CHAPTER 7

The policy process

Eileen T. O’Grady

“There are three critical ingredients to democratic renewal and progressive change in America: good public policy, grassroots organizing and electoral politics.”

Paul Wellstone

Nurses can more strategically and effectively influence policy if they have a clear understanding of the policymaking process. Conceptual models can help to organize and interpret information by depicting complex ideas in a simplified form; to this end, political scientists have developed a number of conceptual models to explain the highly dynamic process of policymaking. This chapter reviews two of these conceptual models.

Health policy and politics

Health policy encompasses the political, economic, social, cultural, and social determinants of individuals and populations and attempts to address the broader issues in health and health care (see Box 7.1 for policy definitions). A clear understanding of the points of influence to shape policy is essential and includes framing the problem itself. For example, if nurses working in a nurse-managed clinic are troubled by staff shortages or long patient waits, they may be inclined to see themselves as the solution by working longer hours and seeing more patients. Defining and framing the problem is the first step in the policy process and involves assessing its history, patterns of impact, resource allocation, and community needs. Broadening and framing the problem to influence or educate stakeholders at the local, state, or federal level could include advocating for better access or funding for nursing workforce development (see Box 7.1).

BOX 7.1

Policy Definitions

Policy is authoritative decision making related to choices about goals and priorities of the policymaking body. In general, policies are constructed as a set of regulations (public policy), practice standards (workplace), governance mandates (organizations), ethical behavior (research), and ordinances (communities) that direct individuals, groups, organizations, and systems toward the desired behaviors and goals.

Health policy is the authoritative decisions made in the legislative, judicial, and executive branches of government that are intended to direct or influence the actions, behaviors, and decisions of others (Longest, 2016).

Policy analysis is the investigation of an issue including the background, purpose, content, and effects of various options within a policy context and their relevant social, economic, and political factors (Dye, 2016).

The next step is to bring the problem to the attention of those who have the power to implement a solution. Other key factors to consider include generating public interest, the availability of viable policy solutions, the likelihood that the policy will serve most of the people at risk in a fair and equitable fashion, and consideration of the organizational, community, societal, and political viability of the policy solution.

Public interest is a fascinating dynamic that is particularly important to influencing policy agendas at the community and broader policy levels. Public awareness is often necessary for political action to take place and for the policy process to be initiated. For example, trends associated with health behaviors (e.g., the increased rates of childhood obesity, drunk driving, smoking, or gun violence), whether gradual or resulting from a crisis situation, can all shift public perception and open a policy debate. Research consistently shows that a wide range of social and economic factors affect health, although this broader causality is beginning to be understood by the public. For example, a poll of rural Americans found that 57% think opioid addiction is a serious and urgent problem in their community, with 49% personally knowing someone who has struggled with opioid addiction. Twenty-five percent said it was the most urgent health problem facing their communities, followed by cancer (12%) and access to care (11%); 64% said solutions were better long-term jobs, improving the quality of local schools, and access to health care (Harvard T.H. Chan School of Public Health, 2018).

As public knowledge increases, trends become increasingly objectionable to some members of society, which propels them to seek solutions. For example, the rate of deaths caused by drunk driving resulted in strict nationwide drunk driving laws, and research on the impact of second-hand smoking led to the near-universal ban on smoking in shared open spaces.

When people have a strong sense that the status quo is unacceptable, they begin to organize in a predicable fashion, leading to actions such as forming coalitions or establishing a nonprofit organization. To move policy agendas forward, organizations must mature and build the resources needed to be effective in the policy realm.

Interest groups, such as trade associations and political action committees, can stimulate a shift from awareness of a policy issue to action, wherein people work collectively to find solutions. Professional nursing organizations serve as an interest group for nurses, not only to explore issues about the advancement of nursing but also to focus on societal issues such as reforming health care, informing the public of emerging diseases and health threats, and addressing health disparities.

Identifying and framing a problem is the first step, but it is also necessary to identify potential solutions. For example, concerns were raised in Washington State about the ability of insured workers to access health care in rural areas. This resulted in a delay in workers returning to work, as well as insufficient reporting of injuries. Because nurse practitioners (NPs) had been restricted in performing some of the functions related to certifying worker disability compensation, worker access to these providers was underused. As a result, the Washington State legislature enacted a pilot program to allow NPs to expand their scope of practice to include serving as attending providers for injured workers. Despite some stakeholder concerns, subsequent analysis of the pilot program established that it was both effective and an efficient use of resources (Sears & Hogg-Johnson, 2009). A policy that will solve the problem is dependent on a thorough analysis of the problem itself and the viable, evidence-based policy options.

Fairness and equity are primary values that inspire nurses and others to participate in the policy process. Fawcett and Russell (2001) consider the equity of a policy as the extent to which it allows the benefits and burdens of nursing practice to be equally distributed to all—in particular, equal access to health services. For many nurses, advocating for fairness and equity is an application of patient advocacy, especially when human rights and health disparities are at stake. As noted in Chapter 1, social determinants of health illustrate that, in addition to individual choices, there are important environmental factors beyond the control of the individual that require collective action if health and health care are to be accessible for all.

Political viability also must be considered. Policy that is considered desirable to both politicians and stakeholders will have the best chance of passage. For example, public concerns about health effects from exposure to second-hand smoke have been communicated to policymakers many times. Although policymakers may want to take action to protect the public from tobacco smoke in public places, the pressure from tobacco companies for policymakers not to act has been equally powerful. As a result, public policy related to second-hand smoking languished for years in many states. However, when local communities in these states changed their ordinances to restrict smoking in public, there was increased pressure on state legislators to take action.

Unique aspects of U.S. policymaking

The United States stands out from peer nations for having one of the most complicated health care delivery and finance systems in the world. It has a highly decentralized delivery “system” that also includes a mix of public and private payers and no single entity, authority, or government agency is ultimately responsible for health care. All of these facts lead to a convoluted patchwork of decision making, causing health care policy in the United States to be a highly complex and politically polarizing process. The current health care structure reflects policy decisions from the values of society, including residual policies from the colonial era. The U.S. Constitution does not specifically mention health care, but the preamble indicates that the federal government should “promote the general welfare.” This lies at the heart of the current political debate between the Democrat and Republican Parties regarding the role of the federal government in health care.

