The Policy Design Process

The Policy Design Process

S i x t h E d i t i o n

Jeri A. MilsteAd, Phd, rN, NeA-BC, FAAN NANCy M. short, drPh, MBA, BsN, rN, FAAN

heAlth PoliCy and PolitiCs A Nurse’s Guide

 

 

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Names: Milstead, Jeri A., editor. | Short, Nancy Munn, editor. Title: Health policy and politics : a nurse’s guide / [edited by] Jeri A.     Milstead, Nancy Munn Short. Other titles: Health policy and politics (Milstead) Description: Sixth edition. | Burlington, MA : Jones & Bartlett Learning,     [2019] | Includes bibliographical references and index. Identifiers: LCCN 2017029269 | ISBN 9781284126372 (casebound) Subjects: | MESH: Legislation, Nursing | Health Policy | Politics | Nurse’s     Role | United States Classification: LCC RT86.5 | NLM WY 33 AA1 | DDC 362.17/30973–dc23 LC record available at https://lccn.loc.gov/2017029269

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Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

Acknowledgments . . . . . . . . . . . . . . . . . . . .x

Contributors . . . . . . . . . . . . . . . . . . . . . . . . xi

Chapter 1 Informing Public Policy: An Important Role for Registered Nurses . . . . . . . . . . . . . . 1

Jeri A. Milstead, Nancy M. Short

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

How Is Public Policy Related to Clinical Practice? . . . . . . . . . . . . . . . . . . . . .2

Healthcare Reform at the Center of the Public Policy Process . . . . . . . . . 11

Developing a More Sophisticated Political Role for Nurses . . . . . . . . . . . . . 11

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Discussion Points . . . . . . . . . . . . . . . . . . . . . 13

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Chapter 2 Agenda Setting: What Rises to a Policymaker’s Attention? . . . . . . . . . 17

Elizabeth Ann Furlong

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Overview of Models and Dimensions . . . . . . . . . . . . . . . . . . . . . . . . 23

Summary Analysis of a National Policy Case Study . . . . . . . . . . . . . . . . . . 32

Theory Application to the Nebraska Nurse Practitioner Case Study . . . . . . . . . . . . . . . . . . . . . . . . . 32

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Discussion Points . . . . . . . . . . . . . . . . . . . . . 34

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Online Resources . . . . . . . . . . . . . . . . . . . . . 36

Chapter 3 Government Response: Legislation . . . . . . . . . 37

Janice Kay Lanier

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Process, People, and Purse Strings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Playing the Game: Strategizing for Success . . . . . . . . . . . . . . . . . . . . . . . . . 50

Thinking Like a Policymaker . . . . . . . . . . . 52

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Discussion Points . . . . . . . . . . . . . . . . . . . . . 55

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Chapter 4 Government Response: Regulation . . . . . . . . . 57

Jacqueline M. Loversidge

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Regulation Versus Legislation . . . . . . . . . 58

Health Professions Regulation and Licensing . . . . . . . . . . . . . . . . . . . . . . 60

The State Regulatory Process . . . . . . . . . 66

The Federal Regulatory Process . . . . . . . 72

Current Issues in Regulation and Licensure: Regulatory Responses . . . . . . . . . . . . . . . . . . . . . . . . . 78

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Discussion Points . . . . . . . . . . . . . . . . . . . . . 81

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Chapter 5 Public Policy Design . . . . . . . . . . . . . 87

Catherine Liao

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 87

The Policy Design Process . . . . . . . . . . . . 90

Contents

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Research Informing the Policy Process . . . . . . . . . . . . . . . . . . . . . . 91

The Design Issue . . . . . . . . . . . . . . . . . . . . . . 92

Policy Instruments (Government Tools) . . . . . . . . . . . . . . . . 93

Behavioral Dimensions . . . . . . . . . . . . . . . 95

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Discussion Points . . . . . . . . . . . . . . . . . . . . . 97

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Chapter 6 Policy Implementation . . . 101

Leslie Sharpe

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 101

Federal and State Policymaking and Implementation 101 . . . . . . . . . . 103

Implementation Research . . . . . . . . . . . 104

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 111

Discussion Points . . . . . . . . . . . . . . . . . . . . 112

References . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Chapter 7 Health Policy and Social Program Evaluation . . . . . . . . 115

Anne Derouin

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 116

Nurses’ Role in Policy/Program Evaluation . . . . . . . . . . . . . . . . . . . . . . . . 117

Challenges to Effective Policy and Program Evaluation . . . . . . . . . . . 122

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 126

Discussion Points . . . . . . . . . . . . . . . . . . . . 128

References . . . . . . . . . . . . . . . . . . . . . . . . . . 129

Online Resources . . . . . . . . . . . . . . . . . . . . 130

Chapter 8 The Impact of EHRs, Big Data, and Evidence-Informed Practice . . . . . . . . . . . 133

Toni Hebda

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 134

Electronic Resources: Their Relationship to Health Care . . . . . . . 135

Big Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

Implications for RNs, APRNs, and Other Healthcare Professionals . . . . . . . . . . . . . . . . . . . . . . 145

References . . . . . . . . . . . . . . . . . . . . . . . . . . 148

Chapter 9 Interprofessional Practice . . . . . . . . . . . 151

J. D. Polk, Patrick H. DeLeon

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 151

References . . . . . . . . . . . . . . . . . . . . . . . . . . 152

The Evolving Interprofessional Universe . . . . . . . . . . . . . . . . . . . . . . . . . . 152

What Is Interprofessional Collaboration? . . . . . . . . . . . . . . . . . . . . 152

Core Attributes of Interprofessional Education . . . . . . . . . . . . . . . . . . . . . . . . . 153

The “Team 4” Concept . . . . . . . . . . . . . . . 155

The Future of IPE and Interprofessional Collaboration . . . . 159

References . . . . . . . . . . . . . . . . . . . . . . . . . . 159

Interprofessional Collaboration to Influence Policy . . . . . . . . . . . . . . . . 160

