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Issues in Today’s Workforce Culture

Based on your reading in chapter 60 (see attachment), why do you think the issues presented in this chapter persist in today’s workforce culture?

Policy & Politics in Nursing and Health Care
Seventh Edition
Diana J. Mason, PhD, RN, FAAN
Rudin Professor of Nursing
Co-Director of the Center for Health, Media, and Policy
School of Nursing
Hunter College
City University of New York
New York, New York
Deborah B. Gardner, PhD, RN, FAAN, FNAP
Health Policy and Leadership Consultant, LLC
Honolulu, Hawaii
Freida Hopkins Outlaw, PhD, RN, FAAN
Adjunct Professor
Peabody College of Education
Vanderbilt University
Nashville, Tennessee
Eileen T. O’Grady, PhD, NP, RN
Nurse Practitioner and Wellness Coach
McLean, Virginia
Table of Contents
Cover image
Title page
About the Editors
What’s New in the Seventh Edition?
Using the Seventh Edition
Unit 1 Introduction to Policy and Politics in Nursing and Health
Chapter 1 Frameworks for Action in Policy and Politics
Upstream Factors
Nursing and Health Policy
Reforming Health Care
Nurses as Leaders in Health Care Reform
Policy and the Policy Process
Forces That Shape Health Policy
The Framework for Action
Spheres of Influence
Health and Social Policy
Health Systems and Social Determinants of Health
Nursing Essentials
Policy and Political Competence
Discussion Questions
Online Resources
Chapter 2 An Historical Perspective on Policy, Politics, and Nursing
“Not Enough to be a Messenger”
Bringing Together the Past for the Present: What We Learned From History
Discussion Questions
Online Resources
Chapter 3 Advocacy in Nursing and Health Care
The Definition of Advocacy
The Nurse as Patient Advocate
Consumerism, Feminism, and Professionalization of Nursing: the Emergence of Patients’ Rights Advocacy
Philosophical Models of Nursing Advocacy
Advocacy Outside the Clinical Setting
Barriers to Successful Advocacy
Discussion Questions
Online Resources
Chapter 4 Learning the Ropes of Policy and Politics
Political Consciousness-Raising and Awareness: the “Aha” Moment
Getting Started
The Role of Mentoring
Educational Opportunities
Applying Your Political, Policy, Advocacy, and Activism Skills
Political Competencies
Changing Policy at the Workplace Through Shared Governance
Discussion Questions
Online Resources
Chapter 5 Taking Action: How I Learned the Ropes of Policy and Politics
Mentors, Passion, and Curiosity
Chapter 6 A Primer on Political Philosophy
Political Philosophy
The State
Gender and Race in Political Philosophy
The Welfare State
Political Philosophy and the Welfare State: Implications for Nurses
Discussion Questions
Online Resources
Chapter 7 The Policy Process
Health Policy and Politics
Unique Aspects of U.S. Policymaking
Conceptual Basis for Policymaking
Bringing Nursing Competence Into the Policymaking Process
Discussion Questions
Online Resources
Chapter 8 Health Policy Brief: Improving Care Transitions
Improving Care Transitions: Better Coordination of Patient Transfers among Care Sites and the Community Could Save
Money and Improve the Quality of Care1
Online Resources
Chapter 9 Political Analysis and Strategies
What is Political Analysis?
Political Strategies
Discussion Questions
Online Resources
Chapter 10 Communication and Conflict Management in Health Policy
Understanding Conflict
The Process of Conversations
Listening, Asserting, and Inquiring Skills
Discussion Questions
Online Resources
Chapter 11 Research as a Political and Policy Tool
So What is Policy?
What is Research When It Comes to Policy?
The Chemistry between Research and Policymaking
Using Research to Create, Inform, and Shape Policy
Research and Political Will
Research: Not Just for Journals
Discussion Questions
Online Resources
Chapter 12 Health Services Research: Translating Research into Policy
Defining Health Services Research
HSR Methods
Quantitative Methods and Data Sets
Qualitative Methods
Professional Training in Health Services Research
Fellowships and Training Grants
Loan Repayment Programs
Dissemination and Translation of Research Into Policy
Discussion Questions
Online Resources
Chapter 13 Using Research to Advance Health and Social Policies for Children
Research on Early Brain Development
Research on Social Determinants of Health and Health Disparities
Advancing Children’s Mental Health Using Research to Inform Policy
Research on Child Well-Being Indicators
Research on “Framing the Problem”
Gaps in Linking Research and Social Policies for Children
Nursing Advocacy
Discussion Questions
Online Resources
Chapter 14 Using the Power of Media to Influence Health Policy and Politics
Seismic Shift in Media: One-to-Many and Many-to-Many
The Power of Media
Who Controls the Media?
Getting on the Public’s Agenda
Media as a Health Promotion Tool
Focus on Reporting
Effective Use of Media
Analyzing Media
Responding to the Media
Discussion Questions
Online Resources
Chapter 15 Health Policy, Politics, and Professional Ethics
The Ethics of Influencing Policy
Reflective Practice: Pants on Fire
Discussion Questions
Professional Ethics
Reflective Practice: Foundational Nursing Documents
Personal Questions
Reflective Practice: Negotiating Conflicts between Personal Integrity and Professional Responsibilities
Personal Question
U.S. Health Care Reform
Reflective Practice: Accepting the Challenge
Personal Question
Reflective Practice: the Medicaid 5% Commitment—an Appeal to Professionalism
Discussion Question
Reflective Practice: Your State Turned Down Medicaid Expansion
Personal Question
Reflective Practice: Barriers to the Treatment of Mental Illness
Personal Question
Ethics and Work Environment Policies
Mandatory Flu Vaccination: the Good of the Patient Versus Personal Choice
Discussion Questions
Online Resources
Unit 2 Health Care Delivery and Financing
Chapter 16 The Changing United States Health Care System
Overview of the U.S. Health Care System
Public Health
Transforming Health Care Through Technology
Health Status and Trends
Challenges for the U.S. Health Care System
Health Care Reform
Opportunities and Challenges for Nursing
Discussion Questions
Online Resources
Chapter 17 A Primer on Health Economics of Nursing and Health Policy
Cost-Effectiveness of Nursing Services
Impact of Health Reform on Nursing Economics
Discussion Questions
Chapter 18 Financing Health Care in the United States
Historical Perspectives on Health Care Financing
Government Programs
The Private Health Insurance and Delivery Systems
The Problem of Continually Rising Health Care Costs
The ACA and Health Care Costs
Discussion Questions
Online Resources
Chapter 19 The Affordable Care Act: Historical Context and an Introduction to the State of Health
Care in the United States
Historical, Political, and Legal Context
Content of the Affordable Care Act
Impact on Nursing Profession: Direct and Indirect
Overall Cost of the Aca
Political and Implementation Challenges
Discussion Questions
Online Resources
Chapter 20 Health Insurance Exchanges: Expanding Access to Health Care
What is a Health Insurance Exchange?
Exchange Purchasers
Other Health Insurance Options
Federal or State Exchanges
Development of the Exchanges
Establishing State Exchanges
The Federal Exchange Rollout: ACA Setback
New York’s Success Story
The Oregon Story
Exchange Features
Marketplace Insurance Categories
Role of Medicaid
Nurses’ Roles with Exchanges
Consumer Education
State Requirements Include Aprns in Exchange Plans
Assessing the Impact of the Exchanges and Future Projections
Discussion Questions
Online Resources
Chapter 21 Patient Engagement and Public Policy: Emerging New Paradigms and Roles
Patient Engagement Within Nursing
Patient Engagement and Federal Initiatives
The VA System: an Exemplar of Patient-Centered Care
From Patient Engagement to Citizen Health
Discussion Questions
Online Resources
Chapter 22 The Marinated Mind: Why Overuse Is an Epidemic and How to Reduce It
Commonly Overused Interventions
Reasons for Overuse
Financial Incentives as the Major Cause of Overuse
The Marinated Mind
Physician and Nurse Acknowledgment of Overuse
Public Reporting to Reduce Overuse
Journalists Advocate for More Transparency About Overuse
Discussion Questions
Online Resources
Chapter 23 Policy Approaches to Address Health Disparities
Health Equity and Access
Policy Approaches to Address Health Disparities
Evaluating Patient-Centered Care
Discussion Questions
Online Resources
Chapter 24 Achieving Mental Health Parity
Historical Struggle to Achieve Mental Health Parity
Implications for Nursing: Mental Health Related Issues and Strategies
Discussion Questions
Online Resources
Chapter 25 Breaking the Social Security Glass Ceiling: A Proposal to Modernize Women’s Benefits1
Benefits for Women
Strengthening the Program
Changes We Oppose
Strengthening Financing
Discussion Questions
Online Resources
Chapter 26 The Politics of the Pharmaceutical Industry
Globalization Concerns
Values Conflict
Direct to Consumer Marketing
Conflict of Interest
Discussion Questions
Online Resources
Chapter 27 Women’s Reproductive Health Policy
When Women’s Reproductive Health Needs are Not Met
Why Do We Need Policy Specifically Directed at Women?
Women’s Health and U.S. Policy
Discussion Questions
Online Resources
Chapter 28 Public Health: Promoting the Health of Populations and Communities
The State of Public Health and the Public’s Health
Impact of Social Determinants and Disparities on Health
Major Threats to Public Health
Challenges Faced by Governmental Public Health
Charting a Bright Future for Public Health
Discussion Questions
Online Resources
Chapter 29 Taking Action: Blazing a Trail…and the Bumps Along the Way—A Public Health Nurse
as a Health Officer
Getting the Job: More Difficult Than You Might Think
Creating Access to Public Health Care in West New York
On-the-Job Training
Political Challenges
Safe Kid Day Arrives
Nurses Shaping Policy in Local Government
Successes and Challenges
Chapter 30 The Politics and Policy of Disaster Response and Public Health Emergency
Purpose Statement
Background and Significance
Presidential Declarations of Disaster and the Stafford Act
Policy Change After September 11
The Politics Underlying Disaster and Public Health Emergency Policy
The Homeland Security Act
Project Bioshield 2004
Pkemra 2006 and Disaster Case Management
National Commission on Children and Disasters 2009
Threat Level System of the U.S. Department of Homeland Security
Discussion Questions
Online Resources
Chapter 31 Chronic Care Policy: Medical Homes and Primary Care
The Experience of Chronic Care in the United States
Medical Homes
The Role of Nursing in Medical Homes
Patient-Centered Medical Homes: the Future
Discussion Questions
Online Resources
Chapter 32 Family Caregiving and Social Policy
Who are the Family Caregivers?
