Florida International University Leadership & Management Triaxal of Actions Discussion

  

Read Chapter on Davis Plus: Discussion of Triaxial of action: Policy, Politics,and Nursing

1- What is Policy?

2- Explain each of them:  Public policy—

Private policy—

Health policy—

Social policy—

Organizational policy?

3- Who was Florence Nightingale, and what was her contribution to the Nursing Field?

4- Who was Lillian Wald?

5- Who was Margaret Sanger, and in what way she helped to the developments of Nursing Field?

6_ What is  (ICN), and what they do?

7- What is s (NLCA) and they do?

Jeanne Blum, RN, is a nurse on a LDRP unit. Recently, the policy and procedures manual for Jeanne’s unit included the premature rupturing of membranes of a laboring patient as a practice acceptable for nurses to perform. Jeanne and some of her coworkers shared their concern over lunch about this new responsibility.They felt uncomfortable with the possibility of cord prolapse and other potential medical complications resulting from this practice. Jeanne gathered data from her state and many others states and noted that her hospital was not in compliance with her professional organization practice standards. Jeanne shared this information with her coworkers. She volunteered to contact the state board of nursing on their behalf to request a declaratory statement on the nurse’s role in the initiation of premature rupturing of uterine membranes. Her state board’s clinical practice committee reviewed her request for a declaratory statement and gathered information from other states. A formal declaratory statement was drafted by the board and made it available on its Web site. A letter from the board was sent to Jeanne’s institution, informing it of the declaratory statement, which stated that the task nurses were requested to perform was beyond their scope of practice based on the Nurse Practice Act.

8- Which stage of the policy model does this scenario represent?

