Advanced Practice Nurses and Public Policy, Naturally

Jeri A. Milstead © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Key© Jones Terms & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Advanced practice registered nurse (APRN): A registered nurse with a master’s or doctoral degree in nursing who demonstrates expert knowledge, skills, and attitudes in the practice of nursing. An © Jones & BartlettAPRN is Learning, certified by LLCa nationally recognized professional© Jones organiza-& Bartlett Learning, LLC NOT FOR SALEtion. OR Four DISTRIBUTION types of APRNs are recognized by mostNOT nurse FOR regulatory SALE OR DISTRIBUTION boards: nurse practitioner (NP), clinical nurse specialist (CNS), certified nurse midwife (CNM), and certified registered nurse anesthetist (CRNA). Client/patient: The recipient of health care; patient carries a “sick” © Jones & Bartlett Learning,connotation LLC whereas client may ©not. Jones The terms & Bartlett will be used Learning, inter- LLC NOT FOR SALE OR DISTRIBUTIONchangeably throughout this chapter.NOT FOR SALE OR DISTRIBUTION Healthcare providers (HCPs): Registered nurses, advanced practice registered nurses (APRNs), physicians, pharmacists, dentists, psychologists, occupational and physical therapists, and physician’s assis- tants© Jones who are& Bartlettlicensed by Learning, a state or territory LLC to provide health care.© Jones & Bartlett Learning, LLC Nursing’sNOT FOR agenda SALE for OR health: DISTRIBUTION Policy expectations of a vision forNOT nurs- FOR SALE OR DISTRIBUTION ing practice that include prevention of illness, promotion of health, empowerment of individuals to assume responsibility for the state of their own health, expertise in the provision of direct nursing care, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 1

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 1 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

2 ■ Chapter 1 Advanced Practice Nurses and Public Policy, Naturally

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC delegationNOT FOR and SALE supervision OR DISTRIBUTION of selected care to appropriate individu-NOT FOR SALE OR DISTRIBUTION als, and the political influence to accomplish these goals. Policy process: Bringing problems to government and obtaining a reply. The process includes agenda setting, design, government © Jones & Bartlettresponse, Learning, implementation, LLC and evaluation. © Jones & Bartlett Learning, LLC NOT FOR SALEPublic OR policy: DISTRIBUTION A program, law, regulation, or otherNOT legal FOR mandate SALE pro- OR DISTRIBUTION vided by governmental agents; also actual legal documents, such as opinions, directives, and briefs that record government decisions.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Introduction This text originally was written to focus on the relevance of public policy to advanced© Jones practice & Bartlett registered Learning, nurses (AP LLCRNs). The Institute of Medicine’s© Jones & Bartlett Learning, LLC report,NOT The FOR Future SALE of Nursing: OR DISTRIBUTION Advancing Health, Leading Change (InstituteNOT FOR of SALE OR DISTRIBUTION Medicine [IOM], 2010), challenged nurses to work with other healthcare professionals in two ways: to learn from them and to help them learn from nurses. In this spirit of interprofessional cooperation and leadership, this text will incorporate a variety of healthcare providers (HCPs) into the dis- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC cussion of public policy, case studies, discussion points, and reader activi- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ties. Although APRNs are the major focus, the astute reader will realize that the process is the same for all HCPs; the theories and scenarios that are presented have relevance to all providers. The authors hope that readers will recognize the spirit of respect and cooperation that is intended and begin © Jones & Bartlett Learning,to “gather LLC at the table” together and© Jonesto make & decisions Bartlett that Learning, truly integrate LLC NOT FOR SALE OR DISTRIBUTIONhealth care that benefits the client/patientNOT FOR. SALE OR DISTRIBUTION

Why “Naturally”? The© policy Jones process & Bartlett is a broad Learning, range of decisionLLC points, strategies, activities,© Jones & Bartlett Learning, LLC andNOT outcomes FOR thatSALE involve OR elected DISTRIBUTION and appointed government officialsNOT and FOR SALE OR DISTRIBUTION their staffs, bureaucratic agencies, private citizens, and interest groups. The process is dynamic, convoluted, and ongoing, not static, linear, or concise. The idea of “messy” may be uncomfortable to nurses who are known to © Jones & expectBartlett action Learning, immediately, LLC but the political arena© requiresJones &patience, Bartlett tact, Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 2 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Why “Naturally”? ■ 3

diplomacy,© Jones and & Bartlettpersistence. Learning, Knowledgeable LLC nurses in advanced© practice Jones & Bartlett Learning, LLC mustNOT demonstrate FOR SALE their OR commitment DISTRIBUTION to action by being a part ofNOT relevant FOR SALE OR DISTRIBUTION decisions that will ensure the delivery of quality health care by appropriate providers in a cost-effective manner. So why would anyone suggest that working at the policy level is “natural” to the nursing profession? This © Jones & authorBartlett proposes Learning, that involvement LLC in policy decisions© Jones and the & political Bartlett pro Learning,- LLC NOT FOR SALEcess is anOR integral DISTRIBUTION part of the role because of ourNOT history, FOR practice, SALE educa OR- DISTRIBUTION tion, and professional organizations. History © Jones & Bartlett Learning,Florence LLC Nightingale is regarded as© theJones mother & Bartlett of nursing Learning, being a profes LLC- NOT FOR SALE OR DISTRIBUTIONsion that requires education and practice.NOT FOR Although SALE reared OR in DISTRIBUTION an upper-class family, she viewed the service that nurses provided as worthy of respect, a standing generally not accorded to nurses at the time. She founded educational programs (known as nurse’s training programs) and began the work© Jonesof creating & Bartlett standards Learning, of care. She LLCused her influence with her© family’s Jones & Bartlett Learning, LLC businessNOT FORand professional SALE OR colleagues DISTRIBUTION to obtain funding to send aNOT cadre FOR of SALE OR DISTRIBUTION trained nurses to the Crimea to care for soldiers during a war. The nurses focused on improving sanitary conditions and food in addition to attending to personal and medical care such as using clean dressings and linen. When she returned to England, she developed education programs that © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC trained women in what became the principles of nursing. These schools NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION raised the reputation of nurses and increased their credibility and visibility in the public’s eye. Nightingale’s political influence became legendary. Over the years, other nurses have taken on health issues at various times and in various ways. Mary Mahoney was the first African American nurse © Jones & Bartlett Learning,in the United LLC States (1879). She was© aJones major advocate& Bartlett for Learning,equal opportuni- LLC NOT FOR SALE OR DISTRIBUTIONties for minorities. Nurses who exertedNOT FORtheir considerableSALE OR DISTRIBUTION political influence in the early 20th century included Clara Barton, who founded the Red Cross; Margaret Sanger, whose leadership for Planned Parenthood resulted in arrest and conviction; and Lillian Wald, who worked diligently with the poor© throughJones &neighborhood Bartlett Learning, settlement LLC houses, helped President Theodore© Jones & Bartlett Learning, LLC RooseveltNOT FOR create SALE the Federal OR DISTRIBUTION Children’s Bureau, and suggested a NOTnational FOR SALE OR DISTRIBUTION health insurance plan. Jessie Scott, DSc, RN, testified frequently before Congress in her position as director of nursing for the U.S. Public Health Service and was instrumental in passing the 1964 Nurse Training Act, leg- © Jones & islationBartlett that Learning, provided LLC funding for nurse education© Jones (especially & Bartlett graduate Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 3 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

4 ■ Chapter 1 Advanced Practice Nurses and Public Policy, Naturally

education)© Jones for & many Bartlett years. Learning, Faye Wattleton, LLC RN, MS, was a forceful© director Jones & Bartlett Learning, LLC of NOTPlanned FOR Parenthood SALE OR in the DISTRIBUTION 1970s and 1980s during a time of greatNOT chal FOR- SALE OR DISTRIBUTION lenge to women’s rights in general and, specifically, the right to determine the health of their own bodies. Ada Sue Hinshaw, PhD, RN, still is remem- bered today for her absolute persistence and her ability to gather a group of © Jones & nursesBartlett in theLearning, late 1980s LLC and 1990s who worked with© Jones federal & legislators Bartlett toLearning, LLC NOT FOR SALEcreate the OR National DISTRIBUTION Center for Nursing Research thatNOT eventually FOR SALE became OR the DISTRIBUTION National Institute for Nursing Research, one of the pillars of the National Institutes of Health. Mary Wakefield, PhD, RN, served as chief of staff for two U.S. senators before she became the current administrator of the Health © Jones & Bartlett Learning,Resources LLC and Services Administration.© Jones There & are Bartlett many examples Learning, of nurses LLC NOT FOR SALE OR DISTRIBUTIONwho have wielded political savvy andNOT power FOR to SALEmake significant OR DISTRIBUTION changes to the profession. Our practice provides a firm basis for involvement in the process of making public policy. Education © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC PublicNOT policy FOR content SALE pervadesOR DISTRIBUTION the nurse education programs ofNOT today FOR in SALE OR DISTRIBUTION ways that would not have been considered in our early culture. The system of nursing education evolved from apprentice, hospital-based training to institutions of higher learning. Practice that once was found primarily in hospitals has moved into all facets of society—long-term care facilities, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC laboratories, clinics, industries, homes, and other situations. Specialization NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION in nursing has moved from the early five major areas (medical, surgical, obstetric, pediatric, psychiatric) to include genetics, informatics, public policy, and a huge array of health- or medically related areas of expertise. Today’s nurse leaders are college-educated with doctoral, master’s, bac- © Jones & Bartlett Learning,calaureate, LLC and associate’s degrees.© BaccalaureateJones & Bartlett programs Learning, are based LLC on NOT FOR SALE OR DISTRIBUTIONa liberal arts education of naturalNOT sciences FOR (to SALE understand OR DISTRIBUTION the health and medical problems encountered), social sciences (recognizing that people live in families, groups, and communities), and the humanities (because nurses address the human condition) and provide a solid, broad education that forms© Jones the philosophical & Bartlett foundation Learning, from LLC which nurses practice. Advanced© Jones & Bartlett Learning, LLC educationNOT FOR builds SALE on education OR DISTRIBUTION and experience and broadens theNOT arena FOR in SALE OR DISTRIBUTION which nurses work to a systems perspective. Nurses not only are well prepared to provide direct care to persons and families, but also act as change agents in the work environments in which they practice. © Jones & BartlettNurses Learning, have developed LLC theories to explain and© predict Jones phenomena & Bartlett that Learning, LLC NOT FOR SALEare met OR in the DISTRIBUTION course of providing care. Nurses alsoNOT incorporate FOR SALE theory ORfrom DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 4 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Why “Naturally”? ■ 5

other© Jones disciplines & Bartlett such as psychology, Learning, anthropology, LLC education, biomedical© Jones & Bartlett Learning, LLC science,NOT andFOR information SALE OR technology. DISTRIBUTION Integration of all of this NOTinforma FOR- SALE OR DISTRIBUTION tion reflects the extreme complexity of nursing care and its provision in an extremely complex healthcare system. Communication skills are integral to the education of nurses, who often must interpret complex medical situa- © Jones & tionsBartlett and termsLearning, into common, LLC understandable, pragmatic© Jones language. & Bartlett Nurse Learning, LLC NOT FOR SALEeducation OR programs DISTRIBUTION have formalized a greater focusNOT on FOR communications SALE OR DISTRIBUTION than any other professional education program. From baccalaureate curricula through all upper levels of nurse education, full courses or major segments of courses on individual communications and group process are © Jones & Bartlett Learning,provided. LLC Information and skills in© these Jones courses & Bartlett are integrated Learning, throughout LLC NOT FOR SALE OR DISTRIBUTIONprograms and applied to practiceNOT in direct FOR patient SALE experiences OR DISTRIBUTION known as clinicals. Communication skills are reinforced as requirements in advanced nurse education programs such as psychiatric nursing. Skills include active listening, reflection, clarification, assertiveness, role playing, and other techniques© Jones that build & Bartlett nurse competence Learning, levels. LLC These same skills are used© Jones when & Bartlett Learning, LLC talkingNOT with FOR policymakers. SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Complexity science “… fosters the health of individuals, families, communities, and our natural environment by helping people use concepts emerging from the new science of complexity” (Plexis Institute, 2009). Complexity science goes beyond systems theory; it acknowledges patterns © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC in chaos, complex adaptive systems, and principles of self-organization and NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION has great applicability to nursing (Curtin, 2010; Lindberg, Nash, & Lindberg, 2008). “The quantum concept of a matrix or field … that connects everything together” (Curtin, 2011, p. 56) informs us that nurses are focused masses of energy who direct their behaviors and actions with patients in an intentional © Jones & Bartlett Learning,way toward LLC accomplishing healthy© Jonesstates. The & Bartlett nurse–patient Learning, (or nurse– LLC NOT FOR SALE OR DISTRIBUTIONprovider) relationship is not incidentalNOT or FOR haphazard, SALE but OR fully DISTRIBUTION cognizant of purpose (Curtin, 2010; Husted, Scotto, & Wolf, 2015). Observing patterns in personal behavior can be useful in working with policymakers as they try to figure out the best or most cost-effective way to address public problems. Creative© Jones ways &of Bartlettexamining Learning, problems and LLC innovative solutions may© Jonesnot be & Bartlett Learning, LLC comfortableNOT FOR to policymakersSALE OR DISTRIBUTION who have learned to be cautious and goNOT slowly. FOR SALE OR DISTRIBUTION Nurses and other professionals can help officials employ new ideas to reach their policy goals. Quantum thinking also is crucial to the effectiveness of an organization in © Jones & theBartlett 21st century Learning, (Porter-O’Grady LLC & Malloch, 2014).© PartnershipsJones & Bartlett are valued Learning, LLC NOT FOR SALEover competition, OR DISTRIBUTION and the old rules of business thatNOT rewarded FOR SALE power OR and DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 5 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

6 ■ Chapter 1 Advanced Practice Nurses and Public Policy, Naturally

ownership© Jones have & Bartlettgiven way Learning,to accountability LLC and shared risk. Transforming© Jones & Bartlett Learning, LLC theNOT old systems FOR SALEinto the OR new DISTRIBUTION systems does not mean merely automatingNOT pro FOR- SALE OR DISTRIBUTION cesses or restructuring the organizational chart. Transformation involves a radical, cross-functional, futuristic change in the way people think. Short- term planning is balanced with strategic planning, and vertical work rela- © Jones & tionshipsBartlett areLearning, replaced LLCwith networks and webs of© people Jones and & knowledge.Bartlett Learning, LLC NOT FOR SALEAll workers OR DISTRIBUTIONat all levels share a commitment to theNOT organization FOR SALE and OR an DISTRIBUTION accountability to define and produce quality work. Rhoades, Covery, and Shepherdson (2011) are “convinced that positive, people-centered cultural values lead to higher performance” (p. 1). All workers share responsibility for © Jones & Bartlett Learning,self-governance, LLC from which both ©the Jones organization & Bartlett and the Learning, worker benefit LLC NOT FOR SALE OR DISTRIBUTION(Porter-O’Grady, Hawkins, & Parker,NOT 1997). FOR Control SALE is OR replaced DISTRIBUTION by leadership. The new leader does not use policing techniques of supervision, but enables and empowers colleagues through vision, trust, and respect (Bennis & Nanus, 1985; Kouzes & Posner, 2007; Porter-O’Grady & Wilson, 2014). Encouragement,© Jones & Bartlett appreciation, Learning, and personal LLC recognition are celebrated© Jones & Bartlett Learning, LLC togetherNOT FORin an SALEeffective OR organization DISTRIBUTION (Kouzes & Posner, 1999). NOTBuilding FOR SALE OR DISTRIBUTION relationships is essential to the success of any current organizational model. Policy content is understood as important to nurses and has become required by accreditation agencies for nurse education programs. Content essential at the undergraduate level includes “policy development … legisla- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC tion and regulatory processes … social policy/public policy … and political NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION activism and professional organizations” (American Association of Colleges of Nursing [AACN], 2008a, p. 21). Content at the master’s level for all students, regardless of their specialty or functional area, includes “policy, organization, and finance of health care” (AACN, 2008b, p. 6). Required content © Jones & Bartlett Learning,for doctoral LLC students in advanced ©practice Jones includes & Bartlett behaviors Learning, to “critically LLC NOT FOR SALE OR DISTRIBUTIONanalyze … demonstrate leadership …NOT inform FOR policy SALE makers OR … educateDISTRIBUTION others … advocate for the profession” (AACN, 2006, p. 13). Course syllabi include learning activities that involve students in various ways—from attending meetings of health-related or public policy–related boards© Jones to arranging & Bartlett time with Learning, legislators LLC and their aides, attending© sessions Jones & Bartlett Learning, LLC of regulatoryNOT FOR boards SALE and OR commissions, DISTRIBUTION and testifying at hearings. NOTDoctoral FOR SALE OR DISTRIBUTION students, especially those in practice doctorates such as the Doctor of Nursing Practice (DNP), may conduct their final capstone projects around changing a law, regulation, or public policy. More action-oriented experi- © Jones & encesBartlett are requiredLearning, at everyLLC level of education. Understanding© Jones & Bartlett the whole Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 6 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Why “Naturally”? ■ 7