Bipartisan–Bicameral Action . . . . . . . . . 160

Personal Reflections . . . . . . . . . . . . . . . . . 163

Discussion Points . . . . . . . . . . . . . . . . . . . . 169

References . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Suggested Readings . . . . . . . . . . . . . . . . . 169

Chapter 10 Overview: The Economics and Finance of Health Care . . . . . . 171

Nancy M. Short

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 173

Economics: Opportunity Costs . . . . . . . 174

Finance: Does More Spending Buy Us Better Health? . . . . . . . . . . . . . 174

Economics: Health Insurance Market . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

Finance: Health Insurance Exchanges . . . . . . . . . . . . . . . . . . . . . . . . 177

Finance: Healthcare Entitlement Programs . . . . . . . . . . . . . 180

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Finance: Payment Models . . . . . . . . . . . . 183

Economics: Information Asymmetry . . . . . . . . . . . . . . . . . . . . . . . 184

Finance: Comparative Effectiveness Research and Quality-Adjusted Life-Years . . . . . . . . . . . . . . . . . . . . . . . . . . 186

Finance: Bending the Healthcare Cost Curve Downward . . . . . . . . . . . . 188

Discussion Points . . . . . . . . . . . . . . . . . . . . 188

References . . . . . . . . . . . . . . . . . . . . . . . . . . 190

Online Resources . . . . . . . . . . . . . . . . . . . . 191

Chapter 11 The Impact of Globalization: Nurses Influencing Global Health Policy . . . . . 193

Dorothy Lewis Powell, Jeri A. Milstead

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 194

Globalization and Its Impact on Nursing and Health Care . . . . . . . . . . 195

The Importance of Understanding the Cultural Context . . . . . . . . . . . . . . . 201

Nurse Involvement in Policy Decisions . . . . . . . . . . . . . . . . . . . . . . . . . 203

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 204

Discussion Points . . . . . . . . . . . . . . . . . . . . 205

References . . . . . . . . . . . . . . . . . . . . . . . . . . 211

Chapter 12 An Insider’s Guide to Engaging in Policy Activities . . . . . . . . 215

Nancy M. Short, Jeri A. Milstead

Strategies to Recognize Political Bias in Information Sources . . . . . . . . 215

Creating a Fact Sheet . . . . . . . . . . . . . . . . 217

Contacting Your Legislators . . . . . . . . . . 219

Example of a Fact Sheet . . . . . . . . . . . . . 220

What to Expect When You Visit Your Policymaker . . . . . . . . . . . . . . . . . . 223

Preparing to Testify . . . . . . . . . . . . . . . . . . 224

Participating in Public Comment Periods (Influencing Rule Making) . . . . . . . . . . . . . . . . . . . . . . 226

How to Write an Op-Ed . . . . . . . . . . . . . . 227

For Serious Thought . . . . . . . . . . . . . . . . . 230

Recommended Nonpartisan Twitter Feeds . . . . . . . . . . . . . . . . . . . . . . 230

Recommended E-Subscriptions . . . . . . . . . . . . . . . . . . . 230

Influential Organizations Affecting Health Policy . . . . . . . . . . . . 231

How to Become a Change Agent in Policy: Betty Sturgeon—One Exemplary Nurse’s Story . . . . . . . . . . . 232

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233

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Preface

This is a contributed text for healthcare professionals who are interested in expanding the depth of their knowledge about public policy and in becoming more sophisticated in their involvement in the political and policy processes. The scope of the content covers the whole process of making public policy within the broad categories of agenda setting; government response; and program/policy design, implementation, and evaluation. The primary focus is at the federal and state levels, although the reader can adapt concepts to the global or local level.

▸ Why a Sixth Edition? The Sixth Edition began with succession planning, when Dr. Nancy Short became co-editor and took on the serious job of planning for this and future editions. Dr. Short’s expertise and credentials demonstrate her comprehensive viewpoint, and she is dedicated to the continuation of this broad-based text on the whole policy process. As founding editor/author, I could not have turned over this text to just anyone. Nancy is an astute editor, has asked relevant and incisive questions, and has been encouraging to me personally. It has been a real pleasure for me to work with her and get to know her deep intellect and caring personality.

The Sixth Edition also introduces new authors with fresh perspectives, all of whom have a significant experiential basis for their expertise. We welcome Dr. Leslie Sharpe, Dr. Toni Hebda, Ms. Catherine Liao, Dr. Anne Derouin, and Dr. Dorothy Powell. We also delight in those who have continued to contribute to this text over the years: Dr. Elizabeth Furlong, Ms. Jan Lanier, Dr. Jaqueline Loversidge, Dr. J. D. Polk, and Dr. Patrick DeLeon. They build on the work of Ardith Sudduth and Dr. Patricia Smart, who retired, and of Dr. Marlene Wilken, Dr. Kimberly Galt, Troy Spicer, and Elizabeth Barnhill. We pledge to continue to challenge our readers to understand the serious business of making public policy and demonstrate their commitment to a democratic republic through their advocacy and involvement. We welcome your comments—let us know how this text has influenced your practice.

▸ Target Audience This text is intended for several audiences:

■ Doctoral and master’s-level students in nursing can use this text for in-depth study of the full policy process. Works of scholars in each segment provide a solid foundation for examining each component. This text goes beyond the

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narrow elementary explanation of legislation, however: It bridges the gap by supporting understanding of a broader policy process in which multiple opportunities for involvement exist.

■ Nurses who work in professional practice in clinical, education, admin- istrative, research, or consultative settings can use this text as a guide for understanding the full range of the policy components that they did not learn in graduate school or may have forgotten. Components are brought to life through nursing research, real-life cases, and theory. This text will help the nurse who is searching for knowledge of how leaders of today influence public policy toward better health care for the future. Nurses in leadership positions clearly articulate nursing’s societal mission. Nurses, as the largest group of healthcare workers in the United States, realize that the way to make a permanent impact on the delivery of health care is to be a part of the decision making that occurs at every step of the healthcare policy process.

