Health Policy Issues

The Little “p” A nurse’s individual expertise is vital to shaping policy change at every level, but nurses must be diligent to share this expertise. From the unit level to the hospital system level, the observation of one nurse could improve quality of care, save the healthcare system hun- dreds of thousands of dollars, improve the efficiency of care delivery, or develop a national policy standard. Yet, an exceptional idea never comes to fruition if it is not heard.

Empowered nurses can use their expertise to enact change in their organization (Bradbury-Jones, Sambrook, & Irvine, 2008). On the contrary, if nurses do not feel empowered, feelings of frustration and failure emerge (Laschinger & Havens, 1996;

The Alliance: Nursing Organization Alliance Nurse in Washington Internship (NIWI) Open to any RN or nursing student (all levels of education) who is interested in learning about current issues in nursing and the legislative process. Each participant spends time meeting with his or her members of Congress while participating in the NIWI Annual Advocacy Days (see Figure 7.2).

www.nursing-alliance.org/Events/NIWI-Nurse-in-Washington-Internship

For Advanced Practice Registered Nurses

American Association of Nurse Practitioners (AANP) Health Policy Fellowship The AANP Health Policy Fellowship program provides AANP members with a comprehensive fellowship experience at the center of health policy and politics in Washington, DC. It is an outstanding opportunity for members with an interest in healthcare policy to promote the health of the nation and the advancement of NPs’ ability to work within their full scope of practice.

www.aanp.org/legislation-regulation/federal-legislation/ health-policy-fellowship

For Nursing Students

American Association of Colleges of Nursing (AACN) Student Policy Summit (SPS) The SPS is a 3-day conference held in Washington, DC, and is open to baccalaureate and graduate nursing students enrolled at an AACN member institution. It is a didactic immersion program focused on the nurse’s role in professional advocacy and the federal policy process (see Figure 7.3).

www.aacnnursing.org/Policy-Advocacy/Get-Involved/Student-Policy-Summit

For Nurse Faculty

AACN’s Faculty Policy Intensive (FPI) The FPI is a 3-day immersion program designed for faculty of AACN member schools interested in actively pursuing a healthcare and nursing policy role. It offers the opportunity to enhance existing knowledge of policy and advocacy by strengthening understanding of the legislative process and the dynamic relationships between federal departments and agencies, national nursing associations, and the individual advocate.

www.aacnnursing.org/Policy-Advocacy/Get-Involved/Faculty-Policy-Intensive

EXHIBIT 7.2 OPPORTUNITIES TO BUILD INTELLECTUAL CAPITAL (continued )

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FIGURE 7.2 Nurses participating in the Nurses in Washington Internship in 2017.

FIGURE 7.3 American Association of Colleges of Nursing Student Policy Summit attendees, taking part in the association’s advocacy day, are featured with cochair of the House Nursing Caucus, Representative David Joyce (R-OH; center).

Manojlovich, 2007). A thorough literature review conducted by Rao (2012) examined the concept of nurse empowerment over time. This analysis revealed that nurses have viewed empowerment through a lens that focuses on organizational structure. According to Rao (2012), nurses rely “too heavily on rigid bureaucratic structures rather than their own professional power to guide practice. Limiting nurses in this way denies the profes- sional power their role affords them and constrains their ability to achieve extraordi- nary outcomes” (p. 401). According to Des Jardin (2001), nurses may not believe that they have a role to “challenge the structure of the health care system or the rules guiding that system” (p. 614). Because policy is change, this can cause tension for nurses (Des Jardin, 2001). Therefore, the first steps in many cases are recognizing one’s intellectual capital and then overcoming the inertia and speaking out. At work, this process starts by regularly attending meetings and bringing forth issues that have policy implications, and nursing expertise can help guide these steps. Substantive policy changes often start when people see problems as they carry out their jobs. The policy may relate to an array of practice or clinical issues. Policy on the Scene 7.1 provides examples of how nurses in adult and pediatric settings made change using intellectual capital.

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SOCIAL CAPITAL The second interdependent component is social capital. As noted, intellectual capi- tal must be expended to be of benefit; it needs to be shared. Developing social capi- tal is essentially relationship building. More specifically, relationships are built and

POLICY ON THE SCENE 7.1: Using Intellectual Capital to Change Practice

APRNs have a unique opportunity to use intellectual capital to help change practice. The work of Dianna Copley, MSN, APRN, ACCNS-AG, CCRN, at the Cleveland Clinic and Sue Nicholas MSN, RN-BC, WHNP-BC, CCCTM at Akron Children’s Hospital are used here to illustrate capital to change practice policy.

