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Public health policy Marcia Stanhope, PhD, RN, FAAN CHAPTER OUTLINE Definitions Governmental Role in U.S. Health Care Healthy People 2020: An Example of National Health Policy Guidance Organizations and Agencies That Influence Health Impact of Government Health Functions and Structures on Nursing The Law and Health Care Laws Specific to Nursing Practice Legal Issues Affecting Health Care Practices The Nurse’s Role in the Policy Process 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. 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. KEY TERMS advanced practice nurses, p. 209 Agency for Healthcare Research and Quality, p. 203 American Association of Colleges of Nursing, p. 213 American Nurses Association, p. 201 block grants, p. 198 boards of nursing, p. 206 categorical funding, p. 205 constitutional law, p. 206 devolution, p. 198 health policy, p. 197 judicial law, p. 206 law, p. 197 legislation, p. 206 legislative staff, p. 209 licensure, p. 208 National Institute of Nursing Research, p. 203 nurse practice act, p. 206 Occupational Safety and Health Administration, p. 201 Office of Homeland Security, p. 205 police power, p. 197 policy, p. 197 politics, p. 197 public policy, p. 197 regulations, p. 206 U.S. Department of Health and Human Services, p. 197 World Health Organization, p. 201 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, understanding 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, which could be a law, a regulation, or a voluntary practice to be followed by a government or institution to obtain a desired end (CDC, 2015). Public policy is described as all governmental activities, direct or indirect, that influence the lives of all citizens (Birkland, 2016). Health policy, in contrast, is a set course of action to obtain a desired health outcome for an individual, family, group, community, or society (WHO, 2018). Policies are made not only by governments, but also by such institutions as a health department or other health care agency, a family, a community, or a professional organization. Politics plays a role in the development of such policies. Politics is found in families, professional and employing agencies, and governments. Politics determines who gets what and when and how they get it (Birkland, 2016). Politics is the art of influencing others to accept a specific course of action. Therefore 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 (Hill & Hill, 2018). Laws govern the relationships of individuals and organizations to other individuals and to government. Through political 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 individuals 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 governments are composed of three branches, each of which has separate and important functions (USA.gov, 2018). The executive 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 departments, and agencies such as the U.S. Department of Health and Human Services (USDHHS). The legislative branch (i.e., Congress 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 and Public Health, previously known as the Division of Nursing prior to the reorganization of the Health Resources and Services Agency (HRSA) of the USDHHS. This division 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 implementation 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 challenged. 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 (Chikhale, 2017; Rothstein & Valletta, 2017). Most legal bases for the actions of Congress in health care are found in Article I, Section 8, of the U.S. Constitution, including 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 controversies, 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 (Hill & Hill, 2018). 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 individual 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 American Indians. In 1934 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 maternal 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 disabled, and the categorically poor. These legislative acts by Congress created programs that were implemented by the executive branch. In March 2010 legislation was passed and signed by President Obama to improve the health of the nation and access to care; this was the health reform law, the Patient Protection and Affordable Care Act (US LAW, PL 111-148, 2010). Changes were made to the implementing of this law by the president and Congress in 2017 (Kaiser Family Foundation, 2017). The USDHHS (known first as the Department of Health, Education, 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 Centers for Medicare and Medicaid Services (CMS). During the 1980s a major effort of the Reagan administration was to shift federal government activities to the states, including federal programs for health care. The process of shifting the responsibility for planning, delivering, and financing programs from the federal level to the states is called devolution. Throughout the 1980s and 1990s Congress 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 health reform law of 2010, stimulus grants were provided to state and local areas to improve health care access (Congressional Research Service, 2017). 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 supported 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 (SCHIP) Act of 1997 provides insurance for children and families who cannot otherwise afford health insurance (U.S. Law, Title Ten SSA, BBA,1997). The program was later called simply the state Child Health Insurance Program. 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 Family Foundation, 2017). In 2017 the current Congress and president made many changes to the ACA of 2010. These changes can be found at https://www.kff.org. 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 (U.S. Law, 2000). This law “addresses emerging threats to the public’s health and authorizes 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 legislation is said to have signaled the beginning of renewed interest in public health as the protector for entire communities. In June 2002 the Public Health Security and Bioterrorism Preparedness and Response Act was signed into law (U.S. Law, 2002, PL 107-188), with $3 billion appropriated by Congress, to implement the following anti-bioterrorism 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 governmental intervention is necessary and effective and how much will be tolerated by citizens. For example, in 2010 about 49 percent of citizens were against the new health care reform acts, and the Republicans were seen as being obstructionists. In 2016, 52 percent of citizens were for government intervention in ensuring all Americans have health care coverage and 45 percent against (Gallup Inc, 2016). 