How can nurses change policy

We talked with her well before the coronavirus took center stage, so we went back to her this week to ask how she would tailor her advice to fit current circumstances.

Eventually, the crisis will abate, new COVID infections will slow down, and folks will recover, so I would encourage advocates not to abandon other pressing concerns. As attention returns to these issues, nursing needs to be prepared. She brings her expertise to lawmaking and to Congress, and this role is probably the pinnacle of how nurses can and should be involved in influencing policy. Of course, most nurses are not going to run for elected office, but I would encourage all nurses to vote, to know who represents them in Congress, to develop relationships with lawmakers, and to learn how to talk about the most pressing issues that affect nurses, their patients, and the health care system.

Nurses also need to know how to engage with lawmakers and their staffs. Many of the large associations brief nurses ahead of time when they bring them to D. They were also passionate about—and felt very protective of—speaking on behalf of patients. Here, agendas are aligned: nurses want these key policy issues to be adequately addressed for their patients to achieve optimal health outcomes.

Policymakers are acutely aware that these issues threaten their ability to deliver a sustainable and accessible healthcare delivery model. The political landscape is perilous for policymakers.

Nurses, for decades, at least in the USA, have enjoyed consistent recognition as the most trusted profession in Gallup Polls. Meaningful policy change can occur at the institutional level, where nurses are accustomed to functioning. These groups offer a unique opportunity for nurses to work with process, workload, personal commitments, and the power of their nursing voice within these conventions. Like any clinical skill, competency, or knowledge is gained as nurses progress from novice to expert clinicians.

Outside the employment setting, there are opportunities to gain confidence in effecting policy change. Nursing professional associations that align with clinical subspecialties are ideal for contributing to professional practice and leadership. Gaining competency around the roles within and the functions of professional associations closely aligns with the political process.

Nurses can begin as a member contributing to online discussions, blogs, or social media interest groups sponsored by the association, then progress to active participation in any number of subcommittees, and finally run for office. However, there are other opportunities far more accessible and intuitive to some. In the USA, fifty percent of the workforce are millennials, 18 many of whom have a unique set of characteristics that can change the playing field.

Millennials want to understand the rationale behind organizational decisions. They want to be active participants of that process and have a desire to be engaged in social responsibility with less focus on profit and more focus on purpose. Most significantly, however, more than any other generation, millennials understand professional and social networks as opposed to the traditional hierarchy. Nurses also encourage their patients to learn about their clinical conditions from reputable sources on social media.

Millennials have matured with social media as a constant presence in their lives and understand the power of a network to leverage change. The report of staff having to care for coronavirus patients without adequate PPE is a failure of health policy. While many health care providers and administrators are voicing concerns, it seems their pleas for help go unheard.

Nurses and other healthcare providers, along with their families, friends, and social networks, need to join in advocating for immediate changes in health policy, particularly the need to provide access to PPE and ventilators.

Nurses can best articulate these needs based on their assessment of the critical situation and share their insights into possible solutions by leveraging the public trust they enjoy. Social media is both familiar and accessible for nurses. Few people would fail to recognize the incredible social activism created by hashtags, such as MeToo that served to uncover women's shared stories of sexual harassment.

While not an example of health policy, social activism illustrates how public engagement can support funding for such. Social media offers an ideal platform for engaging and impacting public policy with limited barriers to entry. Nurses can bypass the bureaucracies of hierarchy. Arabi et al. The nurse can advocate for the change in health system reform, including care coordination and health information technology.

Nurses, as experts, with the trust that comes with being a nurse, will begin to be recognized as a legitimate voice in public policy. Nurses are now using social media to advocate for their patients as well as for themselves. Social media engagement is not without its risks.

A Chicago nurse filed a complaint alleging that she had been fired for warning colleagues via social media that the masks the hospital had provided were inadequate. Another example is nurses taking to social media to speak out about the shortage of PPE.

Beginning health policy advocacy work is a learning process, and we must be prepared to learn as we take our first steps. Those first steps of health policy advocacy may begin along different avenues: consumer groups, workplace settings, nursing organizations, mentor networks, or with elected officials. The steps should be organic and authentic to the individual: phone call, email, letter to the editor of a local newspaper, personalized note to an elected official see Figure 2.

A keen interest in policy and public advocacy can lead to new frontiers. An Australian nurse, Ged Kearney, who once led clinical nursing education in a large Australian health service, successfully made the transition from nurse to politician. Yet, nurses may have limited opportunities to participate in the public debate. A lack of or inadequate existing policy directly impacts the nurse's ability to deliver safe and optimal patient outcomes.