process© Jones of policymaking & Bartlett is Learning, essential for LLC preparing nurses to become© Jones active & Bartlett Learning, LLC withNOT policymakers. FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Nursing care is not just altruistic (although there is a noble component in the philosophy), but intentional action (or inaction) that focuses on a person or group with actual or potential health problems. The education of © Jones & nursesBartlett puts Learning, them in the LLC position of discovering and© Jonesacknowledging & Bartlett health Learning, LLC NOT FOR SALEproblems OR and DISTRIBUTION health system problems that may NOTdemand FOR intervention SALE OR by DISTRIBUTION public policymakers. Practice © Jones & Bartlett Learning,Nursing LLC as a practice profession is© based Jones on theory & Bartlett and evidence. Learning, For many LLC NOT FOR SALE OR DISTRIBUTIONyears that practice was interpretedNOT as direct, FOR hands-on SALE OR care DISTRIBUTION of individuals. Although this still is true, the profession has matured to the point where the provision of expert, direct care is not enough. Nurses of the third millennium stand tall in their multiple roles of provider of care, educator, administrator,© Jones & consultant, Bartlett Learning, researcher, LLCpolitical activist, and policymaker.© Jones & Bartlett Learning, LLC TheNOT question FOR of SALE how much OR aDISTRIBUTION nurse in advanced practice can or shouldNOT take FOR SALE OR DISTRIBUTION on may be raised. The Information/Knowledge Age continues to present new data exponentially. Nurses have added more and more tasks that seem important to a professional nurse and are essential for the provision of safe care to the client. Is political activism necessary? All health professionals © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC are expected to do more with fewer resources. Realistically, how much can NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION a specialist do? The public policy process involves alerting government to issues and obtaining responses. Nurses spot healthcare problems that may need government intervention. Nurses work in areas of direct and indirect patient © Jones & Bartlett Learning,care. Their LLC practice may be directed© Jones toward &individual Bartlett patients, Learning, families, LLC NOT FOR SALE OR DISTRIBUTIONgroups, or communities. Nurses seekNOT evidence FOR through SALE ORinquiry DISTRIBUTION and research in order to provide appropriate interventions. Nursing education programs include courses and units on organizational development, general systems theory, and complexity science. Most nurses are employees (as are most physicians© Jones today) &and Bartlett must navigate Learning, the organizations LLC in which they ©work. Jones By & Bartlett Learning, LLC beingNOT attuned FOR to SALE systems OR issues, DISTRIBUTION nurses have developed the abilityNOT to direct FOR SALE OR DISTRIBUTION questions and identify solutions. This ability is reflected in the relationships that nurses can develop with policymakers. Major-General Irene Trowell-Harris, EdD, RN, USAF, retired, under- © Jones & stoodBartlett the politicalLearning, process LLC when she was named director© Jones of the & DepartmentBartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 7 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

8 ■ Chapter 1 Advanced Practice Nurses and Public Policy, Naturally

of Veterans© Jones Affairs & Bartlett Center forLearning, Women Veterans LLC in 2001. She also was© instruJones- & Bartlett Learning, LLC mentalNOT in FOR establishing SALE aOR nurse DISTRIBUTION residency program for military nursesNOT in theFOR SALE OR DISTRIBUTION office of Senator Daniel K. Inouye (D-HI) in which one nurse from each of the four armed services was assigned (on a rolling basis) to that office for 1 year—a pragmatic and highly intense experience in the process of making © Jones & publicBartlett policy Learning, at the federal LLC level. © Jones & Bartlett Learning, LLC NOT FOR SALENurses OR have DISTRIBUTION many personal stories that illustrateNOT health FOR problems SALE OR and DISTRIBUTION patients’ responses to them. These stories can have a powerful effect when a nurse brings an issue to the attention of legislators and other policymakers. Anecdotes often make a problem more understandable at a personal level, © Jones & Bartlett Learning,and nurses LLC are credible storytellers.© Nurses Jones also & knowBartlett how Learning, to bring research LLC NOT FOR SALE OR DISTRIBUTIONto legislators in ways that can be understoodNOT FOR and SALE can have OR aDISTRIBUTION positive effect. Nurses live in neighborhoods where health problems often surface and can often rally friends to the importance of a local issue. Nurses are con- stituents of electoral districts and can make contacts with policymakers in ©their Jones districts. & Bartlett Nurses vote. Learning, It is not LLC unusual for a nurse to become© Jones the & Bartlett Learning, LLC pointNOT person FOR for SALE a policymaker OR DISTRIBUTION who is seeking information aboutNOT health FOR- SALE OR DISTRIBUTION care issues. A nurse does not have to be knowledgeable about every health problem, but she or he has a vast network of colleagues and resources to tap into when a policymaker seeks facts. The practice of nursing prepares the practitioner to work in the policy arena. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEOrganizational OR DISTRIBUTION Involvement NOT FOR SALE OR DISTRIBUTION Over 20 years ago, a leader in organizational theory, Drucker (1995), addressed the need for more general-practitioner physicians rather than specialists. He redefined the generalist of that time as one who puts mul- © Jones & Bartlett Learning,tiple specialties LLC together rapidly. Nurses© Jones have &benefitted Bartlett from Learning, that thought. LLC NOT FOR SALE OR DISTRIBUTIONIn Drucker’s definition, the advancedNOT FORpractice SALE registered OR DISTRIBUTION nurse (APRN) must be a multidimensional generalist/specialist. This means that the APRN combines knowledge and skills from a variety of fields or subspecial- ties effectively to design the new paradigm of healthcare delivery. This also means© Jones that the & APRN Bartlett must Learning, demonstrate LLC competence in the multiple© Jones roles & Bartlett Learning, LLC in whichNOT FORhe or SALEshe operates. OR DISTRIBUTION To function effectively in the role ofNOT political FOR SALE OR DISTRIBUTION activist, the APRN must realize the scope of the whole policy process, and the process is much broader than how a bill becomes a law. Boards of nursing and other professional regulatory boards exert much © Jones & influenceBartlett Learning,in interpreting LLC statutes that govern nursing.© Jones Scope & Bartlett of practice Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 8 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Why “Naturally”? ■ 9

is defined© Jones by &boards Bartlett and, Learning,because each LLC state and jurisdiction defines© Jones the & Bartlett Learning, LLC practiceNOT ofFOR nursing SALE differently, OR DISTRIBUTION there is wide variation in how theNOT scope FOR of SALE OR DISTRIBUTION practice is conducted. A fear expressed by many boards is the interference with Federal Trade Commission (FTC) rules that restrict monopoly practices. The FTC recently published a policy paper addressing the regulation © Jones & ofBartlett APRNs Learning,with five key LLC findings that policymakers© mustJones pay & attention Bartlett to. Learning, LLC NOT FOR SALEFirst, APRNs, OR DISTRIBUTION after years of research, provide careNOT that FOR is safe SALE and effec OR- DISTRIBUTION tive. Second, physicians’ mandatory supervision of and collaboration with advanced nurse practice is not justified by any concern for patient health or safety. Third, supervision and collaborative agreements required by statute © Jones & Bartlett Learning,or regulation LLC lead to greater cost,© decreased Jones &quality Bartlett of care, Learning, fewer innova LLC- NOT FOR SALE OR DISTRIBUTIONtive practices, and reduced accessNOT to services. FOR SALEFourth, OR APRNs DISTRIBUTION collaborate effectively with all healthcare professionals without inflexible rules and laws. Finally, APRN practice is “… good for competition and consumers” (“FTC Policy Paper,” 2014, p. 11). APRNs must become knowledgeable about the regulatory© Jones process & Bartlett so that theyLearning, can spot LLCopportunities to contribute© or Jones inter- & Bartlett Learning, LLC veneNOT prior FOR to final SALE rulemaking OR DISTRIBUTION (“The Regulatory Process,” 1992). NOT FOR SALE OR DISTRIBUTION Federal and state health-related agencies provide funding for nurse education, conduct surveys to compile nurse demographic data, and manage programs that address health issues. For example the U.S. Department of Health and Human Services (DHHS) is “the principle agency for protecting © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC the health of all Americans and providing essential human services, espe- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION cially for those who are least able to help themselves” (DHHS, n.d.). Check the DHHS website to discover the wide range of bureaus and departments included within DHHS. Professional organizations can bring their influence to the policy process © Jones & Bartlett Learning,in ways LLC that a single person may not.© Jones There are& Bartlett a myriad Learning,of organizations LLC NOT FOR SALE OR DISTRIBUTIONto which nurses belong, includingNOT specialty FOR areas, SALE education-related OR DISTRIBUTION organizations, and leadership-related organizations. For example, the American Nurses Association, the National League for Nursing, and Sigma Theta Tau International state a commitment to advancing health and health care in this© country Jones and/or & Bartlett on a global Learning, scale, as LLC noted in their mission statements© Jones & Bartlett Learning, LLC andNOT goals. FOR These SALE organizations OR DISTRIBUTION are structured to offer nurses opportunitiesNOT FOR SALE OR DISTRIBUTION to develop personal leadership skills. Committees provide occasion to learn about the organization, the mission, and the outreach. Professional associa- tions afford experiences to become knowledgeable about issues pertinent © Jones & toBartlett the organization Learning, or LLCthe profession. These groups© Jones can expand & Bartlett a nurse’s Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 9 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

10 ■ Chapter 1 Advanced Practice Nurses and Public Policy, Naturally

perspective© Jones toward & Bartlett a broader Learning, view of health LLC and professional issues© suchJones as & Bartlett Learning, LLC at theNOT state, FOR national, SALE or OR global DISTRIBUTION level. The change in viewpoint oftenNOT encour FOR- SALE OR DISTRIBUTION ages a member’s foray into the process of public policy. Some nurses are experienced in their political activity. They have served as chairs of legislative committees for professional organizations, worked as campaign managers © Jones & forBartlett elected Learning,officials, or presentedLLC testimony at congressional,© Jones &state, Bartlett or local Learning, LLC NOT FOR SALEhearings; OR a fewDISTRIBUTION have run for office. Political activismNOT is a FORmajor SALE expectation OR DISTRIBUTION of most professional organizations. Many organizations employ lobbyists who carry issues and concerns to policymakers. These sophisticated activists are skilled in the process of © Jones & Bartlett Learning,getting LLCthe attention of government© andJones obtaining & Bartlett a response. Learning, Professional LLC NOT FOR SALE OR DISTRIBUTIONorganizations provide informationNOT about FOR many SALEhealth issues.OR DISTRIBUTION Specialty asso- ciations have their own agendas and are excellent resources from which to learn. Nurses also have an opportunity to voice their own opinions and provide information from their own practices through active participation in organizations.© Jones & Bartlett This give Learning, and take builds LLC knowledge and confidence© Jones when & Bartlett Learning, LLC nursesNOT help FOR legislators SALE andOR othersDISTRIBUTION interpret issues. NOT FOR SALE OR DISTRIBUTION Beverly Malone, PhD, RN, currently chief executive officer, National League for Nursing, was named by President Clinton as a member of the U.S. Delegation to the World Health Assembly (the governing board of the World Health Organization). Then from 2001 to 2006 she served as general © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC secretary of the Royal College of Nursing, the most esteemed professional NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION nurse’s trade union in the world. Joanne Disch, PhD, RN, served as chair of the board of directors for AARP. During her tenure, she was an example of how the knowledge and experience of a nurse has relevance in the broader community. Her influence © Jones & Bartlett Learning,illustrates LLC the extensive effect that ©nurses Jones have & in Bartlett addressing Learning, factors related LLC NOT FOR SALE OR DISTRIBUTIONto aging for a huge population of Americans.NOT FOR Her SALE work withOR DISTRIBUTIONpharmaceutical manufacturers and her strong testimony to Congress in the early years of this century made possible several laws that addressed medication need, incompatibility, and cost for senior citizens. Through her recent term as president© Jones of the & BartlettAmerican Learning, Academy of LLC Nursing she continued to© demon Jones- & Bartlett Learning, LLC strateNOT leadership FOR SALE and political OR DISTRIBUTION shrewdness at the highest level. NOT FOR SALE OR DISTRIBUTION Summary of Reasons So nurses are uniquely prepared to be involved in the process of public © Jones & policyBartlett through Learning, history, LLC practice, education, and organizations.© Jones & BartlettThe nurses Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 10 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Why “Naturally”? ■ 11

cited© Jonesin this chapter& Bartlett are only Learning, a representative LLC few of the leaders who© Jones have & Bartlett Learning, LLC broughtNOT FORthe profession SALE OR to DISTRIBUTIONthe position of respect and advocacyNOT enjoyed FOR SALE OR DISTRIBUTION today. Nurses can do much to improve the healthcare system through policy change. But they cannot do it alone any longer. Nurses and nursing care are at the center of issues of tremendous and long-lasting impact. Nurses © Jones & cannotBartlett afford Learning, to limit LLCtheir actions. It is natural© for Jones nurses & to Bartlett talk with Learning, LLC NOT FOR SALEbureaucrats, OR DISTRIBUTION agency staff, legislators, and othersNOT in public FOR service SALE about OR DISTRIBUTION what nurses do, what nurses and their patients need, and the extent of their cost-effectiveness and long-term impact on health care in this country. For too long, nurses only talked to each other. Each knew his or her value, and © Jones & Bartlett Learning,each told LLC great stories; they “preached© Jones to the choir”& Bartlett of other Learning, nurses instead LLC NOT FOR SALE OR DISTRIBUTIONof sharing their wisdom with thoseNOT who FOR could SALE help change OR DISTRIBUTION the healthcare system for the better. We finally are listening to those who have espoused interprofessional collaboration, and we are realizing that, together with our colleagues in medicine, psychology, pharmacy, dentistry, allied health, and other© Jones professions, & Bartlett we can joinLearning, forces and LLC make a stronger presence© in Jones deter- & Bartlett Learning, LLC miningNOT policy. FOR InSALE the end, OR the DISTRIBUTION patient is the winner. NOT FOR SALE OR DISTRIBUTION Today’s nurses, especially those in advanced practice who have a solid foundation of focused education and experience, know how to market themselves and their talents and know how to harness their irritations and direct them toward positive resolution. Nurses are embracing the whole © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC range of options available in the various parts of the policy process. Nurses NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION are initiating opportunities to sustain ongoing, meaningful dialogues with those who represent the districts and states and those who administer public programs. Nurses are becoming indispensable to elected and appointed officials, and nurses are demonstrating leadership by becoming those officials © Jones & Bartlett Learning,and by LLCparticipating with others in© planning Jones &and Bartlett decision Learning, making. Nurses LLC NOT FOR SALE OR DISTRIBUTIONare realizing that by working withNOT colleagues FOR SALEin other OR health DISTRIBUTION professions they often move an issue forward with more credibility and fewer barriers. The advanced practice registered nurse of the third millennium is techni- cally competent; uses critical thinking and decision models; possesses vision that© is Jones shared &with Bartlett colleagues, Learning, consumers, LLC and policymakers; and functions© Jones & Bartlett Learning, LLC in aNOT vast arrayFOR of SALE roles. One OR of DISTRIBUTION these roles is policy analyst. Policy andNOT politics FOR SALE OR DISTRIBUTION is a natural domain for nurses. We are on the brink of an opportunity for the full integration into practice of the impending major changes in the delivery of care in the United States. Nurses have prepared for these changes by ini- © Jones & tiatingBartlett new Learning, nurse education LLC programs, expanding© the Jones number & Bartlettof master’s Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 11 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

12 ■ Chapter 1 Advanced Practice Nurses and Public Policy, Naturally

and© doctoral Jones programs,& Bartlett and Learning, focusing on LLC issues important to patients© Jones such & Bartlett Learning, LLC as NOTthe just FOR and SALEequitable OR delivery DISTRIBUTION of health care. Nurses can bring NOTa unique FOR SALE OR DISTRIBUTION perspective to healthcare issues.

