Chapter 7 The Policy Process.pptx

THE POLICY PROCESS CHAPTER 7 POLICY PROCESS Paul Wellstone emphasizes the importance of good public policy, grassroots organizing, and electoral politics for democratic renewal and progressive change in America. Nurses can effectively influence policy through a clear un...

THE POLICY PROCESS CHAPTER 7 POLICY PROCESS Paul Wellstone emphasizes the importance of good public policy, grassroots organizing, and electoral politics for democratic renewal and progressive change in America. Nurses can effectively influence policy through a clear understanding of the policymaking process, which can be aided by conceptual models developed by political scientists to simplify complex ideas and explain the dynamic process of policymaking. HEALTH POLICY AND POLITICS Health policy encompasses the political, economic, social, cultural, and social determinants of individuals and populations and attempts to address the broader issues in health and health care (see Box 7.1 for policy definitions). SEE BOX 7.1 FOR POLICY DEFINITIONS Policy is authoritative decision making related to choices about goals and priorities of the policymaking body. In general, policies are constructed as a set of regulations (public policy), practice standards (workplace), governance mandates (organizations), ethical behavior (research), and ordinances (communities) that direct individuals, groups, organizations, and systems toward the desired behaviors and goals. Health policy is the authoritative decisions made in the legislative, judicial, and executive branches of government that are intended to direct or influence the actions, behaviors, and decisions of others (Longest, 2016). Policy analysis is the investigation of an issue including the background, purpose, content, and effects of various options within a policy context and their relevant social, economic, and political factors (Dye, 2016). HEALTH POLICY AND POLITICS A clear understanding of the points of influence to shape policy is essential and includes framing the problem itself. For example, if nurses working in a nurse-managed clinic are troubled by staff shortages or long patient waits, they may be inclined to see themselves as the solution by working longer hours and seeing more patients. Defining and framing the problem is the first step in the policy process and involves assessing its history, patterns of impact, resource allocation, and community needs. Broadening and framing the problem to influence or educate stakeholders at the local, state, or federal level could include advocating for better access or funding for nursing workforce development (see Box 7.1). HEALTH POLICY AND POLITICS Public interest plays a crucial role in influencing policy agendas at community and broader policy levels. Trends associated with health behaviors, such as increased rates of childhood obesity, drunk driving, smoking, or gun violence, can shift public perception and open a policy debate. Research consistently shows that a wide range of social and economic factors affect health, although this broader causality is beginning to be understood by the public. As public knowledge increases, trends become increasingly objectionable to some members of society, leading them to seek solutions. For example, the rate of deaths caused by drunk driving resulted in strict nationwide drunk driving laws, and research on the impact of second-hand smoking led to the near-universal ban on smoking in shared open spaces. Organizations must mature and build resources needed to be effective in the policy realm. Interest groups, such as trade associations and political action committees, can stimulate a shift from awareness of a policy issue to action, wherein people work collectively to find solutions. Professional nursing organizations serve as an interest group for nurses, exploring issues about the advancement of nursing but also focusing on societal issues such as reforming healthcare, informing the public of emerging diseases and health threats, and addressing health disparities. HEALTH POLICY AND POLITICS CONT.. Identifying and framing a problem is the first step, but it is also necessary to identify potential solutions. For example, concerns were raised in Washington State about the ability of insured workers to access health care in rural areas, resulting in a delay in workers returning to work and insufficient reporting of injuries. Nurse practitioners (NPs) were restricted in performing some of the functions related to certifying worker disability compensation, leading to a pilot program to allow NPs to expand their scope of practice to include serving as attending providers for injured workers. Fairness and equity are primary values that inspire nurses and others to participate in the policy process. Advocating for fairness and equity is an application of patient advocacy, especially when human rights and health disparities are at stake. Political viability also must be considered, as policy that is considered desirable to both politicians and stakeholders will have the best chance of passage. UNIQUE ASPECTS OF U.S. POLICYMAKING The United States has one of the most complex health care delivery and finance systems in the world, with a highly decentralized system that includes public and private payers and no single entity, authority, or government agency being ultimately responsible for health care. This leads to a convoluted patchwork of decision making, causing health care policy in the United States to be a