurance or no insurance were more than twice as likely to die in 5 years than patients with private insurance. The researchers found that the disparity in risk of death from cancer by insurance status was approximately 15.5 times larger than the disparity in risk of death from noncancerous causes (Robbins et al., 2010). Furthermore, insurance status is associated with not only inequities in cancer survival, but also differences in cancer stage at diagnosis and treatment options. The American Cancer Society reported that lack of health insurance, along with other barriers, prevents Americans from receiving optimal cancer care. Despite passage of the Patient Protection and Affordable Care Act (ACA) in 2010, Hispanics and Blacks remain most likely to remain uninsured (16% and 11% respectively). This compares to 7% of non-Hispanic Whites. The uninsured and members of many racial and ethnic minority groups are more likely to be diagnosed with a late-stage cancer resulting in fewer, costlier, and less effective treatment and poorer cancer outcomes (American Cancer Society, 2017). Cancer appears to be an ideal example of the impact of health insurance status on health outcomes because it highlights the role of insurance as a gateway to healthcare services and perhaps exposes the cumulative effects of disadvantage over the life course, whereby cancer’s prolonged time from cancer initiation to detection can be a marker of cumulative disadvantage. Illness, therefore, can be a path to poverty. In the United States, 62% of personal bankruptcies filed in 2007 were related to medical problems (Himmelstein, Thorne, Warren, & Woolhandler, 2009). The same study found that 78% of the bankruptcy filers had health insurance when they first became ill, in contrast to 8% in 1981; 60.3% did not have Medicare or Medicaid, but instead had private insurance. In addition to racial and ethnic minorities and the poor, other vulnerable populations such as the nation’s disabled populations and low-income seniors also depend on Medicaid as both a primary and a secondary source of health insurance. Persons with disabilities and low-income seniors are continually threatened by the potential of inequities in healthcare access and lower quality care services. Hence, quality, coordinated, and accessible care is a critical issue for all uninsured vulnerable populations, as well as those dependent on Medicaid. The Medicaid expansion resulting from the enactment of the ACA has had a significant impact on improving the health and well-being of our most vulnerable and underserved populations. Since the implementation of ACA exchanges and Medicaid expansion in October 2013, an additional 17.7 ­million people became newly insured. In October 2016, the USDHHS (2016) estimated that 13.3 ­million more people had enrolled in Medicaid since September 2013 (1 month before the ACA Medicaid expansion) and 9.6 million were deemed newly eligible because of Medicaid expansion. Expanding access to care through Medicaid and ensuring that Medicaid users receive equitable healthcare is necessary for ensuring greater equity in health coverage and healthcare services. Nurses are in a key position to advocate for equitable, quality care for all persons, regardless of insurance status. For a detailed discussion of Medicaid-related issues and priorities for the expansion of Medicaid via the ACA as presented by the Kaiser Family Foundation, please visit www.kff.org/Medicaid.

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HEALTH POLICY: GLOBAL AND THE UNITED STATES Health policy is a subcategory within social policy, and social policy is located within the larger framework of public policy. Public policies inform social policies, which in turn shape health policy, whether at the local, state, national, or global level; they frequently reflect unspoken values and are in turn shaped by the economic and political climates of countries. Policy efforts can be directed to act at the level of the individual within countries or can influence action on the SDOH, which operates outside the level of the individual and across nations. Yet policy making is insignificant unless policies are implemented within society. What does it take to interrupt the cycle of social and economic disadvantage that is so closely linked with health inequities throughout the world and the United States? There is growing national and international consensus that addressing health inequities will require cross-sector policy solutions spanning the continuum of health and healthcare and indeed the life course. Put simply, eliminating health inequities requires equitable access to the material and social resources necessary for health. Therefore, effective U.S. and global policies to eliminate health inequities must contain, to some extent, elements of effective education, employment, and housing policies, among others. Policy solutions and committed resources are also necessary to achieve population health equity. Despite uncertainty regarding the future of the ACA in its current form, the need to reduce health inequities in the United States remains an ongoing and critical challenge. Social and economically disadvantaged populations continue to experience disproportionate adverse health impacts compared with their advantaged counterparts. Healthy People 2020 has broadened its focus on eliminating disparities to include a focus on achieving health equity, eliminating disparities, and improving the health of all groups (USDHHS, 2014). The ACA’s increased emphasis on improving community and population health, in addition to increasing individual’s access to care, has mandated that hospitals and health systems step up their efforts to contribute to the improvement of community and population health outcomes (Carroll-Scott, Henson, Kolker, & Purtle, 2017; Rosenbaum, 2016). We discuss two policy-driven strategies, the Community Benefit Standard and the Health in All Policies, which holds promise for improving population health outcomes, reducing health disparities, and achieving health equity.

Community Benefit Standard In 1913, the U.S. government’s Internal Revenue Service (IRS) enacted the first income tax code whereby qualified organizations received tax-exempt status (IRS, 2014). Over time, the IRS established new criteria for receiving tax-exempt status to reflect more emphasis on community benefit aimed at increasing access to healthcare institutions to extend beyond the minimal requirement of providing charity care as a sole condition for tax-exempt status. In 1969, the IRS increased its requirement by implementing a community benefit standard that expanded its guidelines for taxexempt status to include a greater emphasis on documenting community needs and developing implementation strategies to address those identified needs. The new community benefits requirements were added to the IRS Code by the ACA, and in 2012, ­hospitals and health systems seeking federal tax-exempt status were required to adhere to the new requirements (Rosenbaum,  2016; Rosenbaum, Kindig, Bao, Byrnes, & O’ Laughlin, 2015).

Chapter Thirteen  ELIMINATING HEALTH INEQUITIES  401

Hospital and health system leaders and decision makers are seeking more guidance regarding what constitutes a community benefit and whether addressing the social and economic determinants of health constitutes a community benefit (American Hospital Association, 2017). The evidence base is clear; social and economic factors—­specifically social, environmental, and economic determinants contribute more to health outcomes and health disparities than traditional biological and clinical care factors (Braveman & Gottlieb, 2014). Receiving tax-exempt status by fulfilling the community benefits requirements is clearly advantageous for nonprofit hospitals and health systems. However, the community benefit standard requirement holds tremendous promise for improving community and population health by expanding the emphasis from simple clinical care to include more emphasis on addressing high-priority health needs identified in community health assessments and establishing partnerships outside of the healthcare delivery system to more fully address these identified needs. The call to partner with other clinical, public health, and population health–focused entities strengthens the ability to look at health outcomes through an upstream lens and adopt strategies aimed at ameliorating the SDOH known to adversely influence health outcomes of any community or population. Hospitals are required to disseminate findings from their community health needs assessments and related implementation plans, as well as provide a mechanism for communities to provide feedback, if desired. Reports of this nature outline the overall process of conducting community health needs assessments, highlight identified community health needs, and describe plans to address these identified needs. Visit Advocate Health System’s website to review samples of community health needs assessments and related implementation plans: www.advocatehealth.com/hospital-chna-reports-­ implementation-plans-progress-reports. See relevant resources for the community benefits standard in Exhibit 13.1 and implications for nursing in Exhibit 13.2. EXHIBIT 13.1   COMMUNITY BENEFIT WEBSITES AND ONLINE RESOURCES Advocate Health Care www.advocatehealth.com/hospital-chna-reports-implementation-plansprogress-reports American Hospital Association Tax Exempt Status www.aha.org/advocacy/compliance/tax-exempt-status Catholic Health Association of the United States Community Benefits www.chausa.org/communitybenefit/resources/definingcommunity-benefit Centers for Disease Control and Prevention CDC (2012). Best Practices for Community Health Needs Assessment and Implementation Strategy Development: A Review of Scientific Methods, Current Practices, and Future Potential www.phi.org/uploads/application/files/ dz9vh55o3bb2x56lcrzyel83fwfu3mvu24oqqvn5z6qaeiw2u4.pdf CDC (2017). Policy Resources to Support Social Determinants of Health www.cdc.gov/socialdeterminants/policy/index.htm (continued )

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EXHIBIT 13.1 COMMUNITY BENEFIT RELEVANT WEBSITES AND ONLINE RESOURCES (continued ) Internal Revenue Service Internal Revenue Service. (2013). Community Health Needs Assessments for Charitable Hospitals www.federalregister.gov/documents/2013/04/05/2013-07959/communityhealth-needs-assessments-for-charitable-hospitals National Academies of Science, Engineering, and Medicine (formerly the Institutes of Medicine) Institute of Medicine. 2014. Population health implications of the Affordable Care Act: Workshop summary. Washington, DC: The National Academies Press. www.nationalacademies.org/hmd/Reports/2013/Population-HealthImplications-of-the-Affordable-Care-Act.aspx CDC, Centers for Disease Control and Prevention.

EXHIBIT 13.2  LEVELS OF EVIDENCE-BASED ADVOCACY TO ADDRESS DISPARITIES

IN THE SOCIAL DETERMINANTS OF HEALTH POINT(S) OF POLICY ADVOCACY POLICY TO MODIFY FACTORS INFLUENCING HEALTH

LOCAL

STATE

FEDERAL

SOCIAL AND ECONOMIC CONDITIONS

Child and Youth Development/Education Home Visiting

•

•

•

Family Income Supplementation

•

•

•

Early Childhood Development Programs*

•

•

•

Economic Development Training Incentives Entrepreneurship Training

• •

Enterprise Zones

• •

Empowerment Zones

• •

Poverty Reduction Transfer Programs Living Wage Ordinances Expanded Health Insurance

•

•

•

•

•

•

• (continued )

Chapter Thirteen  ELIMINATING HEALTH INEQUITIES  403

EXHIBIT 13.2  LEVELS OF EVIDENCE-BASED ADVOCACY TO ADDRESS DISPARITIES

IN THE SOCIAL DETERMINANTS OF HEALTH (continued )

POINT(S) OF POLICY ADVOCACY POLICY TO MODIFY FACTORS INFLUENCING HEALTH

LOCAL

STATE

FEDERAL

LIVING AND WORKING CONDITIONS

Healthy Homes Integrated Pest Management

•

•

Smoke-Free Policies*

•

•

Lead Hazard Control*

•

•

•

•

•

Housing Choice Voucher Program* Healthy Neighborhoods Urban Design and Land Use*

•

Farmers' Markets

•

Community Gardens

•

Transportation-Related Improvements

•

Zoning Ordinances

•

Retail Food Stores

•

School-Based Violence Reduction*

•

•

•

•

*Sufficient evidence base to support wide-spread implementation. Source: Reprinted with permission from Webb, B. C. (2012). Moving upstream: Policy strategies to address social, economic, and environmental conditions that shape health inequities. Joint Center for Political and Economic Studies. Retrieved from http://jointcenter.org/sites/default/files/Moving%20 UpStream.%20Policy%20Strategies.pdf

As we witness the ongoing transformations in healthcare, nurses are well suited to engage in the community health needs assessment process. Because of nursing’s holistic and community health orientation, nurses should be at the table developing and administering assessment tools that comprehensively address the myriad of factors influencing health and well-being. Nurses in partnership with hospital and health systems leadership are encouraged to reduce health disparities by seeking solutions beyond just providing clinical care; we should provide care that encompasses upstream approaches and a population health orientation. Given that research in this area is in its infancy, nurses have a unique opportunity to develop a nursing research agenda examining the role and contributions of hospitals in improving community health and well-being. Findings from community assessments should be used to shape nursing

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and interdisciplinary research endeavors and can provide a foundation for evaluating the impact of implementing the community benefits standard. The growing emphasis on community needs assessment and implementation strategies provides nurses with an untapped opportunity to use their influence to shape policies aimed at addressing the SDOH and improving community and population health. Nurses have a rich history of patient advocacy and can use these same skills and passion in the policy arena by educating elected officials about the determinants of health. Information gleaned from this process could be used to address the high-priority health needs identified by the various communities. Finally, although efforts are underway to repeal and replace the ACA, regardless of the outcome, continued advocacy to retain and expand the community benefits standard is needed. Improving community and population health should be an important step in our unrelenting commitment to eliminating health disparities. Nurses are encouraged to become familiar with how hospitals/health systems and institutions where they work or provide care to communities are operationalizing the community benefits standards requirement.

Health in All Policies The current push to include “health in all policies” provides another emerging avenue for improving community and population health. “Health in all policies” is a collaborative approach to improving the health of all people by incorporating health considerations in decision making across sectors and policy areas (Rudolph, Caplan, Ben-Moshe, & Dillon, 2013). Proponents of this approach believe that collaboration across various sectors can improve efficiencies, reduce redundancy, facilitate sharing of resources, and can reduce cost and improve outcomes. This growing field resonates with the current emphasis on embracing upstream approaches to address health disparities by acknowledging the role of SDOH in influencing health outcomes. Policy makers are well suited to adopt this new approach to policy making and are encouraged to do so. No doubt this type of policy making is complex and will require policy makers to seek expertise inside and outside of government to ensure an evidence-based approach to policy making. Webb (2012) provides an excellent discussion on evidence-based policy making and outlines policies that are needed to modify factors influencing health, noting that to be optimally effective, policy work needs to be focused at the appropriate level. See Exhibit 13.2 for a quick guide for government-level approaches for a variety of conditions.

Global Policies to Reduce and Eliminate Health Inequities Globally, several countries have mobilized and formed regional alliances to develop frameworks that address the SDOH and health inequity with the context of a nation’s political, social, and economic systems. In a call for public health advocates for public policy to address social inequities throughout the world, Annas writes: the health and human rights movement should be able to make a difference by focusing public health advocacy on promoting a universally accepted framework of government obligations. Evidence-based public health advocates should loudly and insistently make the case for governments to put population-based prevention programs, such as vaccination, clean water, decent sanitation, basic medical care, and a universally available safety net, as budgetary priority items—ones that should be protected and even expanded in times of economic recession and depression, when vulnerable populations are most at risk. (2013, p. 967)

Chapter Thirteen  ELIMINATING HEALTH INEQUITIES  405

Many resource-poor and developing nations around the globe are working in concert with governmental and private sector entities to develop public health infrastructures to deliver population healthcare services to meet the needs of the public (Council on Foreign Relations, 2013). Private foundations are taking a leading role as well. For example, the Clinton Foundation (n.d.) began an initiative in 2002 to address the HIV/AIDS crisis in developing nations. This has been expanded to include work on malaria, access to new vaccines, and efforts to lower infant mortality. The Bill and Melinda Gates Foundation (n.d.) is working to address hunger and poverty through investment in science and technology. In the United States, the public health infrastructure also needs increased funding and coordination of multiple sectors and resources to meet the public health needs of the population.

History of U.S. Federal Policy Efforts to Reduce and Eliminate Health Inequities In the early 20th century, African American leaders and abolitionists first sounded the alarm that the United States was a nation divided—separate and unequal with wide gaps in health and life expectancy between Whites and Blacks. William Edward Burghardt (W.E.B.) Du Bois (1899) and Booker T. Washington (1914, as cited in Quinn & Thomas, 2001) lamented the lack of access to quality healthcare experienced by Blacks during the early emancipation period. However, the early documentation of health inequities was recorded as far back as 1840 when female Black slaves experienced disproportionately high rates of maternal and infant mortality (Dell & Whitman, 2011). During the period of slavery in the United States, it was argued that the disparate maternal and child health outcomes were biological (Dell & Whitman, 2011). W.E.B. Du Bois countered the biological hypothesis and instead argued that the maternal and child inequities were a result of a combination of social exclusion, racism, and widespread poverty (Dell & Whitman, 2011). Over a century later, researchers and scientists began again, in earnest, to extensively document the persistent unequal care and disparity in life expectancy between Whites and Blacks in the United States. The data were compelling—widespread racial, ethnic, and socioeconomic inequities in healthcare access and health outcomes remain. With the publication of the Report of the Secretary’s Task Force on Black and Minority Health (USDHHS, 1986), a federal focus on racial and ethnic health inequities emerged. This landmark report sounded the alarm regarding the magnitude of disparities among Black and minority populations and led to the creation of the Office of Minority Health, a critical step for developing policies and programs dedicated to improving the health of racial and ethnic minority populations (USDHHS, 1986). Several policy-driven initiatives, reports, and legislative activities have emerged at the federal level since the report on Black and Minority Health. In 2003, the report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, by the National Academy of Medicine (NAM), formerly the Institute of Medicine (IOM), further documented the seemingly entrenched and systemic inequities in healthcare and health outcomes. The NAM (formerly IOM) report focused specific attention on healthcare system factors that contributed to the racial and ethnic inequities (Smedley, Stith, & Nelson, 2003). The Agency for Healthcare Research and Quality (AHRQ), in the annual National Healthcare Disparities Report (2016), revealed that people in poor households received worse care than people in high-income households for about 60% of the healthcare quality measures that were tracked. In addition, Blacks, Hispanics, and American Indians and Alaska Natives received worse care than Whites for about 40% of quality measures (AHRQ, 2016).

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Researchers also noted that for each racial or ethnic minority group, disparities in quality of care were similar to disparities in access to care, although disparities in access tend to be more common than disparities in quality. See Exhibit 13.3 for a listing of key reports shaping health inequity policy discussions. Therefore, despite increased interest and investments in efforts to reduce population inequities, progress toward eliminating social and economic health inequities has been slow (AHRQ, 2016). To date, key federal legislation has focused on numerous efforts to decrease inequities. See Exhibit 13.4 for milestones that have shaped discussions and initiatives focused on eliminating health inequities. Some diversity efforts have included increasing minority and underrepresented persons in healthcare and research, as well as increasing minority recruitment and retention into federally funded research studies. Minority health legislation has focused, expanding healthcare coverage and affordability, which results in improving health outcomes among racial and ethnic minority and vulnerable populations. Efforts have been made to improve coordination of the documentation and evaluation of minority health initiatives at the state and federal levels, as well as the development of standards for data collection on race and ethnicity. More recently, the United States has begun to align its health equity efforts and agenda with a larger global strategy to address social and economic inequities in health through targeted actions on the SDOH. The U.S. federal government, in concert with a number of stakeholders, is increasingly integrating the social determinants into policies designed to reduce and eliminate health inequities. EXHIBIT 13.3  KEY REPORTS SHAPING HEALTH INEQUITY POLICY DISCUSSIONS

AND DEVELOPMENT YEAR

KEY REPORT

1986

Secretary’s Task Force on Black and Minority Health

2000

archive.org/details/reportofsecretar00usdepar Healthy People 2010

2002

2006

www.healthypeople.gov/2010 Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare www.nationalacademies.org/hmd/Reports/2002/UnequalTreatment-Confronting-Racial-and-Ethnic-Disparities-in-HealthCare.aspx Examining the Health Disparities Research Plan of the National Institutes of Health: Unfinished Business

2010

www.nap.edu/catalog/11602/examining-the-health-disparitiesresearch-plan-of-the-national-institutes-of-health Healthy People 2020

2013

www.healthypeople.gov CDC Health Disparities and Inequalities Report: United States, 2013

2016

www.cdc.gov/mmwr/preview/ ind2013_su.html#HealthDisparities2013 AHRQ National Healthcare Quality and Disparities Report www.ahrq.gov/research/findings/nhqrdr/nhqdr15/index.html

Chapter Thirteen  ELIMINATING HEALTH INEQUITIES  407

EXHIBIT 13.4   SNAPSHOT OF U.S. HISTORIC POLICY MILESTONES RELATED TO

HEALTH INEQUITIES, 1986–2010 1986

Office of Minority Health

Created a federal office to improve the health of racial and ethnic minority populations through the development of health policies/ programs that help eliminate health disparities.

1993

NIH Revitalization Act, 1993

Included women and minorities in clinical research unless well justified, reported, and approved by the NIH. Amended in 2001 (Pub. L. 103-43).

1994

Disadvantaged Minority Health Improvement Act of 1990

Developed the capacity of healthcare professionals to address the cultural and linguistic barriers to healthcare delivery and increase access to healthcare for people with limited proficiency in English. This office was reauthorized by the ACA in 2010 (Pub. L. 101-527).

2000

Minority Health and Health Disparities and Education Act

Created the NCMHD at the National Institutes of Health. This law also provided the definition for health disparities, which is used by many today (Pub. L. 106-525).

2000

Minority Health and Health Disparities Research and Education Act

Established the NCMHD to expand the infrastructure of Institutions committed to health disparities research and to encourage the recruitment/retention of scientists in the fields of biomedical, clinical, behavioral, and health services research (Pub. L. 106-525).

2003

Healthcare Equality and Accountability Act of 2003

Aimed to reduce the proven disparities in healthcare and access to medical service between minority communities and other Americans. Members of Congress announce legislation to improve healthcare for Asian Americans and Pacific Islanders. Reintroduced.

2010

Indian Health Improvement Act of 1976

Received permanent reauthorization. Serves as the statutory foundation of the government’s responsibility to provide healthcare to Native Americans. This provision aims to improve the health-promotion and disease-prevention services and access to modernized care facilities, where American Indians and Alaska natives receive care. (Pub. L. 94-437)

2010

ACA

Aids in eliminating health disparities by including provisions such as expanding healthcare coverage and improving access to care. Reauthorized the HHS Office of Minority Health and established Offices of Minority Health within six agencies of HHS. Reauthorized the Indian Health Care Improvement Act (Pub. L. 111-148).

ACA, Affordable Care Act; AHRQ, Agency for HealthCare Policy and Research; CDC, Centers for Disease Control and Prevention; HHS, Health and Human Services; NCMHD, National Center on Minority Health and Health Disparities; NIH, National Institutes of Health.

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Healthy People 2020 The United States’ expanded focus on the social determinants is reflected in Healthy People 2020’s (USDHHS, 2014) aim to achieve health equity, eliminate disparities, and improve the health of all groups. The Healthy People 2020 aim is an expansion of the Healthy People 2010 disparities objective, which aimed to “eliminate, not just reduce, health disparities” (USDHHS, 2014). The Healthy People 2020’s health equity goal includes a “health in all policies” approach. Former U.S. Surgeon General and member of the influential WHO Commission on the SDOH, Dr. David Satcher, advocated for the inclusion of social determinants in all efforts to reduce health inequities. The “health in all policies” approach requires stakeholders to establish collaborative partnerships with a variety of sectors beyond healthcare and include private, industry, education, transportation, economic, and justice system sectors (Satcher, 2010). In fact, several agencies within state and federal governments have established a framework and identified resources to move forward with a “health in all policies” approach to eliminate health inequities. For example, the use of health impact assessments (HIAs) holds promise for reviewing and evaluating social policies designed to improve the health and well-being of populations. The HIA process has been used in European countries and is now outlined in Healthy People 2020 (USDHHS, 2014).

Healthcare Reform … healthcare systems are social and cultural institutions, that are built out of the ­existing social structure, and carry its inequities within them. (Mackintosh, 2001, p. 175)

Healthcare systems play a key role in generating and perpetuating social group health inequities. The U.S. healthcare system is a complex amalgamation of private, for-profit, and public entities (e.g., military, veterans) with various health service and delivery goals that may include delivering quality healthcare services to meet the health needs of the population, increasing access to care for disadvantaged and underserved populations, and decreasing health and healthcare inequities. Furthermore, the health system has to interface and balance the interests of patients and consumers, businesses and purchasers, labor, health plans, clinicians and providers, communities and states, and suppliers. Too frequently, however, the U.S. health system enables exclusionary and inequitable practices that limit access based on health and healthcare by insurance status. Limiting care based on payment methods or inability to pay routinely results in inequitable healthcare experiences. The ACA (2010) is one of the most comprehensive pieces of legislation enacted in the past 40 years and has direct implications for eliminating health inequities. The passage of the ACA presented new opportunities for implementing cross-cutting interventions and strategies that are driven by economic and educational policy framed in the context of the SDOH. The ACA intentionally created a paradigm shift from a focus on disease management to health promotion. This shift not only addressed healthcare reform, but also created more opportunities to eliminate health inequities. Included among other provisions are specific efforts to address minority health within the federal government. Offices of Minority Health were created within six federal agencies: the AHRQ, the CDC, the Centers for Medicare & Medicaid Services, the Food and Drug Administration, Health Resources & Services Administration (HRSA), and the Substance Abuse and Mental Health Services Administration.

Chapter Thirteen  ELIMINATING HEALTH INEQUITIES  409

The National Prevention Strategy (NPS) was created by the ACA. Under the l­eadership of the U.S. Surgeon General and Chair of the National Prevention, Health Promotion, and Public Health Council, the National Prevention Council oversees implementation of the various priorities outlined in the NPS. These activities are designed to reduce the leading causes of preventable death and major illness through tobacco-free living, prevention of drug abuse and excessive alcohol use, healthy eating, active living, injury and violence-free living, reproductive and sexual health, and mental and emotional well-being. In addition to these priorities, four strategic directions were identified (see Exhibit 13.5), and five steps to address health disparities were developed (see Exhibit 13.6). The NPS was developed by the National Prevention Council, which consists of 17 federal agencies, including housing, transportation, and labor. Thus, involvement of many sectors of the federal government is necessary in improving health and health outcomes for individuals, families, and society. Although there are a number of federal initiatives to reduce health inequities, opportunities to reduce health inequities also exist on the local level. The first step is becoming aware of resources within the community through governmental agencies, community, and religious organizations. Next is to take steps to ensure cultural competence within one’s practice arena, modeling desirable behaviors for others, and advocating for resources so that all healthcare providers are culturally competent. Nurses can share with legislators, the media, and decision makers their firsthand knowledge of how low income, lower educational attainment, and limited access to care negatively impact health outcomes. Nurses can advocate for the provision of resources to underserved populations in their own communities. Although we have focused on infant mortality and maternal outcomes, we need to recognize that the problem of health inequities cuts across all healthcare settings, populations, and disease states. Initiatives to reduce health inequities can only be strengthened with nurse involvement and nurse advocacy. See Policy on the Scene 13.1 for an illustration of one community’s efforts to infuse evidence-based practices into community services. EXHIBIT 13.5 NATIONAL PREVENTION COUNCIL STRATEGIC DIRECTIONS FOR A

PREVENTION-ORIENTED SOCIETY Building Healthy and Safe Community Environments

Health begins in communities, which include homes, schools, public spaces, and work sites

Expanding Quality Preventive Services in Both Clinical and Community Settings

When people receive preventive care services, such as immunizations and cancer screenings, they experience better health and lower healthcare costs

Empowering People to Make Healthy Choices

Access to actionable and easy-to-understand information and resources empowers individuals and communities to make healthier choices

Eliminating Health Disparities

Eliminating disparities in achieving and maintaining health can lead to improved quality of life for individuals, families, and communities

Source: From National Prevention Council (2011). National Prevention Strategy. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General. Retrieved from http://www .surgeongeneral.gov/initiatives/prevention/strategy/report.html

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EXHIBIT 13.6  FIVE STEPS TO ADDRESS HEALTH DISPARITIES 1. INCREASE AWARENESS About Health Disparities • Blog or tweet about health disparities in your community or share information via Facebook. • Contact the media with stories about health disparities in your community. • Write a letter to the editor or an opinion article for your local newspaper. • Speak at health fairs, PTA and school board meetings, civic meetings, faith-based events, and other community gatherings. • Take the National Partnership for Action (NPA) Pledge to end health disparities. • Issue a statement from your organization in support of the NPA. 2. BECOME A LEADER for Addressing Health Disparities • Educate others about disparities and share stories about model programs with local organizations or community leaders, as well as the NPA. • Start a petition to get local citizens to support policy recommendations and submit the petition to the appropriate elected officials. • Organize a meeting of local organizations representing diverse sectors and work together to ensure health disparities are on the local and state health agenda. • Form coalitions with local organizations representing diverse sectors and leaders from different racial, ethnic, and other groups affected by health disparities to address common barriers and join the NPA. • Serve as a mentor to a young person in your family, neighborhood, or community. Educate him or her on the issues, encourage him or her to make healthy lifestyle choices, and guide him or her to resources. 3. SUPPORT HEALTHY AND SAFE BEHAVIORS in Your Community • Be a role model and serve nutritious foods at work or social functions. • Involve your employees in a group physical activity or challenge. Participate in National Health Observances—such as AIDS Awareness Days—by sponsoring local health events or encouraging loved ones and colleagues to take action to address their health. • Host seminars in your local library, school, workplace, or other venue to discuss health disparities in your community. Topics could include reducing asthma triggers in the home, managing obesity and chronic illnesses, or indicating how to enroll in public health insurance programs. • Join the Consumer Product Safety Commission’s Pool Safely Campaign to help prevent drowning, which occurs at higher rates among racial and ethnic minorities. 4. IMPROVE ACCESS to Healthcare • Partner with a local healthcare provider or employer to offer free health screenings in your workplace or place of worship. • Ask local healthcare providers to translate health and healthcare information or connect them to an individual or organization who can provide translation services. • Establish a Community Health Worker or Promotoras de Salud program in your community. (continued )

Chapter Thirteen  ELIMINATING HEALTH INEQUITIES  411

EXHIBIT 13.6  FIVE STEPS TO ADDRESS HEALTH DISPARITIES (continued ) 5. CREATE HEALTHY NEIGHBORHOODS • Advocate for more sidewalks, bike lanes, and recreation facilities in your neighborhood. • Encourage local schools, workplaces, and assisted living facilities to provide healthier lunch and snack options. • Ask your neighborhood supermarket to provide fresh fruit and vegetables to the local food bank, ask local restaurants to provide healthy menu options, or organize a farmers’ market that accepts food stamps. • Work with your local government and organizations in your community to collect and track data about health disparities and monitor changes over time. Note: These potential strategies build on the four goals of the National Prevention Strategy (NPS) Stakeholder Strategy for Achieving Health Equity. Source: National Partnership for Action to End Health Disparities. (n.d.). Toolkit for community action. U.S. Department of Health and Human Services, Office of Minority Health. Retrieved from http:// minorityhealth.hhs.gov/npa/files/Plans/Toolkit/NPA_Toolkit.pdf

The ACA illustrates how the big “P” intersects with the little “p” at the community level. A key provision in the 2010 ACA legislation is an $8.6 billion investment in the HRSA to support the Nurse–Family Partnership (NFP) and similar programs over 20 years. The NFP program links a public health nurse with a vulnerable, low-income, first-time mother

POLICY ON THE SCENE 13.1: The San Francisco Health Improvement Partnership: Intersection of Big “P” and Little “p” The San Francisco Health Improvement Partnership’s (SFHIP) communityfocused efforts to achieve health equity activated diverse stakeholders in the San Francisco community, including ethnic-based community health equity coalitions, the local public health department, hospitals and health systems, a health sciences university, a school district, the faith community, and other sectors(Falbe et al., 2016). SFHIP targeted childhood obesity and other chronic diseases afflicting the community through three prevention initiatives: (a) reducing consumption of sugar-sweetened beverages, (b) regulating retail alcohol sales, and (c) focusing on children’s oral health. The SFHIP partnership was able to get city ordinances enacted to regulate the sale and advertising of sugar-sweetened beverages and created a ballot measure establishing a soda tax. To support the reduction in sales and consumption of sugar-sweetened beverages, a majority of San Francisco hospitals committed to implementing healthy-beverage policies that prohibited serving or selling sugar-sweetened beverages. SFHIP also prevented Starbucks and Taco Bell from receiving alcohol licenses in the city of San Francisco and prevented state authorization of the sale of powdered alcohol. To address the tremendous disparities in oral health among the city’s children living in poverty, the SFHIP increased the number of primary care clinics providing fluoride varnish at routine well-child visits from age 3 to 14 years and acquired a state waiver

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to allow dental clinics to be paid for school-based dental services. The SFHIP is an example of a community-based impact model that blends active community engagement with evidence-based policy actions to create a health-promoting environment to achieve health equity among all its members. to enable a healthy pregnancy, improve pregnancy outcomes, reduce rates of high-risk and subsequent pregnancies, reduce childhood injuries and abuse, and reduce developmental and cognitive delays. Public health nurses are the key providers in the evidence-based, community health program. The NFP program has been shown to be cost-effective and touts family and societal benefits by improving the long-term health of children and families (NFP, n.d.). At the community level, public health nurses conduct home visits as part of the NFP program. The nurses provide holistic care and empower first-time mothers and young families by providing basic child-­rearing information and resources.

