For APRNs to make an impact in health policy requires the engagement of each individual (see Table 9.1 ). Developing leadership skills and increasing the understanding of the political process will support the effectiveness of APRNs as they seek to increase their engagement. Business theory has described the concept of “scanning the environment,” the monitoring of the organization’s internal and external environment. APRNs can use this concept in the monitoring of the local and national health policy environ- ment. The individual APRN can extend his or her reach at the federal and state levels by participating in professional organizations whose staff scan the environment daily. Scanning the local environment is just as impor- tant and provides an opportunity for direct involvement, especially for the fledgling political activist. Political process occurs in institutions as well, and engaging locally in small ways can be an avenue to increase confidence in advocacy that will extend to a larger stage.
Locally, APRNs can scan for opportunities to educate others about their role and respond to barriers when identified. It may be as simple as having the language on the school health form changed from physician to pro- vider. When institutional policies set up barriers to full practice authority, the well- informed APRN is positioned to respond. Institutional policies that are more restrictive than necessary may be a result of a knowledge gap. The administrators who created the policy may lack an understanding of changes in federal and state laws that govern APRN practice. When an informed APRN presents data with a request for a change in policy and emphasizes the effect on improved patient care and the benefit to the or- ganization, that APRN will be presenting a strong argument in support of his or her agenda. The uninformed APRN is at the mercy of policies from others that may not represent the current regulations. For example, a portable x- ray company, unaware of the change that occurred in the reg- ulation in the physician fee schedule, may refuse to accept an order from an APRN. This may negatively affect the patient of an uninformed APRN who acquiesces to the policy. However, an informed APRN could use the strategy of providing data, emphasizing the effect on the patient and the benefit to the organization, and may successfully accomplish the objective and benefit colleagues as well.
TABLE 9.1 Policy Resources
Websites Description
LEGISL ATIVE BR ANCH Federal Legislative
Information
www.congress.gov Is the official website for up- to- date information on legislation presented by the Library of Congress
Library of Congress www.loc.gov Serves as an archival resource
House of Representatives www.house.gov Provides a directory of Representatives, leadership, committees, and legislation U.S. Senate www.senate.gov Provides a directory of Senators,
committees, and legislation GovTrack.us www.govtrack.us Is not a government site but
independently tracks the bills that are considered by Congress
Countable www.countable.us Provides updates on the bills being addressed daily in the U.S. Congress.
Provides an avenue for contacting your representatives and informs you of how they voted. Includes an APP for your phone or tablet.
E XECUTIVE BR ANCH
White House www.whitehouse.gov Provides a directory of the executive branch, the executive offices, the White House schedule, and issues
HHS Administration www.hhs.gov Cabinet department
Centers for Disease Control and Prevention
www.cdc.gov A department under HHS resource for many health statistics; publishes the Morbidity and Mortality Weekly Report Centers for Medicare &
Medicaid Services
www.cms.gov Provides comprehensive information on Medicare, Medicaid, CHIP, and resource for statistics
Food and Drug Administration
www.fda.gov Provides safety information, regulatory information
Substance Abuse and Mental Health Services Administration
www.samhsa.gov Is a resource for mental health services and data
Health Resources and Services Administration
www.hrsa.gov Provides information on National Health Service Corps, loans and scholarships, federally qualified health centers
(continued)
National Institute of Nursing Research
www.ninr.nih.gov Provides funding for nursing scientists
RULEMAKING AND REGUL ATION
Federal Register www.federalregister.gov Includes all proposed and final rules; is published daily
Office of Information and Regulatory Affairs
www.Reginfo.gov Publishes the Unified Agenda and Regulatory Plan
Regulations.gov www.regulations.gov Provides access to federal regulatory content; submits comments on documents published in the Federal Register
STATE RESOURCES National Conference of State Legislatures
www.ncsl.org Provides information and resources to state legislatures
National Governors Association
www.nga.org Bipartisan coalition of governors to create a unified response to national issues
RESE ARCH AND POLICY INSTITUTES
Cato Institute www.cato.org A public policy research organization focused on a wide variety of topics, including healthcare and welfare Center on Budget and Policy
Priorities
www.cbpp.org Works on federal and state fiscal policies and programs that affect low- and moderate- income people
The Commonwealth Fund www.commonwealthfund.
org
Private foundation that supports healthcare systems
The Heritage Foundation www.heritage.org Mission is to formulate and support conservative public policies
Kaiser Family Foundation www.kff.org Provides policy analysis on national health issues
COALITIONS
Future of Nursing Campaign for Action
http://campaignforaction.
org
An initiative of AARP, AARP Foundation, and the Robert Wood Johnson Foundation to implement the recommendations in the Institute of Medicine report on nursing
(continued) TABLE 9.1 Policy Resources (continued)
Working Collaboratively
Collaboration with other APRNs through professional engagement in nursing organizations (see Table 9.2) and with other healthcare providers and stakeholders will be a growing requirement in new regulatory models.