Federalism is the system of government in which power is divided between a central authority (federal) and constituent political units (state governments). This division of power and authority, although purposely designed by the founding fathers, is the source of much tension, acrimony, and complexity in U.S. policymaking. Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) are examples of federally driven policies that create a partnership with states to administer health care under federal guidance. Meanwhile, regulation of health professionals, private health insurance coverage, and long-term care policies have long been the domain of the individual states. This complexity between the state and federal spheres illuminates the fragmented and seemingly chaotic approach to solving health care problems in the United States.

Many aspects of the original Affordable Care Act (ACA, 2010) protect states’ rights to choose the degree to which they carry out some of its most important provisions, such as creating health exchanges to expand access to care. This built-in flexibility of the ACA allows states to experiment with local solutions because, for example, what works in Fargo may not work in Manhattan. The ACA escalated tensions between federal mandates and states’ rights, as evidenced by the Supreme Court’s role in settling the dispute resulting from the multistate lawsuit challenging the constitutionality of the ACA’s mandate that every citizen purchase health insurance. In 2012 the Supreme Court upheld the individual mandate as a federal law that states must accept, and it ruled that the expansion of the Medicaid program was constitutional. But, it also protected states’ rights by ruling that states cannot be penalized if they choose not to participate in the expansion (O’Connor & Jackson, 2012).

The trend to allow states increased flexibility in recent decades adds complexity to health policymaking and amplifies the need for nurses to understand the policymaking process. Nurses must be knowledgeable of the structure and players of policymaking so that decision-making bodies are targeted appropriately. For example, there have been incidences of nurses who have approached federal legislators to persuade them to increase funding for school nursing, unaware that school nursing is entirely a local or state issue.

The U.S. Constitution gives the federal government the power to block state laws when it chooses to do so. As noted earlier, state governments have authority to regulate health professionals as part of their charge to protect the public; although this is not in the Constitution, it has been the case since the formation of the nation (Safriet, 1992). This status quo is no longer appropriate because new forms of remote care delivery can render geographic boundaries irrelevant. Federalism is intended to create and sustain a highly decentralized locus of authority and is one of the most important dynamics in U.S. policymaking. This decentralized dynamic also, however, makes health care delivery systems complicated and difficult to reform.

Incrementalism refers to policymaking that proceeds slowly by degrees and is the way that most policymaking proceeds. Within the U.S. Constitution, the three branches of government (executive, legislative, and judicial) are designed deliberately to prevent one person or group from obtaining dictatorial powers. The disadvantage of this “checks and balances” structure is that it is very difficult for comprehensive policy reforms to succeed.

Once in a generation there is a major reform in U.S. health policy: for example, Social Security in the 1930s; Medicare and Medicaid in 1965; CHIP in the 1990s; and the ACA in 2010. However, most health policy reform in the United States has been incremental. The U.S. system empowers political players who represent a minority viewpoint to block the actions of the majority, resulting in paralysis. This was illustrated in 2013, 3 years after the ACA was signed into law, when members of the House of Representatives shut down the government for 16 days (at an estimated cost of $24 billion) in an attempt to defund some of the provisions of the ACA.

Policies in the United States are far easier to stop and obstruct than pass and implement. Policymaking is largely a process of continuous fine-tuning of what already exists. A good example of incrementalism is the policy toward gays in the military. In the early 1990s it was highly controversial to implement the “don’t ask, don’t tell” mandate that allowed gays to serve. By the early 2000s, public opinion on homosexuality shifted dramatically, and the military currently accepts individuals with this sexual orientation. Twenty-five years after “don’t ask, don’t tell,” public acceptance of same-sex couples was evident by the 2015 Supreme Court ruling on marriage equality, making it legal for gays to marry.

Lindblom (1979) first described the concept of incrementalism in the early 1950s. When policymakers face a highly complex, theoretical, or resource-intensive decision and lack the time, capacity, or understanding to analyze all of the various policy options, they may limit themselves to a set of particular strategies instead of tackling the problem holistically. Policy solutions may be restricted to a set of familiar policy options that align with the status quo and lack a thorough evidence base. Therefore incrementalism, although effective in limiting the power of any one person, group, or branch of government, also creates a process that is neither proactive, goal-oriented, nor ambitious; it ossifies timely policy and limits innovation (Weiss & Woodhouse, 1992). There are examples of policy change that are revolutionary in nature, often born out of social movements, a crisis or new technology. The “Me Too” movement is creating revolutionary policy change very rapidly and is highly disruptive of the status quo. What is one day acceptable becomes unacceptable over a matter of weeks, forcing organizations of every type to review and generate policy around sexual misconduct. There are clear downsides to these rapid changes, because systems do not have time to adapt and generate sensible policies.

Conceptual basis for policymaking

Two different yet complementary models from political scientists illustrate how the seemingly chaotic policymaking process has a form, rhythm, and predictability.

Kingdon’s policy streams model

Kingdon (1995) proposed a policy streams model to reflect the issue of “policy looking for a problem.” He described three streams of policy activity: the problem stream, the policy stream, and the political stream. These three streams must align to move through the open policy window at the same time (also referred to as the Garbage Can Model because the three streams must make their way through a minefield of debris). The problem must come to the attention of the policymaker, it must have a menu of viable policy solution options, and it must occur in the right political circumstances.

The problem stream describes the complexities in focusing policymakers on one specific problem out of many. For example, early in the process of developing the language for health reform legislation, policymakers engaged in a long process to define exactly which problems associated with the U.S. health care system should be included in a legislative package. Driving the problem stream are values, so access could be framed as a free market versus social justice issue. Values tend to have a stronger emotional component attached to them so that part of the challenge is the lack of agreement about which problems are the most urgent and require legislation. Some believe that cost is the biggest problem, others want to limit health reform to malpractice reform, and some want to improve access to care or quality. Until the problem is adequately defined, appropriate policy solutions cannot be identified.