OPTION FOR POLICY CHALLENGE: The Case of Marie: An Illustration of How Childhood Exposures to Toxic Environments Equals a Lifetime of Health Disadvantage At 9 years old, Marie does not get to choose the neighborhood in which she lives or the amount or type of food she eats. Neither can Marie make decisions about whether someone is allowed to smoke in her home. Although it is tempting to suggest that Marie’s social conditions are the fault of her mother, a deeper dive will reveal that Marie’s mother also was born into, and grew up in, nearly identical conditions. Marie was simply born into a life of disadvantage and poor health, just as her mother and grandmother before her. Marie has been set up for a lifetime of social and economic disadvantage and will undoubtedly experience the negative health consequences of poverty. The story of Marie is significant in that it highlights the cumulative intergenerational effects of social disadvantage and its correlation to negative health consequences. A clear evidence base links poor health outcomes with residing in disadvantaged neighborhoods that are highcrime, unsafe-food deserts (i.e., low-income communities that do not have access to supermarkets or grocery stores that supply fresh fruits and vegetables), that are also saturated with tobacco advertisements and liquor stores (Levine, 2011; Ross & Mirowsky, 2011; Thornton et al., 2016). Disadvantaged neighborhoods are more likely to have higher proportions of children and families who experience food insecurity (uncertain of having or inability to acquire sufficient food) and therefore are obese and at risk for diabetes and other chronic diseases compared with advantaged neighborhoods (Futrell Dunaway, Carton, Mundorf, Keel, & Theall, 2017; Humphreys, Panter, Sahlqvist, Goodman, & Ogilvie, 2016). Evidence-based strategies proved effective in addressing poverty-associated inequities in childhood obesity are necessarily multifactorial and include a combination of creating healthy environments that allow safe spaces to play and exercise, provide access to healthy foods, and create and support community efforts to prevent and reduce violence (Futrell Dunaway et al., 2017; H. Lee, 2012; Mays, Mamaril, & Timsina, 2016; Thornton et al., 2016). The Policy on the Scene describes a multistakeholder effort to address the neighborhood environment in which children and their families live (Grumbach et al., 2017).

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IMPLICATIONS FOR THE FUTURE We have presented considerable evidence of the nature and impact of health inequities in our society. The following are trends that can have a powerful impact on health inequities: (a) increased demands for improved quality of healthcare, (b) greater recognition of the role of community in reducing health inequities, (c) implementation of healthcare reform, (d) great emphasis on health promotion and prevention of illness, (e) increased use of technology, and (f) greater recognition of environmental impacts on health. These trends will impact how nurses can and should work in the future. We have seen an increase in demands and accountability for improving quality in the delivery of healthcare. With the advance of technology and the use of electronic health records, it is increasingly possible to use data-mining techniques to drill down to very specific outcomes and interaction effects. Consequently, it will be increasingly apparent that health outcomes will not improve without bringing along all sectors of society into an improved high-quality healthcare delivery system. In other words, without addressing unequal treatment, racism, prejudice, and stigma, care cannot rise to a high level of quality. Programs to address cultural competency may be helpful in increasing awareness and addressing unconscious biases. However, healthcare organizations and systems will need to focus on intentionally using these resources to decrease health inequities within their own communities. The use of technology will increase not only by healthcare organizations and individual healthcare providers, but also by individual consumers. Nurse researchers are creatively exploring the use of soap opera videos and text messages to create tailored health messages (Jones et al., 2008; Kim & Glanz, 2013) as healthcare providers are implementing integrated electronic health records. We can expect only an acceleration of changes and innovations in this arena. As with the implementation of any technology, some segments of society and some segments of the healthcare delivery system will lag behind because of a lack of resources. On the other hand, technology is being used to collect epidemiological data in underdeveloped countries, and there is no reason to believe that the potential of technology could not be thoughtfully and creatively applied to reducing health inequities. Our society is increasingly interconnected. Although overall population health indices have improved, we have failed to make progress in certain counties in increasing life expectancy (U.S. Burden of Disease Collaborators et al., 2013). With an ever-growing body of research indicating that where one lives matters in terms of health and how communities influence health and health behavior, greater focus will be on ensuring that our communities are healthy places to live and work. Success in improving health and reducing inequities will require engagement and commitment at a local level. Our communities will become increasingly important in addressing the underlying causes of health inequities such as access to education, a safe place for children to play, and work environments that are free of health hazards. Recognition that health inequities harm everyone will result in an increase in collaborative partnerships of all types: government–private, local–state, education–health, and business–government, to name a few. Employers will increasingly recognize that a healthy workforce will result in a more productive workforce and that a focus on the reduction of employee health benefits is counterproductive without partnering with their employees to improve their health and the health of their families (Partnership for Prevention, 2009). These partnerships will bring together key stakeholders who recognize that each sector of the community has resources and expertise that can be used together to improve health.

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The ACA has specific provisions designed to provide health insurance and eliminate health inequities by creating a legislative framework that protects the right to health, representing a turning point in U.S. healthcare (Majette, 2012). These provisions include the expansion of community health centers, oral and behavioral healthcare services, school-based health centers, nurse-managed health clinics, and community health teams to support medical homes. As these provisions have been implemented, we have seen changes in the number of people who have insurance. From October 2013 to July 2017, an additional 20 million people were covered because of the ACA exchanges and Medicaid expansion provisions within the ACA legislation (USDHHS, 2017). Variation in the beginning stages of the implementation of health insurance exchanges at the state level impeded access to health insurance. Furthermore, having health insurance does not necessarily equal access to healthcare. Having health insurance has not fully addressed unequal treatment when there is access. However, efforts are underway to repeal and/or replace key elements of the ACA legislation. The U.S. House of Representatives and Senate have proposed to repeal the individual mandate and out-of-pocket subsidies that were put in place to manage healthcare costs. In addition, repeal and replace proposals specifically aim to change the ACA tax structure, drastically reduce Medicaid expansion, eliminate premium subsidies, change the structure of the health savings account, and eliminate preexisting conditions protections. If each of these changes are approved by the U.S. House of Representatives and Senate and the president signs the revised version of the healthcare legislation into law, it is anticipated that 23 million more people would become uninsured and have no health insurance coverage by 2026 (Congressional Budget Office, 2017). Therefore, future impacts on the seminal healthcare legislation known as the ACA are unclear. What remains clear, however, is that the debate surrounding the implementation of the ACA will result in further polarization and marginalization of those who have been traditionally disadvantaged in our society. Increasingly, our efforts at improving the health of society will focus on the promotion of health and the prevention of disease. The ACA or its replacement legislation along with other initiatives may accelerate this process. Many health inequities have to do with the underlying conditions that have resulted in greater risk for maternal and infant mortality, physical inactivity, obesity, air pollution, violence, and tobacco and alcohol consumption (Wang, Schumacher, Levitz, Mokdad, & Murray, 2013). The emphasis on evidence-based strategies for addressing these health problems and their underlying antecedents will only grow exponentially. The incidence of natural disasters will have an impact on people in our communities, in particular the most vulnerable, through not only physical health, but also mental health. These events, as we have seen in recent years, will add additional burden to any safety net provided by our communities and its healthcare infrastructure. Thus, any efforts to address health inequities must be coupled with efforts to address the effects of environmental impacts on health including climate change. Access to basic human needs, clean air, safe drinking water, sufficient food, and safe shelter are impacted by climate change and these are most pronounced for those living in the margins of our society. It is important for nurses to be aware of these trends and capitalize on the potential for promoting positive health outcomes for all people. As widely respected and trusted members of healthcare teams, their workplace, and their communities, nurses are in key positions to take a leadership role in working to reduce health inequities and their root causes. As nurses, they are in an ideal position to change the health outcomes

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for future generations. It is more than just a consideration, it is nurses’ responsibility. Implementing The Future of Nursing (Committee on the RWJF Initiative on the Future of Nursing, 2011) recommendations with its call to action for nurses to further their education and to step up to the plate in assuming leadership roles can serve as a vehicle for accelerating the necessary work to reduce health inequities.

KEY CONCEPTS 1. Health is a human right. 2. Health and social inequities are a matter of economics and social justice. 3. Nurses need to be knowledgeable about healthcare and social policies that create inequities to be effective advocates for the populations and communities that they serve. 4. SDOH are the conditions in which people are born, grow, live, work, and age— including the health system—and are shaped by the distribution of money, power, and resources at global, national, and local levels, which are themselves influenced by policy choices. 5. Social and economic determinants drive population health inequities. 6. SDOH have important implications for U.S. and global health policy. 7. Health inequities are unfair differences in the health status of different populations that are closely linked with historical social and economic disadvantage. 8. There are no biological or genetic reasons to explain why socially disadvantaged groups experience significantly poorer health outcomes compared with the socially advantaged. 9. The type of health insurance is a key indicator of SES and class status in the United States. The type of health insurance status is also strongly correlated with race, ethnicity, and SES. 10. SES has a direct influence on the type of health insurance one can obtain, and health insurance has a direct impact on health outcomes. 11. Effective health policy strategies should include education, housing, labor, commerce, urban development, and environmental initiatives. 12. Public health programs such as nurse home-visiting programs for low-income and resource-poor pregnant women have been shown to improve maternal, infant, and family outcomes. 13. Partnerships that extend beyond the boundaries of nursing and healthcare to include education, housing, and economic sectors must be engaged to effectively address population health inequities.

SUMMARY Political advocacy and policy engagement on behalf of people, families, and communities are essential role functions for professional nurses. In the United States, social and economic health inequities are indeed real and present threats to the nation’s health. Given the urgency of such inequities, it is important that today’s nurses be prepared to actively engage in all aspects of the policy-making process where discussions and decisions take place regarding the SDOH and healthcare. However, the health inequity problem cannot be solved solely by nursing; despite being the largest workforce in the United States, nurses will not be able to eliminate health inequities by working in isolation. Rather, nurses have to work to create partnerships with other nurses and with other professions that not only span the healthcare landscape, but also extend

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beyond the borders of healthcare. Diverse cross-sector partnerships will enable nursing to acquire the necessary knowledge, skills, language, and expertise to address the social and economic determinants of health inequities. Once those partnerships are formed, we then must work to better understand the complexity of the deep-rooted drivers of inequities in health among social groups. To be effective and influential in seeking solutions to the persistent inequities in health, nursing must secure diverse cross-sector partnerships. To address the complexity of SDOH, partnerships with government, academia, business, industry, public and private partners, community, and faith-based organizations, to name a few, are needed. In recent years, the call for a partnership approach to advance health by the nursing community has gained momentum (Committee on the RWJF Initiative on the Future of Nursing, 2011; Shalala & Vladeck, 2011). The value of diverse perspectives in addressing health and nursing-related issues is reflected in the committee membership for the landmark report, The Future of Nursing: Leading Change, Advancing Health (Committee on the RWJF Initiative on the Future of Nursing, 2011). The report committee was composed of a cadre of professionals from areas such as business, academia, healthcare delivery, and health policy. Each member of this diverse coalition collectively provided unique perspectives and experiences when shaping the robust action-oriented report. Shalala and Vladeck (2011) echoed a similar call to action when they emphasized the need for nursing to develop allies from a wide variety of fields to effectively garner the political support and capital needed to implement the recommendations outlined in The Future of Nursing report. We must maintain our commitment to develop effective policies and interventions to address and redress societal health inequities. Developing effective policy and following up with policy implementation actions through policy-directed initiatives and strategies are the ways to move forward to achieve the goal of health equity for all.

LEARNING ACTIVITIES 1. Discuss two areas of social and economic health inequities in the patient population you serve and the role that nursing can play in closing the gap in one of the inequities. 2. Identify the annual income and the life expectancy for men and women for the county/ parish where you live. Then identify the counties/parishes in your state that have the highest and lowest annual income and the life expectancy for men and women in those counties/parishes. Compare these life expectancies in your state with two affluent countries such as Japan and Switzerland and then compare these results with two less affluent countries such as Algeria and Bangladesh. 3. Prepare a list of partnerships in your area that have developed programs for health inequities. Discuss nursing’s roles and visibility or lack of roles and visibility in these partnerships. 4. Investigate a common health problem for a hospital, clinic, or community agency based on admissions or visits per year and discuss how health inequities may contribute to the prevalence of the problem. Examples might include obesity, preterm pregnancy, and a specific chronic health condition such as asthma. Identify one strategy that can be used for this problem. 5. Find one article that highlights a nurse-led initiative to help the underserved with health inequities and identify the lessons learned for your specialty area. 6. Identify an upstream strategy to address health inequities related to one of the WHO Millennium Development Goals.

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7. Describe the type of project related to the reduction of health inequities that you could develop if you served as an intern with the WHO. 8. Discuss with hospital leadership within your community how they operationalize the community benefits standard requirement and offer your expertise in addressing the identified community health needs.

E-RESOURCES • Ethnic Minority Fellowship Program http://www.emfp.org • Frist, W. H. (2005). Overcoming disparities in US health care. Health Affairs, 24(2), 445–451 http://content.healthaffairs.org/content/24/2/445.full • GovTrack.us: Tracking the Activities of the United States Congress http://www.govtrack.us • Healthy People 2020 http://www.healthypeople.gov/2020/default.aspx • USDHHS Action Plan to Reduce Racial and Ethnic Health Disparities, 2011 https://minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan_complete.pdf • The Joint Commission. (2014). Advancing effective communication, cultural competence, and patient-and family-centered care: A roadmap for hospitals https://www.jointcommission.org/roadmap_for_hospitals • Kaiser Family Foundation http://www.kff.org • Kaiser Family Foundation. (2016). Disparities in health and health care: Five key questions and answers http://www.kff.org/disparities-policy/issue-brief/disparities-in-health-and -health-care-five-key-questions-and-answers • Kaiser Family Foundation. (2017). How do premiums and cost sharing affect lowincome people in Medicaid? http://www.kff.org/medicaid/press-release/how-do-premiums-and-cost-sharing -affect-low-income-people-in-medicaid • Medicaid http://www.medicaid.gov • The Minority Health and Health Equity Archive http://health-equity.lib.umd.edu • National Association of County and City Health Officials: Roots of Health Inequity http://www.rootsofhealthinequity.org/about-course.php • National Conference of State Legislatures http://www.ncsl.org/research/health/health-disparities-overview.aspx • National Partnership for Action: National Stakeholder Strategy for Achieving Health Equity http://minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=286 • Office of Minority Health: The National CLAS Standards https://minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=286 • Substance Abuse and Mental Health Services Administration http://www.samhsa.gov • World Health Organization: Global Health Observatory (GHO) Data. Health equity monitor http://www.who.int/gho/health_equity/en/index.html

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ACKNOWLEDGMENTS The views expressed are the authors’ and not necessarily those of the HRSA or the USDHHS.

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420   UNIT IV  JUDGING WORTH AND ADVANCING THE CAUSE Internal Revenue Service. (2014). New requirements for charitable 501 (c) (3) hospitals. Retrieved from https://www.irs.gov/charities-non-profits/charitable-organizations/new-requirements -for-501c3-hospitals-under-the-affordable-care-act Jones, C. P., Truman, B. I., Elam-Evans, L. D., Jones, C. A., Jones, C. Y., Jules, R., … Perry, G. S. (2008). Using socially assigned race to probe white advantages in health status. Ethnicity and Disease, 18(4), 496–504. Retrieved from https://www.ethndis.org/priorarchives/ethn-18-04-496.pdf Kim, B. H., & Glanz, K. (2013). Text messaging to motivate walking in older African Americans: A  ­ randomized controlled trial. American Journal of Preventive Medicine, 44(1), 71–75. doi:10.1016/j.amepre.2012.09.050 Lam, L. L., Emberly, E., Fraser, H. B., Neumann, S. B., Chen, E., Miller, G. E., & Kobor, M. S. (2012). Factors underlying variable DNA methylation in a human community cohort. Proceedings of the National Academy of Sciences of the United States of America, 109(Suppl. 2), 17253–17260. doi:10.1073/pnas.1121249109 LaPar, D. J., Damien, J., Bhamidipati, C. M., Mery, C. M., Stukenborg, G. J., Jones, D. R., … Ailawadi, G. (2010). Primary payer status affects mortality for major surgical operations. Annals of Surgery, 252(3), 544–551. doi:10.1097/SLA.0b013e3181e8fd75 LEAD Center. (2015). Policy brief. The impact of employment on the health status and health care costs of working-age people with disabilities. Retrieved from http://www.leadcenter.org/system/files/ resource/downloadable_version/impact_of_employment_health_status_health_care_costs_0.pdf Lee, D. J., Fleming, L. E., LeBlanc, W., Arheart, K. L., Ferraro, K. F., Pitt-Catsouphes, M., … Kachan, D. (2012). Health status and risk indicator trends of the aging U.S. healthcare workforce. Journal of Occupational and Environmental Medicine, 54(4), 497–503. doi:10.1097/JOM.0b013e318247a379 Lee, H. (2012). The role of local food availability in explaining obesity risk among young school-aged children. Social Science & Medicine, 74(8), 1193–1203. doi:10.1016/j.socscimed.2011.12.036 Levine, J. A. (2011). Poverty and obesity in the U.S. Diabetes, 60(11), 2667–2668. doi:10.2337/ db11-1118 Li, Q., & Keith, L. G. (2011). The differential association between education and infant mortality by nativity status of Chinese American mothers: A life-course perspective. American Journal of Public Health, 101(5), 899–908. doi:10.2105/AJPH.2009.186916 MacDorman, M. F., Hoyert, D. L., & Mathews, T. J. (2013). Recent declines in infant mortality in the United States, 2005-2011. NCHS Data Brief No. 120, 1–8. Retrieved from https://www.ncbi.nlm .nih.gov/pubmed/23759138 MacDorman, M. F., Mathews, T. J., Mohangoo, A. D., & Zeitlin, J. (2014). International comparisons of infant mortality and related factors: United States and Europe, 2010. National Vital Statistics Reports, 63(5), 1–6. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25252091 Mackintosh, M. (2001). Do health care systems contribute to inequalities? In D. Leon & G. Walt (Eds.), Poverty, inequality and health (pp. 175–193). London, UK: Oxford University Press. Majette, G. R. (2012). Global health law norms and the PPACA framework to eliminate health disparities. Howard Law Journal, 55(3), 887–936. Retrieved from http://law.howard.edu/sites/default/ files/related-downloads/how_55_3.pdf Matijasevich, A., Victora, C. G., Lawlor, D. A., Golding, J., Menezes, A. M., Araújo, C. L., … Smith, G. D. (2012). Association of socioeconomic position with maternal pregnancy and infant health outcomes in birth cohort studies from Brazil and the UK. Journal of Epidemiology and Community Health, 66(2), 127–135. doi:10.1136/jech.2010.108605 Mathews, T. J., & Driscoll, A. K. (2017). Trends in infant mortality in the United States, 2005–2014. NCHS Data Brief, No 279. Retrieved from https://www.cdc.gov/nchs/data/databriefs/db279.pdf Mathews, T. J., MacDorman, M. F., & Thoma, M. E. (2015). Infant mortality statistics from the 2013 period linked birth/infant death data set. National Vital Statistics Reports, 64(9). Retrieved from https://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_09.pdf Mays, G. P., Mamaril, C.B., & Timsina, L.R. (2016). Preventable death rates fell where communities expanded population health activities through multisector networks. Health Affairs, 35(11), 2005-2013. doi:10.1377/hlthaff.2016.0848

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Mead, H., Cartwright-Smith, L., Jones, K., Ramos, C., Woods, K., & Siegel, B. (2008). Racial and ethnic disparities in U.S. health care: A chartbook. Commonwealth Fund. Retrieved from http:// www.commonwealthfund.org/usr_doc/Mead_racialethnicdisparities_chartbook_1111.pdf National Partnership for Action to End Health Disparities. (n.d.). Toolkit for community action. U.S. Department of Health and Human Services, Office of Minority Health. Retrieved from http:// minorityhealth.hhs.gov/npa/files/Plans/Toolkit/NPA_Toolkit.pdf National Prevention Council. (2011). National Prevention Strategy. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General. Retrieved from http://www .surgeongeneral.gov/initiatives/prevention/strategy/report.html Niu, X., Roche, L. M., Pawlish, K. S., & Henry, K. A. (2013). Cancer survival disparities by health insurance status. Cancer Medicine, 2(3), 403–411. doi:10.1002/cam4.84 Noble, K. G., Houston, S. M., Brito, N. H., Bartsch, H., Kan, E., Kuperman, J. M., … Sowell, E. R. (2015). Family income, parental education and brain structure in children and adolescents. Nature Neuroscience, 18(5), 773–778. doi:10.1038/nn.3983 Nurse-Family Partnership. (n.d.). Pregnancy assistance for first-time moms. Retrieved from http:// www.nursefamilypartnership.org/first-time-moms Panel on DHHS Collection of Race and Ethnic Data, Ver Ploeg, M., & Perrin, E. (Eds.), & National Research Council. (2004). Eliminating health disparities: Measurement and data needs. Washington, DC: National Academies Press. Partnership for Prevention. (2009). Healthy workforce 2010 and beyond. Retrieved from http://www .prevent.org/Publications-and-Resources.aspx Patient Protection and Affordable Care Act of 2010, [Pub. Law No. 111–148]. 124 § 119-1025. (2010). Pulgaron, E. R., & Delamater, A. M. (2014). Obesity and type 2 diabetes in children: Epidemiology and treatment. Current Diabetes Reports, 14(8), 508. doi:10.1007/s11892-014-0508-y Quarells, R. C., Liu, J., & Davis, S. K. (2012). Social determinants of cardiovascular disease risk factor presence among rural and urban Black and White men. Journal of Men’s Health, 9(2), 120–126. doi:10.1016/j.jomh.2012.03.004 Quinn, S. C., & Thomas, S. B. (2001). The National Negro Health Week, 1915–1951: A descriptive account. Minority Health Today, 2(3), 44–49. Retrieved from https://sph.umd.edu/sites/default/ files/files/National_Negro_Health_Week.pdf Robbins, A. S., Chen, A. Y., Stewart, A. K., Staley, C. A., Virgo, K. S., & Ward, E. M. (2010). Insurance status and survival disparities among nonelderly rectal cancer patients in the National Cancer Data Base. Cancer, 116(17), 4178–4186. doi:10.1002/cncr.25317 Robert Wood Johnson Foundation. (2013). Health policy snapshot—Issue brief. How does ­employment—or unemployment—affect health? Retrieved from http://www.rwjf.org/content/ dam/farm/reports/issue_briefs/2013/rwjf403360 Rosenbaum, S. (2016). Hospitals as community hubs: Integrating community benefit spending, community health needs assessment and community health improvement. Economic Studies at Brookings, 1–9. Rosenbaum, S., Kindig, D., Bao, J., Byrnes, M., & O’Laughlin, C. (2015). The value of the nonprofit hospital tax exemption was $24.6 billion in 2011. Health Affairs, 34(7), 1225–1233. doi:10.1377/ hlthaff.2014.1424 Rosenthal, E. (2013, June 30). American way of birth: Costliest in the world. New York Times. Retrieved from http://www.nytimes.com/2013/07/01/health/american-way-of-birth-costliest-in -the-world.html?pagewanted=all&_r=0 Ross, C. E., & Mirowsky, J. (2001). Neighborhood disadvantage, disorder, and health. Journal of Health and Social Behavior, 42(3), 258–276. Retrieved from http://www.aleciashepherd.com/writings/ articles/other/Neighborhood%20Disadvantage%20Disorder%20and%20Health.pdf Rudolph, L., Caplan, J., Ben-Moshe, K., & Dillon, L.. ( 2013). Health in All Policies: A Guide for State and Local Government. Washington, DC and Oakland, CA: American Public Health Association and Public Health Institute.