Unpaid Value of Family Caregiving
Caregiving as a Stressful Business
Supporting Family Caregivers
Discussion Questions
Online Resources
Chapter 33 Community Health Centers: Successful Advocacy for Expanding Health Care Access
Community Health Centers Demonstrate the Advocacy Process for Innovation
The Creation of the Neighborhood Health Center Program
Program Survival and Institutionalization
Continuing Policy Advocacy
The Expansion of Community Health Centers Under a Conservative President
Community Health Centers in the Era of Obamacare
Discussion Questions
Online Resources
Chapter 34 Filling the Gaps: Retail Health Care Clinics and Nurse-Managed Health Centers
Retail Health Clinics
Access and Quality in Retail Clinics
Retail Clinics and Cost
Challenges and Reactions to the Model
Nurse-Managed Health Clinics
Future Directions for Retail Clinics and NMHCs
Discussion Questions
Online Resources
Chapter 35 Developing Families
The Need for Improvement
Social Determinants and Life Course Model
Innovative Models of Care
Health Care Reform
Barriers to Sustaining, Spreading, and Scaling-Up Models
Discussion Questions
Online Resources
Chapter 36 Dual Eligibles: Issues and Innovations
Who are the Duals?
What are the Challenges?
Health Care Delivery Reforms That Hold Promise
Implication for Nurses
Policy Implications
Discussion Questions
Online Resources
Chapter 37 Home Care and Hospice: Evolving Policy
Defining the Home Care Industry
Home Health
Home Medical Equipment
Home Infusion Pharmacy
Private Duty
Reimbursement and Reimbursement Reform
Hospital Use and Readmissions and the Focus on Care Transitions
Quality and Outcome Management
The Impact of Technology on Home Care
Championing Home Care and Hospice and the Role of Nurses
Discussion Questions
Online Resources
Chapter 38 Long-Term Services and Supports Policy Issues
Poor Quality of Care
Weak Enforcement
Inadequate Staffing Levels
Corporate Ownership
Financial Accountability
Other Issues
Home and Community-Based Services
Public Financing
Discussion Questions
Online Resources
Chapter 39 The United States Military and Veterans Administration Health Systems: Contemporary
Overview and Policy Challenges
The MHS and VHA Budgets
Advanced Nursing Education and Career Progression
Contemporary Policy Issues Involving MHS and VHA Nurses
Post-Deployment Health-Related Needs
Seamless Transition
Discussion Questions
Online Resources
Unit 3 Policy and Politics in the Government
Chapter 40 Contemporary Issues in Government
Contemporary Issues in Government
The Central Budget Story
Fiscal Policy and Political Extremism
How Will the Nation’s Economic Health be Addressed?
The Impact of Political Dysfunction
Loss of Congressional Moderates
Congressional Gridlock: Where is the President’s Power?
Beleaguered Health Care Reform
Implementation Challenges
Increasing Access
Affordable Care Act Costs and Savings
Legal Challenges to the ACA
Immigration Reform: Will Health Care be Included?
Current Health Care Access
The Ethics and Economics of Access
Immigration Health Care Reform Options
Rising Economic Inequality
Measuring Wealth
The Great Recession Reshaped the Economy
Costs of Economic Inequality
Impact of Economic Inequality on Health Equity
Effectively Addressing Economic Inequality
Proposed Policy Strategies
Climate Change: Impacting Global Health
Climate Change: It’s Happening
Mitigation Versus Adaptation
International Progress
Adaptation is Local
Examples of Health in All Policies
Nursing Action Oriented Leadership
Discussion Questions
Chapter 41 How Government Works: What You Need to Know to Influence the Process
Federalism: Multiple Levels of Responsibility
The Federal Government
State Governments
Local Government
Target the Appropriate Level of Government
Pulling It All Together: Covering Long-Term Care
Discussion Questions
Online Resources
Chapter 42 Is There a Nurse in the House? The Nurses in the U.S. Congress
The Nurses in Congress
Evaluating the Work of the Nurses Serving in Congress
Political Perspective
Interest Group Ratings
Campaign Financing
Sources of Campaign Funds
Online Resources
Chapter 43 An Overview of Legislation and Regulation
Influencing the Legislative Process
Regulatory Process
Discussion Questions
Online Resources
Chapter 44 Lobbying Policymakers: Individual and Collective Strategies
Lobbyists, Advocates, and the Policymaking Process
Lobbyist or Advocate?
Why Lobby?
Steps in Effective Lobbying
How Should You Lobby?
Collective Strategies
Discussion Questions
Online Resources
Chapter 45 Taking Action: An Insider’s View of Lobbying
Getting Started
Winds of Change Coming in State Legislatures
Political Strategies
There Really is a Need for Lobbyists
Chapter 46 The American Voter and the Electoral Process
Voting Law: Getting the Voters to the Polls
Calls for Reform
Voting Behavior
Answering to the Constituency
Congressional Districts
Involvement in Campaigns
Campaign Finance Law
Types of Elections
The Morning After: Keeping Connected to Politicians
Discussion Questions
Online Resources
Chapter 47 Political Activity: Different Rules for Government-Employed Nurses
Why Was the Hatch Act Necessary?
Hatch Act Enforcement
Penalties for Hatch Act Violations
U.S. Department of Defense Regulations on Political Activity
Internet and Social Media Influence
Discussion Questions
Online Resources
Chapter 48 Taking Action: Anatomy of a Political Campaign
Why People Work on Campaigns
Why People Stop Working on Campaigns
The Internet and the 2012 Election Campaign
Campaign Activities
Discussion Questions
Online Resources
Chapter 49 Taking Action: Truth or Dare: One Nurse’s Political Campaign
Stepping Into Politics
Ethical Leadership
Making a Difference
Lessons Learned
Chapter 50 Political Appointments
What Does It Take to be a Political Appointee?
Getting Ready
Identify Opportunities
Making a Decision to Seek an Appointment
Plan Your Strategy
Confirmation or Interview?
After the Appointment
Experiences of Nurse Appointees
Discussion Questions
Online Resources
Chapter 51 Taking Action: Influencing Policy Through an Appointment to the San Francisco Health
Democracy and Service to the Health Commission
Checks and Balances of Health Commission Activities
Scope of Work of the Health Commission
Infrastructure of the Health Commission
Balancing Health Commission Service with Academia
Introspection: Re-Experiencing Decision Making on the Health Commission
Chapter 52 Taking Action: A Nurse in the Boardroom
My Political Career
My Campaign
Campaign Preparation
Launching the Campaign
Lessons Learned
The Future
Chapter 53 Nursing and the Courts
The Judicial System
Judicial Review
The Role of Precedent
the Constitution and Branches of Government
Impact Litigation
Expanding Legal Rights
Enforcing Legal and Regulatory Requirements
Antitrust Laws and Anticompetitive Practices
Criminal Courts
Influencing and Responding to Court Decisions
Nursing’s Policy Agenda
Discussion Questions
Online Resources
Chapter 54 Nursing Licensure and Regulation
Historical Perspective
The Purpose of Professional Regulation
Sources of Regulation
Licensure Board Responsibilities
Licensure Requirements
The Source of Licensing Board Authority
Disciplinary Offenses
Regulation’s Shortcomings
Discussion Questions
Online Resources
Chapter 55 Taking Action: Nurse, Educator, and Legislator: My Journey to the Delaware General
My Political Roots
Volunteering and Campaigning
There’s a Reason It is Called “Running” for Office
A Day in the Life of a Nurse-Legislator
What I’ve Been Able to Accomplish as a Nurse-Legislator
Tips for Influencing Elected Officials’ Health Policy Decisions
Is It Worth It?
Unit 4 Policy and Politics in the Workplace and Workforce
Chapter 56 Policy and Politics in Health Care Organizations
Financial Pressures From Changing Payment Models
The Broadening Influence of Outcome Accountability
A Door Opens—Policy to Support the Role of the Nurse Practitioner
Discussion Questions
Online Resources
Chapter 57 Taking Action: Nurse Leaders in the Boardroom
Getting Started
Are You Ready?
Discussion Questions
Online Resources
Chapter 58 Quality and Safety in Health Care: Policy Issues
The Environmental Context
The Policy Context: Value-Driven Health Care
Value-Based Payment and Delivery Models
Impact of Value-Driven Health Care on Nursing
Discussion Questions
Online Resources
Chapter 59 Politics and Evidence-Based Practice and Policy
The Players and Their Stakes
The Role of Politics in Generating Evidence
The Politics of Research Application in Clinical Practice
The Politics of Research Applied to Policy Formulation
Discussion Questions
Online Resources
Chapter 60 The Nursing Workforce
Characteristics of the Workforce
Expanding the Workforce
Increasing Diversity
Retaining Workers
Addressing the Nursing Workforce Issues
Discussion Questions
Online Resources
Chapter 61 Rural Health Care: Workforce Challenges and Opportunities
What Makes Rural Health Care Different?
Defining Rural
Rural Policy, Rural Politics
The Opportunities and Challenges of Rural Health
Discussion Questions
Online Resources
Chapter 62 Nurse Staffing Ratios: Policy Options
The Establishment of California’s Regulations
What Has Happened as a Result of the Ratios?
What Next?