The policy stream describes policy goals and the ideas of those in policy subsystems, such as researchers, congressional committee members and staff, agency officials, and interest groups. Ideas in the policy stream disseminate through policy circles in search of problems. Some nursing policy proposals have not clearly aligned with a timely problem stream, such as pushing to get school-based registered nurses (RNs) in every school in the country at a time when there are severe state budget cuts and teacher walkouts due to low pay. The solution proposed must be hitched to an identifiable, timely, and urgent problem.

The third stream, the political stream, describes factors in the political environment that influence the policy agenda, such as an economic recession, special interest media, or pivotal political power shifts. The political circumstances that push problems to the top of the policy agenda need a high degree of public importance and a low degree of stakeholder conflict around the proposed solutions. A great deal of stakeholder conflict weakens the possibility that the policy window will open.

If these three conditions occur at the same time, a policy window opens and progress can be made on the issue. Kingdon (1995) sees these streams as moving constantly; waiting for a window of opportunity to open through couplings of any two streams—particularly when one is the political stream—creates new opportunities for policy change. However, such opportunities are time limited: if change does not occur while the window is open, the problems and options will not be addressed.

For example, although health reform was a high priority for newly elected President Obama in 2009, the economic crisis and recession became a powerful political stream bringing to bear a major debate about how escalating health care costs were making the United States less competitive in the global marketplace. The movement of U.S. jobs overseas and the recession were linked to out-of-control health care costs and the need to reform health care; thus a policy window was opened.

Longest’s policy cycle model

Health policy is a cyclical process. Longest (2016) mapped out an interrelated model to capture how U.S. policymaking works. It is a continuous, highly dynamic cycle that captures the incrementalism inherent in U.S. governmental decision making (Fig. 7.1). In its simplest form, there are three phases to the policy process: a policy formulation phase, a policy implementation phase, and a policy modification phase. Each phase contains a set of actions and activities that produce outcomes or products that influence the next stage. Although simple in design, this model is deceptively complex. Defining the policy problem with adequate clarity so that it gains the attention of policymakers and stakeholders is challenging—each policy problem has many solutions and competitors seeking a place on the policy agenda. The importance of framing and agenda setting is underscored by Doreatha Brande’s (1893 to 1948) quote, “A problem clearly stated is a problem half solved.”

FIG. 7.1Longest’s policy framework.  Source: (Redrawn from Longest, B. [2016]. Health policymaking in the United States [6th ed.]. Chicago: Health Administration Press.)

Policy formulation includes all the activities that are involved in policymaking, including those activities that inform the legislators. It is in this phase that nurses can serve as a knowledge source to legislators in helping to frame problems by bringing nursing stories and patient narratives to illustrate how health problems play out with individual constituents/populations. The most effective time to influence legislation is before it is drafted, so that nurses can help to frame the issues to align with their desire for policy outcomes that are patient centered.

Policy implementation comprises the rule-making phase of policy development. The legislative branch passes the law to the executive branch, which is charged with implementation. This includes adding specificity to the law and may also include, for example, defining “the health care provider” to include advanced practice nurses (provider-neutral terminology). The writing of rules after legislation is passed is a crucial and often overlooked aspect of policymaking (see Chapter 39 on Legislation and Regulation). At this juncture, nurses with appropriate expertise can monitor and influence how the rules are written. Once written, federal regulations are published in the daily Federal Register for 60 days to receive public comment. States have similar regulatory processes.

Stakeholder groups can exert enormous influence during the implementation phase (Regulations.gov, 2013). When strong letter-writing campaigns are used, the rulemaking agency may be forced to publish those comments and make adjustments according to their volume and scientific rigor. It is not unusual for the intent of a policy to get lost in the translation to program development. This rule-making phase is an important leverage point for nurses to closely monitor and respond to regulations through grassroots campaigns.

Two important aspects of American democracy are at play during the public comment phase: (1) informed citizenry—the democratic process only works if its citizenry is informed; and (2) government is not all-knowing—the government acknowledges it does not hold all of the expertise; it must solicit that expertise from the public (Regulations.gov, 2013). An example of rulemaking that limited nursing occurred in 2013 when the Georgia legislature revised its scope of practice law for nurses. The law had many benefits for advanced practice registered nurses (APRNs), but the state’s executive branch made the rules and regulations more restrictive than they were before the legislation was passed. The restrictions caused many APRNs to continue to work under the old scope of practice that was less restrictive (Center to Champion Nursing in America, 2010).

Policy modification allows all previous decisions to be revisited and modified. Policies that were initially pertinent may become inappropriate over time. Almost all policies have unintended consequences, which is why many stakeholders seek to modify policies continuously. Policies may negatively impact the population in myriad unexpected ways. Examples of unintended consequences include the following:

• The Health Insurance Portability and Accountability Act (HIPAA) was created to protect privacy but wreaks havoc when hospital staff are prevented from sharing by phone with family members any information about the status of their gravely ill, out-of-state college-age daughter.

• Information technology designed to capture high-quality data during clinical visits has created an unsatisfying intrusion into the patient-provider relationship.

• Placing caps on Medicare drug benefits to rein in costs has created an uptick in preventable hospital admissions as a result of patients not having access to medicine.

Nurses’ competence in the policymaking process

To effectively influence the policymaking process, nurses must successfully analyze the process and influence it with a high degree of political competence. Policy development that is dominated by public interest generally follows a course of action that is based on data, information, and community values and addresses a solution to an actual or potential problem. It tends to be practical decision making. Stakeholder coalitions that promote the public’s interest can exert enormous influence in shaping health policy.

An example of a provider interest group with a focus on the public interest is the National Association of Pediatric Nurse Practitioners (NAPNAP), which identified childhood obesity as an organizational priority. It participated in a wide range of governmental committees, interviews on news media, and development of clinical practice guidelines, as well as created culturally appropriate resources for parents. Pediatric NPs have effectively participated in a range of policy endeavors to address the alarming childhood obesity epidemic (NAPNAP, 2015). They have published their strongly worded, far-reaching Position Statement on the Prevention and Identification of Overweight and Obesity in the Pediatric Population that recommends policy solutions, clinical solutions, and public awareness campaigns (Box 7.2).