■ Faculty in graduate programs and other current nurse leaders can use this text as a reference for their own policy activity. Faculty and other leaders should be mentors both for their students and for other nurses throughout the profession. Because the whole policy process is so broad, these leaders can track their own experiences through the policy process by referring to the components described in this text.

■ A wide variety of healthcare professionals who are interested in the area of healthcare policy will find this text useful in directing their thoughts and actions toward the complex issues of both healthcare policy and public policy. Physicians, pharmacists, psychologists, dentists, occupational and physical therapists, physician’s assistants, and others will discover parallels with their own practices as they examine case studies and other research. Nurses cannot change huge systems alone. Members of the healthcare team can use this text as a vehicle to educate themselves so that, together, everyone in the healthcare profession can influence policymakers.

■ Those professionals who do not provide health care directly but who are involved in areas of the environment that produce actual and potential threats to personal and community health and safety will find this text a valuable resource regarding how a problem becomes known, who decides what to do about it, and which type of governmental response might result. Envi- ronmental scientists, public health officials, sociologists, political scientists, anthropologists, and other professionals involved with health problems in the public interest will benefit from the ideas generated in this text.

■ Interest groups can use this text as a tool to consider opportunities to be- come involved in public policymaking. Interest groups can be extremely helpful in changing systems because their members’ passion for their causes energizes them to act. Interest groups can become partners in the political activity of nurses by knowing how and when to use their influence to assist advanced practice registered nurses (APRNs) at various junctures in the policy process.

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▸ Using This Text Each chapter in the text is freestanding; that is, chapters do not rely, or necessar- ily build, on one another. The sequence of the chapters is presented in a linear fashion, but readers will note immediately that the policy process is not linear. For example, readers of the policy implementation chapter will find reference to scholars and concepts featured in the agenda-setting and policy design chapters. Such is the nature of the public process of making decisions. The material covered is a small portion of the existing research, arguments, and considered thought about policymaking and the broader political, economic, and social concepts and issues. Therefore, readers should use this text as a starting point for their own scholarly inquiry.

This text can be used to initiate discussions about issues of policy and nurses’ opportunities and responsibilities throughout the process. The case studies presented here should raise questions about what should have happened or why something else did or did not happen. In this way, the text can serve as a guide through what some perceive as a maze of activity with no direction but is actu- ally a rational, albeit chaotic, system. The case studies and discussion points are ideal for planning a class or addressing an audience. Many ideas and concepts are presented, and we hope they serve to stimulate readers’ own creative thoughts about how to engage others. Gone are the days of “the sage on stage”—the teacher who had all the answers and lectured to students who had no questions. Good teachers always have learned from students, and vice versa. Today’s teachers are interactive, technically savvy, curious and questioning, and capable of helping learners integrate large amounts of data and information. This text can serve as a guide and a beginning.

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We continue to thank the staff of Jones & Bartlett Learning for their encourage- ment and guidance when we were writing the Sixth Edition. Their confidence in all the contributors has been consistent and unwavering. Christina Freitas, Product Assistant for Nursing, and Rebecca Stephenson, Product Manager for Nursing, have kept the authors on track in meeting deadlines and provided astute editorial assistance.

We also thank the readers of this text for their interest in the policy and political processes. For those of you who have integrated these components and concepts into your nursing careers, we applaud you. You will continue to contribute to the profession and to the broader society. For those readers who are struggling with how to incorporate one more piece of anything into your role as professional nurse, remember that you are advancing the cause of your own personal work, the profession, and healthcare delivery in the United States and throughout the world every time you use the concepts covered in this text. Nurses are a powerful force and exercise their many talents to further good public policy—policy that, ultimately, must improve health care for patients, consumers, and families.

For the wide range of healthcare professionals (dentists, dietitians, phar- macists, physical and occupational therapists, physicians, physician’s assistants, psychologists, and others) who may be reading this text for the first time, we encourage you to collaborate as colleagues in the 21st-century definition of “team” and integrate policymaking into your practices.

From Jeri: Finally, I want to acknowledge my forever-cheering section—my four children, their spouses and significant others, and three grandchildren. They are always there for me and provide continuous support, encouragement, and un- conditional love. I love you, Kerrin, Sunny, and Heath Nethers, and George Biddle; Joan Milstead; Kevin Milstead and Gregg Peace; and Sara and Steve, and Matthew, Cynthia, and baby Colton Lott. You are a fun bunch, and you make me laugh.

From Nancy: I feel very grateful to have had this opportunity to be mentored by Dr. Jeri Milstead as she plans to step away from her role as the founding editor (for five editions!) of this text. She is a role model for whom there are not enough words to describe: Perhaps an “Energizer bunny” metaphor fits best. I wish to thank my husband, Jim, for his continuous support of all my career endeavors, including shoulder rubs when I’ve been using a mouse for way too many hours. I want to acknowledge my children as well: Kolton, Amanda, and Amber have been consistent cheerleaders while simultaneously acknowledging that health policy may not be the most exciting choice for light reading. I also wish to acknowledge the support and inspiration I regularly receive from colleagues and students at the Duke University School of Nursing—especially from Dr. Terry Valiga. Go Blue Devils!

With gratitude, Jeri A. Milstead and Nancy M. Short

Acknowledgments

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Contributors Patrick H. DeLeon, PhD, MPH, JD, is distinguished professor at the Uniformed Services University of the Health Sciences (Department of Defense) in the School of Nursing and School of Medicine. He was elected to the Institute of Medicine of the National Academies of Science in 2008 and served as president of the American Psychological Association (APA) in 2000. For more than 38 years, he was on the staff of U.S. Senator Daniel K. Inouye (Democrat‒Hawaii), retiring as his chief of staff. Dr. DeLeon has received numerous national awards, includ- ing the Order of Military Medical Merit; Distinguished Service Medal, USUHS; National League for Nursing Council for Nursing Centers, First Public Policy Award; Sigma Theta Tau International Honor Society of Nursing, First Public Service Award; Ruth Knee/Milton Wittman Award for Outstanding Achievement in Health/Mental Health Policy, NASW; Delta Omega Honor Society Award for Outstanding Alumnus from a School of Public Health; APA Outstanding Lifetime Contributions to Psychology Award; American Psychological Foundation Gold Medal for Lifetime Achievement in the Practice of Psychology; and Distinguished Alumni Award, University of Hawaii. Dr. DeLeon is currently the editor of Psy- chological Services and has more than 200 publications to his credit. He earned a PhD in clinical psychology, along with an MS (Purdue University), JD (Catholic University), MPH (University of Hawaii), and BS (Amherst College). Dr. DeLeon also has been awarded three honorary doctorates: PsyD (California School of Professional Psychology), PsyD (Forest Institute of Professional Psychology), and HLD (NOVA Southeastern University).

