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Historical perspective on policy, politics, and nursing Chapter 2  In 1893, Lillian Wald, a young medical student, visited a sick mother of a poor and vulnerable New York City family. She left medical school and returned to nursing, believing nurses could have a greater impac...

Historical perspective on policy, politics, and nursing Chapter 2  In 1893, Lillian Wald, a young medical student, visited a sick mother of a poor and vulnerable New York City family. She left medical school and returned to nursing, believing nurses could have a greater impact on the city's housing, sanitation, nutrition, and educational policies. She established the Henry Street Settlement House in New York City's lower east side, where she believed that living in impoverished, immigrant communities could lead to meaningful change in the city's policies. Wald's vision for the Visiting Nurse Service at the Henry Street Settlement was to provide the best nursing care when ill at home and health promotion and disease prevention. These visiting nurses would respond to calls from families in the community, just as she would respond to calls from physicians. Through hard work and strategic partnerships with insurance companies, donors, schools, and the New York City's Department of Health, Wald prevailed and changed the structure of the U.S. health care system.  Wald, along with her colleagues at the settlement house and other nurse leaders, participated in the establishment of the National Organization of Public Health Nursing in 1912. She created coalitions, such as that with the American Red Cross, when concerned about accessing care in rural communities. She knew how to procure financial resources from private foundations and donors to support many of her public health initiatives. + The issues that Wald and her colleagues set out to address remain central to the current debates about providing the best in health care to vulnerable and dispossessed individuals, families, communities, and populations. The Affordable Care Act (ACA) promised and did increase access to health care, improved quality, and attempted to contain costs by shifting the focus from acute care hospitals to homes, communities, and primary care sites. + Remembering Wald's story shows that nurses have been and will continue to be active participants in health policy debates from the home to the national level and in turning ideas into reality. Exploring the intersections of history and health policy transcends simply knowing stories, as it allows for a richer understanding of the possibilities and problems that resonate in health policy deliberations. Historical case studies can provide tools for considering future policy deliberations and actions. "not enough to be a messenger" + The "new public health" of the 1920s in the United States focused on the individual and their ability to experience greater health through personal, mental, and social hygiene practices. The centerpiece of this agenda was the "periodic medical examination," which was urged for women and children. Public health leadership recognized that cancer and degenerative heart disease were emerging as leading causes of death and urged nurses to demand examinations that would detect susceptibility to these diseases or identify them when there were still treatment options. They also recognized that routine prenatal examinations that identified and treated medical problems offered the best hope of decreasing appallingly high rates of maternal mortality and launched campaigns that urged mothers and fathers to see pregnancy as akin to a disease and not as a normal phenomenon. + In New York City, public health leadership turned to nurses to deliver this message. Public health nurses had long considered themselves and had been considered by others as the "connecting link" between patients and physicians, between and among institutions, and between scientific knowledge and its implementation in the homes they visited. They became the centerpiece of the city's "demonstration projects," an envisioned mix of different types of public and private partnerships that would test ways of delivering this message that were carefully coordinated for efficiencies, cost-effectiveness, and high quality. "not enough to be a messenger" cont.. + Public health nursing leaders in New York City believed that the turn toward health, particularly that of mothers and young children, would define their professional identity and disciplinary independence to a broader community. In 1921, with funds from an anonymous donor, a small group of White New York City public health nurses, some also involved in the demonstration projects, launched The Citizen's Health Protective Society in the middle-class Manhattanville section of the city. This would be a self-sustaining insurance program that promised prenatal care for mothers, attendance at a medically supervised childbirth if delivered at home, and nine visits for all mothers in the postpartum period. It also promised health supervision of babies and preschool children and bedside nursing if sick at home. + However, this practice brought them out of bounded disciplinary interests and into a place at the center of not only their own but also others' agendas. Foundations, families, physicians, and other public health workers all had particular ideas about what nurses should and could do as they delivered their messages of health. + The public health nursing leaders of New York City's demonstration projects never persuaded the Department of Health to let its nurses join any of their projects. The Department of Health maintained that its nurses were official agents of the city with real police power, and it needed to maintain control of their practices. The nurses involved in the health demonstration projects had