There may be a significant lack of nursing representation at the government and boardroom level where decisions are made. We can be an active participant in the process that acutely defines the clinical journey on which we take our patients.

There are a plethora of options for nurses to enter the public fray. Social media is a viable and easy to use forum. To remain silent is a betrayal to the podium of trust that patients have gifted to us. Anders RL. Nursing Forum. National Center for Biotechnology Information , U. Nurs Forum. Robert L. Anders , Dr. Author information Article notes Copyright and License information Disclaimer. Anders, Email: ude. Corresponding author. Anders, Dr.

It requires more than a focus on acute illness but behavioral approaches to modify risk factors including poor diet, obesity, and inactivity. Two thirds of Medicare spending attributed to patients with five or more chronic illnesses. Medicare fee-for-service spending accounts for more than three fourths of the total Medicare spending.

Incidence of chronic illness projected to grow with aging demographics and rising obesity epidemic. The high cost of care is, in part, driven by the greater use of sophisticated medical technology, greater consumption of prescription drugs, and higher healthcare prices charged for these procedures and medications The Commonwealth Fund, Also contributing to high cost is waste.

Not only are the prices for procedures significantly higher in the United States but also the charges for similar procedures vary dramatically, even within the same geographic locale.

The numbers revealed large, seemingly random variation in the costs of services. Looking at cost variation in a smaller geographic area, the Blue Cross Blue Shield study of cost variations for knee and hip replacement surgical procedures in the United States found similar cost variability.

Perhaps, if this outrageous price tag bought value, we as a nation would accept the expense. After all, healthcare is more vital than most other goods or services.

However, the stark reality is that despite outspending all other comparable high-income nations, our system ranks last or near last on measures of health, quality, access, and cost. Examining quality within the system, we know that our healthcare system is fragmented with recurring communication failure and unacceptable levels of error.

The system is difficult to navigate, especially when patients and caregivers are asked to seek care across multiple providers and settings for which there is little to no coordination. There are significant barriers to accessing care, and this problem is disproportionately true for racial and ethnic minorities and those with low-socioeconomic status Agency for Healthcare Research and Quality [AHRQ], With a focus almost exclusively on acute care, the primary care system in the United States is in disarray or, for some, nonexistent despite research data that associate access to primary care with lower mortality rates and lower overall healthcare costs Bates, The absence or underuse of peer accountability, underdeveloped quality improvement infrastructures, lack of accountability for making quality happen, inconsistent use of guidelines and provider decision-support tools, and lack of clinical information systems that have the capacity to collect and use digital data to improve care all contribute to quality care issues Shih et al.

Changing social and disease-type demographics of our citizens is also fueling the mandate for change. People of color face enduring and long-standing disparities in health status including access to health coverage that contributes to poorer health access and outcomes and unnecessary cost.

The AHRQ in its annual National Healthcare Quality and Disparities Report has provided evidence that racial and ethnic minorities and poor people face more barriers to care and receive poorer quality of care when accessed. These facts underscore the imperative for change in our system. The graying of America is another changing social demographic, with significant healthcare implications. Beginning January 1, , the oldest members of the Baby Boom generation turned In fact, each day since that day, today, and for every day for the next 19 years, 10, Baby Boomers will reach the age of 65 years Pew Research Center, Currently, just By , this figure will be 98 million or about twice their current number Administration on Aging, n.

This shift will have significant economic consequences on Social Security and Medicare. Overlapping with the changing social demographics is the change in disease-type demographics due to the fact that there is a rise in chronic disease among Americans and significantly so among older Americans. Chronic disease heart disease, stroke, cancer, Type 2 diabetes, obesity, and arthritis is the leading cause of death and disability for our citizens, affecting an estimated million people.

Thought of by some as the single biggest force threatening U. Not surprisingly, older people are more likely to have more comorbidities.

The situation becomes even more serious when the person also has a disability or activity limitation. Our episodic healthcare model is not meeting the needs of people with chronic conditions and often leads to poor outcomes Anderson, More than a quarter of people with chronic conditions have limitations when it comes to activities of daily living such as dressing and bathing or are restricted in their ability to work or attend school.

The number of people with arthritis is expected to increase to 67 million by and of these 25 million will have arthritis-attributable activity limitations CDC, n. These numbers are conservative, as they do not incorporate the current obesity trends that are likely to add to future cases of osteoarthritis. A significant challenge, both now and for the future, is how to care for and pay for the care—medical treatment and other supportive services—that people with chronic conditions need.