highly complex and politically polarizing process. The current health care structure reflects policy decisions from the values of society, including residual policies from the colonial era. Federalism is the system of government in which power is divided between a central authority (federal) and constituent political units (state governments). This division of power and authority, although purposely designed by the founding fathers, is the source of much tension, acrimony, and complexity in U.S. policymaking. The original Affordable Care Act (ACA) protects states' rights to choose the degree to which they carry out some of its most important provisions, such as creating health exchanges to expand access to care. This built-in flexibility allows states to experiment with local solutions because, for example, what works in Fargo may not work in Manhattan. The Supreme Court upheld the individual mandate as a federal law that states must accept, and it ruled that the expansion of the Medicaid program was constitutional. But it also protected states’ rights by ruling that states cannot be penalized if they choose not to participate in the expansion. UNIQUE ASPECTS OF U.S. POLICYMAKING CONT.. The trend to allow states increased flexibility in recent decades adds complexity to health policymaking and amplifies the need for nurses to understand the policymaking process. Nurses must be knowledgeable of the structure and players of policymaking so that decision-making bodies are targeted appropriately. For example, there have been incidences of nurses who have approached federal legislators to persuade them to increase funding for school nursing, unaware that school nursing is entirely a local or state issue. The U.S. Constitution gives the federal government the power to block state laws when it chooses to do so. However, this decentralized dynamic makes health care delivery systems complicated and difficult to reform. Incrementalism refers to policymaking that proceeds slowly by degrees and is the way that most policymaking proceeds. The U.S. system empowers political players who represent a minority viewpoint to block the actions of the majority, resulting in paralysis. UNIQUE ASPECTS OF U.S. POLICYMAKING CONT.. Policies in the United States are far easier to stop and obstruct than pass and implement. Policymaking is largely a process of continuous fine-tuning of what already exists. A good example of incrementalism is the policy toward gays in the military. In the early 1990s, the "don't ask, don't tell" mandate allowed gays to serve. By the early 2000s, public opinion on homosexuality shifted dramatically, and the military currently accepts individuals with this sexual orientation. Twenty- five years after "don't ask, don't tell," public acceptance of same-sex couples was evident by the 2015 Supreme Court ruling on marriage equality. Incrementalism is effective in limiting the power of any one person, group, or branch of government but also creates a process that is neither proactive, goal- oriented, nor ambitious. There are examples of policy change that are revolutionary in nature, often born out of social movements, crises, or new technology. There are clear downsides to these rapid changes, because systems do not have time to adampt and generate sensible policies CONCEPTUAL BASIS FOR POLICYMAKING Two different yet complementary models from political scientists illustrate how chaotic policymaking process has a form, rhythm, and predictability CONCEPTUAL BASIS FOR POLICYMAKING – KINGDON'S POLICY STREAMS MODEL Kingdon's policy streams model, proposed in 1995, focuses on the process of "policy looking for a problem." He identified three streams of policy activity: the problem stream, the policy stream, and the political stream. These streams must align to move through the open policy window simultaneously, ensuring that the problem comes to the attention of the policymaker, has viable policy solution options, and occurs in the right political circumstances. The problem stream describes the complexities in focusing policymakers on one specific problem out of many, such as defining health reform legislation. Values drive this stream, with values often having a stronger emotional component. Some believe that cost is the biggest problem, while others want to limit health reform to malpractice reform or improve access to care or quality. CONCEPTUAL BASIS FOR POLICYMAKING – KINGDON'S POLICY STREAMS MODEL CONT.... The policy stream describes policy goals and ideas from policy subsystems, such as researchers, congressional committee members, agency officials, and interest groups. Ideas in the policy stream disseminate through policy circles in search of problems. Some nursing policy proposals have not clearly aligned with a timely problem stream, such as pushing for school-based registered nurses in every school during severe budget cuts and teacher walkouts due to low pay. The political stream describes factors in the political environment that influence the policy agenda, such as an economic recession, special interest media, or pivotal political power shifts. The political circumstances that push problems to the top of the policy agenda need a high degree of public importance and a low degree of stakeholder conflict around the proposed solutions. If these conditions occur simultaneously, a policy window opens and progress can be made on the issue. Kingdon sees these streams as constantly moving, creating new opportunities for policy change. However, such