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Triaxial of Action:
Policy, Politics, and Nursing
OBJECTIVES
After reading this chapter, the student should be able to:
â–  Provide fundamental information on how to shape policy in
a political environment.
â–  Define key terms regarding policy.
â–  Review the values that are the foundation for health-care
policies and political processes.
â–  Describe the influences that novice nurses must face related
to policy issues.
OUTLINE
Defining Policy
Defining Politics as It Relates to Policy
History of Nursing Politics
19th Century—Florence Nightingale and Sojourner Truth
Early 20th Century—Lillian Wald
Mid-20th Century—Margaret Sanger
Nursing’s Political Growth in the 21st Century
Policy and Nursing Governance
Regulatory Policy—International and National
History of Nursing Licensure
Professional Nursing Organizations: Where Regulation
Stands Now
NCLEX Testing
Multi-State Licensure Compact
State Boards of Nursing
Organizations for Political Action
American Nurses Association
Nursing Organizations Alliance
National League of Nursing
Policy Models: A Guide
Conceptual Model of Political Development
Four Spheres of Political Influence
Nursing and Political Action
Novice Role: Nursing and Policy
Nursing Values Policy
Policy Position and Ethical Practice
Nursing Policy Issues
Nursing Shortage
Mandatory Staffing Ratios
Policy Affecting Nursing
Cost-Containment Initiatives
Quality Data Reporting
Payment for Performance
Report Cards—Transparency
Growing Need for Policy Action
Patient Advocacy
Access to Care
Trust in the System
Conclusion
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In the nursing profession, there is an educational
void with regard to information related to policy
and politics and the nursing role. In 2009, it has
become even more important that nursing students
are exposed to policy and politics during their educational preparation. This preparation will lay the
foundational understanding of the political process,
assisting nursing students to understand that policy
decisions are part of their environment and preparing graduate nurses to become involved and ultimately to drive the political process. Politics is a
world that is continuously changing, and nurses
have an opportunity to choose political action and
thus become participants in policy changes.
Defining Policy
Policy comes from two different Greek roots, one
meaning demonstration or proof and the other meaning citizenship (Chrichton, 1981). It is the citizenship root that we will be addressing. One definition
of a policy is “a purposeful, overall plan of action or
inaction developed to deal with a problem or a matter of concern in either the public or private sector”
(Milstead, 2004, p. 195). Policy has also been defined
as “the continuous chosen course of action/inaction
directed toward some end” (Kalisch and Kalisch,
1982, p. 61) or simply as “authoritative decision
making” (Stimpson and Hanley, 1991, p. 61). The
following definitions of policy and process will provide a better understanding of these related terms:
Public policy—Affects institutional and individual behaviors such as professional licensure or
legislation. Public policy can address local, state,
or federal issues.
■ Private policy—Usually refers to agency or institutional rulings that address employment through
policies, procedures, directives, and guidelines.
■ Health policy—Refers to health-care reimbursement, resources, and/or services related to public
or private health-care institutions.
■ Social policy—Refers to addressing and promoting the public welfare.
■ Institutional policy—Similar to public policy,
but usually discusses how the institution complies with public policy.
■ Organizational policy—Positions taken by nursing organizations such as specialty nursing
associations like the American Organization of
Registered Nurses (AORN) and national
â– 
nursing organizations like the American Nurses
Association (ANA).
■ Policy analysis—Evaluation of the total effects of
a policy as it relates to political, social, economic,
legal, or ethical aspects of proposed or instituted
policies. (Mason, Leavitt, and Chaffee, 2007)
Defining Politics as It Relates
to Policy
When discussing policy, the subject of politics
inevitably arises, as if these terms can be used interchangeably. Politics is an action or a behavior that is
often used to drive the legislative process. The goal
of political action is to influence the end product—
policy. Politics, closely related to policy, opens the
floodgates to many varied opinions. The term politics means the “influencing the allocation of scarce
resources” (Talbott and Vance, 1982, p. 592).
Opportunities exist to influence the outcomes of
the political process.
Health care deals with the allocation of scarce
resources, dividing limited supplies and resources
among members of society. Scarcity means there are
limitations to available resources and therefore not
everyone will have equal access. Nurses are affected
by and direct the use of scarce health-care resources
and dollars on a daily basis. They are impacted by
the limitations and roadblocks in the health-care
system as they try to obtain authorization from
providers for patient-care services. However, the
profession of nursing feels alienated from the political arena. Even though the profession is significantly impacted and directed by policy decisions, it
has been slow to participate in the process. Nursing
needs to be competent in health-care leadership
dynamics if it is to have input into the workplace.
Nurses respond inconsistently to political
action. On the one hand, they traditionally have
referred to the behavior of goal-oriented colleagues
as “playing politics,” a description that is not meant
in a positive way. However, when they need and
want their nurse executive to be politically aware,
they express opposite views. To benefit personally
and professionally, nurses need a “go-to” person
who is able to accomplish change. Whether one
perceives politics as negative or positive depends
largely on the following factors:
â– 
â– 
Acknowledging individual biases
Knowing how the “game” of politics is played
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Understanding the rules in which politics is
operating
â–  Realizing whether the goals or ends are
important
â–  Realizing when one is in a position to change
the rules of the system (Mason, Leavitt, and
Chaffey, 2007, p. 4)
â– 
Policy and politics are important parts of the nursing profession. Nurses can either help create policy
or will be required to respond to it. Politically
astute nurse executives know that relationshipbuilding and networking are required for successful
leadership. Relationships become valuable when
issues require consensus and compromise. It is
important for every new nurse to realize that
relationship-building starts early and builds
throughout their professional career. Relationshipbuilding cannot be put off until help is needed.
Networking, starting as a personal acquaintance,
builds to invaluable relationships that can be called
upon in a time of need.
History of Nursing Politics
Nursing has had many visionaries and heroines
who have addressed social, cultural, and health
problems. These nurse laureates did not remain
silent, but sought to use their voices to highlight
the injustices affecting broad groups of citizens in
the neighborhoods and across the world. It is
important to celebrate those nurses who worked so
diligently to shape policy in their eras and had the
courage to make a difference.
19th Century—Florence Nightingale
and Sojourner Truth
The most famous nursing visionary, Florence
Nightingale (1820–1910), was a statistician and
politician who lobbied for safer health care. After
the Crimean War, Nightingale was confined to bed
for much of the time but used this time to send her
message to nurses and politicians. She sent roses
and held teas for new graduates, challenging the
new nurses to use principles of infection control in
their practice. Because of her training as a statistician, she valued collecting data that could support
and influence people’s minds. Policy makers found
the information fascinating and came to her bedside seeking useful information. Nightingale’s message was clear and her methods of lobbying for her
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cause were successful: “She was a leader who knew
how to garner the support of her followers,
colleagues and policy makers and used her skills to
change her environment” (Mason, Leavitt,
Chaffee, 2007, p. 14).
Sojourner Truth, originally named Isabella Van
Wagner (1795–1883), who was born into slavery,
provided nursing care to Union soldiers during the
Civil War. Truth became politically active and
sought federal funds to train nurses and physicians.
In her speeches, she actively opposed slavery and
advocated for women’s rights. She became famous
in 1851 at the Women’s Rights Convention in
Akron, Ohio, where she challenged the audience to
advocate for the rights of black women in her
speech “Ain’t I a Women.” She was largely responsible for transforming the gender and racist policies
of that era with regard to health care, women, and
African Americans.
Early 20th Century—Lillian Wald
The modern nursing movement tells the story of
women seeking to provide better health care for
their society. They saw the nurse as needed “not
only for bedside care of the sick, but to help in
seeking out the deep-lying basic causes of illness
and misery, that in the future there may be less
sickness to nurse and cure” (Buhler-Wilkerson,
2001, p. 98). Between 1900 and 1930, nurses
sought first to obtain access to health care for
patients and then authority to control the practice
of nursing. In the 1920s, when society paid nurses
directly for private duty services, Lillian Wald
(1867–1940) was instrumental in the acquisition of
funding for private duty nursing. Wald, one example of nurse leaders at this time, created the Henry
Street Settlement and a school nursing program
and initiated the concept of public health nursing.
Looking back, the accomplishments of the Henry
Street nurses were remarkable, especially in light of
the fact that these efforts were successful socially,
economically, and politically even though women
did not gain the right to vote until 1920. Current
models of public health nursing are based on the
work of these pioneers. They provided “community
prevention activities, advocacy for political change,
and services to those who would otherwise not
receive care” (Chang, Price, and Pfoutz, 2001,
p. 219). Lillian Wald saw a health-care system that
needed change and set out to create policy to
improve societal conditions.
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Scenario
1
May Parker trained at Bellevue
Hospital in New York City in 1910
and upon graduation was hired to work for the Henry
Street Settlement. Her daily responsibilities included
visiting 10 families in a tenement dwelling. These
tenements primarily housed immigrant families
whose main source of income was from factory work.
May noted the high incidence of child truancy from
school due to child and family illnesses. She also
noticed that the family shared the bathroom with six
other tenement families. She observed the bathroom
was not cleaned regularly and that the family members had not been instructed in the importance of
hand washing. May organized a general meeting of
all the tenements and created a schedule with
assigned responsibilities to clean the bathroom and
instructed the families on the importance of washing
their hands. May noticed a reduction in the number
of child illnesses in the tenement following the procedural changes. Did May create a policy action and
implement policy change in this apartment building
in New York City? What impact could May have had
in New York City if her actions had been required of
all tenements in New York City? In later years, the
Health Department did require this policy—and
May gained the right to vote. â– 
Mid-20th Century—Margaret Sanger
Medicaid budget, the third-largest governmental
budget; Virginia Trotter Betts, former ANA president under President Clinton’s administration, was
appointed Senior Health Advisor to the U.S.
Department of Health and Human Services; also
in Clinton’s administration, Dr. Beverly Malone
became the Deputy Assistant Secretary for Health
and Human Services. The visions of all these leaders were grounded in values that reflected a connection between social issues and health. Their
passions were not always welcomed by policy makers, yet they continued to network with those in
power to gain a voice in the health-care system.
Margaret Sanger (1879–1966) was responsible for
changing our nation’s acceptance of family planning.
Even though she struggled with the possibility of jail
and received death threats, she continued to distribute literature that educated women on the prevention
of unplanned pregnancies. Her articles “The Woman
Radical” (1914) and “Family Limitations” (1915)
brought her under federal indictment and forced
her exile to Europe. When she returned to the
United States, her proactive stance and educational
programs reduced the maternal infections and deaths
due to unlicensed individuals performing illegal
abortions. She opened the first birth control clinic in
the United States but, after 9 days, the police closed
the clinic as crowds gathered to seek information and
counseling on birth control. Because she distributed
birth control information, Sanger was arrested for
obscenity and she served 30 days in jail; however,
these efforts culminated in bringing the need for policy change before the public eye. Sanger died at age
87, a few months after the 1965 Supreme Court
decision that made birth control legal for married
couples. It took 50 years of nurses’ efforts to gain legislative support for this at-risk female population.