422   UNIT IV  JUDGING WORTH AND ADVANCING THE CAUSE Satcher, D. (2010). Include a social determinants of health approach to reduce health inequalities. Public Health Reports, 125(Suppl. 4), 6–7. Schnittker, J., & Bacak, V. (2014). The increasing predictive validity of self-rated health. PLoS ONE, 9(1), e84933. doi:10.1371/journal.pone.0084933 Shalala, D., & Vladeck, B. (2011). Leading change: How nurses can attract political support for the IOM Report on the future of nursing. Nurse Leader, 9(6), 38–39, 45. doi:10.1016/j.mnl.2011.09.007 Singh, G. K., & Kogan, M. D. (2007). Persistent socioeconomic disparities in infant, neonatal, and postneonatal mortality rates in the United States, 1969–2001. Pediatrics, 119(4), e929–e939. doi:10.1542/peds.2005-2181 Smedley, B. D., Stith, A. Y., & Nelson, A. R. (Eds.). (2003). Unequal treatment: Confronting racial and ethnic disparities in health. Washington, DC: National Academies Press. Subramanian, S. V., & Kawachi I. (2004). Income inequality and health: What have we learned so far? Epidemiological Reviews, 26(1), 78–91. doi:10.1093/epirev/mxh003 Thornton, R. L., Glover, C. M., Cene, C. W., Glik, D. C., Henderson, J. A., & Williams, D. R. (2016). Evaluating strategies for reducing health disparities by addressing the social determinants of health. Health Affairs, 35(8), 1416–1423. doi:10.1377/hlthaff.2015.1357 U.S. Burden of Disease Collaborators, Murray, C. J. L., Abraham, J., Ali, M. K., Alvarado, M., Atkinson, B. S., … Lopez, A. D. (2013). The state of US health, 1990–2010. Burden of diseases, injuries, and risk factors. Journal of the American Medical Association, 310(6), 591–608. doi:10.1001/ jama.2013.13805 U. S. Department of Health and Human Services. (1986). Report of the secretary’s task force report on black and minority health, volume I: Executive summary. Washington, DC: Government Printing Office. Retrieved from http://minorityhealth.hhs.gov/assets/pdf/checked/1/ANDERSON.pdf U.S. Department of Health and Human Services. (2014). Healthy People 2020. Disparities. Retrieved from http://www.healthypeople.gov/2020/about/disparitiesAbout.aspx U.S. Department of Labor, Bureau of Labor Statistics. (2017). Occupational outlook handbook. Retrieved from https://www.bls.gov/ooh/healthcare/registered-nurses.htm Wang, H., Schumacher, A. E., Levitz, C. E., Mokdad, A. H., & Murray, C. J. L. (2013). Left behind: Widening disparities for males and females in US county life expectancy, 1985–2010. Population Health Metrics, 11, 8. doi:10.1186/1478-7954-11-8 Webb, B. C. (2012). Moving upstream: Policy strategies to address social, economic, and environmental conditions that shape health inequities. Joint Center for Political and Economic Studies. Retrieved from http://jointcenter.org/sites/default/files/Moving%20UpStream.%20Policy%20Strategies.pdf Wennberg, P., Rolandsson, O., Jerdén, L., Boeing, H. Sluik, D., Kaaks, R., … Nöthlings, U. (2012). ­Self-rated health and mortality in individuals with diabetes mellitus: Prospective cohort study. BMJ Open, 2(1), e000760. doi:10.1136/bmjopen-2011-000760 World Bank. (2014, August 25). Poverty and health. brief. Retrieved from http://www.worldbank.org/ en/topic/health/brief/poverty-health World Health Organization. (2012). Environmental health inequalities in Europe. Assessment report. Geneva, Switzerland: Author. Retrieved from http://www.euro.who.int/en/what-we-publish/ abstracts/environmental-health-inequalities-in-europe.-assessment-report World Health Organization. (2017). 10 facts on health inequities and their causes. Retrieved from http://www.who.int/features/factfiles/health_inequities/en World Health Organization, Commission on Social Determinants of Health. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Retrieved from http://www.who.int/social_determinants/thecommission/finalreport/en

FOURTEEN

Valuing Global Realities for Health Policy Judith Shamian Michelle McHugh Slater Unless we are making progress in our nursing every year, every month, every week, take my word for it we are going back.—Florence Nightingale

OBJECTIVES 1. Examine the social responsibility of nursing in the context of global health policy. 2. Identify common issues that unite nurses globally. 3. Compare and contrast key international organizations relevant to health and nursing policy. 4. Describe collaborative strategies designed to advance the nursing profession internationally. 5. Appreciate the role of the nurse as a global citizen.

More than 20 million nurses across the globe are caring for more than seven billion ­people (World Health Organization [WHO], 2017b). Despite these millions of nurses, many people do not have the care they need because the issues that are at the root of many problems are not bound by geographical or geopolitical borders. Lack of education and access to care, poverty, gender inequality, and environmental factors, in addition to healthcare provider shortages, all contribute to health problems, across all nations and geographic regions. As discussed in Chapter 13, nurses have a fundamental role and responsibility to advocate for the population and community. This chapter focuses on that global community. Never more than now can these global connections be so easily recognized. Natural disasters, cross-border violence, infectious diseases, travel, technology, and migration patterns are some of the ways that human connectedness is more visible. Nurses hold a unique role to improve health and contribute to the current and future development goals outlined by the United Nations (UN). Despite the sheer number of nurses and the underlying potential power of nurses to advocate, individual nurses may not recognize, think or act as global citizens or value our global interconnectedness. Thus, nurses are not able to readily appreciate nursing’s potential power to impact healthcare and nursing practice globally. 423

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Nurses frequently express concern about healthcare issues as it relates to their personal practice, their communities, and their environment. Far too often, these concerns are discussed within local communities of practice and do not develop into measurable p ­ rogress towards a common health goal. Nursing practice occurs within a complex environment of multicultural and multiethnic populations. The social responsibility and professional practice obligation of nursing is to impact global health through health promotion, illness prevention, health restoration, and alleviation of suffering (Tyer-Viola et al., 2009). The challenge facing the nursing community is to understand the world stage and global actors participating in the production of healthcare. As we gain an appreciation

POLICY CHALLENGE: Investing in the Future Howard Catton, BSc, MA, RN International Council of Nurses (ICN) Director Nursing and Health Policy, Geneva, Switzerland The healthcare worker shortage is projected out to the year 2030. Nurses and nurse-midwives, making up almost 50% of healthcare workers globally, are center stage. The United Nations (UN) proposes a major reframing of the way governments and policy makers view the healthcare workforce. In March 2016, the UN Eighth Secretary General, Ban Ki-moon, established the 19-member UN HighLevel Commission on Health Employment and Economic Growth (HEEG) to guide the creation of health and social sector jobs to advance inclusive economic growth with emphasis and consideration to the needs of low- and middle-income countries. The challenge was both to convince political powers of the impact of nurses in care and to attain the investments needed to invest in scaling up nursing. This was not easy, given that spending on healthcare has historically been thought of as a drain on the economy, and in many countries the political mantra has been that you need a strong economy to have a strong health system. Judith Shamian, PhD, RN, FAAN, then ICN president, was a member of the Commission. The ICN, representing 16 million nurses and more than 130 national nurses associations, including the American Nurses Association (ANA), has committed to working globally to support the Commission’s plan. Dr. Shamian submitted evidence of nursing contributions to substantiate the logic of investment in nursing profession to advance global health. Key points include: • Nurses are the backbone in the delivery of healthcare services to meet future system demands and ensure universal coverage. • Investing in women in the healthcare workforce will reduce inequities and provide economic benefits by empowering them. • Advanced nursing roles and the extension of scopes of practice of nonphysicians has an enormous potential to impact accessibility to healthcare, especially in rural areas. • The nurse shortage is an action priority, which equates to scaling up educational programs, addressing poor pay, and improving work conditions for nurses. • Nurse migration and recruitment practices impact the healthcare workforce by directly contributing to the shortage in low- and middle-income countries.

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of the plot and subplots behind health inequities, the nursing community needs to increase its focus on engaging key stakeholders in strategic partnerships to shape the global health agenda. As global citizens, nurses are uniquely equipped to address social issues and challenge the status quo.

OVERVIEW OF GLOBAL HEALTH ISSUES On this planet, more than seven billion people live in more than 194 countries with both unique and disparate profiles. These countries or nations have often been labeled using political, economic, or ethnic terms. There is no common definition of criteria for each category of a country’s development; however, prominence is often determined relative to other countries using the gross domestic product (GDP) per capita and the Human Development Index (HDI) measure. The latter is a multifactorial statistic that uses a combination of life expectancy, education, and income factors. Global health issues (GHIs) include a multitude of concerns that directly impact population health. Worldwide, healthcare systems are burdened from chronic underfunding and underdeveloped community and public healthcare, which leads to ever-­ escalating disease and associated costs (Oulton, 2014). Adding to this problem are complex stressors to the already burdened system (Oulton, 2014). Examples of these stressors are illustrated in Figure 14.1 Socioeconomic, cultural, environmental, and equality factors all contribute to health whether positive or negative. Global health is concerned with social determinants of FIGURE 14.1   STRESSORS TO THE HEALTHCARE SYSTEM Changing Demographics • Age variation, life span, workforce issue, life expectancy Climate Change and Global Warming • Extreme weather, floods, drought, food sources, water Clean Water & Sanitation • Morbidity versus mortality, food sources, health, wealth, gender Global Population Growth • Scarcity and depletion of resources, crowding, environmental impact, conflict Migration and Immigration • Conflict, poverty, workforce impact, safety Poverty • Homelessness, gender impact, safety, healthcare access Unemployment • Financial insecurity, unstable economy, mental health, violence, unrest Universal Healthcare Coverage • Morbidity versus mortality, financial security, access, quality Wealth Disparity • Inequality, gender, poverty, political inequality, education

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health that are transnational in nature. Examples of GHI include urbanization, ­climate change, gender equality, tobacco control, injury prevention, violence, human t­ rafficking, migrant workers, obesity, infectious disease, chronic disease, malnutrition, poverty, mental health, and motor vehicle accidents, to name a few. GHIs are all encompassing concerns that affect the healthcare of a population. This means that GHIs are also concerned with the infrastructure of healthcare systems and the global healthcare workforce. The maldistribution of healthcare workers worldwide directly affects the ability of a nation to handle the burden of disease. Migration and economics contribute to potential problems with inequality and the distributive justice of scarce workforce resources. Globalization has led to extensive international travel and trade. Historically, epidemics may have taken weeks to months to a year to traverse a continent. However, as seen in the Ebola virus epidemic in 2014, outbreaks progress more rapidly in a globalized society. In January 2013, Uganda reported six cases of Ebola virus. The outbreak quickly escalated to 28,616 Ebola cases in multiple countries (Guinea, Liberia, Sierra Leone, Italy, Mali, Nigeria, Spain, Britain, and the United States) by the end of 2015 (Centers for Disease Control and Prevention [CDC], 2017). Nations no longer exist in complete isolation. Globalization requires rapid identification and control of potential public health threats to prevent international spread of emerging infectious disease. Although globalization has included extensive international travel and trade and an increase in epidemics, global health reaches far beyond communicable diseases such as Ebola or Zika. Selected GHIs briefly described here include poverty, universal health coverage (UHC), and noncommunicable diseases (NCDs) and chronic disease.

Poverty Poverty is an example of a health and socioeconomic problem that all countries face, even those with relatively high GDPs. Beyond lack of income and resources, poverty is manifested in hunger, malnutrition, limited access to education, social discrimination, exclusion, and limited decision making (UN, 2017b). Highly developed countries in the world contain impoverished populations. For example, 13.5% (43.1  million) of the U.S. population lives in poverty (U.S. Census Bureau, 2016). The highest poverty rates in the U.S. population affect women and children younger than the age of 18. Worldwide, the poverty statistic is 10.7%; 1 in 10 people live in poverty, which is defined as less than $1.90 per day per person (World Bank, 2017). The highest global poverty rates are seen in rural areas with poor educational systems and agricultural economies. Extreme examples of poverty can be seen in sub-­Saharan Africa, where half (389 million) of the extreme poor reside (World Bank, 2017). As world and country leaders focus on international issues, they identify universal issues that drive global health, well-being, and equity. It is well established that the poor across the world usually bear the brunt of global crises and stresses. For example, communicable diseases are often most prevalent in areas with high rates of poverty. Some communicable diseases do not have high per-capita costs associated with their eradication, but these measures are not universally available to the most vulnerable. Likewise, there is greater risk that emerging infectious disease threats will take hold in communities with limited resources devoted to health. Climate change, global economic changes, corruption, privatization of public services, and austerity disproportionately impact the poor (UN Human Rights Council, 2017). Very often, children and older people are disproportionately represented among the poor.

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Universal Health Coverage More than 400 million people have no access to healthcare services (WHO, 2017e). Lack of access is usually found among the poorest of the world’s population regardless of the country of residence, even in high-income countries. The WHO constitution of 1948 declared “the highest attainable standard of health as a fundamental right of every human being,” the first international instrument to take this stance (WHO, 2017e). Seventy years later, the world still struggles with this issue. Care coverage is a central component of the global healthcare agenda. The WHO (2017c) defines UHC as “ensuring that all people have access to needed promotive, preventive, curative and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services.” This definition of UHC embodies three related objectives: (a) equity in access to health services, which means that all who need, not just those who can pay for, services should get them; (b) the quality of health services should be good enough to improve the health of those receiving services; and (c) people should be protected against financial risk, ensuring that the cost of using services does not place people at risk of financial harm (WHO, 2017d). At the heart of the issue is access for all people on the planet to basic healthcare without suffering financial burden. The World Bank (2017) views UHC as “the foundation for individuals to lead productive and fulfilling lives and for countries to have strong economies.” UHC has significant potential to impact multiple Sustainable Development Goals (SDGs) as noted in the next section. Specifically, the target is getting UN member states to commit to trying to achieve the provision of UHC by 2030.

NCD and Chronic Disease NCD is an important global agenda item to recognize in the context of world health. NCDs are also known as chronic illnesses, and they have taken a more prominent role in the global health agenda as a result of the interaction of the many of the stressors found in Figure 14.1. NCDs are not caused by infectious agents but are chronic disease states that progress slowly over time. Although the problem of NCDs in highly industrialized countries is well recognized, nurses need to also be aware of the impact of NCDs as a leading cause of premature death globally. In 2015, 70% (39.5 million) of global deaths were due to an NCD (WHO, 2017c). Cardiovascular disease (17.7 million deaths), cancer (8.8 million), chronic lung disease (3.9 million), and diabetes (1.6 million) constitute the four primary categories of NCDs (WHO, 2017c). The NCD Alliance is an example of a mega-association of over 2,000 nongovernmental organizations (NGOs) brought together as a civil movement to create solutions for the NCD global agenda (NCD Alliance, 2017). Each of the 2,000 NGOs is an organization that focuses on a specific and/or unique NCD factor. Based on its membership, the NCD Alliance is uniquely structured to leverage their expertise. The strategic pillars of the NCD Alliance include: advocacy, accountability, capacity development, and knowledge exchange (NCD Alliance, 2017). Through strategic partnership with GMOs, this advocacy network has developed policy and practice recommendations specific to the NCD agenda for global health. The UN has endorsed the WHO Global Action Plan for the Prevention and Control of NCDs 2013 to 2020. The Global Action Plan has a goal to reduce preventable and avoidable morbidity, mortality, and disability from NCDs by 25% by 2025 (WHO, 2013). The action plan depends on the following primary philosophies: human rights, equity, and national action with international ­cooperation, m ­ ulti­sectoral action, life-course approach, empowerment of people and communities, evidence-based strategies, UHC, and management

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of conflicts of interest. It is recognized that meeting the NCD targets will be challenging. The UN’s commitment to reduction of NCDs is reflected in the establishment of a new high-level global Commission on NCDs in 2017 and plans for the General Assembly to undertake comprehensive review in 2018 of global and national progress regarding early mortality from heart and lung diseases, cancer, and diabetes (WHO, 2017f).

UN DEVELOPMENT GOALS The Millennium Development Goals (MDGs) 2020 (UN, 2017a) and newer SDGs 2030 (UN, 2017b) recognize the responsibilities of each country for the eradication of health inequality. The MDGs are eight goals related to global health supported by the UN. The original target date for the MDGs was 2015. Major declines were achieved in child and maternal mortality rates (WHO, 2017c). Progress was also seen in the prevention and treatment of HIV, tuberculosis (TB), and malaria (WHO, 2017c). The WHO credits success to increases in global funding for health, new partnerships, and civil society (WHO, 2017c). However, the number of global targets for the MDGs were not achieved. To build on the momentum, collaboration, and progress of the MDGs, the UN expanded their work with a new set of goals and targets for the next 15 years. The UN nation states now have 17 SDGs to be achieved by 2030. These SDGs and targets aim for a much stronger synergistic integration among the goals. They focus on ending poverty, fighting inequality, and tackling climate change (UN, 2017b). The SDGs address the delicate balance between human prosperity and environmental protection in a sustainable plan of action. Notable is that the goals recognize the interrelated nature of factors that contribute to global poverty and the need for all countries at all levels of economic development to address poverty within an integrated agenda (Osborn, Cutter, & Ullah, 2015). The goals are 17 steps to a better world and are illustrated in Figure 14.2.

FIGURE 14.2   The UN sustainable development goals. UN, United Nations. Source: From United Nations. (2017b). Sustainable development goals: 17 goals to transform our world. Retrieved from http://www.un.org/sustainabledevelopment

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In 2017, the WHO Department of Health Systems Governance and Financing ­ rojected outcomes based on the resource needs for 67 low- and middle-income p countries representing 95% of total population of interest (Stenberg et al., 2017). Based on the model, approximately $371 billion per year every year through 2030 must be spent on healthcare to reach SDG targets. Model projections also show that 75% of the costs are related to healthcare workforce and infrastructure, 97 million potential lives could be saved, and life expectancy to increase 3 to 8 years based on country (Stenberg et al., 2017). Achieving the SDGs will lead to healthier and more productive population with longer life expectancy and an ability to be a productive member of society.

GLOBAL HEALTH STAKEHOLDERS GHIs require an interdisciplinary and interagency approach with collaboration from many organization. Global health stakeholders may include governments, not-forprofit agencies, community groups, businesses, political parties, health insurance funders, donors, UN agencies, health workers, patients, and health service end-users. Global health is a term that denotes an enhanced awareness and shared responsibility for healthcare inequality in the world (What is global health?, 2011). Global health stakeholders can be defined as individuals or organizations that have a vested interest in programs and plans that affect healthcare inequality and GHI. Global health stakeholders are organized into three categories: international NGOs, intergovernmental organizations (IGOs), and international professional organizations/associations. All organizations in these categories maintain a global presence and agenda specific to their mission, vision, and organizational values. See Exhibit 14.1 for examples of IGOs and NGOs. Some of these are readily recognized, and others reflect diversity of stakeholders across the world. GHI require an interdisciplinary and interagency approach with collaboration from NGOs and IGOs for solutions to emerging health problems. International NGOs often exist by private philanthropy or as a support to an international organization’s agenda. NGOs can be categorized by their primary function: advocacy, policy making, community activism, issue awareness, or program delivery organization. They are often task oriented by common interest groups to provide a range of services specific to their mission platform. Examples of NGOs include international nonprofit organizations and worldwide companies such as the International Committee of the Red Cross (ICRC), Médecins Sans Frontières, the International Rescue Committee (IRC), and Clinton Health Access Initiative (CHAI). IGOs are often termed international organizations. These organizations are composed of sovereign states (member states) representing a specific geographical area with a centralized government. Sovereign states simply stated are a country, nation, or nation-state. IGOs are established most often by treaty or an agreement defining the role and function of the group (Union of International Associations, 2017). Notable examples of IGOs include the UN, the World Bank, International Labour Organization, the European Union (EU), and WHO. International professional associations are organizations with an international membership, scope, or presence. Normally nonprofit, these groups represent a specific profession and their respective interests. For example, the International Council of Nurses (ICN) is a partnership of NNAs representing the interests and speaking on behalf of more than 20 million nurses in the global health arena (ICN, 2017c). International professional nurses associations are united by common goals of select

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EXHIBIT 14.1  SELECTED GLOBAL STAKEHOLDER ORGANIZATIONS

IN HEALTHCARE

ORGANIZATION AND WEBSITE

MISSION

Intergovernmental Organizations International Labor Organization: www.ilo.org

Promotes social justice and internationally recognized in human and labor rights. Enhances social protection and strengthens dialogue on work-related issues.

United Nations: www.un.org

Takes actions on issues confronting humanity such as peace, security, climate change, sustainable development, human rights, terrorism, emergencies, gender equality, and food production.

World Bank: www.worldbank.org

Works to end extreme poverty by reducing the share of the global population that lives in extreme poverty. Promotes shared prosperity by increasing the incomes of the poorest 40% of people in every country.

World Health Organization: www.who.int

Works to build better health for people worldwide. Works to combat diseases and ensure safety of food, air, and water. Nongovernmental Organizations

Bill & Melinda Gates Foundation: www .gatesfoundation.org

Works to help all people lead healthy, productive lives. Improves health, hunger, and extreme poverty in developing countries. Provides access to opportunities to enhance education and improve life in the United States.

Clinton Foundation: www .clintonfoundation.org

Works to improve global health, women’s equality, preventable diseases, economic opportunity, and climate change through philanthropic intitatives.

Florence Nightingale International Foundation: www .icn.ch/who-we-are/ florence-nightingale -international -foundation-fnif

Supports ICN’s work and objectives to advance nursing education, research, and services for the public good. Its GCEF focuses on primary and secondary education for girls in developing countries whose parent or parents have died.

Gretta Foundation: www .grettafoundation.org

Supports nursing education for impoverished persons living in countries with a heavy disease burden to improve the healthcare workforce and improve patient care and outcomes.

International Committee of the Red Cross (ICRC): www.icrc.org

Provides humanitarian protection and assistance for victims of armed conflict and violence. Responds to emergencies and promotes respect for international humanitarian law. (continued )

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EXHIBIT 14.1   SELECTED GLOBAL STAKEHOLDER ORGANIZATIONS IN HEALTHCARE (continued ) ORGANIZATION AND WEBSITE

MISSION

Tkiyet Um Ali: www.tua.jo

Combats hunger and malnutrition in poor citizens through sustainable, healthy food programs, the first such initiative in the Arab world.

Tzu Chi Foundation: tw.tzuchi.org/en

Provides funding to better social and community services, medical care, education, and humanism in Taiwan and globally.

GCEF, Girl Child Education Fund.

specialty nurse groups. Examples include Sigma Theta Tau International (STTI) Honor Society of Nursing, the International Federation of Nurse Anesthetists (IFNA), the International Nurses Society on Addictions (IntNSA), and International Academy of Nursing Editors (INANE). Similarly, the World Medical Association is an international group that represents the interests of physicians. The common thread of international professional associations is the shared professional membership of the group. Some such as ICN have special standing with IGOs and can make statements during IGO’s formal meetings. A basic understanding of the interconnectedness and relationships between NGOs, IGOs, and international professional associations is required in order to understand how the nursing profession may contribute to the 2030 SDGs, UHC, and the global health-related agendas. Often, agendas of these groups overlap and provide an opportunity for collaboration across networks and systems. Pooled resources through supportive partnerships create and synergize momentum toward shared goal attainment. An example of beneficial relations through organizational collaboration around a healthcare issue can be seen with the Global Advisory Panel on the Future of Nursing & Midwifery (GAPFON) Global Advisory Panel. GAPFON was organized by nursing’s international honor society, STTI, to address the vision and future of nursing as one articulated voice in global health (GAPFON, 2017). GAPFON convened key stakeholders to create a unified platform for nursing and midwives to collaborate, to influence policy, and to improve global health outcomes. The top five GHI identified by GAPFON for strategy development are (a) NCDs (chronic diseases), (b) mental health (including substance abuse and violence), (c) communicable diseases, (d) disaster preparedness and response, and (e) maternal–child health (GAPFON, 2017). Sponsorship for the GAPFON report included both global and regional funding from nongovernmental agencies, nursing organizations and associations, and private sector entities. See the Policy on Scene 14.1 illustrating the midwifery and nursing collaboration. Although global decisions are made after complex multilevel and often years-long negotiation, they can directly affect daily lives. The trickle-down effect from global decisions regarding healthcare issues are usually the result of situations and problems identified in many countries. These situations become a global concern, leading to creation of global policies and recommendations. As the trickle-down effect continues, these global policies eventually end up affecting countries, communities and finally, the individual patient. Understanding the connections and systems at play is part of

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POLICY ON THE SCENE 14.1: The GAPFON Model Global Advisory Panel on the Future of Nursing and Midwifery Executive Committee, Sigma Theta Tau International, Indianapolis, Indiana The changing healthcare climate has created an urgent need for nurses and midwives to have impact in deciding and implementing healthcare transformation based on their unique professional perspective. As reflected in The Global Advisory Panel on the Future of Nursing & Midwifery (GAPFON) Model, leadership is fundamental and links other five priorities—“policy/regulation, workforce, practice, education, and research” (GAPFON, 2017). Inherent within the core priorities is the idea of replication and integration across countries and regions. The following analysis shows coalition-building, collaboration, and policy’s interconnectedness with all areas of healthcare advancement within and across regions. Increasing the number of nurses and midwives in elected and appointed government positions is a strategy under the leadership core priority. An education strategy that will be key in promoting “nursing without borders,” and aligning policy voice across countries, is ensuring the accreditation of nursing and midwifery education programs. Teaching nurses and midwives about policy formation in various levels of education will help meet the leadership strategies that promote the placement of nurses and midwives in positions of policy-making leadership. Strong policy formation and implementation will support the workforce strategies, including, but not limited to, retention strategies to meet appropriate skill mix and diversity and meet needs; advanced practiced roles and competencies; and advocating for positive, safe, and healthy work environments for all healthcare workers around the globe. Likewise, within the practice core priority are strategies that will result directly from policy creation. Of significance is one that suggests the creation of a regional plan and system at all levels to address key health issues that can be integrated at healthcare institutions and within communities. Similarly, ensuring a collective voice to expand nursing and midwifery’s practice is encouraged as a strategy toward regional cooperation. The policy/regulation core priority is broadly focused on nurses and midwives having important positions at healthcare policy tables, thus advancing their roles. It also includes establishing global standards for nursing and midwifery practice, including licensure, within and across regions. Research, as a core priority, stems directly from evidence-based policy formation and will impact patient care all over the world. GAPFON strategies in support of this include advocating for policies that optimize research and scope of evidence-based practice, replicating and disseminating studies to increase knowledge, advocating for increased research funding, and using data to develop integrated regional plans that will improve health at all levels. GAPFON Executive Committee Sigma Theta Tau International Cathy Catrambone, PhD, RN, FAAN Tina Darling, MPA Martha Hill, PhD, RN, FAAN (continued )

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Hester Klopper, PhD, MBA, RN, RM, FANSA, FAAN, ASSAF Elizabeth Madigan, PhD, RN, FAAN Beth Tigges, PhD, RN, PNP-BC Richard Ricciardi, PhD, NP, FAANP, FAAN Cynthia Vlasich, MBA, BSN, RN

determining where best the voice of nurses is to be heard to impact the issues at hand. Decide which issues you are passionate about. Focus on a specific issue (e.g., poverty, nutrition, cancer, violence, HIV/AIDS). Collaborate, volunteer, and give voice to nursing’s response to the issue. Recognizing key players in global health and their agendas provides an opportunity for nurses to identify pathways for collaborating around national health issues, local community programs, and direct patient care environments.

GLOBAL NURSING LEADERSHIP Globalization involves the interaction and integration of persons or organizations from different nation-states pushed by international trade and investment largely driven by information technology and economic policy (Levin Institute, 2017). Globalization directly affects culture, environments, economic systems, healthcare, and society. One could argue the effects of globalization may have a negative or positive impact on the community, based on the transformation of local cultures from the global marketplace. Effective global nursing leadership requires an understanding of this globalization and its impact on healthcare systems, communities, and people. Global nurse leaders share the following qualities: system thinker, critical thinker, problem solver, integrity, active listener, skillful communicator, courage, initiative, energy, optimism, perseverance, coping skills, and self-knowledge (Catalano, 2015; Oulton, 2014). These leadership qualities enhance the global nurse leader’s ability to influence and change the cultural and political landscape. Global issues discussed by IGOs such as the UN or the WHO and by international professional association groups such as the ICN are many of the same issues discussed by nurses providing direct patient care to affected populations. These global communities are linked directly to the nursing community, with each benefiting from the other’s knowledge and experience. In spite of the obvious benefits of joint efforts, these groups work in parallel, with the nursing community on one side and the global community on the other, never crossing paths. Everyone loses when no one collaborates. Most of all, the world population does not benefit from the collective experience, knowledge, and wisdom that nursing can provide to the conversation. This presents a challenge for the nursing community. Global nurse leaders, whether individually or at the organizational level need to comprehend the larger systems at play and have a worldview philosophy that engages a broader constituency and partners with major stakeholders in shaping the global health agenda.

Nursing Exemplars At the organization and/or association level, nursing has taken the lead in partnering with global stakeholders to advance a broader agenda, as well as specific goals. Notable examples include the ICN, STTI, the Commission on Graduates of Foreign Nursing Schools, and international nurses’ specialty associations.