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 services 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 children 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 The purpose of this study was to determine the effects of a public health policy on meeting the primary and preventive care needs of children. A survey was used to collect data from both insured and uninsured children. “Parents of 4142 recent enrollees and 5518 established enrollees in the CHIP program responded to the survey (response rates were 46 percent for recent enrollees and 51 percent for established enrollees).” Comparing uninsured children to CHIP enrolled children, the results of the survey indicated CHIP enrollees were more likely to have a well-child visit, receive a range of preventive care services, and have patient-centered care experiences. They were also more likely than uninsured children to have a regular source of care or provider and shorter wait times for appointments. CHIP enrollees received preventive care services at similar rates to privately insured children and were more likely to receive effective care coordination services. “However, CHIP enrollees were less likely than privately insured children to have a regular source of care or provider and nighttime and weekend access to a usual source of care.” In addition to this study other outcomes are indicating that CHIP enrollees are benefiting by improved school attendance and graduations. Nurse use This study supports the value of health policy and the need to evaluate the effectiveness of policy in accomplishing the purposes of the policy. The study can be used by nurses to encourage parents to enroll their children in this program and to encourage legislators to continue to support the funding of the program. CHIP, Children’s Health Insurance Program. From Smith KV, Dye C: How well is CHIP addressing primary and preventive care needs and access for children? Acad Pediatr 15(3): S64–S70, 2015. Financing. In 2016 the largest shares of total health spending were sponsored by the federal government (28.3 percent) and the households (28.1 percent). The private business share of health spending accounted for 19.9 percent of total health care spending, state and local governments accounted for 16.9 percent, while other private revenues accounted for 6.7 percent. These data are very similar from year to year with the governments at all levels and individuals sharing most of the cost burden (https://www.cms.gov). The government also pays for training some health personnel and for biomedical and health care research (NIH, 2018). 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 educated 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 supported other health care providers, such as physicians, most significantly through the program of Graduate Medical Education 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 developing the knowledge base of nursing and promoting nursing services in health care (NINR, 2018a). Information. All branches and levels of government collect, analyze, and disseminate data about health care and health status of the citizens. An example is the annual report Health: United States, compiled each year by the USDHHS (NCHS, 2017). Collecting vital statistics, including mortality and morbidity data, gathering of census data, and conducting health care status surveys are all government activities. Table 9.1 lists examples of available 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. TABLE 9.1 International and National Sources of Data on the Health Status of the U.S. Population Organization Data Sources International United Nations http://www.un.org Demographic Yearbook Population and Vital Statistics Report World Health Organization http://www.who.int World Health Statistics Annual Federal Department of Health and Human Services http://www.hhs.gov Health, United States Healthy People National Health Statistics Reports National Vital Statistics System National Survey of Family Growth National Health Interview Survey National Health and Nutrition Examination Survey National Hospital Care Survey National Nursing Home Survey National Ambulatory Medical Care Survey National Morbidity Reporting System National Immunization Survey National Mental Health Services Survey Estimates of National Health Expenditures AIDS Surveillance Nurse Supply Estimates Department of Commerce http://www.commerce.gov U.S. Census of Population Current Population Survey Population Estimates and Projections Department of Labor http://www.dol.gov Consumer Price Index Employment and Earnings 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 implications 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 (U.S. Law, 1921). 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 and 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 and Screening, Diagnostic and Treatment (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 integrating of health and social services. This act established the importance 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 authority to provide for the protection of the public’s health. This function is carried out in numerous venues, such as by regulating air and water quality and protecting the borders from the influx of diseases by controlling food, drugs, and animal transportation, 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 Americans (DHEW, 1979). In 1989 Healthy People 2000 became a national effort with many stakeholders representing the perspectives of government, state, and local agencies; advocacy groups; academia; and health organizations (USDHHS, 1991). Throughout the 1990s states used Healthy People 2000 objectives 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 communities (USDHHS, 2000). Healthy People 2020 had 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 2030. HEALTHY PEOPLE 2020 A Comparison of the Goals of Healthy People 2000, Healthy People 2010, Healthy People 2020, and Healthy People 2030 Healthy People 2000 Healthy People 2010 Healthy People 2020 Healthy People 2030—Preliminary Objectives Increase the years of healthy life for Americans Increase quality and years of healthy life Attain high quality, longer lives free of preventable disease, disability, injury, and premature death Attain healthy, thriving lives and well-being, free of preventable disease, disability, injury, and premature death. Reduce health disparities among Americans Eliminate health disparities Achieve health equity, eliminating disparities, and improving the health of all groups Eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all. Achieve access to preventive services for all Americans Creating social and physical environments that promote good health for all Create social, physical, and economic environments that promote attaining full potential for health and well-being for all. Promote quality of life, healthy development, and healthy behaviors across all life stages Promote healthy development, healthy behaviors, and well-being across all life stages. Engage leadership, key constituents, and