With the turn of the century and the Institute of Medicine IOM reports, To Err Is Human: Building a Safer Health Care System and Crossing the Quality Chasm , we became increasingly aware that the level of unintended harm in medicine was too high and that there was a compelling need to scrupulously examine and transform systems to make healthcare safer and more reliable. Although, in principle, there was agreement that these six aims were critical for an improved and effective system and should be evident across all settings, the reality is that widespread change did not occur.

As suggested in the report, there was an immense divide between what we knew should be provided and what actually was provided. This divide was not a gap but a chasm, and it was believed that the healthcare system as it existed was fundamentally unable to achieve real improvement without a major system overhaul. Continued skyrocketing of healthcare costs, less than impressive heath status of the American people, safety and quality issues within the healthcare system, growing concerns that cost and quality issues would intensify with changing demographics, and the reality that there were 50 million Americans uninsured and 40 million underinsured in the United States ushered in the Patient Protection and Affordable Care Act of Salmond, The Affordable Care Act ACA is more than insurance reform and greater access for the newly insured but includes programs now led by the CMS aiming to improve quality and control costs—what is being termed value.

Value is in essence a ratio, with quality and outcomes in the numerator and cost in the denominator Wehrwein, For a while, healthcare, like a seesaw, will balance in a precarious state of transition from the old to the new Cipriano, ; however, no one is expecting a return to the old approaches of payment and care.

In fact, it is expected by that 50 cents of every Medicare dollar will be linked to an identified quality outcome or value Burwell, And as the nation's largest insurer, Medicare leads the way in steering new programs and setting the precedent for other private insurers. Quality will be defined in terms of measurable outcomes and patient experience at the individual and population levels, and payments penalties and incentives will be calculated on the basis of the outcomes.

Efficiency will be maximized by reducing waste, avoiding duplicative care, and appropriately using specialists. Outcomes will be tracked over longer periods of time—making care integration and care across the continuum a mandate.

Institutions and providers will be incentivized for keeping people well so as not to need acute hospital or emergency department ED service, for meeting care and prevention criteria, and for ensuring the perceived value of the healthcare experience or patient satisfaction is high. This forces a shift from a provider-centric healthcare system where the provider knows best to a delivery system that is patient-centric and respectfully engages the patient in developing self-management and behavioral change capacity.

Funds have been made available through the ACA via the CMS to help providers invest in electronic medical records and other analytics needed to track outcomes and to provide support in developing the skills and tools needed to improve care delivery and transition to alternative payment models McIntyre, We have been experiencing the first wave of changes toward value-based care for years.

In October , the CMS began denying payment for hospitals' extra costs to treat complications that resulted from certain hospital-acquired conditions HACs. These events represent rare, serious conditions that should not occur.

Some of these HACs occur more commonly and have a comparatively greater impact on cost. This CMS policy was directed to accelerate improvement of patient safety by implementation of standardized protocols to prevent the event. Today, we have the Hospital Acquired Condition Reduction Program, implemented prior to the ACA but formalized under this Act to broaden its definition of unacceptable conditions. It uses financial penalties for high quartile scores in rates of adverse HACs. Lowering these rates has occurred with careful monitoring and surveillance for events, implementation of evidence-based best practices, creating checklists to ensure processes are followed, and transferring patients out of EDs and critical care units as soon as possible.

Bundled payments, a model reimbursing two or more providers for a discrete episode of care over a specific period of time, are being used in orthopaedics for some spine and total hip and knee arthroplasty surgical procedures.

A fully bundled payment system extends beyond the institution, as it includes the surgeons and all other providers involved in the care of the patient during and after surgery. In this bundled model, lump sum payments are given to the institution to cover the episode of care from the preservice or presurgery period, through the procedure itself, and to a postservice period, generally anywhere from 30 to 90 days after surgery.

This eliminates fee-for-service where one payment is made to the hospital, a second payment to the surgeon, and other payments to the anesthetist, the physical therapist, homecare, etc. The bundled payment is a prenegotiated type of risk contract in which providers will not be compensated for any costs that exceed the bundled payment. In addition to breaking down the current payment silos, bundles set quality standards to further the IOM aims of healthcare that eliminates duplication and waste, increases efficiency, uses evidence-based protocols to maximize outcomes, and engages the patient in building capacity for self-care Enquist et al.