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International Council of Nurses The ICN is a federation of more than 130 NNAs, the voice of the more than 20 million nurses worldwide (ICN, 2017c). The ICN is an international organization operated by nurses to represent the nursing profession and influence health policy. The ICN is committed to visionary leadership, innovativeness, solidarity, accountability, and social justice as core organizational values. The ICN has three core areas of active engagement: professional nursing practice, nursing regulation, and s­ ocioeconomic welfare for nurses. The vision of the ICN is to be the voice of ­international ­nursing  by  influencing health, social, and economic policy at all levels (global, regional, country) by communicating evidence and best practice (ICN, 2017b). The ICN is active in social projects that address the MDGs. The ICN TB Project is a partnership with Eli Lilly funded by the United Way. The TB Project has a specific goal of increasing nursing capacity in the prevention, care, and treatment of TB (ICN, 2017b). Social engagement from professional nurses associations can be seen with the ICN’s Girl Child Education Fund (GCEF). The GCEF provides education to orphaned girls in developing countries (ICN, 2016). GCEF works in partnership with a country’s NNA to manage allocation of funds. The ICN also addresses healthcare workforce issues. The ICN Wellness Centre for Health Care Workers program is designed to strengthen healthcare systems by providing complete health services to workers and their families (ICN, 2011). Multiple organizations participate in the wellness ­program, including governments, NGOs, and a corporation. In 2017, ICN launched its Leadership for Change program in China, with funding from Johnson & Johnson that builds on their Campaign for Nursing. This ICN program, already established in 40 countries, is designed to prepare nurses in the world’s most populous country in management, policy, and leadership (ICN, 2017a). These are examples of how partnering can make a difference on the world stage. National Nurses Associations NNAs form the base membership of the ICN. An NNA is an association representing nursing in a specific country, state, or republic. NNAs are formal, nurse-led entities representing the interests of their constituents. The importance of NNAs is immeasurable to nursing practice worldwide because there is no individual membership in the ICN. Nurses with membership within an NNA that is a member ICN NNA are automatically part of the ICN. The core business of the ICN is to strengthen and support NNAs in professional nursing practice, nursing regulation, and the socioeconomic welfare of nurses. NNAs work through the ICN to collaborate for strategic alliances with governmental and nongovernmental agencies, foundations, regional groups, and other NNAs to advocate for nursing globally. The following list is an example of some current member NNAs: American Nurses Association (ANA), Canadian Nurses Association (CNA), Ethiopian Nurses Association (ENA), the Finnish Federation of Nurses, Australian College of Nursing, and the Singapore Nurses Association. Sigma Theta Tau International Sigma Theta Tau International (STTI) Honor Society of Nursing is a leader in global health for nursing through scholarship, leadership, and service to society (STTI, 2017). STTI has more than 135,000 members in over 90 countries, with 520 chapters

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in 700 institutions of higher education. Membership in STTI is by invitation to ­community leaders, and students in baccalaureate and graduate programs who have demonstrated scholarship excellence and high levels of achievement. STTI offers nursing research grants with partner organizations, supports education and research conferences, provides online nursing continuing education, houses the Virginia Henderson Global Nursing e-Repository, mentors with leadership programs, and provides resources for career development. STTI disseminates best-practice, evidence, and nursing research through multiple media modalities. One example is the Journal of Nursing Scholarship which is a peer reviewed nursing journal available online or via mobile apps. STTI influences the global agenda in healthcare through partnerships with IGOs (e.g., UN Economic and Social Council, WHO), NGOs (e.g., Joanna Briggs Institute, American International Health Alliance, Plexus Institute), and international professional organizations (e.g., GAPFON, CNA, ICN). STTI also functions as a connection hub for nurses so that they can network globally in multiple areas of nursing practice and global healthcare.

Commission on Graduates of Foreign Nursing Schools Commission on Graduates of Foreign Nursing Schools (CGFNS) is an NGO that provides verification and knowledge-based practice competency assessment of the healthcare workforce. In the late 1960s, the United States experienced an influx of nurses migrating from other countries. To address the competency assessment of foreigneducated nurses, the W.K. Kellogg Foundation provided funding to the ANA and the National League for Nursing to create the CGFNS in 1977. The main objectives of CGFNS include (a) predictive testing and evaluation for foreign educated nurses (outside the United States), (b) credential evaluation for foreign healthcare workers, (c) data collection and distribution service for international nursing education and licensure, and (d) research studies pertinent to internationally educated nurses (CGFNS, 2018).

Overview of International Nursing Collaborations International organizations are often formed to fill the gaps when healthcare systems reach their stretching points and can no longer meet demands for services. Whether governmental or nongovernmental, international organizations often lack the knowledge and professional expertise of nursing. Collaborative working groups provide opportunities to share resources such as access, knowledge, expertise, and funding. To address this issue, nursing collaborations have been formed with key worldwide networks and programs. These mutually beneficial partnerships operate to complement the strategic plans and actions of the other. Examples include WHO Collaborating Centres, the nursing specialty networks within ICN, and International Specialty Nurses Associations.

WHO Collaborating Centres The WHO Collaborating Centres are institutions within an international collaborative network established to support the WHO’s programs within countries, between countries, and at a global level. Each institution is designated by the WHO DirectorGeneral with the agreement of the director of the independent institutions and after consultation with the national government (WHO, 2017a). Designation as a WHO Collaborating Centre initially lasts 4 years, with possible redesignation for the same

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or a shorter period. Each WHO Collaborating Centre strives to strengthen ­countries’ resources and provide strategic support to the WHO’s programming and ongoing work (2017a). Designated centers may apply for grants for specific programs linked to WHO objectives. WHO Collaborating Centres ­provide two primary functions: (a) implementation of WHO’s mandated program objectives and (b) development of institutional capacity in countries/regions (2017a). Networks of WHO Collaborating Centres have also been created around specific professional fields, with over 700 in 80 countries. Examples of these networks include food safety, nursing and midwifery, traditional medicine, ­international classification, radiation, occupational health, and communicable ­diseases (2017a). The Collaborating Centres have expanded their work from bilateral relations to encompass a broader interrelated focus with multilateral networks.

Specialty Nurses Networks Within ICN ICN has several networks that address the needs of specialized groups within nursing. The ICN Nurse Practitioner/Advanced Practice Nursing Network (NP/APNN) is a specialty nurses association focused on providing international resources for nurse practitioners. The key goal of this network is to advocate for advance practice nursing in both academia and practice. The INP/APNN provides a forum for knowledge, experience, and expertise in advanced practice nursing to be shared with other practitioners, educators, policy makers, regulators, and health planners. The ICN Rural and Remote Nursing Network (RRNN) is a specialty nursing organization focused on collaboration and education for nurses practicing in remote and rural areas globally. The RRNN has a central aim to network and link global nurse care delivery systems for rural populations. This network promotes global awareness of the unique challenges faced in healthcare in rural and remote populations. The specialized skills and competencies of rural nursing practice are disseminated through research and education forums, knowledge sharing, and guideline development. The ICN Telenursing Network promotes the development and implementation of best practices in telehealth nursing technologies. Telehealth is a dynamic, evolving field of practice. The telenursing network provides a forum for addressing issues in telehealth, best practices, expertise, and knowledge development through research. As a newer field of practice, telenursing network aims to be a global resource in telenursing practice, policy, standards, education, and research. Other networks are focused on disaster, HIV-AIDS, education, regulation, research, and students. International Specialty Nurses Associations Intentionally, some organizations are established as international organizations to represent nurses globally (e.g., Wound, Ostomy, and Continence Nurses Society ­ [WOCN], IFNA). The mission of these organization recognizes the responsibilities and commitment to the advancement of educational standards and practices to the nurses and public they serve. Several of the U.S.-based national specialty nurses associations such as the Oncology Nursing Society and Association of periOperative Registered Nurses (AORN) recognize the global nature and impact of their associations’ work. Their programs extend beyond the U.S. boundaries to support nurses globally with evidence-based knowledge and standards of care. See the example of International Federation of Nurse Anesthetists (IFNA) in Policy on Scene 14.2.

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POLICY ON SCENE: International Federation of Nurse Anesthetists Jackie Rowles, DNP, MBA, MA, CRNA, DPNAP, DAAPM, FAAN President, International Federation of Nurse Anesthestists, Bern, Switzerland Nurse anesthetists have been providing safe and high-quality anesthesia care for over 150 years. Studies confirm that nurse anesthetists provide anesthesia services in 107 countries. The International Federation of Nurse Anesthetists (IFNA) was founded by 11 countries in 1989 and is the global organization representing nurse anesthetists. Today, IFNA membership has grown to 45 countries and is dedicated to advancing its global educational curriculum models, education and practice standards, continuous professional development, accreditation, and legislation to progress the art, science, and safety of anesthesia care. These are important aspects in further growth and development of the profession because they play a pivotal role in many countries’ governmental establishment of nurse anesthesia education, recognition, and scope of practice. IFNA country members have formally adopted the established standards that have proved essential to the globalization of the profession. Although nurse anesthetists’ services are used worldwide, practices may vary widely from one country or region to another based on regulatory, legislative, or institutional policy or law. The first set of IFNA standards, including education, practice, and monitoring standards, were developed in 1991 and endorsed by the International Council of Nurses in 2002. The IFNA Code of Ethics was first drafted in 1992. Standards offer a way to evaluate practice and provide the practitioner a framework within which to function and achieve success. Furthermore, these standards are used for evaluating the quality of care provided and helping employers understand how to better use the knowledge, skill, and competencies of the nurse anesthetist. IFNA has operated a voluntary Anesthesia Program Approval Process (APAP) for schools and programs since 2010. IFNA’s approval process is the first of its kind for anesthesia education. The goal of APAP is to encourage programs to comply with IFNA’s Educational Standards for Preparing Nurse Anesthetists via participation in an approval process that allows for cultural, national, or regional variations. The three levels of approval offered are registration, recognition, and accreditation. Different levels of approval take into consideration the diversity of global nurse anesthesia programs, the program’s ability given its national or regional setting, resources that are available to each program, and the commitment of diverse programs to meeting IFNA’s educational quality standards. Twenty-four anesthesia programs located in Asia, Africa, the Caribbean, Europe, and North America were awarded APAP certificates of completion by the end of 2017. The IFNA believes high-quality education and practice standards improve the health and welfare of the global community by promoting development of ­knowledgeable, skilled, and competent anesthesia practitioners. In less than 30 years, the IFNA has achieved remarkable success through the development and adoption of model curricula, education, and practice standards, as well as an education accreditation program. These initiatives have positively impacted education, practice, legislation, and recognition of nurse anesthesia in many countries. More important, these efforts are increasing availability of surgical access and anesthesia care around the world.

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NURSING WORKFORCE The common denominator that ties all the previous GHIs together is the healthcare workforce. To address the SDGs, 40 million new healthcare workers (in addition to replacements) will be needed. Significant differences in the availability of healthcare workers and resources are seen globally. Human resources for health (HRH) is a concept that is concerned with having the right number of healthcare workers to give the right care to the right people at the right time. Heads of state and global organizations recognize the enormous urgency for focusing on the HRH as a cross-cutting solution to all other global agendas. The issue of HRH is multifaceted because the global healthcare workforce is a complex system. This means that components of the healthcare system may or may not interact because the system’s supply and demand change over time based on factors such as relationships, pressures, adaptation, and feedback loops. The problem with this complexity is that the outcomes and behavior of that system are highly unpredictable because the workforce components of the system are interdependent and the components often self-organize and change based on the environment. Factors that directly affect the healthcare workforce in the global healthcare system will push the system to behave in a particular way, resulting in negative or positive outcomes. One component of the HRH concept is workforce migration. A maldistribution of qualified healthcare workers results from nurse migration internationally and abroad. Multiple factors influence the decision to practice out of country. Organizational infrastructures, job security, manageable workloads, workplace safety, compensation, gender inequality, harassment, violence, and discrimination have all contributed to migration of the workforce for better working conditions and a better way of life. In addition, high-income countries faced with nursing shortage concerns have aggressively recruited foreign nurses, often from low- to middle-income countries (Brush & Sochalski, 2007). The Philippines has led the nurse export globally since the 1950s. The preparation and export of Filipino nurses has been driven by market demand. Between 1992 and 2003, close to 88,000 Filipino nurses went overseas to work in 31 different countries (2007). For vulnerable countries, migration of the nurse workforce has a detrimental effect on the community. Countries in sub-Saharan Africa have experienced the void created by migration to the point where urban hospital units are understaffed and unable to meet the current health demands of already impoverished communities. The end result of nurse migration is inequitable access to care and maldistribution of resources. To address issues surrounding nurse migration, the WHO Global Code of Practice on the International Recruitment of Health Personnel enacted in May 2010 promotes ethical practices in international recruitment based on social justice and equitable distribution of health workers (WHO, 2014). The WHO (2016) developed a global strategy for guiding policy makers in meeting the healthcare workforce needs for 2030. Challenges identified include (a) equitable distribution of healthcare workers, including numbers and skill mix; (b) competency in practice, including training issues; (c) quality of care; and (d) healthcare system support in the work environments, including socioeconomics and demographics (Kabene, Orchard, Howard, Soriano, & Leduc, 2006; WHO, 2016).

Equitable Distribution Distribution of the nursing workforce presents its own challenges. First and foremost is the shortage of nursing professionals worldwide when the demographics of

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the population are drastically changing. The aging workforce, especially of nurses, is a ­mismatch to the booming population of elderly. Socioeconomic barriers also exist where the workforce is unequally distributed, leaving some of the most impoverished and highly populated areas without adequate care (WHO, 2016). This problem is further compounded by the migration of healthcare workers to countries with better working conditions. There is an ever-increasing gap between the supply and demand of healthcare workers. This problem is not solved by just increasing the number of workers (Edmonson, McCarthy, Trent-Adams, McCain, & Marshall, 2017). As referenced in the Policy Challenge, the workforce issue demands an innovative approach.

Competency and Quality of Care The quality of the healthcare services provided is directly related to the competence of a nursing professional and the healthcare workforce. The problem with nurse competency indicators is multidimensional. Worldwide, nursing education is not standardized. Licensure is not consistent across nations, leading to a variety of skill levels, clinical experiences, and scope of practice expectations. Consider this, you are a nurse in a Western European country working in a primary care clinic with elderly congestive heart failure patients. Armed conflict and war in Asia leads to a mass exodus of refugees to relocate in town. Would you, as the nurse, necessarily have the skillset to care for the needs of disaster victims and children refugees? Would you be familiar with the culture-specific care required by the refugee population? Could you provide age-appropriate care? Are you trained to handle mental health issues resulting from violence and trauma? Would your town have the resources to provide education and emergent training? Difference in socioeconomic environments and educational backgrounds create inconsistency and potential gaps in quality healthcare. Socioeconomics have a profound effect on the education of a healthcare workforce. Nations lacking the necessary infrastructures for training and development risk having a workforce not providing evidence-based, best practices in the care delivered. Quality care mandates workforce infrastructures that include the creation of healthy safe work environments such as safe staffing and adequate resources. Healthy work environments incorporate occupational health and physical safety with discrimination-free, culturally integrated practices. Nurses should be provided opportunity to collaborate interprofessionally without fear of retaliation or violence. Each country must examine and address this global issue.

Healthy Work Environments The structures in place to support a healthy workforce within healthcare systems are crucial for recruitment and retention. Healthy work environments s­upport ­optimal health and safety in both the patient and healthcare worker through respect, empowerment, and a safe environment (ANA, 2017). Workplace policies in a safe ­environment are designed to protect the healthcare worker. Examples of policy t­opics for creating a healthy environment include staffing plans, workload, caregiver skill mix, nurse fatigue, worker safety, diversity, bullying, harassment, and ­workplace violence. Globally, healthcare systems have not invested in the workforce, leading to a reduction in sustainability (WHO, 2016). This chronic lack of training and education in some countries contributes to the continuous shortage of workers. Undeveloped or inadequate protocols for rural and remote care add to the imbalance of resources

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available and population needs. In some countries, nurses are not paid for months, and violence is a daily reality. Economic hardship, policy change, political systems, and civil unrest often contribute to instability of the workforce in low- and middle-income countries. Given these impacts, it is perhaps not surprising that leading organizations that cut across healthcare are promoting healthy work environments. The WHO, for example, clearly articulates that a healthy workplace framework “…is the right … smart … and … legal thing to do” (Burton, 2010) and that practice guidelines need to be developed. The Institute for Healthcare Improvement has a white paper discussing the importance of a healthy work environment and looking for “joy” in our work, not merely working to eliminate problems such as burnout (Perlo et al., 2017). Nurses must advocate for healthy work environment in their settings and across the world.

ADVOCATING AS A GLOBAL CITIZEN Global citizenship requires an awareness of the world, a respect for diversity, and a desire for social justice from the local level to the worldwide stage (Oulton, 2014). Global health goes beyond geographic boundaries and is concerned with the health of populations. The nursing profession has a social responsibility and commitment to care for society. This social responsibility extends to GHIs and the social determinants of health for the world population. Collaboration, cooperation, negotiation, and leadership are necessary skills for global nurse advocates. Tact and diplomacy, along with the ability to articulate ideas, meaning, and intention, are required for enhancing productive communication to influence a global agenda. The most important attributes for a global leader to cultivate are vision, passion, and emotional intelligence. Vision provides clarity about where you are going. People invest in the process when confident about the direction and path to successful conclusion. Passion inspires a person to commit to the journey. Your passion around a vision engages others to the cause. Emotional intelligence gives a leader the ability to leverage their strengths while investing wisely in relationships. An interprofessional approach to a global health issue increases the chance of success. Interprofessional teams provide an opportunity to view the same issue from multiple perspectives to create a “whole” picture. They provide a means of engaging multiple system stakeholders in the process for maximum impact and help communicate the vision so that the team can act on it. Plan for the team or teams to grow as people unite to the cause. Often, coalitions can help grow and sustain momentum and add manpower to achieve your goal. Every person is a global citizen, and as such, we all have a stake in the outcome. As a starting point, decide which global issue most closely aligns with your personal interests, competencies, and professional goals. Whether it is Ebola, cancer, traffic accidents, or any other topic, you need to ask yourself which global organizations are positioned for engagement with these problems. Initially, consider focusing on organizations within your country or region. Examine what you know about the organizations, reflect on their stakeholders and interactions, determine who influences whom, and analyze their business, public, and professional interests. Then determine your involvement and leverage relationships. You can have a voice and an impact on an issue once you have committed to engagement. See Exhibit 14.2 for action steps to start or increase your global citizenship.

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EXHIBIT 14.2   STRATEGIES FOR INCREASING GLOBAL CITIZENSHIP STRATEGY

ACTION EXEMPLARS

Educate

• Plan a course of action to increase knowledge on global issues. • Invite a global expert to speak at a program or class. • Intentionally review global news, podcasts, and books that highlight other cultures. • Seek out balanced reporting about global healthcare systems.

Support

• Create mentor programs for global visitors/workers. • Participate in a health fair or clinic for migrant workers and immigrants. • Support and volunteer for disaster relief. • Donate resources for global initiative (i.e., book drives for a specific setting).

Travel

• Investigate opportunities to travel abroad with specialty organizations or churches. • Participate in a short-term mission trip. • Escort global visitors to local healthcare and culture sites in community. • Volunteer as a chaperone for a group traveling abroad.

OPTION FOR POLICY CHALLENGE: Investing in the Future Howard Catton In September 2016, the Health Employment and Economic Growth (HEEG) report, which sets a powerful, evidence-based, economic case for investing in the healthcare workforce, including nursing, was introduced to the United Nations (UN) in New York (see www.who.int/hrh/com-heeg/reports/report-expert-group/en). At the launch, the International Council of Nurses (ICN) provided additional rationale and context for the key messages presented to the UN Commission HEEG, reaffirming its commitment to this project. The ICN continues to strategically work with global institutions to develop the 5-year implementation plan for this report because nurses are key to improving access to and maintaining the quality of healthcare. Nurses will be a touchstone for both for the implementation of the Commission’s recommendations and the measurement of their achievement. The ICN has been actively working with its members, the national nursing associations (NNAs), and other policy stakeholders to ensure that governments and other decision makers consider the report and implement its recommendations. It is also advocating for the World Health Organization, the UN, and global agencies to make resolutions calling for implementation and action based on the report’s recommendations. (continued )

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The paramount challenge is shifting and mobilizing political mindsets toward positive decisions and supportive actions for healthcare workforce investment. The presentation of evidence for investment in the healthcare workforce in the HEEG report was a significant achievement. Health investment is a driver of, not a drain on, economic growth, and the report presented powerful evidence to make the economic case for investment in health. The recommendations focus on transforming the healthcare workforce with (a) health sector jobs, (b)  women’s economic participation, (c) scaling up of education and life-long learning, (d) re-formation service models, (e) use of information and technology, and (f) investment in health workers in humanitarian sectors, as well as on enabling change by (g) raising funds to invest in the healthcare workforce, (h) promoting collaboration to support investment in the healthcare workforce, (i) advancing international recognition of healthcare worker qualifications, and (j) conducting research and analysis of health labor markets. The WHO has a newly elected director general, Dr. Tedros Adhanom, whose vision for the organization could provide the momentum for change. Dr. Tedros’s support for the ICN is demonstrated by his attending the ICN Congress and promoting nurses as the “linchpins” in improving access to care and developing universal healthcare coverage. To demonstrate his support of nurses working in extended roles to full scope, Dr. Tedros re-established the role of senior nursing advisor as part of his WHO cabinet and appointed Elizabeth Iro, the former secretary of Health for the Cook Islands, as the chief nursing officer at WHO. The ICN has committed to working with the new director general on his agenda, which has the potential not just to put nurses back at the heart of global health policy, but also to integrate nurses into the leadership structure in WHO regions. This repositioning sends a loud and clear message to countries regarding support and investment in nursing. Nurses have the responsibility to use this window of opportunity. As a global citizen, it is an opportunity to lead in developing the solutions for healthcare workforce issues and promoting access to quality healthcare.

IMPLICATIONS FOR THE FUTURE The future of nursing in policy and practice extends beyond the domestic agenda and involves full engagement in global health and its implications. The Institute of Medicine Future of Nursing report recommends that nurses lead the change in healthcare reform, engage in lifelong learning, and practice to the full extent of licensure and education. Viewing these recommendations from a national perspective is too narrow a view. As seen with recent world epidemics, the downstream effects of a catalyst are felt by everyone. Based on these assumptions, the nursing profession is at a tipping point. It is more important than ever for nurses to advocate for the profession as a cohesive, global voice. Worldwide, nurses must lead the effort to transform healthcare through UHC. UHC has the potential to achieve multiple SDGs. Multifaceted approaches are needed to meet the world population’s goals for health. Two of nursing’s contributions lie in ensuring the appropriate preparation of the nurse workforce and an adequate of number of nurses. As a profession, we must ensure that the training and competence of every nurse meets current standards of practice. Internationally, nurses must practice to the full extent of their licensure and education. In each country and region, nursing needs to identify the minimum standards for education

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and practice. Too few healthcare workers are available for the world population, especially in rural and remote regions. Nurses have the potential to meet this growing demand for services if the proper policies and legislation are enacted and if the economic impact of nursing to a nation’s health is recognized by policy makers. Therefore, it is incumbent on nurses to ensure that the proper policies are put into place to make these a reality.

KEY CONCEPTS 1. The SDGs 2030 recognize the responsibilities that each country must assume to eradicate health inequality and the unique role that nurses hold in improving health. 2. Nurses are uniquely positioned in roles to assess, advocate, evaluate, and partner with individuals, populations, legislators, and organizations to address GHIs. 3. Nurses have a social responsibility and professional practice obligation to participate in global healthcare. 4. Global health stakeholders are individuals or organizations that have a vested interest in programs and plans that affect healthcare inequality and GHIs. 5. Globalization involves the contact and integration of individuals and organizations from different countries, and it has far reaching impacts on culture, healthcare, environments, economic systems, and society. 6. Global nurse leaders must comprehend the larger systems at play and have a worldview philosophy to engage and partner in shaping the global health agenda. 7. Global health goes beyond geographic boundaries and is concerned with the health of populations and equity in the distribution of health resources. 8. GHIs require an interdisciplinary approach with collaboration from NGOs and IGOs for solutions to emerging health problems. 9. UHC is a central component of the global healthcare agenda. 10. HRH is concerned with having the right number of healthcare workers to give the right care to the right people at the right time. 11. Collaboration, cooperation, negotiation, and leadership are necessary skills for global nurse advocates. 12. Every person is a global citizen and as such has a stake in global health outcomes.

SUMMARY The world is increasingly shrinking. Expansion of borders, globalization, migration, demographic shifts, and technology have impacts on the healthcare environment. GHIs are no longer isolated within single nations or patient populations. The health of low-income nations can directly impact large, economically advantaged countries. Awareness is the first step in addressing a global health agenda. The challenge lies in how best to maximize nursing expertise to impact global health. Nurses are fundamental and recognized as essential in strategies to improve health. Whether acting as an individual or working within an organization, nurses all over the world demonstrate the power of and contribute to the global health policy. Organizations such as the UN and the WHO have publicly highlighted nursing contributions and have invested in the nursing profession to advance global health. Examining the economic value of nurses’ contributions to the well-being of a country’s citizens and investing the nurse workforce are key to improving health and prosperity. Nurses can work to ensure the appropriate investment in the nursing workforce. Likewise, by valuing global realities, you can today join the efforts to advance global health through health policy.

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LEARNING ACTIVITIES 1. Review the WHO website for Global Health Observatory (GHO) data. Select a global health priority and review the global trends associated with it. 2. Research the SDGs for 2030. Select one SDG. Create an educational infographic around a specific target or goal for the population directly affected. 3. Review the ICN networks on the ICN website. Find the mission statement and strategic goals for a network related to your area of clinical practice. Is there opportunity to collaborate? How might you participate in the network? 4. The UN is involved in more than 20 campaigns (issues). Visit the UN website and select a campaign of interest to you. Perform a stakeholder analysis. If you were a change agent, what objectives would you need to be aware of for a successful outcome? 5. The World Bank is a global partnership for sustainable solutions to global health concerns. Select a region. What are the priorities the World Bank is focused on in that region? Who has the World Bank partnered with the address these priorities? 6. Consider the multiple issues contributing to the global workforce shortage (e.g., migration, education, economics, working conditions, workplace violence, gender inequality, restrictions in scope of practice). Research one contributing factor. Create an action plan to address the factor identified. How can you create awareness? Is there legislation in already in place to address the issue? If not, what legislation could be enacted?