opportunities are time-limited, and if change does not occur while the window is open, the problems and options will not be addressed. CONCEPTUAL BASIS FOR POLICYMAKING – KINGDON'S POLICY STREAMS MODEL CONT..... The policy stream describes policy goals and ideas from policy subsystems, such as researchers, congressional committee members, agency officials, and interest groups. Ideas in the policy stream disseminate through policy circles in search of problems. Some nursing policy proposals have not clearly aligned with a timely problem stream, such as pushing for school-based registered nurses in every school during severe budget cuts and teacher walkouts due to low pay. The political stream describes factors in the political environment that influence the policy agenda, such as an economic recession, special interest media, or pivotal political power shifts. The political circumstances that push problems to the top of the policy agenda need a high degree of public importance and a low degree of stakeholder conflict around the proposed solutions. If these conditions occur simultaneously, a policy window opens and progress can be made on the issue. Kingdon sees these streams as constantly moving, creating new opportunities for policy change. However, such opportunities are time-limited, and if change does not occur while the window is open, the problems and options will not be addressed. CONCEPTUAL BASIS FOR POLICYMAKING – LONGEST'S POLICY CYCLE MODEL Longest's policy cycle model outlines the three phases of health policy in the United States: policy formulation, implementation, and modification. The policy formulation phase involves all activities involved in policymaking, including those that inform legislators. Nurses can serve as a knowledge source to legislators in this phase by bringing nursing stories and patient narratives to illustrate how health problems play out with individual constituents/populations. The most effective time to influence legislation is before it is drafted, so that nurses can help frame the issues to align with their desire for policy outcomes that are patient- centered. Policy implementation comprises the rule-making phase of policy development. The legislative branch passes the law to the executive branch, which is charged with implementation. This includes adding specificity to the law and may also include defining "the health care provider" to include advanced practice nurses (provider-neutral terminology). Nurses with appropriate expertise can monitor and influence how the rules are written. Once written, federal regulations are published in the daily Federal Register for 60 days to receive public comment. CONCEPTUAL BASIS FOR POLICYMAKING – LONGEST'S POLICY CYCLE MODEL CONTI.. Stakeholder groups can exert enormous influence during the implementation phase. When strong letter-writing campaigns are used, the rulemaking agency may be forced to publish those comments and make adjustments according to their volume and scientific rigor. This rule-making phase is an important leverage point for nurses to closely monitor and respond to regulations through grassroots campaigns. During the public comment phase, two important aspects of American democracy are at play: (1) informed citizenry—the democratic process only works if its citizenry is informed; and (2) government is not all-knowing—the government acknowledges it does not hold all of the expertise; it must solicit that expertise from the public. An example of rulemaking that limited nursing occurred in 2013 when the Georgia legislature revised its scope of practice law for nurses. Policy modification allows all previous decisions to be revisited and modified. Almost all policies have unintended consequences, which is why many stakeholders seek to modify policies continuously. Examples of unintended consequences include the Health Insurance Portability and Accountability Act (HIPAA), information technology designed to capture high-quality data during clinical visits, and placing caps on Medicare drug benefits to rein in costs. NURSES’ COMPETENCE IN THE POLICYMAKING PROCESS Nurses play a crucial role in shaping policymaking processes, requiring a high degree of political competence and data analysis. Public interest- driven policy development focuses on practical decision-making and stakeholder coalitions that promote public interest. For instance, the National Association of Pediatric Nurse Practitioners (NAPNAP) has identified childhood obesity as an organizational priority and has actively participated in various policy endeavors to address the epidemic. They have published a Position Statement on the Prevention and Identification of Overweight and Obesity in the Pediatric Population, which recommends policy solutions, clinical solutions, and public awareness campaigns. NURSES’ COMPETENCE IN THE POLICYMAKING PROCESS CONT... Leaders of advocacy organizations should adopt best practices to promote their health-related mission. Once policy influence is a priority, a governmental relations team or firm can be formed to provide anticipatory guidance. This approach shifts maturing organizations away from reacting to policy changes and towards strategic leadership. Effective advocacy organizations continuously analyze the environment and focus on the ever-changing political landscape. Professional nursing organizations, such as the American Academy of Nursing and the American Nurses Association, are concerned not only with public policy affecting the health of