Epidemiology, the Basis for Public Health

Public Health Policy

Marcia Stanhope, PhD, RN, FAAN Dr. Marcia Stanhope is currently an Associate of the Tufts and Associates Search Firm, Chicago, Ill. She is also a consultant for the nursing program at Berea College, Kentucky. She has practiced commu nity and home health nu rs ing, has served as an administrator and consultant in home health, and has been involved in the development of tw o nurse-managed centers . At one t ime in her career, she held a public policy fel- lowship and worked in the office of a U.S. senator. She has taught commun ity health, public health, epide- miology, policy, primary care nursing, and administration courses . Dr. Stanhope formerly directed the Division of Community Health Nursing and Adm inistration and served as Associate Dean of the College of Nursing at the University of Ke ntucky. She has been responsible for both undergraduate and graduate courses in population-centered nursing. She has also ta ught at the University of Virgin ia and the University of Alabama , Birmingham . During her career at the University of Kentuc ky she was appointed to the Good Samaritan Foundation Chair and Professorship in Community Health Nu rs ing, and was honored w ith the University Provost's Public Scholar award. Her presentations and publications have been in the areas of home health, community health, and community-focused nursing practice, as well as primary care nursing.

ADDITIONAL RESOURCES @ Evolve website http://evolve.elsevier.com/Stanhope • Case Studies • Healthy People 2020 • Glossary • WebLinks • Answers to Practice Application • Quiz

OBJECTIVES - -··-· - -~-"" ·----~ ~ -·· ------ ---------------------------

After reading this chapter, the student should be able to do the following: 1. Discuss the structure of the U.S. government and health

care roles. 2. Identify the functions of key governmental and quasi-

governmental agencies that affect public health systems and nursing, both around the world and in the United States.

KEY TERMS

3. Differentiate between the primary bodies of law that affect nursing and health care.

4. Define key terms related to policy and politics. 5. State the relationships between nursing practice, health

policy, and politics. 6. Develop and implement a plan to communicate with

policy makers on a chosen public health issue.

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advanced practice nurses, p. 182 Agency for Healthcare Research and Quality, p. 174 American Association of Colleges of Nursing, p. 184 American Nurses Association, p. 172 block grants, p. 169 boards of nursing, p. 177 categorical funding, p. 176 constitutional law, p. 176 devolution, p. 169 health policy, p. 168 judicial law, p. 177 law,p.168 legislation, p. 177 legislative staff, p. 179

licensure, p. 179 National Institute of Nursing Research, p. 174 nurse practice act, p. 177 Occupational Safety and Health Administration, p. 173 Office of Homeland Security, p. 176 police power, p. 169 policy, p. 168 politics, p. 168 public policy, p. 168 regulations, p. 177 U.S. Department of Health and Human Services, p. 168 World Health Organization, p. 172 -See Glossary for definitions

167

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PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing

Definitions Governmental Role in U.S. Health Care

Trends and Shifts in Governmental Roles Government Health Care Functions

Healthy People 2020: An Example of National Health Policy Guidance

Organizations and Agencies that Influence Health International Organizations Federal Health Agencies Federal Non-Health Agencies State and Local Health Departments

Impact of Government Health Functions and Structures on Nursing

The Law and Health Care Constitutional Law Legislation and Regulation Judicial and Common Law

Nurses are an important part of the health care system and are greatly affected by governmental and legal systems. Nurses who select the community as their area of practice must be especially aware of the impact of government, law, and health policy on nursing, health, and the communities in which they practice. Insight into how government, law, and political action have changed over time is necessary to understand how the health care system has been shaped by these factors. Also, understand- ing how these factors have influenced the current and future roles for nurses and the public health system is critical for better health policy for the nation.

Nurses have historically viewed themselves as advocates for the health of the population. It is this heritage that has moved the discipline into the policy and political arenas. To secure a more positive health care system, nurse professionals must develop a working knowledge of government, key governmental and quasi-governmental organizations and agencies, health care law, the policy process, and the political forces that are shaping the future of health care. This knowledge and the motivation to be an agent of change in the discipline and in the community are necessary ingredients for success as a population-centered nurse.

DEFINITIONS To understand the relationship between health policy, politics, and laws, one must first understand the definitions of the terms. Policy is a settled course of action to be followed by a govern- ment or institution to obtain a desired end (CDC, 2014). Public policy is described as all governmental activities, direct or indi- rect, that influence the lives of all citizens (Birkland, 2010). Health policy, in contrast, is a set course of action to obtain a desired health outcome for an individual, family, group, com- munity, or society (WHO, 2014). Policies are made not only by governments, but also by such institutions as a health depart- ment or other health care agency, a family, a community, or a professional organization.

Laws Specific to Nursing Practice Scope of Practice Professional Negligence

Legal Issues Affecting Health Care Practices School and Family Health Home Care and Hospice Correctional Health

The Nurse's Role in the Policy Process Legislative Action Regulatory Action The Process of Regulation Nursing Advocacy

Politics plays a role in the development of such policies. Politics is found in families, professional and employing agen - cies, and governments. Politics determines who gets what and when and how they get it (Birkland, 2010). Politics is the art of influencing others to accept a specific course of action. There- fore, political activities are used to arrive at a course of action (the policy). Law is a system of privileges and processes by which people solve problems based on a set of established rules; it is intended to minimize the use of force (Yourdictionary, 2014). Laws govern the relationships of individuals and organi- zations to other individuals and to government. Through politi- cal action, a policy may become a law, a regulation, a judicial ruling, a decision, or an order.

After a law is established, regulations further define the course of action (policy) to be taken by organizations or indi- viduals in reaching an outcome. Government is the ultimate authority in society and is designated to enforce the policy whether it is related to health, education, economics, social welfare, or any other society issue. The following discussion explains the role of government in health policy.

GOVERNMENTAL ROLE IN U.S. HEALTH CARE In the United States, the federal and most state and local gov- ernments are composed of three branches, each of which has separate and important functions (Truman, 2014). The execu - tive branch is composed of the president ( or state governor or local mayor) along with the staff and cabinet appointed by this executive, various administrative and regulatory dep artments, and agencies such as the U.S. Department of Health and Human Services (USDHHS). The legislative branch (i.e., Con- gress at the federal level) is made up of two bodies: the Senate and the House of Representatives, whose members are elected by the citizens of particular geographic areas. There is a federal Division of Nursing, a section within the Health Resources and Services Agency (HRSA) of the USDHHS, that refines criteria

for nursing education programs as funded by Congress and

affirmed by the President. The judicial branch is composed of a system of federal, state,

and local courts guided by the opinions of the Supreme Court.

Each of these branches is established by the Constitution, and

each plays an important role in the development and imple-

mentation of health law and public policy.

The executive branch suggests, administers, and regulates

policy. The role of the legislative branch is to identify problems

and to propose, debate, pass, and modify laws to address those

problems. The judicial branch interprets laws and their meaning,

as in its ongoing interpretation of states' rights to define access

to reproductive health services to citizens of the states.

One of the first constitutional challenges to a federal law

passed by Congress was in the area of health and welfare in

1937, after the 74th Congress had established unemployment

compensation and old-age benefits for U.S. citizens (U.S. Law,

1937a). Although Congress had created other health programs

previously, its legal basis for doing so had never been chal-

lenged. In Stewart Machine Co. v. Davis (U.S. Law, 1937b), the

Supreme Court (judicial branch) reviewed this legislation and

determined, through interpretation of the Constitution, that

such federal governmental action was within the powers of

Congress to promote the general welfare. It was obvious in 2008

and beyond that unemployment benefits are important to the

economy and to individuals who lose jobs during a national

economic crisis (ELS, 2010). Most legal bases for the actions of Congress in health care

are found in Article I, Section 8 of the U.S. Constitution, includ-

ing the following: 1. Provide for the general welfare.

2. Regulate commerce among the states.

3. Raise funds to support the military.

4. Provide spending power. Through a continuing number and variety of cases and con-

troversies, these Section 8 provisions have been interpreted by

the courts to appropriately include a wide variety of federal

powers and activities. State power concerning health care is

called police power (Legal Information Institute, 2014). This

power allows states to act to protect the health, safety, and

welfare of their citizens. Such police power must be used fairly,

and the state must show that it has a compelling interest in

taking actions, especially actions that might infringe on indi-

vidual rights. Examples of a state using its police powers include

requiring immunization of children before being admitted to

school and requiring case finding, reporting, treating, and

follow-up care of persons with tuberculosis. These activities

protect the health, safety, and welfare of state citizens.

Trends and Shifts in Governmental Roles The government's role in health care at both the state and federal

level began gradually. Wars, economic instability, and political

differences between parties all shaped the government's role.

The first major federal governmental action relating to health

was the creation in 1798 of the Public Health Service (PHS).

Then in 1890 federal laws were passed to promote the public

health of merchant seamen and Native Americans. In 1934

CHAPTER 8 Public Health Policy

Senator Wagner of New York initiated the first national health

insurance bill. The Social Security Act of 1935 was passed to

provide assistance to older adults and the unemployed, and it

offered survivors' insurance for widows and children. It also

provided for child welfare, health department grants, and mater-

nal and child health projects. In 1948 Congress created the

National Institutes of Health (NIH), and in 1965 it passed very

important health legislation creating Medicare and Medicaid to

provide health care service payments for older adults, the dis-

abled, and the categorically poor. These legislative acts by Con-

gress created programs that were implemented by the executive

branch. In March 2010, the most recent legislation passed and

signed by President Obama to improve the health of the nation

and access to care was the health reform law, the Patient Protec-

tion and Affordable Care Act (US LAW, PL 111-148). See Chapter

3 for in-depth information (Kaiser Family Foundation, 2010a).

The U.S. Department of Health and Human Services

(USDHHS) (known first as the Department of Health, Educa-

tion, and Welfare [DHEW)) was created in 1953. The Health Care

Financing Administration (HCFA) was created in 1977 as the key

agency within the USDHHS to provide direction for Medicare

and Medicaid. In 2002 HCFA was renamed the Center for Medi-

care and Medicaid Services (CMS). During the 1980s, a major

effort of the Reagan administration was to shift federal govern-

ment activities to the states, including federal programs for health

care. The process of shifting the responsibility for planning, deliv-

ering, and financing programs from the federal level to the states

is called devolution. Throughout the 1980s and 1990s, Congress

has increasingly funded health programs by giving block grants

to the states. Devolution processes including block granting

should alert professional nurses that state and local policy has

grown in importance to the health care arena. With the new

health reform law, stimulus grants have been provided to state

and local areas to improve health care access (HRSA, 2010).

The role of government in health care is shaped both by the

needs and demands of its citizens and by the citizens' beliefs

and values about personal responsibility and self-sufficiency.