BOX 7.2

Example of a Position Statement: NAPNAP Position Statement on Immunizations

The National Association of Pediatric Nurse Practitioners (NAPNAP) supports the timely and complete immunization of all infants, children, adolescents, and adults in an attempt to maximize the health and well-being of all people. Routine childhood immunizations prevent as many as 3 million deaths per year. In addition, 1.5 million deaths per year could be avoided if global vaccination efforts continue to improve (World Health Organization, 2017).

During the past two decades, immunization exemptions have steadily risen until the 2012–2013 school year, when the rate of immunization exemptions plateaued. Still, immunization exemptions corrode community immunity provided by population-based vaccination programs, and this warrants careful and continued monitoring to prevent vaccine-preventable disease outbreaks in the United States (Omer, Porter, Allen, Salmon, & Bednarczyk, 2018).

The Centers for Disease Control and Prevention (CDC) Committee on Infectious Diseases and the Advisory Committee on Immunization Practices annually review and recommend routine vaccination to prevent 17 vaccine preventable diseases (CDC, 2015, 2018b). In concert with the American Academy of Pediatrics, NAPNAP recognizes the importance of timely vaccinations for children and strongly encourages parents to adhere to the recommended immunization schedule as the best way to protect their children and community from vaccine-preventable infectious diseases (American Academy of Pediatrics, 2018).

NAPNAP considers nurse practitioners (NPs) to be in the best position to inform parents of the scientific and evidence-based foundation of the current immunization recommendations. This education must include the most current scientific evidence related to vaccine safety, risk, and benefits. Parents should know how to find the most current, correct, and evidence-based resources. Conversely, they must be informed about sources and dangers of misinformation. Using a nonjudgmental approach, NPs are compelled to inform parents about the risks of not vaccinating their children as recommended by the evidence.

NAPNAP expects NPs to be skillful clinicians and encourages NPs to become identified as leaders in the health and safety of children and families. NPs must remain knowledgeable about the ever-changing science of vaccination and recommendations for immunizations. Promoting vaccines should be done at the individual, local, state, national, and international levels. NPs are encouraged to participate on employer, hospital, school, local, state, and national committees that address immunization policies and practices, including advocating for increased funding for vaccines.

In an effort to ensure that all pediatric populations are protected against vaccine-preventable illness and remain healthy, NAPNAP affirms that NPs and other pediatric health care providers must do the following.

1. Ensure access to timely immunization for all children.

2. Avoid any and all missed opportunities to vaccinate.

3. Consider every health care encounter as a means to review immunization records, educate parents about immunization safety and efficacy, and vaccinate as needed.

4. Acknowledge the ultimate goal of immunizing children in a timely fashion is to maximize the health of each individual child.

5. Encourage and enable parents and caregivers to critically evaluate vaccine information.

6. Recommend parents, caregivers, and other adults to remain compliant with recommended immunizations for their age and risk group in order to protect children in their care.

7. Distribute the evidence-based CDC Vaccine Information Statements (VISs) for each recommended vaccine to parents and caregivers at every immunization encounter (CDC, 2018a).

8. Ensure adherence to immunization schedules by utilizing electronic health records, statewide vaccine registries, and recall systems to promote continued development of these systems.

9. Remain knowledgeable via local or national immunization groups, educational programs or conferences, evidence-based research articles, and peer-reviewed journals.

10. Immediately incorporate changes in immunization policies, recommendations, and practices into daily practice (Kroger, Duchin, & Vazquez, 2017).

11. Provide complete, accurate, and culturally sensitive educational programs about immunizations to the public, childcare centers, schools, and community groups, including information on benefits, safety, evidence-based quality resources, and the importance of active and timely participation in immunization programs.

12. Utilize news, social media, and other applicable communication methods to influence and direct the conversation regarding immunization safety, efficacy, and necessity.

13. Utilize quality improvement principles to evaluate immunization practices for the purpose of improving compliance with recommended immunization practices and educating members of the health care team.

14. Lead policy change in states to eliminate nonmedical exemptions for school entry.

15. Actively participate on local, state, and national committees, advisory groups, and other venues that impact policies concerning childhood immunization practices.

16. Support any local, state, or federal legislation that aims to keep childhood immunizations available, accessible, and affordable for all children regardless of social or economic status or the type of health insurance.

17. Serve as immunization expert on local, regional, or national committees to support the safety and efficacy of childhood immunization programs.

18. Advocate for an integrated national immunization infrastructure to ensure the supply and delivery of vaccines, maintenance of coverage rates, outbreak control, and immunization education (Groom et al., 2015).

19. Understand the responsibility to report adverse outcomes following any immunization to the Vaccine Adverse Event Reporting System (VAERS; CDC, 2017) and the purpose of the Vaccine Injury Compensation Program (VICP; U.S. Department of Health and Human Services, Health Resources and Services Administration, 2018).

20. Keep informed of the incidence of vaccine-preventable diseases in your area, and be proficient in the ability to diagnose the illness.

21. In the event of vaccine-preventable disease diagnosis, encourage parents to keep children with vaccine-preventable disease at home from school and out of public settings for the duration of the outbreak as recommended by state and national guidelines (Aronson & Shope, 2016).

In summary, NAPNAP is an organization whose mission is to empower pediatric nurse practitioners, pediatricfocused advanced practice registered nurses, and their interprofessional partners to enhance child and family health through leadership, advocacy, professional practice, education, and research and is committed to the health and wellbeing of all children and their families. NAPNAP recognizes the immense benefits of immunizations for children and the community alike. NAPNAP encourages NPs, as well as other pediatric health care providers, to consistently assess patient immunization status, limit missed opportunities to vaccinate, support immunization programs, and promote community awareness of the value of immunization of all children. NPs are compelled to be informed clinicians, skilled communicators, strong leaders, advocates, and champions for evidence-based immunization programs. It is the position of NAPNAP that NPs and elected leaders at the local, state, and federal levels support legislative efforts to appropriate funds for comprehensive immunization delivery, for a national immunization registry, and to maintain the VAERS and VICP programs.