Policy and Nursing Governance
Nursing has always been an active voice in support
of patient safety, protection of the public, professional and ethical behaviors, competency, and standardization in education and scope of practice.
Historically, however, nurse leaders have been
polarized, struggling to gain a voice for nursing but
unable to reach consensus on professional direction. In order to be regarded as a profession, standardization and regulation were necessary.
Nursing’s Political Growth
in the 21st Century
Regulatory Policy—International
and National
In the 1990s and over the last decade, many nurses
have made their mark in the political arena.
Khristine Gebbie, RN, served as the AIDS czar;
Sheila Burke, RN, was chief of staff to Senate
Majority Leader Bob Dole; Carolyn Davis became
the head of the Health Care Financing Agency and
was responsible for shaping the Medicare and
The International Council of Nurses (ICN) is a
federation of national nursing associations, representing more than 120 countries. This group is
operated by nurses who work to ensure quality
patient care, sound global health policies, the
advancement of nursing knowledge, and worldwide
respect for the nursing profession. ICN’s code of
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ethics is the foundation for nursing practice
throughout the world.
The National Council of State Boards of
Nursing (NCSBN) was established in 1978. This
not-for-profit organization’s membership is comprised of the boards of nursing in the 50 states, the
District of Columbia, and the 5 United States
territories (American Samoa, Guam, Northern
Marina Islands, Puerto Rico and the Virgin
Islands). This organization’s main purposes are to
advance regulatory excellence for the protection of
the public, which includes NCLEX testing, policy
analysis, research, oversight of the uniformity of
regulations for nursing practice, and the collection
of data related to nursing licensure (NCSBN,
2008b). NCSBN’s values of integrity, accountability,
quality, vision, and collaboration support its goals
for public health, safety, and welfare.
society made up of differing cultures and languages.
Health-care delivery became a societal issue.
History of Nursing Licensure
Competence of All Practitioners Regulated by the
Board of Nursing
â–  Nursing regulation is responsible for upholding
licensure requirements for competence in the
various levels of nursing practice.
â–  Competence is assessed at initial licensure/entry
and during the career life of all practitioners.
To define the role of the nurse in all nations, a campaign began in 19th-century England to support
the identification of graduate nurses through licensure, but there was strong opposition to allowing
nursing organizations to participate in nursing
licensure. This conflict delayed the enactment of
laws to govern the profession. Isabel Hampton
Robb, the first American Nurses Association president, commented on the need for nursing regulation: “in the absence of educational and professional
standards, I am sadly forced to admit that the term
‘trained nurse’ means anything, everything and
next to nothing” (University of North Carolina
Television, 2002, par 3). New Zealand became in
1901 the first country to license nurses. In 1903,
North Carolina became the first state to enact a
nursing registration law. New Jersey, New York, and
Virginia followed in that same year. These early
laws recognized nursing as a profession, provided
title protection, and established standards of practice to protect the public. The laws were controversial, however, and there were inconsistencies from
state to state.
The ultimate purpose of regulation is to protect
the public. A noted example of the need for this
protection was demonstrated as a result of the rise
of industrialization in the United States. At this
time, a mass migration of people to the major cities
occurred, which stressed the cities’ infrastructure
and resources. These transplanted consumers of
health care were now in a new environment, in a
Professional Nursing Organizations: Where
Regulation Stands Now
Today’s state nursing regulations provide guidelines
for protecting the public and advancing the profession of nursing, principles to assist the nurse with
decision-making, and standards for safe and effective care. The NCSBN, as the national nursing regulatory body, provides guiding principles for nursing regulations and governance to all states and
territories (NCSBN, 2008a).
Protection of the Public
Nursing regulation exists to protect the health,
safety, and welfare of the public in their receipt of
nursing services.
Due Process and Ethical Decision-Making
â–  Nursing regulation is conducted in a manner to
provide fair, reasoned and consistent decisions
and due process.
â–  Boards of nursing hold nurses accountable for
ethical decision-making and professional
responsibility.
Shared Accountability
Nursing regulation requires shared accountability
for distinguishing individual versus system errors
and potential for error.
Strategic Collaboration
Nursing regulation requires collaboration with
multiple strategic individuals and agencies in the
interest of public protection, patient safety, and the
education of nurses.
Evidenced-Based Regulation
Nursing regulation uses evidenced-based standards
of practice, advances in technology, and demographic and social research in its mission to protect
the public.
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Response to the Marketplace and Health-Care
Environment
â–  Nursing regulation requires timely and thoughtful responsiveness to the evolving marketplace.
â–  Clarity in scope of practice and congruence with
the community needs for nursing care are essential.
Globalization of Nursing
â–  Nursing regulation occurs at the state level and
concurrently works to standardize regulations
and access to licensure.
â–  Nursing regulation acknowledges and addresses
the social, political and fiscal challenges of globalization. (NCSBN, 2007, p. 1)
The need for regulation in the nursing field can be
summed up using four critical reasons: information
asymmetry, bundling of services, secondary harm,
and forum for complaints.
1. Information Asymmetry. It is almost impossible for the average consumer to collect and evaluate information about health care because the
system is technically complicated and the consumer’s use of the services may be infrequent.
Even consumers who would be willing to evaluate
a number of potential resources before making
critical decisions may be prevented from doing so.
People dealing with crisis may be in shock, grieving, or unable to make this type of decision.
2. Bundling of Services. The majority of nurses
are employees of hospitals and other health-care
agencies. The agency and the nurse are bundled.
Regulation of health-care providers creates an
assurance that providers in all settings have met
government requirements before entering practice.
3. Secondary Harm. An incompetent healthcare provider who fails to identify an infectious
disease may not only affect the client but also
contribute to the unknowing spread of disease.
Health-care regulation attempts to provide
safeguards when there can be potential risk to
multiple persons affected indirectly by services
provided to others.
4. Forum for Complaints. Regulation boards
serve as an objective third party when dealing
with citizen complaints regarding service. The
boards of nursing provide a system of checks
and balances for the public. Their members
have expertise to evaluate the technical, often
complicated, professional issues and have been
charged with the responsibility of protecting the
public. These regulatory boards provide a forum
to hear citizens’ concerns. (NCSBN, 1996, p. 6)
NCLEX Testing
A consistent approach to regulation among the
member states and territories allows nurses to
migrate from one state to another. Although all
50 states and territories have different Nurse
Practice acts, the entry-level measurement tool, the
NCLEX exam, is recognized by all. This uniform
test allows nurses to apply for reciprocity or
endorsement within the 50 states and territories. It
also is a means for internationally educated nurses
seeking a U.S. nursing license to apply for endorsement, providing they speak English and have transcripts that demonstrate education which meets or
exceeds the U.S. standards. Unless a state is a member of the multi-state licensure compact, each nurse
must obtain and maintain the specific state requirements for each nursing license that they hold.
Multi-State Licensure Compact
The Multi-State Licensure Compact is a new way of
looking at licensure and regulation of nurses. The
Nurse Licensure Compact Administrators (NLCA)
officially organized on January 10, 2000, for the purpose of protecting the public’s health and safety by
promoting compliance with the laws governing the
practice of nursing. “The mutual recognition model
of nurse licensure allows a nurse to have one license
(in his or her state of residency) and to practice in
other states (both physical and electronic), subject to
each state’s practice law and regulation. Under mutual
recognition, a nurse may practice across state lines
unless otherwise restricted” (NCSBN, 2008, par. 1).
Each state must enact legislation authorizing the
NLCA to oversee the exchange of information
between other members of the compact. States entering the compact also adopt administrative rules and
regulations for implementation of the compact. Over
the last 10 years, states have been slow to begin the
legislative process to implement a multi-state licensure option for their nurses. As of 2008, 21 of the
50 states had adopted and implemented the nurse
licensure compact (see Box 1).
Multi-state licensure is an important policy that
assists nurses in their practice as they travel, move,
or work intrastate jobs that are covered by the compact. In terms of disciplinary action, the nurse
is subject to the (home) state board of nursing.
(A home state is the state in which the nurse has
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Box 2-1
States That Have Adopted Through
Legislation a Multi-State Compact
(RN and LPN/VN)
Arizona
Arkansas
Colorado
Delaware
Idaho
Iowa
Kentucky
Maine
Maryland
Mississippi
Nebraska
New Hampshire
New Mexico
North Carolina
North Dakota
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Wisconsin
Data from NCSBN, 2008.
primary residency.) State Nurse Practice acts, however, differ, and nurses, whether or not they have a
multi-state license, are to abide by the regulations
of the Nurse Practice Act of the state in which they
are working. In the remaining nonparticipating
states, any nurse seeking employment as a nurse
within that state must obtain state licensure prior
to the first day of work. “On August 16, 2002, the
NCSBN Delegate Assembly approved the adoption of model language for a licensure compact for
advanced practice registered nurses (APRNs). Only
those states that have adopted the RN and
LPN/VN Nurse Licensure Compact may implement a compact for APRNs. On March 15, 2004,
Utah was the first state to enter the APRN
Compact” (NCSBN, 2004).
Scenario
2
Carol Longo, RN, is a travel nurse
working in a pain clinic affiliated
with a local community hospital. Carol has been
practicing for 20 years and is currently licensed in
two multi-state licensure compact states. After experiencing multiple back surgeries and chronic back
pain herself, she felt that this clinical setting was
ideal, as she would be able to relate to her patients
and provide the caring needed by this group of
patients. As part of the health-care team, Carol is
an eyewitness to the successful transformation of
patients who experience pain relief from a regimen
prescribed by one of the pain management specialists.
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The Nurse Practice Act is a set of state laws that
govern the members of the nursing profession in
each state. The act differs from state to state but
the common denominator is regulation for the protection of the public. The act “aims to protect the
public from an unsafe nurse by ensuring minimum
requirements for the practice of nursing” (Mikos,
2004, p. 21). The board of nursing influences how
each state’s nursing profession implements and
interprets the act based on the authority granted to
it by the state legislature and the governor. The specific state nurse practice act sets the foundation and
authority of the board of nursing to establish and
maintain professional standards. The acts address
common issues; establish the scope of practice for
professional, vocational and practical nursing; oversees schools of nursing; and sets the requirements
for licensure. The acts also provide guidelines for
discipline, that is, supervision, suspension, and corrective actions.
Nursing is 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 (Nightingale, 1859,
p.75). Definitions of nursing have evolved to
acknowledge six features essential to professional
nursing:
“Provision of a caring relationship that facilitates health and healing, “
â–  Attention to the range of human experiences
and responses to health and illness within the
physical and social environments,
â– 
Carol, assisting a patient on a stretcher, experiences
rebound back pain and decides to self-prescribe a
common pain regimen to herself. Feeling empowered and entitled, Carol steals a medication prescription pad and copies the prescriptions, signs the
physician’s name, and submits the prescription to a
local pharmacy. A pharmacist at the local pharmacy
questions the authenticity of the prescription and
calls the physician to verify it. The physician notified
the state board of nursing. According to the Nurse
Practice Act, is the home/residency state or the practice state responsible for investigating and taking