These beliefs and values often clash with society's sense of

responsibility and need for equality for all citizens. A federal

example of this ideological debate occurred in the 1990s over

health care reform. The Democratic agenda called for a health

care system that was universally accessible, with a focus on

primary care and prevention. The Republican agenda sup-

ported more modest changes within the medical model of the

delivery system. This agenda also supported reducing the

federal government's role in health care delivery through cuts

in Medicare and Medicaid benefits. The Democrats proposed

the Health Security Act of 1993, which failed to gain Congress's

approval. In an effort to make some incremental health care

changes, both the Democrats and the Republicans in Congress

passed two new laws. The Health Insurance Portability and

Accountability Act (HIPAA) allows working persons to keep

their employee group health insurance for up to 16 months

after they leave a job (U.S. Law 107-105, 1996). The State Child

Health Improvement Act (SCHIP) of 1997 provides insurance

for children and families who cannot otherwise afford health

insurance (U.S. Law, 1997).

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PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing

With the latest health care reform, numerous debates occurred in the House of Representatives and the Senate until there was agreement that the Senate version of the bill would be passed. On March 30, 2010 President Obama signed into law the Health Care and Education Reconciliation Act of 2010, which made some changes to the comprehensive health reform law and included House amendments to the new law (Kaiser, 2010B). See Chapter 3 for further discussion.

This discussion has focused primarily on trends in and shifts between different levels of government. An additional aspect of governmental action is the relationship between government and individuals. Freedom of individuals must be balanced with governmental powers. After the terrorist attacks on the United States in September (World Trade Center attack) and October (anthrax outbreak) of 2001, much government activity was being conducted in the name of national security.

It is interesting to note that before September 11, 2001, the Congress and President, recognizing that the public health system infrastructure needed help, passed "The Public Health Threats and Emergencies Act" (PL 106-505) in 2000. This law "addresses emerging threats to the public's health and autho- rizes the Secretary of HHS to take appropriate response actions during a public health emergency, including investigations, treatment, and prevention" (Katz et al, 2014, p. 133). This leg- islation is said to have signaled the beginning of renewed inter- est in public health as the protector for entire communities. In June 2002 the Public Health Security and Bioterrorism Pre- paredness and Response Act was signed into law (US Law 2002, PL 107-188), with $3 billion appropriated by Congress, to implement the following antibioterrorism activities: • Improving public health capacity • Upgrading of health professionals' ability to recognize and

treat diseases caused by bioterrorism • Speeding the development of new vaccines and other

countermeasures • Improving water and food supply protection • Tracking and regulating the use of dangerous pathogens

within the United States (Katz et al, 2014) Yet there is considerable debate on just how much govern-

mental intervention is necessary and effective and how much will be tolerated by citizens. For example, in 2010 approximately 49% of citizens were against the new health care reform acts, and the Republicans were seen as being obstructionists. In 2014, 50% of citizens were for government intervention and 50% against (Debate.org, 2013).

Government Health Care Functions Federal, state, and local governments carry out five health care functions, which fall into the general categories of direct services, financing, information, policy setting, and public protection.

Direct Services Federal, state, and local governments provide direct health ser- vices to certain individuals and groups. For example, the federal government provides health care to members and dependents of the military, certain veterans, and federal prisoners. State and local governments employ nurses to deliver a variety of services

to individuals and families, frequently on the basis of factors such as financial need or the need for a particular service, such as hypertension or tuberculosis screening, immunizations for chil- dren and older adults, and primary care for inmates in local jails or state prisons. The Evidence-Based Practice box presents a study that examined the use of a state health insurance program.

EVIDENCE-BASED PRACTICE Th e purpose of this study was to examine the changes in access to care, use of services , and quality of care among children enrolled in Child Health Plus (CHPlus), a state hea lth insurance program for low-income ch il dren that became a model for the State Child Hea lth Insurance Program (SC HIP). A before-and-after design was used to eva luate the health care experience of children the year before and the year after enrollment in the state health insurance program. The study consisted of 2126 chil dren from New York State, ran ging from birth to 12.99 years of age. Results indicated that the state health insu rance program for low-income children was associated with improved access, use, and quality of care. The development and implementa - tion of SC HIP was an outcome of the soaring costs of health care and the fact that there were 11 million un insured children in the United States at the time of the study. It was the largest public investm ent in child health in 30 years .

Nurse Use Th is study su pports the value of health policy and the need to evaluate the effectiveness of policy in accomplishi ng the purposes of the policy.

From U.S. Department of Health and Human Services: Healthy People 2010: understanding and improving health, ed 2, Wash ington, DC,2000, U.S . Government Printing Office.

Financing Governments pay for some health care services; the 2011 per- centage of the bill paid by the government was about 46.3%, and this is projected to increase to 47.6% by the year 2015. The government also pays for training some health personnel and for biomedical and health care research (NCHS, 2014). Support in these areas has greatly affected both consumers and health care providers. Federal governments finance the direct care of clients through the Medicare, Medicaid, Social Security, and SCHIP programs. State governments contribute to the costs of Medicaid and SCHIP programs. Many nurses have been edu- cated with government funds through grants and loans, and schools of nursing in the past have been built and equipped using federal funds. Governments also have financially sup- ported other health care providers, such as physicians, most significantly through the program of Graduate Medical Educa- tion funds.

The federal government invests in research and new program demonstration projects, with NIH receiving a large portion of the monies. The National Institute of Nursing Research (NINR) is a part of the NIH and, as such, provides a substantial sum of money to the discipline of nursing for the purpose of develop- ing the knowledge base of nursing and promoting nursing ser- vices in health care (NINR, 2014) .

Information All branches and levels of government collect, analyze, and dis- seminate data about health care and health status of the citizens.

, TAB LE 8-1 International and National Sources of Data on the Health Status of the U.S. Population

Organization

International United Nations

World Health Organization

Federal Department of

Health and Human Services

Department of Commerce

Department of Labor

Data Sources

http://www.un.org/ Demographic Yearbook http://www.who.int/en/ World Health Statistics Annual

http//www.hhs.gov

National Vital Statistics System

National Survey of Family Growth

National Health Interview Survey

National Health Examination Survey

National Health and Nutrition Examination Survey

National Master Facility Inventory

National Hospital Discharge Survey

National Nursing Home Survey

National Ambulatory Medical Care Survey

National Morbidity Reporting System

U.S . Immunization Survey Surveys of Mental Health Facilities

Estimates of National Health Expenditures

AIDS Surveillance Nurse Supply Estimates http://www.commerce.gov U.S Census of Popu lation Current Population Survey Population Estimates and Projections

http://www.dol.gov Consumer Price Index Employment and Earnings

An example is the annual report Health: United States, 2013,

compiled each year by the USDHHS (NCHS, 2014). Collecting

vital statistics, including mortality and morbidity data, gather-

ing of census data, and conducting health care status surveys

are all government activities. Table 8-1 lists examples of avail-

able federal and international data sources on the health status

of populations in the United States and around the world. These

sources are available on the Internet and in the governmental

documents' section of most large libraries. This information is

especially important because it can help nurses understand the

major health problems in the United States and those in their

own states and local communities.

Policy Setting

Policy setting is a chief governmental function. Governments at

all levels and within all branches make policy decisions about

health care. These health policy decisions have broad implica-

tions for financial expenses, resource use, delivery system

change, and innovation in the health care field. One law that

has played a very important role in the development of public

health policy, public health nursing, and social welfare policy in

the United States is the Sheppard-Towner Act of 1921 (USDHHS,

HRSA, 2010).

CHAPTER 8 Public Health Policy

The Sheppard-Towner Act made nurses available to provide

health services for women and children, including well-child

and child-development services; provided adequate hospital

services and facilities for women and children; and provided

grants-in-aid for establishing maternal-child welfare programs.

The act helped set precedents and patterns for the growth of

modern-day public health policy. It defined the role of the

federal government in creating standards to be followed by

states in conducting categorical programs such as the Women,

Infants, and Children (WIC) and Early Periodic Screening and

Developmental Testing (EPSDT) programs. The act also defined

the position of the consumer in influencing, formulating, and

shaping public policy; the government's role in research; a

system for collecting national health statistics; and the integrat-

ing of health and social services. This act established the impor-

tance of prenatal care, anticipatory guidance, client education,

and nurse-client conferences, all of which are viewed today as

essential nursing responsibilities.

Public Protection

The U.S. Constitution gives the federal government the author-

ity to provide for the protection of the public's health. This

function is carried out in numerous venues, such as by regulat-

ing air and water quality and protecting the borders from the

influx of diseases by controlling food, drugs, and animal trans-

portation, to name a few. The Supreme Court interprets and

makes decisions related to public health, such as affirming a

woman's rights to reproductive privacy (Roe v. Wade), requiring

vaccinations, and setting conditions for states to receive public

funds for highway construction/repair by requiring a minimum

drinking age.

HEALTHY PEOPLE 2020: AN EXAMPLE OF NATIONAL HEALTH POLICY GUIDANCE

In 1979 the surgeon general issued a report that began a 30-year

focus on promoting health and preventing disease for all Amer-

icans (DHEW, 1979). In 1989, Healthy People 2000 became a

national effort with many stakeholders representing the per-

spectives of government, state, and local agencies; advocacy

groups; academia; and health organizations (USDHHS, 1991).

Throughout the 1990s states used Healthy People 2000 objec-

tives to identify emerging public health issues. The success of

this national program was accomplished and measured through

state and local efforts. The Healthy People 2010 document

focused on a vision of healthy people living in healthy com-

munities. Healthy People 2020 has four overarching goals, which

can be found in the Healthy People 2020 box; this box compares

the goals of Healthy People documents from 2000 to 2020.

ORGANIZATIONS AND AGENCIES THAT INFLUENCE HEALTH International Organizations In June 1945, following World War II, many national govern-

ments joined together to create the United Nations (UN). By

charter, the aims and goals of the UN deal with human rights,

PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing

~ HEALTHY PEOPLE 2020 A Comparison of the Goals of Healthy People 2000, Healthy People 2010, and Healthy People 2020

Healthy People 2000

Increase the years of healthy life for Americans

Reduce health disparities among Americans

Achieve access to preventive services for a 11 Americans

Healthy People 2010

Increase quality and years of hea I thy I ife

Eliminate health disparities

Healthy People 2020

Atta ini ng high quality, longer lives fre e of preventable di sease, disability, injury, and premature death

Achieving health equity, eliminating di sparities, an d improving the health of all groups

Creating social and physical environments that promote good health for all

Promoting quality of life, healthy development, and healthy behaviors across all life stages

From U.S. Department of Hea lth and Human Se rvices : Leading indicators.In Healthy People 2000, 2010, & 2020, Washington, DC, 1989,1999, 2010, U.S. Government Prin ting Office.

world peace, international security, and the promotion of eco- nomic and social advancement of all the world's peoples. The UN, headquartered in New York City, is made up of six principal divisions, several subgroups, and many specialized agencies and autonomous organizations. With the approval and support of the UN Commission on the Status of Women, five world confer- ences on women have been held. At these conferences, the health of women and children and their rights to personal, educational, and economic security as well as initiatives to achieve these goals at the country level were debated and explored, and policies were formulated (United Nations, 1975, 1980, 1985, 1995, 2000). The work of the UN and the world conferences continues with agendas to include the development of human beings, eradica- tion of poverty, protection of human rights, investment in health, education, training, trade, economic growth, and a continued emphasis on women (United Nations, 2014).