The National Association of Pediatric Nurse Practitioners would like to acknowledge the following members from the Immunization Special Interest Group (SIG) for their contribution to this statement: Lacey Eden, MS, NP-C; Cheryl Cairns, DNP, CPNP, RN, APN; Karlen E. Luthy, DNP, FNP-C, FAAN, FAANP; and Mary Koslap-Petraco, DNP, PPCNP-BC, CPNP, FAANP.

References

American Academy of Pediatrics. (2018). Immunization schedules for 2018. Itasca, IL: Author. Retrieved from https://redbook.solutions.aap.org/SS/Immunization_Schedules.aspxcdc.

Aronson, S.S. & Shope, T.R. (2016). Managing infectious disease in child care and schools (4th ed.). Elk Grove Village, IL: American Academy of Pediatrics. Retrieved from http://ebooks.aappublications.org/content/managing-infectious-diseasesinchild-care-and-schools-4th-ed.

Centers for Disease Control and Prevention. (2015). Epidemiology and prevention of vaccine-preventable diseases. Atlanta, GA: Author. Retrieved from www.cdc.gov/vaccines/pubs/pinkbook/genrec.html.

Centers for Disease Control and Prevention. (2017). Vaccine adverse event reporting system (VAERS). Atlanta, GA: Author. Retrieved from www.cdc.gov/vaccinesafety/ensuringsafety/monitoring/vaers/index.html.

Centers for Disease Control and Prevention. (2018a). Instructions for using Vaccine Information Statements. Atlanta, GA: Author. Retrieved from www.cdc.gov/vaccines/schedules/hcp/adult.html.

Centers for Disease Prevention and Control. (2018b). Recommended immunization schedule for children and adolescents aged 18 years or younger, United States, 2018. Atlanta, GA: Author. Retrieved from www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html.

Groom, H., Hopkins, D.P., Pabst, L.J., Morgan, J.M., Patel, M., Calonge, N.,… & Community Preventive Services Task Force. (2015). Immunization information systems to increase vaccination rates: A community guide systematic review. Journal of Public Health Management and Practice, 21, 227–248.

Kroger, A.T. Duchin, J., & Vazquez, M. (2017). General best practice guidelines for immunizations. Best practice guidelines for immunization of the Advisory Committee for Immunization Practice (ACIP). Atlanta, GA: Centers for Disease Control and Prevention. Retrieved from www.cdc.gov/vaccines/hcp/aciprecs/general-recs/downloads/general-recs.pdf.

Omer, S.B., Porter, R.M., Allen, K., Salmon, D.A., & Bednarczyk, R.B. (2018). Trends in Kindergarten rates of vaccine exemption and state-level policy, 2011–2016. Open Forum Infectious Diseases, 5(2), 1–6.

U.S. Department of Health and Humans Services, Health Resources and Services Administration. (2018). National vaccine injury compensation program. Rockville, MD: Author. Retrieved from www.hrsa.gov/vaccine-compensation/index.html.

World Health Organization. (2017). Immunization coverage. Geneva, Switzerland: Author. Retrieved from www.who.int/news-room/fact-sheets/detail/immunization-coverage.

From NAPNAP position statement on Immunizations. Journal of Pediatric Health Care, 32(6), A9–A11. Retrieved from www.jpedhc.org/article/S0891-5245(18)30378-X/pdf. Reprinted with permission of the Journal of Pediatric Health Care.

Longest (2016) has identified best practices that leaders of advocacy organizations undertake to promote their health-related mission. Once the organization makes policy influence a priority, a governmental relations (or affairs) team is formed (or a firm is contracted) to do the work. If these teams are competent, they can transform the effectiveness of the organizations by giving the CEO (and/or board of directors) anticipatory guidance. The ability of organizations to anticipate lead time and direct resources appropriately is the key function of a strong public policy team. This anticipatory approach moves maturing organizations away from reacting to policy changes and toward strategic leadership. Effective advocacy organizations are continuously analyzing the environment, primarily looking out (not in) at the ever-changing political landscape.

Professional nursing organizations (e.g., the American Academy of Nursing, the American Nurses Association, and many nursing specialty groups) are concerned not only with public policy that impacts the health of all people but also with policy that impacts nurses and the practice of nursing. These organizations, individually and collectively, support policies that are in the best interest of their members.

Engaging in policy analysis

Issue analysis is similar to the nursing process: it is necessary to clearly identify the problem (including the context of the problem, alternatives for resolution and the consequences of each, along with specific criteria for evaluating the alternatives) and recommend the optimal solution. Issue papers or policy briefs provide the mechanism to do this. These identify the underlying issue and stakeholders and specify solutions along with their positive and negative consequences. Issue papers help to clarify arguments in support of a position, recognize the arguments of the opposition, and lay out the evidence or lack thereof for an issue and potential solutions.

A one-page, “leave-behind” position statement provides a summary for the policymaker to read and gain a grasp of the issue quickly. A standard format for a policy brief includes summary of the issue, background information, analysis of alternatives, a recommendation for action, references, and personal contact information (Box 7.3).

BOX 7.3

Example of a Policy Brief: The American Academy of Nursing. Elder Justice: Preventing and Intervening in Elder Mistreatment Policy Brief

Introduction

In the United States, as many as 1 in 10 older adults and 47% of persons with dementia living at home experience some form of mistreatment (Institute of Medicine [IOM], 2014). Elder mistreatment results in diminished well-being and quality of life and violates the rights of older adults to be safe and free from violence. Elder mistreatment can occur anywhere—in the home, in care and residential facilities, and in the community. It can also be malignantly contagious within settings and families and across the lifespan (Dong, 2012). With the rapid growth of the U.S. population of older adults, now estimated to reach 84 million by the year 2050 (Ortman, Velkoff, & Hogan, 2014), the issue of elder mistreatment is a major national health concern.