E-RESOURCES • Centers for Disease Control and Prevention https://www.cdc.gov • Civicus: World Alliance for Civil Participation https://civicus.org • Commission on Graduates of Foreign Nursing Schools http://www.cgfns.org • Forum of University Deans of South Africa (FUNDISA) http://fundisa.ac.za • Global Health Workforce Alliance http://www.who.int/workforcealliance/en • High-Level Commission on Health Employment and Economic Growth (HEEG) http://www.who.int/hrh/com-heeg/en • International Council of Nurses http://www.icn.ch • International Labour Organization http://www.ilo.org • Levin Institute http://www.levininstitute.org • NCD Alliance https://ncdalliance.org • Our World in Data https://ourworldindata.org • Our World in Data: Global Extreme Poverty https://ourworldindata.org/extreme-poverty • Sigma Theta Tau International http://www.sigmanursing.org

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• Sigma Theta Tau International MDG http://www.sigmanursing.org/connect-engage/our-global-impact/stti-and-the -united-nations/the-millennium-development-goals-and-me • Union of International Associations http://www.uia.org • United Nations http://www.un.org • World Health Organization: Stakeholder Analysis http://www.who.int/workforcealliance/knowledge/toolkit/33.pdf

REFERENCES American Nurses Association. (2017). Healthy work environment. Retrieved from https://www .nursingworld.org/practice-policy/work-environment Brush, B., & Sochalski, J. (2007). International nurse migration: Lessons from the Philippines. Policy, Politics, & Nursing Practice, 8(1), 37–46. doi:10.1177/1527154407301393 Burton, J. (2010). WHO healthy workplace framework: Background and supporting literature and practices. Geneva, Switzerland: WHO. Retrieved from http://www.who.int/occupational_health/ healthy_workplace_framework.pdf Catalano, J. (2015). Nursing now! Today’s issues, tomorrow’s trends (7th ed.) Philadelphia, PA: F. A. Davis. Centers for Disease Control and Prevention. (2017). Ebola (Ebola virus disease). Retrieved from https://www.cdc.gov/vhf/ebola/outbreaks/index.html Commission on Graduates of Foreign Nursing Schools. (2018). About us. Who we are. Retrieved from http://www.cgfns.org/about Edmonson, C., McCarthy, C., Trent-Adams, S., McCain, C., & Marshall, J. (2017). Emerging global issues: A nurse’s role. Online Journal of Issues in Nursing, 22(1), 2. doi:10.3912/OJIN .Vol22No01Man02 Global Advisory Panel on the Future of Nursing & Midwifery. (2018). GAPFON: Outcomes report and next steps. Indianapolis, IN: Sigma Theta Tau International. Retrieved from http://www .­nursinglibrary.org/vhl/handle/10755/621599 Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. International Council of Nurses. (2011). Wellness centres for health care workers. Retrieved from http://www.icn.ch/what-we-do/wellness-centres-for-health-care-workers International Council of Nurses. (2016). Girl Child Education Fund. Retrieved from http://www.icn .ch/what-we-do/girl-child-education-fund International Council of Nurses. (2017a). New leadership programme launched in China by International Council of Nurses and Johnson & Johnson. Retrieved from http://www.icn.ch/ images/stories/documents/news/press_releases/PR_28_LFC%20China.pdf International Council of Nurses. (2017b). Welcome to the ICN TB/MDR-TB project. Retrieved from http://www.icn.ch/tb-mdr-tb-project/welcome-to-the-icn-tb-mdr-tb-project.html International Council of Nurses. (2017c). Who we are. Retrieved from http://www.icn.ch/who-we-are/ who-we-are Kabene, S., Orchard, C., Howard, J., Soriano, M., & Leduc, R. (2006). The importance of human resources management in healthcare: A global context. BioMed Central, 4(20). doi:10.1186/1478-4491-4-20 Levin Institute. (2017). Globalization 101. Retrieved from http://www.globalization101.org/ what-is-globalization NCD Alliance. (2017). Making NCD prevention and control a priority everywhere. Retrieved from https://ncdalliance.org

446   UNIT IV  JUDGING WORTH AND ADVANCING THE CAUSE Osborn, D., Cutter, A. & Ullah, F. (2015). Universal sustainable development goals: Report of a study by stakeholder forum. Retrieved from https://sustainabledevelopment.un.org/content/ documents/1684SF_-_SDG_Universality_Report_-_May_2015.pdf Oulton, J. (2014). Leading nursing globally. Health Emergency and Disaster Nursing, 1, 29–33. doi:10.24298/hedn.2014-1.29 Perlo, J., Balik, B., Swensen, S., Kabcenell, A., Landsman, J., & Feeley, D. (2017). IHI framework for improving joy in work. IHI white paper. Cambridge, MA: Institute for Healthcare Improvement. Retrieved from http://www.ihi.org Sigma Theta Tau International. (2017). STTI organizational fact sheet. Retrieved from http://www .sigmanursing.org/why-sigma/about-stti/sigma-theta-tau-international-organizational-fact-sheet Stenberg, K., Hanssen, O., Edejer, T., Bertram, M., Brindley, C., Meshreky, A., … Soucat, A. (2017). Financing transformative health systems towards achievement of the health sustainable development goals: A model for projected resource needs in 67 low-income and middle-income countries. Lancet Global Health, 5, e875–e887. doi:10.1016/s2214-109x(17)30263-2 Tyer-Viola, L., Nicholas, P., Corless, I., Barry, D., Hoyt, P., Fitzpatrick, J., & Davis, S. (2009). Social responsibility in nursing: A global perspective. Policy, Politics, & Nursing Practice, 10(2), 110–119. doi:10.1177/1527154409339528 Union of International Associations. (2017). What is an intergovernmental organization? Retrieved from https://uia.org/faq/yb3 United Nations. (2017a). Millennium development goals and beyond 2015. Retrieved from http:// www.un.org/millenniumgoals United Nations. (2017b). Sustainable development goals: 17 goals to transform our world. Retrieved from http://www.un.org/sustainabledevelopment United Nations Human Rights Council. (2017). Report of the special rapporteur on the right to human development. Retrieved from http://www.ohchr.org/Documents/Issues/Development/SR/ SRRightDevelpment_IntroductiontoMandate.pdf U.S. Census Bureau. (2016). Income and poverty in the United States: 2015. Retrieved from https:// www.census.gov/library/publications/2016/demo/p60-256.html What is global health? (2011). Journal of Global Health. Retrieved from http://www.ghjournal.org/ what-is-global-health World Bank. (2017). Poverty. Retrieved from: http://www.worldbank.org/en/topic/poverty/overview World Health Organization. (2013). Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Geneva, Switzerland: Author. World Health Organization. (2014). Migration of health workers: WHO code of practice and the global economic crisis. Geneva, Switzerland: Author. Retrieved from http://www.who.int/hrh/ migration/14075_MigrationofHealth_Workers.pdf World Health Organization. (2016). Global strategy on human resources for health: Workforce 2030. Geneva, Switzerland: Author. Retrieved from http://who.int/hrh/resources/ pub_globstrathrh-2030/en World Health Organization. (2017a). Collaborating Centres. Retrieved from http://www.who.int/ collaboratingcentres/en World Health Organization. (2017b). Global health observatory data: Health workforce. http://www .who.int/gho/health_workforce/en World Health Organization. (2017c). Global health observatory data: NCD mortality and morbidity. Retrieved from http://www.who.int/gho/ncd/mortality_morbidity/en World Health Organization. (2017d). Health financing for universal coverage: What is universal coverage? Retrieved from http://www.who.int/health_financing/universal_coverage_definition/en World Health Organization. (2017e). Human rights and health. Fact sheet. Retrieved from http:// www.who.int/mediacentre/factsheets/fs323/en World Health Organization. (2017f). WHO to establish high-level commission on noncommunicable diseases. Retrieved from http://www.who.int/mediacentre/news/statements/2017/ncd-commission/en

FIFTEEN

Taking Action, Shaping the Future Rebecca M. Patton Margarete L. Zalon Ruth Ludwick Nurses must see policy as something they can shape rather than something that happens to them.—Institute of Medicine (2011)

OBJECTIVES 1. Identify the critical role and responsibility of all nurses to advance policy for quality, safety, access to healthcare, and the advancement of the profession. 2. Identify leadership strategies that enhance nursing’s policy influence. 3. Compare and contrast the development of nurses’ policy roles in different settings and at different points in their careers in relation to their personal goals. 4. Explore leveraging the role in nursing and healthcare organizations for political activism.

When each nurse takes one step and joins with other nurses, then more than 3.6 ­million nurses will be taking steps together to strengthen nursing, improve health, and fulfill our contract with society to advocate for the “care of individuals, families, groups, communities, and populations” (American Nurses Association [ANA], 2010, p. 5). The involvement of all nurses in policy provides the best strategy for creating the preferred future for nursing practice and the advancement of health for all. Numerous strides have been made in policy when nurses are involved, but the reality is that to keep pace with the numerous changes in healthcare, it is imperative that all nurses across all settings be involved in policy. Nurses in all settings, including those in leadership roles, advanced practice registered nurses (APRNs), nurse managers, administrators, educators, and researchers have tremendous opportunities and responsibilities to influence future generations of nurses. Each nurse must not only be involved individually, but also bear the broader obligation as leaders to help put in place the structural and process components that encourage and support nurses in a variety of direct care roles to become involved in policy making. Thought leaders in nursing in the United States

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and beyond have  called for more active nurses involvement in policy (Benton, 2012; Committee on the Robert Wood Johnson Foundation [RWJF] Initiative on the Future of Nursing, 2011; Kunavikitul, 2014). This is critical not only for policy at the little “p” level, but also for the future strength of nursing influence at the big “P” level. Widespread involvement requires a paradigm shift to nurses’ active widespread involvement in policy. In the new norm, large numbers of nurses are active in policy, tackling the issues and solving problems at work, in the community, nationally, and globally. Becoming a policy advocate, to rephrase the words of Dwight Eisenhower, 34th president of the United States, ought to be the part-time profession of every citizen (or nurse). The purpose of this chapter is to more closely examine the creation of a paradigm shift to nurses’ greater involvement in policy, creating the structures and processes to facilitate such involvement. We hope to engender a commitment from you, our readers, about the active roles that should be taken in policy now and in the future as your careers evolve. The Policy Challenge illustrates how the commitment to policy can unfold and grow. Increasing nurses’ engagement in policy is vital to advancing policy for the profession and the health of the public.

POLICY CHALLENGE: A Journey Toward Activism: A Novice’s Perspective Shelly Malberti, DNP, RN, Assistant Professor, Cuyahoga Community College (Tri-C), Cleveland, Ohio Nursing is my love and my passion. However, over the years, I have grown concerned about the increasing demands and the decreasing number of resources made available to perform my job safely. Change is needed. At the start of my career, I believed that advancing within the organization would allow my voice to be heard. I believed that if I became a manager, presented the research and evidence to support the need for more resources, and wrote a compelling proposal, then healthcare leaders would listen. Despite my efforts and numerous proposals to my bosses, nursing needs remained invisible to the healthcare institution and the community. In September 2008, Ohio passed a safe staffing bill. I was so excited to be part of real change. I was a nurse manager at the time, and when our hospital held its first meeting with the nurses, the room was overflowing with eager voices waiting to be heard. I told my boss how happy I was to see the nurses involved and that the legislation was long overdue. She pulled me aside and told me that I should watch what I say or I “may be considered a union girl, which could be career limiting.” It was at that moment I realized that my advocacy efforts needed to be outside of the healthcare institution. I needed to become involved in policy making. I needed to move from the bedside to the boardroom, but as a novice, I did not know where to begin. I did not even know how a bill became law. And thus, the journey began. See Option for Policy Challenge

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NURSES’ CRITICAL ROLE IN ADVANCING POLICY There are far too many examples at the little “p” and big “P” levels in which nurses have not had the interest, have not had the clout, have been intimidated, or have been held back with the words, “you’re only a nurse” to prevent the implementation of policies with negative or unintended consequences. Some policies have long-standing implications for how nursing is practiced. Nurses have a critical role in advancing policy that directly impacts the profession and addresses for the quadruple aims of quality and safety, improved health, reduced cost, and improved work life of healthcare providers (Bodenheimer & Sinsky, 2014).

Advancing Policy for the Profession To advance nursing, promote health, and protect patients, nurses need not only to be proactive with clinical issues, but also to monitor and address issues related to the state of the profession. Ignoring or not addressing issues can have significant policy implications. Title protection and practice barriers are two areas related to practice that bear active monitoring and ongoing advocacy. Sunset laws are another example (see Chapter 3). Another example is described in the following section is the nurses’ work environment.

Title Protection It is easy to take the title nurse for granted. This title is still not protected in 11 states, meaning that anyone can call oneself a nurse (ANA, 2013; see Figure 15.1). This practice is a common occurrence in healthcare providers’ offices, where medical assistants might be called nurses or refer to themselves as a doctor’s nurse. When people who are not nurses call themselves by this title, it, at minimum, creates confusion in the eyes of the public. It is very often illegal, but clearly unethical, deceitful, and potentially harmful. A number of state nurses associations have marshaled considerable efforts to block legislation that would allow lay persons to use the title Christian Science nurse. Each of us has a duty to not only identify ourselves as an RN or as an APRN in all of our interactions with the public and other healthcare providers, but to also address the improper use of the title nurse in our daily encounters with the healthcare system. Language issues also directly impact APRNs. The term midlevel provider is used quite often when referring to APRNs in discussions regarding their titling and practice. However, using midlevel provider does not reflect the roles and responsibilities of APRNs and perpetuates a focus on hierarchy instead of interprofessional collaboration. Do we call anyone high-level or low-level providers? Using this term, and allowing the continued use of this term, creates confusion for the public, insurers, and other key stakeholders. Practice Barriers Full practice authority for APRNs is not a reality across the United States. As with the practice of nursing, each state or territory has its own laws, rules, and regulations governing advanced practice, in addition to federal laws, rules, and regulations that also impact advanced practice. Careful attention needs to be paid in each jurisdiction so that APRNs can practice in accordance with their education and expertise. The challenge is that each different scenario has a separate set of stakeholders and a different history and perspective that needs to be addressed. Keep in mind the unique circumstances in each jurisdiction; we are reminded of Tip O’Neill Jr.’s quote that

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Enacted legislation/adopted regulations to date: AR, AZ, CA, CO, DE, FL, GA, HI, ID, KS, KY, IL, MD, MN, MO, MS, MT, NC, ND, NE, NH, NM, NV, NY, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY

FIGURE 15.1  States with title “nurse” protection. Source: Reprinted with permission from the American Nurses Association. (2013, December 12). Title “nurse” protection. Retrieved from http://www.nursingworld.org/MainMenuCategories/ Policy-Advocacy/State/Legislative-Agenda-Reports/State-TitleNurse

“All politics is local.” The recent Veterans Health Administration policy granting full practice authority to nurse practitioners (NPs), clinical nurse specialists, and certified nurse-midwives (CNMs) and the enhanced Nurse Licensure Compact illustrates the evolving policy landscape related to the profession (see Chapter 8). Although initiatives like these pave the way for APRNs across the United States, the complexity of how each advanced practice situation plays out at the state level is different. Not all APRNs are solely regulated by the nurse board within each state. Some states have joint regulations, some have joint regulations for prescriptive authority, and, in some instances, one type of APRN is regulated by the board of nursing and another is regulated by the board of medicine. Uniformly changing regulatory oversight of the nurse board is not without its challenges. For example, in Pennsylvania, CNMs are regulated by the medical board and may delegate because delegation regulations are in place under the Medical Practice Act. However, no delegation regulations are in place for nurses in Pennsylvania; thus, moving regulatory authority to the nurse board would restrict the ability of CNMs to delegate (specifically, to lay midwives). Thus, it is important to monitor proposed regulations, and be at the table when initial drafts are requested. Legislative and regulatory changes could, at the same time, enhance one area of practice but inadvertently create a stumbling block that impedes practice or access to care elsewhere.

Work Environment Title recognition and barriers to practice are just two issues facing the nursing profession. Beyond legislative and regulatory details governing these issues, policies are important to nurses working toward achieving the Quadruple Aims of healthcare. Published research has indicated that the work environment of nurses is related to the quality of care (Aiken et al., 2012; Djukic, Kovner, Brewer, Fatehi, & Cline, 2013; Tvedt, Sjetne, Helgeland, Løwer, & Bukholm, 2017). If policies are not in place within organizations to achieve a positive work environment, then remedies to address the work environment issue have been sought through policy implementation in the larger arena at the state or national level. Staffing legislation is where different proposals have been put forth reflecting the beliefs and values of different constituencies within nursing to address the work environment of nurses.

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Although most nurses and APRNs work within larger healthcare systems, many nurses also work in small-scale, and many times under-resourced, settings, and thus establishing structures that foster policy advocacy in these environments is also critical. For example, ambulatory surgery and endoscopy centers typically have less regulatory oversight. Yet each of these settings employs nurses who are witness to the implementation of its policies and procedures. One of the worst infection-control lapses occurred at the Nevada endoscopy clinics owned by a single gastroenterologist. This lapse created a public health crisis of enormous proportions, in which up to 63,000 patients might have been exposed to hepatitis C. Only one nurse, who was employed at the clinic for only 3 days, reported her concerns about improper charting practices to a regulatory body (Leary & Diers, 2013). In this environment, rife with breakdowns in practice standards, nurses were too intimidated regarding their advocacy responsibilities to address these concerns. Lest we think that this was an isolated incident, the Centers for Disease Control and Prevention (CDC) reports that over 150,000 patients have been advised of their potential exposure to bloodborne pathogens since 2001 (CDC, 2017). In response, the CDC leads the Safe Injection Practices Coalition, which created the One & Only Campaign to raise public and professional awareness. Given the sheer number of notifications, it is likely that many nurses were involved with or observed breakdowns in practice. With the expansion of primary care, attention is now being drawn to factors critical to establishing a positive work environment in these settings. Not surprisingly, NP–physician relations, independent practice and autonomy, professional visibility, organizational support, and NP–administrative relationships impact productive practice environments and have the potential to impact primary care work capacity (Poghosyan, Liu, Shang, & D’Aunno, 2017). Similar work is underway to examine the practice environment for certified registered nurse anesthetists (CRNAs) (Boyd & Poghosyan, 2017). Creating a work environment that ensures opportunities for nurses to take an active role in controlling their practice and to positively influence the critical factors in that work environment will entail policy knowledge and work. The challenge as a profession is to help nurses understand the policy implications of day-to-day practice and the way that organizational, legislative, and regulatory initiatives can, in turn, impact policy in everyday practice. The issues need continued activism and monitoring for new developments that are on the horizon as the nature of healthcare and the myriad of providers evolve.

Advancing Policy for Quality, Safety, and Access to Healthcare Improving quality, safety, and access to healthcare requires much more than providing excellent performance in your respective work arena; it requires being a thought leader and driver of change and policy. The link of nurse-sensitive quality indicators to the work of nurses and the importance of economic evaluations are discussed in Chapter 12. These same measures and economic evaluations can help make the case much stronger when nurses seek policy changes and want to enforce policy. Hospital-acquired infections (HAIs) are one nurse-sensitive indicator that can be used to illustrate this interplay between cost, quality, and the need for policy. Another area is the increasing call for nurses to be actively engaged in antibiotic stewardship in both frontline work and patient education (ANA & CDC, 2017). Safety is another area where nurses’ policy input is critical. Nurses are at the sharp edge of safety, frequently the first to make note of safety issues, and often the first to act on preventing harm to a patient. To achieve a safety culture, nurses need to advocate on behalf of their individual patients, but also speak up within their organizations

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and beyond. Being silent in an organization has been recognized as a serious threat to patient safety (Henriksen & Dayton, 2006). Communication errors and adverse events may be related to hesitancy in speaking up (Okuyama, Wagner, & Bjinen, 2014). Being a leader requires being an advocate. Nurses can be the leaders and drivers of change in advancing policy related to safety initiatives. Although there is much value in implementing safety programs, nurses need to be at policy tables, setting the agenda for efforts to improve safety. An example of a safety practice being adopted in some hospitals where nurse advocacy is needed is the adoption of red rules (i.e., rules that cannot be broken). If these rules are broken, the outcome may be serious patient harm. The practice of red rules was adopted from highly reliable industries (e.g., airlines), but they should not be confused with organizational policies such as infection control. A common red rule across a hospital might be patient verification technique or time-out before an invasive procedure. An important role for nurses in the development of red rules is the guidance they can provide in making sure that the rules are not used to improve adherence to policies already in place or to replace policies that are not working; others are (a) working to ensure that the approach to evaluating a red rule is applied uniformly across departments and (b) conducting studies of the impact of red rules on safety and on nurses beliefs about blame in a safety culture (Jones & O’Connor, 2016). Nurses have a long history of being at the forefront of promoting access to care because of leaders such as Lillian Wald and Mary Breckinridge. Nurses in public health and nurses providing care in community-based clinics engage in strategies to promote access on a daily basis. Issues related to access to care are played out in nurse-managed centers, and the walk-in clinics for healthcare being established across the country in drugstores and supermarkets. These market forces bring in additional stakeholders, who have an interest in removing practice barriers for NPs. Nurses must be politically astute to capitalize on these opportunities in the interest of promoting access to care (see Chapter 13). Expanding access to care can be enhanced not only by removing practice barriers for APRNs, but also by enhancing the roles of RNs as team members in primary care practices. APRNs have had an integral role in the delivery of care in retail-based health clinics because they provide access points for more individuals to enter the healthcare system (ANA, 2009). The urgent need to increase primary care capacity led to a high-level policy discussion, sponsored by the Josiah Macy Jr. Foundation (2016), regarding the role of RNs as team members in primary care. The ensuing report indicated that RNs need to be appropriately prepared and used to meet the primary care needs of the nation. Two of the key recommendations include strengthening primary care content and learning experiences in prelicensure RN and RN bachelor of science in nursing (BSN) education, as well as redesigning primary care practice to use RNs’ abilities. The appropriate use of RNs in primary care has been demonstrated to improve health outcomes, reduce cost, and improve patient satisfaction (Josiah Macy Jr. Foundation, 2016). RNs can be used to enhance transitional care, medication reconciliation, care coordination, chronic disease management, and patient education to name a few primary care roles. Although we typically think of the removal of barriers to practice in the context of advanced practice nurses, to achieve access to care, nurses at all levels are needed to practice at the full scope of their education and abilities. More will be expected of nurses, including the ability to demonstrate health policy competencies set forth by the American Association of Colleges of Nursing (AACN) in its Essentials Series for nursing education at the baccalaureate, master’s, and practice doctorate levels (AACN, 2006, 2008, 2011; http://www.aacnnursing.org/Education-Resources/AACN-Essentials). The goal, final end-point, or outcome of access to care is better health. Although great strides are being made in access to care, there are parts of the country where

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access to care is being increasingly limited and where the death rates and other indicators of population health are worse than the rest of the country's and even worse than in previous years. Many of these same regions have significant practice barriers for APRNs. See Figure 15.2 for map showing the requirements by state for NPs. Some of the newer changes in laws specifically require certified nurse practitioners (CNPs) to be involved in the political process (O’Rourke, Crawford, Morris, & Pulcini, 2017). Shaping social policy not only is critical for access to care, but is an ethical responsibility of all nurses, not just a dedicated few. The challenge is to increase the commitment of all nurses: not only those working in tandem for broader issues, but also those working on issues germane to a practice specialty area to advance health.

VT ME

WA

ND

MT

OR

MN MI

WY

UT

CO

CA AZ

IN

IL

KS OK

NM

PA

IA

NE NV

NY

WI

SD

ID

OH VA

KY

NC

TN AR

MD DC

SC AL

MS TX

DE

WV

MO

NH MA RI CT NJ

GA

LA

AK

FL HI

Full Practice NPs are regulated by a BON and have full, autonomous practice and prescriptive authority without a requirement or attestation for physician supervision, delegation, consultation, or collaboration: AK, AZ, DC, HI, IA, ID, MT, ND, NH, NM, OR, RI, WA, WY

Full Practice or Reduced Practice with Transition

Reduced or Restricted Practice

NPs are regulated by a BON and have full autonomous practice and prescriptive authority but require a postlicensure/certification periods of supervision, collaboration, or mentorship: CO˙, CT, DE˙, MD˙, ME˙, MN˙, NE, NV˙, SD˙, VT˙, WVˆ˙

[Washington, D.C. is included as a state in this map.]

NPs are regulated by a BON or a combination of BON and BOM oversight exists; requirement or attestation for physician supervision, delegation, consultation, or collaboration for authority to practice and/or prescriptive authority: AL, AR, CA, FL, GA, IL†, IN, KS, KY, LA, MA, MI, MO, MS, NC, NJ, NY, OH, OK, PA, SC, TN, TX, UT, VA, WI

CO: 1,000-hour post-licensure practice period CT: 3-year and a minimum of 2,000-hour post-licensure practice period DE: 2-year and a minimum of 4,000-fulltime-hour post-licensure period

IL: 4,000-hour post-licensure practice period + 250 continuing education/ training units; Controlled substances Schedule II opioids and benzodiazepine prescribing requires physician consultation

MD: 18-month post-licensure practice period

† APRNs credentialed in a hospital, hospital affiliate, or ambulatory-

ME: 24-month post-licensure practice period MN: 2,080-hour post-licensure practice period NE: 2,000-hour post-licensure practice period NV: 2-year or 2,000-hour post-licensure practice period SD: 1,040-hour post-licensure practice period VT: 2-year and 2,400-hour post-licensure practice period NY: 3,600-hour post-licensure practice period and attestation of physician collaboration required

surgical treatment center may practice without a written collaboration agreement WV: 3-year post-licensure practice period; ˆExcludes Schedules I,II controlled substances, antineoplastics, radiopharmaceuticals, and general anesthetics * State may not require post-licensure/certification period of supervision,

collaboration, or mentorship when an experienced NP endorsing into the state has met the regulatory requirement through experience in another state

FIGURE 15.2  Summary of practice for NPs. BOM, board of medicine; BON, board of nursing; NPs, nurse practitioners. Source: Reprinted with permission from Phillips, S. J. (2017). 30th annual APRN legislative update: Improving access to healthcare one state at a time. Nurse Practitioner, 43(1), 27–54. doi:10.1097/01. NPR.0000527569.36428.ed

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LEADERSHIP STRATEGIES TO ADVANCE NURSING’S POLICY INFLUENCE Leadership strategies to advance nurses’ policy influence include understanding the policy competencies of new nurse graduates and new hires of an organization; increasing participation in health policy through professional development; and fostering membership and active involvement in associations, organizations, or specialty interest groups in nursing, across disciplines and with the public. In the previous chapters, we have focused largely on how a nurse can become involved in policy and strategies that can be taken at each step of the policy-making process. Nurses’ collective impact is much greater when we maximize the potential in nursing’s power of numbers. Thus, one step at the time taken by an individual nurse can become 3 million steps taken together. Getting to these steps together requires nurse leaders, at every level and in every setting, creating the expectation that nurses will be policy activists. See the Policy on the Scene that illustrate how one nurse became a policy activist.

POLICY ON THE SCENE 15.1: Taking the Perspective of Others Deborah Gross, DNSc, RN, FAAN, Leonard and Helen Stulman Endowed Professor in Psychiatric and Mental Health Nursing, School of Nursing, School of Medicine, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland When I started my career, I did not think of policy. My goal was to make a ­difference for families with young children through research. I was looking to expand the Chicago Parent Program, which was initially created as a research intervention. My colleague, Harriet Kitzman, PhD, RN, FAAN, a Fellow in the American Academy of Nursing, connected me with David Olds, PhD, who along with Harriet founded the Nurse Family Partnership. David very kindly invited me to observe a Congressional briefing he was leading to get support for legislation that would allow federal funding for the Nurse Family Partnership. One of the challenges with any of these preventive health interventions is getting sustainable funding. The hearing, which I believe was in 2009, was hosted by Reps. Kenneth Salazar (CO) and Lois Capps, RN (CA). David presented the research data, and Julia Isaacs of the Brookings Institution presented the economic data. After their presentations, a mother accompanied by her 2-year-old and a nurse presented on their experiences with the program. As compelling as the research and economic data were, it was this triad captured who stole the show. Not a single question from the congressional staffers was asked of the researchers, all were directed to the mother and the nurse. It drove home for me that while research data and the economic evaluation are essential for opening the door, the personal context made the difference in convincing the legislators about the program’s value. Now, I use personal stories when possible. We recently, for example, created a 90-second testimonial video of Baltimore parents to show the impact of parenting research and programs. What nurses bring to policy is that their research is linked to practical problems that are often couched in the stories of real people and their perceptions. (continued )

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When I moved to Baltimore, I connected with key leaders in the school district. What I have learned is that you need to talk differently to different audiences because their concerns are different. This is what nurses do; they listen and know what people care about. When I talked with school principals to see if they would be interested in implementing the Chicago Parent Program in their school, I first ask them about what they worry about, what keeps him up at night. Once you know what others care about, you can frame the discussions in ways that can address those concerns. Parenting is a sensitive issue. In introducing the parenting program, for example, I am careful to keep my approach positive, recognizing that parenting is hard for everyone and that the program will make things easier for them as parents or will save time or money. Like other healthcare professionals, nurses tend to think about these interventions from their own perspective rather than from the perspective of the audience they want to help. So sometimes. we lose them. We need to learn how to adapt our messages so that they will be heard by the many different types of consumers we want to help or engage. Every time you do policy work, there is a next step. We just finished a study comparing the Chicago Parent Program, which uses a group-based format, to another program considered to be “the gold standard,” which uses an individual parent–child coaching model. We demonstrated equally effective outcomes but with a 50% cost reduction, and it was reimbursed through Medicaid because the children had a diagnosed behavior problem. The next phase of the work will focus on getting the program reimbursed before children get a mental health diagnosis so that we can prevent problems before they become serious. Who wants to give a child a mental health diagnosis at the age of 5? Now we are working toward obtaining a waiver for the diagnosis code from Medicaid. My efforts to improve health now begin with deliberate thoughtfulness at the front end of policy, and I often work incrementally to change regulations. The lessons learned are listening to the voices of those impacted, telling stories about the personal impact, and leveraging influence through networking to determine the best policy solution. It is important to think about policy at the front end, the front end of your projects and early in your career. Resources are available to help you. Informal and formal networking, mentoring, and education are keys to policy work. Even though I backed into my policy journey I am now driving policy looking forward for the next problem, connection, and policy solution.