One of the special autonomous organizations growing out of the UN is the World Health Organization (WHO). Estab- lished in 1946, WHO relates to the UN through the Economic and Social Council to achieve its goal to attain the highest pos- sible level of health for all persons. "Health for All" is the creed of the WHO. Headquartered in Geneva, Switzerland, the WHO has six regional offices. The office for the Americas is located in Washington, DC, and is known as the Pan American Health Organization (PAHO).

The WHO provides services worldwide to promote health, it cooperates with member countries in promoting their health efforts, and it coordinates the collaborating efforts between countries and the disseminating of biomedical research. Its ser- vices, which benefit all countries, include a day-to-day informa- tion service on the occurrence of internationally important diseases; the publishing of the international list of causes of disease, injury, and death; monitoring of adverse reactions to

drugs; and establishing of world standards for antibiotics and vaccines. Assistance available to individual countries includes support for national programs to fight disease, to train health workers, and to strengthen the delivery of health services. The World Health Assembly (WHA) is the WHO's policy-making body, and it meets annually. The WHA's health policy work provides policy options for many countries of the world in their development of in-country initiatives and priorities; however, although WHA policy statements are important everywhere, they are guides and not law. The WHA's most recent policy statement on nursing and midwifery was released in 2013, and the current worldwide shortage of professional nurses is now on the WHO agenda and is being addressed by country (WHA, 2011; WHO, 2010; WHO, 2013).

The World Health Report, first published in 1995, is WHO's leading publication. Each year the report combines an expert assessment of global health, including statistics relating to all countries, with a focus on a specific subject. The main purpose of the report is to provide countries, donor agencies, interna- tional organizations, and others with the information they need to help them make policy and funding decisions. In the 2010 report, the WHO mapped out what countries can do to modify their financing systems so they can move more quickly toward this goal-universal coverage-and sustain the gains that have been achieved. The report builds on new research and lessons learned from country experience. It provides an action agenda for countries at all stages of development and proposes ways that the international community can better support efforts in low-income countries to achieve universal coverage and improve health outcomes (WHO, 2010).

The presence of nursing in international health is increasing. Besides offering direct health services in every country in the world, nurses serve as consultants, educators, and program planners and evaluators. Nurses focus their work on a variety of public health issues, including the health care workforce and education, environment, sanitation, infectious diseases, well- ness promotion, maternal and child health, and primary care. Dr. Naeema Al-Gasseer of Bahrain has served as the scientist for nursing and midwifery at the WHO; Marla Salmon, former dean of nursing at The University of Washington, chaired a Global Advisory Group on Nursing and Midwifery; and Linda Tarr Whelan served as the U.S. Ambassador to the UN Com- mission on the Status of Women. Virginia Trotter Betts, past president of the American Nurses Association (ANA), served as a U.S. delegate to both the WHA and the Fourth World Con- ference on Women in Beijing in 1995, where she participated on the negotiating team of the conference to develop a platform on the health of women across the life span. Many U.S. nurse leaders, such as Dr. Carolyn Williams, current author in this book, have been WHO consultants.

Federal Health Agencies Laws passed by Congress may be assigned to any administrative agency within the executive branch of government for imple- menting, supervising, regulating, and enforcing. Congress decides which agency will monitor specific laws. For example, most health care legislation is delegated to the USDHHS. However, legislation concerning the environment would most

likely be implemented and monitored by the Environmental

Protection Agency (EPA), and that concerning occupational

health by the Occupational Safety and Health Administration

(OSHA) in the U.S. Department of Labor.

U.S. Department of Health and Human Services

The USDHHS is the agency most heavily involved with the

health and welfare of U.S . citizens. It touches more lives than

any other federal agency. The following agencies have been

selected for their relevance to this chapter.

Health Resources and Services Administration. The Health

Resources and Services Administration (HRSA) has been a long-

standing contributor to the improved health status of Americans

through the programs of services and health professions educa-

tion that it funds. The HRSA contains the Bureau of Health

Professions (BHPr), which includes the Division of Nursing as

well as the Divisions of Medicine, Dentistry, and Allied Health

Professions. The Division of Nursing is the key federal focus for

nursing education and practice, and it provides national leader-

ship to ensure an adequate supply and distribution of qualified

nursing personnel to meet the health needs of the nation.

At the 122nd meeting of the Division of Nursing's National

Advisory Council for Nursing Education and Practice

(NACNEP), the participants discussed the role of public health

nurses in participating in primary care in their communities.

The speaker indicated several factors that need to be in place to

support the public health nurse role:

• Baccalaureate standard for entry into practice

Ongoing stable funding for health departments

• Competitive salaries commensurate with responsibilities

Interventions grounded in and responsive to community

needs • Consideration of health determinants

• Experience in health promotion and prevention

Long-term trusting relationships in the community (i.e., with

clients) Established network of community partners

Commitment to social justice and eliminating health

disparities In the council's twelfth report to Congress (USDHHS, 2013a)

the council recommended further investment by the govern-

ment in public health nursing, arguing the need based on system

changes and the Affordable Care Act implementation, greater

need to connect public health and care delivery with front-line

public health nurses, plus the economic benefits of supporting

this investment. Through the input of the NACNEP, the Divi-

sion of Nursing sets policy for nursing nationally.

Centers for Disease Control and Prevention. The Centers

for Disease Control and Prevention (CDC) serve as the national

focus for developing and applying disease prevention and

control, environmental health, and health promotion and edu-

cation activities designed to improve the health of the people

of the United States. The mission of the CDC is to protect

America from health, safety and security threats, both foreign

and in the United States. Whether diseases start at home or

abroad, are chronic or acute, curable or preventable, human

error or deliberate attack, CDC fights disease and supports

communities and citizens to do the same. As such CDC increases

CHAPTER 8 Public Health Policy

the health security of our nation (CDC, 2014A) The CDC seeks

to accomplish its mission by working with partners throughout

the nation and the world in the following ways:

• To provide health security

• To detect and investigate health threats

To tackle the biggest health problems causing death and

disability • To conduct research that will enhance prevention

• To promote healthy and safe behaviors, communities, and

environments To develop leaders and train the public health workforce,

including disease detectives

• To develop and advocate sound public health policies

• To implement prevention strategies

• To promote healthy behaviors

• To foster safe and healthful environments

To provide leadership and training

The outbreak of summer 2014 is an example of how the CDC

fulfills its mission. The Shiga toxin-producing Escherichia coli

outbreak linked to raw clover sprouts affected six states

and 19 people, and 44% were hospitalized. Idaho was the state

that was most likely the source of the outbreak. The CDC regu-

larly collects data about foodborne illnesses through the National

Notifiable Disease Surveillance System on a weekly basis through

the CDC MMWR weekly report from states. Because of the

recognized increase in cases, states were asked to report aggre-

gate numbers of cases twice a week along with foodborne-related

hospitalizations and complications. The CDC implemented an

investigation to track the cases and worked with state and local

health departments to perform the following:

Detect the possible outbreak

• Define and find cases Generate hypotheses about the likely source

• Test the hypothesis • Find the point of contamination

• Control the outbreak from further spread

• Decide when the outbreak is over.

By August 2014, there had been about 19 cases beginning in

June 2014. In 3 months there were cases in 6 states. Figure 8-1

presents a CDC map indicating cases per state (CDC, MMWR

Dispatch, 2014b). The six states involved were California

(1), Idaho (3), Michigan (1), Montana (2), Utah (1), and Wash -

ington (11). By August 2014 CDC determined the outbreak to

be over. Although few people were involved in this outbreak,

the outcome could have been deadly to the persons who ate the

sprouts. While the Ebola virus of West Africa continues to

spread, the CDC is monitoring the effects of the virus as part

of their global monitoring system. CDC has information and

training materials ready for those who may need to use the

materials (CDC, 2014c). The CDC has taken an active role in

the recent outbreak of measles as a result of exposure to the

virus at Disneyland in California. This outbreak resulted in 140

people from seven states being infected. On 1/23/2015, the CDC

issued a health advisory to all public health and health care

facilities nationwide (Zipprich et al, 2015).

National Institutes of Health. Founded in 1887, NIH today is

one of the world's foremost biomedical research centers, and the

federal focus point for biomedical research in the United States.

" "·:·.-,, .... ,- -¢r(. >~£-;.·\~:

f/,'::,:~\ r:,z~i~;~i; PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing

FIG 8-1 The number of reported Escherichia coli cases linked to multistate outbreak, by state-United States, May to August, 2014 (From Centers for Disease Control and Prevention: Epidemiologv of Escherichia coli outbreak, United States, Atlanta, 2014 USDHHS.)

The NIH is composed of 27 separate institutes and centers. The goal of NIH research is to acquire new knowledge to help prevent, detect, diagnose, and treat disease and disability, from the rarest genetic disorder to the common cold. The NIH mission is to uncover new knowledge that will lead to better health for every- one. The NIH works toward that mission by conducting research in its own laboratories; supporting the research of nonfederal scientists in universities, medical schools, hospitals, and research institutions throughout the country and abroad; helping in the training of research investigators; and fostering communication of medical and health sciences' information (NIH, 2010a).

In late 1985 Congress overrode a presidential veto, allowing the creation of the National Center for Nursing Research within the NIH. In 1993 the Center became one of the divisions of the NIH and was renamed the National Institute of Nursing Research (NINR). The research and research-related training activities previously supported by the Division of Nursing were transferred to the new Institute. The NINR is the focal point of the nation's nursing research activities. It promotes the growth and quality of research in nursing and client care, provides important leadership, expands the pool of experienced nurse researchers, and serves as a point of interac- tion with other bases of health care research. The mission of NINR is to promote and improve the health of individuals, families, communities, and populations.