the public across multiple sectors to take action and design policies that improve the health and well-being of all. From U.S. Department of Health and Human Services: Healthy People 2000, 2010, 2020, 2030, Washington, DC, 1991, 2000, 2010, 2020, U.S. Government Printing Office. Organizations and agencies that influence health International organizations In June 1945, following World War II, many national governments joined together to create the United Nations (UN). By charter the aims and goals of the UN deal with human rights, world peace, international security, and the promotion of economic 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, world conferences on women were 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). Over a period of five years reviews were conducted of the outcomes of the four conferences. The work of the UN and the world conferences continues with agendas to include the development of human beings, eradication of poverty, protection of human rights, investment in health, education, training, trade, economic growth, reduction of disaster risk, and a continued emphasis on women (United Nations, 2000.). One of the special autonomous organizations growing out of the UN is the World Health Organization (WHO). Established in 1946, WHO relates to the UN through the Economic and Social Council to achieve its goal to attain the highest possible 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 services, which benefit all countries, include a day-to-day information 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 (WHO, 2013a), followed by two global meetings in 2015 (WHA, 2011; WHO, 2016). The current worldwide shortage of professional nurses is now on the WHO agenda and is being addressed by many countries (WHA, 2011; WHO, 2010; WHO, 2013a). The WHO recently released a publication on the history of nursing and midwifery (WHO, 2017), and a document discussing global and strategic directions for strengthening nursing and midwifery (WHO, 2016; WHO, 2017). 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, international 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 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 2013 report builds on the previous research with a focus on the importance of research in advancing progress toward universal health coverage (WHO, 2013b) 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, wellness 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 Commission 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 Conference 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 implementing, 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 education that it funds. The HRSA contains the Bureau of Health Workforce (BHW), which includes the Division of Nursing as well as the Divisions of Medicine and Dentistry, and Allied Health Professions. The Division of Nursing and Public Health is where the key federal focus for nursing education and practice is located. National leadership is provided 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 on 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 12th report to Congress (USDHHS, 2013) the council recommended further investment by the government 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 Division of Nursing sets policy for nursing nationally. The 13th report focused on incorporating interprofessional education and practice into nursing (USDHHS, 2015), and the 14th report provides recommendations for preparing nurses for new roles in population health management (USDHHS, 2016a). Centers for disease control and prevention. The Centers for Disease Control and Prevention (CDC) serves as the national focus for developing and applying disease prevention and control, environmental health, and health promotion and education 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 works to increase 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 PHS, since 1798, and the CDC, since 1941, have worked to protect the public from harm. While the Zika virus is an example of how this is done, there have been numerous examples throughout U.S. history of dangerous epidemics and the responses to these epidemics to keep the public healthy. Beginning in 1633 and through 2017 the most dangerous epidemics in the United States, in chronological order, were smallpox, yellow fever, cholera, scarlet fever, typhoid fever, influenza, diphtheria, polio, measles, water contamination, pertussis, and human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (CDC, 2018a). The Zika virus outbreak of 2016 is but one example of how the CDC fulfills its mission. Zika virus disease is an arboviral disease usually causing mild illness; however, congenital infection is associated with microcephaly and other birth defects. Although most cases in residents of U.S. states were travel associated, local transmission was reported. In 2016 a total of 5168 confirmed or probable cases of noncongenital Zika virus disease with symptom onset during January 1–December 31, 2016, were reported to ArboNET (see chapter 22 ) from U.S. states and the District of Columbia. Most (95 percent) cases were travel associated. Locally acquired disease accounted for four percent of cases, with transmission occurring in Florida (218) and Texas (6). Forty-seven cases (one percent) were acquired through other routes, including sexual transmission (45), laboratory transmission (1), and person-to-person through an unknown route (1). Because of the recognized numbers of cases, states were asked to report aggregate numbers of cases twice a week along with Zika-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 2017 the numbers of cases related to the Zika virus were decreasing. Although the risk for travel-associated Zika virus disease appears to be decreasing, it is important that persons traveling to areas with a risk for Zika virus transmission continue to take precautions, including using strategies to prevent mosquito bites and sexual transmission. Fig. 9.1 presents a CDC map indicating cases per state (CDC, 2018a). All states were involved. By August 2017 the CDC determined the outbreak to be over. FIG. 9.1Number of confirmed and probable Zika virus disease cases, by state of residence—50 U.S. states and the District of Columbia, January 1–December 31, 2016. 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. 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 everyone. 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, 2017). 