Anne Derouin, DNP, APRN, CPNP, FAANP, is assistant professor at Duke University School of Nursing. She currently serves as lead faculty for the PNP‒Primary Care/MSN program at Duke University School of Nursing. She also teaches in the ABSN, DNP, and master of biological sciences programs at Duke. Dr. Derouin is on the Executive Advisory Board for the Duke‒Johnson & Johnson Leadership Training program and has served as a coaching circle mentor to Duke-J&J Fellows since 2013. As a Certified Pediatric Nurse Practitioner, she has provided adolescent primary care services at community and school-based health centers affiliated with Duke’s Department of Community and Family Medicine for nearly two decades. A member of the inaugural DNP program at Duke University School of Nursing, she earned an MSN/PNP-PC from Duke University and a BSN from the University of Michigan.

Dr. Derouin, who serves as the North Carolina advocacy chair for the National Association of Pediatric Nurse Practitioners (NAPNAP), is considered an adolescent clinical expert. She is active in the Society of Adolescent Health and Medicine (SAHM) and the American Academy of Nurse Practitioners (AANP) and is the co-chair for the Adolescent Special Interest Group of NAPNAP.

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She has participated in pediatric, school-based health, and advanced nursing prac- tice advocacy efforts at state and federal levels and has been selected for advocacy fellowships for several professional organizations, including the School-Based Health Alliance (formally National Assembly of School-Based Health Centers), Nurse in Washington Internship (NIWI), Shot@Life (World Health Organization’s global vaccine efforts), and as a Faculty Policy Intensive Fellow for the American Association of Colleges of Nursing (AACN).

Elizabeth Ann Furlong, PhD, JD, MA, MS, BSN, RN, is associate professor emerita at Creighton University, Omaha, Nebraska. Dr. Furlong developed and taught health policy courses in a master’s program in healthcare ethics at the Center for Health Policy and Ethics, in health administration, and at undergraduate and graduate levels in a school of nursing. Her doctoral dissertation focused on the policy initiation, legislative process, and eventual creation of the National Institute of Nursing Research. Dr. Furlong has been active for decades in health policy advocacy for vulnerable populations and for the nursing profession through civic engagement; in partisan political activities; and through participation on local, state, and national boards of directors of nonprofit associations and nursing and health organizations. She currently serves on the board of directors of the Association of Safe Patient Handling Professionals the Omaha Visiting Nurses Association, and the Douglas County Nursing Home Foundation. Dr. Furlong earned a JD (Creighton University, Omaha, Nebraska), a PhD and MA in political science with a major in health policy (University of Nebraska, Lincoln), an MS (University of Colorado, Denver), a BSN (Marycrest College, Davenport, Iowa), and a diploma from Mercy School of Nursing (Davenport, Iowa).

Toni Hebda, PhD, MSIS, RN-BC, CNE, is professor of nursing at Chamberlain College MSN online program and co-author of The Handbook of Informatics for Nurses and Healthcare Professionals, now in its sixth edition. She has presented internationally and nationally on nursing informatics, practiced as a staff nurse, taught nursing, and worked in information services. She is nationally certified in nursing informatics through the American Nurses Credentialing Center. Dr. Hebda is a member of the American Medical Informatics Association, the American Nurses Association, Sigma Theta Tau International, the American Nursing Informatics Association, and the Healthcare Information and Manage- ment Systems Society.

Dr. Hebda earned a PhD, MSIS, and MNEd from the University of Pittsburgh, a BSN from Duquesne University, and a diploma from Washington (Pennsylvania) Hospital School of Nursing. The focus of her doctoral program was on higher education. Her dissertation examined the use of computer-assisted instruction among baccalaureate programs.

Janice Kay Lanier, JD, RN, has spent the better part of her nursing career in the health policy arena. Beginning in 1981, when she was selected to participate in the competitive Ohio Legislative Service Commission Internship Program, her involvement in public policy has taken her in many different directions. Working for three state senators and staffing the Ohio Senate health committee for a year gave her a look at the inner workings of the legislative process and its players. That

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year convinced her of how important policymaking is to nurses and the nursing profession, so she became the director of government affairs for the Ohio Nurses Association (ONA). During her 25-plus years as a lobbyist and consultant on behalf of nursing, she was at the forefront of many initiatives, including recognition of advanced practice nursing and efforts to enact safe staffing legislation in Ohio. She also served as associate executive director of the Ohio Board of Nursing, which provided an opportunity to be involved in the regulatory side of policymaking. In 2008, she ran unsuccessfully for the Ohio House of Representatives—an experience that offered her insights into yet another aspect of public policymaking. Currently, she teaches health policy to graduate nursing students at The Ohio State University, chairs the ONA Health Policy Council, and serves on the Ohio Asso- ciation of Advanced Practice Nurses Full Practice Authority Committee. She has received numerous awards in recognition of her advocacy efforts at the local, state, and national levels. Ms. Lanier earned a JD and BA in political science from The Ohio State University and a diploma from St. John’s Hospital School of Nursing.