NINR supports and conducts clinical and basic research and research training on health and illness across the life span. The research focus encompasses health promotion and disease pre- vention, quality of life, health disparities, and end of life. NINR seeks to extend nursing science by integrating the biological and behavioral sciences, using new technologies to research ques- tions, improving research methods, and developing the scien- tists of the future (NINR, 2011).

Agency for Healthcare Research and Quality. The Agency for Healthcare Research and Quality (AHRQ) is the lead

federal agency charged with improving the quality, safety, effi- ciency, and effectiveness of health care for all Americans. As one of 12 agencies within the USDHHS, AHRQ supports health services research that will improve the quality of health care and promote evidence-based decision making. AHRQ is committed to improving care safety and quality by developing successful partnerships and generating the knowledge and tools required for long-term improvement. The goal of AHRQ research is to promote measurable improvements in health care in America. The outcomes are gauged in terms of improved quality of life and client outcomes, lives saved, and value gained for what we spend (AHRQ, 2014a).

By examining what works and what does not work in health care, the AHRQ fulfills its missions of translating research find- ings into better client care and providing consumers, policy makers, and other health care leaders with information needed to make critical health care decisions. In 1999, Congress, through legislation, specifically directed AHRQ to focus on measuring and improving health care quality; promoting client safety and reducing medical errors; advancing the use of infor- mation technology for coordinating client care and conducting quality and outcomes research; and seeking to eliminate dis- parities in health care delivery for the priority populations of low-income groups, minorities, women, children, older adults, and individuals with special health care needs.

The AHRQ published protocols for care of clients with a variety of health problems. These protocols became the stan- dards of health care delivery. The agency continues to maintain a clinical practice guidelines clearinghouse for use by clinicians and others. In addition, the AHRQ had a project called "Put Prevention into Practice" to promote the use of standardized protocols for primary care delivery for clients across the age span (see Schedule of Clinical Preventive Services in AHRQ, 2014b). Today there is a program titled The Practice-Based Research Network that rapidly develops and assesses methods

____________________ C_H_A_P_TE_R_ 8_ P_u_b_li_c_H_e_a_lt_h_P_o_li -'cy,____.-

and tools to ensure that new scientific evidence is incorporated

into real-world practice settings (AHRQ, 2014c).

Centers for Medicare and Medicaid Services. One of the

most powerful agencies within the USDHHS is the CMS, which

administers Medicare and Medicaid accounts and guided

payment policy and delivery rules for services for 100 million

people in 2014 (CMS, 2014). In addition to providing health

insurance, CMS also performs a number of quality-focused

health care or health-related activities, including regulating of

laboratory testing, developing coverage policies, and improving

quality of care. CMS maintains oversight of the surveying and

certifying of nursing homes and continuing care providers

(including home health agencies, intermediate care facilities for

the developmentally disabled, and hospitals). It makes available

to beneficiaries, providers, researchers, and state surveyors

information about these activities and nursing home quality.

Federal Non-Health Agencies Although the USDHHS has primary responsibility for federal

health functions, several other departments of the executive

branch carry out important health functions for the nation.

Among these are the Defense, Labor, Agriculture, and Justice

Departments.

Department of Defense The Department of Defense delivers health care to members of

the military, to their dependents and survivors, to National Guard

and reserve members, and to retired members and their families.

The assistant secretary of defense for health affairs administers a

variety of health care plans for service personnel: TriCare Prime

(a managed care arrangement) and an option for fee-for-service

plans called TriCare Standard as well as TriCare Extra with many

other options available. In each branch of the uniformed services,

nurses of high military rank are part of the administration of

these health services (U.S. Department of Defense, 2014).

Department of Labor The Department of Labor houses OSHA, which imposes work-

place requirements on industries. These requirements shape the

functions of nurses and the types of health services provided to

workers in the workplace. A record-keeping system required by

OSHA greatly affects health records in the workplace. Each state

has an agency similar to OSHA that also monitors and inspects

industries, as well as the health services delivered to them by nurses.

Needlestick injuries and other sharps-related injuries that

result in occupational bloodborne pathogen exposure continue

to be an important public health concern, especially to health

care workers. In response to this serious situation, Congress

passed the Needle Stick Safety and Prevention Act, which

became law on November 6, 2000. To meet the requirements of

this act, OSHA revised its Bloodborne Pathogen Standard to

become effective on April 18, 2002. This act clarified the respon-

sibility of employers to select safer needle devices as they

become available and to involve employees in identifying and

choosing the devices. The updated standard also required

employers to maintain a log of injuries from contaminated

sharps (OSHA, 2008; 2011; OSHA, 2013).

Department of Agriculture

The Department of Agriculture houses the Food and Nutrition

Service, which oversees a variety of food assistance activities.

This service collaborates with state and local government

welfare agencies to provide food stamps to needy persons to

increase their food purchasing power. Other programs include

school breakfast and lunch programs, WIC, and grants to states

for nutrition education and training. In 2013, WIC provided

support for 53% of all infants born in the United States.

Although these programs have been successful, the increasing

use of the process of giving federal block grants to states (rather

than implementing national programs) may threaten the effec-

tiveness of these programs because of differences in how deci-

sions are made at the state level on how to spend money on

nutrition (USDA, 2013).

Department of Justice

Health services to federal prisoners are administered within the

Department of Justice. The Federal Bureau of Prisons is respon-

sible for the custody and care of approximately 214,000 federal

offenders (Bureau of Federal Prisons, 2014). The Medical and

Services Division of the Bureau of Prisons includes medical,

psychiatric, dental, and health support services with commu-

nity standards in a correctional environment. Health promo-

tion is emphasized through counseling during examinations,

education about effects of medications, infectious disease pre-

vention and education, and chronic care clinics for conditions

such as cardiovascular disease, diabetes, and hypertension. The

Bureau also provides forensic services to the courts, including

a range of evaluative mental health studies outlined in federal

statutes. Health care for prisoners is highly regulated because of

a series of court decisions on inmates' rights.

State and Local Health Departments Depending on funding, public commitment and interest, and

access to other resources, programs offered by state and local

health departments vary greatly. Many state and local health

officials report that employees in public health agencies lack

skills in the core sciences of public health, and that this has

hindered their effectiveness. The lack of specialized education

and skill is a significant barrier to population-based preventive

care and the delivery of quality health care to the public. Public

health workforce specialists report that the number of retirees

expected in this decade will result in a major shortage of public

health workers, including nurses. More often than at other levels

of government, nurses at the local level provide direct services.

Some nurses deliver special or selected services, such as

follow -up of contacts in cases of tuberculosis or venereal disease

or providing child immunization clinics. Other nurses have a

more generalized practice, delivering services to families in

certain geographic areas (PHF, 2010; University of Michigan

Center of Excellence in Public Health Workforce Studies, 2013).

At the local and state levels, coordinating health efforts

between health departments and other county or city depart-

ments is essential. Gaps in community coordination are showing

up in glaring ways as states and communities scramble to

PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing

address bioterrorism preparedness since September 11, 2001, and since such natural disasters as Hurricane Katrina. The United States had 220,000 people lose their homes in 2013 due to extreme storms and tornadoes in Oklahoma and another 100,000 from flooding in Colorado. Health departments are on the front line in such occurrences (see Chapter 46).

IMPACT OF GOVERNMENT HEALTH FUNCTIONS AND STRUCTURES ON NURSING The variety and range of functions of governmental agencies have had a major impact on the practice of nursing. Funding, in particular, has shaped roles and tasks of population-centered nurses. The designation of money for specific needs, or cate- gorical funding, has led to special and more narrowly focused nursing roles. Examples are in emergency preparedness, school nursing, and family planning. Funds assigned to antibioterror- ism cannot be used to support unrelated communicable disease programs or family planning.

The events of September 11, 2001, have had the public and the profession of nursing concerned about the ability of the present public health system and its workforce to deal with bio- terrorism, especially outbreaks of deadly and serious communi- cable diseases. For example, smallpox vaccinations were stopped in 1972, but immunity lasts for only 10 years; although there have been no reported cases since the early 1970s, almost no one in the United States retains their immunity. Thus, the population is vulnerable to a smallpox outbreak, and smallpox could be used as a weapon ofbioterrorism. Two laboratories in the world retain a small amount of the smallpox virus. Because of these potential threats, the U.S. government has begun to increase production of the vaccine (NIH, 201 Ob). Few public health professionals are knowledgeable of the symptoms, treatment, or mode of trans- mission of this disease . Most health professionals, including reg- istered nurses (RNs), who currently work in the United States, have never seen a case of anthrax, smallpox, or plague-the three major biological weapons of concern in the world today. A few have now seen the effects of the Ebola virus. The USDHHS and the federal Office of Homeland Security have provided funds to address this serious threat to the people of the United States.

One of the first things being done is the rebuilding of the crumbling public health infrastructures of each state to provide surveillance, intervention, and communication in the face of future bioterrorism events and natural disasters. On December 19, 2006, President George W. Bush signed the Pandemic and All-Hazards Preparedness Act (PAHPA), which was intended to improve the organization, direction, and utility of preparedness efforts. PAHPA centralizes federal responsibilities, requires state-based accountability, proposes new national surveillance methods, addresses surge capacity, and facilitates the develop- ment of vaccines and other scarce resources (Morhard and Franco, 2013). On March 13, 2013, President Barrack Obama signed the Pandemic and All-Hazards Preparedness Reauthori- zation Act into law. The 2013 law reauthorizes funding for public health and medical preparedness programs that enable communities to build systems to support people in need during and after disasters (USDHHS, 2013B).

THE LAW AND HEALTH CARE The United States is a nation of laws, which are subject to the U.S. Constitution. The law is a system of privileges and pro- cesses by which people solve problems on the basis of a set of established rules. It is intended to minimize the use of force. Laws govern the relationships of individuals and organizations to other individuals and to government. After a law is estab- lished, regulations further define the course of actions to be taken by the government, organizations, or individuals in reach- ing an agreed-on outcome. Government and its laws are the ultimate authority in society and are designed to enforce official policy whether it is related to health, education, economics, social welfare, or any other society issue. The number and types of laws influencing health care are ever increasing. Definitions of law (Catholic University of America, 2010) include the following:

A rule established by authority, society, or custom The body of rules governing the affairs of people, communi- ties, states, corporations, and nations A set of rules or customs governing a discrete field or activity ( e.g., criminal law, contract law)

These definitions reflect the close relationship of law to the community and to society's customs and beliefs.

The law has had a major impact on nursing practice. Although nursing emerged from individual voluntary activities, society passed laws to give formality to public health and, through legal mandates (i.e., laws), positions and functions for nurses in community settings were created. These functions in many instances carry the force of law. For example, if the nurse discovers a person with smallpox, the law directs the nurse and others in the public health community to take specific actions. In another example, in a mumps outbreak, a nurse and other health professionals are required to report mumps cases. This reporting requirement helps with locating and treating cases so cases can be treated or isolated as they occur to prevent further spreading of disease . Three types of laws in the United States have particular importance.