What Nurses Have to Offer Colleagues and © Jones & PolicymakersBartlett Learning, to LLCMake Sustainable Change© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Numbers Nurses can bring numbers to the policy arena. Nurses comprise the larg- © Jones & Bartlett Learning,est group LLC of healthcare workers in© the Jones world. & According Bartlett Learning,to a 2008 report LLC NOT FOR SALE OR DISTRIBUTIONof registered nurses, there are 3.1NOT million FOR registered SALE nursesOR DISTRIBUTION in the United States, 84.8% of whom are working in nursing. Fifty percent hold bachelor’s degrees in nursing; 13.2% have masters or doctoral degrees (DHHS, 2010). One-third of the RN workforce is near retirement age. Projections indicate© Jones that &the Bartlett long-standing Learning, nurse LLC shortage is becoming worse© Jones now & Bartlett Learning, LLC thatNOT baby FOR boomers SALE are retiring.OR DISTRIBUTION This group of consumers grew up NOTin a time FOR SALE OR DISTRIBUTION of economic abundance and will expect an abundance of healthcare services when they leave the workforce. Nurse education programs recognize the opportunity to expand program enrollment but are faced with a dearth of qualified faculty and appropriate sites for direct care practice known as © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC clinical space. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Technology Nurses can bring their considerable knowledge of technology to the policy process. Nurse educators and administrators are using technology to © Jones & Bartlett Learning,enhance LLC and supplement the learning© Jones process. & Patient Bartlett simulators Learning, are mod LLC- NOT FOR SALE OR DISTRIBUTIONels that can mimic healthcare problemsNOT FORin a laboratory. SALE OR These DISTRIBUTION models are very sophisticated and expensive, and can be programmed to mirror a heart attack, congestive heart failure, or any number of health conditions and emergencies. For best effect, students work in teams with colleagues from nursing,© Jones medicine, & Bartlett physical Learning, therapy, and LLC emergency medical technology;© Jones & Bartlett Learning, LLC medicalNOT residents; FOR SALE and others.OR DISTRIBUTION The lab approach can ease the need forNOT direct FOR SALE OR DISTRIBUTION experience with patients because of the focused approach and because a scenario can be analyzed and replayed for different outcomes. Boards of nursing are concerned about how much simulation is appropriate, but it is © Jones & clearBartlett that simulationLearning, is LLC an asset to learning. Another© Jones benefit & of Bartlett simulation Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 12 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

What Nurses Have to Offer to Make Sustainable Change ■ 13

is the© Jones experience & Bartlett of working Learning, with a team. LLC Interprofessional education© Jones is & Bartlett Learning, LLC fairlyNOT new FOR in most SALE educational OR DISTRIBUTION programs, although the concept NOThas been FOR SALE OR DISTRIBUTION discussed for many years. The use of simulators is a natural way to implement the idea of interprofessional collaboration. Online education also has become a major force in the United States. © Jones & WhetherBartlett described Learning, as distanceLLC learning, electronic© education,Jones & Bartlettor another Learning, LLC NOT FOR SALEsimilar ORterm, DISTRIBUTION most nursing education programs useNOT at leastFOR some SALE form OR of DISTRIBUTION teaching that is not face-to-face (F2F) in a single classroom. Although cor- respondence courses were available in some educational institutions, the term “distance learning” was pioneered as television courses in the 1960s, © Jones & Bartlett Learning,in which LLC a group of students met© together Jones at& aBartlett location Learning,remote from LLC the NOT FOR SALE OR DISTRIBUTIONcustomary classroom and were taughtNOT by FOR a faculty SALE member OR DISTRIBUTION in the primary classroom. Today’s e-learning affords opportunities to learn in a flexible, anytime schedule that is not grounded in geography or time. Classes are held synchronously (all students together at one time) or asynchronously (each© Jonesstudent &may Bartlett enter a Learning,virtual classroom LLC at any time, not necessarily© Jones as & Bartlett Learning, LLC a group)NOT FORor a combination SALE OR ofDISTRIBUTION both. The sophistication of softwareNOT systems FOR SALE OR DISTRIBUTION provides students and faculty with a wide range of presentations. Telehealth, an outgrowth of e-learning and advanced diagnostic technology, allows patients and providers access to each other’s domain without concerns about transportation, time lost from work, childcare during visits, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC and other major reasons why patients do not make or keep appointments. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION This sophisticated technology first was tested by military personnel and found to be an effective method for training and for practice. Currently phone applications are available that connect patients directly to providers who can monitor conditions, prescribe treatments and medications, and © Jones & Bartlett Learning,deliver LLCeducational information.© Ethical Jones issues, & Bartlett cost of Learning, equipment, LLC the NOT FOR SALE OR DISTRIBUTIONlearning curve of the provider andNOT patient, FOR and SALE laws ORand DISTRIBUTIONregulations are dictating how much telehealth the public will embrace. Education Nurses© Jones can bring & Bartlett the same Learning, creativity toLLC solving public policy issues© Jones that & Bartlett Learning, LLC theyNOT used FOR in addressing SALE OR educational DISTRIBUTION issues. Although the professionNOT hasFOR SALE OR DISTRIBUTION not solved the “entry” problem, there are efforts to move closer to requiring a bachelor of science in nursing (BSN) degree as the beginning point for professional nursing. Aiken and colleagues have reported over and over © Jones & thatBartlett hospitals Learning, with higher LLC proportions of baccalaureate-prepared© Jones & Bartlett nurses Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 13 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

14 ■ Chapter 1 Advanced Practice Nurses and Public Policy, Naturally

demonstrate© Jones decreased& Bartlett patient Learning, morbidity LLC and mortality (Aiken et ©al., Jones 2003, & Bartlett Learning, LLC 2011,NOT 2014; FOR Van SALE den HeedeOR DISTRIBUTION et al., 2009; You et al., 2013; Wiltse-Nicely,NOT FOR SALE OR DISTRIBUTION Sloane, & Aiken, 2013). Aiken’s research includes studies in the United States and in nine European countries. Over 90 nurse generalist and specialty organizations are on record as supporting the BSN as an entry point © Jones & toBartlett professional Learning, nursing. LLC Some states are moving legislation© Jones or & regulation Bartlett toLearning, LLC NOT FOR SALErequire ORthat DISTRIBUTION graduates of hospital diploma and associateNOT FOR degree SALE programs OR DISTRIBUTION obtain a BSN within 10 years of graduation in order to be relicensed as registered nurses (RNs). Although the National Council of State Boards of Nursing has stated it is not ready to support legislation or regulation that © Jones & Bartlett Learning,requires LLC a BSN to practice as a registered© Jones nurse, & Bartlettthe marketplace Learning, is moving LLC NOT FOR SALE OR DISTRIBUTIONin a different direction. There is aNOT mounting FOR SALEwave of OR healthcare DISTRIBUTION agencies that are limiting new hires to those with at least BSNs and have developed policies that require RNs with associate’s degrees or diplomas to complete a BSN within 5 years of employment. Academic institutions have expanded or ©created Jones RN-to-BSN & Bartlett programs Learning, in response LLC to the demand. © Jones & Bartlett Learning, LLC NOTAccelerated FOR SALE nurse OReducation DISTRIBUTION programs, recalling similar programsNOT FOR SALE OR DISTRIBUTION during World War II, have been developed at the bachelor’s and master’s degree levels. These programs were created to accept applicants with college degrees in fields other than nursing and provide the student with an opportunity to graduate with a degree in nursing in an abbreviated time period; © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC graduates are eligible to sit for the National Council Licensure Examination NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION (NCLEX-RN) to become registered nurses. These popular programs provide new avenues that address the nurse shortage. A new education model at the master’s level, the clinical nurse leader (CNL), was created by the American Association of Colleges of Nursing © Jones & Bartlett Learning,(AACN), LLC the national organization© of Jones deans and& Bartlett directors Learning, of baccalaureate LLC NOT FOR SALE OR DISTRIBUTIONand higher-degree nurse programsNOT (AACN, FOR 2008c). SALE DuringOR DISTRIBUTION meetings of leaders of the AACN, the American Organization of Nurse Executives, and other employers of nurses, the AACN asked: Are educational institutions providing appropriate professionals for the workforce? The answer was that the© nurses Jones of today& Bartlett and the Learning, future should LLC be educated to manage a© popula Jones- & Bartlett Learning, LLC tionNOT of patients/clients FOR SALE (suchOR DISTRIBUTION as a group of diabetics or those with congestiveNOT FOR SALE OR DISTRIBUTION heart failure) both in a hospital setting and after discharge and should be able to make changes at a microsystem (i.e., unit) level. The CNL master’s- level program was proposed in 2003 to address those recommendations. As © Jones & ofBartlett 2014, 38 Learning, states conducted LLC CNL programs whose© Jonesgraduates & canBartlett sit for Learning, a LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 14 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

What Nurses Have to Offer to Make Sustainable Change ■ 15

national© Jones certification & Bartlett exam Learning, that provides LLC credibility to employers.© In Jones 2014 & Bartlett Learning, LLC thereNOT were FOR more SALE than 3,000 OR DISTRIBUTIONcertified CNLs (AACN, 2014a). NOT FOR SALE OR DISTRIBUTION At about the same time as the CNL program was initiated, much work had been accomplished in moving APRNs toward doctoral education as an entry point. Rationale included granting a degree appropriate to the © Jones & knowledgeBartlett Learning, base and credit LLC hours required in master’s-level© Jones APRN & Bartlett programs Learning, LLC NOT FOR SALEand placing OR DISTRIBUTIONthe advanced practitioner on a level withNOT other FOR health SALE profes OR -DISTRIBUTION sionals. Note that a physician (MD), dentist (DDS), physical therapist (DPT), occupational therapist (OTD), and audiologist (AuD) require a practice doctorate. In 2004, AACN members voted to establish a practice doctoral © Jones & Bartlett Learning,degree, LLCDoctor of Nursing Practice© (DNP), Jones and & toBartlett require Learning,that all advanced LLC NOT FOR SALE OR DISTRIBUTIONnursing practice move from the master’sNOT FOR level toSALE the DNP OR byDISTRIBUTION 2015 (AACN, 2014b). The DNP is an expert in patient care and designs, administers, and evaluates the delivery of complex health care in new organizational arrangements and at the systems level. Areas of concentration are offered in direct care,© Jonesinformatics, & Bartlett executive Learning, administration, LLC and health policy. Although© Jones & Bartlett Learning, LLC someNOT nurse FOR educators SALE stillOR expressDISTRIBUTION concern over the impact of theNOT DNP FORon SALE OR DISTRIBUTION APRN practice (Cronenwett et al., 2011), by 2013 more than 214 programs existed with 2,443 enrolled students and 14,699 graduates. The CNL and DNP also reflect a change in how health care is provided. Certified CNLs work at the unit micro level (not the health systems macro © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC level) and provide direct care to groups of patients, which includes teaching NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION with the goal of self-management of their own health problems. Patients learn to notice early indicators of changes in their conditions so that they may seek help before serious symptoms arise, with the goal being to keep patients as healthy as possible and to reduce hospital readmissions. The © Jones & Bartlett Learning,DNP provides LLC care at the macro systems© Jones level; & that Bartlett is, this Learning, provider is LLCalert NOT FOR SALE OR DISTRIBUTIONto problems in the healthcare organizationNOT FOR and SALE can seek OR solutions DISTRIBUTION through policy changes. DNPs develop relationships within and outside the healthcare network in order to facilitate transformation.

Positive© Jones Relationships & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NursesNOT will FOR bring SALE their ORpositive DISTRIBUTION relationships with other stakeholdersNOT with FOR SALE OR DISTRIBUTION whom they have common issues. Nurses will lead the movement of interprofessional practice, education, and research to the policy arena. Perhaps the greatest potential for change in the education of nurses will be the © Jones & effectBartlett of the Learning, report from LLC the Institute of Medicine© (IOM)Jones of & the Bartlett National Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 15 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

16 ■ Chapter 1 Advanced Practice Nurses and Public Policy, Naturally

Academies,© Jones The & BartlettFuture of Nursing:Learning, Leading LLC Change, Advancing Health© Jones(IOM, & Bartlett Learning, LLC 2010).NOT Under FOR theSALE aegis OR of DISTRIBUTION and funded by the Robert Wood NOTJohnson FOR SALE OR DISTRIBUTION Foundation (RWJF), the report recognizes that nurses (the largest healthcare workforce in the United States) must be an integral part of a healthcare team. The report provided four key messages (IOM, 2010, pp. 1–3): © Jones & Bartlett1. Nurses Learning, should practiceLLC to the full extent© of Jones their education & Bartlett and Learning, LLC NOT FOR SALEtraining. OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. © Jones & Bartlett Learning,3. Nurses LLC should be full partners© Jones with physicians & Bartlett and Learning, other healthcare LLC NOT FOR SALE OR DISTRIBUTIONprofessionals in redesigningNOT health FOR care SALEin the United OR DISTRIBUTION States. 4. Effective workforce planning and policymaking require better data collection and an improved information infrastructure.

©How Jones the messages & Bartlett are beingLearning, received LLC by the intended audiences—“policy© Jones & Bartlett Learning, LLC makers;NOT national, FOR SALE state, ORand localDISTRIBUTION government leaders; payers; and healthNOT care FOR SALE OR DISTRIBUTION researchers, executives, and professionals—including nurses and others—as well as … licensing bodies, educational institutions, philanthropic organizations, and consumer advocacy organizations” (IOM, 2010, p. 4)—is having a seismic impact on nursing education, practice, administration, and research. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Removing barriers to practice, expanding leadership opportunities, doubling NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION the number of nurses with doctorates, and greatly increasing bachelor’s degrees to 80 percent of the workforce will require money, commitment, energy, and creativity. Removing barriers to practice also will require a change in laws and, especially, regulations to allow nurses and other health © Jones & Bartlett Learning,professionals LLC to practice at the top© of Jones their education & Bartlett and Learning,experience. LLC NOT FOR SALE OR DISTRIBUTIONA consortium of professional organizationsNOT FOR SALE already OR is movingDISTRIBUTION forward together to address common problems. The Josiah Macy Jr. Foundation (2014) developed recommendations that support working together in five areas: (1) engagement, (2) innovative models, (3) education reform, (4) revi- sion© ofJones regulatory & Bartlett standards, Learning, and (5) LLCrealignment of resources. ©In Jones 2009, & Bartlett Learning, LLC leadersNOT from FOR six SALEnational OR organizations DISTRIBUTION met to establish the InterprofessionalNOT FOR SALE OR DISTRIBUTION Education Collaborative (IPEC, n.d.): the American Association of Colleges of Nursing (AACN), American Association of Osteopathic Colleges of Medicine (AAOCM), American Association of Colleges of Pharmacy, © Jones & AmericanBartlett Learning,Dental Education LLC Association (ADEA),© Association Jones & ofBartlett American Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 16 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Healthcare Reform in the Center of the Public Policy Process ■ 17

Medical© Jones Colleges & Bartlett (AAMC), Learning, and Association LLC of Schools and Programs© Jones of & Bartlett Learning, LLC PublicNOT Health FOR (ASPPH).SALE OR In 2013DISTRIBUTION they expanded to include the CEONOT of theFOR SALE OR DISTRIBUTION American Association of Colleges of Pharmacy (AACP). IPEC developed four core competencies for interprofessional collaborative practice: (1) values/ ethics, (2) roles/responsibilities, (3) interprofessional communication, and © Jones & (4)Bartlett teams andLearning, teamwork. LLC Geraldine “Polly” Bednash,© Jones PhD, RN, & Bartlettimmediate Learning, LLC NOT FOR SALEpast chief OR executive DISTRIBUTION officer of the AACN, is the currentNOT chair FOR of SALE IPEC. OR DISTRIBUTION It is now up to nurses and our other professional colleagues to advance health care so that both patients and professionals will benefit. Nurses are not only reforming nurse education and practice, but also providing leader- © Jones & Bartlett Learning,ship in LLCgathering other healthcare© professionals Jones & Bartlett (practitioners Learning, and educa LLC- NOT FOR SALE OR DISTRIBUTIONtors) to begin paradigm-changing NOTdiscussions FOR SALEto reform OR the DISTRIBUTION entire system. The new system will focus on health care, prevention of disease/disability, and health promotion. Research will continue to produce breakthroughs in biomedical, behavioral science, and other relevant areas and will provide evidence© Jones for best & Bartlett practice. Learning,Research on LLCoutcomes of treatment will© become Jones & Bartlett Learning, LLC essential.NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION The whole economic basis of capitalism—that is, the manufacturing system—had become rapidly outdated by the beginning of the 21st century. The new paradigm for organizations in this century began with a move to a perspective that was outside the usual way of thinking. What work is done, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC where it is done, how it is done, by whom it is done, and what it costs are NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION important questions, and APRNs can provide creative answers. Exhibit 1-1 compares the old paradigm of sick care and the new paradigm of health care.