all people but also with policy affecting nurses and the practice of nursing. These organizations support policies in the best interest of their members individually and collectively. BOX 7.2 EXAMPLES OF POSITIONSTATEMENT The National Association of Pediatric Nurse Practitioners (NAPNAP) is a leading organization that advocates for the timely and complete immunization of all infants, children, adolescents, and adults to maximize the health and well- being of all people. Routine childhood immunizations prevent as many as 3 million deaths per year and could be avoided if global vaccination efforts continue to improve. However, immunization exemptions have steadily risen over the past two decades, corroding community immunity provided by population-based vaccination programs. The Centers for Disease Control and Prevention (CDC) Committee on Infectious Diseases and the Advisory Committee on Immunization Practices annually review and recommend routine vaccination to prevent 17 vaccine preventable diseases. NAPNAP recognizes the importance of timely vaccinations for children and strongly encourages parents to adhere to the recommended immunization schedule as the best way to protect their children and community from vaccine-preventable infectious diseases. Nurses are considered to be in the best position to inform parents of the scientific and evidence-based foundation of the current immunization recommendations. This education must include the most current scientific evidence related to vaccine safety, risk, and benefits. Parents should know how to find the most current, correct, and evidence-based resources, while also being informed about sources and dangers of misinformation. Using a nonjudgmental approach, NPs are compelled to inform parents about the risks of not vaccinating their children as recommended by the evidence. NPs are expected to be skillful clinicians and encourage them to become identified as leaders in the health and safety of children and families. They must remain knowledgeable about the ever-changing science of vaccination and recommendations for immunizations. Promoting vaccines should be done at the individual, local, state, national, and international levels. NPs are encouraged to participate on employer, hospital, school, local, state, and national committees that address immunization policies and practices, including advocating for increased funding for vaccines. BOX 7.2 EXAMPLES OF POSITION STATEMENT CONTI.. To ensure that all pediatric populations are protected against vaccine-preventable illness and remain healthy, NAPNAP affirms that NPs and other pediatric health care providers must do the following: 1. Ensure access to timely immunization for all children. 2. Avoid missed opportunities to vaccinate. 3. Consider every health care encounter as a means to review immunization records, educate parents about immunization safety and efficacy, and vaccinate as needed. 4. Acknowledge the ultimate goal of immunizing children in a timely fashion is to maximize the health of each individual child. 5. Encourage and enable parents and caregivers to critically evaluate vaccine information. 6. Recommend parents, caregivers, and other adults to remain compliant with recommended immunizations for their age and risk group in order to protect children in their care. 7. Distribute the evidence-based CDC Vaccine Information Statements (VISs) for each recommended vaccine to parents and caregivers at every immunization encounter. 8. Ensure adherence to immunization schedules by utilizing electronic health records, statewide vaccine registries, and recall systems to promote continued development of these systems. 9. Participate actively on local, state, and national committees, advisory groups, and other venues that impact policies concerning childhood immunization practices. 10. Support any local, state, or federal legislation that aims to keep childhood immunizations available, accessible, and affordable for all children regardless of social or economic status or the type of health insurance. 11. Keep informed of the incidence of vaccine-preventable diseases in your area and be proficient in the ability to diagnose the illness. 21. In the event of vaccine-preventable disease diagnosis, encourage parents to keep children with vaccine-preventable disease at home from school and out of public settings for the duration of the outbreak as recommended by state and national guidelines. ENGAGING IN POLICY ANALYSIS Policy analysis is a process similar to nursing, requiring a clear identification of the problem, its context, alternatives, and their consequences. This is achieved through issue papers or policy briefs, which specify solutions and their consequences. These papers clarify arguments for a position, identify opposition arguments, and outline evidence or lack thereof for an issue and potential solutions. A one-page position statement provides a quick summary for policymakers, while a standard policy brief format includes a summary, background information, analysis of alternatives, a recommendation for action, references, and personal contact information. ENGAGING IN POLICY ANALYSIS CONT.. BOX 7.3 Elder mistreatment is a significant national health concern in the United States, with 1 in 10 older adults and 47% of persons with dementia living at home experiencing some form of mistreatment. This mistreatment results in diminished well-being and quality of life, violating the rights of older adults to be safe and free from violence. The