In her first few months in practice as a new clinical nurse specialist (CNS), Dianna Copley observed inconsistency in care for hospitalized patients who needed a wearable cardiac defibrillator. As a new CNS, it was on her list of prob- lems to tackle, along with preparing for an upcoming presentation she had at the National Association of Clinical Nurse Specialists annual conference. She was presenting on her recent transition from clinical nurse to CNS. While at the con- ference, she attended a presentation describing an interprofessional approach to the care of patients wearing cardiac defibrillators. She also learned that this low-volume, high-risk device has inadvertently shocked healthcare providers. The CNS collaborated with CNS colleagues, clinical nurses, and nurse leaders to create guidelines for caring for patients with such defibrillators. The guideline was identified as having implications across the entire healthcare system and span of adult care, including emergency services, critical care, and medical– surgical nursing. What started as one CNS wanting to improve care in her own unit became a new policy supporting care provided by over 22,000 nurses in the system (Dianna Copley, personal communication, November 9, 2017).

In the second example, Sue Nichols, made her change when she participated in her hospital’s evidence-based practice (EBP) learning community. Her work led to a revised policy for taking family histories in a maternal–fetal medicine (MFM) practice. As part of her EBP project, Ms. Nicholas collaborated with a team that found a self-report of family history might improve the comprehen- siveness of the history, result in a timelier completion of the history, and facili- tate opportunities for earlier and more comprehensive genetic counseling. Using the Rosswurm-Larrabee Model for planned change, Ms. Nicholas and the team synthesized evidence for analysis by linking the problem, interventions, and out- comes. They found that a self-report using a standardized pregnancy health tool increased identification of families at risk for inheritable disease and women at risk for pregnancy difficulties. The tool was easy for patients to use and under- stand, and it was free of charge. After institutional review board approval, the project was trialed for 6 months, with the results showing a dramatic increase in genetic counseling from 7% to 71% after the implementation of the self-report process. Subsequently, the completion of the pregnancy health tool became a standard policy in the completion of family histories for the MFM practice (Meghan Weese, MSN, RN, CPN, NEA-BC, Magnet® coordinator, personal com- munication, November 6, 2017).

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nurtured with key decision makers at the state and national levels to influence policy change. For the nursing profession, social capital should be the most basic, intui- tive, and strongest form of capital. Nurses create relationships with their patients, their patients’ families, fellow nurses, managers, and so on. Contextually, it relates to the key elements that are necessary for a positive relationship, namely, honesty and trust. As is often repeated in this book, but not capitalized on by nurses, the nurs- ing profession consistently ranks highest among all others as being the most honest profession (Brenan, 2017).

The Big “P” Social capital at the big “P” level involves the development of relationships with appointed and elected officials. Members of Congress listen to the voices of their constituents. This is a reality that every lobbyist inherently knows well. It is constituents, not the registered lobbyists, who reelect legislators to serve another term. Therefore, opinions of constituents are tremendously more relevant than any political wonk in the nation’s capital. Even though many believe that and there is evidence that wealth plays an influ- ential role in swaying policy, the value of constituents’ opinions and support cannot be dismissed; however, constituents must make their opinions known.

To simply be a nurse constituent in the district of a member of Congress does not mean your voice will be heard among the other hundreds of thousands of constitu- ents. You must be savvy. One of the best ways to accomplish this is to gain guidance from national or state nurses associations. If a nurse has an opportunity to directly communicate with a member of Congress, a nurses association’s lobbyist could provide background on the member’s political positions, information about what Congress is currently debating and what message would be most relevant, and talk- ing points to help prepare for an interaction (see Chapter 10) This is the job of regis- tered lobbyists: to prepare their members to be politically savvy through relationships or social capital. In relation to the big “P” political scientists have described these as grasstops.

Essentially, nursing needs to develop more grasstops. Grasstops are defined as lead- ers, such as those within an industry or field, who “usually know who within their sphere shares their interests and what other prominent leaders may be interested” (Gibson, 2010, p. 91). They also embody the social capital necessary to influence a member of Congress. “The member may listen to that person and no one else on a particular issue” (Gibson, 2010, p. 91). Many times, the grasstops are constituents who have supported members of Congress either politically (worked on a campaign) or financially (provided an individual donation to a campaign) or who are leaders in their industry (Goldstein, 1999).

To summarize, nursing can build its social capital by having individuals who are savvy (intellectual capital) and who have developed relationships with their elected representatives or staff: in other words, grasstops. The goal is to develop a meaning- ful relationship. That relationship helps the individual nurse be a valued and trusted resource to that member of Congress. At the core of social capital is developing a long- standing relationship.

Meaningful relationships can be nurtured through financial or personal volun- teerism. If financially contributing to the campaign of a member of Congress is not feasible, consider volunteering to work on the campaign. If your political views do not align with your current members of Congress, work on the campaign of their

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opponent. Also consider being an ever-present voice in your legislators’ offices, no matter their views or party affiliations. This activity can and has led to nurses becom- ing a major resource and influence on a legislator, a governor, or staff member.