Constitutional Law Constitutional law derives from federal and state constitutions. It provides overall guidance for selected practice situations. For example, on what basis can the state require quarantine or isola- tion of individuals with tuberculosis? The U.S. Constitution specifies the explicit and limited functions of the federal gov- ernment. All other powers and functions are left to the indi- vidual states. The major constitutional power of the states relating to population-centered nursing practice is the state's right to intervene in a reasonable manner to protect the health, safety, and welfare of its citizens. The state has police power to act through its public health system, but it has limits. First, it must be a "reasonable" exercise of power. Second, if the power interferes or infringes on individual rights, the state must dem- onstrate that there is a "compelling state interest" in exercising its power. Isolating an individual or separating someone from a community because that person has a communicable disease has been deemed an appropriate exercise of state powers. The

state can isolate an individual even though it infringes on indi-

vidual rights (such as freedom and autonomy), under the fol-

lowing conditions (Lee et al, 2012):

• There is a compelling state interest in preventing an

epidemic. • The isolation is necessary to protect the health, safety, and

welfare of individuals in the community or the public as a

whole. • The isolation is done in a reasonable manner.

The legal and medical communities along with AIDS

(acquired immunodeficiency syndrome) activists rejected (and

made the case) that the social quarantine of individuals with

AIDS was unnecessary. Thus, individual freedom and auton-

omy of the individual come before "compelling state interest"

unless science warrants another conclusion (Swendiman and

Elsea, 2010).

Legislation and Regulation Legislation is law that comes from the legislative branches of

federal, state, or local government. This is referred to as Statute

Law because it becomes coded in the statutes of a government

(Birkland, 2010). Much legislation has an effect on nursing.

Regulations are specific statements of law related to defining

or implanting individual pieces of legislation or statute law.

For example, state legislatures enact laws (statutes) establishing

boards of nursing and defining terms such as registered nurse

and nursing practice. Every state has a board of nursing.

The board may be found either in the department of licensing

boards of the health department or in an administrative agency

of the governor's office. Created by legislation known as a

state nurse practice act, the board of nursing is made up of

nurses and consumers. The functions of this board are

described in the nurse practice act of each state and generally

include licensing and examination of RNs and licensed practi-

cal nurses; licensing and/or certification of advanced practice

nurses; approval of schools of nursing in the state; revocation,

suspension, or denying of licenses; and writing of regulations

about nursing practice and education.

The state boards of nursing operationalize, implement, and

enforce the statutory law by writing explicit statements (rules)

on what it means to be an RN, and on the nurse's rights and

responsibilities in delegating work to others and in meeting

continuing education requirements.

All nurses employed in community settings are subject to

legislation and regulations. For example, home health care

nurses employed by private agencies must deliver care accord-

ing to federal Medicare or state Medicaid legislation and

regulations, so the agency can be reimbursed for those services.

Private and public health care services rendered by nurses

are subject to many governmental regulations for quality

of care, standards of documentation, and confidentiality of

client records and communications. All state health dep art-

ments have a public health practice reference that governs the

practice of nurses and others, and state public health laws

that define the essential public health services that must be

offered in the state as well as the optional services that may also

be offered.

CHAPTER 8 Public Health Policy

Judicial and Common Law Both judicial law and common law have great impact on

nursing. Judicial law is based on court or jury decisions. The

opinions of the courts are referred to as case law (Birkland,

2010). The court uses other types oflaws to make its decisions,

including previous court decisions or cases. Precedent is one

principle of common law. This means that judges are bound by

previous decisions unless they are convinced that the older law

is no longer relevant or valid. This process is called distinguish-

ing, and it usually involves a demonstration of how the current

situation in dispute differs from the previously decided situa-

tion. Other principles of common law such as justice, fairness,

respect for individual's autonomy, and self-determination

are part of a court's rationale and the basis upon which to make

a decision.

LAWS SPECIFIC TO NURSING PRACTICE

Despite the broad nature and varied roles of nurses in practice,

two legal arenas are most applicable to nurse practice situations.

The first is the statutory authority for the profession and its

scope of practice, and the second is professional negligence or

malpractice.

Scope of Practice The issue of scope of practice involves defining nursing, setting

its credentials, and then distinguishing between the practices of

nurses, physicians, and other health care providers. The issue is

especially important to nurses in community settings, who have

traditionally practiced with much autonomy.

Health care practitioners are subject to the laws of the state

in which they practice, and they can practice only with a license.

The states' nurse practice acts differ somewhat, but they are the

most important statutory laws affecting nurses. The nurse prac-

tice act of each state accomplishes at least four functions: defin-

ing the practice of professional nursing, identifying the scope

of nursing practice, setting educational qualifications and other

requirements for licensure, and determining the legal titles

nurses may use to identify themselves. The usual and customary

practice of nursing can be determined through a variety of

sources, including the following:

• Content of nursing educational programs, both general

and special • Experience of other practicing nurses (peers)

Statements and standards of nursing professional

organizations Policies and procedures of agencies employing nurses

Needs and interests of the community

Updated literature, including research, books, texts, and

journals • Internet sites if it can be determined that the site is a profes-

sional source of information All of these sources can describe, determine, and refine the

scope of practice of a professional nurse. Every nurse should

know and follow closely any proposed changes in the practice

acts of nursing, medicine, pharmacy, and other related

PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing

professions. The nurse should always examine all legislation, rules, and regulations related to nursing practice. For example, a review of the pharmacy act will let the nurse know whether to question the right to dispense medications in a family plan- ning clinic in a local health department. Defining the scope of practice forces one to clarify independent, interdependent, and dependent nursing functions.

Just as practice acts vary by state, so do the evolving issues and tensions of scopes of practice among the health professions. In past years, several state legislatures ( working closely with the National Council of State Boards of Nursing) embarked on a legislative effort to develop the Interstate Nurse Licensure Compact. The compact allows mutual recognition of generalist nursing licensure across state lines in the compact states. By 2014, 24 states had adopted the compact (NCSBN, 2014).

Professional Negligence Professional negligence, or malpractice, is defined as an act ( or a failure to act) that leads to injury of a client. To recover money damages in a malpractice action, the client must prove all of the following: 1. That the nurse owed a duty to the client or was responsible

for the client's care 2. That the duty to act the way a reasonable, prudent nurse

would act in the same circumstances was not fulfilled 3. That the failure to act reasonably under the circumstances

led to the alleged injuries 4. That the injuries provided the basis for a monetary claim

from the nurse as compensation for the injury Reported cases involving negligence and population -centered

nurses are rare. However, the following is an example:

Home Nurse Fails to Properly Supervise Bottle Feeding of Child With Tracheal Tube for Oxygen-Death-$4.5 Million Verdict

The plaintiff, a child, age sixteen months, suffered insuf- ficiency of her lungs and required a continuous supply of oxygen via a tracheal tube. She required constant supervi - sion by a home health nurse.

In January 2008, during the day a bottle of formula was given by the nurse. The formula entered the tracheal tube and lungs. After several minutes the nurse observed that the child had stopped breathing and began cardiopulmonary resuscitation. The child did not survive. It was determined that the child had suffered asphyxiation due to ingestion of vomited material.

The plaintiff claimed that the child had choked and gagged throughout the nurse's resuscitation attempts and that CPR was not the correct method of resuscitating the child. The plaintiff claimed that the tracheal tube should have been cleared or changed.

The case was initially brought against the defendant nurse's employer, the home care agency, and the hospital which had provided the tracheal tube. The claims against the hospital were discontinued and the matter proceeded to trial against the home care agency. The defendant did not contest liability.

According to a published account a $4.5 million verdict was returned for the child's pain and suffering. A defense motion to set aside the verdict was pending.

With permission from Medical Malpractice Verdicts,

Settlements & Experts; Lewis Laska, Editor, 901 Church St., Nashville,

TN 37203-3411,2013 1-800-298-6288.

An integral part of all negligence actions is the question of who should be sued. When a nurse is employed and functioning within the scope of employment, the employer is responsible for the nurse's negligent actions. This is referred to as the doc- trine of respondeat superior. By directing a nurse to carry out a particular function, the employer becomes responsible for neg- ligence, along with the individual nurse. Because employers are usually better able to pay for the injuries suffered by clients, they are sued more often than the nurses themselves , although an increasing number of judgments include the professional nurse by name as a co-defendant. In some instances, if the agency is found liable, the agency may in turn sue the nurse for negli- gence. At least, the nurse often loses the job.

Thus, it is imperative that all nurses engaged in clinical prac- tice carry their own professional liability insurance. Nurses may have personal immunity for particular practice areas, such as giving immunizations. In some states, the legislature has granted personal immunity to nurses employed by public agencies to cover all aspects of their practice under the legal theory of sov- ereign immunity (Cherry and Jacobs, 2013).

Nursing students need to be aware that the same laws and rules that govern the professional nurse govern them. Students are expected to meet the same standard of care as that met by any licensed nurse practicing under the same or similar circum- stances. Students are expected to be able to perform all tasks and make clinical decisions on the basis of the knowledge they have gained or been offered, according to their progress in their educational programs and along with adequate educational supervision.

LEGAL ISSUES AFFECTING HEALTH CARE PRACTICES Specific legal issues of nursing vary depending on the setting where care is delivered, the clinical arena, and the nurse's func- tional role. The law, including legislation and judicial opinions, significantly affects each of the following areas of nursing prac- tice. Nurses responsible for setting and implementing program priorities need to identify and monitor laws related to each special area of practice.

School and Family Health Nurses employed by health departments or boards of education may deliver school and family health nursing. School health legislation establishes a minimum of services that must be pro- vided to children in public and private schools. For example, most states require that children be immunized against certain communicable diseases before entering school. Children must

have had a physical examination by that time, and most states

require at least one physical at a later time in their schooling.

Legislation also specifies when and what type of health screen-

ing will be conducted in schools ( e.g., vision and hearing

testing). These requirements are found in statutory laws of

states. Some states are now requiring a simple dental examina-

tion in schools for the purpose of referring children to a dental

health professional if needed.

Statutes addressing child abus e and neglect make a large

impact on nursing practice within schools and families. Most

states require nurses to notify police and/or a social service

agency of any situation in which they suspect a child is being

abused or neglected. This is one instance in which the law man-

dates that a health professional breach client confidentiality to

protect someone who may be in a helpless or vulnerable posi-

tion. There is civil immunity for such reporting, and the nurse

may be called as a witness in a court hearing of the case.