Catherine Liao, MSPH, BS, is director of government relations for Duke Health System, a position in which she is responsible for leading the implementation of a comprehensive and diversified federal government relations program working to strengthen Duke Health’s identity and reputation in biomedical research, education, training, and service. Prior to joining Duke, she served for nearly six years in the Washington, D.C., Office of Congressman David Price (North Carolina‒04) handling health, education, labor, and housing appropriations issues. She has worked as a research assistant at the North Carolina Institute of Medicine, assisting staff with review of federal health reform legislation and recommendations for implementation at the state level. She also completed an administrative fellowship and served in the Office of the Chief of Staff at the Durham Veterans Affairs Medical Center. Ms. Liao holds an MS in public health from the University of North Carolina’s Gillings School of Global Public Health and a BA in political science from the University of North Carolina at Chapel Hill.

Jacqueline M. Loversidge, PhD, RNC-AWHC, CNS, is assistant professor of clinical nursing at The Ohio State University College of Nursing. Dr. Loversidge has been educating undergraduate and graduate students in the areas of health policy and regulation, evidence-based practice, and leadership in nursing and health care for nearly 15 years. She has extensive experience in state regulation, having held two positions on the Ohio Board of Nursing (OBN)—associate executive director and education consultant. While at OBN, she served on several National Council of State Boards of Nursing (NCSBN) committees, including the Committee on Special Projects, responsible for transformation of the paper-and-pencil NCLEX licensure examination to computer adaptive mode. Dr. Loversidge’s research interests focus on advances in health professions education that have an impact on healthcare quality and safety and are informed by an evidence base. Two major areas fall under that umbrella: (1) health policy, regulation, and advocacy, including licensure and scope of practice; and (2) interprofessional education, including supporting foundations found in organizational structures and cultures. Dr. Loversidge earned a PhD in higher education policy and leadership from The Ohio State University; a master’s degree with a major in nursing from Wright

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State University, Dayton, Ohio; a BSN from Ohio University, Athens, Ohio; and a diploma from Muhlenberg Hospital School of Nursing, Plainfield, New Jersey.

Jeri A. Milstead, PhD, RN, NEA-BC, FAAN, is senior nurse consultant for public policy, leadership, and education. Dr. Milstead is professor and dean emerita at University of Toledo College of Nursing, where she served for 10 years; was di- rector of graduate programs at Duquesne University (Pittsburgh, Pennsylvania) for 3 years; and was a faculty member at Clemson University (South Carolina) for 10 years. She is the founding editor and senior author of Health Policy and Politics: A Nurse’s Guide, with copies sold in 22 countries (6 of 7 continents), and Handbook of Nursing Leadership: Creative Skills for a Culture of Safety. She has authored invited chapters in four other current nursing textbooks, has published in national and international journals, and was editor-in-chief of The Interna- tional Nurse from 1995 to 2006, when the publication was retired. Dr. Milstead was a policy advisor in the Washington, D.C., office of Senator Daniel K. Inouye (Democrat‒Hawaii), was president of the State Board of Nursing for South Carolina, and held leadership positions in the State Nurses Associations in Ohio, Pennsylvania, and South Carolina. She is a fellow of the American Academy of Nursing and a member of ANA/ONA and Sigma Theta Tau International. She is board certified as a Nurse Executive‒Advanced by the American Nurses Credentialing Commission.

Dr. Milstead has been honored with the Mildred E. Newton Distinguished Educator award (OSU College of Nursing Alumni Society) and membership in the Cornelius Leadership Congress (ONA’s “most prestigious” award), named a Local Nursing Legend by the Medial Heritage Center at OSU, and placed in the Ohio Senior Citizens Hall of Fame and the Washington Court House (Ohio) School System Academic Hall of Fame. She was named a “Transformer of Nursing and Health Care” (OSU CON Alumni Association) and a “Pioneer” in distance education and a career achievement award (Utah); she also received the Creative Teaching Award (Duquesne University) and two political activism awards. From 2005 through 2008, she was appointed to the Toledo‒Lucas County Port Authority, where she chaired the port committee and was a member of a trade delegation to China. She has conducted research or consultation in the Netherlands, Jordan, Nicaragua, and Cuba.

Dr. Milstead holds a PhD in political science with majors in public policy and comparative politics from the University of Georgia; an MS and BS, cum laude, in nursing from The Ohio State University; and a diploma from Mt. Carmel Hospital School of Nursing, where she is a Distinguished Alumna and current member of the board of trustees.

J. D. Polk, DO, MS, MMM, CPE, FACOEP, is chief health and medical officer of the National Aeronautics and Space Administration (NASA) located in Washington, D.C. He is the former dean of medicine at Des Moines University (Iowa) College of Osteopathic Medicine. Prior to that, Dr. Polk was the assistant secretary (acting) for health affairs and chief medical officer of the U.S. Department of Homeland Security (DHS), assuming this post after serving as the principal deputy assistant secretary for health affairs and deputy chief medical officer. Before coming to DHS, Dr. Polk was the chief of space medicine for the NASA Johnson Space Center in

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Houston, Texas. He has also served as state emergency medical services medical director for the state of Ohio and chief of Metro Life Flight in Cleveland, Ohio. He has served on the board of directors for the Red Cross of Greater Iowa, the board of directors of ChildServe of Iowa, the board of trustees for the American Public University System, the board of directors of the American Association for Physician Leadership, and has been a member of the American Osteopathic Association’s Commission on Osteopathic College Accreditation. Dr. Polk is a fellow of the American College of Osteopathic Emergency Physicians and an associate fellow of the Aerospace Medicine Association.

Dr. Polk is well published in the fields of emergency medicine, disaster medicine, space medicine, and medical management. He is a clinical associate professor of emergency medicine at the Edward Via College of Osteopathic Medicine and affiliate associate professor and senior fellow in the School of Public Policy at George Mason University. He has received numerous awards and commendations, including citations from the Federal Bureau of Investigation, White House Medical Unit, Association of Air Medical Services, and U.S. Air Force, and has received the NASA Center Director’s Commendation, the NASA Exceptional Service Medal, the National Security and International Affairs Medal, and the NASA Exceptional Achievement Medal.