Policy Competencies of New Graduates and New Hires A first step in expanding the number of nurses involved in policy is for nurse leaders to understand the beginning health policy competencies of nurses. Being familiar with the AACN’s Essentials Series, which defines specific competencies regarding health policy for graduates of baccalaureate, master’s, and doctoral programs is a starting point. The Essentials documents for each educational level describe the foundational knowledge of the practitioner of nursing regarding health policy and set expectations for the policy role of nurses, with this role expanding at each successive educational level. Exhibit 15.1 illustrates key action-oriented competencies from a longer comprehensive list of strategies related to knowledge and attitudes about policy making. The health policy competencies, as identified by the AACN in the essentials ­documents, provide specific actions that are grounded in the ANA Code of Ethics for Nurses (2015). Ethically, nurses are expected to participate in improving healthcare environments,

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EXHIBIT 15.1  COMPARISON OF SELECTED ACTION-ORIENTED POLICY

COMPETENCIES AT EACH EDUCATIONAL LEVEL

Baccalaureate

• Participate as a nurse in political processes and grassroots legislative efforts to influence policy • Advocate for consumers and for the nursing profession

Master’s

• Participate in policy development and implementation at each level • Interpret research for policy makers • Advocate for policies that improve the health of the public and the profession of nursing

Doctoral

• • • •

Analyze health policy proposals Influence policy makers Educate policy makers and others Advocate for nursing within policy and healthcare communities • Lead in development and implementation of health policy at all levels • Provide leadership for health policy for health financing, regulation, and delivery • Advocate for social justice, equity, and ethical policies in health

Sources: American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. Washington, DC: Author; American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author; American Association of Colleges of Nursing. (2011). The essentials of master’s education in nursing. Washington, DC: Author.

c­ollaborating with others in meeting healthcare needs, and shaping social policy (see Chapter 2). These expectations require nurses to take an active role in policy. Being familiar with these competencies enables leaders to incorporate them into the orientation process for new nurse hires and for yearly and/or merit performance reviews such as professional advancement programs, sometimes called clinical ladders. Incorporating expectations in work environments helps bridge the often-noted gap between education and practice. Understanding the health policy competencies of nurses is a first step in marshaling the strength of numbers. The profession can ill afford the hard-earned health policy competencies being left at the door as nurses graduate from educational programs and move into their new roles. These competencies can be marshaled by taking a lesson from our colleagues in the military, where the expectation is not only that nurses develop and refine their skills for a specific clinical role, but also that they assume leadership roles to take policy action. The growth of nurse residency programs provides a ready-made mechanism for incorporating the expectation of leadership and policy engagement. Although the Institute of Medicine’s report, The Future of Nursing: Leading Change, Advancing Health (Committee on the RWJF Initiative on the Future of Nursing, 2011), recommends the establishment of residencies for new nurses, new advanced practice nurses, and nurses who are switching to a new specialization, developers of these programs can also include content and experiential learning activities supporting the policy role of nurses at the little “p” level within an organization and

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beyond. This can be accomplished by transitioning some of the structured activities of nurse residency programs to add a focus on policy involvement. Likewise, expectations for professional growth, which have been increasingly incorporated into job descriptions, can include involvement in professional activities. Policy work can be enhanced by harnessing the competencies of new graduates of prelicensure and advance nursing education programs to support organizational initiatives. An example is illustrated with the Legislative Action Interest Group (LAIG) developed at Boston Children’s Hospital, which partners the hospital’s nursing department with its governmental relations office (Waddell, Audette, DeLong, & Brostoff, 2016). This partnership involves nurses learning about health policy, engaging in policy activities with policymakers, and collaborating with the hospital’s lobbyists. This involvement creates more informed nurses, who bring their knowledge to the practice arena, which in turn strengthens nursing within their own healthcare organizations. Replicating the LAIG model can lead to more nurses becoming engaged in policy work. Other opportunities for policy involvement should be considered by nurses taking on new roles (e.g., employment at pharmaceutical companies, in retail pharmacies, and at insurance companies). Thus, when nurses advance their education through formal program enrollment, or advance in organizational leadership, involvement in policy will not be a brand-new competency needing development; instead, policy advocacy can be built on a solid foundation.

Health Policy Professional Development Numerous programs exist to enhance the professional development of nurses in health policy. Some programs are of a general nature and are open to nurses with a requirement to develop a specific area of expertise. The American Academy of Nursing (AAN)/American Nurses Foundation/ANA/National Academy of Medicine Scholarin-Residence is specifically available to nurses. In Chapter 7, Lauren Inouye describes her experience in the Nurse in Washington Internship (NIWI). However, there are many more opportunities for gaining policy expertise. Each has a defined focus that can be used as a stepping stone to wider policy involvement. It is important that nurses be well represented in these programs and take advantage of the available opportunities. See Exhibit 15.2 for a select list of fellowship programs. Policy fellowships are also available in public health through the CDC, as well as in health services research. Some states also have policy fellowships. One aspect of health policy development is learning to take the perspective of others through programs such as those mentioned in Exhibit 15.2.

Fostering Membership and Active Involvement in Associations and Policy Increasing the numbers of nurses involved in policy is vital to leveraging our full advocacy policy potential as nurses. Much of our policy work is accomplished through numbers achieved by membership in associations, specialty organizations, or grassroots groups. Whether a nurse is an educator who requires student nurses to attend professional meetings or encourages them to join nursing (e.g., National Student Nurses Association [NSNA]) or other student groups, an agency manager or administrator who fosters staff nurses’ involvement in shared governance (as described in Chapter 9), or a staff nurse who covers for other nurses so that they can attend a meeting or who invites a colleague to attend a shared governance or professional meeting, all nurses have a role in fostering engagement and involvement in policy.

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EXHIBIT 15.2   SELECTED HEALTH POLICY FELLOWSHIP PROGRAMS PROGRAM

WEBSITE

American Academy of Nursing/American Nurses Foundation/American Nurses Association/ National Academy of Medicine Nurse Scholar-in-Residence

nam.edu/programs/health-policy -educational-programs-and-fellowships/ nurse-scholar-in-residence-program/

American Hospital Association and National Patient Safety Foundation Comprehensive Patient Safety Leadership Fellowship

www.hpoe.org/PSLF/PSLF_main.shtml

Health and Aging Policy Fellows

www.healthandagingpolicy.org

Robert Wood Johnson Foundation: Health Policy Fellows

www.healthpolicyfellows.org

www.aannet.org/resources/awards-and -scholarships/iom-scholar-in-residence

Policy involvement provides nurses with the opportunity to learn about practice standards and to engage with other nurses to obtain guidance and information about addressing policy issues of serious concern. Whether taking concerns to a professional association would have made a difference in the hepatitis C scenario in Nevada is unknown. Nurses can work together to create a paradigm shift so that practice problems are acknowledged, discussed, and addressed. Nurses who participate in professional associations build on the policy advocacy foundation begun in educational programs and bring their expertise to enhancing the environments in which they live and work. Many times, nurses become inspired about an issue but are not familiar with the processes for advancing the policy process. Although this book outlines many of the steps in policy making, the ANA, state nurses associations, specialty associations, and their affiliates have their own spheres of influence and provide critical expertise on the nuances of policy processes within that sphere. Nursing has the numbers to be a powerful influence. The profession has a wellestablished, respected national association (ANA) with state and local affiliates. In addition to ANA, many associations at the national, state, and local levels address the special interests of nurses. Working together, these groups can be leveraged to strengthen nursing’s influence across healthcare at the organizational, local, state, national, and international levels. Considerable effort has been made through the Nursing Community, a coalition of more than 60 associations representing over one million nurses, the Campaign for Action at the Center to Champion Nursing in America (CCNA), and the Nurses on Boards Coalition to expand nursing’s influence through the placement of nurses in key positions. Nurses associations are working on key appointments at the state level. Often, these positions are perceived to be only hospital or health-focused boards. However, relevant experience and/or influence can be garnered by serving on boards of communitybased affiliates of nonprofit organizations, schools, libraries, food banks, and agencies related to environmental hazards, to name a few. These efforts can expand influence into all the communities where nurses live and work.

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An important strategy for helping foster involvement is recognizing the policy work that nurses carry out. This recognition can take several forms, including individually recognizing nurses and engaging groups through selected activities, as well as through promotion of a particular policy (see Chapter 10). The purpose is not only to provide recognition for an individual’s contributions to policy efforts, but also to enhance visibility in a selected community. Recognition within organizations or associations creates excitement and fosters member engagement. It also provides additional opportunities to bring the policy to the attention of key stakeholders. Most important, recognizing the work of policy activists creates a culture in which policy advocacy becomes the norm rather than the exception. When key issues emerge, state associations, specialty associations, educational institutions, healthcare systems, and other groups have convened summits and other highlevel, high-visibility activities, along with the attendant media activities, to heighten the publicity around a specific issue. These activities often lead to the production of a white paper, position statement, or policy brief that has enduring influence on the profession and beyond. An example of such a well-known document is the 1965 ANA Position Paper on entry to practice (ANA, 1965). Fast forward to 2017, to the signing into law of the requirement for RNs in New York to obtain a BSN within 10 years of initial licensure. Although this is a landmark achievement, it also illustrates the long path to achieving policy goals that combines the use of evidence, perseverance, and political skill. The work of nursing cuts across disciplines. There are numerous opportunities for interdisciplinary policy work. Examples include the Gerontological Society of America (GSA) and Academy Health, which recognize the integral role of policy in their conference and other activities. Opportunities for interprofessional collaboration in policy are available in nearly every specialization (e.g., critical care, cardiovascular care, pain management, patient safety, long-term care).

POLICY ROLES Policy activities and expectations can be incorporated into existing structures within educational institutions and organizational structures. All nurses can help foster policy activities and expectations. In this section, we focus on the roles of educators and nurses with graduate education that hold managerial and advanced practice roles because the work of both groups is necessary to avoid a continuing gap between education and practice related to policy.

Nurse Educator To increase the number of nurses versed in policy, a concerted effort is needed to ensure that educational strategies are substantive and meaningful and engage students to use advocacy skills in the multiple policy arenas. This includes the adequate preparation of faculty teaching this content. Educators would not think about having someone teach a clinical content course without the requisite background. The same consideration needs to be given to faculty assigned to teach policy. Someone who has never been involved in policy or is not a member of a professional association is not qualified. Faculty have a pivotal role in teaching, modeling, and mentoring students in advocacy and policy, but they must also have basic policy competencies themselves if they and the nursing profession are to be successful in the policy arena. In a survey of nurse faculty at all levels of undergraduate and graduate programs by Staebler et al. (2017), 46% of the respondents indicated lack of expertise was a barrier

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to teaching policy. The lack of expertise as exemplified by this comment, “Much of the time, the faculty have little ‘real’ policy experience.…” Other barriers were related to lack of (a) priority by administration, (b) engagement by faculty, (c) interest from students, and (d) relevance (Staebler et al., 2017). This study also found, as might be expected, that policy teaching was more evident at the graduate level with 66% to 68% reporting separate courses at the master’s and doctoral levels. Thus, it may not be surprising that new graduates, who often are focused on honing clinical skills and who may not have had a strong acclimatization to policy will have limited policy involvement. Evidence indicates that a strong foundation in policy led by educators who are well grounded in policy has the potential to increase the policy competencies of nurses (Byrd et al., 2012; Perry & Emory, 2017; Primomo, 2007). These complementary findings indicate that significant investment in the value of policy education for nurses, with the implementation of policy content in nursing curricula, has the potential to reap rewards for the profession. Strengthening policy-related activities in nursing educational programs can include a range of activities: establishing and strengthening health policy courses, integrating policy learning activities across courses, creating expectations for professional association involvement, and expanding the emphasis on civic or service learning that focuses on upstream activities to advance health advocacy. Nurse educators have demonstrated the value of health-policy courses in changing nurses’ or future nurses’ attitudes toward policy involvement (Hahn, 2010; Hearne, 2008; Houck & Bongiorno, 2006; Primomo, 2007; Wall, Novak, & Wilkerson, 2005). The activities described in these studies provide guidance to nurse educators who are rapidly gearing up to develop and strengthen their doctor of nursing practice (DNP) program offerings. Education for policy can take place in dedicated coursework in both nursing and with other disciplines, as well as through experiential learning accomplished with professional activities and involvement in specific policy issues germane to clinical content. Incorporating policy activities always begs the question: If we add to the curricula, what might be deleted or changed? Although adding to health policy curricula might be a long-term solution, there are opportunities to incorporate a policy focus within the existing curricula. These include service learning activities, as well as strengthening of the support for leadership activities through the student nurses association. Courses with heavy clinical content can include the policy implications drawn from healthcare disparities, genetics, and access to care, as well as quality and safety initiatives. The latter almost always includes implications for policy. Other healthcare professional groups have the same issues in preparing their workforce for policy activism amid calls to action by their leaders. A policy course can include formal lectures and classroom exercises, integration of real-world experiences, guest lecturers with direct policy experience, and a culminating experiential learning activity (Hearne, 2008). Infusing policy-related content into nursing curricula can be accomplished by incorporating a policy focus into clinically oriented discussions. At the undergraduate level, this can be accomplished on a regular basis in the clinical setting as students learn about the processes of care. When issues related to common clinical problems, such as safety, documentation, and pain relief, are discussed, policy can and should be addressed. Reviewing the policies associated with these topics can help students see how policy can guide resolution of care problems, how policy can be developed, or where there are gaps between practice and policy. Likewise, students’ policy awareness can be enhanced by consistent inclusion of health policy implications in classroom discussions. Incorporating policy discussions

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into clinical conferences also means that adjunct faculty, who often provide clinical teaching, need to be well versed in policy. Policy content and expectations should be included in preceptor orientations. Embedding policy-related content at the master’s level should also occur in clinical and classroom settings. Interest and involvement in policy by nurse faculty serve as important modeling of policy activist behaviors. An exemplar of effective role modeling for professional development in relation to policy is the American Association of Nurse Anesthetists (AANA). The AANA maintains a membership penetration well over 90%, enabling it to have a large presence in Washington with one of the largest healthcare Political Action Committee funds. Much of this is accomplished with a strong educational foundation in health policy in nurse anesthetist educational programs. Given AANA’s membership penetration, it is likely that this phenomenon is replicated in their state affiliates across the nation. As has been demonstrated, important policy advances for the profession occur at the state level. At the level of the doctorate, many opportunities for policy work present themselves. In DNP programs, the final scholarly project or capstone might focus on a policy issue or might minimally include policy implications of the project (see Chapter 5). The growth of programs offering nursing doctorates with an emphasis on the health policy and leadership roles of nurses provides unique opportunities for strengthening policy advocacy. Policy courses and capstone courses in policy provide the opportunities for immersion experiences in policy, allowing students to explore issues in depth and engage in multiple steps of the policy-making process. The growth of these programs also creates the need to develop the policy competencies of faculty across the curriculum. Service learning activities, which have been widely incorporated into nursing curricula, can increase students’ sensitivity and awareness of social justice issues. Very often, these activities focus on providing individual service to members of disadvantaged communities. Systematically expanding this focus to include upstream activities designed to have a larger, more proactive approach can help students learn about the vital role of policy making in advancing health. A community and/or health promotion focus can be used as a service-learning structure for the development of health policy competencies at the undergraduate level (Broussard, 2011; O’Brien-Larivée, 2011). Similarly, the NSNA’s Leadership University provides a structured mechanism for providing course credit for leadership-related learning activities that include, among others, shared governance, legislation, and community health and disaster projects (NSNA, n.d.). Creating an expectation of policy advocacy and involvement needs to happen across a curriculum so that the value of advocacy in health policy can be internalized. When health policy is only a strategy that is mentioned or addressed in a final capstone course, students have difficulty understanding the connections to their daily practice and may see participation in health policy advocacy as an unnecessary and boring impediment to the development of the competencies required to transition to a new practice role.

Nurses in Advanced Organizational Roles Equally important to the full realization of nurse policy engagement is the role of nurses in organizations where care is delivered (e.g., hospitals, community). Nurse managers and nurses with advanced degrees (e.g., APRNs) have critical roles for active policy engagement not only individually, but also in mentoring, coaching, role modeling, and creating structures and processes that facilitate direct nurse care involvement in policy.

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As the group of nurses most often responsible for developing, monitoring, evaluating, and changing policy, nurses with advanced organizational roles are in a unique position to help other nurses understand policy not only within the work setting, but also outside the organization in associations and community work. Their advanced role and often advanced education provide opportunities for engagement that direct-care nurses frequently or readily do not see. Some policy roles of organizational nurse leaders (e.g., incorporating policy expectations into orientation, residency programs, performance reviews, and other similar activities) have been alluded to in previous sections. A strong commitment is called for from organization nurse leaders to help direct-care nurses connect their work in shared governance to policy. The shared governance model provides structure for nurses to have input into their practice and work environment, and the input related to policy is one of the vital elements to success. Through shared governance, nurses are empowered to use their clinical intellectual capital and to use and gain social capital, which are necessary skills to move policy advocacy from the little “p” to the big “P.” The challenge is how to foster the involvement of direct-care nurses, who are paid an hourly rate and often face staffing issues, because they may feel unprepared to also address policy issues. Others may not want to be part of politics because they believe that they chose a profession where service and hard work in care delivery are the only requirements. However, healthcare is not a world unto itself that is devoid of policy and politics. No matter what we do, policy and the concomitant politics that go with the formulation, development, implementation, and evaluation of policy have a pervasive influence over practice. Policies drive our practices. Our interactions with patients involve policy and our understandings of policies. As laws are implemented through regulations and as regulations are interpreted in practice settings, policy and politics drive the strategies designed for the implementation of care. Likewise, if we are not at the table to influence policies that impact our practice and the profession’s ability to promote quality, safety, and access to healthcare for all, others are ready to step up to the plate, perhaps in a way that might not be productive for nursing or healthcare. Our policy mission is to not only provide policy solutions to address healthcare or professional needs, but also to keep the public’s health at the forefront of policy makers’ decision-making processes. It is, therefore, necessary to make sure that nurses understand the shared governance structure of the nursing organization and can not only tell you where to locate the documents that describe this structure, but also be able to identify all the parts and the interconnections. More importantly, it is necessary that nurses see the value of the structure for themselves, know the location (e.g., department, unit), and know the organization’s nurse leaders’ value-shared governance. In addition, nurses need to know how to get involved and to have the support they need (e.g., time back, coverage, paid time) to attend and carry out the work of the council or committee of shared governance to which they belong. These activities require organizational leaders to demonstrate that they believe in the value of shared governance and that they are willing to expend resources and energy to implement and provide ongoing support for shared governance. This support starts with the chief nurse officer and extends across all leadership. These resources include professional development for direct care nurses so that they can better understand shared governance and the necessary space, time, and financial resources to do so. With the increasing emphasis on interprofessional practice and shared governance for patient care across disciplines, it is important that nursing’s voice and perspective are not lost (see Chapter 11).

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A clear example of when the organization has failed in shared governance is when whistle-blowing occurs. This issue can be seen in the hepatitis C story shared in the Work Environment section. This story is a clear example of why internal policies to address nurse concerns are vital for protecting patients and nurses. Shared governance makes it hard for nurses to work in silos, and working in silos makes it easier for bad behavior to go undetected and violations to be unreported. As Fletcher, Sorrell, and Silva (1998) succinctly state, “Our underlying premise is that when whistleblowing occurs there is an institutional failure” (para. 11). Organizational nurse leaders can also help build a culture that values policy advocacy by using several strategies: role modeling, coaching, and mentoring. First, as a leader, take inventory of your policy activities and memberships for self-evaluation and also for the potential that they may have for being shared. If, for example, you are an APRN, consider inviting a nursing student who works at your agency or a student you precept in your advanced practice area to attend a local membership meeting. For new members of shared governance committees, remember to have an established orientation process (see Chapter 11). Finally, providing recognition for nurses involved in policy, while noted earlier, bears repeating, specifically as it relates to the organization. Through organizational and unit newsletters, the accomplishments in policy, appointments to boards, memberships, and offices held should be noted. Imagine working in perioperative nursing and not knowing a colleague was on a national subcommittee of the Association of periOperative Registered Nurses (AORN). Names of nurses sitting on shared governance councils or committees should be highlighted in the areas where they work and posted on easily accessible resources such as an organization’s intranet and/or Internet site. All nurses have roles in policy, and nurses with advanced education have not only individual roles, but also roles in assisting direct care nurses in policy advancement. Public health nurses, nurse informaticists, nurse case managers, and every nursing position one can identify require policy advocacy. In chapters throughout this book, we have detailed these roles. The important contributions of nurses to the development of policy occur at the local, state, and national levels. In an increasingly global, changing, and often uncertain world nurses around the world face similar challenges in advancing health policy, within the context of their unique environments. Leadership development provides a foundation for the development of competencies in policy.

POLICY ROLES IN TIMES OF CHANGE AND UNCERTAINTY Many people, including nurses, avoid talking about politics and complain that they “hate” politics. “Yet politics can no more be avoided than traffic on a freeway. It always exists” (Condon, 2015, p. 115). Although while politics may create instability in a number of arenas, the reality is that change and uncertainty are omnipresent both in our professional practice and in health policy. Regardless of the setting, when nurses assume responsibility for the care of patients, there is uncertainty, whether it is related to trying to figure out what is happening with a patient, to predicting what strategy might work best for patient teaching, to determining best method for delivering anesthesia, or to reducing the incidence of opioid addiction in our communities. We address uncertainty in practice by developing and practicing our competencies so that we are prepared to handle new and unexpected situations. Similarly, we can address uncertainties in the policy arena by developing and performing policy competencies. As citizens and professionals, we must know the policy process and, most important, participate in

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advocacy efforts throughout our careers. Being informed and engaged prepares us for new challenges in the ever-changing healthcare landscape, as well as obstacles created under the guise of normal political differences that are cleverly designed to deliberately derail the goal of healthcare for all. See the Policy on Scene by Mary Wakefield, PhD, RN, FAAN. She has held several senior policy positions, including acting U.S. Deputy Secretary of Health and Human Services and the administrator of the Health Resources and Services Administration under President Barack Obama.

POLICY ON THE SCENE 15.2: Improving Health Through Public Policy: The Runway of Opportunity Mary Wakefield, PhD, RN, FAAN, Former Acting Deputy Secretary of the Department of Health and Human Services, and Former Administrator, Health Resources and Services Administration Never underestimate what you as a nurse bring to health policy. Nurses have rich, first-hand experiences in healthcare that the brightest minds working in health policy might envy. The education and practice of professional nurses spans the science of health and acute and chronic illnesses across individuals and families. This expertise, coupled with delivering care in health systems and in the community, positions nurses to apply knowledge that can uniquely inform health policy. Without the benefit of real-life context for how health challenges impact people, policymakers can craft policies that do not adequately or accurately reflect meaningful solutions. Engaging in the policy-making process is a new experience for many nurses. However, similar to learning communication skills or vital signs, the process can be readily learned. Given the expertise of the nursing profession, every nurse has a role in policy development. Whether nurses are caring for four patients on a shift, teaching 40 students in a classroom, or managing a 400-bed hospital, by engaging in health policy, the breadth of nurses’ experiences can be used to improve the health of millions of people. This critically important work can be a full-time career. It can also be part of the professional work of nurses who care for patients, work as faculty, serve as administrators, or carry out research. Early in my nursing career, health policy was unfamiliar terrain, one of my family’s stories inspired me to embrace the potential to improve care through nursing’s contribution to health policy. Many decades ago, with my mother and four small children, my father left Wisconsin to establish a new aviation business in North Dakota. As an aviator in Wisconsin, he had built a solid business, including scores of students he was teaching to fly. His friends asked him why he would even consider uprooting and moving his family and leave behind a well-­established business. The answer was straightforward. Where others saw flat, desolate land— he saw opportunity. To him, all of North Dakota was a runway! He could land his plane anywhere. He was willing to risk uncertainty for new and expanded opportunity in a place where he believed he could have an even bigger impact. That lesson and then the lessons of being a nurse have stayed with me. To be a nurse is to effectively deal with uncertainty while delivering care. For example, nurses recognize that patients react to heart failure differently, and every (continued )

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family wrapped around a patient with heart failure is different. Nurses are patient-­ centered and flexible in meeting the needs of patients where they are. What is equally ­important is recognizing that although delivering care in the moment is important, much of the care that patients receive and much of what nurses do is driven by policy and determined outside of the direct care arena. Issues related to access to care, reimbursement, and even the location where care is delivered are influenced by health-related public policy. Consequently, influencing the health and healthcare for patients and families requires nurses to cast a net wider, reaching beyond delivering patient care. Because of its impact, engaging in health policy is a vital focus for nurses committed to improving health. Influencing policy means taking clear positions. Like cars in neutral, nurses who are neutral when it comes to health-related public policy miss critically important opportunities to advance the health of patients and communities and to advance the profession. There have been recent tectonic shifts in healthcare (e.g., the enactment of the Affordable Care Act. There are more shifts underway. We cannot always see with clarity what will happen in the policy arena, and taking positions can mean taking risks. However, given the significant impact on health, it is important to bring nursing knowledge to engage in the policy arena. Key to working in policy is knowing both the “what” and the “why” (i.e., understanding what positions different stakeholders have and why they hold them). Determining why individuals and organizations have certain positions helps you understand their priorities and values and can allow you to find common ground or compromise. Of course, it can also help you recognize where a shared agenda does not exist. Most important in my health policy experience has been my ability to lead conversations, opinion editorials, and speeches with the fact that I am a nurse. The receptivity and appreciation for a nurse’s perspective should not be surprising given the fairly consistent survey finding of strong public trust in nurses. With this trust comes an obligation to fully use our expertise on the public’s behalf, including stepping out of our comfort zone. Because of its far-reaching impact on health and healthcare, involvement in policy is every nurse’s responsibility. To achieve our goals for the health of the nation and to advance the contributions of the profession, there is a policy component to the work of every professional nurse. Increasingly nurses face real-world events either in person or through the news. Mass shootings, terrorism, disasters, military conflict, partisan divisions, economic issues, and changing technology require change and may result in personal insecurity. Lack of supplies ranging from basic medicine shortages to electricity add to uncertainty. The news itself is overwhelming, with technology immediately alerting us when a story breaks. Aside from dealing with these extreme conditions, it is also necessary to develop skill in sifting through and making sense of what you are experiencing and what you are hearing in the news. Being able to discern legitimate sources of information and make informed opinions about the best policies is an important skill. The spread of "fake news" with inaccurate information has contributed to the uncertainty and impactful world consequences. A Pew Research Center survey indicated that 89% of Americans are confused by news with misleading information. News challenged as fake, whether or not true, impacts how people interpret and respond to policy topics and elected representatives. Fake news is dangerous and can lead to conflicting information, which creates bias and a citizenship

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prone to political apathy and uncertainty. It can have unintended consequences (e.g., if citizens in the path of a hurricane were advised to ignore evacuation orders). Developing policy competencies enables nurses to become more discerning in evaluating legitimate sources of information. It is not only leadership development that is important for health policy advocacy. Also important are paradigm shifts and a culture that creates expectations and rewards nurses for their active engagement in policy (see the Option for Policy Challenge). The challenge for the future is for all nurses individually to recognize and embrace their roles and to support each other individually and in groups to move the policy agenda for the profession and healthcare for all forward. Nurses occupy a place of trust. To build on that trust, we must advance our health policy and advocacy skills. It requires that we improve our ability to negotiate and compromise. Often, this can be accomplished by choosing words and planning action thoughtfully and with a purpose. As stated in Chapter 4’s Policy Challenge, words matter. The sensitivity of language can make the difference in not only understanding the issue but also building relationships rather than creating divisions.

OPTION FOR POLICY CHALLENGE: A Journey Toward Activism: A Novice’s Perspective Shelly Malberti For me, the first steps began by returning to school to complete my master’s and to join my state nurses association. I learned a lot during that time. My writing skills improved and my knowledge about the use of evidence to support practice increased, but my advocacy remained on the fringes. I wrote papers, attended meetings, and forwarded written statements regarding nursing issues to my social media friends, however; I still was not achieving my goal of taking an active role in policy change. Real motivation began when I enrolled in my doctor of nursing practice (DNP). I was taking a health policy class, and I began to understand that policies are choices that organizations or portions of the population make that provide a channel for allocating resources. Policies reflect the values, attitudes, and beliefs of those designing them and provide the means to apportion resources to attain goals. It was during this class that I began to feel reenergized, so I took the leap. I became involved in select committees of the Ohio Nurses Association (ONA), ran to be a delegate at their state convention, and attended ANA Hill Day in Washington, DC. On the advice of my mentors from school, I also began to meet with influential nurses in my community who were more than willing to provide direction on how to become more politically active. I was still (and remain) very passionate about safe staffing and knew this was the time for me to take action. I wrote my first reference proposal for the ONA convention. I completed an extensive literature search, reviewed previously written reference proposals, spoke with nurses who had written proposals and then wrote a Safe Nurse Staffing proposal. The proposal was approved at the convention, and staffing remains a focus of the ONA. I continue to remain active with my state association and have recently been appointed to the ONA Health Policy Council. My journey will not stop here; it has only just begun. I see myself becoming a board member and furthering my commitment to addressing national or international nursing issues. In fact, I now have the confidence and knowledge and plan to run for office.