The Comprehensive Care for Joint Replacement model is a bundled approach targeting higher quality and more efficient care for Medicare's most common inpatient surgical procedures—hip and knee replacements. Institutions under this model have reengineered patient care processes and standards developing standardized clinical pathways to enhance reliability or consistency in care.

Processes identified as important include comprehensive patient teaching spanning from the preadmission phase to the postdischarge recovery phase, standardized order sets, early mobilization, redesign of services for colocation for patient rather than provider ease, use of nurse practitioners to champion the pathway and ensure compliance, and implementing efforts to move patients from the hospital to home with home healthcare as opposed to hospital to inpatient rehabilitation to home with home healthcare Enquist et al.

Practicing in a bundled model requires that organizations examine the distribution of costs across the service or episode, identify, understand, and eliminate variation, map evidence-based pathways of care, coordinate care with providers across the continuum, and use ongoing evaluation and analytics to identify where care can be managed more efficiently and effectively American Hospital Association, n.

Moving forward, we will see greater attention to addressing preventive and chronic care needs across an entire population.

The emphasis will be on interventions that prevent acute illness and delay disease progression and will require a true interprofessional team model to accomplish.

Accountable Care Organizations ACOs and Patient-Centered Medical Homes are expected to improve primary care and care across the continuum by incentivizing providers to be accountable for improving patient and population health outcomes through cost-sharing approaches to reimbursement.

It is more than the traditional health visit and will require a focus on both the individual and the population to advance health. Primary healthcare under the ACA stresses prevention, health promotion, continuous comprehensive care, team approaches, collaboration, and community participation Gottlieb, , p. If ACOs are to achieve their goals to improve the health of populations and realize a positive profit margin, they will need to adopt new ways of thinking about health.

There is growing awareness that overall health outcomes are influenced by an array of factors beyond clinical care. As can be seen, health outcomes defined as length and quality of life are determined by factors in the physical environment, social and economic factors, clinical care, and health behaviors.

Using this framework, it is easy to recognize the critical need to incorporate behavioral factors and social context when trying to improve well-being and health outcomes.

Individual behavioral determinants include addressing issues related to diet, physical activity, alcohol, cigarette, and other drug use, and sexual activity, all of which contribute to the rates of chronic disease.

The social and physical contexts together comprising what is called social determinants of health of where a person lives and works influence half of the variability in overall health outcomes, yet rarely are considered when one thinks of healthcare. If we are to achieve true population health, it will be essential to have models in which clinical care is joined with a broad array of services supporting behavioral change and is integrated or coordinated with other community and public health efforts to address the social context in which people live and work.

Used with permission. The Future of Nursing: Leading Change, Advancing Health asserts that nursing has a critical contribution in healthcare reform and the demands for a safe, quality, patient-centered, accessible, and affordable healthcare system IOM, To deliver these outcomes, nurses, from the chief nursing officer to the staff nurse, must understand how nursing practice must be dramatically different to deliver the expected level of quality care and proactively and passionately become involved in the change.

These changes will require a new or enhanced skill set on wellness and population care, with a renewed focus on patient-centered care, care coordination, data analytics, and quality improvement. Transformation and the changes required will not be easy—at the individual or systems level. Individually, it requires an examination of one's own knowledge, skills, and attitudes and whether that places you as ready to contribute or resist the coming change. At an organizational level, it requires an analysis of mission, goals, partnerships, processes, leadership, and other essential elements of the organization and then overhauling them, thus disrupting things as we know it.

The reality is that everyone's role is changing—the patients', physicians', nurses', and other healthcare professionals'—across the entire continuum of care. Success will come if all healthcare professionals work together to transform and leverage the contribution of each provider working at full scope of practice. Achieving patient-centered, coordinated care requires interprofessional collaboration, and it is an opportunity for nursing to shine.

We must shift from a care system that focuses on illness to one that prioritizes wellness and prevention. This means that wellness- and preventive-focused evaluations, wellness and health education programs, and programs to address environmental or social triggers of preventable disease conditions and care problems must take an equal importance of focus as the disease-focused clinical intervention that providers deliver Volland, What does this look like in the real-world orthopaedic setting?

For example, workplace programs to assess and prevent back and other musculoskeletal diseases and disabilities or fall-reduction programs held in the community to improve mobility for seniors both address specific populations with an aim of keeping the group well and preventing musculoskeletal injury. Upstream of joint surgery could entail intervening prior to surgery with programs around weight loss and exercise that could prevent many chronic musculoskeletal disorders and ultimately avoid or delay surgery and improve outcomes in the case that surgery is needed.