Dr. Polk received his degree in osteopathic medicine from A. T. Still Univer- sity in Kirksville, Missouri. He completed his residency in emergency medicine with the Mt. Sinai hospitals via Ohio University and completed his training in aerospace medicine at the University of Texas Medical Branch. He is board certified in both emergency medicine and aerospace medicine. Dr. Polk holds an MS in space studies from the American Military University, a master’s degree in medical management from the University of Southern California’s Marshall School of Business, and a master’s certificate in public health from the University of New England.

Dorothy Lewis Powell, EdD, MS, ANEF, FAAN, is professor emeritus of nursing and associate dean at Duke University School of Nursing, where she founded the Office of Global and Community Health Initiatives (OGACHI). OGACHI is responsible for the development of short-term study-abroad programs across several continents for undergraduate and graduate students. She has been a dean and associate dean of nursing in higher education for more than 47 years.

Throughout her professional life, Dr. Powell has been engaged in policy-oriented endeavors, including a commitment to the poor and underserved, particularly the homeless. She has secured grants in excess of $10 million, including funding that established a nurse-managed clinic for the homeless and the acclaimed Nursing Careers for the Homeless People project in Washington, D.C. She has held local and state-level positions through the American Nurses Association, the American Association of Colleges of Nursing, as a fellow in the American Academy of Nursing, and the NLNAC Academy of Nursing Education. For a number of years, she was a member of the advisory committee for Partners Investing in Nursing’s Future, Robert Wood Johnson Foundation, and on sev- eral Department of Health and Human Services councils. She has represented professional nursing education associations before Congress and participated in a variety of policy-advocacy conferences and meetings. Since her retirement in 2014, she has become actively involved in politics at the local and state

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levels, serving as precinct chair and chairman of the Durham County African American Caucus.

Dr. Powell has traveled to 47 countries conducting projects, training students, serving as a consultant, studying, planning and hosting conferences, and engaging in leisure-time activities. She has a host of current and former mentees who are excelling in practice, education, research, and policy. Dr. Powell earned an EdD in the administration of higher education from the College of William and Mary, Williamsburg, Virginia, with further study in higher education in the School of Education at Harvard University; an MS in maternal‒infant nursing from Catholic University of America, Washington, D.C.; and a BSN from Hampton University (Hampton, Virginia).

Leslie Sharpe, DNP, FNP-BC, is a clinical assistant professor at the University of North Carolina at Chapel Hill (UNC-CH) School of Nursing. She serves as the lead provider and manager of Sylvan Community Health Center in North Caro- lina. Dr. Sharpe facilitated the opening and ongoing growth of this school-based community health center with the goal of increasing access to health care. Her faculty role with UNC-CH School of Nursing includes establishing innovative faculty practice settings in underserved communities. She educates nurse prac- titioners and nurses about actively engaging in advocacy efforts related to health policy and improving the health of North Carolinians. As chairperson of the North Carolina Nurses Association’s Nurse Practitioner Council Executive Committee from 2011 to 2014, she represented nurse practitioners at state legislative polit- ical events and educated legislators and other stakeholders in health care about advanced practice registered nurse issues. She currently serves as the NP PAC treasurer. One of her passions is serving as a mentor for nurse practitioners in the legislative and advocacy arena; as such, she facilitates a “leadership circle” of local APRNs in the North Carolina Research Triangle area. Dr. Sharpe completed her DNP at Duke University.

Nancy Munn Short, DrPH, MBA, BSN, RN, FAAN, is associate professor at Duke University School of Nursing in Durham, North Carolina, where she has been on faculty since 2003. From 2002 to 2006, she served as an assistant dean at the school. Dr. Short received the School of Nursing’s Distinguished Teaching Award in 2010 and the Outstanding DNP Faculty award in 2010, 2011, 2013, 2015, 2016, and 2017 (the DNP program began in 2009). She teaches health policy, comparative international health systems, transformational leadership, and health economics. In 2009, she was recognized as an Arnold J. Kaluzny Distinguished Alumnus by the School of Public Health. Dr. Short completed a postdoctoral fellowship as a Robert Wood Johnson Foundation Health Policy Fellow from 2004 to 2007. As a part of this fellowship, in 2005, she served as a health legislative aide for the U.S. Senate Majority Leader Bill Frist. With Darlene Curley, she served as co-chair of an AACN think tank charged with making recommendations to the board regarding ways to improve health policy education for nurses.

Dr. Short is nationally known as an advocate for public health. She has provided consultation to the University of North Carolina (UNC) Public Health Management Academy, the UNC Institute for Public Health on international issues related to distance learning, and the Johnson & Johnson Nurse Leadership Program at Duke. She is a fellow in the American Academy of Nursing.

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Dr. Short served as a member of the Durham County (North Carolina) Board of Health. In 2014, she completed a two-year tenure on the board of directors of the National Association of Local Boards of Health, where she specialized in the development of performance standards for the approximately 3,000 boards of health in the United States. Under the auspices of the U.S. Department of State, she delivered leadership and quality management training to a bicommunal (Turk and Greek) program for nurses in Cyprus.

Dr. Short earned a doctor of public health degree with a major in health policy and administration at the University of North Carolina’s Gillings School of Global Public Health and an MBA and BSN from Duke University.

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© Visions of America/Joe Sohm/Photodisc/Getty

KEY TERMS

Advanced practice registered nurse (APRN): A registered nurse with an advanced degree, certified by a nationally recognized professional organization. Four types of APRNs are nurse practitioner (NP), clinical nurse specialist (CNS), certified nurse– midwife (CNM), and certified registered nurse anesthetist (CRNA). Often, nurse executives or administrators are referred to as nurses in advanced roles.

Healthcare provider professionals (HCPs): Registered nurses, advanced practice registered nurses (APRNs), physicians, pharmacists, dentists, psychologists, occupational and physical therapists, dieticians, social workers and physicians’ assistants, and others who are licensed or authorized by a state or territory to provide health care.