action to discipline Carol? â– 
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Integration of objective data with knowledge
gained from an appreciation of the patient or
group’s subjective experience,
â–  Application of scientific knowledge to the
processes of diagnosis and treatment through
the use of judgment and critical thinking,
â–  Advancement of professional nursing knowledge
through scholarly inquiry, and
â–  Influence on social and public policy to promote
social justice. (ANA, 2004, p. 20)
â– 
The concept of ensuring ongoing competency for
nurses is addressed differently in the 50 U.S. states
and territories. Some states require continuing education to document competency. Other states feel
that continuing education does not guarantee competency and that more measurable standards should
be sought.
State Boards of Nursing
The state boards of nursing oversee applications for
the establishment of new schools of nursing and
subject them to a review to ensure the school’s
quality and efficacy. Applicants are required to
demonstrate the ability to provide the material and
human resources necessary for success. Material
resources include budgets, physical space allocation, and library resources for Internet and traditional literature searches. Human resources involve
the teaching and administrative faculty’s clinical
experience. All students should evaluate a nursing
school based on successful completion rates,
NCLEX scores, and student–teacher ratios. When
the students are ready to apply to take the NCLEX
examination, a Level II FBI criminal background
check is performed. Students must be aware that
Scenario
3
Tom Rio is a 26-year-old senior
nursing student at Jamestown
University. His class has just received a lecture on
preparing the application for NCLEX submission. He tries to listen intently but his mind is
racing back 10 years, when, as a teenager, he made
poor choices. He remembers the summer night
when he and his four friends decided to go drinking at the lake. After numerous beers, one of the
boys challenged him to “borrow” the car of one of
the local high school teachers. After arriving at
the teacher’s home, the groups pried open the
garage door, then jimmied the car door and
the Level II criminal background check includes
any and all criminal offenses regardless of the age
of the applicant at the time of criminal activity.
Organizations for Political Action
The Internet allows nurses to stay connected to their
profession, and it is important for today’s nurse to
remain actively involved. Tomorrow’s health-care
policy changes are being developed today and nursing
can either lead these changes or remain a passive recipient.The Political Action Committee (ANA-PAC) of
the American Nurses Association (ANA), the
national professional organization for nursing, offers
full-service representation for the entire nursing
population. The ANA-PAC is a bipartisan effort on
behalf of the ANA that seeks to raise funds used to
improve health care. This committee uses the funds
to endorse candidates who demonstrate their support of legislation and regulatory action that is in
alliance with the goals of the ANA (ANA, 2008a).
The National League of Nursing (NLN) strives
to develop nursing leaders by setting standards and
improving nursing education. The Nursing
Organization Alliance (NOA), a coalition of all
nursing organizations, offers a forum for collaboration on important issues that affect all the organizations. The National Student Nurse Association
(NSNA) provides educational and resource support
to future nurses.
American Nurse Association
The ANA is dedicated to the promotion of “health
and the care of the sick [and] has served as the
forum for discussing the nation’s critical health
hot-wired the car. They were all elated as they
drove the car at high speeds on the country roads.
Before the driver could react, a tree was in their
path. The impact destroyed the car and permanently injured two of the four boys. All of the boys
were arrested, fined, and sentenced to community
service and probation. They were unable to gain
driver’s licenses prior to turning 21 years of age.
On the advice of their attorney, all were told not
to include this legal episode on any official
documentation, as their juvenile records were
frozen. Tom starts to question this advice. What
should he do? â– 
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issues throughout the last century” (ANA, 2005,
p. 4). The ANA provides a structure that encourages and allows nurses to discuss, debate, evaluate,
and share thoughts that potentially drive the
future goals of their profession. It provides an
avenue for uniting the voices of all nurses, inclusive
of all practice settings. ANA’s first meeting, in
1897, established goals “to establish and maintain
a code of ethics; elevate the standard of nursing
education; and promote the usefulness and honor,
the financial and other interests of nursing” (ANA,
2005, p. 4). Over the years, these goals have been
redefined based on the core needs of current nurses. ANA advances nursing by encouraging high
standards, promoting nursing’s role in the workplace, and lobbying Congress and regulatory agencies on health-care issues that affect nursing and
the public (ANA, 2005).
The power of the ANA is seen in the strength
of its affiliations. ANA’s Web site (2008) lists 21 professional nursing affiliates, which include the
American Association of Critical-Care Nurses;
the American Association of Nurse Anesthetists;
the American Psychiatric Nurses Association; the
American Association of Perioperative Registered
Nurses; the Association of Rehabilitation Nurses; the
Association of Women’s Health, Obstetric, and
Neonatal Nurses; the Emergency Nurses Association;
the National Association of Orthopedic Nurses; and
the Oncology Nursing Society. Through its current
membership and the membership of its affiliates, the
voice of the ANA unites these various nursing
specialties on policy issues and represents the nursing
profession of tomorrow. All nurses can benefit
from the ANA’s (2003) trio of interlinked and indispensable references that provide essential practice
guidelines:
Nursing: Scope and Standards of Practice
Code of Ethics for Nurses with Interpretive
Statements
■ Nursing’s Social Policy Statement (ANA, 2003)
â– 
â– 
The NSNA is a 50,000-member organization that
was started in 1969. The NSNA’s “mission is to
mentor students preparing for initial licensure as
registered nurses, and to convey the standards,
ethics, and skills that students will need as responsible and accountable leaders and members of the
profession” (NSNA, 2008) This group sponsors
scholarships for nursing students, annual meetings,
and educational resources.
27
Nursing Organizations Alliance
Nurses today should network and build relationships that influence health care through legislative
and regulatory processes. NOA has created the
2005 Nurse in Washington Internship (NIWI)
program, facilitating the ability of policy-minded
nurses to meet and discuss policy. The internship
objectives include the following:
Describing how nurses can be involved and
influence policy at the local and national level
â–  Discussing how to work effectively with legislative staff to advance policy agendas
â–  Networking with other nurses with similar
clinical/political interests
â–  Describing key steps to affect change in the
legislative issues at the grassroots level
â–  Identifying legislative, political, and economic
forces driving health-care policy and delivery
changes today
â–  Discussing the impact of fiscal and budgetary
changes on health policy formation and implementation (NOA, 2005)
â– 
The NIWI agenda for the internship includes topics involving the role of media in policy, an overview
of developing legislation, nursing’s sphere of influence, linking practice policy and politics, the role of
coalitions, and the role of special-interest groups
and how they influence health policy and societal
issues in nursing practice. These topics are part of
daily community news and nursing practice. As citizens and as nurses, policy and politics affect us.
National League of Nursing
Nurses are leaders in their profession, and as leaders they seek opportunities to advocate for nursing
standards and educational programs. The Web site
of the NLN encourages all nurses to become active
and to use their voices to support nursing. NLN is
a primary source of information utilized for legislation and regulations affecting nursing education. In
addition, this nursing education organization
informs its members of the best teaching practices,
meeting the needs of the diverse student population and the various education programs across the
county (NLN, 2007).
The Government Affairs Action Center
allows nurses to review current legislative bills
and the schedule of the latest congressional hearings. Nurses are encouraged to voice their individual thoughts related to current political and
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nursing education perspectives. The organization
identifies goals to meet the needs of its diverse
population in their changing health-care environment. NLN supports and champions the
advancement of nursing education (NLN, 2007).
The NLN will shape and influence the future
of nursing by supporting nursing education for
all nurses and nursing students, influencing
the policy decision-making process by shaping
tomorrow’s health-care system.
Policy Models: A Guide
Conceptual models are important because they
illustrate a process graphically. The following policy models demonstrate the evolution of political
awareness in nursing. The first model, Conceptual
Model of Political Development, provides an
overview of the developmental stages of the nursing profession. Over time, the profession has
evolved, moving through various stages of policy
development. The second model, The Four Spheres
of Political Influence, demonstrates the power of the
policy process. The model visually demonstrates
the intersection of communities that impact today’s
health-care environment.
Conceptual Model of Political
Development
The Conceptual Model of Political Development was
published by Cohen and colleauges (1996) and
describes the political development of the profession. “The model stages mirror the stages that
Scenario
4
Carla Chase, RN, has an opportunity
to see her state legislature in session. She attends a session of the Health
Appropriations Committee, where she notices four
of the five bills to be presented that day would
greatly impact the nurses in her state. She thinks to
herself, “Who will speak for the nurses in my
state?” As she observes the committee activities and
actions, she notices an opportunity for the members of the audience to speak to the committee
members. The formal process, she notes, requires
you to fill out a form, highlighting the area of concern. Once called upon by the committee chair,
individual nurses navigate to become key players
in policy arenas. The stages are:
“Buy-in
Self-Interest
â–  Political Sophistication
■ Leadership” (p. 261)
â– 
â– 
The first stage of the model addressed the awakening of nursing to the importance of the policy
process and the impact it has on their profession. In
the late 1960s and early 1970s, policy decisions
related to and impacting nursing were decided
without the input of nursing organizations.
Nursing leaders recognized that as a profession,
nursing needed to become politically active. To
gain a voice nurses needed to unite around common policy issues and thus develop Buy-In from
the profession. “Nursing’s first political action committee (PAC), Nurses Coalition for Action in
Politics, was formed by a small group of savvy nurse
leaders in New York” (Mason et al, 2007, p. 12).
This group later became the Political Action
Committee for the ANA.
Stage 2 is Self-Interest. The nursing profession
moves into this self-interest domain when, as a
professional group, it determines its policy interest
and voice (Cohen et al, 1996). Nursing’s commitment is demonstrated by individual donations of
support. This funding provides nursing the power
needed to gain support at a state and national level.
Through individual nurses’ participation, the
ANA-PAC became the third largest health-care
federal interest group.
each person has 3 minutes to give an opinion. The
next speaker introduces herself as a lobbyist for her
state’s nursing association. The speaker is articulate
and concisely addresses the concerns of nursing as
a profession. Carla is impressed by the person’s
knowledge of the political, legal, and social aspects
of this proposed bill. The speaker is successful in
changing the minds of the voting members.
Ultimately, this changes the outcome of the vote,
and the bill is successfully defeated. Carla wonders
how the outcome might have been different if the
representative from the nurse association was not
there to be the voice of nursing. â– 
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Over time, the Political Sophistication stage
takes shape. By the mid- to late-1990s, policy makers started to recognize nursing as a powerful
voice in health-care reform. In 1997, President
Clinton supported nursing through the appointment of national nursing leaders to the Advisory
Commission on Consumer Protection and Quality
in the Healthcare Industry. The commission’s goal
was to reform the health-care system in the United
States. It gave prominent position to nurses in its
recommendations for reforming health care.
Although in 2004 President Clinton’s health-care
reform plan failed by not passing in the Senate,
nursing did make progress. Advanced Practice
Nurses (APNs) gained the ability to bill the
Centers for Medicare and Medicaid Services
(CMS) under the indirect supervision of a medical
physician and the ability to deliver care to hospice