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 interaction 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 prevention, 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 questions, improving research methods, and developing the scientists of the future (NINR, 2018b). Ag ency for healthcare research and quality. The Agency for Healthcare Research and Quality (AHRQ) is the lead federal agency charged with improving the quality, safety, efficiency, 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, 2018). By examining what works and what does not work in health care, the AHRQ fulfills its missions of translating research findings 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 information technology for coordinating client care and conducting quality and outcomes research; and seeking to eliminate disparities 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 standards of health care delivery. The agency maintained a clinical practice guidelines clearinghouse for use by clinicians and others. However, after July 2018 the clearinghouse was closed due to lack of funding. Today there is a program titled the Practice-Based Research Network that rapidly develops and assesses methods and tools to ensure that new scientific evidence is incorporated into real-world practice settings (AHRQ, n.d.). 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 guides payment policy and delivery rules for services for millions of Americans (CMS, 2018). 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, 2018). Department of labor. The Department of Labor houses OSHA, which imposes workplace 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 Needlestick Safety and Prevention Act, which became law on November 6, 2000 (U.S. Law, 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 responsibility 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). 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. WIC has provided support for up to 53% of all infants born in the United States (USDA, 2015). In 2017, 7.3 million women, infants, and children received WIC benefits, with the majority of that being infants and children (USDA, 2018). 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 effectiveness of these programs because of differences in how decisions are made at the state level on how to spend money on nutrition (USDA, 2018). Department of justice. Health services to federal prisoners are administered within the Department of Justice. The Federal Bureau of Prisons is responsible for the custody and care of about 185,000 federal offenders (Bureau of Federal Prisons, 2018). The Medical and Services Division of the Bureau of Prisons includes medical, psychiatric, dental, and health support services with community standards in a correctional environment. Health promotion is emphasized through counseling during examinations, education about effects of medications, infectious disease prevention 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 (APHA, 2013; Beck & Boulton, 2016; 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 departments is essential. Gaps in community coordination are showing up in glaring ways as states and communities scramble to 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 categorical funding, has led to special and more narrowly focused nursing roles. Examples are in emergency preparedness, school nursing, and family planning. Funds assigned to anti-bioterrorism 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 bioterrorism, especially outbreaks of deadly and serious communicable 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 of bioterrorism. Two laboratories in the world retain a small amount of the smallpox virus. Because of these potential threats, the U.S. government began to increase production of the vaccine and currently has stockpiled enough vaccine to vaccinate the population in the event of a terrorist attack (NIH, 2014). Few public health professionals are knowledgeable of the symptoms, treatment, or mode of transmission of this disease. Most health professionals, including registered 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 (U.S. Law, 2006). PAHPA centralizes federal responsibilities, requires state-based accountability, proposes new national surveillance methods, addresses surge capacity, and facilitates the development of vaccines and other scarce resources (Morhard & Franco, 2013; USDHHS, 2014). On March 13, 2013, President Barrack Obama signed the Pandemic and All-Hazards Preparedness Reauthorization Act into law (U.S. Law, 2013). 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, 2016b). 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 processes 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 established, regulations further define the course of actions to be taken by the government, organizations, or individuals in reaching 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 (Hill & Hill, 2018) include the following: • A rule established by authority, society, or custom • The body of rules governing the affairs of people, communities, 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 isolation of individuals with tuberculosis? The U.S. Constitution specifies the explicit and limited functions of the federal government. All other powers and functions are left to the individual 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 demonstrate 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 individual rights (such as freedom and autonomy), under the following conditions (Gostin & Wiley, 2016; Phua, 2013): • 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 activists rejected (and made the case) that the social quarantine of individuals with AIDS was unnecessary. Thus individual freedom and autonomy of the individual come before “compelling state interest” unless science warrants another conclusion (Cole, 2014). 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, 2016). Much legislation has an effect on nursing. Regulations are specific statements of law related to defining or enacting 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 practical 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 according 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 departments have a public health practice reference that governs the practice of nurses and others. Also, state public health laws define the essential public health services that must be offered in the state as well as the optional services that may also be offered. 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, 2016). The court uses other types of laws 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 distinguishing, and it usually involves a demonstration of how the current situation in dispute differs from the previously decided situation. 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. Scop e 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 practice act of each state accomplishes at least four functions: defining 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 professional 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 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 planning 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 (NLC). The compact allowed mutual recognition of generalist nursing licensure across state lines in the compact states. In 2017 the Enhanced Nurse Licensure Compact (eNLC) was implemented, replacing the original NLC. Under the eNLC, nurses in participating states are able to have one multistate license, thus able to practice in person or by telehealth within their home state and other eNLC states. As of January 2018, 29 states had adopted the eNLC (NCSBN, 2018). 