Policy: A consciously chosen course of action: a law, regulation, rule, procedure, administrative action, incentive, or voluntary practice of governments and other institutions.

Policy process: Problem identification, agenda setting, policy design, government/organizational response, budgeting, implementation, and evaluation of the policy.

Politics: The process of influencing the allocation of scarce resources. Public policy: A program, law, regulation, or other legal mandate provided by

governmental agents; also, actual legal documents, such as opinions, directives, and briefs that record government decisions.

Rules and regulations: Rules are a set of instructions that tell us the way things are to be done. Regulations are rules authorized by specific legislation. Comment on proposed rules and regulations at https://www.regulations.gov.

Informing Public Policy: An Important Role for Registered Nurses Jeri A. Milstead and Nancy M. Short

1

CHAPTER 1

 

 

▸ Introduction In 2010, the Institute of Medicine* (IOM) issued a report, The Future of Nursing: Advancing Health, Leading Change, that challenged nurses to work with other healthcare professionals in two ways: to learn from them and to help them learn from nurses. In this spirit of interprofessional cooperation and leadership, this text will incorporate a variety of healthcare provider professionals (HCPs) into the discussion of public policy, case studies, discussion points, and reader activities.

▸ How Is Public Policy Related to Clinical Practice?

It is the authors’ belief that nurses and other HCPs are ideally positioned to participate in the policy arena because of their history, education, practice, and organizational involvement.

In this chapter, policy is an overarching term used to define both an entity and a process. The purpose of public policy is to direct problems to the government’s attention and to secure the government’s response.

The definition of public policy is important because it clarifies common misconceptions about what constitutes policy. In this text, the terms public policy and policy are interchangeable. The process of creating policy can be focused in many areas, most of which are interwoven. For example, environmental pol- icy deals with determinants of health such as hazardous materials, particulate matter in the air or water, and safety standards in the workplace. Education policies are more than tangentially related to health—just ask school nurses. Regulations define who can administer medication; state laws dictate which type of sex education can be taught. Defense policy is related to health policy when developing, investigating, or testing biological and chemical weapons. There is a growing awareness of the need for a health-in-all-policies approach to strategic thinking about policy.

Statutes: Written laws passed by a legislative body. Statutes differ from “common law” in that common law (also known as case law) is based on prior court decisions. Statutes may be enacted by both federal and state governments and must adhere to the rules set in the Constitution.

System (capital “S”): The U.S. healthcare delivery and finance system (usage specific to this text).

system (lowercase “s”): A group of hospitals and/or clinics that form a large healthcare delivery organization (usage specific to this text).

* The name of the Institute of Medicine was changed to the National Academy of Med- icine in 2016.

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Health policy directly addresses health problems and is the specific focus of this text. In general, policy is a consciously chosen course of action: a law, regulation, rule, procedure, administrative action, incentive, or voluntary practice of governments and other institutions. By comparison, politics is the process of influencing the allocation of scarce resources.

Policy as an Entity Official government policies reflect the beliefs and values of elected members, the administration in power, and the will of the American people. Official policies provide direction for the philosophy and mission of government organizations. Some policies, known as position statements, report the opinions of organizations about issues that members believe are important. For example, state boards of nursing (government agencies created by legislatures to protect the public through the regulation of nursing practice) publish advisory opinions on what constitutes competent and safe nursing practice.

Laws (or statutes) are one type of policy entity that serve as legal directives for public and private behavior. Laws are made at the international, federal, state, and local levels and are considered the principal source in guiding conduct. Lawmaking usually is the purview of the legislative branch of government in the United States, although presidential vetoes, executive orders, and judicial interpretations of laws also have the force of law.

Judicial interpretation occurs in three ways: (1) through courts’ interpre- tation of the meaning of broadly written laws that are vague regarding details; (2) by determining how some laws are applied—that is, by resolving questions or settling controversies; or (3) by interpreting the Constitution and declaring a law unconstitutional, thereby nullifying the entire statute (Litman & Robins, 1991). For example, the 1973 Rehabilitation Act prohibited discrimination against people with handicaps by any program that received federal assistance. Although this may have seemed fair and reasonable at the outset, courts adjudicated questions of how much accommodation is “fair and reasonable” (Wilson, 1989). In general, courts are idealized as being above the influence of political activity that surrounds the legislature. The court system, especially the federal court system, may also resolve conflicts between levels of government (state and federal).

Regulations and rules are another policy entity discussed elsewhere in this text. Although they often are included in discussions of laws, regulations differ from statutes. Once the legislative branch enacts a law, the executive branch of government administers that law’s implementation. The executive branch consists of the president, the White House staff, multiple agencies, commissions, and departments that carry out the work of implementing and monitoring laws for the public benefit. Government agencies formulate regulations that achieve the intent of the statute. Overall, laws are written in general terms, and regulations are written more specifically to guide the interpretation, administration, and enforcement of the law. The Administrative Procedures Act, enacted in 1946, ensures a structure and process that is published and open, in the spirit of the founding fathers, so the average constituent can participate in the process of public decision making.

All these policy entities evolve over time and are accomplished through the efforts of a variety of actors or players. Although commonly used, the terms

How Is Public Policy Related to Clinical Practice? 3

 

 

position statement, resolution, goal, objective, program, procedure, law, and reg- ulation really are not interchangeable with the word policy. Rather, they are the formal expressions of policy decisions. For the purposes of understanding just what policy is, nurses must grasp policy as a process.

Policy as a Process For purposes of analysis, policymaking comprises five processes:

■ Agenda setting ■ Government response (usually legislation and regulation) ■ Policy design ■ Implementation ■ Evaluation of the policy outcomes ■ Economics and finance of policy

The steps in the policy process are not necessarily sequential or logical. For example, the definition of a problem, which usually occurs in the agenda-setting phase, may change during fact-finding and debate. Program design may be altered significantly during implementation. Evaluation of a policy or program (often considered the last phase of the process) may propel onto the national agenda (often considered the first phase of the process) a problem that differs from the originally identified issue. For the purpose of organizing one’s thoughts and conceptualizing the policy process, we will examine the policy process from a linear perspective in this text, but you should recognize that this path is not always strictly followed.