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IMPLICATIONS FOR THE FUTURE The next great frontiers in healthcare influenced by nursing practice will depend on the extent to which nurses are actively involved in policy. A number of issues will have a critical impact on nursing. One such example is the projected cuts to federally qualified health centers, which serve 26 million people across the United States (Abreu, 2017). However, nurses in all settings will need to vigorously monitor, refine, and develop healthcare policy at the little “p” and big “P” levels so that we are seen as not only the most trusted healthcare professionals, but also the most trusted sources for health policy and advocacy. Pioneering efforts will be needed to develop new competencies and skills for future health policy work given the increasing complexity of the world. Leading the way in policy is an immersion experience in life that it is not easy; it is often messy and evolving, and it requires opening the doors of opportunity without waiting for an invitation. Redesigning sustainable health care reform cannot be successful without its largest provider group, nursing, being fully engaged. Figures 15.3 and 15.4 reflect how the role of nurses in healthcare reform has changed since the 1960s. Does the future hold the promise of a nurse as a leader of the executive office? Building solutions for closing the gap between expected new-graduate competencies and expected and rewarded performance competencies will increasingly focus on leadership development, as well as interprofessional collaboration that includes policy roles. Specific policy initiatives will focus on safety, the workplace environment, and the needs of our communities with regard to basic supplies of food, water, air, and housing. As we have seen with natural disasters and health inequities, our own communities where we live and work provide opportunities for nurses to be actively involved in policy activities related to quality, safety, and access to healthcare for all, as well as healthcare cost containment. Additional safety initiatives will focus on finding the balance among being at the sharp end of safety, where nurses are often the last professional to have an interaction with a patient before a threatening event, and developing the

FIGURE 15.3  Early healthcare reform discussion in the Oval Office with President Kennedy and one nurse, ANA president, Margaret Dolan. ANA, American Nurses Association.

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FIGURE 15.4  Fifty years later, President Obama in the Oval Office discussing healthcare reform with members of Congress, including nurse representatives, Lois Capps, RN; Eddie Bernice Johnson, RN; and Carolyn McCarthy, RN; along with ANA president, Rebecca M. Patton and other ANA members. ANA, American Nurses Association.

network of skills while also moving science and policy forward to protect the public. The economic value of nursing will increasingly be reflected in discussions and decisions made at policy tables. Therefore, nurses will be called on to participate and contribute to the economic evaluation of their care. The aforementioned set of complex forces (i.e., workforce needs, quality and safety, healthcare reform, and environmental health) reinforce the important role of leadership in health policy at the little “p” and the big “P” levels, whether one is advocating for government activities, institutional decisions, organizational positions, or professional standards. The pivotal role of leadership is supported with strong empirical data. Research has demonstrated that high-resonant leadership, in which leaders are in tune with themselves, is significantly related to lower patient mortality (Cummings, Midodzi, Wong, & Estabrooks, 2010), as well as to better work environments and hospital safety climate (Olds, Aiken, Cimiotti, & Lake, 2017). Magnet® hospitals, which model transformational leadership, have significantly better work environments, lower mortality, and lower instances of failure to rescue (McHugh et al., 2013) and, for very-low-birthweight babies, have significantly lower 7-day mortality and rates of nosocomial infections and severe intraventricular hemorrhage (Lake et al., 2012). Another type of leadership impacting policy that is now receiving much attention is the dearth of nurses serving on hospital governing boards. Limited nurse input into the policy making of an organization makes it more difficult to fully operationalize safe quality care because employers of nurses do not have a valuable frontline perspective when making policy. Leadership is the focus in two of the eight recommendations of The Future of Nursing report: “expand opportunities for nurses to lead and diffuse collaborative improvement efforts” and “prepare and enable nurses to lead change to advance health” (Committee on the RWJF Initiative on the Future of Nursing, 2011, pp. 11, 14). In fact, other Future of Nursing recommendations relate to (a) education (BSN-prepared nurses, doctoral preparation, lifelong learning, and residencies), (b) practicing to full scope of education

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and training, and (c) workforce data infrastructure as providing support for the development of the leadership role of nurses in society. To be a leader in nursing, one must be well versed in the strategies and tools of policy, and these recommendations, when achieved, will help provide the needed base structure for larger nurse involvement in policy from bedside to boardroom. The AAN has taken the initiative to publicize the impact of nursing on outcomes through its Edge Runners program. Although this program is designed to highlight the impact of nursing through quantifiable outcomes, these really are stories of nursing leadership in action. These initiatives could not have been accomplished without dedicated, committed, knowledgeable, and savvy nurse leaders working to improve policy. Edge Runner Ruth Watson Lubic, a MacArthur Foundation “Genius” Award recipient, was known for creating a free-standing childbearing center in the southwest Bronx, an underserved community. She used her award to create a successful midwife/NP-run program, the Family Health and Birth Center (FHBC), providing low-income women with cost-effective maternal/child care in Washington, DC. The FHBC lowered preterm births, reduced the incidence of low birth weight, and decreased the number of cesarean sections performed (AAN, 2013). Dr. Lubic’s leadership in creating a successful nurse-midwife–led maternal and child care program provides not only the evidence that can be used by other organizations seeking to replicate her results, but also the financial savings that can be used to sway policy makers to obtain additional funding, as well as changes in reimbursement practices. These successful Edge Runner programs can and should be used as models for other organizations and as springboards for nurses to develop essential leadership competencies. The leadership of nurses in advocacy roles occurs not only through formal positions, but also in the daily routine activities of staff nurses. Nurses serve important roles as members of committees, councils, and workgroups, where policy with a little “p” the policy that impacts nurses and their patients at the sharp end, is identified, planned, developed, and evaluated. We need to make sure that nurses work not only in nurse groups, but also in multidisciplinary groups. Substantive improvements in care will be hampered if interdisciplinary collaboration is not the norm. For example, a hospital may have a falls prevention committee, but if nurses do not interact with physicians, pharmacists, physical therapists, and other healthcare professionals, it may be difficult, if not impossible, to reduce fall rates, especially over time as rates are monitored and evaluated and drift from policy occurs. All that are impacted by policy must be involved in its development. We know that being silent within an organization has repercussions for the safety and well-being of our patients (Henriksen & Dayton, 2006). Likewise, being silent within our society, our organizations, our associations, our community, and our government has repercussions for the advancement of our profession and the well-being of the patients entrusted to our care. Taking an active role in policy is every nurse’s responsibility as a member of our profession. Leadership in advocacy requires careful thought and preparation, and an ability to negotiate a complex set of relationships. As with many leadership roles, no one single action or skill set will position a nurse to assume a leadership role. Networking, being at the right place at the right time; having education, experience, and competencies; and having passion about an issue are all important for nurses in advancing to the next level of advocacy. With some very slight modifications, these lessons can be applied to numerous other advocacy roles in one’s organization and community, as well as at the state, federal, and international level.

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KEY CONCEPTS 1. All nurses in all settings need to be actively engaged in policy to capitalize on the potential of more than 3 million nurses taking steps together to advance health. 2. Strengthening policy competencies is about fostering the expectation that all nurses will be leaders. 3. Language matters in advancing practice, removing practice barriers, and protecting the public. 4. Removal of practice barriers is a complex, ongoing process that involves multiple layers of legislation and regulation at the local, state, and national levels. 5. All nurses need to be involved in policy issues at their place of work to enhance quality of care and make improvements in practice and the work environment. 6. Daily practice provides numerous opportunities to shape and advance practice in promoting quality, safety, and access to healthcare for all. 7. Nurses need to be at the policy table formulating policy, rather than just serving as the implementers of policy. 8. Nurse organizational leaders play a key role in advancing the policy competencies of nurses through role modeling, education, and provision of opportunities for participating in policy formulation, implementation, and evaluation. 9. Shared governance provides numerous opportunities for nurses to develop policy competencies. 10. Policies created at the local, state, and national levels may not necessarily be synchronous with the advancement of the nursing profession and practice policies at the organizational level. 11. The development of policy competencies needs to be embedded in routine activities such as evaluation, as well as in orientation, nurse residencies, and other specialized programs. 12. Leadership development requires a paradigm shift away from a primary focus on the attainment of clinical competencies and toward a focus that also includes a concomitant development of policy skills. 13. Exemplars of leadership development can be used as models for the development of policy competencies. 14. Policy making, much like patient care situations, can be uncertain and unpredictable. 15. Nurses need to be involved in professional associations to realize the potential of strength in numbers because these groups are concerned with and are actively engaged in addressing nursing practice issues at state and national levels. 16. Organizational nurse leaders have an important role in building a culture in nursing that values and fosters policy advocacy.

SUMMARY The roles of nurses individually and collectively are basic to healthcare transformation and the necessary policy needed to achieve the Quadruple Aim of enhancing patient experience, improving population health, reducing cost, and improving the work life of health care providers. It is indefensible for nurses to be told or to believe their only duty for care is direct service. Ethically, we are bound to be at the policy table. If not invited, we must knock loud and hard on the door and, when necessary, just walk in. The strategies for achieving more nurse involvement rests with the best educated who

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not only have the competencies but also often hold the positions of leadership that can most easily effect change. New structures and processes in education and work settings are needed to facilitate the professional development of policy for all nurses commensurate with their roles. The gap between education and practice needs to be bridged for nurses to fully take action and expand policy horizons.

LEARNING ACTIVITIES 1. Identify at least five resources that are available related to an issue that interests to you. 2. Compare the state BSN essentials with those of graduate nurses, and explore how, as a nurse with graduate education, you will support BSN-prepared nurses or nurses returning to school for their BSN in activities in policy at the big “P” and little “p” levels. 3. Develop a plan for two policy activities at any level that you can achieve within 6 months and then within 1 year. Identify the amount of effort it will take and your strategies for accomplishing the activities, as well as your rationale for selecting the activities. 4. Make a list of all the policy activities that you have participated in during the past 5 years. Critically analyze your participation in terms of personal growth and your contribution to the association, cause, or organization that you helped. 5. Describe potential responses to nurses who indicate they are not involved in associations because they do not believe in policy activity. 6. Develop a one-page resume that highlights your policy activities that can be used to accompany an application to serve on a state or national health policy committee. 7. Formulate a response to nurse colleagues who, when learning that you are enrolled in a health policy class, complain that they hate politics. 8. Identify two areas of uncertainty in healthcare that can serve as springboards for ­policy-change opportunities. Provide rationales for your selections.

E-RESOURCES • American Association of Colleges of Nursing: Essentials Documents http://www.aacnnursing.org/Education-Resources/AACN-Essentials • American Association of Nurse Practitioners: Position Statements and Papers https://www.aanp.org/publications/position-statements-papers • American Nurses Association: Position Statements http://www.nursingworld.org/positionstatements • Barton Associates: Scope of Practice Laws: Interactive Nurse Practitioner (NP) Scope of Practice Law Guide http://www.bartonassociates.com/nurse-practitioners/nurse-practitioner-scopeof-practice-laws • Centers for Disease Control and Prevention (CDC): Fellowships, Internships, and Learning Opportunities https://www.cdc.gov/Fellowships • Future of Nursing Campaign for Action at the Center to Champion Nursing in America http://campaignforaction.org • The Huffington Post, Life Expectancy Shortest in Southern “Poverty Belt” (INFOGRAPHIC), Death and the Poverty Belt http://www.huffingtonpost.com/2013/07/19/life-expectancy-_n_3624495.html

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• National Student Nurses Association http://www.nsna.org • Nurses on Boards Coalition (NOBC) https://www.nursesonboardscoalition.org • The Nursing Community http://www.thenursingcommunity.org

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Centers for Disease Control and Prevention. (2017). The one & only campaign. Retrieved from https://www.cdc.gov/injectionsafety/1anonly.html Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Condon, B. (2015). Politically charted issues in nursing’s teaching-learning environments. Nursing Science Quarterly, 28(2), 115–120. doi:10.1177/08943184155716 Cummings, G. G., Midodzi, W. K., Wong, C. A., & Estabrooks, C. A. (2010). The contribution of hospital nursing leadership styles to 30-day patient mortality. Nursing Research, 59(5), 331–339. doi:10.1097/NNR.0b013e3181ed74d5 Djukic, M., Kovner, C. T., Brewer, C. S., Fatehi, F. K., & Cline, D. D. (2013). Work environment factors other than staffing associated with nurses’ ratings of patient care quality. Health Care Management Review, 38(2), 105–114. doi:10.1097/HMR.0b013e3182388cc3 Fletcher, J., Sorrell, J., & Silva, M. (1998). Whistleblowing as a failure of organizational ethics. Online Journal of Issues in Nursing, 3(3), Manuscript 3. Retrieved from http://o``Vol31998/No3Dec1998/ Whistleblowing.html Hahn, J. (2010). Integrating professionalism and political awareness into the curriculum. Nurse Educator, 35(3), 110–113. doi:10.1097/NNE.0b013e3181d95040 Hearne, S. A. (2008). Practice-based teaching for health policy action and advocacy. Public Health Reports, 123(Suppl. 2), 65–70. doi:10.1177/00333549081230S209 Henriksen, K., & Dayton, E. (2006). Organizational silence and hidden threats to patient safety. Health Services Research, 41(4 Pt 2), 1539–1554. doi:10.1111/j.1475-6773.2006.00564.x Houck, N. M., & Bongiorno, A. W. (2006). Innovations in the public policy education of nursing students. Journal of the New York State Nurses Association, 37(2), 4–9 Retrieved from https://www .nysna.org/nursing-practice/journal-new-york-state-nurses-association#.W0qgJ9hKhBw Jones, L. K., & O’Connor, S. J. (2016). The use of red rules in patient safety culture. Universal Journal of Management, 4(3), 130–139. doi:10.13189/ujm.2016.040306 Josiah Macy Jr. Foundation. (2016). Registered nurses: Partners in transforming primary care. Recommendations from the Macy Foundation Conference on preparing registered nurses for enhanced roles in primary care. Retrieved from http://macyfoundation.org/docs/macy_ pubs/201609_Nursing_Conference_Exectuive_Summary_Final.pdf Kunavikitul, W. (2014). Moving towards the greater involvement of nurses in policy development. International Nursing Review, 61(1), 1–2. doi:10.1111/inr.12092 Lake, E. T., Staiger, D., Horbar, J., Cheung, R., Kenny, M., Patrick, T., & Rogowski, J. A. (2012). Association between hospital recognition for nursing excellence and outcomes of very low weight infants. Journal of the American Medical Association, 307(16), 1709–1716. doi:10.1001/ jama.2012.504 Leary, E., & Diers, D. (2013). The silence of the unblown whistle: The Nevada hepatitis C public health crisis. Yale Journal of Biology and Medicine, 86(1), 79–87. Retrieved from https://www.ncbi.nlm .nih.gov/pubmed/23483090 McHugh, M. D., Kelly, L. A., Smith, H. L., Wu, E. S., Vanak, J. M., & Aiken, L H. (2013). Lower mortality in Magnet hospitals. Medical Care, 51(5), 383–388. doi:10.1097/MLR.0b013e3182726cc5 National Student Nurses Association (n.d.). Leadership. Retrieved from http://www.nsna.org/leadership-university.html O’Brien-Larivée, C. (2011). A service-learning experience to teach baccalaureate nursing students about health policy. Journal of Nursing Education, 50(6), 332–336. doi:10.3928/01484834-20110317-02 Okuyama, A., Wagner, C., & Bjinen, B. (2014). Speaking up for patient safety by hospitalbased health professionals: A literature review. BMC Health Services Research, 14, 61. doi:10.1186/1472-6963-14-61 Olds, D. M., Aiken, L. H., Cimiotti, J. P., & Lake, E. T. (2017). Association of nurse work environment and safety climate on patient mortality: A cross-sectional study. International Journal of Nursing Studies, 74, 155-161. doi:10.1016/j.ijnurstu.2017.06.004

474   UNIT IV  JUDGING WORTH AND ADVANCING THE CAUSE O’Rourke, N. C., Crawford, S. L., Morris, N. S., & Pulcini, J. (2017). Political efficacy and participation of nurse practitioners. Policy, Politics, and Nursing Practice. 18(3), 135–148. ­ doi:10.1177/1527154417728514 Perry, C., & Emory, J. (2017). Advocacy through education. Policy, Politics and Nursing Practice. Advance online publication. doi:10.1177/1527154417734382 Phillips, S. J. (2017). 30th Annual APRN legislative update: Improving access to healthcare one state at a time. Nurse Practitioner, 43(1), 27–54. doi:10.1097/01.NPR.0000527569.36428.ed Poghosyan, L., Liu, J., Shang, J., & D’Aunno, T. (2017). Practice environments and job satisfaction and turnover intentions of nurse practitioners: Implications for primary care workforce capacity. Health Care Management Review, 42(2), 162–171. doi:10.1097/HMR.0000000000000094 Primomo, J. (2007). Changes in political astuteness after a health systems and policy course. Nurse Educator, 32(6), 260–264. doi:10.1097/01.NNE.0000299480.54506.44 Staebler, S., Campbell, J., Cornelius, P., Fallin-Bennett, A., Fry-Bowers, E., Kung, Y. M., … Miller, J. (2017). Policy and political advocacy: Comparison study of nursing faculty to determine current practices, perceptions and barriers to teaching health policy. Journal of Professional Nursing, 33(5), 350–355. doi:10.1016/j.profnurs.2017.04.001 Tvedt, C., Sjetne, I. S., Helgeland, J., Løwer, H. L., & Bukholm, G. (2017). Nurses’ reports of staffing adequacy and surgical site infections. International Journal of Nursing Studies, 75, 58–64. doi:10.1016/j.ijnurstu.2017.07.008 Waddell, A., Audette, K., DeLong, A., & Brostoff, M. (2016). A hospital-based interdisciplinary model for increasing nurses’ engagement in legislative advocacy. Policy, Politics, and Nursing Practice, 17(1), 15–23. doi:10.1177/1527154416630638 Wall, B. M., Novak, J. C., & Wilkerson, S. A. (2005). Doctor of nursing practice program development: Reengineering health care. Journal of Nursing Education, 44(9), 396–403. https://www.healio .com/nursing/journals/jne/past-issues#

Index AACN. See American Association of Colleges of Nursing; American Association of Critical Care Nurses AACN Standards for Establishing and Sustaining Healthy Work Environments, 55 AAN. See American Academy of Nursing AANA. See American Association of Nurse Anesthetists AANP. See American Association of Nurse Practitioners AARP Foundation, 265 ACA. See Affordable Care Act access to healthcare, 451–453 accountability for actions, 44 ACLU. See American Civil Liberties Union ACNM. See American College of Nurse-Midwives ACOG. See American College of Obstetricians and Gynecologists action-oriented policy, 456 activism, 39, 40 ASC. See American Community Survey Adams Influence Model (AIM), 273, 274 Adapting Standards of Care Under Extreme Conditions, 113, 173 advanced practice registered nurses (APRNs), 109, 168, 182, 199, 204, 217, 237, 281, 303, 333, 340, 451 appointments, 340 barriers for, 25, 59, 452, 453 language issues, 449 in Medicare QPP, 209 professional licensure laws, 76 value of, 63 advocacy, 41 ANA position statements, 56–58 clinical practice, 48 community, 58–60 definition of, 39 historical roots of, 40 international, 61 International Council of Nurses on, 39 literature, 39

moral distress, 48 national, 60–61 organizations, 63–64 practice barriers, 48, 63 professional and societal expectations for, 41–42 public expectation for, 50–51 for safe patient handling and mobility, 38, 64 social justice, 48–49 understaffing, 62–63 whistle-blowing, 44 workplace, 55–56 Advocacy Capacity Tool, 277 advocacy competencies collaboration, 53 communication, 52 influence, 52–53 problem solving, 51 resource identification, 54–55 advocacy days, 201 advocacy plan, 261 assessment of resources, 273–278 building momentum, 278 coalitions and alliances, 265–267 dealing with unexpected, 281–283 framing of issue, 269–270 future implications, 285 goal refinement, 268–269 influence policy, 273, 274 leadership for, 263–267 narratives creation, 278–280 networking policy-maker allies, 280 phases of activating, 261–262 presentation of, 278 professional associations, 263–264 staffing, 281, 283 strategies for activating, 267–273 sustainability of, 283–284 targeting audience, 271–272 toolkits, 265 Advocate Health Care, 401 advocates, 41, 52 475

476  INDEX Affordable Care Act (ACA), 59, 83, 109, 132, 141–142, 185, 234, 270, 281, 368, 399, 400, 404, 407, 414 Agency for Healthcare Research and Quality (AHRQ), 135, 238, 370, 405, 408 agenda definition, 163–164, 166 development, 171–172 establishment, 173–174 importance of, 166–167 interest groups, 176–177 jurisdiction, 182–183 legislation, 183 levels, 168–170 litigation, 185–186 raising awareness, 181 agenda setting, 163–164, 166–167 agenda universe, 169 AHA. See American Hospital Association AHCA. See American Health Care Act AHRQ. See Agency for Healthcare Research and Quality AIM. See Adams Influence Model alarm fatigue, 330, 382 Alliance for Justice, 277 ambulatory surgery centers (ASCs), 182 American Academy of Nursing (AAN), 18, 146–147, 310, 347 American Association of Colleges of Nursing (AACN), 77, 168, 202, 203, 219, 314, 452 American Association of Critical Care Nurses (AACN), 55 American Association of Nurse Anesthetists (AANA), 215, 264, 266–267, 461 American Association of Nurse Practitioners (AANP), 168 American Cancer Society, 399 American Civil Liberties Union (ACLU), 185 American College of Nurse-Midwives (ACNM), 168 American College of Obstetricians and Gynecologists (ACOG), 282 American Community Survey (ACS), 276 American Health Care Act (AHCA), 24, 313 American Hospital Association (AHA), 51, 113, 348, 349, 401, 458 American Journal of Nursing, 265, 350 American Nurse Today, 299 American Nurses Advocacy Institute (ANAI), 201 American Nurses Association (ANA), 10, 14, 26, 84, 109, 208, 226, 264, 266, 296, 329, 340, 424, 434 Code of Ethics for Nurses, 5, 38, 42–48, 51, 236

Nursing: Scope and Standards of Practice, 41 Nursing’s Social Policy Statement, 74 Social Policy Statement, 57 American Nurses Association v. Torlakson, 174 American Nurses Credentialing Center (ANCC), 65, 226 American Nurses Foundation (ANF), 457 American Organization of Nurse Executives (AONE), 10 American Recovery and Reinvestment Act (ARRA) of 2009, 381 American Red Cross, 48 American Society of Anesthesiologists (ASA), 215 amicus briefs, 94 amicus curiae (friends of the court), 94, 185 ANA. See American Nurses Association ANAI. See American Nurses Advocacy Institute ANCC. See American Nurses Credentialing Center Anesthesia Program Approval Process (APAP), 437 ANF. See American Nurses Foundation AONE. See American Organization of Nurse Executives AORN. See Association of periOperative Registered Nurses APAP. See Anesthesia Program Approval Process APIC. See Association for Professionals in Infection Control and Epidemiology APRN Consensus Model, 112 APRNs. See advanced practice registered nurses ARRA. See American Recovery and Reinvestment Act of 2009 ASA. See American Society of Anesthesiologists ASCs. See ambulatory surgery centers Association for Professionals in Infection Control and Epidemiology (APIC), 172 Association of periOperative Registered Nurses (AORN), 137–138, 144, 168, 179, 436, 463 Aurora Health Care board, 345 autonomy, 41–42 awareness, of policy agenda, 181 backgrounders, 314–315 benchmarking, 362–364 beneficence, 42 BHB Sleep Initiative: Alone. Back. Crib., 143 Bill and Melinda Gates Foundation, 405

INDEX  477

blogs, 300 board membership, effectiveness in, 345–346 boards of nursing (BONs), 16, 66, 81, 164, 182 BONs. See boards of nursing brainstorming, 231 briefings, 213, 318–319 broadcast media, 311 Campaign for Action, 180, 458 Canadian Nurses Association (CNA), 434 cancer survival, 399 CANE. See Coalition to Advance Nursing Education capital, 195 financial, 215–220 intellectual, 198–204 political, 207–215 social, 204–207 CARE. See Caregiver Advise, Record, Enable care coordination, 24–25 care coverage, 427 Caregiver Advise, Record, Enable (CARE) Act, 265, 267 catheter-related bloodstream infections (CRBSIs), 142 Catholic Health Association of the United States, 401 CCNA. See Center to Champion Nursing in America CCTP. See Community-Based Care Transitions Program CDC. See Centers for Disease Control and Prevention Center for Healthcare Governance, 349 Center for Innovation, 247 Center to Champion Nursing in America (CCNA), 91, 265 Centers for Disease Control and Prevention (CDC), 144, 401, 408, 451 Centers for Medicare & Medicaid Services (CMS), 22, 141, 199, 209, 247, 374, 408 Centers for Medicare & Medicaid Services Innovation Center (CMS Innovation Center), 199 central line–associated bloodstream infection (CLABSI), 142 certified nurse midwives (CNMs), 210 certified nurse practitioners (CNPs), 453 certified registered nurse anesthetists (CRNAs), 186, 210, 219, 237, 248–249, 266, 451 CGFNS. See Commission on Graduates of Foreign Nursing Schools

change, 231 alteration, 231, 233, 234 characteristics of, 231 definitions specific to, 229 descriptions for, 228 dialectical, 233–234 drivers of, 232 evolutionary, 234 facilitation of, 248–250 healthcare policy, 225 human agency, 231, 233, 234 implementation, 230–231 levels of change, 232, 233, 234 life cycle, 233 predictability of, 232, 233, 234 resistance to, 249–250 teleological driver, 233 theories of, 227–229 time parameters, 231, 233, 234 childhood obesity, 392 chronic disease, 427–428 chronic illnesses. See noncommunicable diseases CLABSI. See central line–associated bloodstream infection Clinical and Translational Science Awards (CTSAs), 133 clinical handoffs, 243 clinical ladders, 456 clinical narrative, 279 clinical nurse specialists (CNS), 25–26, 204, 210 clinical practice guidelines (CPGs), 137, 141 CMF. See Congressional Management Foundation CMS. See Centers for Medicare & Medicaid Services CNA. See Canadian Nurses Association CNMs. See certified nurse midwives CNPs. See certified nurse practitioners CNS. See clinical nurse specialists coalition, 53, 59, 64, 111, 179–181, 212–215, 220, 348, 458 Coalition for Patients’ Rights (CPR), 53 Coalition to Advance Nursing Education (CANE), 165, 186 Code of Ethics for Nurses, 264 Code of Ethics for Nurses With Interpretive Statements, 41, 51, 64 collaboration, 53 collaborative governance structure, 263 collective activism, 63 Colorado Supreme Court, 249 Commission on Graduates of Foreign Nursing Schools (CGFNS), 435

478  INDEX Commission on the Social Determinants of Health (CSDH) report, 395 Commonwealth Fund, 130 communication, 52, 62, 123, 198, 207, 210–211, 277, 291, 294–296 community, 58–60 Community-Based Care Transitions Program (CCTP), 141–142, 199 community health needs assessment, 403–404 competencies action-oriented policy, 456 advocacy. See advocacy competencies health policy, 456 leadership, 454 policy, 455–457, 466 self-assessment of, 44 complex adaptive systems, 230 congressional agenda, 196, 212, 215, 216 congressional committees, 83–86 Congressional Management Foundation (CMF), 198 conscientious objection, 45, 292–293 consumer groups, 176, 177, 297 conventional communication methods, 292 converged media, 292 CPGs. See clinical practice guidelines CPR. See Coalition for Patients’ Rights CRBSIs. See catheter-related bloodstream infections CRNAs. See certified registered nurse anesthetists crowdsourcing, 302 CSDH report. See Commission on the Social Determinants of Health report CTSAs. See Clinical and Translational Science Awards data, for resources assessment, 276 decision agenda, 169 decision-making roles, 353 deep dive strategy, 230 Deficit Reduction Act (DRA), 374 demographic data, 276 determinants of health, 368, 391, 395–399 DHHS. See Department of Health and Human Services dialectical change/innovation, 233–234 diffusion, 140 diffusion of innovations, 151, 230 digital communication, 292 digital media, 292 directed creativity, 230