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 insufficiency of her lungs and required a continuous supply of oxygen via a tracheal tube. She required constant supervision 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 doctrine of respondeat superior. By directing a nurse to carry out a particular function, the employer becomes responsible for negligence, 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 codefendant. In some instances, if the agency is found liable, the agency may in turn sue the nurse for negligence. At least, the nurse often loses the job. Thus it is imperative that all nurses engaged in clinical practice 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 sovereign immunity (Cherry & Jacobs, 2017). 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 circumstances. 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 functional role. The law, including legislation and judicial opinions, significantly affects each of the following areas of nursing practice. 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 provided 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 screening 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 examination in schools for the purpose of referring children to a dental health professional if needed. Statutes addressing child abuse 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 mandates that a health professional breach client confidentiality to protect someone who may be in a helpless or vulnerable position. 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 services 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 responsibilities, 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 incarcerated individuals. For example, physical examinations are 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 constitutional law. If minimal services are not provided, it is a violation 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, providing 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, professional advocacy for logical health policy that considers equality 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 consequences 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 professional 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 Association of Public Health Nurses (APHN) at the national or state level, and in certain specialty organizations like the Quad Counsel Coalition of Public Health Nursing Organizations. Check your Practice As a member of the National Student Nurses Association, you have been asked to participate in a write-in campaign to alert your legislator about the reduction in funding for public health efforts which keep our populations healthy. What would you do? How would you address the issue and who would you communicate with? 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 legislative representatives and senators. An important part of the legislative process is the work of the legislative staff. These 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 relationship with key legislative staffers can be as important to achieving 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 introduced 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. Fig. 9.2 shows the necessary formal process of the legislative pathway. FIG. 9.2How a bill becomes a law. Source: (From Mason DJ, et al.: Policy and politics in nursing and health care, ed. 7, St. Louis, 2016, Elsevier.) Nurses can be involved in the legislative process at any point. Many professional nursing associations have legislative committees 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. 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 consideration 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 9.1,9.2, and 9.3. 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 communication links for issues (e.g., a phone tree or Internet distribution list), and participating in organizations to ensure their effective involvement in health policy and politics. Box 9.1 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 probably 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. • 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’ organization or by nurses employed at a health care facility, 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 DJ, et al.: Policy and politics in nursing and health care, ed. 7, St. Louis, 2016, Elsevier. Box 9.2 Tips for Written Communication with Legislators • Communicate in writing to express opinions: letters or email. • 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 email. • 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 U.S. Representative Honorable Jane Doe Honorable Jane Doe United States Senate House of Representatives Washington, DC 20510 Washington, DC 20515 Dear Senator Doe: Dear Representative Doe: Modified from Mason DJ, et al.: Policy and politics in nursing and health care, ed. 7, St. Louis, 2016, Elsevier. Box 9.3 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 existing 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 friendly. • 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 election campaigns. • Explore opportunities for involvement through internships, fellowships, and volunteer work at all levels (local, state, and national). Modified from previous works of Mason DJ, et al.: Policy and politics in nursing and health care, ed. 7, St. Louis, 2016, Elsevier. HOW TO Be an Effective Communicator • Use simple communications that will be readily understood. • Choose language that clearly conveys information to individuals of diverse 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 Medicare that authorized APN reimbursement regardless of specialty or client location in the Balanced Budget Act of 1997 (U.S. Law, 1997) required the sustained efforts of the ANA and other national nursing organizations over a long period (Phillips, 2018; USDHHS, CMS, 2016c). During that time, individual nurses provided testimony to Congress and to MEDPAC (the physicians’ 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 provided position papers and fact sheets to help legislators understand 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) and the Safe Staffing for Nurse and Patient Safety Act (ANA Capitol Beat.Org, 2018). These laws required health care agencies to make public some information on nurse staff levels, staff mix, and outcomes, and it required 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 legislators. 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 dramatically 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 criteria for carrying out certain laws. Fig. 9.3 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. FIG. 9.3The process of writing regulations. 