shared no investment with their supporting philanthropies in involving the city's own public health nurses. By the end of the formal demonstration period in 1928, both private and public health nurses in New York City supervised the independent practices of other public health nurses. This was a substantive achievement, as public health nurses employed by New York City finally gained control of their own nursing practices. "not enough to be a messenger" cont. The demonstration projects also focused on service to mothers and young children and research on the most pressing issues in public health nursing. They launched a program that continued a long-standing nursing mission to provide bedside nursing to sick residents in their own homes, strengthened outreach to pregnant women, started new health education services for preschool children, and began sustained research projects about the organization of public health nursing work. In 1928, the demonstration projects recast itself as a postgraduate training site for public health nursing students in New York, from around the nation and international sites of Rockefeller Foundation philanthropy. New York City's health demonstration projects eventually established what are currently the norms for primary, pregnancy, dental, and pediatric care. However, this change came almost painfully slowly through the day-to-day work of public health nurses going door to door, street to street, school to school, and neighborhood to neighborhood preaching the gospel of good health to those without access to resources. Support for public health nursing did decline in the 1930s as nurses realized that it was "not enough to be a messenger," but it was as much about families taking responsibility for their health. New York City's public health nurses worked in a context increasingly dominated by the rise in hospitals and outpatient clinics where families increasingly sought health care. However, they paid little attention to warnings about the implications of these new clinical sites for public health practice. This narrow focus allowed them to professionally ignore one of the most pressing public health issues in the city and the United States in the early 1930s: the newly rising rates of maternal mortality attributed by both the New York Academy of Medicine and the Maternity Center Association to poor obstetric practices in hospitals. Bringing together the past for the present: What we learned from history In 2009, the Robert Wood Johnson Foundation (RWJF) and the Institute of Medicine (IOM) commissioned a study to develop recommendations for reconceptualizing nursing practice and education. The committee was diverse in age, profession, political leanings, and race/ethnicity, including consumer representation. The committee's recommendations reflected the changing health care political landscape and the multiple stakeholders and thought leaders who were or would be partners with nurses to improve patient care. The final report, The Future of Nursing: Leading Change, Advancing Health, reflected the diversity of the committee and the stakeholders as well as the political landscape of health reform being debated. The Campaign for Action, an initiative of the AARP and the RWJF, has provided the foundation for policy change through the development of state action coalitions and nationally based coalitions such as Nurses on Boards. The first recommendation that nurses should practice to the fullest extent of their knowledge and skills links the story of New York public health nurses to the nurses of the present. The conceptualization of the role of public health nurses with families and communities, as well as their aims and efforts to fully incorporate their skills and knowledge into their practice, reflects historic continuities of nursing practice over the past century. Bringing together the past for the present: What we learned from history cont.. Since the report was issued, nine states have removed practice barriers to allow nurse practitioners to practice independently, and numerous other states are expanding their practice acts. At the national level, retail clinics, health care service sites in drug stores, and big box stores typically staffed with nurse practitioners are growing in number and popularity. Nurse-managed health centers are recognized by many health systems as a practice model that can provide access to high-value care for people with limited resources. However, this recognition does not always translate to policy change. Health policy researcher Debra Stone notes that there is no strict dichotomy between reason and power and between policy and politics. The IOM's The Future of Nursing report placed nurses at the center of a perfect storm of forces, reflecting the political, economic, and social context that propelled both professional and public interests. The history of both public health nurses and nurse practitioners serves as a reminder of the importance of public need when public disciplinary interests are articulated. The history of the health care system can provide insight into the power dynamics that drive policymaking. Public health nurses of the 1920s and 1930s were seen as policy solutions for improving the nation's healthcare at a specific time and place. However, policymaking is untidy and requires choices to include and exclude others, and to view the world in a particular way when other visions are possible. Nurse practitioners, like the Public Health Department and the Rockefeller Foundation, were not as adept at understanding this reality or thriving within an environment when political alliances were flexible and shifting. Bringing together the past for the present: What we learned from history cont.. Currently, as we reformulate our healthcare system to be more accessible, efficient, and inclusive, policymakers are making