patients. One result of this change was the
increased enrollment of nurses in the master’s-level
nurse-practitioner track, but the outcome was not
as positive as expected because the health-care
reform movement did not accomplish its original
goals. ARNPs, in many areas of the country, were
left feeling as though they were caught between
medicine and nursing. Health care has yet to remedy the policy issues that caused this chasm within
the system.
Stage 4, Leadership, is the political identity that
nursing is striving to attain and is the highest level
of political involvement. By achieving this stage,
nurses will become the initiators and directors of
future policy and will acquire a multidimensional
Scenario
5
Jeanne Blum, RN, is a nurse on a
LDRP unit. Recently, the policy and
procedures manual for Jeanne’s unit included the premature rupturing of membranes of a laboring patient
as a practice acceptable for nurses to perform. Jeanne
and some of her coworkers shared their concern over
lunch about this new responsibility.They felt uncomfortable with the possibility of cord prolapse and
other potential medical complications resulting from
this practice. Jeanne gathered data from her state and
many others states and noted that her hospital was
not in compliance with her professional organization
practice standards. Jeanne shared this information
with her coworkers. She volunteered to contact the
29
focus unified around a common purpose. In
addition, nurses at this level will be able to communicate in the language of the policy maker, feel confident, and gain acceptance in positions of authority.
Once this stage has been reached, nurses would
potentially be considered for such roles as Secretary
for Health and Human Services, university presidents, cabinet positions, legislators, and appointed
government officials. Since the 1990s, nurses have
achieved leadership roles in health-care policy
development (Rubotsky, 2000; Wakefield, 1997). A
more consistent presence of nurses at this leadership level will ensure nursing’s involvement in critical policy changes. Historically, the nurse has been
an advocate for patients, and the public will benefit
from nursing’s assumption of leadership roles.
Four Spheres of Political Influence
More than 25 years ago (1973), Wilma Scott Heide
addressed nurses’ leadership roles within society and
the health-care system. As the then president of the
National Organization for Women (NOW), she
challenged nurses to become leaders and developed
a model that depicted the four spheres of political
action. These spheres—Workplace, Government,
Professional Organization, and Community—are
still relevant to nurses in today’s environment. It is
important to realize that the four spheres are overlapping and interconnected. The community
sphere, however, touches all of the other spheres.
The first sphere, Workplace, is impacted by professional organizations, government, and community standards. The mandated implementation of
state board of nursing on their behalf to request a
declaratory statement on the nurse’s role in the initiation of premature rupturing of uterine membranes.
Her state board’s clinical practice committee
reviewed her request for a declaratory statement and
gathered information from other states. A formal
declaratory statement was drafted by the board and
made it available on its Web site. A letter from the
board was sent to Jeanne’s institution, informing it of
the declaratory statement, which stated that the task
nurses were requested to perform was beyond their
scope of practice based on the Nurse Practice Act.
Which stage of the policy model does this scenario
represent? â– 
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safety locks on all needles by the U.S. Occupational
Safety and Health Administration (OSHA) is an
example of a workplace policy. Data demonstrated
that nurses were incurring a growing number of
workplace needle-stick injuries in their daily routines. Nurses were most vulnerable when dealing
with needles used in the treatment of patients who
may have had blood-borne pathogens. Karen Daley
(2000), a registered nurse, played a key role in the
policy change regarding the mandated use of safetylock needles by health-care facilities. By sharing
her personal and professional story, she provided a
human side to the dangers of needle-stick injuries.
With the assistance of professional nursing organizations and members of the U.S. House of
Representative and Senate, bills were submitted
and eventually passed (Mason et al, 2008).
The designation Magnet Recognition Program
for Nursing by the American Nurses Credentialing
Center (a subsidiary of the American Nurses
Association) is another example of nurses assisting
in the development of workplace policies. The
goals of this program are to
promote quality in a milieu that supports professional practice;
â–  identify excellence in the delivery of nursing
services to patients/residents: and
â–  provide a mechanism for the dissemination of
“best practices” in nursing services (American
Nurses Credentialing Center, 2008).
â– 
The program is based on a foundation of collaborative problem-solving and decision-making that
promotes the autonomy of the staff nurse. “When
nursing is given authority in line with their responsibility, autonomy, and control over patient care
resources, they are in a better position to establish
positive relationships” (Aiken, Havens, and Sloane,
2000, p. 32). Nurses are impacted by the policy and
procedure in their health-care institutions. As they
enter into the work environment, nurses should
take an interest in the process of policy development. Magnet-designated nursing divisions foster
this interest by delineating roles and responsibilities in governance of the staff nurse.
Government, as the second sphere, affects all of
us. Government plays an important role in nursing,
defining what nursing is and what nurses do, influencing reimbursement, and affecting access to care.
An example of government providing leadership
in addressing public and private concerns is its
reaction to the Institute of Medicine (IOM) report
“To Err is Human: Building a Safer Health
System” (2000). The IOM report revealed that the
U.S. health-care system was killing anywhere
from 44,000 to 98,000 people a year. It spearheaded active risk-management and performanceimprovement measures and stimulated efforts to
increase the quality of care.
In another example, the Legislative Network for
Nursing (LNN) discussed the Joint Commission’s
(TJC) “speak-up program,” which empowers
patients to be involved in their care and encourages
them to take an active role in decision-making
(LNN, 2005). This report emphasizes the importance of listening to the voice of the patient to
achieve improved health-care outcomes. The
patient should be encouraged to speak up when
something is not quite right about the care being
received. For example, a nurse can educate the
patient to ask about a discrepancy in medications—
a different-color pill, altered day or time, and so on.
The nurse could then stop the administration of
medication immediately and validate the five rights
of medication administration. (Considering that
the data in the IOM report were collected in 1999
and published in 2000, one may question why the
health-care system took so long to implement corrective action. In 2009, we still see hospitals struggling to put this program fully in place.)
Professional Organizations, represented in the
third sphere, have been instrumental in shaping
nursing practice and developing standards of care.
These powerful organizations have through their
lobbying efforts influenced how the public envisions nursing. Having a nursing presence on the
national and state levels in legislative campaigns
ensures that nursing’s agenda will be promoted. At
the 2006 ANA House of Delegates meeting in
June, however, it was noted “the membership of the
ANA was down to 150,000. This is a decline of
about 25 percent in the past decade and represents
only 5% of the 2.9 million nurses in this country”
(Mason, 2006, p. 11). This professional organization represents nurses, communicates their values,
and speaks on their behalf. The organization and its
affiliates are essential advocates for both nurses and
patients, but they need nurses collectively to support their efforts.
The fourth sphere, Community, could be one’s
neighborhood and/or extended neighborhood via
the Internet involving groups of people with like
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interests. The first three spheres co-exist within the
sphere of community. Nurses rely on community
resources, and these resources become invaluable in
the promotion of health treatments. “Government
officials, health care administrators, patients, corporate managers, presidents of private and public
organizations—all players who can effect change in
health policy—are affiliated with at least one community: the one in which they live”(Mason,
Leavitt, and Chaffee, 2002, p. 15). Nurses need to
remember that in their community—local or
worldwide—they are representing their profession.
Nursing and Political Action
The nurse’s world has changed dramatically over
the last 100 years. The profession has seen dramatic
changes in health-care policy, and these changes
have reshaped the concepts and foundations on
which health-care systems have evolved. But even
as the health-care systems changed, the nurse’s role
has remained pivotal as the nucleus of the health
delivery system. Unfortunately, the role of nursing
often goes unnoticed until it is absent. Nurses are
poor at marketing the unique value that they bring
to the health-care delivery system.
The registered nurse is the only health care professional who is specifically educated to: 1) assess the
patient to determine health status and risks,
unhealthy lifestyles, minor health problems, and
health education needs for patients and their families; 2) provide support and reassurance while caring for present or potential health problems; and
Scenario
6
In January 2005, CMS implemented
the policy changes that impacted
the payment rate and billing criteria for chemotherapeutic medications. Debbie Alexander, RN,
worked in an office-based chemotherapy unit and
was a certified nurse specialist in chemotherapy.
She was aware that CMS was including new
Common Procedural Terminology (CPT) in the
new 2005 manual that would be implemented in
January. Debbie was also aware that her professional journals said the reason for the changes was to
control the rising costs of medication and ensure
that all patients would have access to therapy. CMS
offered a comment period in April/May 2005 and
31
3) advocates for primary and preventative care services. (ANA, 1997, p. 4)
Now is the time for nursing to identify and articulate the importance of its role in the health-care
system. Nursing cannot afford to wait to be noticed
or to be invited to offer its perspective if it wishes
to be part of the decision-making process in policy
development.
Novice Role: Nursing and Policy
Today’s nurses are just beginning to understand and
to become active in the legal decisions that are
impacting the health and wealth of the system.
Historically, nurses have functioned as an oppressed
group in a patriarchal health-care system. Gender is
still an issue, as over 90% of graduating nurses are
female (NLN, 1994). Based on these statistics, nurses should be in a position of power, but instead, as
Baer (1997) stated, “nurses blame each other for
nursing’s problems, rather than the system” (p. 257).
The profession must seek to identify common
goals, unite around these goals, and communicate
with a single voice. Nursing must envision the value
of lending a voice to the political process. Nurses
understand the importance that policy plays in the
nursing profession and realize that if health care is
to retain a caring focus while it seeks to control the
economics of the system, they must become
involved. Nurses today struggle to assure that in an
industry focused on cost containment, caring
remains a core value. Political caring is the balance
of caring related to values and the struggle for scare
resources (Ray, 1989).
was encouraged by the Oncology Nursing Society
(ONS), as a semiactive member, to read the proposed CMS federal ruling in the Federal Register.
Debbie did not have the time to access the federal
ruling on the Internet and she did not participate
in the comment period. In February, Debbie was
very frustrated by her gynecologic oncologist’s urging her to decrease the time patients were occupying a treatment chair and by the cumbersome new
coding that, to her, did not accurately reflect how
she delivered care to her patients. If Debbie had
been more actively involved in communicating her
knowledge to CMS in her state, could she have
made a difference? â– 
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“The perfect health care system is like perfect
health—a noble aspiration but one that is impossible to attain” (Bodenheimer and Grumbach, 2002, p.
206). McLuhan and Fiore (1968) described the
world as “a global village in which each one affected
all inhabitants” (Milstead, 2004, p. 249). The reality
is that the United States does not have a health-care
system to which other countries aspire. The U.S.
health-care system ranks poorly in comparison to
other countries’ systems, and the United States is the
only industrialized country that has been unable to
implement universal health care for its citizens
(Conyers, 2003, p. 193). Moreover, the problems that
plague the U.S. health-care system are not evenly
distributed throughout society. There is a correlation
between poverty and lower social status and poor
health, nutrition, and limited access to health care.
Gender and ethnicity also impact access to care.
Nursing assists the patient in gaining health-care