Discussion Questions
Online Resources
Chapter 63 The Contemporary Work Environment of Nursing
Primary Factors
Secondary Factors
American Hospital Association (AHA) Report
Crucial Communication
Discussion Questions
Online Resources
Chapter 64 Collective Strategies for Change in the Workplace
Building a Culture of Change
Workplace Cultures Differ
Implementing the Change Decision
Examples of Change Decisions
Discussion Questions
Online Resources
Chapter 65 Taking Action: Advocating for Nurses Injured in the Workplace
Life Lessons
Becoming a Voice for Back-Injured Nurses
Establishing the Work Injured Nurses Group USA (WING USA)
Legislative Efforts to Advance Safe Patient Handling
The Future
Chapter 66 The Politics of Advanced Practice Nursing
Political Context of Advanced Practice Nursing
The Political Issues
Toward New APN Politics: Overcoming Appeasement and Apathy
Discussion Questions
Chapter 67 Taking Action: Reimbursement Issues for Nurse Anesthetists: A Continuing Challenge
Nurse Anesthesia Practice
Nurse Anesthesia Reimbursement
Advocacy Issues in Anesthesia Reimbursement
TEFRA: Defining Medical Direction
Physician Supervision of CRNAs: Medicare Conditions of Participation
Medicare Coverage of Chronic Pain Management Services
Chapter 68 Taking Action: Overcoming Barriers to Full APRN Practice: The Idaho Story
Nurturing the Passion to Achieve Statutory Change
Building Broad Coalitions and Relationships
Sustaining the Effort and the Vision
Removing Barriers to Autonomous APRN Practice
The Stars Align
The 2012 NPA Revision
Chapter 69 Taking Action: A Nurse Practitioner’s Activist Efforts in Nevada
Being a Leader
Activism Means Leaving Your Comfort Zone
Honing Your Verbal and Nonverbal Messages
Activism Requires Funding Knowledge
Developing Activist Skills Through Experience
Chapter 70 Nursing Education Policy: The Unending Debate over Entry into Practice and the
Continuing Debate over Doctoral Degrees
The Entry Into Practice Debate
The Entry Into Advanced Practice Debate
Discussion Questions
Online Resources
Chapter 71 The Intersection of Technology and Health Care: Policy and Practice Implications
Public Policy Support for HIT
Discussion Questions
Online Resources
Unit 5 Policy and Politics in Associations and Interest Groups
Chapter 72 Interest Groups in Health Care Policy and Politics
Development of Interest Groups
Functions and Methods of Influence
Landscape of Contemporary Health Care Interest Groups
Assessing Value and Considering Involvement
Discussion Questions
Online Resources
Chapter 73 Current Issues in Nursing Associations
Nursing’s Professional Organizations
Organizational Life Cycle
Current Issues for Nursing Organizations
Discussion Questions
Online Resources
Chapter 74 Professional Nursing Associations: Operationalizing Nursing Values
The Significance of Nursing Organizations
Evolution of Organizations
Today’s Nurse
Organizational Purpose
Associations and Their Members
Leadership Development
Opportunities to Shape Policy
Influencing the Organization
Discussion Questions
Online Resources
Chapter 75 Coalitions: A Powerful Political Strategy
Birth and Life Cycle of Coalitions
Building and Maintaining a Coalition: the Primer
Pitfalls and Challenges
Political Work of Coalitions
Evaluating Coalition Effectiveness
Discussion Question
Online Resources
Chapter 76 Taking Action: The Nursing Community Builds a Unified Voice
The Necessity of Coalitions
Coalition Formation
Defining a Coalition’s Success: the Importance of Leadership and Goal Setting
A Perspective on Nursing’s Unified Voice
Nursing Unites: the Nursing Community
Chapter 77 Taking Action: The Nursing Kitchen Cabinet: Policy and Politics in Action
The Context
Discussion Questions
Chapter 78 Taking Action: Improving LGBTQ Health: Nursing Policy Can Make a Difference
LGBTQ Rights in the United States
Nursing and LGBTQ Advocacy
Taking Action
Online Resources
Chapter 79 Taking Action: Campaign for Action
The Future of Nursing Report
A Vision for Implementing the Future of Nursing Report
Success at the National Level
Success at the State Level
Online Resources
Chapter 80 Taking Action: The Nightingales Take on Big Tobacco
Tobacco Kills
Ruth’s Story
The Personal Becomes Political
Compelling Voices
Strategic Planning
Kelly’s Story
Policy Advocacy
Shareholder Advocacy: “the NURSES are Coming…”
Extending the Message
What NURSES Can Do
Nursing is Political
Lessons Learned: Nursing Activism
Discussion Questions
Online Resources
Unit 6 Policy and Politics in the Community
Chapter 81 Where Policy Hits the Pavement: Contemporary Issues in Communities
What is a Community?
Healthy Communities
Partnership for Improving Community Health
Determinants of Health
Discussion Questions
Online Resources
Chapter 82 An Introduction to Community Activism
Key Concepts
Taking Action to Effect Change: Characteristics of Community Activists and Activism
Challenges and Opportunities in Community Activism
Nurses as Community Activists
Discussion Questions
Online Resources
Chapter 83 Taking Action: The Canary Coalition for Clean Air in North Carolina’s Smoky
Mountains and Beyond
Lessons in Communicating
Persuasion: the Integrated Resource Plan Example
Speaking to Power
Clean Air: a Mixed Blessing
The Crucible of Financial Challenge
Efficient and Affordable Energy Rates Bill
Nurses’ Role in Environmental Stewardship
Chapter 84 How Community-Based Organizations Are Addressing Nursing’s Role in Transforming
Health Care
Community as Partner and the Community Anchor
Accountable Care Community
Superstorm Sandy
the Population Care Coordinator
Hospital Partnerships and Transitional Care
Vulnerable Patient Study
Discussion Questions
Online Resources
Chapter 85 Taking Action: From Sewage Problems to the Statehouse: Serving Communities
Sewage Changed My Life
My Campaigns
The Value of Political Activity in Your Community
Leadership in the International Community
Mentoring Other Nurses for Political Advocacy
Recommendations for Becoming Involved in Politics
Chapter 86 Family and Sexual Violence: Nursing and U.S. Policy
Intimate Partner and Sexual Violence Against Women
State Laws Regarding Intimate Partner and Sexual Violence
Federal Laws Related to Intimate Partner and Sexual Violence
Health Policies Related to Intimate Partner and Sexual Violence
Child Maltreatment
State and Federal Policies Related to Child Maltreatment
Health Policies Related to Child Maltreatment
Older Adult Maltreatment
State and Federal Legislation Related to Older Adult Maltreatment
Health Care Policies Related to Older Adult Maltreatment
Opportunity for Nursing
Discussion Questions
Online Resources
Chapter 87 Human Trafficking: The Need for Nursing Advocacy
Encountering the Victims of Human Trafficking
Advancing Policy in the Workplace
Role of Professional Nursing Associations
Advocating for State Legislation and Policy on Human Trafficking
Advancing Policy Through Media and Technology
Trafficking as a Global Public Health Issue
The World of the Victims
International Policy
U.S. Response to Human Trafficking
Discussion Questions
Online Resources
Chapter 88 Taking Action: A Champion of Change: For Want of a Hug
What Happened?
The Struggle to Find Help
We Got Help, but What About Others?
Commitment in My Community
Meeting Basic Needs
Gang Violence Prevention
It Takes a Village
Chapter 89 Lactivism: Breastfeeding Advocacy in the United States
Why Advocate for Breastfeeding?
The Historic Decline in Breastfeeding in the United States
Culture of Breastfeeding
Action to Support Breastfeeding
The Need for Breastfeeding Advocacy Education
Discussion Questions
Online Resources
Chapter 90 Taking Action: Reefer Madness: The Clash of Science, Politics, and Medical Marijuana
A Plant with an Image Problem
Once upon a Time, Cannabis Was Legal
How and Why Did the Marijuana Prohibition Begin?
My Introduction to the Problem of Medical Cannabis Use
An Opportunity for Education
Barriers and Strategies
Patients Out of Time
The Tide is Shifting
Looking Ahead at a Paradigm Shift
Chapter 91 International Health and Nursing Policy and Politics Today: A Snapshot
Global Health
The Policy Role of the World Health Organization
The Millennium Development Goals
Beyond the Millennium Development Goals
Human Resources for Health
Advanced Nursing Practice
The World Health Organization and Nursing
Nursing’s Policy Voice
Getting Involved
Discussion Questions
Chapter 92 Infectious Disease: A Global Perspective
Determinants of Infectious Disease Introduction and Transmission
Ebola Virus Disease Outbreak: West Africa, 2014
Surveillance and Reporting
Discussion Questions
Online Resources
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Library of Congress Cataloging-in-Publication Data
Policy & politics in nursing and health care / [edited by] Diana J. Mason, Deborah B. Gardner,
Freida Hopkins Outlaw, Eileen T. O’Grady.—Seventh edition.
p.; cm.
Policy and politics in nursing and health care
Includes bibliographical references and index.
ISBN 978-0-323-24144-1 (pbk. : alk. paper)
I. Mason, Diana J., 1948-, editor. II. Gardner, Deborah B., editor. III. Outlaw, Freida Hopkins,
editor. IV. O’Grady, Eileen T., 1963-, editor. V. Title: Policy and politics in nursing and health care.
[DNLM: 1. Nursing–United States. 2. Delivery of Health Care–United States. 3. Politics–United
States. 4. Public Policy–United States. WY 16 AA1]
Senior Content Strategist: Sandra Clark
Content Development Manager: Laurie Gower
Senior Content Development Specialist: Karen Turner
Content Development Specialist: Jennifer Wade
Publishing Services Manager: Jeff Patterson
Senior Project Manager: Clay S. Broeker
Design Direction: Ashley Miner
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
About the Editors
DIANA J. MASON, PhD, RN, FAAN, is the Rudin Professor of Nursing and Co-Founder and CoDirector of the Center for Health, Media, and Policy (CHMP) at Hunter College and Professor at the
City University of New York. She served as President of the American Academy of Nursing (20132015) and as Strategic Adviser for the Campaign for Action, an initiative to implement the
recommendations from the Institute of Medicine’s Future of Nursing report, to which she
contributed. From 2012 to 2015 she served as Co-President of the Hermann Biggs Society, an
interdisciplinary health policy salon in New York City.
Dr. Mason was editor-in-chief of the American Journal of Nursing for over a decade. Under her
leadership, the journal received numerous awards for editorial excellence and dissemination,
culminating in the journal being selected by the Specialized Libraries Association in 2009 as one of
the 100 most influential Journals of the Century in Biology and Medicine—the only nursing journal
to be selected for this distinction.
As a journalist, she has produced and moderated a weekly radio program on health and health
policy (Healthstyles) for 30 years. She blogs for HealthCetera (www.centerforhealthmediapolicy.com) and
for the JAMA News Forum. In 2009, she was appointed to the National Advisory Committee for
Kaiser Health News—the only nurse and health professional on the Committee.
She is the lead co-editor of The Nursing Profession: Development, Challenges, and Opportunities, part of
the Robert Wood Johnson Foundation Health Policy Book Series. She has been the lead co-editor of
all seven editions of Policy & Politics in Nursing and Health Care.
She is the recipient of numerous honors, including Honorary Doctorates from Long Island
University and West Virginia University; fellowship in the New York Academy of Medicine; and
the Pioneering Spirit Award from the American Association of Critical Care Nurses.
DEBORAH B. GARDNER, PhD, RN, FAAN, FNAP, is a health policy and leadership consultant.
She has more than 35 years of health care experience as a clinician, manager, trainer, and consultant
delivering care across diverse institutional and community settings. Dr. Gardner practiced as a
psychiatric mental health clinical nurse specialist for 15 years. She received a PhD in Nursing
Administration and Health Policy from George Mason University.
At the National Institutes of Health (NIH) Clinical Center she established and held the position as
the Director of Organizational Planning and Workforce Development for 10 years. She served at the
Bureau of Health Professionals, Health Resources and Services Administration (HRSA) as a senior
consultant collaborating on the implementation of the Affordable Care Act (ACA) (2010-2012). As
the Director of the Hawaii State Center for Nursing, she led the State’s Campaign for Action
Coalition, a Robert Wood Johnson Foundation Initiative to support the Institute of Medicine’s
Future of Nursing report.
In 2012 she served as a member of the Hawaii Governor’s Healthcare Transformation Steering
Committee to assess and refocus Hawaii’s health care delivery system for alignment to the ACA
A Fellow in the American Academy of Nursing and in the National Academy of Practice, she was
instrumental in establishing the National Center for Interprofessional Practice and Education in
Minneapolis, Minnesota. She has received numerous awards, including the HRSA Administrator’s
Special Citation for National Leadership in Interprofessional Education and Collaborative Practice,
an International Coaching Federation Award for Excellence in the Establishment of an Outstanding
Executive Coaching Program, the NIH Director’s Award for Outstanding Mentoring and
Innovation in Organizational Development Strategies, and the “Profiles in Excellence” alumni
honors award from Oklahoma Baptist University.
Dr. Gardner has written numerous book chapters and articles. She serves on the Editorial Board for
Nursing Economic$ and writes the Policy and Politics column. She is a professional speaker on
interprofessional practice and education teams, advanced practice nursing, and health policy issues.