© Jones & Bartlett Learning,Healthcare LLC Reform in the© CenterJones & of Bartlett the Learning, LLC NOT FOR SALE OR DISTRIBUTIONPublic Policy Process NOT FOR SALE OR DISTRIBUTION There was talk for decades about reforming the U.S. healthcare system. In the 1990s, President Clinton established a group that made major recommendations, but the constant pressure of special interest groups, such as pharmaceutical© Jones & andBartlett insurance Learning, companies LLC that protected their own© Jones inter- & Bartlett Learning, LLC ests,NOT delayed FOR and SALE ultimately OR DISTRIBUTION derailed any serious attempt at overhaulingNOT FOR SALE OR DISTRIBUTION this huge system. During the George W. Bush administration, defense was the number one issue on the agenda and health care was not a priority. President Obama declared early in his administration that a major prior- © Jones & ityBartlett would Learning,be health care LLC for all, and in 2010 the© Patient Jones Protection & Bartlett and Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 17 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

18 ■ Chapter 1 Advanced Practice Nurses and Public Policy, Naturally

Old Paradigm New Paradigm Hospital-based acute care Short-term hospital stays, outpatient © Jones & Bartlett Learning, LLC surgery, mobile/satellite© clinics, Jones telehealth/ & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONtelemedicine NOT FOR SALE OR DISTRIBUTION Physician in charge; nurses Team approach; collaborative; respect for all and others as subordinates providers as full team members Physician as primary deci- Relevant professionals and patient make treat- © Jones & Bartlett Learning,sion LLCmaker ment© decisions Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONTraditional care “as we Evidence-basedNOT FOR practice SALE OR DISTRIBUTION have always done it” Segmented care focused Seamless, coordinated, holistic care on separate body parts/ ©systems Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTPrimary FOR care physicianSALE OR and DISTRIBUTIONPatient-centered medical/health home NOT FOR SALE OR DISTRIBUTION specialist separated Paper records; some EHR systems that generate data used for electronic health records change that can be retrieved for meaningful (EHRs) use (i.e., as evidence for change) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Fee-for-service Mix of reimbursement packages NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Hierarchical organizations Value-based organizations Positivist, linear thinking Complexity science: quantum principles, patterns noted in chaos; networks are essential; interpersonal relationships are indispensable © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Affordable Care Act (commonly known as the ACA) was established, a huge first© for Jones the United & Bartlett States. Learning, LLC © Jones & Bartlett Learning, LLC NOTToday’s FOR policymakers SALE OR seem DISTRIBUTION to be more divided than at any time NOTin recent FOR SALE OR DISTRIBUTION history; choices often are dichotomous or mutually exclusive and rulings follow a strict party line. Compromise can be perceived as losing power, and power seems to be revered over common sense or the common good. © Jones & SplinterBartlett groups Learning, or loose LLC arrangements of radical thinkers© Jones have & appearedBartlett on Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 18 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Healthcare Reform in the Center of the Public Policy Process ■ 19

the© political Jones scene& Bartlett and are Learning, challenging LLC the traditional two- or three-party© Jones & Bartlett Learning, LLC system.NOT A FOR long-time SALE congressperson OR DISTRIBUTION told this author that she has neverNOT seen FOR SALE OR DISTRIBUTION this much bitterness and antagonism in her more than 30 years of elected office. Many citizens are becoming more and more angry over the inertia and lack of meaningful legislation and deep polarization on issues. Future © Jones & electionsBartlett will Learning, reflect the LLC degree of dissatisfaction among© Jones voters. & BartlettNurses will Learning, LLC NOT FOR SALEhave to OR be especially DISTRIBUTION sensitive to the political positionsNOT ofFOR all policymakers SALE OR DISTRIBUTION when working in this arena. Communications techniques learned in basic baccalaureate and graduate programs will enable the nurse to transcend some of the pressures encountered in working through the political process. © Jones & Bartlett Learning,Physicians, LLC psychologists, pharmacists,© Jones and other & Bartlett professionals Learning, will have LLC to NOT FOR SALE OR DISTRIBUTIONadd communications content to theirNOT curricula FOR SALE in order OR to DISTRIBUTION increase their effectiveness with policymakers. The healthcare system in the United States is in the midst of huge changes. Many health problems are the result of lifestyles that do not support© health.Jones Obesity,& Bartlett hypertension, Learning, and LLC cardiovascular illnesses© are Jones only & Bartlett Learning, LLC threeNOT that FOR are mentioned SALE OR frequently. DISTRIBUTION In order to promote a healthyNOT popu FOR- SALE OR DISTRIBUTION lation, we are in the early phases of a move toward prevention of illness and disability and promotion of healthy living. Many people know how to live a healthy life, but just as many do not actually engage in healthy practices. Healthcare professionals are changing the way they assess, diagnose, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC counsel, and treat patients. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION People are living longer and are encountering many chronic problems. Who would have thought 5 years ago that cancer today is considered a chronic disease? Surgery has made great strides, especially as minimally inva- sive methods and robotics are perfected. Genetics and genomics have opened © Jones & Bartlett Learning,up a whole LLC discipline that incorporates© Jones gene & splicing Bartlett and Learning, manipulation, LLC NOT FOR SALE OR DISTRIBUTIONgenetic testing and counseling, andNOT many FOR other SALE approaches OR DISTRIBUTION to what have been considered irreversible or inevitable conditions. The use of prosthetics in many forms and for many body parts is maturing into a fast-growing business, especially with the recovery and return of military personnel from wars.© BodyJones parts & Bartlettgrown in laboratoriesLearning, from LLC stem cells taken from a ©recipient Jones & Bartlett Learning, LLC willNOT reduce FOR the probabilitySALE OR of DISTRIBUTION autorejection. Behavioral health expertsNOT (e.g., FOR SALE OR DISTRIBUTION psychologists, psychiatrists, mental health nurses) must be integrated into the health team to help people address issues such as posttraumatic stress and other problems. Ethical questions are integral to policy arguments, © Jones & especiallyBartlett asLearning, appropriations LLC are examined with a critical© Jones eye toward& Bartlett costs. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 19 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

20 ■ Chapter 1 Advanced Practice Nurses and Public Policy, Naturally

©Federal Jones reform & Bartlett has mandated Learning, programs LLC and policies that will© demand Jones & Bartlett Learning, LLC actionNOT that FOR is different SALE ORfrom DISTRIBUTION what is available today. The Patient ProtectionNOT FOR SALE OR DISTRIBUTION and Affordable Care Act of 2010 (ACA) is a federal law that is expected to transform how, where, and by whom health care is provided and how that care will be paid for. Whether or not the programs envisioned in the law © Jones & willBartlett succeed Learning, (i.e., meet theLLC needs of the populace and© Jones be politically & Bartlett accept Learning,- LLC NOT FOR SALEable) is ORbeing DISTRIBUTION played out through federal and stateNOT legislatures, FOR SALEpresidential OR DISTRIBUTION influence, and judicial decisions. Bills were introduced in 2011 to seriously amend and terminate the law. Judicial decisions have been made and the courts will continue to weigh issues surrounding this program. Nurses and © Jones & Bartlett Learning,nurse organizations LLC will be strong voices© Jones in the & debates Bartlett that Learning, will have lasting LLC NOT FOR SALE OR DISTRIBUTIONinfluence on health care in this country.NOT FOR SALE OR DISTRIBUTION Hospitals are concerned with staffing the workforce with nurses and other healthcare providers. Staffing levels have become a huge issue, with two opposing camps: one supports actual numbers of nurses per patient or ©per Jones unit and & theBartlett other supportsLearning, principles LLC of staffing rather than© Jonesactual & Bartlett Learning, LLC numbers.NOT FOR The CaliforniaSALE OR Nurses DISTRIBUTION Association (CNA), originally a stateNOT affil FOR- SALE OR DISTRIBUTION iate of the American Nurses Association, broke from the ANA mainly over staffing issues. The CNA (the group kept the name), under the umbrella of the National Nurses Organizing Committee (NNOC), became politically active in several states in its desire to establish legal, specific, numerical © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC nurse-to-patient ratios. The ANA, in contrast, established “principles of NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION staffing” that required including patient acuity, diagnosis, type of nursing unit, and other considerations rather than specific numbers. Buerhaus (2008, 2009) presented data and thoughtful discussion to support the need for nurses as the primary workforce in the United States. ANA brought © Jones & Bartlett Learning,together LLC over 700 nurses whose work© Jones resulted & Bartlettin a document Learning, that assists LLC NOT FOR SALE OR DISTRIBUTIONnurses in constructing finance-basedNOT arguments FOR SALE that supportOR DISTRIBUTION safe staffing plans and that those plans use the knowledge of nurses in direct patient care (Lineweaver, 2013). Most care providers recognize the problems inherent in offering care to the© uninsured Jones & and Bartlett underinsured. Learning, The LLCdisparity in care seen in low© Jonessocio- & Bartlett Learning, LLC economicNOT FOR groups SALE and ORvulnerable DISTRIBUTION populations (e.g., children, theNOT elderly) FOR SALE OR DISTRIBUTION and groups with specific health concerns (e.g., diabetics, smokers) presents enormous challenges. Nurses have proffered solutions that have been taken seriously by major policy players. The Health Resources and Services © Jones & AdministrationBartlett Learning, (an agency LLC within the U.S. Bureau of© HealthJones Professions) & Bartlett has Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 20 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Healthcare Reform in the Center of the Public Policy Process ■ 21

convened© Jones webinars & Bartlett since 2009 Learning, on major LLC topics of quality improvement© Jones and & Bartlett Learning, LLC reporting,NOT FOR health SALE information OR DISTRIBUTION technology (IT) diligence, health ITNOT imple FOR- SALE OR DISTRIBUTION mentation/opportunities for workflow and budgeting, meaningful use, workforce and safety net providers, and health and quality programs and topics. Tactics and solutions gleaned from participants are used to develop © Jones & strategiesBartlett toLearning, address these LLC major problems (Health© Resources Jones & and Bartlett Services Learning, LLC NOT FOR SALEAdministration, OR DISTRIBUTION 2010–2011). NOT FOR SALE OR DISTRIBUTION For some policymakers, this seems as if nurses are trying to expand the scope of their practice. This opinion often comes about because policymakers do not know what nurses do or the actual dimensions of their roles. © Jones & Bartlett Learning,The nurse LLC of today and the future© isJones “not your & Bartlett mother’s Learning, nurse,” to paraLLC- NOT FOR SALE OR DISTRIBUTIONphrase an old automobile commercial.NOT Haas’sFOR SALE(1964) earlyOR DISTRIBUTIONstudy of nurses clarified that their role had four dimensions: task, authority or power, deference or prestige, and affect or feelings. Each of those dimensions has changed drastically over the past 10 years. Nurses simply want to practice at the© Jones level of &their Bartlett education Learning, and within LLC legal and professional definitions.© Jones & Bartlett Learning, LLC NOTExpanding FOR theSALE historical OR DISTRIBUTIONboundaries of nursing takes skill in negotiation,NOT FOR SALE OR DISTRIBUTION diplomacy, assertiveness, expert communication, and leadership. Sometimes physician and nurse colleagues are threatened by these behaviors, and it takes persistence and certainty of purpose to proceed. Nurses must speak out as articulate, knowledgeable, caring professionals who contribute to © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC the whole health agenda and who advocate for their patients and the com- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION munity. All healthcare professions have expanded the boundaries of practice from their beginnings. Practice reflects societal needs and conditions; homeostasis is not an option if the provision of health care is to be relevant. The American Academy of Nursing (AAN), a prestigious organization © Jones & Bartlett Learning,of approximately LLC 2,000 select nurse© leaders Jones who & Bartlettwork to change Learning, health LLC care NOT FOR SALE OR DISTRIBUTIONat the policy level, created a Raise theNOT Voice FOR campaign SALE thatOR “providesDISTRIBUTION a plat- form to inform policymakers, the media, health providers and consumers about nurse-driven activities and solutions for an ailing health care system” (American Academy of Nursing, 2010, p. 1). This program, funded by a grant from© Jonesthe Robert & BartlettWood Johnson Learning, Foundation, LLC cites “Edge Runners”—nurses© Jones & Bartlett Learning, LLC whoNOT are leading FOR SALE the way OR to healthcare DISTRIBUTION reform by creating models ofNOT care that FOR SALE OR DISTRIBUTION “demonstrate significant clinical and financial outcomes” (p. 2). AAN members are committed to transforming the healthcare system from the “current hospital-based, acuity-oriented, physician-dependent paradigm towards a © Jones & patient-centered,Bartlett Learning, convenient, LLC helpful, and affordable© Jones system” & (p. Bartlett 1). Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 21 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

22 ■ Chapter 1 Advanced Practice Nurses and Public Policy, Naturally

©A majorJones influence & Bartlett in how Learning, health care LLC is delivered is occurring as more© Jones and & Bartlett Learning, LLC moreNOT people FOR use SALE online OR resources. DISTRIBUTION Patients bring articles about diseasesNOT and FOR SALE OR DISTRIBUTION conditions to their healthcare providers. Providers surf electronic databases in search of accurate information. The expansion of knowledge and the rapidity with which it can be disseminated has grown exponentially in ways © Jones & thatBartlett were not Learning, possible evenLLC 5 years ago. A unique resource,© Jones The & Nurse’s Bartlett Social Learning, LLC NOT FOR SALEMedia Advantage OR DISTRIBUTION (Fraser, 2011), explains social mediaNOT and, FORmore importantly,SALE OR DISTRIBUTION discusses the necessity for nurses to understand how to use media resources in order to practice effectively in a fast-changing world.