access. To be effective in today’s health-care delivery
system, nurses need education in order to understand the economics that drive the system. Ignoring
the business rules related to health care will impact
the quality of the services nurses can deliver.
Nursing Values Policy
“Nurses represent the largest aggregate of health care
professionals, well over 2 million in the United
States alone, and yet their participation in policy
decisions has traditionally been minimal” (Griepp,
2002, p. 35). Nursing has the knowledge, experience,
and ability to offer invaluable insight into the issues
that are plaguing the health-care system, a complex
and chaotic system about all aspects of which nurses
Scenario
7
Judith Dresser, RN, works in a large
Midwest teaching hospital located
in the inner city. She had enjoyed working in the
emergency room of her hospital over the last
7 years. For 6 of those years, Judith often worked
with a nursing assistant by the name of Danisha.
Danisha was African American and had three
children still at home. Over the last several years,
Danisha’s husband had suffered from hypertension, had mild cardiac episodes, and was prescribed cardiac medication. In the last month,
Danisha’s husband was laid off from work in a
local car factory. He lost his health benefit and
was offered COBRA coverage, but the expense
are uniquely qualified to speak. Nurses, as members
of an interdisciplinary team, are at the bedside of the
patient, supporting the patient’s family and carrying
out the plan of care indicated by the physician.
Nurses cannot afford to be one-dimensional in their
approach to decision-making and problem-solving.
Their ability to adapt to a changing environment,
to demonstrate technical knowledge, and to utilize
a keen sense of intuition based on previous experience makes them key to the success of any policy
effort. Who better to drive the policy planning and
development?
The policy process is a fluid system that addresses community needs, develops a strategy and carries
it through to a legislative solution. “Public policy is
policy made at the legislative, executive, and judicial
branches of federal, state, and local levels of government that affects individual and institutional behaviors under the respective government’s jurisdiction”
(Harrington and Estes, 2008, p. 7). Once solutions
are implemented, the evaluation process cannot be
undervalued or forgotten. It is important that the
evaluation of policy is ongoing, ensuring that the
policy results remain positive. Without an objective
evaluation of the change implemented, alterations
to policy may compound the problem instead of
solve it.
Policy Position and Ethical Practice
“Ethics is a generic term for various ways of understanding and examining the moral life” (Beauchamp
and Childress, 2001, p. 1). According to Shroeter,
Derse, Junkerman, and Schiedermayer’s book
Practical Ethics for Nurses and Nursing Students
was more than the family could afford. If Danisha
adds her husband and children to her health plan,
then she would have to pay an additional $700.00
per month. Danisha shares her concerns with
Judith. Both women have witnessed the difficulty
patients have had over the last year in obtaining
emergency cardiology care when arriving in the
ER without insurance. Danisha is realistic, however, in knowing that her income would not support her family. Judith learns that currently
Danisha’s family does not meet the income level
required to apply for Medicaid based on her
current salary. What should Judith do to help her
colleague? â– 
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(2002), today’s health-care environment of cost
containment has added ethical stressors that impact
health-care delivery. The nurse faces stressors that
strain the relationships between the provider and
the patient. These pressures include the following:
Divided loyalties
Limitations on authorized tests and treatment
â–  Limited choice of physician specialist and treatment facility
â– 
â– 
In addition, such problems as a CEO’s padding of
profits, carriers “cherry-picking” patients, confidentiality, restricted access offered to indigent
patients, and limitations on medical choices are
common occurrences in today’s health-care environment. In responding to the community’s health
needs, nursing is affected by policy initiatives and
ethical issues.
In today’s health-care environment, nurses strive
to utilize ethical principles in their relationships
with patients, families, and other health-care professionals. Honoring patients’ wishes and listening
to their needs are foundational ethical principles
that build to “a first step in transforming our
healthcare environments into sanctuaries of healing
and excellence” (Rushton, 2007, p. 154). Healthcare professionals frequently face ethical dilemmas.
Each member of the interdisciplinary team has a
different view when approaching a complex situation that lacks a clear treatment option. It is important for the nurse facing these difficult circumstances to analyze the situations honestly, articulate
the options, include the patient and/or family in
the decision, acknowledge the acceptance of moral
conflict, and utilize best judgment in selecting the
correct path.
Nursing Policy Issues
Why should nurses become active in the development of policy and politics? To strengthen their
profession, they need to become a voice that is valued and heard. Legislative issues impacting nurses
today include nursing shortages, safe patient lifting, mandatory staffing ratios, access to care, and
nurse specialization. Starting in 1999 and for the
next 7 consecutive years, nursing rated highest in
an annual honesty and ethics poll conducted by the
Gallup organization. In the most recent survey,
“eighty-four percent of Americans called their
honesty and ethical standards high or very high”
33
(Gallup Survey, 2008, p. 1). It is not surprising that
nurses consistently have ranked first over the years,
as every American family has experienced hospitalization of a loved one. When this occurs, nurses
are ever present—meeting the needs of the patient
and the family and providing valuable support
( Johnson and Johnson, 2008). As trusted professionals, nursing is responsible for championing
policies that will improve nursing and health care
for the future.
Nursing Shortage
According to the American Association of Colleges
of Nursing (AACNa, 2008), the United States is
experiencing a nursing shortage, the negative impact
of which will increase as the Baby Boomer generation moves into retirement. To compound the problem, there is a significant shortage of nurse faculty as
colleges and universities try to increase their enrollment. Statistics from the National Council of State
Boards of Nursing (NCSBN), seen in Table 1, indicate that the number of first-time nurses taking the
NCLEX exam decreased each year from 1994 until
2002. The trend reversed, however, in 2003, when
the numbers began to increase each year. It took a
decade (from 1995 to 2005) for the total of number
of test-takers to surpass the 1995 statistics, a trend
that has continued. The good news is tempered,
however, when the census data for those same years
are examined. In 1995, the U.S. census counted 260
million people, and by 2006 the number increased to
over 299 million.
Also noted in Table 1 are the significant numbers
of internationally educated students, which showed
a marked increase after 2002. Dr. Peter Buerhaus
and colleagues conducted a study for the Journal
of the American Medical Association (2000) that predicted a 20% shortage of nurses in the year 2020.
AACN published a report, 2003–2004 Enrollment
and Graduations in Baccalaureate and Graduate
Programs in Nursing, stating that 15,944 qualified
nursing applicants were turned away from baccalaureate nursing programs due to a lack of faculty and
facilities (AACN, 2004b). This issue is being
addressed at the state and national legislative levels
through bills that offer scholarships to entry-level
nurses and advanced degrees to encourage pursuit of
faculty positions. Funding is being sought to increase
the number of nurse educators; however, with many
state budgets being reduced during the economic
recession, these dollars may be difficult to find.
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Table 2-1
Number of Students Taking the NCLEX® for the First Time: Comparing Total of U.S.
First-Time Students to Total International Educated Students Taking the NCLEX
Year
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
PROGRAM
Diploma
7335
6346
5240
3978
3161
2679
2310
2424
2565
3162
3540
3810
3688
BSN
31,195
32,278
31,828
30,142
28,107
26,048
24,832
25,806
26,630
30,648
35,496
41,349
45,781
Associates
57,908
55,554
52,396
49,045
45,255
42,665
41,567
42,310
47,423
53,275
60,053
65,390
69,890
TOTAL
Spec. Program
172
148
155
74
84
83
50
64
109
92
98
164
220
USA EDUCATED
96,610
94,326
89,619
83,239
76,607
71,475
68,759
70,604
76,727
87,177
99,187
110,713
119,579
FOREIGN EDUCATED
11,068
7986
6574
6045
6381
7506
8613
12,723
16,490
18,285
17,980
25,908
33,768
Source: NCLEX statistics from National Council of State Boards of Nursing, https://www.ncsbn.org/1237.htm.
Mandatory Staffing Ratios
The Department of Human Services (DHS) mandated that California implement a mandatory
nurse-to-patient ratio as of January 2002. The
California Hospital Associations (CHA) and
Association of California Nurse Leaders (ACNL)
proposed the minimum ratios. The health-care
industry lobbied against the mandatory nursing
ratios, feeling that the cost of the minimum
staffing standards would be a burden when it
came to recruitment and salaries. The mandatory
staffing ratios has resulted in closures of patient
units and increases in staffing expense as a result
of not having the staff on hand to meet the ratio
requirement. California has struggled to meet the
staffing requirements and has recruited from outside the United States in an effort to bolster the
pool of potential nurses. Nationally, a trend has
developed of nurses within the United States
being willing to go to California for short periods
of time. These nurses are drawn by the high
salaries and short-term commitment. Short
working stays and high hourly salary rates in
California allow the nurses to return to their
home states, having achieved their previous yearly
income in far fewer months. The high cost of living in California relative to other states makes
permanent relocation not a desirable option.
However, the shift of working nurses to
California has produced a nursing resource deficit
in other states.
Policy recommendations on this issue are
pending in many states, and the nursing profession needs to actively engage legislators on
the proposed bills. Proponents of this legislation
cite research studies that document a direct relationship between higher nursing staffing ratios
and negative patient outcomes (Aiken et al,
2002; Needleman et al, 2002). Nurses support
ratios, seeking to improve their working conditions and enhance safe patient care. The following is an excerpt from “Experienced Nurses
Tell Their Story” published by the ANA in
June 2008:
I have been a nurse for 13 years. I find myself struggling day to day with the increase in patient acuity
and the nurse to patient ratios. You stand on your
feet for more than thirteen hours without lunch
breaks most days! There needs to be change in the
whole country, and lawmakers need to enforce the
safe staffing act or hospitals will continually subject
nurses to unsafe working conditions. The majority
of skin breakdown and falls could be prevented if
ratios were lower, and nurse burnout would be
another area that would decrease! I hope someone
listens, I hope positive results will happen, because I
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will probably be joining that group of RNs that
decided to leave the profession for good.
–A Registered Nurse who practices in
Connecticut. (ANA, 2008b, p. 1)
“However, mandatory ratios, if imposed nationally,
may result in increased overall costs of care with no
guarantees for improvement in quality or positive
outcomes of hospitalization” (Welton, 2007, p. 1).
A recent review of nearly 100 staffing studies by
the Agency for Healthcare Research and Quality
AHQR did not find a causal relationship between
nurse staffing levels and patient adverse events and
mortality (Kane et al, 2007). The status of the economic health of the United States in 2008 and
beyond as well as the shortage of available nurses
makes it appear that mandatory nurse staffing
ratios will be a difficult legislative initiative to sell.
In 2008, ANA launched a campaign called Safe
Staffing Saves Lives. ANA is committed to safeguarding the critical role that nurses play in patient
safety and quality care. The ANA has, however,
tempered its approach to legislative mandated
ratios, as was used in California, with a less prescriptive proposal, maintaining the roles of hospitals and nursing in accountability and decisionmaking on this issue. ANA’s proposal offers a broad
approach that allows each facility to tailor nurse
staffing to the specific needs of each unit, based on
factors including
1. patient acuity, the experience of the nursing staff,
2. the skill mix of the staff,
3. available technology,
4. and the support services available to the nurses
(ANA, 2008).
This stance protects the professional status of nurses,
allowing them to govern their environment and to
make key decisions related to their patients. The
IOM stated, “nursing is a critical factor in determining the quality of care in hospitals and the
nature of patient outcomes” (ANA, 2008, p. 2).
These efforts seem congruent with the need to foster a positive working environment that in turn will
help retain nurses.
Policy Affecting Nursing
Nurses are seeking practice environments that allow
them to work efficiently, effectively, and comfortably