Occupational health is another special area of practice that

has specific legal requirements as a result of state and federal

statutes. Of special concern are the state workers' compensation

statutes, which provide the legal foundation for claims of

workers injured on the job. Access to records, confidentiality,

and the use of standing orders are legal issues that have great

practice significance to nurses employed in industries.

Home Care and Hospice Home care and hospice services rendered by nurses are shaped

through state statutes and have specific nursing requirements

for licensure and certification. Compliance with these laws is

directly linked to the method of payment for the services. For

example, a service must be licensed and certified to obtain

payment for services through Medicare. Federal regulations

implementing Medicare/Medicaid have an enormous effect on

much of nursing practice, including how nurses record details

of their visits, record time spent in care activities, and document

client care and the client's status and progress.

In addition, many states have passed laws requiring nurses

to report elder abuse to the proper authorities, as is done with

children and youth. Laws affecting home care and hospice ser-

vices have focused on such issues as the right to death with

dignity, rights of residents of long-term facilities and home

health clients, definitions of death, and the use of living wills

and advance directives. The legal and ethical dimensions of

nursing practice are particularly important. Individual rights,

such as the right to refuse treatment, and nursing responsibili-

ties, such as the legal duty to render reasonable and prudent

care, may appear to be in conflict in delivering home and

hospice services. Much case discussion (sometimes including

outside ethics consultation) may be needed to resolve such

conflicts.

Correctional Health Correctional health nursing practice is significantly shaped by

federal and state laws and regulations and by recent Supreme

Court decisions. The laws and decisions primarily relate to the

type and amount of services that must be provided for incarcer-

ated individuals. For example, physical examinations are

CHAPTER 8 Public Health Policy

required for all prisoners after they are sentenced. Regulations

specify basic levels of care that must be provided for prisoners,

and access to care during illness is a particular focus. Court

decisions requiring adequate health services are based on con-

stitutional law. If minimal services are not provided, it is a viola-

tion of a prisoner's right to freedom from cruel and unusual

punishment. Such decisions provide a framework that strongly

influences the setting of nursing priorities. For example, provid-

ing care to the sick would take priority over wellness or health

education classes.

THE NURSE'S ROLE IN THE POLICY PROCESS

The number and types of laws influencing health care are

increasing. Because of this, nurses need to be involved in the

policy process and understand the importance of involvement

of nursing to the clients they serve.

For nurses to effectively care for their client populations and

their communities in the complex U.S. health care system, pro-

fessional advocacy for lo gical health policy that considers equal-

ity is essential. Professional nurses working in the community

know all too well about the health care problems they and their

clients encounter daily, and it is through policy and political

activism that both big-picture and long-term solutions can be

developed. Although the term policy may sound rather lofty, health

policy is quite simply the process of turning health problems

into workable action solutions. Health policy is developed on

the three-legged stool of access, cost, and quality. The policy

process, which is very familiar to professional nurses, includes

the following: • Statement of a health care problem

• Statement of policy options to address the health problem

• Adoption of a particular policy option

Implementation of the policy product (e.g., a service)

Evaluation of the policy's intended and unintended conse-

quences in solving the original health problem

Thus the policy process is very similar to the nursing process,

but the focus is on the level of the larger society and the

adoption strategies require political action. For most profes-

sional nurses, action in the policy arena comes most easily

and naturally through participation in nursing organizations

such as the ANA at the state level or the Association of

Community Health Nursing Educators (ACHNE) or the Asso-

ciation of State and Territorial Directors of Nursing (ASTDN)

at the national or state level, and in certain specialty organiza-

tions like the American Association of Specialty Nursing

Organizations.

Legislative Action It is often helpful to review the legislative and political processes

that may have been a part of high school education. It becomes

important material to remember as a professional career is

embarked upon. The people within geographic jurisdictions elect their legis-

lative representatives and senators. An important part of the

legislative process is the work of the legislative staff. These

PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing

individuals do the legwork, research, paperwork, and other activities that move policy ideas into bills and then into law. In addition to the individual legislator's office, the congressional committee staffs are also important. They are usually experts in the content of the work of a committee, such as a health and welfare committee. Frequently, developing a working relation- ship with key legislative staffers can be as important to achiev- ing a policy objective as the relationship with the policy maker (i.e., the legislator).

The legislative process begins with ideas (policy options) that are developed into bills. After a bill is drafted, it is intro- duced to the legislature, given a number, read, and assigned to a committee. Hearings, testimony, lobbying, education, research, and informal discussions follow. If the bill is passed from the legislative committee, the entire House of Representatives hears the bill, amends it as necessary, and votes on it. A majority vote moves the bill to Senate where it is read and amended, and then a vote is taken. Figure 8-2 shows the necessary formal process of the legislative pathway.

Nurses can be involved in the legislative process at any point. Many professional nursing associations have legislative com- mittees made up of volunteers, governmental relations staff professionals, and sometimes political action committees (PACs), all engaged in efforts to monitor, analyze, and shape health policy.

BOX 8-1 Tips for Visits with Legislators • Face-to-face visits are viewed as the most effective. • Call ahead and ask how much time the staff or legislator is able to give you. • When you arrive, ask if the appointment time is the same or if a scheduled vote

on the House/Senate floor is going to need the legislator's attention. • Engage in small talk at the beginning of the conversation only if the staff or

legislator has time. • Structure time so that the issue can be briefly presented. The visit will prob-

ably be 15 minutes or less. • Allow an opportunity for the staff or Congress member to seek clarity or ask

questions. • Offer to provide additional information or find answers to questions asked.

Common methods of influencing health policy outcomes include face -to -face encounters, personal letters, mailgrams, electronic mail, telephone calls, testimony, petitions, reports, position papers, fact sheets, letters to the editor, news releases, speeches, coalition building, demonstrations, and lawsuits. Depending on the issue, any of these can be effective. Although most business, including politics and the policy agendas, are dependent upon the Internet today for instant communication and quick response, all of these methods continue to be of great importance in influencing policy agendas. For example, if a face-to-face encounter is used with a legislator or a staffer, these persons can put a "face on the policy" agenda, and the reality that the policy affects real persons is an important consider- ation when the legislator or staff pushes the policy agenda forward. Guidelines on communication are provided in the How To box. Tips on communication and visiting legislators and their staffs, as well as general tips on political action, are presented in Boxes 8-1, 8-2, and 8-3. Political activities in which nurses can and should be involved include a wide variety of activities such as being informed voters (a must!), participating in a political party, registering others to vote, getting out the vote, fundraising for candidates, building networks or commu- nication links for issues (e.g., a phone tree or Internet distribu- tion list), and participating in organizations to ensure their effective involvement in health policy and politics.

• Do not assume that the legislator or the legislator's staff is well informed on the issue.

• Leave a one- or two-page fact sheet on the issue. • Numbers count. If the views you express are shared by a local nurses' orga-

nization or by nurses employed at a health care faci lity, let the legislator know.

• Invite Congress members and their staffs to conferences or meetings of nurses' organizations, or to tour nursing facilities to meet others interested in the same policy issues.

• If appropriate, invite the media and let the legislator know. • Follow up with a letter of thanks to both the legislator and the staffer.

Modified from Mason D et al: Pol icy and politics in government, ed 5,St Louis, 2007, Elsevier. BOX 8-2 Tips for Written Communication with Legislators • Communicate in writing to express opinions. • Identify yourself as a nurse. • Acknowledge the Congress member's work as positive or negative, but be

courteous. • Follow up on meetings or phone calls with a letter or e-mai l. • Share knowledge about a particular problem. • Recommend policy solutions so the legislator or staff will know why you are

writing. • The letter should be typed, a maximum of two pages, and focused on one

or two issues at most. • The purpose of the letter should be stated at the beginning. • Present clear and compelling rationales for your concern or position on an

issue. • If the purpose of the letter is to express disappointment regarding a stance

on an issue or a vote that has been cast, the letter should be as positive as possible.

• Write letters thanking a Congress member for taking a particular position on an issue.

• A letter to the editor of the local newspaper or a nursing newsletter praising a legislator's position (with a copy forwarded to the legislator) is welcome publicity, especially during an election year.

• If you visited with the legislator or a staffer, review the major points covered in person and answer any questions that were raised during conversation.

• Have personal business cards and include them with letters. • Address written correspondence as follows (the same general format applies

to state and local officials):

U.S. Senator Honorable Jane Doe United States Senate Washington. DC 20510 Dear Senator Doe:

U.S. Representat ive Honorable Jane Doe House of Representatives Washington, DC 20515 Dear Representative Doe:

Modified from Mason D et al: Policy and politics in government, ed 5,St Loui s, 2007, Elsevier.

CHAPTER 8 Public Health Policy

Nursing Involvement

Provide member of Congress

with information to draft bill

The Federal Level s: lssoe ldectmed HR 1

Introduced in

House

S2 Introduced in

Senate

t t I r

Provide testimony

Provide testimony and information to committee members

Lobby members in district and Washington, DC

Continue lobbying efforts

Send emails and make phone calls

Sendletterto President

1

J.. I

Referred to Referred to

House committee Senate committee

I I 1 I

Referred to Referred to

subcommittee subcommittee

I I I

Reported by Reported by

full committee full committee

I I I I

Rules committee I I

action 2 I

I I

I t I

I y

I Floor Action Floor Action

t I I

House debate, 3 Senate de bate,

vote on passage vote on passage

' ' I I

' I

-----~,-------------------------· ......_ I Conference action

Compromise version Compromise version

voted on voted on

------.... 4 .---- Presidential action

VETOED SIGNED

1 A bill goes to full committee first , then to special subcommittees for hearings, debat e , revisions, and approval. The same

process occurs when it goes to full committee. It either dies in committee or procee ds to the next step.

2 Only the House has a Rules Committee to set the "rule" for floor action and conditio ns for debate and amendments. In the

Senate, the leadership schedules action. 3 The bill is debated, amended , and passed or defeated. If passed, it goes to the oth

er chamber and follows the same

path. If each chamber passes a similar bill , both versions go to conference. 4 The President may sign the bill into law, allow it to become law without his signature

, or veto it and return it to Congress .

To override the veto, both houses must approve the bill by a two-thirds majority vot e.

FIG 8-2 How a bill becomes a law. (From Mason DJ, Leavitt JK, Chaffee MW: Policy and politics

in nursing and health care, ed 6, St Louis, 2011, Elsevier.)

PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing

BOX 8-3 Tips for Action • Become informed. • Become acquainted with elected officials. • Become involved in the state nurses' association. • Build communication and leadership skills. • Increase your knowledge about a range of professional issues. • Expand and strengthen your professional network. • Build relationships within the profession and with representatives of public

and private sector organizations with an interest in health care. • Be aware of what is taking place in health care beyond the environment and

the practice in which you work. • Communicate with legislators regularly and share expertise and perspective

on issues related to health care and nursing. • Offer your expertise to assist in developing new legislation, modifying exist-

ing legislation or regulations.