The American Academy of Nursing’s Strategic Goal #3 (2014–2017)—to lead change to improve health and healthcare and drive policy—is especially related to this issue. Health care professionals in regular contact with vulnerable older adults—including the nation’s 3 million nurses—are in an ideal position to identify and report suspected cases of mistreatment; they are, however, among the least likely to do so (Schmeidel, Daly, Rosenbaum, Schmuch, & Jogerst, 2012). This policy brief summarizes some of the most relevant information in the field of elder mistreatment and recommends partnered action by health professions organizations and other stakeholders to promote elder justice and improve overall health and well-being of this vulnerable group.

Background

The successful legislation of the Elder Justice Act in 2010 as a part of the Patient Protection and Affordable Care Act (United States. Congress. Senate. Committee on Finance, 2006) has done much to accelerate nationally the deserved attention that elder mistreatment in all of its forms demands. Unfortunately, to date, no funds have been appropriated by Congress to carry out the important provisions of this Act or its earlier iteration (Older Americans Act Amendments of 2006, October 17, 2006) related to direct services, education or policy and resource development for elder justice. The American Academy of Nursing is committed to justice for all individuals and especially those who are frail, disadvantaged, and potentially incapable of defending themselves in the presence of elder mistreatment. Two of the Academy’s special interest groups—Aging and Psychiatric, Mental Health & Substance Abuse—stand ready to bring to bear their collective resources and talents to help address this serious and potentially fatal syndrome.

There is currently no overarching theory or conceptual framework for elder mistreatment, although several borrowed from other fields (Ecological Model, Sociocultural Model, Cycle of Violence Theory, Life Course Perspective as examples) have been used (IOM, 2013). And, while there is no universally accepted definition, the Elder Justice Roadmap Project (Connolly, Brandl, & Brekman, 2014) has defined it broadly as physical, sexual, or psychological abuse, as well as neglect, abandonment, and financial exploitation of an older person by another person or entity, that occurs in any setting (e.g., home, community, or facility), either in a relationship where there is an expectation of trust and/or when an older person is targeted based on age or disability. Elder justice recognizes an older person’s rights and his or her ability to be free of abuse, neglect, and exploitation. The Elder Justice Act defines elder justice activities as “efforts to prevent, detect, treat, intervene in, and prosecute elder abuse, neglect, and exploitation and to protect elders with diminished capacity while maximizing their autonomy” (United States Congress Senate Committee on Finance, 2006).

A number of risk factors for elder mistreatment and its subsequent health outcomes create opportunities for prevention or intervention. These include increased physical dependency of frail elders on caregivers; fewer family members living in the same geographic region or caregivers being elderly or impaired themselves; substance abuse, cognitive impairment and mental illness among caregivers and/or the mistreated as well as poverty, age, race, functional disability, frailty, loneliness and low education (Fulmer, 2013). For the elder, the experience of mistreatment itself, in any of its forms, often also results in behavioral health symptoms including depression, risk of suicide, anxiety, cognitive dysfunction, and sleep difficulty; self-treatment with drugs and alcohol; injuries and morbidities resulting in higher use of emergency department, hospital and nursing home services, and greater mortality (Dong, 2014). Thus, elder mistreatment is not only harmful to individuals, but is also detrimental to social, legal, and health systems (Vognar & Gibbs, 2014).

There is growing interest in and commitment to the prevention and treatment of elder mistreatment among national agencies and institutes whose collaboration could achieve greater impact. The recent release of the Elder Justice Roadmap (Connolly et al., 2014), developed with support from the Department of Justice (DOJ) and the Department of Health and Human Services (HHS), provides impetus and guidance for advancing strategic policy, practice, education, and research initiatives that can help move forward components of the recently enacted Elder Justice Act and recommendations from the IOM’s 2013 Forum on Global Violence workshop (2014). Furthermore, the 2015 White House Conference on Aging (WHCoA) has identified four themes, of which Elder Justice is one. Elder justice is also a priority area for the American Academy of Nursing which has a broad and deep reach in national policy and can play a critical role in helping to advance the recommendations from these initiatives. All nurses and other health professional groups must capitalize on the opportunities created by these recent initiatives to contribute to the national conversation. Their input and feedback can help shape the aging policy landscape through a variety of mechanisms, including listening sessions, regional forums, social media, and the WHCoA website. In addition, they can help to educate legislators and their policy staff by sharing this policy brief.

Recommendations

Health professionals, and especially nurses, play an extraordinarily important role in the advancement of our understanding of and response to the complex phenomenon of elder mistreatment. As the largest professional health care workforce, nurses serve at the frontline in the prevention, assessment, and management of elder mistreatment. Partnered organizational support of efforts related to prevention, recognition and treatment, education and training, and research will make important inroads in solving this critical problem. The following recommendations align with those found in the Elder Justice Roadmap (Connolly et al., 2014).

Prevention

Nurses and other health professionals should support elder mistreatment prevention by aligning with existing efforts to shore up community-based networks and resources that buttress and sustain older adults and their families. Programs currently gaining momentum include Age Friendly Communities and the Village Movement, both aimed at enhancing safe and healthy aging-in-place.

The academy recommends

• Encouragement of all health professionals, including nurses, to use opportunities like social media, online resources, and public service messaging to combat ageism and raise the public’s awareness of elder mistreatment and its severity, identifying high-risk situations and the need to intervene before mistreatment arises or escalates.

• Engagement of state and Area Agency on Aging efforts to provide supports, improve awareness of at-risk elders, and facilitate effective preventive resources.

• Heightened attention to needs of underserved, isolated, or vulnerable populations at highest risk for mistreatment, e.g., a partnership with National Indigenous Elder Justice Initiative housed at the University of North Dakota’s Center for Rural Health, among others.

• Increased awareness of the activities and products of the International Network for the Prevention of Elder Abuse, a nongovernmental organization affiliated with the United Nations.

• Better preparation of older adults and adult children who will take care of their aging parents through public awareness and caregiver education and training.

Recognition and treatment

Health professions societies and academies should advocate broader use of efforts to recognize and intervene in elder mistreatment. These include integrated care models (IOM, 2012), routine screening, and use of related evidence-based intervention models.