FREIDA HOPKINS OUTLAW, PhD, RN, FAAN, is an adjunct professor in the Peabody College of
Education, Vanderbilt University, Nashville, Tennessee. She served as the Assistant Commissioner,
Division of Special Populations, Tennessee Department of Mental Health and Substance Abuse
Services. In this role, she helped to develop policies and initiatives that improved treatment for
children with mental health and substance abuse issues. She provided leadership in securing $32
million of federal funding to support transforming the mental health system for children and their
families and was part of the leadership instrumental in passing legislation to create the Children’s
Mental Health Council, which developed a plan for a statewide system of care implementation,
which continues today.
She participated in the American Nurses Association Minority Fellowship Legislative Internship
Program. Her passion was further ignited when state and national policies impacted delivery of
mental health services to children and their families to which she provided mental health services at
the University of Pennsylvania nurse-managed health center. Dr. Outlaw received a Department of
Health and Human Services Policy Academy Grant to lead a team of child-serving agencies,
community stakeholders, families, and youth to work on transforming mental health care for
children and families through planning, policy, and practice. Dr. Outlaw a member of the Robert
Wood Johnson Foundation (RWJF) Collaborative National Advisory Committee, whose function is
to advise the faculty of the RWJF Nursing and Health Policy Collaborative, University of New
Mexico, College of Nursing. She is a Fellow in the American Academy of Nursing and is an active
member of the Psychiatric Mental Health and Substance Abuse Expert Panel.
She has written frequently on the areas of depression, impact of racism, and stress on the health of
African Americans; management of aggression; seclusion and restraint; religion, spirituality, and
the meaning of prayer for people with cancer; and children’s mental health. She has received
recognition for her excellence in clinical practice and for her work to improve the mental health of
children and their families.
EILEEN T. O’GRADY, PhD, NP, RN, is a certified Nurse Practitioner and Wellness Coach who
uses an evidence-based approach with people to reverse or prevent disease. She believes deeply
that more attention must be paid to getting us unstuck from lifestyles that do not support wellness.
She speaks professionally at universities, associations, corporations, schools, and communities on
the importance of thoughtful self-care, patient engagement, and how to identify and remedy a life
that is out of balance. She is currently adjunct faculty in the Graduate Schools of Nursing at Pace
University, Georgetown University, Duke University, and George Washington University, where
she was given an Outstanding Teacher Award.
She has held a number of leadership positions with professional nursing associations, most notably
as a founder and vice chair of the American College of Nurse Practitioners (now the American
Association of Nurse Practitioners). She was a 1999 Policy Fellow in the U.S. Public Health Service
Primary Care Policy Fellowship and in 2003 was given the American College of Nurse Practitioners
Legislative Advocacy Award for her leadership on nurse practitioner policy issues. She is the 2013
recipient of the Loretta Ford Lifetime Achievement Award and the Virginia Council of Nurse
Practitioners Advocate of the Year Award.
She is a co-editor and author of Advanced Practice Nursing: An Integrative Approach, 5th edition
(Elsevier, 2013) and has authored numerous articles and book chapters as well as a monthly column
on advanced practice nursing and health policy for 10 years in Nurse Practitioner World News.
She has taught nurses and physicians both nationally and internationally with the U.S. Peace Corps.
Dr. O’Grady has practiced as a primary care provider for 15 years and is now certified as a life
coach through the International Coaching Federation and as an Adult Nurse Practitioner through
the American Nurses Credentialing Center. Dr. O’Grady holds three graduate degrees: a Master of
Public Health from George Washington University, a Master of Science in Nursing, and a Doctor of
Philosophy in Nursing/Health Policy from George Mason University. She has dual citizenship in
Ireland and the United States. www.eileenogrady.net
Greg Abell
Sound Options Group, LLC
Bainbridge Island, Washington
Charles R. Alexandre PhD, RN
Quality and Regulation
Butler Hospital
Providence, Rhode Island
Carmen Alvarez PhD, C-NP, CNM
Julio Bellber Post-Doctoral Fellow
Department of Health Policy
George Washington University
Washington, DC
Angela Frederick Amar PhD, RN, FAAN
Assistant Dean for BSN Education and Associate Professor
Nell Hodgson Woodruff School of Nursing
Emory University
Atlanta, Georgia
Coral T. Andrews MBA, RN, FACHE
Founding Executive Director
Hawaii Health Connector
Honolulu, Hawaii
Susan Apold PhD, RN, ANP-BC, FAAN, FAANP
Robert Wood Johnson Foundation Executive Nurse Fellow
Clinical Professor of Nursing
New York University
New York, New York
Kenya V. Beard EdD, GNP-BC, NP-C, ACNP-BC, CNE
Associate Vice President for Curriculum and Instruction
Center Multicultural Education and Health Disparities
Jersey College
Teterboro, New Jersey
Mary L. Behrens MS, FNP-BC, FAANP
Family Nurse Practitioner
Westside Woman’s Clinic
Casper, Wyoming
Susan I. Belanger PhD, MA, RN, NEA-BC
Education, Training, and Research
Sibley Memorial Hospital/Johns Hopkins Medicine
Assistant Professor
School of Nursing and Health Studies
Georgetown University
Washington, DC
Katherine N. Bent RN, PhD, CNS
Assistant Commissioner, Compliance Policy
U.S. Food and Drug Administration
Silver Spring, Maryland
Jonathan Bentley BS, RN
RN Care Coordinator
Harris Regional Hospital
Sylva, North Carolina
Carmina Bernardo MA, MPH
Doctor of Public Health Student
Health Policy and Management Track
Graduate Center
City University of New York
New York, New York
Virginia Trotter Betts MSN, JD, RN, FAAN
President and Chief Executive Officer
HealthFutures, Inc.
Nashville, Tennessee
Linda Burnes Bolton DrPH, RN, FAAN
Vice President, Nursing and Chief Nursing Officer
Cedars-Sinai Medical Center
Los Angeles, California
Marilyn Waugh Bouldin MSN, RN, PNP
Board of Directors
Heart of the Rockies Regional Medical Center
Retired Director
Chaffee County Public Health
Salida, Colorado
Rebecca (Rice) Bowers-Lanier EdD, MSN, MPH, RN
B2L Consulting
Richmond, Virginia
Patricia K. Bradley PhD, RN, FAAN
Associate Professor
College of Nursing
Villanova University
Villanova, Pennsylvania
Edie Brous MS, MPH, JD, RN
Nurse Attorney
New York, New York
Mary Lou Brunell MSN, RN
Executive Director
Florida Center for Nursing
Florida Action Coalition
Orlando, Florida
Kelly Buettner-Schmidt PhD, RN
Associate Professor of Nursing
North Dakota State University
Fargo, North Dakota
Josepha E. Burnley DNP, FNP-C
Nurse Consultant
Health Resources and Services Administration
Rockville, Maryland
Rachel Burton
Research Associate
Health Policy Center
Urban Institute
Washington, DC
Ann Campbell MPH, MSN, AGPCNP-BC, RN
Primary and Palliative Care Nurse Practitioner
Mary Manning Walsh Home
Integrative Health Nurse Practitioner
The Original Bloom
New York, New York
Demetrius Chapman PhD(c), MPH, MSN(R), APRN, PHCNS-BC
Associate Director
New Mexico Board of Nursing
Albuquerque, New Mexico
Peggy L. Chinn PhD, RN, FAAN
Professor Emerita
University of Connecticut
Advances in Nursing Science
Oakland, California
Yoon Jeong Choi MSN, MPhil, RN
PhD Candidate
School of Nursing
Columbia University
New York, New York
Glenda Christiaens PhD, RN, AHN-BC
Former President
American Holistic Nurses Association
Salt Lake City, Utah
Mary Ann Christopher MSN, RN, FAAN
Avon, New Jersey
Angela K. Clark MSN, PhD(c), RN
Graduate Student
College of Nursing
University of Cincinnati
Cincinnati, Ohio
Sean P. Clarke PhD, RN, FAAN
Professor and Associate Dean
Undergraduate Programs
William F. Connell School of Nursing
Boston College
Chestnut Hill, Massachusetts
Sally S. Cohen PhD, RN, FAAN
IOM/AAN/ANA/ANF Distinguished Nurse Scholar-in-Residence (2014-2015)
Virginia P. Crenshaw Endowed Chair
Robert Wood Johnson Foundation Nursing and Health Policy Collaborative
College of Nursing
University of New Mexico
Albuquerque, New Mexico
Judith B. Collins RNC, MS, WHNP, FAAN
Faculty Emerita
Schools of Nursing and Medicine
Founding Director
Health Policy Office and Women’s Health Center
Virginia Commonwealth University
Richmond, Virginia
Karen S. Cox PhD, FACHE, RN, FAAN
Executive Vice President and Co-Chief Operating Officer
Children’s Mercy Kansas City
Kansas City, Missouri
Barbara I.H. Damron PhD, RN, FAAN
New Mexico Higher Education Department
Santa Fe, New Mexico
Patricia D’Antonio PhD, RN, FAAN
Killebrew-Censtis Term Professor in Undergraduate Nursing Education
Senior Fellow
Leonard Davis Institute of Health Economics
School of Nursing
University of Pennsylvania
Philadelphia, Pennsylvania
C. Christine Delnat MSN, RN
Assistant Professor
Department of Nursing
St. Mary-of-the-Woods College
Terre Haute, Indiana
Erin M. Denholm MSN, RN, RWJENF
SVP Clinical Transformation
Centura Health
Denver, Colorado
Catherine M. Dentinger FNP, MPH
Career Epidemiology Field Officer
New York City Department of Health and Mental Hygiene
Centers for Disease Control and Prevention
New York, New York
Betty R. Dickson BS
Retired Contract Lobbyist
Barnardsville, North Carolina
Michele J. Eliason PhD
Associate Professor
Department of Health Education
San Francisco State University
San Francisco, California
Jeanette Ives Erickson RN, DNP, FAAN, NEA-BC
Chief Nurse and Senior Vice President for Patient Care
Massachusetts General Hospital
Boston, Massachusetts
Carroll L. Estes PhD
Professor of Sociology
Founding Director
Institute for Health and Aging
University of California, San Francisco
San Francisco, California
Robin Dawson Estrada PhD, PNP-BC, RN
Assistant Professor
College of Nursing
University of South Carolina
Columbia, South Carolina
Sandra Evans MAEd, RN
Executive Director
Idaho Board of Nursing
Boise, Idaho
Julie Fairman PhD, RN, FAAN
Nightingale Professor in Nursing
Barbara Bates Center for the Study of the History of Nursing
Robert Wood Johnson Foundation Future of Nursing Scholars Program
School of Nursing
University of Pennsylvania
Philadelphia, Pennsylvania
Lola M. Fehr MS, CAE, PRP, RN, FAAN
Fehr Consulting Resources
Greeley, Colorado
Loretta C. Ford PNP, EdD, RN, FAAN, FAANP
Professor and Dean Emerita
School of Nursing
University of Rochester, New York
Elizabeth B. Froh PhD, RN
Clinical Supervisor
Lactation Team and Human Milk Management Center
Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Beth Gharrity Gardner MA, PhD(c)
PhD Candidate
Department of Sociology
University of California, Irvine
Irvine, California
Catherine Alicia Georges EdD, RN, FAAN
Professor and Chairperson
Department of Nursing
Lehman College
Bronx, New York
Rosemary Gibson MSc
Senior Advisor
The Hastings Center
Garrison, New York
Greer Glazer PhD, RN, CNP, FAAN
University of Cincinnati College of Nursing
Schmidlapp Professor of Nursing
Cincinnati, Ohio
Barbara Glickstein MPH, MS, RN
Center for Health, Media and Policy
Hunter College
City University of New York
New York, New York
Bethany Hall-Long PhD, RNC, FAAN
State Senator
State of Delaware 10th District
Professor of Nursing
University of Delaware
Newark, Delaware
Mary Mincer Hansen PhD, RN
Adjunct Associate Professor
MPH Program and Global Health Department
Des Moines University
Des Moines, Iowa
Tine Hansen-Turton MGA, JD, FCPP, FAAN
Chief Executive Officer
National Nursing Centers Consortium
Chief Strategy Officer
Public Health Management Corporation
Philadelphia, Pennsylvania
Charlene Harrington PhD, RN
Professor Emeritus of Nursing and Sociology
School of Nursing
University of California
San Francisco, California
Mary Ann Hart MSN, RN
Program Director
Graduate Program in Health Administration
Assistant Professor of Nursing and Health Administration
School of Nursing, Science, and Health Professions
Regis College
Weston, Massachusetts
Heidi Hartmann PhD
Institute for Women’s Policy Research
Research Professor
George Washington University
Washington, DC
Susan B. Hassmiller PhD, RN, FAAN
Senior Adviser for Nursing
Future of Nursing: Campaign for Action
Robert Wood Johnson Foundation
Princeton, New Jersey
Barbara Hatfield RN
Former Delegate
West Virginia House
Charleston, West Virginia
Pamela J. Haylock PhD, RN, FAAN
Oncology Care Consultant
Medina, Texas
Adjunct Instructor
Schreiner University
Kerrville, Texas
Margaret Wainwright Henbest MSN, RN
Executive Director
Nurse Leaders of Idaho
Boise, Idaho
Karrie Cummings Hendrickson PhD, MSN, RN
Finance Clinical Coordinator
Department of Analytic Strategy
Yale New Haven Health System
New Haven, Connecticut
Linda Hirota Hevenor MPH, MS, RN
Director of Patient Safety
Department of Quality and Operational Excellence
Providence, Rhode Island
Sarah Hexem JD
Law and Policy Program Manager
National Nursing Centers Consortium
Philadelphia, Pennsylvania
Anne Hudson RN, C, BSN
Work Injured Nurses Group USA
Public Health Nurse
Coos County Public Health Department
Coos Bay, Oregon
Randall Steven Hudspeth PhD, MS, APRN-CNP/CNS, FRE, FAANP
Executive Clinical Consultant
Hudspeth LLC
Boise, Idaho
Lauren Inouye MPP, RN
Associate Director of Government Affairs
American Association of Colleges of Nursing
Washington, DC
Brenda Isaac RN, BSN, MA, NCSN
Lead School Nurse
Kanawha County Schools
Charleston, West Virginia
Jean E. Johnson PhD, RN, FAAN
Professor and Founding Dean (retired)
School of Nursing
George Washington University
Washington, DC
Jane Clare Joyner RN, MSN, JD
Senior Policy Fellow
American Nurses Association
Silver Spring, Maryland
Louise Kahn MSN, MA, RN, CPNP
Specialty Nurse
Center for Development and Disability
University of New Mexico
Albuquerque, New Mexico
David M. Keepnews PhD, JD, RN, NEA-BC, FAAN
Professor and Director of Graduate Programs
Hunter-Bellevue School of Nursing
Hunter College, City University of New York
New York, New York
Karren Kowalski PhD, RN, NEA-BC, ANEF, FAAN
President and Chief Executive Officer
Colorado Center for Nursing Excellence
Denver, Colorado
School of Nursing
Texas Tech University Health Sciences Center
Lubbock, Texas
Mary Jo Kreitzer PhD, RN, FAAN
Center for Spirituality and Healing
School of Nursing
University of Minnesota
Minneapolis, Minnesota
Bryan Krumm MSN, CNP
Psychiatric Nurse Practitioner
Sage Neuroscience Center
Albuquerque, New Mexico
Ellen T. Kurtzman MPH, RN, FAAN
Assistant Research Professor
School of Nursing
George Washington University
Washington, DC
Susan R. Lacey RN, PhD, FAAN
Leadership, Research, and Empowerment Consultant
Huntsville, Alabama
Jean Larson RN, MSN
Board Member
Canary Coalition
Leicester, North Carolina
Kathryn Laughon PhD, RN, FAAN
Associate Professor
School of Nursing
University of Virginia
Charlottesville, Virginia
Roberta P. Lavin PhD, APRN-BC
Associate Dean for Academic Programs and Professor
University of Missouri, St. Louis
St. Louis, Missouri
Judith K. Leavitt RN, MEd, FAAN
Health Policy Consultant
Barnardsville, North Carolina
Sandra B. Lewenson EdD, RN, FAAN
Lienhard School of Nursing
College of Health Professions
Pace University
Pleasantville, New York
Elena Lopez-Bowlan APRN, MSN, FNP-BC
Examiner, Compensation and Pension
Veterans Administration Sierra Nevada Health Care System
Reno, Nevada
Robert J. Lucero PhD, MPH, RN
Associate Professor of Nursing
College of Nursing
University of Florida
Research Health Scientist
HSR&D Center of Innovation on Disability and Rehabilitation Research
North Florida/South Georgia Veterans Health System
Gainesville, Florida
Beverly Malone PhD, RN, FAAN
Chief Executive Officer
National League for Nursing
Washington, DC
Ruth E. Malone PhD, RN, FAAN
Professor and Nursing Alumni/Mary Harms Endowed Chair
Department of Social and Behavioral Sciences
School of Nursing
University of California
San Francisco, California
Mary Lynn Mathre RN, MSN, CARN
President and Co-Founder
Patients Out of Time
President and Founding Member
American Cannabis Nurses Association
Howardsville, Virginia
DeAnne K. Hilfinger Messias PhD, RN, FAAN
College of Nursing and Women’s and Gender Studies
University of South Carolina
Columbia, South Carolina
Gina Miranda-Diaz DNP, MS/MPH, RN
New Jersey State Licensed Health Officer
Health Department
West New York, New Jersey
Assistant Professor
Department of Nursing
Lehman College
Bronx, New York
Suzanne Miyamoto PhD, RN
Senior Director of Government Affairs and Health Policy
American Association of Colleges of Nursing
Washington, DC
Wanda Montalvo MSN, MPhil, RN
Montalvo Consulting
Staten Island, New York
Alan Morgan MPA
Chief Executive Officer
National Rural Health Association
Washington, DC
Ellen S. Murray MS
Colin Powell School for Civic and Global Leadership
City College of New York
City University of New York
New York, New York
Colonel (Retired) John S. Murray PhD, RN, CPNP-PC, CS, FAAN
Pediatric Nurse Consultant and Graduate Student
Online Master of Science in Global Health Program
Feinberg School of Medicine and Professional Studies
Northwestern University
Boston, Massachusetts
Len M. Nichols PhD
Professor of Health Policy
Center for Health Policy Research and Ethics
George Mason University
Fairfax, Virginia
Karen O’Connor PhD, JD
Jonathan N. Helfat Distinguished Professor of Political Science
American University
Washington, DC
Terry O’Neill JD
National Organization of Women (NOW)
NOW Foundation
New York, New York
Douglas P. Olsen PhD, RN
Associate Professor
College of Nursing
Michigan State University
East Lansing, Michigan
Katie Oppenheim BSN, RN
Staff Nurse
Birth Center
Von Voigtlander Women’s Hospital
University of Michigan Health System
Ann Arbor, Michigan
Judith A. Oulton RN, BN, MEd, DSc (Hon)
Oulton, Oulton, and Associates
Tatamagouche, Nova Scotia, Canada
Sharon Pappas PhD, RN, NEA-BC, FAAN
Chief Nursing Officer
Porter Adventist Hospital
Chief Nurse Executive
Centura Health
Denver, Colorado
Lynn Price JD, MSN, MPH
Professor and Chair
Graduate Nursing
School of Nursing
Quinnipiac University
Hamden, Connecticut
Chad S. Priest JD, MSN, RN
Assistant Dean for Operations and Community Partnerships
School of Nursing
Indiana University
Adjunct Assistant Professor of Emergency Medicine
Disaster Medicine Fellowship Program
School of Medicine
Indiana University
Indianapolis, Indiana
Joyce A. Pulcini PhD, RN, PNP-BC, FAAN, FAANP
Director of Community and Global Initiatives
School of Nursing
George Washington University
Washington, DC
Frank Purcell BS
Senior Director, Federal Government Affairs
American Association of Nurse Anesthetists
Washington, DC
Susan C. Reinhard PhD, RN, FAAN
Senior Vice President
AARP Public Policy Institute
Chief Strategist
Center to Champion Nursing in America
Washington, DC
Victoria. L. Rich PhD, RN, FAAN
Associate Professor
Nursing Administration
School of Nursing
University of Pennsylvania
Philadelphia, Pennsylvania
Nancy Ridenour PhD, APRN, BC, FAAN
Dean and Professor
College of Nursing
University of New Mexico
Albuquerque, New Mexico
Karen M. Robinson PhD, PMHCNS-BC, FAAN
Gerontology Professor
Executive Director
Caregivers Program of Research
School of Nursing
University of Louisville
Louisville, Kentucky
Beth L. Rodgers PhD, RN, FAAN
College of Nursing
University of New Mexico
Albuquerque, New Mexico
Carol A. Romano PhD, RN, FAAN
Rear Admiral (Retired)
Dean and Professor
Graduate School of Nursing
Uniformed Services University
Bethesda, Maryland
Carol F. Roye EdD, RN, CPNP, FAAN
Associate Dean for Faculty Scholarship
Lienhard School of Nursing
Pace University
New York, New York
Angie Ross MEd
Winter Park, Florida
Alice Sardell PhD
Department of Urban Studies
Queens College
City University of New York
Doctorate of Public Health Program
School of Public Health
City University of New York
Flushing, New York
Chelsea Savage DNP, MSHA, BA, RN, CPHRM
Professional Liability Investigator
Virginia Commonwealth University Medical Center
Richmond, Virginia
Christine Ceccarelli Schrauf PhD, RN, MBA
Associate Professor
School of Nursing
Elms College
Chicopee, Massachusetts
James Mark Simmerman PhD, RN
Asia Pacific Regional Director of Epidemiology
Sanofi Pasteur Vaccines
Bangkok, Thailand
Arlene M. Smaldone PhD, CPNP, CDE
Associate Professor of Nursing
Assistant Dean
Scholarship and Research
School of Nursing
Columbia University
New York, New York
Andréa Sonenberg PhD, WHNP, CNM-BC
Associate Professor
Graduate Program
Lienhard School of Nursing
College of Health Professions
Pace University
Pleasantville, New York
Diane L. Spatz PhD, RN-BC, FAAN
Professor of Perinatal Nursing
Helen M. Shearer Professor of Nutrition
School of Nursing
University of Pennsylvania
Nurse Researcher and Director of the Lactation Program
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Joanne Spetz PhD, FAAN
Philip R. Lee Institute for Health Policy Studies
Associate Director for Research Strategy
Center for the Health Professions
University of California, San Francisco
San Francisco, California
Caroline Stephens PhD, MSN, APRN, BC
Assistant Professor
Department of Community Health Systems
Associate Director
Hartford Center of Gerontological Nursing Excellence
School of Nursing
University of California, San Francisco
San Francisco, California
Elaine D. Stephens MPH, FHHC, RN
Executive Vice President
National Association for Home Care and Hospice
Washington, DC
Patricia W. Stone PhD, RN, FAAN
Centennial Professor in Health Policy
Director of the Center for Health Policy
School of Nursing
Columbia University
Visiting Professor for Faculty of Health
University of Technology, Sydney
Sydney, New South Wales, Australia
Lisa Summers CNM, DrPH
Director of Policy and Advocacy
Centering Healthcare Institute
Boston, Massachusetts
Elaine Tagliareni EdD, RN, CNE, FAAN
Chief Program Officer
National League for Nursing
Washington, DC
Carol R. Taylor PhD, MSN, RN
Professor of Nursing, Senior Clinical Scholar
Kennedy Institute of Ethics
Georgetown University
Washington, DC
Clifton P. Thornton MSN, BS, BSN, RN, CNMT
Pediatric Nurse Practitioner
Research Nurse
School of Nursing
John Hopkins University
Baltimore, Maryland
Cora Tomalinas BSN, PHN, Retired RN
FIRST 5 Santa Clara County
Governing Board Santa Clara County
Re-Entry Collaborative
San Jose Mayor’s Gang Prevention Task Force Policy and Technical Team
San Jose, California
Brian Valdez JD
Policy and Development Specialist
National Nursing Centers Consortium
Philadelphia, Pennsylvania
Tener Goodwin Veenema PhD, MPH, MS, RN, FAAN
Associate Professor
School of Nursing
John Hopkins University
Center for Refugee and Disaster Response
Johns Hopkins Bloomberg School of Public Health
Baltimore, Maryland
Antonia M. Villarruel PhD, RN, FAAN
Professor and Margaret Bond Simon Dean of Nursing
School of Nursing
University of Pennsylvania
Philadelphia, Pennsylvania
Elizabeth Waetzig JD
Founding Partner
Change Matrix, LLC
Granger, Indiana
Laura M. Wagner PhD, RN, GNP, FAAN
Assistant Professor
School of Nursing
University of California, San Francisco
San Francisco, California
Jamie M. Ware JD
Policy Director
National Nursing Centers Consortium
Manager of Strategic Policy Initiatives
Public Health Management Corporation
Philadelphia, Pennsylvania
Joanne R. Warner PhD, RN
Dean and Professor
School of Nursing
University of Portland
Portland, Oregon
Catherine M. Waters PhD, RN, FAAN
Department of Community Health Systems
School of Nursing
University of California, San Francisco
San Francisco, California
Ellen-Marie Whelan PhD, CRNP, FAAN
Senior Advisor
Centers for Medicare and Medicaid Services Innovation Center
Washington, DC
Kathleen M. White PhD, RN, NEA-BC, FAAN
Associate Professor and Track Coordinator
Health Systems Management and MSN/MBA
Master’s Entry into Nursing Program
Department of Acute and Chronic Care
School of Nursing
John Hopkins University
Baltimore, Maryland
Marie Davis Williams MSW, LCSW
Deputy Commissioner
Tennessee Department of Mental Health and Substance Abuse Services
Nashville, Tennessee
Shanita D. Williams PhD, MPH, APRN
Nursing Education and Practice Branch
Division of Nursing and Public Health
Bureau of Health Workforce
Health Resources and Services Administration
Rockville, Maryland
Rita Wray BC, MBA, RN, FAAN
Founder and Chief Executive Officer
Wray Enterprises, Inc.
Jackson, Mississippi
Alixandra B. Yanus PhD
Assistant Professor of Political Science
High Point University
High Point, North Carolina
Phyllis S. Brenner PhD, RN, NEA-BC
Professor of Nursing and Nursing Administration Program Director
College of Nursing and Health
Madonna University
Livonia, Michigan
Dian Colette Davitt PhD, RN
Associate Professor
Webster University
St. Louis, Missouri
Michelle L. Edmonds PhD, FNP-BC, CNE
Professor of Nursing
School of Nursing
Jacksonville University
Jacksonville, Florida
Teresa Keller PhD, RN
Associate Director for Undergraduate Studies
School of Nursing
New Mexico State University
Las Cruces, New Mexico
Karen Kelly EdD, RN, NEA-BC
Continuing Education
Associate Professor
School of Nursing
Primary Care and Health Systems Nursing
Southern Illinois University, Edwardsville
Edwardsville, Illinois
Carol A. Mannahan EdD, RN, NEA-BC
Assistant Professor
Kramer School of Nursing
Oklahoma City University
Oklahoma City, Oklahoma
Brenda B. Rowe MN, JD, RN
Associate Professor
Georgia Baptist College of Nursing of Mercer University
Atlanta, Georgia
Melissa V. Sirola BSN, MSN, MBA, RN
Adjunct Instructor
Caldwell University
Caldwell, New Jersey
Annette Weiss PhD, RN, CNE
Assistant Professor
Expressway RN Program Director
Misericordia University
Dallas, Pennsylvania
In 2010, the Institute of Medicine challenged the nation and the nursing profession to ensure that
nurses are participating as leaders in decision making about health, health care, and health policy.
The landmark report The Future of Nursing: Leading Change, Advancing Health is bringing attention to
this most valuable resource for transforming health in the United States.
I’ve had the privilege of serving as Chairperson of the Strategic Advisory Committee for the
Future of Nursing: Campaign for Action that is charged with overseeing the implementation of the
report’s recommendations. Specifically, the report recommends the expansion of “opportunities for
nurses to lead and diffuse collaborative improvement efforts,” including in health systems, and
aims to “prepare and enable nurses to lead change to advance health.” For this latter
recommendation, the report specifically calls for “public, private, and governmental health care
decision makers at every level [to] include representation from nursing on boards, on executive
management teams, and in other key leadership positions.”
Leading—as a clinical bedside leader, executive in a health care organization, member of a state
or federal health advisory body, or a legislator at the local, state, or federal level—requires knowing
how private and public policies are made, exquisite political skills, and the confidence and
willingness to guide the decisions and actions of individuals and groups. These are not easy skills to
learn but are essential for every nurse who wants to lead.
I know the importance of learning how to lead. For more than 10 years, I was Chief of Staff for
former Senate Majority Leader and presidential candidate Bob Dole of Kansas, after working as a
professional staff member for the Senate Committee on Finance and, later, as Deputy Staff Director
of that committee. These superb opportunities gave me a deep understanding of policymaking and
of the leadership and political skills that are required to shape policy. I never questioned that nurses
should do this kind of work. It was my good fortune to “learn the ropes” as President of the
California Student Nurses Association and later as Program Director for the National Student
Nurses Association.
Society must recognize the important perspectives that nurses can bring to decision-making
tables, but nurses must be ready to fully engage in the important health-related decisions of our
day. Policy & Politics in Nursing and Health Care is an invaluable resource for nurses to learn the
ropes of being leaders in local, state, national, and international organizations—from the bedside to
the boardroom to the backrooms of policymaking. It provides guidelines and an important
framework for developing leaders. For the more sophisticated nurse leaders, it offers in-depth
analyses of important policy issues within a political context.
Policy & Politics in Nursing and Health Care has been in publication for 30 years. This essential
resource continues to prepare the current and future generations of nurse leaders. We must use it
wisely if we’re to achieve the recommendations in The Future of Nursing. Our nation’s health
depends upon nurses being leaders in transforming health and health care in the United States and
Sheila Burke MPA, RN, FAAN
Faculty Research Fellow, Malcolm Weiner Center for Social Policy Adjunct Lecturer, John.
F. Kennedy School of Government at Harvard University Chair, Government Relations and Public Policy, Baker, Donelson,
Bearman, Caldwell & Berkowitz
On the threshold of significant change, we find ourselves at a pivotal time for health care in the
United States. For far too long, Americans have been served by a fragmented health care system
and one that has heavily emphasized acute care, at the expense of keeping people well. It has come
with a price tag of about $2.7 trillion a year. Costs have been ticking ever upward until recently. As
a result, health care services have been unaffordable and largely inaccessible to millions of
Americans. For all Americans, consistent care quality could not be guaranteed.
The Affordable Care Act has been instrumental in helping the nation reset this picture. Even in
the midst of heated rhetoric and misinformation, the law is moving us forward on insurance
coverage for previously uninsured Americans, access to care, improved care quality, and new
payment mechanisms. Addressing these things is crucial to improving health care and the health of
the nation.
Nurses are already central to this law and the change that it seeks to produce. The law includes
opportunities to spread models of care that nurses were instrumental in developing, such as home
visitation programs for high-risk mothers, programs for all-inclusive care of elders, nurse-managed
health centers, and transitional care. The law uses provider-neutral language and improves the
Medicare payment rate for nurse midwives. It also includes substantial funding to increase the
primary care workforce, including nurses.
These and other elements of the law reflect engagement of various constituencies, including
nursing. Policymaking is not for the timid. It requires mastery of knowledge and skills in the art
and science of politics and the policy process. Though nursing organizations have long had
influential leaders at national, state, and local levels, this set of competencies hasn’t been universal
across members of the profession.
I know well the growth in nursing’s policymaking savvy. I have been a part of some of the
important health policy discussions of our day and have watched as other nurses have sought to
use their knowledge to inform laws and regulations that govern health care. Some years ago, as the
director of a Center for Health Policy, Research and Ethics, I led an annual policy program on policy
and political development for nurses. I also have had the privilege of serving as Chief of Staff to two
U.S. Senators, serving as a member of the Institute of Medicine and the Medicare Payment Advisory
Commission, and chairing the National Advisory Council for the Agency for Healthcare Research
and Quality. In his first term, President Barack Obama appointed me to serve as the Administrator
of the Health Resources and Services Administration, a division of the U.S. Department of Health
and Human Services. In this capacity, my responsibilities included helping to lead the nation’s
efforts to ensure that we have a well-prepared nursing and health care workforce that can meet the
vast and varied health needs of the nation. However, we need many more nurses at the multitude
of policy tables at local, state, and federal levels. There may be as many opportunities for nurses to
engage in this arena as there are nurses.
The health of the nation can directly benefit when nurses have sophisticated knowledge and skill
in policymaking and its political context. We should expect no less of members of our profession—
and deliver no less for our nation.
Mary Wakefield PhD, RN, FAAN
Acting Deputy Secretary U.S. Department of Health and Human Services
The Affordable Care Act (ACA) had just become the law of the land as the prior edition of Policy &
Politics in Nursing and Health Care (sixth edition) was going to press. Now, its implementation is
benefiting many of the previously uninsured, reducing health care costs, and moving our nation on
the path toward the Triple Aim: improving people’s experiences with care, improving health
outcomes for the population, and reducing health care costs. And yet, it has illuminated the
complexities and failures of a health care system that lags behind other nations in promoting health.
Indeed, there is a growing recognition that health care’s consumption of approximately 18% of the
U.S. gross domestic product is undermining efforts to promote the health of families and
communities rather than treating preventable illnesses—and at a very high price in humanistic and
monetary terms.
This current edition of Policy & Politics in Nursing and Health Care focuses on the changes that the
ACA has brought about, its deficiencies that mandate further reform in health care, and the
importance of social determinants of health, or “upstream factors,” that must be addressed if we are
to have communities and a nation that thrive in terms of economic, social, and health dimensions.
In concert with the Institute of Medicine’s report The Future of Nursing: Leading Health, Advancing
Change, this book highlights the role that nurses and other health professionals can play in leading
the transformation of health care and creating healthy communities.
The book does this with the continuing aim of appealing to all nurses, from novice to expert, as
well as other health professionals, although in this edition we have placed a stronger emphasis on
the implications of the issues discussed for advanced practice nurses, including those pursuing or
holding the doctorate of nursing practice (DNP). The DNP was designed to prepare nurses as
clinical leaders who could develop evidence-based approaches to improving the health of specific
populations. The book’s emphasis on both reforming health care and addressing upstream factors
that promote health is particularly suited to nurses with DNPs. However, we maintain that every
nurse has a social responsibility to shape public and private policies to promote health. As such,
this edition is designed to appeal to undergraduate, master’s, DNP, and PhD students, as well as to
practicing health professionals.
What’s New in the Seventh Edition?
This edition continues the almost 30-year approach of prior editions that have led others to describe
the book as a “classic” in nursing literature. However, classics become stagnant if not refreshed. A
new team of editors has brought a fresh perspective to this edition. The order of authorship on the
cover does not reflect effort; rather, the editing of this book was truly a team effort. The new team is
a result of transitions in the lives of former co-editors Judith Leavitt and Mary Chaffee. Certainly,
their imprint, and that of the first-co-editor, Susan Talbott, continues to manifest throughout the
book, but there is much that has changed.
Central to these changes are updates on the Affordable Care Act and its implementation, its impact
on nursing and the health of people, the role of politics in our health care system, and the need for
further policy reforms. As noted previously, the importance of improving the health of people
while reducing health care spending by addressing upstream factors or social determinants of health is a
major theme.
We have also further developed the conceptual framework for the book, as described in Chapter 1.
This chapter also emphasizes the competencies that nurses are expected to demonstrate at the
conclusion of undergraduate and graduate programs.
Evidence-based policy is another major theme that continues in this edition, but with more
emphasis. Throughout the book, authors have provided more depth and breadth to the evidence
that undergirds policy issues and potential responses, with the understanding that evidence is
necessary, but often not sufficient, for policy change.
Indeed, it is the political context of policy change that must be addressed for success in many
policy-related endeavors. As such, individual and community activism continue to be emphasized as
ways for nurses and other health professionals to contribute to and lead policy change. New and
updated vignettes (called Taking Action) provide real-life examples of such activism.
Some of the continuing chapters have new authors with fresh perspectives. Other new content
• Using research to advance health and social policies
• Highlights of the ACA, with implications for nurses and other health professionals
• The politics of advanced practice nursing
• Ethical dimensions of policy and politics
• The new health insurance exchanges
• Patient engagement
• Overtreatment
• Social Security and women
• Women’s reproductive health
• Public health
• Emergency preparedness
• Developing families
• Dual eligibles
• Nurses in boardrooms
• Quality and safety in health care
• Nurses’ work environments
• The intersection of technology and health care
• Community-based organizations addressing health
Using the Seventh Edition
Using the book as a course text. Faculty will find content in this book that will enhance learning
experiences in policy, leadership, community activism, administration, research, health disparities,
and other key issues and trends of importance to courses at every educational level. Many of the
chapters will help students in clinical courses understand the dynamics of the health system.
Students will find chapters that assist them in developing new skills, building a broader
understanding of nursing leadership and influence, and making sense of the complex business and
financial forces that drive many actions in the health system. The book presents an in-depth view of
the issues that impact nurses and suggests a variety of opportunities for nurses to engage in the
policy issues about which they care deeply.
Using the book in government activities. The unit on policy and politics in the government includes
content that will benefit nurses considering running for elective office, seeking a political
appointment, and learning to lobby elective officials about health care issues.
Using the book in the workplace. Policy problems and political issues abound in nursing workplaces.
This book offers critical insights into how to effectively resolve problems and influence workplace
policy as well as how to develop politically astute approaches to making changes in the workplace.
Using the book in professional organizations. Organizations use the power of numbers. The unit on
associations and interest groups will help groups determine strategies for success and how to capitalize on working with other groups through coalitions.
Using the book in community activism. With an expanded focus on community advocacy and
activism, readers will find information they need to effectively influence remedies to policy
problems in their local communities.
In every edition of this book, the co-editors have expressed their sincere gratitude to the many
authors who have contributed their time and expertise to write a chapter out of a commitment to
furthering the education of nurses and other health professionals on policy and politics. This edition
is no exception. We are grateful for the thoughtful contributions of more than 100 authors and hope
that readers will learn from them.
We are also grateful for the enduring contributions and imprint of the prior co-editors of this
book that have made it the leading resource in its field. Susan Talbott was the co-editor on the first
edition; Mary Chaffee on the fourth through sixth editions; and Judith Leavitt on the second
through sixth editions. We hope that they are pleased with the continued development of the book.
We owe a huge debt of thanks to Beth Gardner, the book’s editorial manager for this edition. She
tracked and managed 92 manuscripts, kept the co-editors moving along, coordinated our
communications, and was simply amazingly organized. In the midst of this, she married, pursued a
doctoral dissertation, and remained in good humor. Beth, we are grateful for your superb work.
We also acknowledge the continuing support of Elsevier and the editorial team that worked with
Sandy Clark, including Karen Turner. We are indebted to Clay Broeker, an extraordinary production manager who has worked on the last three editions of the book. Thank you, Clay, for your
continued commitment to excellence in publishing.
Each of us has some special people to acknowledge.
Diana Mason
I want to acknowledge my husband, James Ware, for his continued support of my long days of
work, including on this book.
My thanks, too, for the support I have received from Dean Gail McCain, Graduate Director David
Keepnews, Barbara Glickstein, and my colleagues at Hunter College; the Center for Health, Media
and Policy; and the City University of New York.
Deborah Gardner
Undertaking this editing experience would not have been possible without the consistent support of
my husband, Dan. I also want to express my great joy in sharing this project with my daughter and
colleague, Beth Gardner.
I also thank Mary Wakefield, who mentored me through my first experience in writing a policy
chapter. As a co-author with her back in 1998, I learned from the best. Last but not least, Judith
Leavitt, co-editor of four editions of this text, supported me as an author in other editions and
believed I could take on this editing role.
Freida Outlaw
Special thanks to my husband, Lucius Outlaw, Jr., my greatest supporter; my delightful sons and
the two lovely wives and one special woman in their lives; my mother, sister, and her family; my
wonderful friends who have been with me from the beginning (BFF Lois Oliver); and my new
friends. You are my village. I would like to express my gratitude to Martha Pride, PhD, RN, my
psychiatric nursing professor at Berea College, and to Dr. Hattie Bessent and the Minority
Fellowship Program for the support and guidance given to me.
Eileen O’Grady
A heartfelt thanks to Dr. Loretta Ford, founding mother of the nurse practitioner role. Writing a
chapter with her is a privilege. We are so fortunate to see true leadership firsthand. She has shown
us, with a sparkle in her eye, how to live courageously and be of maximal service. It is fortunate to
know somebody so fearless and funny.
Thank you to all of those (including each author in this book) who stepped out of the safety of
their clinical roles and took a risk to speak out on behalf of better health care in a larger venue.
Introduction to Policy and Politics in Nursing
and Health Care
Chapter 1 Frameworks for Action in Policy and Politics
Chapter 2 An Historical Perspective on Policy, Politics, and Nursing
Chapter 3 Advocacy in Nursing and Health Care
Chapter 4 Learning the Ropes of Policy and Politics
Chapter 5 Taking Action: How I Learned the Ropes of Policy and Politics
Chapter 6 A Primer on Political Philosophy
Chapter 7 The Policy Process
Chapter 8 Health Policy Brief: Improving Care Transitions
Chapter 9 Political Analysis and Strategies
Chapter 10 Communication and Conflict Management in Health Policy
Chapter 11 Research as a Political and Policy Tool
Chapter 12 Health Services Research: Translating Research into Policy
Chapter 13 Using Research to Advance Health and Social Policies for Children
Chapter 14 Using the Power of Media to Influence Health Policy and Politics
Chapter 15 Health Policy, Politics, and Professional Ethics
Frameworks for Action in Policy and Politics
Eileen T. O’Grady, Diana J. Mason, Freida Hopkins Outlaw, Deborah B. Gardner
“The most common way people give up their power is by thinking they don’t have any.”
Alice Walker
March 31, 2013 marked an important deadline in the implementation of landmark legislation, the
Affordable Care Act (ACA)1, also known as Obamacare. By that date those eligible to enroll for
insurance coverage through the marketplace had to purchase a plan if they were to avoid a 2015 tax
penalty of $95 or 1% of their annual income (whichever was higher). Amid a frenzy of media
attention, an estimated 8 million people signed on for coverage during open enrollment—the period
between October 2012 and the deadline—exceeding the revised target of 6.5 million (Kennedy,
2014). And the numbers kept increasing, as millions more enrolled in Medicaid or the Children’s
Health Insurance Program (known as CHIP) (Centers for Medicare and Medicaid Services [CMS],
Nurses were essential to these enrollments. For example, Adriana Perez, PhD, ANP, RN, an
assistant professor at Arizona State University College of Nursing, used her role as president of the
Phoenix Chapter of the National Association of Hispanic Nurses to organize town hall meetings
with Spanish-speaking state residents to explain the ACA and encourage enrollment among those
with a high rate of un- or under-insurance. She also developed a training model in partnership with
AARP-Arizona and used it to empower Arizona nurses to educate multicultural communities on
the basic provisions of the ACA. Through many such initiatives, the United States reduced the
number of uninsured people by over 10 million in 2014; the number is projected to be 20 million by
2016 (Congressional Budget Office [CBO], 2014).
However, access to coverage does not necessarily mean access to care, nor does it ensure a
healthy population. Health care access means having the ability to receive the right type of care
when needed at an affordable price. The U.S. health care system is grounded in expensive, hightech acute care that does not produce the desired outcomes we ought to have and too often
damages instead of heals (National Research Council, 2013). Despite spending more per person on
health care than any other nation, a comparative report on health indicators by the Organisation for
Economic Co-operation and Development (2013) shows that the United States performs worse than
other nations on life expectancy at birth for both men and women, infant mortality rate, mortality
rates for suicide and cardiovascular disease, the prevalence of diabetes and obesity in children, and
other indicators.
In 1999, the Institute of Medicine (IOM) issued a report, To Err is Human: Building a Safer Health
System, which estimated that health care errors in hospitals were the fifth leading cause of death in
the U.S. (IOM, 1999). By 2011, preventable health care errors were estimated to be the third-leading
cause of death (Allen, 2013; James, 2013). The ACA includes elements that can begin to create a
high-performing health care system, one accountable for the provision of safe care, as well as
improved clinical and financial outcomes. It aims to move the health care system in the direction of
keeping people out of hospitals, in their own homes and communities, with an emphasis on
wellness, health promotion, and better management of chronic illnesses.
For example, the ACA uses financial penalties to prod hospitals to reduce 30-day readmission
rates. It also provides funding for demonstration projects that improve “transitional care,” services
that help patients and their family caregivers to make a smoother transition from hospital or
nursing home to their own homes to help reduce preventable hospital readmissions. Based, in part,
on research by Mary Naylor, PhD, RN, FAAN, professor of nursing at the University of
Pennsylvania School of Nursing, these demonstrations are stimulating creative methods of
accountability across health care settings, with most using nurses for care coordination and
transitional care providers (CMS, n.d.; Coalition for Evidence-Based Policy, n.d.; Naylor et al., 2011).
Upstream Factors
Promoting health requires more than a high-performing health care system. First and foremost,
health is created where people live, work, and play. It is becoming clear that one’s health status may
be more dependent on one’s zip code than on one’s genetic code (Marks, 2009). Geographic analyses
of race and ethnicity, income, and health status repeatedly show that financial, racial, and ethnic
disparities persist (Braveman et al., 2010). Individual health and family health are severely
compromised in communities where good education, nutritious foods, safe places to exercise, and
well-paying jobs are scarce (Halpin, Morales-Suárez-Varela, & Martin-Moreno, 2010). Creating a
healthier nation requires that we address “upstream factors”; the broad range of issues, other than
health care, that can undermine or promote health (also known as “social determinants of health”
or “core determinants of health”) (World Health Organization [WHO], n.d.). Upstream factors
promoting health include safe environments, adequate housing, and economically thriving
communities with employment opportunities, access to affordable and healthful foods, and models
for addressing conflict through dialogue rather than violence. According to Williams and colleagues
(2008), the key to reducing and eliminating health disparities, which disproportionately affect racial
and ethnic minorities, is to provide effective interventions that address upstream factors both in and
outside of health care systems. Upstream factors have a large influence on the development and
progression of illnesses (Williams et al., 2008). The core determinants of health will be used to
further elucidate and make concrete the wider, more comprehensive set of upstream factors that
can improve the health of the nation by reducing disparities. Figure 1-1 depicts the core
determinants of health developed by the Canadian Forces Health Services Group.
FIGURE 1-1 Surgeon General’s Mental Health Strategy: Canadian Forces Health Services Group—An
Evolution of Excellence. (From www.forces.gc.ca/en/about-reports-pubs-health/surg-gen-mental-health-strategy-ch-2.page.)
A focus on such factors is essential for economic and moral reasons. Even in the most affluent
nations, those living in poverty have substantially shorter life expectancies and experience more
illness than those who are wealthy, with high costs in human and financial terms (Wilkinson &
Marmot, 2003). To date however, most of the focus on reducing disparities has been on health
policy that addresses access, coverage, cost, and quality of care once the individual has entered the
health care system–despite the fact that for more than a decade research has established that most
health care problems begin long before people seek medical care (Williams et al., 2008). Thus,
changing the paradigm requires knowledge about the political aspects of the social determinates of
health and the broader core determinants. Political aspects of the social determinants of health
appear in Box 1-1.
Box 1-1
Political Aspects of the Social Determinants of Health
• The health of individuals and populations is determined significantly by social factors.
• The social determinants of health produce great inequities in health within and between societies.
• The poor and disadvantaged experience worse health than the rich, have less access to care, and
die younger in all societies.
• The social determinants of health can be measured and described.
• The measurement of the social determinants provides evidence that can serve as the basis for
political action.
• Evidence is generated and used in a continuous cycle of evidence production, policy
development, implementation, and evaluation.
• Evidence of the effects of policies and programs on inequities can be measured and can provide
data on the effectiveness of interventions.
• Evidence regarding the social determinants of health is insufficient to bring about change on its
own; political will combined with evidence offers the most powerful strategy to address the
negative effects of the social determinants.
Adapted from National Institute for Health and Clinical Excellence. (2007). The Social Determinants of Health: Developing an
Evidence Base for Political Action. Final report to the World Health Organization Commission on the Social Determinants of
Health. Lead authors: J. Mackenbach, M. Exworthy, J. Popay, P. Tugwell, V. Robinson, S. Simpson, T. Narayan, L. Myer, T.
Houweling, L. Jadue, and F. Florenza.
The ACA begins to carve out a role for the health care system in addressing upstream factors. For
example, the law requires that nonprofit hospitals demonstrate a “community benefit” to receive
federal tax breaks. Hospitals must conduct a community health assessment, develop a community
health improvement plan, and partner with others to implement it. This aligns with a growing
emphasis on population health: the health of a group, whether defined by a common disease or
health problem or by geographic or demographic characteristics (Felt-Lisk & Higgins, 2011).
Consider the 11th Street Family Health Services. Located in an underserved neighborhood in
North Philadelphia, this federally qualified, nurse-managed health center (NMHC) was the
brainchild of public health nurse Patricia Gerrity, PhD, RN, FAAN, a faculty member at Drexel
University School of Nursing. She recognized that the leading health problems in the community
were diabetes, obesity, heart failure, and depression. Working with a community advisory group,
Gerrity realized that the health center had to address nutrition as an “upstream factor” that could
improve the health of those living in the community. With no supermarket in the neighborhood
until 2011, she invited area farmers to come to the neighborhood as part of a farmers’ market. She
also created a community vegetable garden maintained by the local youth. And area residents were
invited to attend nutrition classes on culturally relevant, healthful cooking. 11th Street Family
Health Services is one of over 200 NMHCs in the United States that have improved clinical and
financial outcomes by addressing the needs of individuals, families, and communities (American
Academy of Nursing, n.d., b). The ACA authorizes continued support for these centers, although
the law does not mandate they be funded. Congress would have to appropriate funding for
NMHCs but has not done so. (See Chapter 34 for a more detailed discussion of NMHCs.)
The ACA may not go far enough in shifting attention to the health of communities and
populations. One approach gaining notice is that of “health in all policies,” the idea that
policymakers consider the health implications of social and economic policies that focus on other
sectors, such as education, community development, tax codes, and housing (Leppo et al., 2013;
Rudolph et al., 2013). As health professionals who focus on the family and community context of
the patients they serve, nurses can help to raise questions about the potential health impact of
public policies.
Nursing and Health Policy
Health policy affects every nurse’s daily practice. Indeed, health policy determines who gets what
type of health care, when, how, from whom, and at what cost. The study of health policy is an
indispensable component of professional development in nursing, whether it is undertaken to
advance a healthier society, promote a safer health care system, or support nursing’s ability to care
for people with equity and skill. Just as Florence Nightingale understood that health policy held the
key to improving the health of poor Londoners and the British military, so are today’s nurses
needed to create compelling cases and actively influence better health policies at every level of
governance. With national attention focused on how to transform health care in ways that produce
better outcomes and reduce health care costs, nursing has an unprecedented opportunity to provide
proactive and visionary leadership. Indeed, the Institute of Medicine’s landmark report, The Future
of Nursing: Leading Change, Advancing Health (2011), calls for nurses to be leaders in redesigning
health care. But will nurses rise to this occasion?
Health care opinion leaders in a 2010 poll identified two reasons nurses would fall short of
influencing health care reform: too many nurses do not want to lead, and with over 120 national
organizations, nursing often fails to present a united front (Gallup, 2010). As the largest health care
profession, nursing has great potential power. Yet, similar to many professions, it has struggled to
collaborate within its ranks or with other groups on pressing issues of health policy. The IOM
report has provided a rallying point for nursing organizations to work together and engage other
stakeholders to advance its recommendations.
Reforming Health Care
The Triple Aim
In 2008, Don Berwick, MD, and his colleagues at the Institute for Healthcare Improvement (IHI)
first described the Triple Aim of a value-based health care system (Berwick, Nolan, & Whittington,
2008): (1) improving population health, (2) improving the patient experience of care, and (3)
reducing per capita costs. This framework aligns with the aims of the Affordable Care Act.
The Triple Aim represents a balanced approach: by examining a health care delivery problem
from all three dimensions, health care organizations and society can identify system problems and
direct resources to activities that can have the greatest impact. Looking at each of these dimensions
in isolation prevents organizations from discovering how a new objective, decreasing readmission
rates to improve quality and reduce costs, for instance, could negatively impact the third goal of
population health, as scarce community resources are directed to acute care transitions and unintentionally shifted away from prevention activities. Solutions must also be evaluated from these
three interdependent dimensions. The Triple Aim compels delivery systems and payors to broaden
their focus on acute and highly specialized care toward more integrated care, including primary
and preventive care (McCarthy & Klein, 2010).
The IHI (n.d.) identified these components of any approach seeking to achieve the Triple Aim:
• A focus on individuals and families
• A redesign of primary care services
• Population health management
• A cost-control platform
• System integration and execution
Note that these possess the goal of creating a high-performing health care system but do not
focus on geographic communities or social determinants per se. However, these two concepts can
be incorporated into the Triple Aim of improving the health of populations and reducing health
care costs.
The Triple Aim is easy to understand but challenging to implement because it requires all providers, including nurses, to broaden their focus from individuals to populations. The success of the
nursing profession’s continued evolution will hinge on its ability to take on new roles, more
cogently and creatively engaging with patients and stepping into executive and leadership roles in
every sector of heath care. But it must do so within an interprofessional context, leading efforts to
break down health professions’ silos and hierarchies and keeping the patient and family at the
center of care.
The ACA and Nursing
The ACA is arguably the most significant piece of social legislation passed in the United States since
the enactment of Medicare and Medicaid in 1965. Implementation continues to be a vexing process
and a political flashpoint. It has defined the ideologies of U.S. political parties, and yet the public
remains largely uninformed and misinformed about the legislation; 3 years after its passage, 4 out
of 10 Americans were still unaware of many of its provisions and unsure that the ACA had become
law (The Henry J. Kaiser Family Foundation, 2013). (Chapter 19 provides a thorough description of
the ACA.) The ACA is ov…
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