The opportunities for nurse input throughout the policy process are unlim- ited. Nurses are articulate experts who can address both the rational shaping of policy and the emotional aspects of the process. Nurses cannot afford to limit their actions to monitoring bills; they must seize the initiative and use their con- siderable collective and individual influence to ensure the health, welfare, and protection of the public and healthcare professionals.

Why You Are the Right Person to Influence Health Policy Nursing’s education requirements, communication skills, rich history, leadership, and trade association involvement, as well as our practice venues, uniquely qualify nurses to influence thought leaders and policymakers. Nursing and nurses have an ongoing impact on health and social policies. FIGURE 1-1 illustrates some aspects of nurses’ impact on the health and well-being of populations.

Advanced studies build on education and experience and broaden the arena in which nurses work to a systems perspective, including both regional health systems and the overall U.S. System of healthcare delivery and finance. Nurses not only are well prepared to provide direct care to persons and families but also act as change agents in the work environments in which they practice and the states/nations where they reside.

Nurses have developed theories to explain and predict phenomena they encounter in the course of providing care. In their practice, nurses also in- corporate theory from other disciplines such as psychology, anthropology, education, biomedical science, and information technology. Integration of all

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FIGURE 1-1 Historical timeline of nurses who influenced policy. (continues)

1852 Florence Nightingale used statistics to advocate for improved education for nurses, sanitation, and equality.

1861 Clarissa “Clara” Barton was a hospital nurse in the American Civil War. She founded the American Red Cross.

1879 Mary Mahoney was the first African American nurse in the United States and a major advocate for equal opportunities for minorities.

1903 North Carolina creates first Board of Nursing in nation and licenses the first registered nurse.

1906 Lillian D. Wald, nurse, humanitarian, and author. She was known for contributions to human rights and was the founder of Amer- ican Community Nursing. She helped found the NAACP.

1909 The University of Minnesota bestows the first bachelor’s degree in nursing.

1916 Margaret Higgins Sanger was an American birth control activist, sex educator, writer, and nurse. Sanger popularized the term “birth control” and opened the first birth control clinic in the United States (later evolved into Planned Parenthood).

1925 Frontier Nursing Service was established in Kentucky with ad- vanced practice nurses (midwives).

1955 RADM Jessie M. Scott, DSc, served as assistant surgeon general in the U.S. Public Health Service; led division of nursing for 15 years; testimony before Congress on the need for better nursing training led to the 1964 Nurse Training Act, the first major legislation to provide federal support for nurse education during peacetime.

1966 NP role created by Henry Silver, MD, and Loretta Ford, RN. 1967 Luther Christman, PhD, became the first male dean of a School

of Nursing (at Vanderbilt University). Earlier in his career, he had been refused admission to the U.S. Army Nurse Corps because of his gender. He was the founder of the American Association for Men in Nursing, as well as a founder of the National Student Nurses Association.

1971 Idaho statutorily recognizes advanced practice nursing. 1978 Faye Wattleton, CNM, was elected president of the Planned Par-

enthood Federation of America—the first African American and youngest person ever to hold that office. First African American woman honored by the Congressional Black Caucus.

1987 Ada S. Hinshaw, PhD, became the first permanent leader at the National Institute of Nursing Research at the National Institutes of Health.

1989 Geraldine “Polly” Bednash, PhD, headed the American Associ- ation of Colleges of Nursing’s legislative and regulatory advocacy programs as director of government affairs. She became CEO of AACN in 1989 and co-authored AACN’s landmark study of the financial costs to students and clinical agencies of baccalaureate and graduate nursing education.

How Is Public Policy Related to Clinical Practice? 5

 

 

1992 Eddie Bernice Johnson, BSN, was the first nurse elected to the U.S. Congress (D-TX). Strong voice for African Americans and pro-nursing policies.

1996 Beverly Malone, PhD, elected president of the American Nurses Association; President Clinton appointed her to Advisory Com- mission on Consumer Protection and Quality in the Health Care Industry and to the post of deputy assistant secretary for health within the Department of Health and Human Services.

1998 Lois G. Capps, BSN, California Representative to the U.S. House from 1998–2017, where she founded the Congressional Nursing Congress.

2001 Major General Irene Trowell-Harris, EdD, RN, USAF (Ret.), director of Department of Veterans Affairs, Center for Women Veterans. Instrumental in establishing fellowship for military nurses in the office of Senator Daniel K. Inouye (D-HI).

2009 Mary Wakefield, PhD, became the first nurse appointed as di- rector of the Health Resources and Services Administration. In 2015, she became the Acting Deputy Secretary for the Department of Health and Human Services. Served as Chief of Staff for U.S. Senators Quentin Burdick (D-ND) and Kent Conrad (D-ND).

2010 Mary D. Naylor, PhD, a member of the Medicare Payment Ad- visory Commission influenced health policy with membership on the RAND Health Board, the National Quality Forum Board of Directors, and as pastchair of the Board of the Long-Term Quality Alliance.

2013 Joanne Disch, PhD, influenced health policy as chair of the na- tional board of directors for the American Association of Retired Persons and the American Academy of Nursing.

FIGURE 1-1 Historical timeline of nurses who influenced policy. (continued)

this information reflects the extreme complexity of nursing care and its provi- sion within an extremely complex healthcare system. Nurses understand that partnerships are valued over competition, and that the old rules of business that rewarded power and ownership have given way to accountability and shared risk. Transformation of today’s broken healthcare system will require a radical, cross-functional, futuristic change in the way people think. Observing patterns in personal behavior can be useful when working with policymakers as they try to figure out the best or most cost-effective way to address public problems. Creative ways of examining problems and innovative solutions may cause discomfort among policymakers who have learned to be cautious and go slowly. Nurses and other professionals can help officials employ new ideas to reach their policy goals by sharing stories and interpreting data to show how those data affect patients and professionals.

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