while at the same time integrating patient-centered
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care. Due to increasing fragmentation, the poor coordination of health-care services, and the resulting
acceleration of costs, the current health-care system
can no longer support additional spending. Healthcare providers are resigned to the need to identify and
offer the highest possible quality of care at the available level of expenditure. Nursing is affected by these
cost-containment efforts. At the same time, the public and payers are demanding improved patient safety and clinical outcomes. In order to increase the
public’s trust in the health-care system, legislators
have implemented regulation to increase the transparency of health-care outcomes and have made this
information available to the public. Facilities are now
required (either by regulation or through reduced
reimbursement) to report patient safety and outcome
information to various agencies. Multiple agencies
are involved in this patient safety effort.
Cost-Containment Initiatives
For over two decades, the U.S. health-care system
has made incremental changes to reduce spending.
The efforts have not succeeded, and some might
say that the efforts to rein in spending have created
a more bureaucratic system, adding administrative
costs. “National health spending is estimated to
have grown almost 7 percent in 2007, reaching over
$2 trillion, or roughly $7,800 person. The growth
rate is expected to hold steady at nearly 7 percent
through 2017, reaching more that $4 trillion
dollars” (Keehan et al, 2008). In 2008, the United
States was the only industrialized country without
federally supported health care. In addition,
Americans today spend more out-of-pocket dollars
on health care than citizens in any other industrialized countries (Bodenheimer and Grumbach,
2009). The rising health-care costs have been associated with increased barriers to access and the
inclination of patients to choose, because of their
personal budgets, not to follow their plan of care
(e.g., refilling prescriptions, scheduling nonacute
surgical procedures, seeking preventative care, visiting the physician for nonacute health problems,
etc.) (Commonwealth Fund, 2008). As a result,
hospital emergency rooms are experiencing an
increased number of patients who are uninsured
and underinsured. In 2007, the number of uninsured persons in the United States had risen to over
47 million, with 25% of these individuals making
less than $25,000 per year (Bodenheimer and
Grumbach, 2009). Uncompensated care provided
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to these citizens has further increased the healthcare expense to providers across the country.
Managed care has responded by increasing
insurance premiums to employers and patients. The
cost of the Medicare and Medicaid programs, as a
percentage of the gross domestic product (GDP),
has risen dramatically and is predicted to rise even
higher with the aging of the Baby Boomer generation. Medicare and Medicaid programs have implemented guidelines aimed at ensuring that the
services provided are appropriate and necessary and
address the patient’s problem. When compared to
the other industrialized countries, a large part of the
higher level of health-care spending in the United
States is related to the utilization of technology.The
United States develops, implements, and utilizes
technology at a higher volume that other nations,
yet the outcomes do not demonstrate a higher level
of outcomes for the patient.(Bodenheimer and
Grumbach, 2009).
During the 2008 presidential election, the
nation cast its vote, in part, for health-care reform.
The current system cannot be sustained and will be
particularly strained at a time when the nation has
limited surplus money. Most providers feel there is
overuse of the resources in the system, yet feel the
public expects this level of care. In 2006, 74% of the
people felt the system was in a state of crisis
(Bodenheimer and Grumbach, 2009).
A national health plan, making health care an
entitlement for all citizens, has been attempted
many times in the 20th century, and each time
opposition has successfully defeated the efforts. In
2009, President Obama pledged to improve healthcare access to all citizens while reducing unnecessary health-care spending. The U.S. health-care
system has been called a paradox of excess and deprivation (Enthoven and Kronick, 1989). Health
care is distributed unequally across the nation;
spending varies for the same needed services from
state to state and citizens who have paid for insurance feel they are entitled to the highest level of
care. Yet, there remains a large subset of the population, commonly the poor and minorities, who
consistently receive the lowest level of care.
Nursing has an opportunity to support and participate in the health-care reform effort. The nurse’s
perspective offers a unique view of health-care
delivery. Nursing provides insight that is needed
to ensure that health-care reform choices make
sense. Nursing’s role in this process will be an
important investment toward ensuring that quality
health care is made available to all, that the system
investment in nursing will support successful
implementation of these changes, and that all citizens are afforded equal health-care choices.
Quality Data Reporting
Quality initiatives are changing the health-care
environment by requiring ongoing monitoring of
outcomes. Many organizations, including the ANA
Quality Initiative in 1994, the National Database
of Nursing Quality Indicators (NDNQI) in1997,
the National Quality Forum (NQF) in 2006, CMS
in 2007, and TJC in 2007, have endorsed mandated
data reporting of patient-focused indicators. These
indicators offer transparency of high-volume,
problem-prone, patient-care outcomes (Swan,
2008; Table 2).
NDNQI data submission is voluntary. “More
than 1,200 hospitals in fifty states including the
District of Columbia participate in NDNQI as of
early 2008” (Swan, 2008, p. 195). Nurse-sensitive
indicators are based on three concepts that are
felt to be directly impacted by nursing interventions: (a) structure (FTEs and staff mix), (b) process
(assessment), and (c) patient outcomes. The analysis
of quality data has provided identification, measurement, and benchmarking of patients outcomes
related to interventions of acute-care registered
nurses. “The CMS incentivized conditions,
NDNQI nursing-sensitive acute care indicators,
and the fifteen nursing-sensitive indicators
endorsed by the national quality forum (NQF)
address many similar issues”; their integration and
intersection is depicted in Table 2 (Swan, 2008,
p. 196). It is interesting to note that the IOM report
“To Err is Human” was published in 2000, and the
study, revisited in 2002, showed only minor quality
improvement in the U.S health-care system. CMS,
beginning in 2007, announced that it would cease to
pay extra for specific hospital-acquired conditions
that have been identified as avoidable.
Payment for Performance
Stimulated by the quality initiatives, the need for
accountability, and public disclosure, the Bush
administration enacted the Deficit Reduction Act
(DRA) of 2005. This legislation required a quality
adjustment in the Medicare DRG payment for
certain hospital-acquired conditions, because
indicators pointed to a growth in the number of
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Table 2-2
Comparison of NDNQI, NQF, and CMS Acute-Care Indicators
Acute-Care Topic
NDNQI Indicator
NQF Indicator
CMS Indicator
Falling
Injuries caused by falls in
the hospital
Injuries caused by falls in
the hospital
Patient falls
Fall prevalence
Patient falls with injury
Falls with injury
Pressure ulcer rate: community
acquired/ hospital
acquired/unit acquired
Hospital-acquired pressure
ulcers
Hospital-acquired pressure
ulcers
Restraint prevalence
Restraint prevalence
Patients are at-risk for falls
when restrained
Nosocomial infection rate:
• Ventilator-associated
pneumonia
• Central line-associated
bloodstream infections
• Catheter-associated
urinary tract infections
Nosocomial infection rate:
• Ventilator-associated
pneumonia for ICU and
high-risk nursery patients
• Central line catheterassociated bloodstream
infection rate for ICU and
high-risk nursery patients
• Urinary catheter-associated
urinary tract infection
for intensive care unit
patients
Catheter-associated
bloodstream infections
Staff mix
Skill mix
Nursing hours per patient
day
Nursing hours per patient
day
RN surveys: job satisfaction/
practice environment
scale
RN surveys: practice
environment scale—
nursing work index
Nurse turnover
Voluntary turnover
RN education and
certification
Smoking cessation
counseling for acute
myocardial infarction
Smoking cessation
counseling for heart failure
Smoking cessation
Counseling for pneumonia
Death among surgical
inpatients with treatable
serious complications
(failure to rescue)
Pressure Ulcers
Restraint
Nosocomial Infection
Mix
Hours
RN Surveys
Turnover
Other
Pediatric pain assessment
cycle
Pediatric IV infiltration rate
Psychiatric patient assault
rate
Adapted from Swan, B. A. (May/June 2008). Nursing Economic$ 26(3), 195–201.
Catheter-associated urinary
tract infections
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hospital-acquired complicating conditions. Based
on the nurse’s visible position as the provider
directly responsible for patient assessment and
intervention, many of these hospital-acquired conditions can be prevented. Competent nursing care,
therefore, can help hospitals minimize lost revenue
while at the same time safeguard the outcomes of
its patients. The program, titled “HospitalAcquired Conditions and Present on Admission
Indicators Reporting” (HAC & POA), is a dramatic payment rule change for Medicare. CMS is
responsible for safeguarding the Medicare Trust
Fund and is a response to the predicted shortfall in
this fund over the next 10 years. Commercial insurance carriers have also implemented payment rules
that are aligned with these new CMS practices.
In preparation for this program, hospitals in
selected states began coding POA complication
codes and gathering data in October 2007.
Beginning in October 2008, patients with these
codes, not indicated as POA and with no other
severity complicating condition (cc) as described in
the bill, are no longer qualified for the higher DRG
(Federal Register, May 3, 2007). This policy is
based on an economic and quality perspective
designed to improve and safeguard the U.S. healthcare system for tomorrow’s citizens.
Report Cards—Transparency
“Regulators, employers, and payers say that public
reporting can encourage best practices”(Hanys, 2007,
p. 11). The publication of the IOM’s 2000 report
stimulated a number of patient quality initiatives and
encouraged many public and private organizations to
seek ways to communicate and provide transparency
about safety to the public. Following the IOM
report, state and federal legislatures stepped in and
implemented data-collecting and reporting tools
aimed at making health quality transparent to the
public. The Leapfrog Group, comprised of 150 public and private organizations, was formed to encourage significant change in the safety of health care in
America (Binder, 2008). It collected data and formatted it to be understandable and accessible to the
public, the ones making the decisions regarding care
sites and providers. In addition, this group sought to
create financial rewards for reported positive outcomes to promote high-quality health care.
The Quality Initiative was launched nationally in
2002 for nursing homes and was expanded in 2003
to home health agencies and hospitals. In 2004, the
Quality Initiative was further expanded to include
care settings for the end stage renal disease ESRD
patient. With the support of the CMS, AHRQ, The
Joint Commission, and many other organizations, a
hospital quality report card was created for the public. Private organizations and state repositories were
compiled to offer consumers access. Web sites such
as www.healthgrades.com provided comparative
mortality data and corrective reporting related to a
physician and/or a facility. These reports are offered
for a nominal sum to the consumer.
In 2005, the CMS launched a Web site,
www.hospitalcompare.hhs.gov, allowing patients to
look at how the hospitals in their city performed.The
reporting on this site, created through the efforts of
the CMS, the Department of Health and Human
Services, and other members of the Hospital Quality
Alliance (HQA), was considered voluntary; however,
an incentive of a 0.4% reduction in CMS payments
was instituted in 2005 for nonparticipating facilities.
Specific measures of medical and surgical outcomes
were collected from patient surveys, which were sent
to recent patients and contained questions regarding
the quality of care they received during their hospital
stay. The survey responses were sorted into “process
of care measures,” providing percentages that allowed
the public to see how the respondents rated the
health care provided. The process of care measures
included the following:
Eight measures related to heart attack care
Four measures related to heart failure care
â–  Seven measures related to pneumonia care
â–  Five measures related to surgical care improvement
â–  Two measures related to asthma care for
children only (CMS, 2008)
â– 
â– 
This information is made available to healthcare consumers on the Web site and was designed
to provide the patient with information to allow
comparison of one health-care facility with
another (Hospital Compare, 2008). Researchers
continue to evaluate evidence and measures that
warrant reporting. These data also support guidelines that are created to assure evidence-based and
safe health-care practices.
Growing Need for Policy Action
The role of the Health and Human Services
Department includes directing the nation’s efforts