The academy recommends

• A campaign to encourage nurses and others in primary care settings to ask privately—of every client age 65 and older—the screening question, “Do you feel safe at home?”

• Expansion of Medicare/Medicaid reimbursement to better cover screening and basic first level mental health services by primary care provider staff. This will enhance inclusion of routine screening for mistreatment, substance use and mental health problems as part of the annual Medicare health promotion visit.

• Recognition by the National Quality Forum of elder mistreatment assessment as a quality indicator across healthcare settings, thus enhancing adoption of the practice.

• Advocacy for scaling up use in primary care settings of depression and substance use intervention models that work, such as IMPACT or SBIRT.

• Support for the Administration on Aging (AoA)’s National Center on Elder Abuse (NCEA) to heighten awareness and serve as a resource for policy makers, social service and health care practitioners, the justice system, researchers, advocates, and families.

Education and training

The Health Resources and Services Administration, in concert with the AoA’s National Center for Elder Abuse, should convene a group to determine key training models and materials that would address attention to mistreatment in clinical practice and make recommendations for health sciences curricula and continuing education. This collaborative effort will also enhance broad-based learning for advocates, caregivers, community leaders, financial services industry personnel, and legal/law enforcement workers, as well as health care professionals and social service providers.

The academy recommends

• Interprofessional training to address ageism, mistreatment and behavioral health at pre- and post-professional levels.

• Mandatory continuing education for nurses on elder abuse, similar to the recent National Council of State Boards of Nursing requirement for child abuse education; this model could also be used by other health professions.

• A requirement by the National Academies of Practice that all distinguished practitioners have an awareness of and plan for addressing all forms of family violence, including elder mistreatment.

• Contribute, use, disseminate, and review training materials for the Elder Abuse Training Repository of the NCEA, a national resource center dedicated to the provision of information to professionals and the public, technical assistance, and training to state and community-based organizations.

Research

The National Institute for Nursing Research, in partnership with the National Institute on Aging, the Substance Abuse and Mental Health Services Administration and the Department of Justice together with its Elder Justice Steering Committee and nongovernmental funding agencies, should establish guidelines for setting priorities and securing funding to advance a RESEARCH AND PROGRAM EVALUATION AGENDA that addresses recommendations from the Elder Justice Roadmap.

The academy recommends

• Prioritization of research on elder mistreatment in all its forms, as this emphasis is crucial to fostering quality of life for older adults and a just and healthier society.

• Strategic promotion of prevention research priorities and evaluation strategies identified in the Elder Justice Roadmap, as well as Adult Protective Services intervention studies and recruitment to the elder justice field researchers with expertise in studying prevention.

• Assurance that critical research foci include epidemiology of this multidimensional and complex problem, especially psychological abuse.

• Demonstration of effectiveness of preventive, early recognition, surveillance, intervention (including legal), and rehabilitative programs in diverse individuals, including those with cognitive impairment, across settings.

• Inclusion of projects that result in recommendations for promoting and protecting resilience, mental health and coping and that empower older people, their families, and their communities.

Acknowledgment

This policy brief was prepared by the Expert Panel on Aging and the Psychiatric, Mental Health & Substance Abuse Expert Panel on behalf of the American Academy of Nursing. We gratefully recognize Terry Fulmer, PhD, RN, FAAN, Lois Evans, PhD, RN, FAAN, Kitty Buckwalter, PhD, RN, FAAN, Marie Boltz, PhD, RN, CRNP, FAAN, and Tara Cortes PhD, RN, FAAN, for their contributions in authoring this policy brief.

References

Connolly, M.-T., Brandl, B., & Brekman, R. (2014). Elder justice roadmap report. Washington, DC: U.S. Department of Justice.

Dong, X. (2012). Elder abuse and the contagion of violence: One size doesn’t fit all. Washington, DC: Institute of Medicine.

Dong, X. (2014). Elder abuse: research, practice, and health policy: The 2012 GSA Maxwell Pollack Award lecture. The Gerontologist, 54, 153–162

Fulmer, T. (2013). Mistreatment of older adults. In S. Durso, & G. Sullivan (Eds.). Geriatric review syllabus: A core curriculum in geriatric medicine (8th ed., pp. 104–108). New York: American Geriatrics Society.

Institute of Medicine. (2012). The mental health and substance use workforce for older adults: In whose hands? Washington, DC: National Academies Press.

Institute of Medicine. (2014). Forum on global violence prevention: Elder abuse and its prevention (pp. 59–66). Washington, DC: National Research Council.

Older Americans Act Amendments of 2006, Public Law 109–365 (October 17, 2006).

Ortman, J.M., Velkoff, V.A., & Hogan, H. (2014). An aging nation: The older population in the United States (Current Population Reports). Washington, DC: U.S. Census Bureau.

Schmeidel, A.N., Daly, J.M., Rosenbaum, M.E., Schmuch, G.A., & Jogerst, G.J. (2012). Healthcare professionals’ perspectives on barriers to elder abuse detection and reporting in primary care settings. Journal of Elder Abuse & Neglect, 24, 17–36

United States Congress Senate Committee on Finance. (2006). Elder Justice Act: Report (to accompany S.2010). Washington, DC: U.S. GPO.

Vognar, L. & Gibbs, L.M. (2014). Care of the victim. Clinics in Geriatric Medicine, 30, 869–880.

From Elder justice: Preventing and intervening in elder mistreatment. Nursing Outlook, 63(5), 610–613. Retrieved from www. nursingoutlook.org/article/S0029-6554(15)00256-0/fulltext. Reprinted with permission of the American Academy of Nursing.

Infusing the evidence base into health policy

Data and research are highly valuable in understanding a health policy issue and in developing a solution to the problem. It is assumed that health policy driven by an evidence base will link the evidence, policy solution, and the significance of the situation. However, evidence may support opposing views of a policy solution. For example, will expanding access to care for the poor increase or decrease costs? There is evidence that supports both sides of this policy debate, and the cost shifting currently in place for most delivery systems makes it difficult to ascertain which view is correct—or which values are most important.