• Identify yourself as a nurse with associated education and expertise. • Let people know that nurses are capable of functioning in many different

roles and making substantial contributions. • Be confident. • Do not burn bridges. • Be friendl y. • Lend a hand to other nurses. It benefits all of us. • Find an experienced mentor to work with you if you are new to the policy

arena. • Volunteer, seek appointments, or participate in elections in campaigns. • Explore opportunities for involvement through internships, fellowships, and

volunteer work at all levels (local, state, and national).

Modified from Mason D, Keavitt JK, Chaffee MW: Policy and politics ingovernment, ed 5, St Louis, 2007, Elsevier.

I HOW TO Be an Effective Communicator • Use simple communications that will be readily understood. • Choose language that clearly conveys information to individuals

of dive rse cultures, different ages, and different educational backgrounds. • Target oral or written communication to the issue and omit jargon

unique to medicine and nursing. • State your expertise on the issue first. • Briefly describe your education and experience. • Identify the relevance of the issue beyond nursing. • Provide information regarding the impact of the issue on the

legislator 's constituents. • Present accurate, credible data. • Do not oversell or give inaccurate information about the problem. • Present information in an organized, thorough, concise form that

is based on factual data {when available). • Give examples.

The direct reimbursement of advanced practice nurses (APNs) in the Medicare program is one example of how nurses can use their influence. The inclusion of amendments to Medi- care that authorized APN reimbursement regardless of specialty or client location in the Balanced Budget Act of 1997 required the sustained efforts of the ANA and other national nursing organizations over a long period (Nursing World, 2000; USDHHS, CMS, 2011. During that time, individual nurses provided testimony to Congress and to MEDPAC (the physi- cians' political action committee) on the importance of direct reimbursement to APNs. Many APNs worked closely and vigorously with their congressional representatives to lobby for this Medicare amendment. Even more wrote letters and pro- vided position papers and fact sheets to help legislators under- stand the value of APNs. Although the process took more than 10 years to achieve fully, APN reimbursement in Medicare became a reality. Both the nursing profession and Medicare beneficiaries will benefit from the enhanced access of Medicare clients to APNs.

The ANA was likewise a strong supporter for the Patient Safety Act of 1997 (ANA, 1997). This law requires health care agencies to make public some information on nurse staff levels,

staff mix, and outcomes, and it requires the USDHHS to review and approve all health care acquisitions and mergers. All of these requirements are to determine any long-term effect on the health and safety of clients, communities, and staff.

On the state legislative level, all 50 states have passed title protection for APNs; this was achieved by individual nurses, state nurses associations, and various nursing specialty groups participating in the legislative process with the 50 state legisla- tors. Title protection means that only certain nurses who meet state criteria can call themselves advanced practice nurses.

Regulatory Action The regulatory process, although it may not be as visible a process as legislation, can also be used to shape laws and dra- matically affect health policy. This process should be on the radar screen of professional nurses who wish to successfully participate in policy activity.

At each level of government, the executive branch can and, in most cases, must prepare regulations for implementing policy for new laws and new programs. These regulations are detailed, and they establish, fix, and control standards and cri- teria for carrying out certain laws. Figure 8-3 shows the steps in the typical process of writing regulations. When the legislature passes a law and delegates its oversight to an agency, it gives that agency the power to make regulations. Because regulations flow from legislation, they have the force of law.

The Process of Regulation After a law is passed, the appropriate executive department begins the process of regulation by studying the topic or issue. Advisory groups or special task forces are sometimes formed to provide the content for the regulations. Nurses can influence these regulations by writing letters to the regulatory agency in charge or by speaking at open public hearings. Many letters are now accepted by Internet.

After rewriting, the proposed regulations are put into final draft form and printed in the legally required publication (e.g., at the federal level, the Federal Register). Similar registers exist in most states, where regulations from state executive

CHAPTER 8 Public Health Policy

Changes in practice

occur

...... ...... Legislation

passed by Congress

President signs bill into law

Final regulations published

Final regulations

drafted

Time set for hearing and public comments

Regulations drafted

and published

President assigns

law to Executive department

Executive department studies law

FIG 8-3 Th e process of w riting regulations.

departments, including state health departments, are published.

Public comment is called for in written form or oral presenta-

tion within a given period. Revisions made to proposed regulations are based on public

comment and public hearing. Depending on the amount and

content of the public reaction, final regulations are prepared or

more study of the area and issues is conducted. Final published

regulations carry the force of law. When regulations become

effective, health care practice is changed to conform to the new

regulations. Monitoring administrative regulations is essential

for the professional nurse, who can influence regulations by

attending the hearings, providing comments, testifying, and

engaging in lobbying aimed at individuals involved in the

writing of the regulations. Concrete written suggestions for

revision submitted to these individuals are frequently persua-

sive and must be acknowledged by government in publishing

the final rules. An excellent example of how nurses must con-

tinue to influence health policy outcomes, even after positive

legislation has passed, occurred after the passage of the Bal-

anced Budget Act of 1997 (PL 105-33, 1997). The HCFA began

to implement the BBA '97 through the publication of draft

regulations seeking to define APN practice and Medicare reim-

bursement. The nursing community responded vigorously with

negative opinions about the initial restrictive definitions and

requirement. Their reactions were effective and reshaped the

final regulations to recognize the state definitions for APN prac-

tice autonomy. Final regulations, published in a Code of Regulations (both

federal and state), usually lead to changes in practice. For example,

Medicare regulations setting standards for nursing homes and

home health are incorporated into these agencies' manuals. In

the case of APN reimbursement, some Medicare fiscal interme-

diaries have had difficulty in recognizing APNs as appropriate

providers, but professional nursing organization advocates have

forcefully addressed these implementation barriers.

Nursing Advocacy Advocacy begins with the art of influencing others (politics) to

adopt a specific course of action (policy) to solve a societal

problem. This is accomplished by building relationships with

the appropriate policy makers-the individuals or groups

that determine a specific course of action to be followed by a

government or institution to achieve a desired end (policy

outcome). Relationships for effective advocacy can be built in a

number of ways. In January 2006, Medicare Part D-the prescription drug

benefits policy-became effective. Public health professionals

need to continue to assist many vulnerable persons to under-

stand the value of enrolling in Part D, to educate them on how

to use the benefits, and to ensure that the populations who are

PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing

"dually" enrolled in both Medicare and Medicaid are registered. Coordinating efforts between civic, religious, and health care agencies to provide health education is a necessity.

A letter or visit to the district, state, or national office of a legislator to discuss a particular policy or health care issue can be interesting, educational, and effective. Contributions of money, labor, expertise, or influence may also be welcomed by the policy makers involved in setting a course of action to obtain a desired health outcome for an individual, a family, a group, a community, or society (health policy). In addition, one may develop a grassroots network of community and profes- sional friends with a mutual interest in health policy advocacy. The network may be able to promote health policy initiatives for the community. During the Obama presidential campaign, many advocacy networks were established via the Internet and monies were solicited using this process.

Many special-interest groups in health care have the poten- tial, desire, and resources to influence the health policy process. A tremendous advantage that nursing has in advocating for issues and in influencing policy makers is the force of its numbers, since nursing is the largest of the health professions. However, nursing must organize its numbers in such a way that each nurse joins with others to speak with one voice. The great- est effect will be had when all nurses make similar demands for policy outcomes.

During 2002, the nursing profession spoke clearly, distinctly, and together on a serious problem for the health arena and for the profession: the nursing shortage. Health care facilities and employers were having ever-increasing difficulty finding expe- rienced nurses to employ. In addition, the need for RNs was predicted to balloon in the next 20 years because of the aging of the U.S. population, technological advances, and economic factors. Demand for RNs was anticipated to increase by 22% by the year 2008. This increased demand for professional nurses, coupled with the expected retirement of a rapidly aging nursing workforce, placed a tremendous stress on the health care system.

The workforce shortage resulted from a complex set of factors such as fewer young people entering the profession, declining nursing school enrollment, the aging of the current nurse workforce, and uncomfortable working conditions in which nurses felt pressured to "do more with less." On Decem- ber 4, 2009, the BLS (2009) reported that the health care sector of the economy was continuing to grow, despite significant job losses in nearly all major industries. During the same time period a shortage of registered nurses was projected to spread across the country between 2009 and 2030 (AJMQ, 2012).

The American Association of Colleges of Nursing (AACN) remained concerned about the shortage of RNs and worked with schools, policy makers, other organizations, and the media to bring attention to this health care crisis. AACN worked to enact legislation, identify strategies, and form collaborations to address the nursing shortage (AACN, 2010). However, in June 2011 it was reported that employers and staffing agencies posted more than 121,000 new job ads for Registered Nurses in May, up 46% from May 2010 (AACN, 2014).

Advocacy by expert and committed health professionals can bring about positive change for the profession, the community,

and the clients that nurses serve. Keeping up to date on issues within government, professional organizations, law, and public policy is vitally important. Informed activism directed toward a professional role, image, and value for professional nurses, and toward a health care system in the United States that provides high quality and affordable universal access to health care, should be a life-long commitment for all profes- sional nurses.

~"'I LINKING CONTENT TO PRACTICE An example of how the policy pro cess works follows, involving a nursing organization and individual members. Whether you are a member of a group as described below, or working on your own to influence health policy, the steps described here apply.

Over a 15-month time frame. the American Nu rses Associ ation was invol ved in advocating for health care reform. During the presidential campaign, can- didates were educated about the nursing profession and ANA's Agenda for Health System Reform. ANA and its members participated in national media interviews and local med ia events. The message was th at the association and its members believed th at health care is a basic right. ANA collaborated with the nursing comm unity to outline the profession's priorities as proposals were developed in Congre ss. Testimony was given before three key congressional committees. ANA representatives met with White House and congressional health care reform staff. and took part in two presidential press conferences at the White Hou se .

As reported by ANA, thousands of nurses joined ANA's hea lth care reform team. sending letters to representatives of Congress. sharing their stories, and meeting with members of Congress. They also participated in rallies and events.

For more info rm ation on ANA's health care reform work, vis it http:// www.rnaction.org/toolkit.

@® FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES • Targeted competency: Quality improvement • Knowledge: Describe strategies for learning about the outcomes of care

in the public setting • Skills: Seek information about outcomes of care for populations served in

care settings • Attitudes: Appreciate that continuous quality improvement is an essential

part of the da ily work of all professionals

QI Question The Quad Council competency of po licy development and program planning skills indicates that the beginning PHN collects information that will inform policy decisions. Also the PHN describes the legislative policy development process and identifies outcomes of current health policy relevant to PHN prac- tice. The 2014 outbreak of the Ebola virus in the United States brought quick recognition that there was a need for improvement in policies related to infec- tious disease control. What were the indicators that the infection control poli- cies in place were not sufficient to prevent the spread of disease? Describe the CQI data collection processes that determined the need for policy change. What ro le did nurses and organized nursing play in improving the infection control policy and guidelines nationally? What has been the outcome of the new policy and how were populations affected both locally and nationally?

I PRACTICE APPLICATION Larry was in his final rotation in the Bachelor of Science in

nursing program at State University. He was anxious to com-

plete his final nursing course, because upon graduation he

would begin a position as a staff nurse specializing in school

health at the local health department. His wife was expecting

their first child, and she h ad been receiving prenatal care at the

health department. Larry was aware that a few years ago the federal government

had, by law, provided block grants to states for primary care,

maternal-child health programs, and other health care needs of

states. He had read the Federal Register and knew that the regu-

lations for these grants had been written through USDHHS

departments. He was aware that these regulations did not

require states to fund specific programs.

Larry read in the local newspaper that the health department

was closing its prenatal clinic at the end of the month. When

I KEY POINTS • The legal basis for most congressional action in health care

can be found in Article I, Section 8, of the U.S. Constitution.

• The five major health care functions of the federal govern-

ment are direct service, financing, information, policy

setting, and public protection.

• The goal of the World Health Organization is the attainment

by all people of the highest possible level of health.

• Many federal agencies are involved in government health

care functions. The agency most directly involved with the

health and welfare of Americans is the U.S. Department of

Health and Human Services (USDHHS).

• Most state and local governments have activities that affect

nursing practice. • The variety and range of functions of governmental agencies

have had a major impact on nursing. Funding, in particular,

has shaped the role and tasks of nurses.

• The private sector ( of which nurses are a part) can influence

legislation in many ways, especially through the process of

writing regulations. • The number and types of laws influencing health care are

increasing. Because of this, involvement in the political

process is important to nurses.

• Professional negligence and the scope of practice are two

legal aspects particularly relevant to nursing practice.

• Nurses must consider the legal implications of their own

practice in each clinical encounter.

The federal and most state governments are composed of

three branches: the executive, the legislative, and the judicial.

CHAPTER 8 Public Health Policy

his state had received its block grant, it decided to spend the

money for programs other than prenatal care. Larry found that

a 3-year study in his own state showed improved pregnancy

outcomes as a result of prenatal care. The results were further

improved when the care was delivered by population-centered

nurses. After Larry's daughter was born, he read in the Federal

Register that states could apply for federal stimulus funds and

receive a grant for home visiting services to support mothers

and new babies. Larry was concerned that, as a student, he would have little

influence on how such grant dollars would be spent. However,

he decided to call his classmates together to plan a course of

action. What would such an action plan include?

Answers can be found on the Evolve site.

• Each branch of government plays a significant role in health

policy. The U.S. Public Health Service was created in 1798.

• The first national health insurance legislation was challenged

in the Supreme Court in 1937.

• Health: United States (NCHS, 2013) is an important source

of data about the nation's health care problems.

• In 1921 the Sheppard-Towner Act was passed, and it had an

important influence on child health programs and

population-centered nursing practice.

• The Division of Nursing, the National Institute of Nursing

Research, and the Agency for Healthcare Policy and Research

are governmental agencies important to nursing.

Nurses, through state and local health departments, function

as consultants, policy advocates, population level and direct

care providers, researchers, teachers, supervisors, and

program managers. • The state governments are responsible for regulating nursing

practice within the state. • Federal and state social welfare programs have been devel-

oped to provide monetary benefits to the poor, older adults,

the disabled, and the unemployed.

• Social welfare programs affect nursing practice. These pro-

grams improve the quality of life for special populations,

thus making the nurse's job easier in assisting the client with

health needs. • The nurse's scope of practice is defined by legislation and by

standards of practice within a specialty.

PART 2 Forces Affecting Health Care Delivery and Population-Centered Nursing

I CLINICAL DECISION-MAKING ACTIVITIES I. Conduct an interview with a local health officer. Ask for

information from a 10-year period. Try to see trends in pop- ulation size, health needs and corresponding roles, and activ- ities of government that were implemented to meet these changes. What were some of the problems you identified?

2. Examine a current health department budget and compare it with a budget from previous years. Has there been any impact on health care because · of changes in government spending ( especially before and after the passing of the Patient Protec- tion and Affordable Care Act)? Give an example.

3. Locate your state register or other documents, such as news - papers, that publish proposed regulations. Select one set of proposed regulations and critique them. Submit your opinion in writing as public comment, or attend the hearing and testify on the regulations. Be sure to submit something in writing. Evaluate your participation by stating what you learned and whether the proposed regulations were changed in your favor.

REFERENCES Agency for Healthcare Research and

Quality: At a Glance. Bethesda, MD, 2014a, USDHHS. Accessed at: www.AHRQ.gov. on 8/15/2012 .

Agency for Healthca re Research and Qual ity: Clinical Practice Guidelines. Bethesda, MD, 20 14b, USDHHS. Accessed at: www.AHRQ.gov. on 9/15/2014 .

Agency for Healthcare Research and Quality: Practice Based Research Network. Bet hesda, MD, 20 14c, USDHHS. Accessed at: www.AHR Q.gov. on 9/15/2014.

American Association of Colleges of Nursing: Fact Sheet on the Nursing Shortage. Wash ington, DC, May 2010, AACN.

American Association of Colleges of Nursing: About AACN: Mission and Strategic Plan. Wa shi ngton, DC, May 2014, AACN.

American Journa l of Medical Quality: Un ited States Reg istered Nurse Workforce Report Card and Shortage Forecast. January 2012.

American Nurses Assoc iation: Press Release, ANA Applauds Introduction of Patient Safety Act of 1997. March 1997. Avai lable at: http://www.nursingworld.org. Accessed December 10, 2010.

Birkla nd T: An Introduction to the Policy Process, ed 3. Armonk, NY, 2010, M.E. Sharpe.

Bureau of Federal Prisons: We ekly population report. 2014. Available at: http://www.bop.gov. Accessed 9/15/2014.

Catholic University of America: Definitions of law. 2010. Ava ilable at: http://www.faculty.cua.edu. Accessed August 2010.

Centers for Disease Control and Prevention: Public Health Policy, United States. Atlanta, 2014a, USDH HS. Accessed at: www.cdc.gov . on 9/16/2014.

Centers for Di sease Control and Prevention: Epidemiology of Esche rich ia Co li and Multistate Outbreak, United States. At lanta, 2014b, USDHHS. Accessed at: www.cdc.gov. on 9/16/20 14

Centers for Disease Control and Prevention: Ebola Outbreak. Atlanta, 2014c. Accessed at: www.cdc.gov. on 9/16/2014.

Centers for Medicare and Medicaid Services. Washington, DC, 2014. Accessed at: www.CMS.gov. on 9/15/2014.

Cherry 8, Jacobs SR: Contemporary Nursing Issues, Trends and Management, ed 6. St Louis, 2013, Elsevier.

Debate.Org: Is government intervention ruining health care in America. 2013 . Accessed at: www. debat e.org. on 9/15/2014.

Department of Health, Education and W elfare: Improving Health. Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention, DHEW Publication No . 79-55-71 W ashin gton, DC, 1979, U.S . Government Printing Off ice. http:// www.census.gov/statab/. Accessed July 2002.

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Health Resou rce s and Services Adm inistration: Open

4. Find and review your state nurse practice act and define your scope of practice. Give examples of your practice boundaries.

5. Contact your local public health agency to discuss the state's official powers in regulating epidemics, such as the measles outbreak in Orange County, California, (HCA, 2014) and anthrax exposures related to bioterrorism.

6. Explore the state's right to protect the health , safety, and welfare of its citizens.

7. Ask about the conflict between the state's rights and indi- vidual rights and how such issues are resolved.

8. Ask about the standards of care that apply to this issue and how it is decided which services offered to clients should be mandatory and which should be voluntary.

9. Explore how the role of public health differs in these epidem- ics compared with the past epidemics of smallpox and tuber- culosis. Be specific.

Opportunities . Roc kvi lle, M D, 2010, USDHHS. www .hrsa.gov. Accessed December 11, 2010.

Kaiser Family Foundat ion: Fastfacts. Menlo Park, CA, 2010A, Kaiser.

Kaiser Fami ly Foundation: Summary of New Health Reform Law, PowerPoint "New Insurance Market Rules. Men lo Park, CA, June 201 OB, Ka iser. www.healthreform.kff.org.

Katz R, Macintyre A, Barbera J: Emergency public health. In Pines JM , Abualenain J, Scott J, et al, editors: Emergency Care and the Public 's Health. Hoboke n, NJ, 2014, John Wiley and Sons, Ltd.

Lee LM, Heilig CM , Wh ite A: Et hica l justification for conducting public health surveillance without patient consent. Am J Public Health 102(1 ):38-44, 2012.

Legal Information Institute: Police power of governments. Ithaca, NY, Cornell University. Accessed at: www.law.cornell. edu. on 9/15/2014.

Mason DJ, Leavitt JK, Chaffee MW: Policy and Politics in Nursing and Health Care, ed 6. St Louis, 2011 , Elsevier.

Morhard R, Franco C: The Pandemic and All-H azards Preparedness Act: Its contributions and new potential to increase public health preparedness . Biosecur Bioterror 11 (2) 145-152, 2013 . Available at: http://on line. liebertpub .com/doi/ pdf/10.1089/bsp.2013.0042. Accessed May 7, 20 14.

National Center for Health Statistics: Hea lth: United States, 2013.

Hyattsville, MD, 2014, U.S. Government Printing Office.

National Council of State Boards of Nursing: Map of NLC states. 2014. https://www.ncsbn.org. Accessed on 9/15/2014.

National Institutes of Health: Structure and Goals. Bethesda, MD, 201 Oa, USDHHS .

National Institutes of Health: Smallpox Vaccines . Bethesda, M D, July 2, 2010b, USDHHS.

Nat iona l Institute of Nursing Research: National Institutes of Health: Mission and Strategic Plan . Bethesda, MD, 2011, USDHHS.

Nationa l Institute of Nursing Research: National Institutes of Health: Funding Opportunities. Bethesda , MD, 20 14, USDHHS.

Nursing World, Leg islat ive Branch : State government relations: advanced practice recognition wit h Medicaid re imbursement. 2000. Available at: http:// www.nursingworld.org. Accessed Decembe r 10, 2010.

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CHAPTER 8 Public Health Policy

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