choices about providers and services. Nurse practitioners are part of policy solutions, such as the norming of retail clinics and nurse-managed health centers. However, they need to remember that strategic alliances shift, new stakeholders emerge, and future policy decisions may not always be rational but will always be political. New political stakeholders, as seen since the 2016 election, will have the power to reshape health care according to their own alliances. There are both historical continuities and differences in the stories of public health nurses of the 1920s and 1930s and the growing appeal of nurse practitioners nowadays to policymakers and stakeholders. The ability to build coalitions and partnerships is as critical today as it was in the 1920s and 1930s. Nurse practitioners lacked a unified coalition to move their interest forward, and they lacked interested groups and partners outside of nursing to help broaden their appeal. Data supporting the value and quality of nurse practitioner services began appearing in the early 1970s, but it did not stimulate the interests of lawmakers at the state and federal levels. Organized medicine was indeed "organized" and had powerful lobbies and leadership that kept its message simple and consistent, which would be replayed for decades. Bringing together the past for the present: What we learned from history cont.. The public health nurse narrative highlights the importance of creating bridges between the community and the health system. In the late 1970s, professional nursing organizations like the American Nurses Association (ANA) seized a strategic opportunity to reformulate their policy agenda. Building on the growing body of studies that indicated high patient satisfaction and clinical effectiveness of nurse practitioners as providers, the ANA built policy positions that situated nurse practitioners as normative providers for groups such as older adults, children, and healthy adults. A deceptively strong and influential patient movement was also beginning to support nurse practitioner–provided care. Although patient support was unorganized and lacked a single leader, patients across the country showed their appreciation by returning for follow-up visits and bringing in their family and neighbors. The ANA effectively built upon the momentum patients provided to begin to form coalitions and work more effectively with the nascent nurse practitioner organizations to generate more powerful policy positions and partnerships. However, sometimes coalitions are not enough to move the policy levers. Even as nurses built coalitions and patients became their advocates through the 1980s and 1990s, there were pieces missing. For example, medical organizations influential in the policy arena did not offer nurses large-scale support. Most physician organizations were not interested in partnerships and still held strong political capital at the state and national levels. Individual physicians certainly supported nurse practitioners in their own practices, but much of organized medicine did not see them as independent providers or partners. Bringing together the past for the present: What we learned from history cont.. Organized medicine could situate nurses in this way because it still had enormous political power and resources, but physicians’ cultural authority has now been challenged. Fraud and payment scandals and the exposing of physicians’ relationships with pharmaceutical companies generated public skepticism during a time of patient empowerment movements and civil and women’s rights movements. In their search, patients found nurse practitioners qualified and value-based providers, educated and willing to see the patient as the “source of control” as the IOM report Crossing the Quality Chasm posited. The stories of nurse practitioners and public health nurses are connected by the ability to thrive and continue negotiations within a slow and subtle policy process. Incremental change occurred in health policy at the turn of the 21st century, which can be illustrated by the shift in the language defining who could provide care and receive payment. As the power dynamics in health care started to shift, nurse practitioners gained new partners and support. By the time the IOM’s The Future of Nursing report was published in 2011, patient support, coalition building, and new partnerships had more effectively positioned nurse practitioners to be a consistent part of the policy process. A litany of factors including rising health care costs, a shifting focus from specialty to primary care, and a shortage of primary care providers created a demand for new and more efficient models of care. Nurses gained willing and energetic partners in the public media and with the patients they served.  Conclusion The stories of public health nurses shaping health outcomes of immigrant populations during the early 20th century and the evolving policy support for nurse practitioners highlight the impact of healthcare policies and politics on the delivery of care. Nurses are not a homogenous group, and their traditional methods of care often focus on traditional methods rather than addressing primary health care. However, the value public health nurses bring to community and population health encourages nurses to participate in policymaking and advocate for their inclusion in healthcare solutions. Nurse practitioners must learn to participate effectively while maintaining patient advocacy and equity in a reframed healthcare arena with shifting values and priorities. Both stories highlight the messy nature of policymaking and the importance of coalitions and partnerships as stabilizing agents in uncertain policy environments. History provides valuable data that can help nurses advocate for the role of the profession in improving health care in the United States.