Another barrier to crafting policy is that there can be a lack of clarity about the evidence that is needed. Nurses generally understand that evidence-based practice is based on science. However, there is a hierarchy of what constitutes evidence from scientific inquiry that ranges from systematic review, randomized controlled trials, cohort studies, case-control studies, cross-sectional surveys, case reports, expert opinion, and anecdotal information (Glasby & Beresford, 2006). This hierarchy can make it difficult to reach an agreement among stakeholders, policymakers, and the public about what evidence is appropriate and most valuable for health policy. New evidence may need to be developed before one can move ahead with a policy recommendation; this may include evidence informed by input from community stakeholders. Although policymaking is dependent on good data and evidence about what works, data and evidence may not be enough to outweigh the influence of the political environment.

Policy-relevant research

Despite the debate over what constitutes evidence and which evidence is relevant for health policy, health services research (HSR) can be very effective in developing policy options. HSR is a far broader form of research than clinical research in that it is a multidisciplinary field of scientific inquiry that looks at how people gain access to health care, how much care costs, and what happens to patients as a result of this care. The main goals of HSR are to identify the most effective ways to deliver high-quality, cost-effective, safe care across systems (Agency for Healthcare Research and Quality [AHRQ], 2013). These include issues such as the restructuring of health services, human resource use in health care settings, primary care design, patient safety and quality, and patient outcomes. For example, Linda Aiken’s work on safe staffing (Aiken, 2007; Aiken et al., 2002), Mary Naylor’s work on transitions in care for older adults (Naylor et al., 2004), and Mary Mundinger’s work on the use of NPs (Mundinger et al., 2000) are widely cited in policy literature. There has been an increase in comparative effectiveness research, which uses a design to inform decisions about Medicare. It uses a range of data sources to compare the costs and harms of various treatment decisions and is commonly used to study the cost effectiveness of drugs, medical devices, and surgical procedures.

Conclusion

Goethe wrote, “Everything is hard before it is easy,” and it underscores the importance of going after meta-causes of problems in our health care system. Nurses should seize opportunities to be active in all policy arenas to assure that solutions improve the health of people. In addition to lobbying policymakers, nurses can run for elective office at all levels of government; nurses serve in policy research roles; as policy analysts within professional nursing or patient advocacy organizations and health care institutions and within state or federal agencies; and as staff to policymakers. Nursing leaders have had considerable impact on policy from their leadership positions in organizations such as AARP, the National Academy of Medicine, and the Health Services and Resources Administration. Such involvement in health policy is a natural extension of nurses’ role as advocate.

Discussion questions

1. Identify a problem you face regularly in your clinical setting. Next, identify how this problem could be framed as a policy issue.

2. The Kingdon and Longest models help us to interpret how policy works. Select one model and apply it to a policy issue you care about.

3. Name three actions you and your peers could do to strengthen nursing’s influence in the policy process?

References

Agency for Healthcare Research and Quality. (2013). An organizational guide to building research capacity. Retrieved from www.ahrq.gov/funding/training-grants/hsrguide/hsrguide.html.

Aiken L. Supplemental nurse staffing in hospitals and quality of care Journal of Nursing Administration 2007;37: 335-342.

Aiken L., Clarke S., Sloane D., Sochalski J., Silber J. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction JAMA 16, 2002;288: 1987-1993.

Center to Champion Nursing in America. Access to care and advanced practice nurses: A review of Southern U.S. practice laws 2010; AARP Public Policy Institute. Retrieved from https://campaignforaction.org/resource/access-care-advanced-practice-nurses-review-southern-us-practice-laws/.

Dye R. Understanding public policy. 15th ed. 2016; Pearson New York.

Fawcett J., Russell G. A conceptual model of nursing and health policy Policy, Politics, & Nursing Practice 2, 2001;2: 108-116.

Glasby J., Beresford P. Who knows best? Evidence-based practice and the service user contribution Critical Social Policy 1, 2006;26: 268-284.

Harvard T.H., Chan School of Public Health. Life in rural America 2018; NPR/Robert Wood Johnson Foundation/Harvard School of Public Health. Retrieved from www.rwjf.org/en/library/research/2018/10/life-in-rural-america.html.

Kingdon J.W. Agendas, alternatives, and public policies 1995; Little, Brown Boston.

Lindblom C. Still muddling, not yet through Public Administration Review 6, 1979;39: 517-526.

Longest B. Health policymaking in the United States. 6th ed. 2016; Health Administration Press Chicago.

Mundinger M., Kane R., Lenz E., Totten A., Tsai W., Cleary P., . . . Shelanski M. Primary care outcomes in patients treated by nurse practitioners or physicians: A randomized trial JAMA 2000;283: 59-68.

National Association of Pediatric Nurse Practitioners. (2015). Position statement on childhood obesity. Retrieved from www.jpedhc.org/article/S0891-5245(15)00152-2/fulltext.

Naylor M., Brooten D., Campbell R., Maislin G., McCauley K.,… Schwartz J. Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial Journal of the American Geriatric Society 7, 2004;52: 675-684.

O’Connor M., Jackson W. Analysis: U.S. Supreme Court upholds the Affordable Care Act: Roberts rules? The National Law Review 2012; Retrieved from www.natlawreview.com/article/analysis-us-supreme-court-upholds-affordable-care-act-roberts-rules.

Regulations.gov. (2013). eRulemaking program [website to enable citizens to search, view and comment on regulations issued by the US Government]. Retrieved from www.regulations.gov/#!aboutProgram.

Safriet B. Health care dollars and regulatory sense: The role of advanced practice nursing Yale Journal on Regulations 1992;417: 442-445.

Sears J., Hogg-Johnson S. Enhancing the policy impact of evaluation research: A case study of nurse practitioner role expansion in a state workers’ compensation system Nursing Outlook 2, 2009;57: 99-106.

Weiss A., Woodhouse E. Reframing incrementalism: A constructive response to the critics Policy Sciences 1992;25: 255-273.

Online resources

The Campaign to Promote Civic Education. www.new.civiced.org/programs/promote-civics

The Center for Responsive Politics: Open Secrets. www.opensecrets.org