Disadvantaged Minority Health Improvement Act (1990), 407 disaster recovery, 320–321 disciplinary research, 138 disruptive innovation, 230 dissemination, 140, 148, 149–150 DNP program. See doctor of nursing practice (DNP) program doctor of nursing practice (DNP) program, 460 Donabedian’s framework, 364–367, 371 DRA. See Deficit Reduction Act drug abuse, 171 dynamics of organizational culture, 230 Ebola virus, 426 EBP. See evidence-based practice economic environment, 114 economic resources, 276–277 Edge Runners program, 347, 469 educators’ roles, advancing policy, 449–451 EHRs. See electronic health records electronic communications, 313–314 electronic databases, 210 electronic health records (EHRs), 145, 353 electronic media, 296 elevator speech, 53, 306, 331 elite theory, 166 emergency department, casualty nursing in, 262, 284 Emergency Nurses Association (ENA), 10, 168, 262, 266 empowerment advocacy plan, 263 through coalition and alliances, 265–267 ENA. See Emergency Nurses Association; Ethiopian Nurses Association enhanced Nurse Licensure Compact (eNLC), 226, 227, 253–254 eNLC. See enhanced Nurse Licensure Compact entrepreneurial roles, 341 environmental issues, 26–28 environmental scan, 113–114 equity, 49, 348 Ethiopian Nurses Association (ENA), 434 ethnicity, 42, 49, 394–395, 397–398 evaluation, 47, 122, 138, 139, 142, 295, 351, 359, 361 evidence, in policy-making process, 361 evidence-based practice (EBP), 130, 132, 136–138, 154, 382 evidence-informed health policy making, 132

INDEX  479

Evidence-Informed Policy Network (EVIPNet), 132 EVIPNet. See Evidence-Informed Policy Network evolutionary change/innovation, 234 executive orders, 92–93 Facebook, 298–299 Faculty Policy Intensive (FPI), 202 FDA. See Food and Drug Administration federal agency appointment selection, 93 Federal Emergency Management Agency (FEMA), 284 Federal Register, 85 FEMA. See Federal Emergency Management Agency fidelity, 42 financial capital, 215 big “P” level, 215–217 little “p” level, 217–220 lobbying, 215–216, 217 political action committees, 216–217 Finnish Federation of Nurses, 434 Food and Drug Administration (FDA), 252, 408 formal legislative process, 78 formal political process, 332 formative evaluation, 369 fostering membership, 457–459 FPI. See Faculty Policy Intensive free rider syndrome, 211–212, 213 From Silence to Voice (Gordon & Buresh), 280 fundraising, 181, 300, 305 Future of Nursing: Leading Change, Advancing Health, The, 165, 276, 285 Future of Nursing, The (IOM report), 9, 59, 91, 92, 123, 124, 302, 348, 349, 415, 456, 468 Gallup poll, 13, 51, 73, 347, 348 GAPFON Model. See Global Advisory Panel on the Future of Nursing & Midwifery Model GCEF. See Girl Child Education Fund GHIs. See global health issues Girl Child Education Fund (GCEF), 434 Global Action Plan, 427 Global Advisory Panel on the Future of Nursing & Midwifery (GAPFON) Model, 431–433 global citizenship, 440–441

Global Code of Practice on the International Recruitment of Health Personnel (WHO), 438 global health, 429 global health issues (GHIs), 425–426, 438 chronic disease, 427–428 noncommunicable diseases, 427–428 poverty, 426 universal health coverage, 427 global health policies community benefit standard, 400–404 “health in all policies,” 404 health inequities, 404–407 healthcare reform, 408–412 Healthy People 2020, 408 global health stakeholders, 429–433 global nursing leadership, 433 globalization, 426, 433 grassroots, 116, 177, 195, 201, 209–211, 214, 294 grasstops, 196, 205–206, 210 HAIs. See healthcare-associated infections HANYS. See Health Association of New York State harnessing evidence, public policy disciplinary research, 138 dissemination strategies, 148–153 EBP approach, 136–138 quality improvement, 139–140 translating evidence into policy, nurse’s role, 140–147 HCUP. See Healthcare Cost and Utilization Project HDI. See Human Development Index Health Affairs, 279 Health Affairs Health Policy Briefs, 130 Health Association of New York State (HANYS), 165 health disparities, 49, 410–411 Health Employment and Economic Growth (HEEG), 424, 441, 442 health impact assessments (HIAs), 408 “health in all policies,” 404 health inequities, 392 access to care and insurance, 397–399 education, 396–397 federal initiatives to reduce, 409 future implications, 413–415 health disparities versus, 393–395 health insurance, 397–399 income and employment opportunities, 395–396 infant mortality rate, 396–397

480  INDEX health inequities (cont.) national and global, 393–394 nature of, 392 policies to reduce, 404–405 policy discussions, 406 race and ethnicity in United States, 394–395 recognition, 413 social determinants of, 395–399 U.S. federal policy for reducing, 405–407 U.S. historic policy milestones, 407 WHO definition, 393 health information exchanges (HIEs), 381 health insurance, 397–399 cancer survival, 399 healthcare workers, 398–399 private insurance plans, 397 status, 398 health insurance exchanges, 22, 23 health investment, 442 health policy, 170, 185, 400–404. See also global health policies health policy professional development, 457 Health Resources & Services Administration (HRSA), 183, 408 healthcare-associated infections (HAIs), 172, 451 Healthcare Cost and Utilization Project (HCUP), 370 Healthcare Equality and Accountability Act of 2003, 407 healthcare institutions, 173 healthcare reform, 21–26, 109, 408–412, 467, 468 healthcare systems, 17, 49–50, 185, 345, 374, 408, 425–426, 438 Healthy Food in Health Care program, 185 Healthy People 2020, 408 healthy work environments, 439–440 HEEG. See Health Employment and Economic Growth HIAs. See health impact assessments HIEs. See health information exchanges high reliability organization (HRO), 17 Home Alone AllianceSM, 265 Honor Society of Nursing, 431 Hospital Value-Based Purchasing (HVBP) program, 374 HRH. See human resources for health HRO. See high reliability organization HRSA. See Health Resources & Services Administration Human Development Index (HDI), 425 human resources for health (HRH), 438

HVBP. See Hospital Value-Based Purchasing program ICN. See International Council of Nurses ICN Nurse Practitioner/Advanced Practice Nursing Network (INP/APNN), 436 IFNA. See International Federation of Nurse Anesthetists IGOs. See intergovernmental organizations IHI. See Institute for Healthcare Improvement impact litigation, 185 implementation science, 140 IMR. See infant mortality rate INANE. See International Academy of Nursing Editors Indian Health Improvement Act of 1976, 407 indicators, 104, 180, 363, 372, 375 individual nurse-patient relationships, 13 infant mortality rate (IMR), 144, 396–397 influence, advocacy competencies, 52–53 influence policy, 273 infographics, 301–302 informal politics, 331 innovation, 65, 151, 342, 345 alteration, 231, 233, 234 characteristics of, 231 definitions specific to, 229 descriptions for, 228 dialectical, 233–234 evolutionary, 234 facilitation of, 248–249 human agency, 231, 233, 234 levels of change, 232, 233, 234 life cycle, 233 predictability of, 232, 233, 234 resistance to, 249–250 teleological, 233 theories of, 230 time parameters, 231, 233, 234 innovation space, 231 INP/APNN. See ICN Nurse Practitioner/ Advanced Practice Nursing Network Instagram, 300 Institute for Healthcare Improvement (IHI), 16 Institute for Safe Medication Practices (ISMP), 16 Institute of Medicine (IOM), 9, 49, 123, 135, 165, 276, 340, 405, 444, 456 institutional/organizational agenda, 169 institutional review board (IRB), 138, 204 intellectual capital, 198 big “P” level, 198–202 little “p” level, 202–204 interconnectedness, 367–368

INDEX  481

interest groups, 39, 80, 83, 167, 172, 174, 175–177, 178, 181, 183, 185, 210, 212, 216, 295, 454 intergovernmental organizations (IGOs), 429, 430, 433 Internal Revenue Service (IRS), 400, 402 International Academy of Nursing Editors (INANE), 431 International Council of Nurses (ICN), 12, 39, 61, 429, 434 Rural and Remote Nursing Network, 436 specialty nurses networks within, 436 telenursing network, 436 work with global institutions, 441 International Federation of Nurse Anesthetists (IFNA), 431, 436, 437 International Nurses Society on Addiction (IntNSA), 266, 431 international nursing collaborations, 435–436 international professional associations, 429 Internet, 296–297 interprofessional collaboration, 19–20 Interprofessional Education Collaborative (IPEC), 19 IntNSA. See International Nurses Society on Addiction inverted pyramid, 308, 314 IOM. See Institute of Medicine IOM Committee on Quality of Health Care, 16 IPEC. See Interprofessional Education Collaborative IRB. See institutional review board IRS. See Internal Revenue Service ISMP. See Institute for Safe Medication Practices Joint Commission, The, 20, 144, 185, 359 Journal of Nursing Scholarship, 435 journalists, 312 judicial actions, 93–94 jurisdiction, 78, 94, 182–183, 449–450 Kaiser Family Foundation, 73 Kellogg Foundation, 199, 277, 435 knowledge transfer, 140 LAIG. See Legislative Action Interest Group LANO. See Louisiana Alliance of Nursing Organizations LDA. See Lobbying Disclosure Act

leadership, 432, 468–469 for advocacy plan, 263–267 professional associations and, 263–264 Leadership for Change (ICN’s programs), 61 legislation, 198 for federal statutes, 85 policy makers and, 87 process, 78, 80–82 reenactment laws, 81 Legislative Action Interest Group (LAIG), 457 legislative agenda, 11, 181, 208 levels of change, 232 licensure change, 226 policy models, 254 life cycle change/innovation, 233 litigation, 185–186 Lobby Days, 59, 213 lobbying financial capital, 215–216, 217 political capital, 207–208, 210 Lobbying Disclosure Act (LDA), 207, 208 lobbyist, 60, 116, 199, 201, 205, 213, 215–216 logic model, 367 Louisiana Alliance of Nursing Organizations (LANO), 186 Louisiana State Nurses Association (LSNA), 185–186 LSNA. See Louisiana State Nurses Association MACRA. See Medicare Access and CHIP Reauthorization Act Magnet Recognition Program, 65, 165 manpower, in advocacy plan, 274–275 MAP. See Measure Applications Partnership marketing, 150, 301 MDGs. See Millennium Development Goals Measure Applications Partnership (MAP), 19 media advocacy. See also message development; social media campaigns, 294, 295 directories, 304 health policy, 294–296 interviews, 294 media convergence, 292, 298 media outlets, 295, 302 Medicaid, 398, 399, 414 Medicare, 109, 234 Medicare Access and CHIP Reauthorization Act (MACRA), 130

482  INDEX Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, 374 Medline, 134, 152 mentorship, 46, 341 message delivery, 311–321 message development press advisories, 310 press releases, 308–310 professional associations, 305 reporter calls, 307 sound bites, 307 talking points, 306 written pitches, 306–307 Michigan Keystone ICU Project, 142 Millennium Development Goals (MDGs), 428 mind mapping, 230 Minnesota Nurses Association (MNA), 176–177 Minority Health and Health Disparities and Education Act (2000), 407 Minority Health and Health Disparities Research and Education Act (2000), 407 minority health legislation, 406 MMA. See Medicare Prescription Drug, Improvement, and Modernization Act MNA. See Minnesota Nurses Association moral resilience, 48 motorcycle helmet legislation, 246 NACNS. See National Association of Clinical Nurse Specialists NAM. See National Academy of Medicine NAPNAP. See National Association of Pediatric Nurse Practitioners narratives creating, 278–280 elements of, 279 NAS. See National Academy of Sciences National Academies of Science, Engineering, and Medicine, 402 National Academy of Medicine (NAM), 276, 405 National Academy of Sciences (NAS), 129 National Association of Clinical Nurse Specialists (NACNS), 168, 204 National Association of Pediatric Nurse Practitioners (NAPNAP), 168, 349 National Center for Advancing Translational Sciences (NCATS), 134, 135 National Center for Healthcare Leadership, 349

National Center for Nursing Research (NCNR), 130 National Council of State Boards of Nursing (NCSBN), 113, 226, 253, 266, 276 National Database of Nursing Quality Indicators (NDNQI), 10, 276, 363 National Guideline Clearinghouse, 141 National Healthcare Disparities Report, 405 National Institute of Nursing Research (NINR), 130, 135 National Institute of Occupational Safety and Health (NIOSH), 10 National Institutes of Health (NIH), 129, 134, 135 National League for Nursing, 54, 64 National Licensure Compact (NLC), 226–227 national nursing associations (NNAs), 429, 434, 441 National Nursing Workforce Study, 276 National Patient Safety Foundation (NPSF), 14, 458 National Patient Safety Goals (NPSG), 144 National Pressure Ulcer Advisory Panel (NPUAP), 138 National Prevention Council, 409 National Prevention Strategy (NPS), 409 National Quality Forum (NQF), 19, 20 National Sample Survey of Registered Nurses (NSSRN), 276, 372 natural disasters, 26–27, 173 NCATS. See National Center for Advancing Translational Sciences NCD Alliance, 427 NCDs. See noncommunicable diseases NCNR. See National Center for Nursing Research NCSBN. See National Council of State Boards of Nursing ND program. See nursing doctorate program NDNQI. See National Database of Nursing Quality Indicators networking, 12, 179–180, 206, 295, 297, 300, 302, 341 New York Organization of Nurse Executives and Leaders (NYONEL), 164–165 New York State Nurses Association (NYSNA), 164 news conferences, 318–319 NFP program. See Nurse-Family Partnership program NGOs. See nongovernmental organizations

INDEX  483

Nightingale, Florence, 13, 26, 37, 129, 294, 329, 346 NIH. See National Institutes of Health NIH Revitalization Act (1993), 407 NIH Road Map for Medical Research, 133 Nine Essential Phases of Policy Team Work guidelines, 226–227 NINR. See National Institute of Nursing Research NIOSH. See National Institute of Occupational Safety and Health NIWI. See Nurse in Washington Internship NLC. See National Licensure Compact NMHCs. See nurse-managed health centers NNAs. See national nursing associations NOBC. See Nurses on Boards Coalition noncommunicable diseases (NCDs), 427–428 nongovernmental organizations (NGOs), 427, 429, 430–431 nonmaleficence, 42 NPA. See nurse practice act NPAA. See Nurse Practitioner Alliance of Alabama NPS. See National Prevention Strategy NPSF. See National Patient Safety Foundation NPSG. See National Patient Safety Goals NPUAP. See National Pressure Ulcer Advisory Panel NQF. See National Quality Forum NSSRN. See National Sample Survey of Registered Nurses nurse advocate, 38, 52, 54, 65, 187 nurse anesthetists, 437 nurse educator, 459–461 Nurse in Washington Internship (NIWI), 202, 457 nurse practice act (NPA), 57, 184 Nurse Practitioner Alliance of Alabama (NPAA), 346 nurse residency programs, 456 nurse staffing, 19, 25, 368, 379 Nurse-Family Partnership (NFP) program, 411, 412 nurse-managed health centers (NMHCs), 58 nurse-sensitive indicators, 451 Nurses Environmental Advocacy Team for Ohio (NEATO), 267 Nurses on Boards Coalition (NOBC), 91, 340, 341 Nursing Community Coalition, 213 nursing doctorate (ND) program, 75, 461 nursing lens, 330, 336–338, 346–347

Nursing: Scope and Standards of Practice, 41, 51, 64, 264 nursing voice, 90 nursing workforce, 438 competency and quality of care, 439 equitable distribution, 438–439 healthy work environments, 439–440 Nursing’s Social Policy Statement, 264 NYONEL. See New York Organization of Nurse Executives and Leaders NYSNA. See New York State Nurses Association OAC. See Obesity Action Coalition OASIS. See Outcome and Assessment Information Set Obamacare, 21, 368 Obesity Action Coalition (OAC), 299 OECD. See Organization for Economic Cooperation and Development Office for Human Research Protections (OHRP), 138, 139 Office of Minority Health (1986), 407 Office of Policy, Communications and Strategic Alliances (OPCSA), 134, 135 Offices of Minority Health, 408 OHRP. See Office for Human Research Protections Oncology Nursing Society (ONS), 168, 436 Online Journal of Issues in Nursing, 383 ONS. See Oncology Nursing Society OPCSA. See Office of Policy, Communications and Strategic Alliances opinion editorials (op-eds), 313 opposition assessment, 178 Organization for Economic Cooperation and Development (OECD), 363 organizational chain of command, 39, 48, 62 organizational factors, 151 organizational leadership, 243–244 organizational logics, 230 organizational nurse leaders, 462, 463 organizational policy-oriented newsletters backgrounders, 314–315 briefings, 318–319 images, 315–316 interviews, 316–317 policy briefs, 314–315 policy makers, 314 press conferences, 318–319 speeches, 316 tip sheets, 314–315 organizational structure, 151, 203, 365, 459

484  INDEX Outcome and Assessment Information Set (OASIS), 363 outcomes, 366–367, 372 PAAC. See Peer Assistance Advisors Committee PACs. See political action committees patient advisory councils, 112 patient-centered medical homes (PCMH), 24–25 Patient-Centered Outcomes Research Institute (PCORI), 133, 135, 248 Patient Protection and Affordable Care Act (PPACA), 23–24, 109, 234, 303, 368, 399 provisions, 21–22 workforce needs, 14–16 patient safety, 14, 16–20, 43, 55, 56, 57, 142, 144, 167, 179–180, 227, 330, 348, 360, 377, 451–453 patient’s right to privacy, 44 pay for performance, 15, 374 PCMH. See patient-centered medical homes PCORI. See Patient-Centered Outcomes Research Institute Peer Assistance Advisors Committee (PAAC), 266–267 Pennsylvania State Nurses Association (PSNA), 28, 267 persistence, 180 PEST analysis. See political, economic, sociocultural, technological analysis PESTLE. See political, economic, sociocultural, technological, legal, environmental analysis Pipeline to Placement initiative, 348 Plum Book, 93 POHEM. See POpulation HEalth Model policy, 329 accountability, 374–377 action-oriented, 456 advocacy, 461 analysis, 361–362 benchmarking, 362–364 change and uncertainty, 463–464 change measurement, 369–372 competencies, 455–457, 465, 466 congressional committees, 83–86 costs, 376–377 data sources, 372–373 education for, 459 evaluation, 361 failures, 375 fellowship programs, 457–458 influential voice in, 96

intended and unintended consequences, 80, 82, 377, 379, 380–382 interconnectedness, 367–368 involvement, 458, 460 issues, 361 and legislation, 81, 87 nursing scholarship, 386 outcome, 365, 366–367, 382–383 and political action, 96 for profession, 449–451 roles, 459–463 scholarship, 383–385 strategies for influencing, 82, 89 structure, 364–365 transparency, 374–377 policy analysis methods, 119–123, 139 policy brief, 314–315 policy change, 246–247 policy failure adverse selection issues, 252 asymmetrical information, 251–252 design and implementation, 252–253 inappropriate objectives, 251 moral hazard issue, 252 suggestions for avoiding, 252 policy formation, 236, 254 intent of, 243 mechanisms of, 255 need for, 238–239 team dynamics around, 240 threat to integrity of, 252 policy group, 238, 241 policy maker, 116, 130–134, 140, 148, 151, 153, 166, 172–173, 181, 196, 198, 207, 212, 294, 295, 296, 311, 314, 374 policy process, 365–366 basic phases, 7 essential elements in, 251 journey, 9–14 levels, 6 nurse’s role, 5–6 readiness strategies, 13 workforce needs, 14–16 policy research, 138 policy teamwork, 235, 239 clinical handoffs, 243 collective agreement, 241–242 context, timeline, powers, and deliverables, 238–239 decision making, 242 foundational need, 235–236 organizational leadership, 243–244 policy statements, 244–245 right stakeholders, 238

INDEX  485

simple policy statements, 244, 245 team leadership, 240 team tools and dynamics, 241 policy translation, 245–248 policy-making cycle, 7–9, 74, 106 political action committees (PACs), 75, 92, 208, 216–217 political activism, 6, 11, 63, 74, 302–304, 340 political capital, 196–197, 207 big “P” level, 207–209 coalition building, 212–214 free rider syndrome, 211–212 grassroots, 209–211 little “p” level, 214–215 political, economic, sociocultural, technological (PEST) analysis, 114–116 political, economic, sociocultural, technological, legal, environmental (PESTLE) analysis, 115 political environment, 114, 118 political skills, 60, 331 politics, 74, 331 appointment process, 340 board service, 343–346 community and work, 341 elected positions, 339–343 influence, power to, 330–335 nurse leaders, 336 nursing lens, 336–338, 346–347 nursing voice, 90 opportunities, 347–351 registering and voting, 90–91 staff, 340–341 volunteers, 91, 340–341 POpulation HEalth Model (POHEM), 122 post-test evaluation design, 371 poverty, 426, 428 power, 5, 74, 78, 166, 330–335 PPACA. See Patient Protection and Affordable Care Act PR. See public relations practice barriers, 48, 59, 63, 106, 109, 112, 123, 183, 217, 449–450 precautionary principle, 49–50 press conferences, 318–319 press releases, 308-310 problem, defining, 171–172 problem identification, 105–106, 163, 382 environmental scanning, 113–114 external factors, 113, 114, 116 internal factors, 113, 116 PEST analysis, 114–116

policy analysis, 119–123 scenario analysis, 118 steps, 122–123 SWOT analysis, 116–118 tools, 113 working group formation, 111–113 problem solving, advocacy competencies, 51 professional associations, 46–47, 78, 83–86, 89, 141, 167, 176, 177 professional issues panels, 340 program evaluation, 359 program theory, 367 prototyping, 231 PSAs. See public service announcements PSNA. See Pennsylvania State Nurses Association public expectation, for advocacy, 50–51 public health, 133, 301–302 public hearings, 83, 84, 85 public insurance, 398 public policy, 39, 60, 115, 129, 173, 184, 294, 321, 362, 400, 404 public relations (PR), 297 public service announcements (PSAs), 312 punctuated equilibrium, 230 QI. See quality improvement QR code, 301 QSEN. See Quality and Safety Education for Nurses quality, 16–20, 139–145, 362–364, 368, 451–453 Quality and Safety Education for Nurses (QSEN), 17, 19 Quality and Safety in Nursing, 350 Quality Cost Model of Advanced Practice Nurses (APNs) Transitional Care, 138 quality improvement (QI), 22, 139–140, 148, 154, 174, 350, 362–364 race, 394–395, 398 RACs. See regional action coalitions Raise the Voice (AAN campaign), 347 randomized controlled trials (RCTs), 137 RCTs. See randomized controlled trials readiness, assessment of, 277–278 reenactment laws, 81 regional action coalitions (RACs), 175 registered nurse first assistants (RNFAs), 176–177 regulations, 78, 80, 81, 139, 183–185 regulatory process, 184

486  INDEX Report of the Secretary’s Task Force on Black and Minority Health, 405 Research-to-Policy Collaboration (RPC), 133 resistance to change, 249–250 resource identification, advocacy competencies, 54–55 resources, assessment of, 273 communication, 277 data, 276 economic resources, 276–277 people and manpower, 274–275 readiness, 277–278 risk adjustment, 375 RN Action Center, 275 RNFAs. See registered nurse first assistants Robert Wood Johnson Foundation (RWJF), 130, 165, 168, 198, 212, 265, 276 Rosswurm-Larrabee Model, 204 RPC. See Research-to-Policy Collaboration RWJF. See Robert Wood Johnson Foundation safety, 451–453 San Francisco Health Improvement Partnership (SFHIP), 411–412 scenario analysis, 118 scenario planning, 230–231 Science and Environmental Health Network (SEHN), 50 Scope of Practice Partnership (SOPP), 53 SDGs. See sustainable development goals SDOH. See social determinants of health secondary outcomes, 370 SEHN. See Science and Environmental Health Network SES. See socioeconomic status SFHIP. See San Francisco Health Improvement Partnership shared governance, 38, 46, 62, 457, 461–463 short-term programs, 201 Sigma Theta Tau International (STTI), 431, 434–435 Singapore Nurses Association, 434 SNAs. See state nurses associations social capital, 204–205, 204–207 big “P” level, 205–206 little “p” level, 206–207 social determinants of health (SDOH), 395–399, 400, 402–403 social inequities, 391 social justice, 37, 48–49 social marketing, 301–302 social media, 181, 198, 275, 292 blogs, 300

challenges for, 304 Facebook, 299 Instagram, 300 Internet and, 296 and political activism, 302–304 public health, 301–302 QR code, 301 social marketing, 301–302 tools, 297–301 Twitter, 299–300 video streaming, 300 Social Security Act, 234 social web, 296 sociocultural environment, 114 socioeconomic status (SES), 392, 395, 398 SOPP. See Scope of Practice Partnership sound bites, 307 speeches, 181, 316 SPS. See Student Policy Summit SQUIRE. See Standards for Quality Improvement Reporting Excellence SRNAs. See student registered nurse anesthetists stakeholder analysis, 148 stakeholders, 174–175, 239 Standards for Establishing and Sustaining Healthy Work Environments, 55 Standards for Quality Improvement Reporting Excellence (SQUIRE), 384 state nurses associations (SNAs), 59–60, 62, 172, 201, 458 strengths, weaknesses, opportunities, and threats (SWOT) analysis, 116–118 structure, 62, 64, 65, 151, 203, 212, 213, 359 STTI. See Sigma Theta Tau International Student Policy Summit (SPS), 202–203 student registered nurse anesthetists (SRNAs), 266 Substance Abuse and Mental Health Services Administration, 408 substance use disorder (SUD), 266–267 substantive policy, 203 SUD. See substance use disorder summative evaluation, 369 sustainability management, 382 sustainable development goals (SDGs), 428–429 SWOT analysis. See strengths, weaknesses, opportunities, and threats analysis systematic review, 133, 151, 153, 380 systemic agenda, 169 TCM. See Transitional Care Model team dynamics, 235, 240

INDEX  487

team leadership, 241 decision making, 242 disciplined team, 240 technological environment, 115 technology, in healthcare organizations, 413 technology transfer theory, 132 teleological change/innovation, 233 time parameters, 231 title protection, 449 To Err Is Human (IOM report), 16, 167 tobacco use, efforts to reduce, 269 toxic environments, childhood exposures to, 392–393, 412 traditional media, 292 transformational leadership, 65 Transitional Care Model (TCM), 139, 142, 199 translating evidence into policy, nurse’s role, 140–141 translational research, 133, 134 transparency, 22, 374–377 Twitter, 299–300 UHC. See universal health coverage UHG. See UnitedHealth Group UN. See United Nations unaligned interest groups, 178 understaffing, 62–63 Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care report, 49, 405 United Nations (UN), 423, 424, 427, 428–429, 433 UnitedHealth Group (UHG), 341 universal health coverage (UHC), 427, 442 U.S. Constitution, 77, 78 U.S. Department of Health and Human Services (DHHS), 93, 138, 183–184, 393, 394, 399 U.S. Department of Veterans Affairs (VA), 167 U.S. government branches, 79

U.S. House of Representatives and Senate, 414 U.S. Public Health Service (USPHS) Commissioned Corps, 50 USPHS Commissioned Corps. See U.S. Public Health Commissioned Corps VA. See Veterans Affairs venue shopping, 182 Veterans Affairs (VA), 237 Veterans Health Administration (VHA), 76, 237, 450 VHA. See Veterans Health Administration video streaming, 300 Vimeo, 300 violence against nurses bill, 9–11 Visiting Nurse Service of New York, 346 volunteer, 91, 111, 116, 121, 180, 207, 275, 319, 332, 340–341 vote buying, 216 Wald, Lillian, 346, 452 Washington State Department of Health, 184 websites, 54, 296–297 whistle-blowing, 44, 63, 463 WHO. See World Health Organization WHO Collaborating Centres, 435–436 work environment, 55, 450–451 workforce migration, 438 working group, formation, 111–113 workplace safety, 14 World Health Organization (WHO), 26, 132, 144, 393, 394–395, 427–429, 433, 438 World Medical Association, 431 World Wide Web (WWW), 296 WWW. See World Wide Web YouTube, 300