© Jones & Bartlett Learning,Developing LLC a More Sophisticated© Jones & PoliticalBartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONRole for Nurses NOT FOR SALE OR DISTRIBUTION There has been a major shift in the roles that nurses assume. In addition to clinical experts, nurses are entrepreneurs, decision makers, and political activists.© Jones The nurse’s& Bartlett role must Learning, be examined LLC to determine if there is© a Jonespower & Bartlett Learning, LLC differential,NOT FOR what SALE the unwritten OR DISTRIBUTION rules are that acknowledge deference,NOT and FOR SALE OR DISTRIBUTION how both actors exhibit or control feelings. Many nurses realize that to control practice and move the profession of nursing forward as a major player in the healthcare arena, nurses have to be involved in the legal decisions © Jones & aboutBartlett the healthLearning, and welfare LLC of the public, decisions© Jonesthat often & areBartlett made inLearning, LLC NOT FOR SALEthe governmental OR DISTRIBUTION arena. NOT FOR SALE OR DISTRIBUTION For many nurses, political activism used to mean letting someone else get involved. Today’s nurse tunes in to bills that reflect a particular passion (e.g., driving and texting), disease entity (e.g., diabetes), or population (e.g., childhood obesity). Although this activity indicates a greater involvement © Jones & Bartlett Learning,in the political LLC process, it still misses© aJones broader & comprehension Bartlett Learning, of the whole LLC NOT FOR SALE OR DISTRIBUTIONpolicymaking process that providesNOT many FOR opportunities SALE OR forDISTRIBUTION nurse input before and after legislation occurs. Nurses who are serious about political activity realize that the key to establishing contacts with legislators and agency directors is through ongoing© Jones relationships & Bartlett with Learning, elected and LLC appointed officials and their© Jonesstaffs. & Bartlett Learning, LLC By NOTdeveloping FOR SALEcredibility OR with DISTRIBUTION those active in the political processNOT and FOR SALE OR DISTRIBUTION demonstrating integrity and moral purpose as client advocates, nurses are becoming players in the complex process of policymaking. Nurses have learned that by using nursing knowledge and skill they © Jones & couldBartlett gain Learning, the confidence LLC of government actors.© Communications Jones & Bartlett skills Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 22 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Developing a More Sophisticated Political Role for Nurses ■ 23

that© wereJones learned & Bartlett in basic Learning,skills classes LLCor in psychiatric nursing classes© Jones are & Bartlett Learning, LLC criticalNOT in FOR listening SALE to ORthe discussionDISTRIBUTION of larger health issues andNOT in being FOR SALE OR DISTRIBUTION able to present nursing’s agenda for health. Personal stories gained from professional nurses’ experience anchor altruistic conversations with legislators and their staffs in an important emotional link toward policy design. © Jones & Nurses’Bartlett vast Learning, network of LLC clinical experts produces nurses© Jones in direct & Bartlett care who Learning, LLC NOT FOR SALEprovide OR persuasive, DISTRIBUTION articulate arguments with peopleNOT “on FOR the Hill” SALE (i.e., ORU. S. DISTRIBUTION congressman and senators who work on Capitol Hill) during appropriations committee hearings and informal meetings. Nurses participate in formal, short-term internship programs with © Jones & Bartlett Learning,elected LLCofficials and in bureaucratic© Jonesagencies. & Most Bartlett of the Learning, programs LLCwere NOT FOR SALE OR DISTRIBUTIONcreated by nurse organizations thatNOT were FOR convinced SALE of OR the DISTRIBUTION importance of political involvement. The interns and fellows learn how to handle constituent concerns, how to write legislation, how to argue with opponents yet remain colleagues, and how to maneuver through the bureaucracy. They carry© theJones message & Bartlett of the necessity Learning, of the LLCpolitical process to the larger© profesJones- & Bartlett Learning, LLC sion,NOT although FOR theSALE rank OR and DISTRIBUTION file still are not active in this role. NOT FOR SALE OR DISTRIBUTION As nurses move into advanced practice and advanced practice demands master’s and doctoral degree preparation, the role of the nurse in the policy process has become clearer. Through the influence of nurses with their legislators, clinical nurse specialists, certified nurse midwives, certified registered © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC nurse anesthetists, and certified nurse practitioners are named in several pieces NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION of federal legislation as duly authorized providers of health care. The process has been slow; however, the deliberate way of including more nurse groups over time demonstrates that getting a foot in the door is an effective method of instituting change in the seemingly slow processes of government. Some © Jones & Bartlett Learning,groups LLCof nurses do not understand© theJones political & Bartlett implications Learning, of incremen LLC- NOT FOR SALE OR DISTRIBUTIONtalism (the process of making changesNOT gradually) FOR SALE and want OR allDISTRIBUTION nurse groups named as providers at one time. They do not understand that most legislators do not have any idea what registered nurses do. Those nurse lobbyists who worked directly with legislators and their staff in early efforts bore the brunt of discontent© Jones within& Bartlett the profession Learning, and LLC worked diligently and purposefully© Jones & Bartlett Learning, LLC to provideNOT FOR a unified SALE front OR on DISTRIBUTION Capitol Hill and to expand the definitionNOT FOR of SALE OR DISTRIBUTION provider at every opportunity. The designation of advanced practice nurses as providers was an entry to federal reimbursement for some nursing services, a major move toward improved client and family access to health care. Advanced © Jones & practiceBartlett nurses Learning, became LLCacutely aware of the critical© importance Jones & of Bartlett the role ofLearning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 23 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

24 ■ Chapter 1 Advanced Practice Nurses and Public Policy, Naturally

political© Jones activist. & BartlettNot only didLearning, APRNs need LLC the basic knowledge, they© Jonesunder- & Bartlett Learning, LLC stoodNOT the FOR necessity SALE of practicing OR DISTRIBUTION the role, developing contacts, workingNOT with FOR SALE OR DISTRIBUTION professional organizations, writing fact sheets, testifying at hearings, and maintaining the momentum and persistence to move an idea forward. Although many nurses still focus their political efforts and skills on the © Jones & legislativeBartlett Learning,process, they LLC understand the comprehensiveness© Jones & of Bartlett the policy Learning, LLC NOT FOR SALEprocess, OR the DISTRIBUTIONmuch broader process that precedes andNOT follows FOR legislation. SALE OR For DISTRIBUTION APRNs to integrate the policy role into the character of expert nurse they must recognize the many opportunities for action. APRNs cannot afford to do their own thing—that is, only provide direct patient care. They cannot © Jones & Bartlett Learning,ignore theLLC political aspects of any issue.© Jones Nurses & whoBartlett have foughtLearning, the battles LLC NOT FOR SALE OR DISTRIBUTIONfor recognition as professionals, forNOT acknowledgment FOR SALE OR of DISTRIBUTIONautonomy, and for formal acceptance of clinical expertise worthy of payment for services have enabled APRNs today to provide reimbursable, quality services to this nation’s residents. ©Today’s Jones nurses & Bartlett have a muchLearning, clearer LLC understanding of what constitutes© Jones & Bartlett Learning, LLC nursingNOT andFOR how SALE nurses OR must DISTRIBUTION integrate political processes into theirNOT prac FOR- SALE OR DISTRIBUTION tices to further the decisions made by policymakers. Nurses continue to focus on the individual, family, community, and special populations in the provision of care to the sick and infirm and on the activities that surround health promotion and the prevention of disease and disability. Advanced © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC practice nurses have a foundation in expert clinical practice and can trans- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION late that knowledge into understandable language for elected and appointed officials as the officials respond to problems that are beyond the scale or impact of individual healthcare providers. As nurses continue to refine the art and science of nursing, forces external to the profession compel the © Jones & Bartlett Learning,nursing LLC community to consider another© Jones aspect—the & Bartlett business Learning, of nursing— LLC NOT FOR SALE OR DISTRIBUTIONthat is paradoxical to the profession’sNOT long FOR history SALE of altruism. OR DISTRIBUTION

What Is Public Policy? So,© what Jones do the & Bartlettchanges in Learning, education, LLCpractice, and organizations© have Jones to & Bartlett Learning, LLC do NOTwith policymaking, FOR SALE especiallyOR DISTRIBUTION in the public arena? A brief overviewNOT of theFOR SALE OR DISTRIBUTION entire policy process will clarify what policy is and how influencing government policies has become crucial to the profession of nursing. In this chapter, policy is an overarching term used to define both an entity © Jones & andBartlett a process. Learning, The purpose LLC of public policy is to direct© Jones problems & Bartlett to govern Learning,- LLC NOT FOR SALEment and OR secure DISTRIBUTION government’s response; in contrast,NOT politics FOR SALEis the use OR of DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 24 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

What Is Public Policy? ■ 25

influence© Jones to direct& Bartlett the responses Learning, toward LLC goals. Although there ©has Jones been & Bartlett Learning, LLC muchNOT discussion FOR SALE about OR the boundariesDISTRIBUTION and domain of governmentNOT and theFOR SALE OR DISTRIBUTION extent of difference between the public and private sectors, that debate is beyond the scope of this chapter. The definition of public policy is important because it clarifies common © Jones & misconceptionsBartlett Learning, about whatLLC constitutes policy. In ©this Jones text, the & termsBartlett public Learning, LLC NOT FOR SALEpolicy and OR policy DISTRIBUTION are interchangeable. The process NOTof creating FOR policy SALE can OR be DISTRIBUTION focused in many arenas most of which are interwoven. For example, envi- ronmental policy deals with health issues such as hazardous materials, par- ticulate matter in the air or water, and safety standards in the workplace. © Jones & Bartlett Learning,Education LLC policy is more than tangentially© Jones related & Bartlett to health—just Learning, ask school LLC NOT FOR SALE OR DISTRIBUTIONnurses. Regulations define who canNOT administer FOR medicationSALE OR to DISTRIBUTION students; state laws dictate what type of sex education can be taught. Defense policy is related to health policy when developing, investigating, or testing biological and chemical weapons. Health policy directly addresses health problems and is the© Jones specific &focus Bartlett of this Learning, text. LLC © Jones & Bartlett Learning, LLC PolicyNOT as FOR an EntitySALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION As an entity, policy is seen in many forms as the “standing decisions” of an organization (Eulau & Prewitt, 1973, p. 495). As formal documented directives of an organization, official government policies reflect the beliefs © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC of the administration in power and provide direction for the philosophy NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION and mission of government organizations. Specific policies usually serve as the “shoulds” and “thou shalts” of agencies. Some policies, known as position statements, report the opinions of organizations about issues that members believe are important. For example, state boards of nursing (gov- © Jones & Bartlett Learning,ernment LLC agencies created by legislatures© Jones to protect & Bartlett the public Learning, through LLC the NOT FOR SALE OR DISTRIBUTIONregulation of nursing practice) publishNOT advisoryFOR SALE opinions OR onDISTRIBUTION what constitutes competent and safe nursing practice. Agency policies can be broad and general, such as those that describe the relationship of an agency to other governmental groups. Procedure manuals in government© Jones & hospitalsBartlett thatLearning, detail steps LLC in performing certain© nursing Jones & Bartlett Learning, LLC tasksNOT are FORexamples SALE of the OR results DISTRIBUTION of policy directives, but are not consideredNOT FOR SALE OR DISTRIBUTION policies. Policies serve as guidelines for employee behavior within an insti- tution. Although policies and procedures often are used interchangeably, policies are considered broader and reflect the values of the administration. © Jones & BartlettLaws are Learning, types of policy LLC entities. As legal directives© Jones for public & Bartlettand private Learning, LLC NOT FOR SALEbehavior, OR laws DISTRIBUTION serve to define action that reflectsNOT the will FOR of society—orSALE OR at DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 25 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

26 ■ Chapter 1 Advanced Practice Nurses and Public Policy, Naturally

least© aJones segment & ofBartlett society. LawsLearning, are made LLC at the international, federal,© Jones state, & Bartlett Learning, LLC andNOT local FOR levels SALEand have OR the DISTRIBUTION impact of primary place (i.e., are consideredNOT theFOR SALE OR DISTRIBUTION principal source) in guiding conduct. Lawmaking usually is the purview of the legislative branch of government in the United States, although presi- dential vetoes, executive orders, and judicial interpretations of laws have © Jones & theBartlett force of Learning, law. LLC © Jones & Bartlett Learning, LLC NOT FOR SALEJudicial OR interpretationDISTRIBUTION is noted in three ways.NOT First, FOR courts SALE may inter OR -DISTRIBUTION pret the meaning of laws that are written broadly or with some vagueness, though laws often are deliberately written with language that addresses broad situations. Agencies that implement the laws then write regulations © Jones & Bartlett Learning,that are LLC more specific and guide the© implementation.Jones & Bartlett However, Learning, courts LLCmay NOT FOR SALE OR DISTRIBUTIONbe asked to determine questions inNOT which FOR the SALElaw is unclear OR DISTRIBUTION or controver- sial (Williams & Torrens, 1988). For example, the 1973 Rehabilitation Act prohibited discrimination against the handicapped by any program that received federal assistance. Although this may have seemed fair and reasonable© Jones at the & outset, Bartlett courts Learning, were asked LLC to adjudicate questions© ofJones how & Bartlett Learning, LLC muchNOT accommodation FOR SALE OR is “fair” DISTRIBUTION (Wilson, 1989). Second, courts canNOT deter FOR- SALE OR DISTRIBUTION mine how some laws are applied. Courts are idealized as being above the political activity that surrounds the legislature. Courts also are considered beyond the influence of politically active interest groups. The court system, especially the federal court system, has been called upon to resolve conflicts © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC between levels of government (state and federal) and between laws enacted NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION by the legislature and their interpretation by powerful interest groups. For example, courts may determine who is eligible or who is excluded from participation in a program. In this way, special interest groups that sue to be included in a program can receive “durable protection” from favorable court © Jones & Bartlett Learning,decisions LLC (Feldstein, 1988, p. 32). ©Third, Jones courts & Bartlett can declare Learning, the laws made LLC NOT FOR SALE OR DISTRIBUTIONby Congress or the states unconstitutional,NOT FOR thereby SALE nullifying OR DISTRIBUTION the statutes entirely (Litman & Robins, 1991). Courts also interpret the Constitution, sometimes by restricting what the government (not private enterprise) may do (Wilson, 1989). ©Regulations Jones & areBartlett another Learning, type of policy LLC initiative. Although they© Jones often & Bartlett Learning, LLC areNOT included FOR in SALE discussions OR DISTRIBUTION of laws, regulations are different. OnceNOT a lawFOR SALE OR DISTRIBUTION is enacted by the legislative branch, the executive branch of government is charged with administrative responsibility for implementing the law. The executive branch consists of the president and all of the bureaucratic agen- © Jones & cies,Bartlett commissions, Learning, and LLC departments that carry out© the Jones work &for Bartlett the public Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 26 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

What Is Public Policy? ■ 27

benefit.© Jones Agencies & Bartlett in the government Learning, formulateLLC regulations that© achieve Jones & Bartlett Learning, LLC theNOT intent FOR of the SALE statute. OR On DISTRIBUTION the whole, laws are written in generalNOT terms, FOR SALE OR DISTRIBUTION and regulations are written more specifically to guide the interpretation, administration, and enforcement of the law. The Administrative Procedures Act (APA) was created to provide opportunity for citizen review and input © Jones & throughoutBartlett Learning, the process LLC of developing regulations. ©The Jones APA ensures & Bartlett a struc Learning,- LLC NOT FOR SALEture and OR process DISTRIBUTION that is published and open, in theNOT spirit FOR of the SALE founding OR DISTRIBUTION fathers, so that the average constituent can participate in the process of public decision making. All of these entities evolve over time and are accomplished through the © Jones & Bartlett Learning,efforts ofLLC a variety of actors or players.© Jones Although & Bartlett commonly Learning, used, the terms LLC NOT FOR SALE OR DISTRIBUTIONposition statement, resolution, goal, objective,NOT FORprogram, SALE procedure, OR DISTRIBUTION law, and regulation really are not interchangeable with the word policy. Rather, they are the formal expressions of policy decisions. For the purposes of understanding just what policy is, nurses must grasp policy as a process. Policy© Jones as a Process& Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION In viewing policy as a guide to government action, nurses can study the process of policymaking over time. Milio (1989) presents four major stages in which decisions are made that translate to government policies: (1) agenda setting, (2) legislation and regulation, (3) implementation, and (4) evalua- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC tion. Agenda setting is concerned with identifying a societal problem and NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION bringing it to the attention of government. Legislation and regulation are formal responses to a problem. Implementation is the execution of policies or programs toward the achievement of goals. Evaluation is the appraisal of policy performance or program outcomes. © Jones & Bartlett Learning,In each LLC stage, formal and informal© Jones relationships & Bartlett are developedLearning, among LLC NOT FOR SALE OR DISTRIBUTIONactors both within and outside ofNOT government. FOR SALE Actors OR can DISTRIBUTION be individuals, such as a legislator, a bureaucrat, or a citizen, but they also can be institutions, such as the presidency, the courts, political parties, or special-interest groups. A series of activities occurs that brings a problem to government, which© Jones results &in Bartlettdirect action Learning, by the government LLC to address the ©problem. Jones & Bartlett Learning, LLC GovernmentalNOT FOR responsesSALE OR are DISTRIBUTION political; that is, the decisions about NOTwho gets FOR SALE OR DISTRIBUTION what, when, and how are made within a framework of power and influence, negotiation, and bargaining (Lasswell, 1958). One must recognize that the policy process is not necessarily sequen- © Jones & tialBartlett or logical. Learning, The definition LLC of a problem, which© Jones usually &occurs Bartlett in the Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 27 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

28 ■ Chapter 1 Advanced Practice Nurses and Public Policy, Naturally

agenda-setting© Jones & phase, Bartlett may Learning, change during LLC legislation. Program design© Jones may & Bartlett Learning, LLC be NOTaltered FOR significantly SALE OR during DISTRIBUTION implementation. Evaluation of a NOTpolicy FOR or SALE OR DISTRIBUTION program (often considered the last phase of the process) may propel onto the national agenda (often considered the first phase of the process) a problem that differs from the original. However, for the purpose of organizing one’s © Jones & thoughtsBartlett and Learning, conceptualizing LLC the policy process, the© policyJones process & Bartlett is exam Learning,- LLC NOT FOR SALEined in ORthis chapterDISTRIBUTION from the linear perspective. NOT FOR SALE OR DISTRIBUTION The opportunities for nurse input throughout the policy process are unlimited and certainly not confined narrowly to the legislative process. Nurses are articulate experts who can address both the rational shaping of © Jones & Bartlett Learning,policy andLLC the emotional aspects ©of Jonesthe process. & Bartlett Nurses Learning,cannot afford LLC to NOT FOR SALE OR DISTRIBUTIONlimit their actions to monitoring bills;NOT they FOR must SALE seize theOR initiative DISTRIBUTION and use their considerable collective and individual influence to ensure the health, welfare, and protection of the public and healthcare professionals.