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 departments, including state health departments, are published. Public comment is called for in written form or oral presentation 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 persuasive and must be acknowledged by government in publishing the final rules. An excellent example of how nurses must continue to influence health policy outcomes, even after positive legislation has passed, occurred after the passage of the Balanced Budget Act of 1997 (BBA ’97 ) (U.S. Law, 1997). The HCFA began to implement the BBA ’97 through the publication of draft regulations seeking to define APN practice and Medicare reimbursement. 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 practice 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 intermediaries 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 in understanding the value of enrolling in Part D, to educate them on how to use the benefits, and to ensure that the populations who are “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 professional 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 potential, 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 greatest 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 experienced 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 percent 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. Concerns regarding nursing workforce shortages continue today, anticipating a shortage of 154,018 RNs by 2020 and 510,394 RNs by 2030 (Zhang et al., 2017). Additionally, certain states and regions are expected to be impacted more than others. Predictions for 2030 anticipate both shortages and surpluses in the nursing workforce, ranging from a shortage of 44,500 full-time equivalents (FTEs) in California to a surplus of 53,700 FTEs in Florida. The states expected to have the greatest RN shortages in 2030 include California, Texas, New Jersey, and South Carolina (USDHHS, HRSA, 2017). The workforce shortage results from a complex set of factors, such as population growth, fewer young people entering the profession, shortage of nursing school faculty, the aging of the current nurse workforce and national population, changes in health care reimbursement, and uncomfortable working conditions in which nurses felt pressured to “do more with less” (AACN, 2017; USDHHS, HRSA, 2017). The American Association of Colleges of Nursing (AACN) remains concerned about the shortage of RNs and works with schools, policy makers, other organizations, and the media to bring attention to this health care crisis. AACN is working to enact legislation, identify strategies, and form collaborations to address the nursing shortage (AACN, 2017). 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 lifelong commitment for all professional nurses. Linking Content to Practice An example of how the policy process 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 Nurses Association (ANA) was involved in advocating for health care reform. During the presidential campaign, candidates 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 media events. The message was that the association and its members believed that health care is a basic right. ANA collaborated with the nursing community to outline the profession’s priorities as proposals were developed in Congress. 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 House. As reported by ANA, thousands of nurses joined ANA’s health 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 information on ANA’s health care reform work, visit http://www.rnaction.org or www.nursingworld.org. 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 daily work of all professionals. Quality improvement question The Quad Council competency of policy development and program planning skills indicates that the beginning public health nurse (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 practice. 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 infectious disease control. What were the indicators that the infection control policies in place were not sufficient to prevent the spread of disease? Describe the continuous quality improvement (CQI) data collection processes that determined the need for policy change. What role 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? Practice application Larry was in his final rotation in the Bachelor of Science in nursing program at State University. He was anxious to complete 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 had 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 and child health programs, and other health care needs of states. He had read the Federal Register and knew that the regulations 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 his state had received its block grant, it decided to spend the money for programs other than prenatal care. Larry found that a three-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. 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 government 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. • 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, 2017) 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 Quality 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 developed to provide monetary benefits to the poor, older adults, the disabled, and the unemployed. • Social welfare programs affect nursing practice. These programs 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. Clinical decision-making activities 1. Conduct an interview with a local health officer. Ask for information from a 10-year period. Try to see trends in population size, health needs and corresponding roles, and activities 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 Protection and Affordable Care Act)? Give an example. 3. Locate your state register or other documents, such as newspapers, 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. 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 (CDC, 2018b), 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 individual 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 epidemics compared with the past epidemics of smallpox and tuberculosis. Be specific. Additional resources Evolve website http://evolve.elsevier.com/Stanhope/community/ • Answers to Practice Application • Case Study • Glossary • Review Questions References Agency for Healthcare Research and Quality. Profile Retrieved from https://www.ahrq.gov 2018; USDHHS Bethesda, MD. Agency for Healthcare Research and Quality: Practice Based Research Network, Bethesda, MD, n.d, USDHHS. Retrieved from https://pbrn.ahrq.gov. American Association of Colleges of Nursing. Fact Sheet on the Nursing Shortage Retrieved from http://www.aacnnursing.org 2017; AACN Washington, DC. American Nurses Association. 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