At the organizational and individual practitioner levels, wellness means thinking about the patient beyond the current event hospital or office and considering what must be assessed or done to maximize the person's wellness. For example, a year-old woman presents to the ED for a fall. She identified that she had been having some leg edema and could not wear her normal shoes so was walking in a slipper-type shoe and slipped.

The acute episode is treated by obtaining an x-ray film to rule out fracture and a cardiac review to determine cause for edema. A wellness perspective would go further and consider what are the possible risks for future falls—a gait analysis would be done, screening for osteoporosis would be arranged for, and a plan to prevent or reduce risk to prevent subsequent falls and potential fractures would be implemented with possible referral to a Matter of Balance program that could support the patient with strategies to reduce falling and increase strength and balance.

Knowing the answer to these questions allows for the development of a more individualized, holistic plan of care that can begin at the moment and subsequently be coordinated and managed across the continuum by RNs and other providers no matter the care continuum setting. Whether looking to stay well or recover from acute illness or live well with chronic illness, there are few community-based programs that meet one's rehabilitation and wellness needs. Nursing and other healthcare professionals such as therapists and social workers are well positioned to lead entrepreneurial ventures that partner with community centers YMCAs, adult day care, housing, etc.

Another necessary characteristic of the transformed healthcare system must be an unwavering focus on the patient. Patient- and family-centered care , rather than provider-centric care, is essential if patients and families are to assume responsibility for self-management. The IOM defines patient-centered care as:. Health care that establishes a partnership among practitioners, patients, and their families when appropriate to ensure that decisions respect patients' wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care.

Practicing from a patient-centered approach means acknowledging that patients, not providers, know themselves best and realizing that quality care can only be achieved when we integrate patients and families into decision making and care and focus on what is important to patients. Without this, we will never deliver value.

It helps define patient-reported outcomes or outcomes of medical care that are defined by the patient directly. Engaging the patient in shared decision making and shared care planning with patient-reported outcomes at the center of the plan of care is essential for patient activation in self-management. With patient-reported outcomes in mind, nurses can partner with patients in providing client education and coaching to strengthen the patient's capacity toward goal achievement.

Use of motivational interviewing and action planning as a strategy to assist patients with behavioral change is a needed skill. With action plans and goals at the forefront, the nurse provides ongoing information on treatment plans, provides coaching and counseling to build self-confidence in relation to new behaviors, coordinates reminders for preventive and follow-up care, and ensures that handoffs provide the next set of providers with needed information to continue the plan of care and avoid duplicative ordering.

An integrated care continuum is posited to be a key strategy for achieving the triple aim—better quality, better service, and lower costs per unit of service. But what is the continuum and what is the role of the nurse in care coordination across the continuum? The continuum of care concept was proposed in and was conceptualized as a patient-centered system that guides and follows individuals over time potentially from birth to end of life through a comprehensive array of seamless health, mental health, and social services spanning all levels and intensity of care Evashwick, The World Health Organization , p.

As the continuum consists of services from wellness to illness, from birth to death, and from a variety of organizations, providers, and services, ongoing coordination to prevent or minimize fragmentation is critical. All patients need care coordination as it serves as a bridge—making the fragmented health system become coherent and manageable—an asset for both the patient and the provider. For some patients, a more intensive form of care coordination is needed and may be assigned a care manager to oversee their condition and changing care needs during the different trajectories of their chronic illness.

Others may require a time-limited set of care and coordination services to ensure care continuity across different sites or levels of care. This care, referred to as transitional care, has been a major focus, as it has been validated that transitions represent high-risk periods for safety issues and negative outcomes because of lack of continuity of care Enderlin et al.

To contend with these issues, the ACA set goals to reduce fragmentation of care. Numerous transitional care models such as Naylor's Transitional Care Model, Coleman's Care Transitions Program, and Project Re-engineered Discharge have demonstrated efficacy in reducing readmissions, reducing visits to the ED, improving safety, and improving patient satisfaction and outcomes ANA, ; Enderlin et al.

Care coordination is not something that is delegated to one individual or unique to an individual who may hold the title of care coordinator or navigator. All nurses, no matter what their role, must prioritize care coordination.

With this in mind, all nurses should move away from the notion of discharging patients, which implies that their responsibilities for care are finished. In contrast, nurses should provide care with a mind to transitioning the patient to the next level or stage. Transitioning implies a joint responsibility for care coordination over time.