to protect the health of all Americans and provide
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services to the needy. This department is one of the
largest civilian departments in the government.
Following the departure of Tommy Thompson, the
20th secretary, Michael O. Leavitt was sworn into
office. His efforts during his tenure have included
enrolling millions of seniors and disabled persons
in the new Medicare prescription drug program;
mobilizing the nation’s pandemic preparedness;
increasing the implementation of health information technology standards; overseeing the medical
response to national disasters; changing Medicaid
statutes to provide insurance coverage to more people; and initiating a nationwide campaign to transform the health-care sector into a value-driven system. His focus includes a desire to make health care
more transparent in both quality and price. Leavitt
is also challenging the drug manufacturers to
reduce the time and expense of bringing safe and
effective drugs to market.
Historically, nurses have separated the roles of
policy and practice as health-care providers. White
(1985) offered one explanation grounded in the
nursing belief that “policy is the domain of managers and practice the domain of nurses” (p. 28). In
1992, Sohier stated that while nurses are positioned
to influence policy-making and development, few
have the knowledge or hold the power positions
that allow them to do so. In order to change the
course of policy events, nurses need the knowledge
of leadership and decision-making skills to influence future legislation and policy; however, nurses
have demonstrated a deficiency in these areas. But
today’s nurses find themselves in a challenging
Scenario
8
James and Donna O’Hearn are trying to conceive their first child.
Donna hears about a well-known fertility specialist
located in a tertiary health-care center in a city
3 hours away from where they live. James and
Donna are comfortable traveling outside their town
in order to be less likely to come in contact with people they know. Their privacy related to their infertility issue is an important concern. Upon arrival at the
physician’s office, they are asked to write their name,
telephone number, and address on the patient signin sheet. The sign-in sheet is available for view by all
patients when they register. James mentions to
Donna his concern about the amount of information
39
industry in which the U.S. economy can no longer
support the rising costs of health care. Nurse-based
expenses are examined closely. To ensure that society does not underinvest in nursing, nurses must
develop knowledge of public policy and the legislative process. Education programs offered to undergraduate and graduate nurses that include public
health policy as a requirement for preparation will
help nurses gain the skills needed to influence the
political process.
Nursing has an opportunity to comment and
participate in policy changes via the Internet and
through professional organizations. The CMS
publishes proposed policy changes in the Federal
Register and notifies providers, offering a comment
period. CMS regulations and policy are commonly
implemented by other commercial carriers. All
nurses can participate in these CMS comment
periods easily from work or home. Professional
nursing organizations—such as the ANA, NLN,
Nursing Specialty Organization, and so on—can
unify efforts for lobbying and political action activities, synthesizing proposed legislative bills and setting nursing’s own political agenda. Based on the
numbers and specializations within the nursing
field, it may not be realistic to think that the profession will ever agree on a specific course of action
for any one legislative action. Consensus may, however, be reached when enough members participate
and become active. It is important to contact professional nursing organizations and provide feedback or attend meetings. The nursing voice is the
only way the nursing perspective will be heard.
and its availability to other patients and family
members. After James and Donna are called in to see
the physician, Donna’s friend Julie and her husband,
who also have an appointment with the infertility
specialist that day, arrive. Their appointment is
20 minutes after James and Donna’s. Julie immediately notices Donna’s information on the sign-in
sheet and says to her husband, “I didn’t know that
James and Donna were trying to have a baby.” Julie
calls Donna at home the next day, wanting to discuss
their common experiences. Donna is upset and feels
her privacy has been invaded. Did the specialist
maintain the “minimally necessary” ruling that is
contained in the HIPAA regulation? â– 
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Patient Advocacy
“To see what is right, not do it, is want of courage
or of principles” (Confucius circa 551–479 BC).
This quote from an ancient Chinese philosopher
supports the more current definition of advocacy by
Corish (2005): “the term advocacy can be stated in
its simplest form as standing up for what one
believes and for both self and others” (p. 478).
Smith (2004) stated that advocacy has been recognized as an important nursing responsibility since
the time of Florence Nightingale. The definition
and responsibilities assigned to the action of advocacy, however, are multifocal. Nurses, as advocates,
promote the ability of the patient to make
informed decisions, acting as the liaison between
other providers and individuals (Marguis and
Huston, 2009).
Access to Care
Who are the uninsured in the United States today?
They include people of all ages, races, educational
levels, and geographic regions. The number of
uninsured Americans has risen significantly over
the last 10 years, and it is estimated that over
47 million people are now without health insurance
(U.S. Census Bureau, 2007). Over the years, this
topic has been discussed in the media and debated
by policy makers, with no resolution. The IOM’s
Web site (2008) mentions that the result of the rising number of uninsured means that a population
of citizens in diminished health—who use more
resources when they access health care—is more
likely to die prematurely. Often the care of the
uninsured goes unpaid, and these costs are often
absorbed by physicians, hospitals, and other
providers. “As insurance premiums rise and more
employers drop coverage, an increasing number of
Americans are living without health insurance.
Nearly 90 million people—more than one in three
non-elderly Americans—went without health
coverage for all or part of 2006–2007” (Families
USA, 2007, p. 1). Issues and facts that broaden our
understanding of the magnitude of the problem of
limited access to care include the following:
1. Four out of five of uninsured individuals represent working families. (Families USA, 2007)
2. Employment and geographic demographics are
important and affect the uninsured numbers as
private insurance is “closely tied to employment
and eligibility for public programs are partly
determined by work and income criteria that
differ between states.” (National Academy of
Science, 2003a, p. 1)
3. Families with incomes lower than 150% of the
Federal Poverty Level (FPL) show a rise in the
number of uninsured. (National Academy of
Science, 2003a)
4. New Census data show that 8.1 million children under the age of 18 were uninsured in
2007. This is a slight decrease since the previous year, but 428,000 more than in 2004, the
last year there was a decline in the number of
uninsured children. (Families USA, 2007)
5. The United States health-care system has failed
to provide universal health care and has evolved
through incremental advances into a “patchwork of care in which many holes remain.”
(Etheredge and Uhlig, 2003, p. 1)
6. Single-parent homes or homes with minorities
and young adults between 18 and 34 years of
age are most likely to have no insurance. It is
important to note that public coverage for
children ends at their 19th birthday unless they
are in school. (National Academy of Science,
2003b)
The risk of becoming uninsured touches us all.
Policy initiatives appear to be a long way off from
achieving the goal of universal care. The ANA has
lobbied and supported universal health care since
the early 1900s, stating “only a single-payer system,
fairly funded and universally applied, will make
healthcare a right of everyone living within our
borders” (ANA, 1999, p. 6).
Trust in the System
“Trust is the expectation that individuals and
institutions will meet their responsibilities to us”
(Kirkman, 2003, p. 174). Over the last 10 years, an
increasing number of patients have lost trust in the
health-care system and providers have lost trust in
the patients whom they are trying to help. Patients
feel that their wants and needs are not the priority of
the medical care system. Greed, as a motivating factor, appears to be a growing concern. The relationships have changed among patient, provider, and
carrier, leaving few satisfied with the health-care
industry. An adversarial atmosphere has resulted.
As payers have reduced health-care benefits,
patients are upset and frustrated. There appears to
be a lack of patient understanding and education
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related to the system. Patients invest in insurance to
avoid the risk of high medical costs should an illness occur, but when services are required, payment
seems limited. Patients’ co-insurance payments and
deductibles have risen as the payer portion of their
bill decreased, and patients have become angry and
confused by misleading billing. The costs of technology and pharmaceuticals have only increased
their dissatisfaction. Price gouging and poorly
designed billing rules add to their mistrust. Healthcare out-of-pocket costs have risen beyond what an
average person can afford to pay (Bodenheimer and
Grumbach, 2009).
Initially, patients blamed their mistrust on hospital regulations; when the system only got worse, this
feeling extended to their physician. The physician/
patient relationship changed dramatically after the
1980s. Today, feelings about the system have
evolved to the point where physicians assess the
patients under their care in terms of their potential
for litigation .The number of malpractice claims
rises each year, with many claims costing providers
lawyer’s fees before ultimately being dropped prior
to litigation. Approximately 40% of legal claims do
not represent medical errors yet result in patients
receiving monetary benefits. The legal fees from
these cases represent 54% of the provider’s original
fee (Bodenheimer and Grumbach, 2009).
Today’s health-care system “is burdened with
expensive, unfounded litigation that harasses physicians who have done nothing wrong, while failing
to discipline or educate most physicians committing actual medical negligence and to compensate
most true victims of negligence”(Bodenheimer
and Grumbach, 2009, p. 125). The malpractice
system—to compensate patients injured during
medical care and to prevent negligent physicians
and providers from harming patients—does not
seem to be achieving its goals (Sage and Kersh,
2006). Gone is the mutual symbiotic relationship
that existed between a patient and the provider.
Today’s environment causes patients to select their
primary care physician according to their insurance
physician network. Relationships become fleeting,
as employers’ are forced to annually shop for the
lowest health-care premium.
Ease of access to health-care information via the
Internet has also changed the practitioner/patient
relationship. Historically, health-care education,
delivered by the practitioner, functioned in a oneway direction. The Internet now offers a conflicting
41
plethora of informational resources that patients
often review prior to treatment. Patients now
actively engage in a search for health-care information and expect a two-way conversation about their
condition and options for treatment. Gone is the
previous elevated societal view of the benevolent
practitioner. Human error and near misses make
headlines and have become a concern.
The nurse/patient relationship has also seen
changes. Suddenly nursing loyalties are pulled in
two directions: “Nurses may act as advocates by
either helping others to make informed decisions,
by acting as an intermediary in the environment,
or by directly intervening on the behalf of others”
(Marquis and Huston, 2009, p. 120). But nurses
are impacted by rules and policies designed to
keep expenses down, increase profits, and reduce
the time they are required to spend with their
patients. “Most nurses believe that patients have a
prima facie, or conditional right, to autonomy or
self-determination. In other words, clients ought
to be able to choose the type, extent, and quantity
of health care services” (Raines, 1997, p. 43).
Managed care, however, has created a contract
atmosphere. Care is predetermined, and length of
hospital stay has become a benchmark that is targeted for reduction and for comparisons to similar facilities on a national basis. With shorter
lengths of stay, nurses are forced to respond by
providing higher levels of self-care education as
they discharge a patient who may not be completely recovered. Nurses have become frustrated
with their work environment, limited staffing, and
inability to change the system. They have begun
to communicate their frustrations to the patient
and to others.
The mistrust of the health-care system in the
United States has been compounded by the fact
that patients have very high expectations of medical care that are not tempered by financial responsibilities for the services they seek. Insured
patients rarely pay medical expenses themselves.
“When spending other people’s money, patients
and their doctors are much less concerned about
the size …
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