An© OverviewJones & Bartlett of the Learning, Policy Process LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Advanced practice registered nurses should have an overview of the total process so that they do not get stuck on legislation. Many useful articles and books have been written about policy in general and even about specific policies, but few have addressed the scope of the policy process or defined © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC the components. The elements of agenda setting (including problem defi- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION nition), government response (legislation, regulation, or programs), and policy and program implementation and evaluation are distinct entities, but are connected as parts of a whole tapestry in the process of public decision making. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONAgenda Setting NOT FOR SALE OR DISTRIBUTION Getting a healthcare problem to the attention of government can be a tremendous first step in getting relief. The actual mechanism of defining a healthcare problem is a major political issue. APRNs have the capacity and opportunity© Jones to & identify Bartlett and Learning, frame problems LLC from multiple sources.© Jones & Bartlett Learning, LLC NOTThe choice FOR of SALE a clinical OR problem DISTRIBUTION on which to focus one’s energy isNOT a major FOR SALE OR DISTRIBUTION decision. A nurse may be working in a specialized area and may see a need for more research or alternatives to existing treatment options; for example, those who work with patients and families with breast cancer already may © Jones & haveBartlett a passion Learning, for issues LLC critical to this area. Other ©topics Jones receiving & Bartlett attention Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 28 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

An Overview of the Policy Process ■ 29

include© Jones diabetes, & Bartlett obesity, AIDS,Learning, early detectionLLC and treatment of© prostate Jones & Bartlett Learning, LLC cancer,NOT child FOR and SALE parent OR abuse, DISTRIBUTION cardiac problems in women, andNOT empow FOR- SALE OR DISTRIBUTION ering caregivers (Hash & Cramer, 2003; Pierce & Steiner, 2003). Professional problems that are especially critical to nurses in advanced practice include reducing barriers to autonomy and reimbursement for © Jones & nursingBartlett services. Learning, Workplace LLC issues include advocacy© Jones for workplace & Bartlett safety Learning, LLC NOT FOR SALEand management OR DISTRIBUTION strategies for training and redeployingNOT FOR nurses SALE as workOR DISTRIBUTION sites change. Related social problems that affect nurses include the increase of street violence and bioterrorism. A plethora of problems and “irritations” can arouse the passion of a nurse in advanced practice. © Jones & Bartlett Learning,APRNs LLC must come to understand© Jones the concepts & Bartlett of windows Learning, of opportu LLC- NOT FOR SALE OR DISTRIBUTIONnity, policy entrepreneurs, and politicalNOT elites.FOR SALESound bites OR and DISTRIBUTION word bites are tools used to gain the attention of viewers and readers and serve as a shortcut or an abbreviated version of a statement. Originally created as off-hand remarks, these oral and written snippets have become planned tactics. For example,© Jones a nurse & Bartlett who speaks Learning, at a press conferenceLLC or who delivers a© message Jones & Bartlett Learning, LLC to aNOT politician FOR should SALE have OR a DISTRIBUTIONwritten message that includes bulleted NOTsound FOR or SALE OR DISTRIBUTION word bites that underscore the message and that emphasize the important points. These brief, focused points can serve as talking points for the media or a politician as they consider the message later. Another tactic that APRNs and their healthcare colleagues must develop is the 30-second elevator speech. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Any healthcare professional should have a brief, succinct explanation of the NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION role of the professional, the problem to be addressed, or a proposed solution that can be shared verbally with a policymaker. Petitioners rarely are given much time to discuss issues, so a short, to-the-point statement may be the first, best opportunity to be heard. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONGovernment Response NOT FOR SALE OR DISTRIBUTION The government response to public problems often emanates from the legislative branch and usually comes in three forms: (1) laws, (2) rules and regulations, and (3) programs. Because only senators and representatives can introduce© Jones legislation & Bartlett (not evenLearning, the president LLC can bring a bill to the© floor Jones of & Bartlett Learning, LLC eitherNOT house), FOR these SALE elected OR DISTRIBUTIONofficials command respect and attention.NOT The FOR SALE OR DISTRIBUTION work of legislation is not clear-cut or linear. Informal communication and influence are the coin of the realm when trying to construct a program or law from the often vague wishes of disparate groups. The committee © Jones & structureBartlett ofLearning, both houses LLC is a powerful method of© accomplishing Jones & Bartlett the work Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 29 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

30 ■ Chapter 1 Advanced Practice Nurses and Public Policy, Naturally

of ©government. Jones & ConferenceBartlett Learning, committees LLC are known as the “Third ©House Jones of & Bartlett Learning, LLC Congress”NOT FOR (How SALE Our Laws OR Are DISTRIBUTION Made, 1990) because of their powerNOT to force FOR SALE OR DISTRIBUTION compromise and bring about new legislation. APRNs must appreciate the difference between the authorization and appropriations processes and seek influence in both arenas. Becoming involved directly with legislators © Jones & andBartlett their staffs Learning, has been LLC a training ground for many© APRNs.Jones Supporting& Bartlett or Learning, LLC NOT FOR SALEopposing OR passage DISTRIBUTION of a bill often has served as the firstNOT contact FOR with SALE the polit OR -DISTRIBUTION ical process for many nurses, but this often has been the stopping point for these nurses because they were unaware of other avenues of involvement, such as the follow-up process of regulations and rulemaking. © Jones & Bartlett Learning,Lowi LLC (1969) notes that administrative© Jones rulemaking & Bartlett is oftenLearning, an effort LLC to NOT FOR SALE OR DISTRIBUTIONbring about order in environmentsNOT that FOR are unstable SALE ORand DISTRIBUTIONfull of conflict. Some regulations codify precedent; others break new ground and address issues not previously explicated. An example of the latter is the Federal Trade Commission’s (FTC’s) Trade Regulation Rules. In 1964, the FTC, whose mission© Jones is to protect& Bartlett the consumer Learning, and LLC enforce antitrust legislation,© Jones wrote & Bartlett Learning, LLC regulationsNOT FOR requiring SALE health OR DISTRIBUTION warnings on cigarette packages. TheNOT tobacco FOR SALE OR DISTRIBUTION industry reacted so fiercely that Congress quickly passed a law that nullified the regulations and replaced them with less stringent ones (West, 1982). Decades passed before no-smoking rules actually were mandated in public places. Persistence and timing are integral to policymaking. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Programs are concrete manifestations of solutions to problems. Program NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION design often is a joint effort of legislative intent, budgetary expediency, and political feasibility. There are many opportunities for nurses in advanced practice to become involved in the design phase of a program. Selecting an agency to administer the program, choosing the goals, and selecting the © Jones & Bartlett Learning,tools that LLC will ensure eligibility and© participationJones & Bartlett are all decisions Learning, in which LLC NOT FOR SALE OR DISTRIBUTIONthe APRN should offer input. NOT FOR SALE OR DISTRIBUTION Policy and Program Implementation It is important that APRNs keep reminding their colleagues that the phases of the© Jones policy process& Bartlett are not Learning, linear and LLC that policy activities are fluid© Jones and & Bartlett Learning, LLC moveNOT within FOR and SALE among OR the DISTRIBUTION phases in dynamic processes. The implementaNOT FOR- SALE OR DISTRIBUTION tion phase includes those activities in which legislative mandates are carried out, most often through programmatic means. The implementation stage also includes a planning ingredient. Problems occur in program planning © Jones & ifBartlett technological Learning, expertise LLC is not available. This is particularly© Jones & important Bartlett toLearning, LLC NOT FOR SALEnurses, OR who DISTRIBUTION are experts in the delivery of health careNOT in theFOR broadest SALE sense. OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 30 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

An Overview of the Policy Process ■ 31

©If Jonesgovernment & Bartlett officials Learning,do not know LLC qualified, appropriate experts,© Jones deci- & Bartlett Learning, LLC sionsNOT about FOR program SALE planning OR DISTRIBUTION and design often are determined byNOT legisla FOR- SALE OR DISTRIBUTION tors, bureaucrats, or staff who know little or nothing about the problem or the solutions. As excellent problem solvers, APRNs have many opportunities to offer ideas and solutions. One strategy is to employ second-order © Jones & changeBartlett to Learning,reframe situations LLC and recommend pragmatic© Jones alternatives & Bartlett toLearning, LLC NOT FOR SALEimplementers OR DISTRIBUTION (de Chesnay, 1983; Watzlawick, Weakland,NOT FOR & Fisch,SALE 1974). OR DISTRIBUTION Bowen (1982) uses probability theory to demonstrate how program success could be improved. She suggests putting several clearance points (instances where major decisions are made) together so that they could be negotiated © Jones & Bartlett Learning,as a package LLC deal. She also advocates© beginningJones & theBartlett bargaining Learning, process LLCwith NOT FOR SALE OR DISTRIBUTIONalternatives that have the greatest chanceNOT FOR for success SALE and OR using DISTRIBUTION that success as a foundation for building more successes, a strategy she refers to as a “bandwagon approach” (p. 10). In the past, nurses have done the opposite: focused on failure and the perceived lack of nursing power. APRNs have begun© Jones to note & successes Bartlett in Learning, the political LLC arena and are building a ©new Jones level & Bartlett Learning, LLC of successNOT FOR and esteem.SALE TheOR nurseDISTRIBUTION in advanced practice today uses theNOT strate FOR- SALE OR DISTRIBUTION gies of packaging, success begets success, and persistence in a deliberate way so that nurses can increase their effective impact in the implementation of social programs. Another tactic useful to APRNs is a positive type of group process called appreciative inquiry (Hammond, 2013; Havens, Wood, & © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Lehman, 2006), in which participants focus on what has worked or what they NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION want to happen in a situation rather than getting mired down in examples that have not worked in the past. Appreciative inquiry moves beyond the typ- ical problem-solving model and can lead to positive organizational change. Although nurses most often work toward positive impact, they have © Jones & Bartlett Learning,found thatLLC opposition to an unsound© Jones program & canBartlett have a Learning,paradoxical posiLLC- NOT FOR SALE OR DISTRIBUTIONtive effect. Although not in the publicNOT arena,FOR SALEan example OR DISTRIBUTIONof phenomenal success in the judicious use of opposition occurred when the professional body of nursing rose up as one against the American Medical Association’s 1988 proposal to create a new type of low-level healthcare worker called a registered© Jones care & technician. Bartlett TheLearning, power emerged LLC as more than 40 nurse© organiJones- & Bartlett Learning, LLC zationsNOT stood FOR together SALE inOR opposition DISTRIBUTION to an ill-conceived proposal thatNOT would FOR SALE OR DISTRIBUTION have placed patients in jeopardy and created dead-end jobs. Policy and Program Evaluation © Jones & ForBartlett nurses Learning, who have worked LLC beyond the nursing ©process Jones through & Bartlett the pro Learning,- LLC NOT FOR SALEcess of ORclinical DISTRIBUTION reasoning (Pesut & Herman, 1999),NOT evaluation FOR SALE seems toOR be DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 31 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

32 ■ Chapter 1 Advanced Practice Nurses and Public Policy, Naturally

a logical© Jones component & Bartlett of the Learning, policy process. LLC Evaluation is the systematic© Jones & Bartlett Learning, LLC applicationNOT FOR of methodsSALE OR of socialDISTRIBUTION research to public policies and programs.NOT FOR SALE OR DISTRIBUTION Evaluation is conducted “to benefit the human condition to improve profit, to amass influence and power, or to achieve other goals” (Rossi & Freeman, 1995, p. 6). Evaluation research is a powerful tool for defending viable pro- © Jones & grams,Bartlett for Learning,altering structures LLC and processes to strengthen© Jones programs, & Bartlett and Learning, LLC NOT FOR SALEfor providing OR DISTRIBUTION rationale for program failure. Goggin,NOT Bowman, FOR SALE Lester, OR and DISTRIBUTION O’Toole (1990) propose that researchers investigate program implementation within an analytical framework rather than a descriptive one. They argue that a “third generation” of research established within a sound the- © Jones & Bartlett Learning,ory would LLC strengthen the body of ©knowledge Jones & of Bartlett the policy Learning, process. APRNs LLC NOT FOR SALE OR DISTRIBUTIONcan contribute to both the theory NOTand the FOR method SALE of evaluation. OR DISTRIBUTION Evaluation should be started early and continued throughout a program. An unconscionable example of a program that should have been stopped even before it was begun is the Tuskegee “experiment.” From 1932 to 1972, a group© Jones of African & Bartlett Americans Learning, was used LLC as a control group and denied© Jones anti- & Bartlett Learning, LLC bioticNOT treatment FOR SALE for syphilis, OR DISTRIBUTION even after treatment was known toNOT be suc FOR- SALE OR DISTRIBUTION cessful (Thomas & Quinn, 1991). Beyond evaluation research, this study clearly points out the moral and ethical concerns that are mandated when researchers work with human beings. Should a study or program be started at all? At what point should it be stopped? What is involved in “informed © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC consent”? If a program involves experimental therapy, what are the methods NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION for presenting subjects with relevant data so that participation preferences are clear (Bell, Raiffa, & Tversky, 1988)? These kinds of questions should be considered automatically by today’s researchers, but it is the responsibility of APRNs as consumer agents to ask the questions if they have not been © Jones & Bartlett Learning,asked or LLC if there is any doubt about© theJones answers. & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION An Exciting Future The multiple roles of the APRN—provider of direct care, researcher, consultant,© Joneseducator, & administrator,Bartlett Learning, consumer LLC advocate, and political ©activist— Jones & Bartlett Learning, LLC reflectNOT the FOR changing SALE and OR expanding DISTRIBUTION character of the professionalNOT nurse. FOR SALE OR DISTRIBUTION Today is the future; action today sets the direction for what health care becomes for coming generations. As true professionals with a societal mandate and a comprehensive body of knowledge, nurses function as visionar- © Jones & iesBartlett who are Learning, grounded inLLC education, research, and© experience. Jones & APRNs Bartlett serve Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 32 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

An Exciting Future ■ 33

as ©the Jones link between & Bartlett human Learning, responses toLLC actual and potential health© Jones prob- & Bartlett Learning, LLC lemsNOT and FOR the solutions SALE ORthat DISTRIBUTIONmay be addressed in the government arena.NOT FOR SALE OR DISTRIBUTION Full integration of the policy process becomes evident when professional nurses discern early the social implications of health problems, seize the opportunity to inform public officials with whom the nurses have credible © Jones & relationships,Bartlett Learning, provide LLCobjective data and subjective© Jones personal & storiesBartlett that Learning, LLC NOT FOR SALEhelp translate OR DISTRIBUTION big problems down to a level of understanding,NOT FOR propose SALE alterOR -DISTRIBUTION native solutions that acknowledge reality, and participate in the evaluation process to determine the effectiveness and efficiency of the outcomes.