Offering time and expertise is a significant determinant in one’s ability to influence a member of Congress and staff. These relationships do not form overnight. Do not give up even when you are told “no.” Even when you have differing political leanings than the member of Congress, you can have the opportunity to educate the legislator or staff about issues that are important.

Relationship building takes tenacity, particularly when you are working with a con- gressional office that might not have the same viewpoint and may never support the issue at hand. This should never be a reason not to visit a member of Congress and staff and pass on the opportunity to educate them about the issue and the importance to their constituency. “No” does not always mean never.

Grasstop relationships are important in nursing, as exemplified in the Policy Challenge and Option for Policy Challenge in this chapter. The type of social capital that a high-level professional position in leadership or in politics provides is important in not only opening doors to the discussion of issues, but also providing support that can sway support of or defeat a project or legislation. Although discussed under the big “P” here, there are grasstop advocates at the little “p” level. As a chair of a local political party or a local board, you may have access to influencing to influence other opinion leaders.

The Little “p” Social capital can ensure policy change at the little “p” level in many of the same ways as at the big “P.” The goal is developing relationships with individuals making the policy decisions and with individuals who have intellectual and social capital themselves. It is critical to identify who those individuals are and how you can connect with them. Often, at the big “P” level, the individuals with whom you want to develop relationships may be obvious, and at the little “p” level, it is sometimes less clear. At first, one may think of only the organizational hierarchy where you work as important in building social capital. Those relationships are vital. However, a good strategy is starting with your existing base of relationships and then broadening those relationships and networks. Consider all your acquaintances as potential opportunities to extend your social capi- tal. As your network grows, it extends to people who do not necessarily think like you or do the same job as you. You will become less insulated in your views, friendships, and networks.

As discussed in the section Political Capital, there is power in numbers. Building a network of colleagues (nurses and non-nurses) who agree with the premise of the policy change can better solidify the chances of its implementation. Demonstrating that more than one individual supports the policy change can influence the decision. Establishing this network can sometimes be done easily. Talking during a shift or dur- ing an after-hour socialization are some ways. Oprah Winfrey popularized her “book club,” and thousands began discussing literature. Take a cue from Oprah to create a “policy club,” a network that can offer information and assistance.

Building social capital at the local level can be accomplished in many ways: attending continuing education programs provided by your employer, participating in district nurses associations or other nurses’ groups, serving as a moderator for educational sessions, joining or participating in local organizations’ social events or journal clubs,

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using break times to socialize with key leaders in your organization, or volunteering for your organization’s community events. For example, one new graduate built social capital when she was asked by her nurse manager to volunteer for her hospital’s community health fair a week before her employment start date because one of the volunteers had an emergency. The graduate had experience in organizing community events. She fulfilled an important need in making the event a success while building important social capital.

A particularly effective way of learning about social capital is from a mentor. Mentors can, formally or informally, help you by advising you through stories and exemplars of how they were successful and not so successful in relationship building. Nurse leaders, such as committee chairs, managers, or nurse executives, can serve as mentors. Successful nurse leaders embrace helping nurses with less experience; they often tell you they owe their success to a mentor or mentors. They believe in paying it forward.

Whether social capital is built at the state, national, or local level, the key is not necessarily quantity, but quality. As your network grows, it is important to monitor and continually scan for changes in opinions, relationships, and opportunities to advance your social capital. Just as in building any relationship, it takes time and commitment to establish a trusted long-term relationship. A visit or phone call once a year is not enough. Consistent, regular communication is necessary. At the big “P” level, consis- tently taking the time to send your legislators a new study or simply checking in and offering assistance establishes that necessary connection. Moreover, creating opportu- nities to connect with your network at the little “p” level is also accomplished through consistent purposeful communications. Simple measures for maintaining a relation- ship yield great return on the social capital investment and can ultimately assist in creating policy changes.

POLITICAL CAPITAL Political capital is influence. It can take multiple forms: financial, social, and intellec- tual. For the context of this section, political capital is described as advocacy and “lob- bying” efforts undertaken by nurses and the nursing profession.

Often when the term lobbying is heard, it may carry a negative connotation, depending on an individual’s experience with the political process. Lobbying used in the general sense is promoting an agenda to influence specific decisions. However, there are precise definitions and regulations for lobbying at the federal and state levels that govern practices. The education of policy makers (e.g., providing information) and advocacy on an issue (see Chapter 2) are closely related but often misunderstood. The concepts of grassroots, free riders, and coalitions are introduced and clarified in relation to lobbying (see the section Financial Capital for the financial aspects of lobbying).

The Big “P” At the federal level, the Lobbying Disclosure Act (LDA) defines lobbying contact as any oral, written, or electronic communication to a federal official that is made on behalf of a client as specified in the LDA (Office of the Clerk, 2017). Moreover, lob- bying activities include “any efforts in support of such contacts, including preparation