American Academy of Nursing's Strategic Goal #3 (2014–2017) is related to this issue, as healthcare professionals in regular contact with vulnerable older adults are among the least likely to identify and report suspected cases of mistreatment. The Elder Justice Act, which was successfully passed in 2010, has done much to accelerate the attention needed to address elder mistreatment. However, no funds have been appropriated by Congress to carry out the important provisions of this Act or its earlier iteration related to direct services, education, or policy and resource development for elder justice. There is growing interest in and commitment to the prevention and treatment of elder mistreatment among national agencies and institutes. The recent release of the Elder Justice Roadmap provides impetus and guidance for advancing strategic policy, practice, education, and research initiatives that can help move forward components of the recently enacted Elder Justice Act and recommendations from the IOM’s 2013 Forum on Global Violence workshop. ENGAGING IN POLICY ANALYSIS CONT.. BOX 7.3 All nurses and other health professional groups must capitalize on the opportunities created by these recent initiatives to contribute to the national conversation and shape the aging policy landscape through various mechanisms, including listening sessions, regional forums, social media, and the WHCoA website. Health professionals, particularly nurses, play a crucial role in the prevention, assessment, and management of elder mistreatment. To address this issue, they should support prevention efforts by aligning with community-based networks and resources that support older adults and their families. This includes using social media, online resources, and public service messaging to combat ageism and raise public awareness of elder mistreatment. ENGAGING IN POLICY ANALYSIS CONT.. BOX 7.3 Recognition and treatment efforts should include integrated care models, routine screening, and evidence-based intervention models. A campaign to encourage nurses to ask "Do you feel safe at home" for every client aged 65 and older is recommended. Expanding Medicare/Medicaid reimbursement to better cover screening and basic first-level mental health services by primary care provider staff will enhance inclusion of routine screening for mistreatment, substance use, and mental health problems. Education and training should be coordinated between the Health Resources and Services Administration and the Administration on Aging's National Center on Elder Abuse. Interprofessional training should address ageism, mistreatment, and behavioral health at pre- and post-professional levels. Mandatory continuing education for nurses on elder abuse is also recommended. Research should prioritize research on elder mistreatment in all its forms, strategic promotion of prevention research priorities, and demonstration of effectiveness of preventive, early recognition, surveillance, intervention, and rehabilitative programs in diverse individuals. Projects that result in recommendations for promoting and protecting INFUSING THE EVIDENCE BASE INTO HEALTH POLICY Data and research are crucial in understanding health policy issues and developing solutions. Evidence-based health policy links evidence, policy solutions, and the significance of the situation. However, evidence may support opposing views, such as expanding access to care for the poor. The current cost shifting in most delivery systems makes it difficult to determine which view is correct or which values are most important. Another barrier to crafting policy is a lack of clarity about the evidence needed. There is a hierarchy of evidence from scientific inquiry, which can make it difficult to reach an agreement among stakeholders, policymakers, and the public about what is appropriate and valuable for health policy. New evidence may need to be developed before policy recommendations can be made. Policymaking relies on good data and evidence, but it may not be enough to outweigh the influence of the political environment. POLICY RELATED RESEARCH Health services research (HSR) is a multidisciplinary field of scientific inquiry that focuses on how people access healthcare, the cost of care, and the impact on patients. Its main goals are to identify effective ways to deliver high-quality, cost-effective, and safe care across systems. HSR addresses issues such as restructuring health services, human resource use, primary care design, patient safety, and patient outcomes. Research by Linda Aiken, Mary Naylor, and Mary Mundinger on safe staffing, transitions in care for older adults, and the use of natural resources (NPs) is widely cited in policy literature. Comparative effectiveness research has also increased, using data sources to compare the costs and harms of various treatment decisions and studying the cost effectiveness of drugs, medical devices, and surgical procedures. CONCLUSION Goethe's quote emphasizes the importance of addressing the root causes of health care system problems. Nurses should actively participate in policy arenas to improve people's health. They can lobby policymakers, run for government positions, serve as policy researchers, analysts, and staff to policymakers. Nursing leaders, such as those in organizations like AARP, the National Academy of Medicine, and the Health Services and Resources Administration, have a significant impact on policy. This involvement in health policy is an extension of nurses' role as advocates.