New delivery models include accountable care organizations, medical/
health homes, and retail clinics. These models are intended to be patient centered and to help contain costs. The Center for Medicare and Medicaid Innovation at the CMS was an agency created as a result of ACA. The center is charged with testing new healthcare delivery models. APRNs need to be aware of these initiatives and become active participants in the development of the models. Remember the warning: If you’re not at the table you’re on the menu.
As the public became more aware of the value of the patient- centered care provided by APRNs, coalitions formed outside of healthcare to support expansion of advanced practice nursing. It is equally important for APRNs to articulate their expertise and the contribution that advanced practice nursing can make to the success of the new delivery models, working to- gether with other professionals to meet the objectives of improved quality at cost savings. With increased emphasis on interprofessional collaboration and new graduates who are prepared with interprofessional educational experiences, obstacles that have separated professionals in the past will hopefully be removed. Interprofessional models emphasize collaboration and increase the understanding of the expertise that each profession brings to the care of the patient.
The Policy Process and the Nursing Process
The cyclical nature of Longest’s ( 2016 ) Health Policy Making Model has similarities with the nursing process: assessment, planning, intervention, and evaluation. The policy- making process, moving from a problem to the implementation of a program that aims to fix it, requires the separation of one problem from another. It requires us to understand that many solutions
Robert Wood Johnson Foundation
www.rwjf.org Shares evidence and promotes change in healthcare through partnerships and collaboration
The Nursing Community www.thenursingcommunity.
org
A coalition of 61 national nursing organizations that strive to “Speak With One Voice”
CHIP, Children’s Health Insurance Program; HHS, Health and Human Services.
TABLE 9.1 Policy Resources (continued)
exist, to prioritize our needs, to interact and compromise with many other interests, and to be ready to respond to change, which is certain to come in a highly dynamic environment. With a more in- depth understanding of the legislative process, the rulemaking, and the development of regulation that follows, APRNs are prepared to apply that understanding to address their own concerns. Developing their leadership ability and connecting to their colleagues at the local, state, and national levels are essential to accomplishing policy change.
A Story of Successful Advocacy
On May 24, 2016, a rule to amend the VA’s Medical Regulations to permit full practice authority for all four roles of advanced practice nurses was published in the Federal Register (APRN, 2016). This policy window was opened as a result of the problem of corruption that was revealed in 2014 with secret waiting lists created to disguise the lack of access available to veterans needing care. The VA treats 9 million veterans and is the largest healthcare system in the United States. In introducing the rule change, the VA cited the long wait times that had led to some deaths. They reported that more than a half million veterans were waiting at least 30 days for care, and another 300,000 were waiting 31 to 60 days. As nursing groups acti- vated their membership to comment on the rule in Regulations.gov, the re- sponse was incredible. The document received 225,000 comments and the AANP reported that 88% of Americans surveyed agreed veterans should have direct access to APRNs.
The rationale for the move to allow APRNs full practice authority was all about access and not an ideological statement regarding APRN quality.
The greatest resistance to the rule came from the anesthesiologists, and a key argument from them was the lack of a problem with access to an- esthesia services. Their opposition was successful and certified registered nurse anesthetists (CRNAs) were removed from the final rule. This final rule was published on December 14, 2016, and included three APRN roles, NPs, CNSs, and CNMs. Of interest is the fact that currently the VA does not have CNMs on their staff, but they are exploring including them in the future.
The final rule became effective on January 13, 2017. In an article by GraduateNursingEDU (2017), the question was raised if this change, which allows for APRNs in all 1,500 VA medical facilities to practice to the full extent of their education and training regardless of the law of the state where the facility is located, would be a tipping point for APRN practice in the private sector as well. As each individual VA facility implements this new regulation, it will become one of the best demon- stration models available to support future efforts in states still striving for APRNs’ ability to practice to their full scope. This is an important time for APRNs to be vigilant and watch for open policy windows in their community.
SUMMARY
Healthcare policy is a moving target for each new administration. Although there was progress made with the Affordable Care Act, much is needed to fix the healthcare system. APRNs should and must be at the table when the reforms are suggested, made, and implemented. This can be accomplished only by becoming engaged in the political process at the local, state, and na- tional levels. Involvement will require knowledge of legislation that impacts healthcare and APRN practice, how to engage politicians, participation in pro- fessional organizations, and becoming immersed in the politics of healthcare.
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