© Jones & Bartlett Learning,Educating LLC Our Political Selves© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONNurses in advanced practice mustNOT be politicallyFOR SALE active. OR Basic DISTRIBUTION content in undergraduate nursing programs must be reexamined in light of the needs of the profession. Educators must do more than plant the seeds of interest and excitement in baccalaureate students; they must model activism by ©talking Jones about & Bartlett the bills Learning,they are supporting LLC or opposing, by organizing© Jones & Bartlett Learning, LLC studentsNOT FORto assist SALE in election OR DISTRIBUTION campaigns, and by demanding not onlyNOT that FOR SALE OR DISTRIBUTION students write letters to officials, but also that they mail them and provide follow-up. Educators can develop games in which students maneuver through a virtual bureaucracy to move a health problem onto the agenda. Brainstorming © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC techniques can lead students to discover innovative alternative solutions. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Baccalaureate students can analyze policy tools to discover how and when to use them. Teachers of research methods and processes can use political scenarios to point out how to phrase clinical questions so that legislators will pay attention. Program effectiveness can be studied in research and © Jones & Bartlett Learning,clinical LLCcourses. The theoretical components© Jones & taught Bartlett in class Learning, and followed LLC NOT FOR SALE OR DISTRIBUTIONby practical application through NOTparticipation FOR SALE in political OR DISTRIBUTION and legislative committees in professional organizations must serve as basic training for the registered nurse. Graduate education must demand demonstrated knowledge and application© Jones of more & extensive Bartlett and Learning, sophisticated LLC political processes. All ©graduate Jones & Bartlett Learning, LLC programNOT FORfaculty SALE should OR serve DISTRIBUTION as models for political activism. TheNOT atmo FOR- SALE OR DISTRIBUTION sphere in master’s and doctoral programs should heighten the awareness of students who are potential leaders. Faculty can motivate students by displaying posters that announce polit- © Jones & icalBartlett events Learning,and by including LLC students in discussions© of Jones nursing & issues Bartlett framed Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 33 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

34 ■ Chapter 1 Advanced Practice Nurses and Public Policy, Naturally

in a© policy Jones context. & Bartlett Students Learning, who spot educators LLC at rallies and other© political Jones & Bartlett Learning, LLC andNOT policy FOR occasions SALE are OR learning DISTRIBUTION by example, so faculty should NOTadvertise FOR SALE OR DISTRIBUTION their experiences as delegates to political and professional conventions. A few faculty can serve as mentors for students who need to move from informal to sustained, formal contact with policymakers and who have a © Jones & policyBartlett track Learning, in their career LLC trajectories. Both faculty© Jones and students & Bartlett should Learning, LLC NOT FOR SALEconsider OR actual DISTRIBUTION experience in government offices asNOT a means FOR of SALElearning OR the DISTRIBUTION nitty-gritty of how government functions and of demonstrating their own leadership capabilities. If students hesitate and seem passive about involvement, educators must © Jones & Bartlett Learning,help these LLC nurses determine where© their Jones passions & Bartlett are, which Learning, may help LLC stu- NOT FOR SALE OR DISTRIBUTIONdents focus on where they might start.NOT OftenFOR theSALE novice OR can DISTRIBUTION be enticed by centering on a clinical problem. Every nurse cannot assume responsibility for all of the profession’s problems or work on every healthcare issue. Issues can be at the practice level or the systems level (e.g., funding for nurse education© Jones or nurse-led & Bartlett research). Learning, Each nurse LLC must choose the issue in ©which Jones to & Bartlett Learning, LLC investNOT energy, FOR time, SALE and OR other DISTRIBUTION resources. Nurses can make a differenceNOT in theFOR SALE OR DISTRIBUTION new healthcare system. Strengthening Organized Nursing The most productive and efficient way to act together is through a strong © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC professional organization. As organizations in general have restructured NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION and reengineered for more efficient operation, so will the professional asso- ciations. APRNs have a knowledge base that includes an understanding of how organizations develop and change. This theoretical knowledge must serve as a foundation for leadership in directing new organizational struc- © Jones & Bartlett Learning,tures that LLC are responsive to members© Jonesand other & importantBartlett Learning, bodies. National LLC NOT FOR SALE OR DISTRIBUTIONleaders must talk with state and NOTlocal leadersFOR SALE as new OR configurations DISTRIBUTION are conceived. States must confer among themselves to share innovations and knowledge about what works and what does not. Issues such as the role of collective bargaining units within the total organizational© Jones & structure, Bartlett theLearning, position LLCof individual membership© vis-à-vis Jones & Bartlett Learning, LLC stateNOT membership, FOR SALE the politicalOR DISTRIBUTION role of a specialized interest groupNOT (nurses) FOR SALE OR DISTRIBUTION in creating public policy, and the issue of international influence in nursing and health care require wisdom and leadership that APRNs must exert as the American Nurses Association addresses its place as a major voice of © Jones & thisBartlett country’s Learning, nurses. TheLLC National League for Nursing© Jones (NLN) & Bartlett will exert Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 34 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

An Exciting Future ■ 35

leadership© Jones as many& Bartlett nurse educationLearning, programs LLC encourage graduates© toJones con- & Bartlett Learning, LLC tinueNOT their FOR education SALE andOR earnDISTRIBUTION bachelor’s degrees in nursing. AccreditingNOT FOR SALE OR DISTRIBUTION agencies (e.g., the Commission on Collegiate Nursing Education and the Accreditation Commission for Education in Nursing) must continue to be visionary and flexible in developing criteria and processes for accreditation. © Jones & BoardsBartlett of Learning,nursing must LLC not become trapped in the© Jones slowness & withBartlett which Learning, LLC NOT FOR SALEgovernment OR DISTRIBUTION bureaucracy can be mired, but must beNOT bold andFOR at theSALE forefront OR DISTRIBUTION of developing regulations that protect the public and allow nurses to work at their full capacity. Issues inherent in multistate licensure are being debated today, and the © Jones & Bartlett Learning,outcome LLC will reflect the extent to© which Jones nurses & Bartlett will use Learning,concepts of LLCtele- NOT FOR SALE OR DISTRIBUTIONhealth in their practices. Because NOTAPRNs FOR already SALE are eligibleOR DISTRIBUTION for Medicare reimbursement for telehealth services that are provided in specified rural areas (Burtt, 1997), these nurses are rich resources and must be included in reasoned discussions on this issue. State boards of nursing in every state and© jurisdiction Jones & faceBartlett issues Learning, of appropriate LLC methods of recognizing advanced© Jones & Bartlett Learning, LLC nursingNOT practice,FOR SALE the role OR of DISTRIBUTION the government agency in regulatingNOT nursing FOR SALE OR DISTRIBUTION and other professions, and the analysis of educationally sound and legally defensible examinations for candidates. Nurses who have been reluctant to become political cannot afford to ignore their obligations any longer. Each nurse counts, and collectively © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC nursing is a major actor in the effort to ensure the country’s healthy future. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Nurses have expanded their conception of what nursing is and how it is practiced to include active political participation. A nurse must choose the governmental level on which to focus: federal, regional, state, or local. The process is similar at each level: Identify the problem and become part © Jones & Bartlett Learning,of the solution. LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONAdvanced practice registered nursesNOT FOR understand SALE theOR scopeDISTRIBUTION of service delivery, continuity of care, appropriate mix of caregivers, and expertise that can be provided by interprofessional teams. By being at the forefront of understanding, nurses have a moral and ethical mandate to lead the public policy© Jones process. & Dynamic Bartlett political Learning, action LLC is as much a part of the advanced© Jones & Bartlett Learning, LLC practiceNOT ofFOR nursing SALE as is OR expert DISTRIBUTION direct care. NOT FOR SALE OR DISTRIBUTION Working with the Political System By now, many APRNs have developed contacts with legislators, appointed © Jones & officials,Bartlett and Learning, their staffs. LLC A group that offers nurse© interaction Jones & is Bartlett the Senate Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 35 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

36 ■ Chapter 1 Advanced Practice Nurses and Public Policy, Naturally

Nursing© Jones Caucus & Bartlett (AACN, 2010). Learning, Established LLC in March 2010, this group© Jones pro- & Bartlett Learning, LLC videsNOT a forum FOR for SALE educating OR DISTRIBUTION senators on issues important to nurses,NOT as well FOR SALE OR DISTRIBUTION as for hearing senators’ concerns. Four senators established the caucus: Jeff Merkley (D-OR), Mike Johanns (R-NE), Barbara Mikulski (D-MD), and Olympia Snowe (R-ME). The Senate Nursing Caucus follows the lead of the © Jones & CongressionalBartlett Learning, Nursing LLC Caucus in the U.S. House of© Representatives,Jones & Bartlett begun Learning, LLC NOT FOR SALEin 2003 OR by DISTRIBUTIONRepresentatives Lois Capps (D-CA) andNOT Ed FOR Whitfield SALE (R-KY) OR DISTRIBUTION (American Nurses Association, 2003). Members hold briefings on the nurse shortage, patient and nurse safety issues, preparedness for bioterrorism, and other relevant and pertinent issues and concerns. © Jones & Bartlett Learning,APRNs LLC must stay alert to issues© and Jones be assertive & Bartlett in bringing Learning, problems LLC to NOT FOR SALE OR DISTRIBUTIONthe attention of policymakers. It isNOT important FOR to SALE bring successOR DISTRIBUTION stories to legislators and officials—they need to hear what good nurses do and how well they practice. Sharing positive information will keep the image of nurses in an affirmative and constructive picture. Legislators must run for office (and U.S.© Representatives Jones & Bartlett do this Learning, every 2 years), LLC so media coverage with ©an JonesAPRN & Bartlett Learning, LLC whoNOT is pursuing FOR SALE noteworthy OR DISTRIBUTION accomplishments is usually welcomedNOT eagerly. FOR SALE OR DISTRIBUTION Nurses absolutely must get their act together and work toward a unified voice on issues that affect the public health and the nursing profession. Whatever their differences in the past—anger from entry-into-practice arguments that have dragged on for over half a century; disparagement and ani- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC mosity among those with varied levels of education; cerebral and pragmatic NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION concerns about gaps between education and practice, practice and administration, or administration and education—nurses must put these kinds of divisive, emotional issues behind them if they expect to be taken seriously as professionals by elected and appointed public officials and policymakers. © Jones & Bartlett Learning,The 2010 LLC IOM report is a wake-up© call Jones for nurses & Bartlett to work Learning, at their highest LLC NOT FOR SALE OR DISTRIBUTIONlevels and to work with other healthNOT professionals. FOR SALE OR DISTRIBUTION Nurses cannot afford to stop arguing critical issues internally, but they must learn how to argue heatedly among themselves—and then go to lunch together. Nurses can learn lessons from television shows such as Meet the Press,© JonesThis Week, & TheBartlett O’Reilly Learning, Factor, and LLCThe McLaughlin Group about© howJones to & Bartlett Learning, LLC challenge,NOT FOR contest, SALE dispute, OR DISTRIBUTION contend, and debate issues passionately,NOT and FOR SALE OR DISTRIBUTION then shake hands and respect the opponent’s position. Passionate issues must not polarize the profession any longer and, more important, must not stand in the way of a unified voice to the public. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 36 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Discussion Points ■ 37

Conclusion© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Nurses in advanced practice must have expert knowledge and skill in change, conflict resolution, assertiveness, communication, negotiation, and group process to function appropriately in the policy arena. Professional © Jones & autonomyBartlett Learning,and collaborative LLC interdependence are© possible Jones within & Bartlett a polit Learning,- LLC NOT FOR SALEical system OR DISTRIBUTIONin which consumers can choose accessNOT to qualityFOR SALE health ORcare DISTRIBUTION that is provided by competent practitioners at a reasonable cost. Nurses in advanced practice have a strong, persistent voice in designing such a healthcare system for today and for the future. © Jones & Bartlett Learning,The LLCpolicy process is much broader© Jones and more& Bartlett comprehensive Learning, than LLC the NOT FOR SALE OR DISTRIBUTIONlegislative process. Although individualNOT FORcomponents SALE canOR be DISTRIBUTION identified for analytical study, the policy process is fluid, nonlinear, and dynamic. There are many opportunities for nurses in advanced practice to participate throughout the policy process. The question is not whether nurses should become involved in the political system, but to what extent. In the whole © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC policy arena, nurses must be involved with every aspect. Knowing all of the NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION components and issues that must be addressed in each phase, the nurse in advanced practice finds many opportunities for providing expert advice. APRNs can use the policy process, individual components, and models as a framework to analyze issues and participate in alternative solutions. © Jones & BartlettNursing Learning, has a rich history.LLC The professional nurse’s© Jones values & ofBartlett altruism, Learning, LLC NOT FOR SALErespect, OR ethics, DISTRIBUTION integrity, and accountability to consumersNOT FOR remain SALE strong. OR DISTRIBUTION In some ways, the evolution of nurse roles has come full circle, from the political influence recognized and exercised by Nightingale to the influence of current nurse leaders with elected and appointed public officials. © Jones & Bartlett Learning,The APRN LLC of the 21st century practices© Jones with & a solidBartlett political Learning, heritage LLC and NOT FOR SALE OR DISTRIBUTIONa mandate for consistent and powerfulNOT FOR involvement SALE ORin the DISTRIBUTION entire policy process.

Discussion© Jones Points& Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT1. Read FOR Nightingale’s SALE OR NotesDISTRIBUTION on Nursing (1859) and other historicalNOT FOR SALE OR DISTRIBUTION sources from the mid-1800s and discuss how Nightingale’s personal and family influence moved her agenda for the Crimea and for nursing education. How does this have implications for the future? © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 37 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

38 ■ Chapter 1 Advanced Practice Nurses and Public Policy, Naturally

©2. JonesDiscuss & implications Bartlett Learning, of the “BSN LLC in 10” movement in relation© toJones your & Bartlett Learning, LLC NOTown FOR education. SALE ORResearch DISTRIBUTION opportunities for BSNs and forNOT APRNs. FOR SALE OR DISTRIBUTION Dream about positions that might not be available today. 3. Compare the definitions of nursing according to Nightingale, Hen- derson, the ANA, and your own state nurse practice act. What are the © Jones & Bartlettdifferences Learning, in a legal LLC definition versus a professional© Jones definition? & Bartlett What Learning, LLC NOT FOR SALEare OR the DISTRIBUTION similarities? What did definitions includeNOT orFOR not SALEinclude ORthat DISTRIBUTION reflected the state of nursing at the time? Construct a definition of nursing for today and for 10 years from now. 4. Discuss the role of research in nursing. What has been the focus over © Jones & Bartlett Learning,the LLC past century? What is the© Jones pattern & of Bartlett nursing Learning,research vis-à-vis LLC NOT FOR SALE OR DISTRIBUTIONtopic, methodology, and relevance?NOT FOR To SALE what extentOR DISTRIBUTION do you think nursing research has had an impact on nursing care? Cite examples. 5. Trace the amount of federal funding for nursing research. Do not limit your search to federal health-related agencies; that is, investigate © Jonesdepartments & Bartlett (commerce, Learning, environment, LLC transportation, etc.),© military Jones & Bartlett Learning, LLC NOTservices, FOR SALEand the OR Veterans DISTRIBUTION Administration. What funding opportuniNOT FOR- SALE OR DISTRIBUTION ties exist for nurse scientists? 6. Read books and articles about the changing paradigm in healthcare delivery systems. Discuss the change in nursing as an occupation and nursing as a profession. What does this mean in today’s transforma- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC tional paradigm? NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 7. Consider a thesis, graduate project, or dissertation on a specific topic (e.g., clinical problems, healthcare issues) using the policy process as a framework. Identify policies within public agencies and discuss how they were developed. Interview members of an agency policy com- © Jones & Bartlett Learning,mittee LLC to discover how policies© Jones are changed. & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION 8. Have faculty and students bringNOT to FORclass official SALE governmental OR DISTRIBUTION policies. What governmental agency is responsible for developing the policy? For enforcing the policy? How has the policy changed over time? What are the consequences of not complying with the policy? What © Jonesis needed & Bartlettto change Learning,the policy? LLC © Jones & Bartlett Learning, LLC NOT9. Identify FOR nurses SALE who OR are DISTRIBUTION elected officials at the local, state, orNOT national FOR SALE OR DISTRIBUTION level. Interview these officials to determine how the nurses were elected, what their objectives are, and to what extent they use their nurse knowledge in their official capacities. Ask the officials if they © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 38 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Discussion Points ■ 39

© Jonestapped & into Bartlett nurse groups Learning, during LLC their campaigns. If so, what© didJones the & Bartlett Learning, LLC NOTnurses FOR contribute? SALE OR If not,DISTRIBUTION why? NOT FOR SALE OR DISTRIBUTION 10. Discuss the major components of the policy process and discuss the fluidity of the process. Point out how players move among the components in a nonlinear way. © Jones & Bartlett11. Using Learning, Exhibit 1-1 LLC as a framework, construct a© healthcare Jones & organization Bartlett Learning, LLC NOT FOR SALEin OR which DISTRIBUTION access is provided and quality careNOT is assured. FOR WhatSALE are OR the DISTRIBUTION barriers to this type of paradigm? 12. Develop an assessment tool by which students can determine their own level of knowledge and involvement in the policy process. Reminder: © Jones & Bartlett Learning,Stretch LLC your thinking beyond© legislative Jones & activity. Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION 13. Watch television programsNOT in which FOR participants SALE OR discuss DISTRIBUTION national and international issues, then analyze the patterns of verbal and non- verbal communication, pro-and-con arguments, and other methods of discussion. Discuss your analysis within the framework of gender © Jonesdifferences & Bartlett in communication Learning, and LLC utility in the political arena.© Jones & Bartlett Learning, LLC 14.NOT Construct FOR SALE a list of OR ways DISTRIBUTION in which nurses can become more knowledgeNOT FOR- SALE OR DISTRIBUTION able about the policy process. Choose at least three activities in which you will participate. Develop a tool for evaluating the activity and your knowledge and involvement. 15. Select at least one problem or irritation in a clinical area and brain- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC storm with other APRNs or graduate students on how to approach a NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION solution. Discuss funding sources; be creative. 16. Attend a meeting of the state board of nursing, the district or state nurses association, or a professional convention. Identify issues discussed, resources used, communication techniques, and rules © Jones & Bartlett Learning,observed. LLC Evaluate the usefulness© Jones of the & session Bartlett to yourLearning, practice. LLC NOT FOR SALE OR DISTRIBUTION 17. Discuss what skills (task, interpersonal,NOT FOR etc.) SALE and attitudesOR DISTRIBUTION are required for the nurse in the new paradigm. Who is best prepared to teach these skills, and what teaching techniques should be used? How will they be evaluated? Develop a worksheet to facilitate planning. 18.© JonesDiscuss & at Bartlett least five Learning,strategies for LLC helping nurses integrate these© Jones skills & Bartlett Learning, LLC NOTinto FOR their SALE practices. OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 19. Convene a group of healthcare professionals and discuss common problems, potential solutions, and strategies to move forward.

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 39 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

40 ■ Chapter 1 Advanced Practice Nurses and Public Policy, Naturally

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALECase OR DISTRIBUTIONStudy: Pill Mills NOT FOR SALE OR DISTRIBUTION APRNs have prescriptive authority including the ability to prescribe narcotics. In the past 10 years there have been only one or two instances in which APRNs have been sanctioned by the board of © Jones & Bartlettnursing Learning,for abusing prescriptiveLLC authority. Many© legislators Jones & do Bartlett not Learning, LLC NOT FOR SALErealize OR that DISTRIBUTION APRNs have this authority. There hasNOT been FOR a recent SALE surge OR DISTRIBUTION in “pill mills” (sites where prescriptions for large amounts of narcotics are provided without actual patient assessment). No nurses have been involved in writing these prescriptions. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONDiscussion Points NOT FOR SALE OR DISTRIBUTION 1. What can a nurse do to be invited to the table when a task force is convened by the governor or state health director? © Jones2. What & otherBartlett healthcare Learning, professionals LLC should be included© in Jonesthe & Bartlett Learning, LLC NOT FORdiscussion? SALE What OR DISTRIBUTIONstate agencies and regulatory boards NOTcould FOR SALE OR DISTRIBUTION add value to the discussion? 3. Identify three issues that might derail a focus on the safety of the public during these discussions. What tactics can the nurse use © Jones & Bartlettto Learning, bring a discussion LLC back to the issue of© safety? Jones & Bartlett Learning, LLC NOT FOR SALE4. OR How DISTRIBUTION can information about this issue beNOT disseminated FOR SALE within OR DISTRIBUTION the profession and to those outside the profession?

Aiken, L. H., Cimiotti, J. R., Sloane, D. M., Smith, H. L., Flynn, L., & Neff, D. F. (2011). Effects ©of Jones nurse staffing & Bartlett on patient Learning,deaths in hospitals LLC with differing nurse work environments.© Jones & Bartlett Learning, LLC NOTMedical FOR Care, 49 SALE(12), 1047–1053. OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Aiken, L. H., Clarke, S. R., Cheung, R. B., Sloane, D. M., & Silber, J. H. (2003). Educational levels of hospital nurses and surgical patient mortality. Journal of the American Medical Association, 290(12), 1617–1623. Aiken, L. H., Sloane, D. M., Bruyneel, L., Van den Heede, K., Griffiths, P., Busse, R., et al. © Jones & Bartlett(2014). Learning,Nurse staffing andLLC education and hospital mortality© Jones of European & Bartlett countries: Learning, A LLC NOT FOR SALEretrospective OR DISTRIBUTION observational study. The Lancet, 383(9931), NOT1824–1830. FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 40 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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American© Jones Academy & Bartlett of Nursing. Learning, (2010). Raise theLLC voice. Retrieved from http://www.aannet© Jones & Bartlett Learning, LLC NOT.org/raisethevoice FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION American Association of Colleges of Nursing. (2006). Essentials of doctoral education for advanced nursing practice. Washington, DC: Author. American Association of Colleges of Nursing. (2008a). Essentials of baccalaureate education for professional nursing practice. Washington, DC: Author. © Jones & AmericanBartlett Association Learning, of Colleges LLC of Nursing. (2008b). Essentials© Jones of master’s & Bartlett education for Learning, LLC NOT FOR SALEadvanced OR practiceDISTRIBUTION nursing. Washington, DC: Author. NOT FOR SALE OR DISTRIBUTION American Association of Colleges of Nursing. (2008c). Brief history of the CNL. Retrieved from http://www.aacn.nche.edu/cnl/about/history American Association of Colleges of Nursing. (2010). Senate nursing caucus. Retrieved from http://www.aacn.nche.edu/government-affairs/senate-nursing-caucus © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC American Association of Colleges of Nursing. (2014a). CNL certification. Retrieved from NOT FOR SALE OR DISTRIBUTIONhttp://www.aacn.nche.edu.leading initiatives/cnl-certification/pdfNOT FOR SALE OR DISTRIBUTION American Association of Colleges of Nursing. (2014b). DNP fact sheet: The doctor of nursing practice. Retrieved from http://www.aacn.nche.edu/media/FactSheets/dnp.htm American Nurses Association. (2003, March 19). American Nurses Association commends ©Reps. Jones Capps, &Whitfield Bartlett for forming Learning, congressional LLC nursing caucus. Retrieved from http://www© Jones & Bartlett Learning, LLC .nursingworld.org/-pressrel/2003/pr0319.htm NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Bell, D. E., Raiffa, H., & Tversky, A. (1988). Decision making. Cambridge, MA: Cambridge University Press. Bennis, W., & Nanus, B. (1985). Leaders. New York: Harper and Row. Bowen, E. (1982). The Pressman-Wildavsky paradox: Four addenda on why models based on © Jones & Bartlettprobability Learning, theory can predict LLC implementation success and© suggest Jones useful & Bartletttactical advice Learning, LLC NOT FOR SALEfor implementers.OR DISTRIBUTION Journal of Public Policy, 2(1), 1–22. NOT FOR SALE OR DISTRIBUTION Buerhaus, P. I., Staiger, D. O., & Auerbach, D. I. (2008). The future of the nursing workforce in the United States: Data, trends, and implications. Sudbury, MA: Jones & Bartlett Publishers Buerhaus, P. I. (2009). Messages for thought leaders and health policy makers. Nursing Economics, 2(2), 125–127. © Jones & Bartlett Learning,Burtt, K. LLC(1997). Nurses use telehealth to address© Jones rural health & Bartlett care needs, Learning, prevent hospitaliza LLC- NOT FOR SALE OR DISTRIBUTIONtions. The American Nurse, 29(6), 21. NOT FOR SALE OR DISTRIBUTION Cronenwett, L., Dracup, K., Grey, M., McCauley, L., Meleis, A., & Salmon, M. (2011). The doctor of nursing practice: A national workforce perspective. Nursing Outlook, 59(1), 9–17. Curtin, L. (2010). Quantum nursing. American Nurse Today, 5(9), 47–48. Curtin, L. (2011). Quantum nursing II: Our field of influence. American Nurse Today, 6(1), 56. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC de Chesnay, M. (1983). The creation and dissolution of paradoxes in nursing practice. Topics NOTin Clinical FOR Nursing SALE, 5(3), 71–80.OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Drucker, P. F. (1995, December). The age of social transformation. The Atlantic. Retrieved from http://www.theatlantic.com/past/docs/issues/95dec/chilearn/drucker.htm Eulau, H., & Prewitt, K. (1973). Labyrinths of democracy. Indianapolis, IN: Bobbs-Merrill. © Jones & Feldstein,Bartlett P. Learning,J. (1988). The politics LLC of health legislation. Ann Arbor,© JonesMI: Health & Administration Bartlett Learning, LLC NOT FOR SALEPress. OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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42 ■ Chapter 1 Advanced Practice Nurses and Public Policy, Naturally

Fraser,© Jones R. (2011). & TheBartlett nurse’s social Learning, media advantage LLC. Indianapolis, IN: Sigma ©Theta Jones Tau & Bartlett Learning, LLC NOTInternational. FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FTC policy paper examines competition and the regulation of APRNs. (2014). The American Nurse, 46(3), 11. Goggin, M. L., Bowman, A. O., Lester, J. P., & O’Toole, L. J., Jr. (1990). Implementation theory and practice: Toward a third generation. New York: HarperCollins. © Jones & Haas,Bartlett J. E. (1964). Learning, Role conception LLC and group consensus (Research Monograph© Jones No. & 17). Bartlett Columbus, Learning, LLC NOT FOR SALEOH: OR The OhioDISTRIBUTION State University, Bureau of Business Research.NOT FOR SALE OR DISTRIBUTION Hammond, S. A. (2013). The thin book of appreciative inquiry. Bend, OR: Thin Book. Hash, K. M., & Cramer, E. P. (2003). Empowering gay and lesbian caregivers and uncovering their unique experiences through the use of qualitative methods. Journal of Gay and Lesbian Social Services, 15(1/2), 47–64. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Havens, D. S., Wood, S. O., & Lehman, J. (2006). Improving nursing practice and patient care. NOT FOR SALE OR DISTRIBUTIONJournal of Nursing Administration, 36(16),NOT 463–470. FOR SALE OR DISTRIBUTION How our laws are made. (1990). (House Document 101–139). Washington, DC: U.S. Government Printing Office. Husted, G. L., Scotto, C., & Wolf, K. (2015). Bioethical decision making in nursing and health care: ©A Jonessymphonological & Bartlett approach (5th Learning, ed.). New York: LLC Springer. © Jones & Bartlett Learning, LLC InstituteNOT of FOR Medicine. SALE (2010). OR The futureDISTRIBUTION of nursing: Leading change, advancing health. Washington,NOT FOR SALE OR DISTRIBUTION DC: National Academies Press. Interprofessional Education Collaborative. (n.d.). About IPEC. Retrieved from http://www .ipecollaborative.org/About_IPEC.html Josiah Macy Jr. Foundation. (2014). Publications. Retrieved from http://www.macyfoundation © Jones & Bartlett.org/publications/publications/aligning-interprofessional-education Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEKouzes, J.,OR & Posner, DISTRIBUTION B. (1999). Encouraging the heart: A leader’s guideNOT to rewardingFOR SALE and recognizing OR DISTRIBUTION others. San Francisco, CA: Jossey-Bass. Kouzes, J., & Posner, B. (2007). The leadership challenge (4th ed.). San Francisco, CA: Jossey-Bass. Lasswell, H. D. (1958). Politics: Who gets what, when, how. New York: Meridian. Lindberg, C., Nash, S., & Lindberg, C. (2008). On the edge: Nursing in the age of complexity. © Jones & Bartlett Learning,Medford, LLC NJ: Plexus Press. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONLineweaver, L. (2013). Nurse staffing 101: ANOT decision-making FOR SALE guide for theOR RN DISTRIBUTION. Washington, DC: American Nurses Publishing. Litman, T. J., & Robins, L. S. (1991). Health politics and policy (2nd ed.). Albany, NY: Delmar. Lowi, T. (1969). The end of liberalism. New York: Norton. Milio,© N.Jones (1989). Developing& Bartlett nursing Learning, leadership inLLC health policy. Journal of Professional© JonesNursing, & Bartlett Learning, LLC NOT5(6), 315. FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Nightingale, F. (1859). Notes on nursing. Cambridge, England: Cambridge University Press. Patient Protection and Affordable Care Act of 2010. (2010). Pub. L. No. 111-148, 124 Stat. 119. Pesut, D., & Herman, J. (1999). Clinical reasoning: The art and science of critical and creative thinking © Jones & Bartlett(2nd ed.). Learning, Albany, NY: DelmarLLC Learning. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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Pierce,© Jones L., & Steiner, & Bartlett V. (2003). TheLearning, male caregiving LLC experience: Three case studies.© Jones Stroke, & Bartlett Learning, LLC NOT34(1), FOR315. SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Plexus Institute. (2009, July). Making sense of complexity. Singapore: Civil Service College. Retrieved from http://c.ymcdn.com/sites/www.plexusinstitute.org/resource /collection/17978F03-1F91-4D5E-971C-651E9F9DC5FC/Cognitive_Edge_-_Making_ Sense_of_Complexity_-_2009.pdf © Jones & Porter-O’Grady,Bartlett Learning, T., Hawkins, LLC M. A., & Parker, M. L. (1997). ©Whole-systems Jones shared& Bartlett governance: Learning, LLC NOT FOR SALEArchitecture OR DISTRIBUTION for integration. Gaithersburg, MD: Aspen. NOT FOR SALE OR DISTRIBUTION Porter-O’Grady, T., & Malloch, K. (2014). Quantum leadership: Building better partnerships for sustainable health. Burlington, MA: Jones and Bartlett Learning. The regulatory process. (1992). Capitol Update, 10(23), 1. Rhoades, A., Covery, S. R., & Shepherdson, N. (2011). Building values: Creating an equitable © Jones & Bartlett Learning,culture LLC that outperforms the competition. San© Jones Francisco, & CA: Bartlett Jossey-Bass. Learning, LLC NOT FOR SALE OR DISTRIBUTIONRossi, P. H., & Freeman, H. E. (1995). Evaluation:NOT AFOR systematic SALE approach OR (5th DISTRIBUTION ed.). Beverly Hills, CA: Sage. Thomas, S. B., & Quinn, S. C. (1991). The Tuskegee syphilis study, 1932 to 1972: Implications for HIV education and AIDS risk reduction education programs in the black community. American Journal of Public Health, 8(11), 1498–1505. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC U.S. Department of Health and Human Services. (n.d.) About HHS. Retrieved from http://www NOT.HHS.gov/about FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION U.S. Department of Health and Human Services, Health Resources and Services Administration. (2010). The registered nurse population: Findings from the 2008 national survey sample of registered nurses. Retrieved from http://bhpr.hrsa.gov/healthworkforce/rnsur- veys/rnsurveyfinal.pdf © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Van den Heede, K., Lesaffre, E., Diya, L., Vieugels, A., Clarke, S. P., Aiken, L. H., et al. (2009). NOT FOR SALEThe OR relationship DISTRIBUTION between inpatient cardiac surgery mortalityNOT and FOR nurse SALE numbers OR and DISTRIBUTION educational level: Analysis of administrative data. International Journal of Nursing Studies, 46, 796–803. Watzlawick, R., Weakland, C. E., & Fisch, R. (1974). Change. New York: W. W. Norton. West, W. F. (1982, September/October). The politics of administrative rulemaking. Public © Jones & Bartlett Learning,Administration LLC Review, 420–426. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONWilliams, S. J., & Torrens, P. R. (Eds.). (1988).NOT Introduction FOR SALE to health ORservices DISTRIBUTION (3rd ed.). Albany, NY: Delmar. Wilson, J. Q. (1989). American government institutions and policies (4th ed.). Lexington, MA: D. C. Heath. Wiltse-Nicely,© Jones K. L.,& Sloane,Bartlett D. M., Learning, & Aiken, L. H. LLC(2013, June). Lower mortality for ©abdominal Jones & Bartlett Learning, LLC aorta aneurysm repair in high volume hospitals contingent on nurse staffing. Health NOTSystems FOR Research SALE, 48(3), 972–991.OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION You, L.-M., Aiken, L. H., Sloane, D. M., Liu, K., He, G.-P., Hu, Y., et al. (2013). Higher per- centage of baccalaureate nurses were strongly associated with relationships to better patient outcomes. International Journal of Nursing Studies, 59(2), 154–161. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284068245_CH01_PASS02.indd 43 30/08/14 4:26 pm © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION