I: Emerging Areas Shaping Health Policy
Policy Directives, Scientific Challenges, and Patterns
Patricia A. Grady and Ada Sue Hinshaw
This text, Using Nursing Research to Shape Health Policy, expands the concept of nursing research’s role in informing health policy. It builds on the foundation provided by a previous text, Shaping Health Policy Through Nursing Research (Hinshaw & Grady, 2011), which was intended to help stimulate the reader to incorporate the idea of using nursing research to influence health policy. Successful research programs were provided as exemplars. A great deal has been accomplished in this area since that time. Increasingly, the results of nursing research are being woven into practice and are influencing health policy. We have entered an important era when seminal health policy directives that have emerged on our national landscape are influenced by and have the potential to markedly impact nursing and health care in the future. This text addresses those areas and provides a perspective on impact and potential impact for the future.
The text also outlines new clinical nursing research areas and innovative scientific patterns that are changing research in the discipline. It presents new research programs of senior scientists with funding longevity, and discusses how their research has shaped policy. Moreover, it addresses the potential for influence within other programs of research. The chapters are grouped into two sections: the first section comprises introductory chapters on policy directives; the second, scientific challenges and patterns. The text also incorporates senior scientists’ presentations of their research and the ways in which that research has shaped health policy.
NATIONAL HEALTH POLICY DIRECTIVES
A number of major health policy directives of the past several years have been important in shaping health care decisions and professional programs. These include the Affordable Care Act (ACA), the Institute of Medicine/National Academy of Medicine (IOM/NAM) Future of Nursing report, and the genomic nursing science blueprint. These three were selected for discussion because of their major impact on health care and the profession of nursing. In addition, these national directives have influenced or have been influenced by the discipline’s research programs, and this influence will continue.
Major national health policy directives are shaped by research, as one of many factors, and research is sometimes influenced by the evidence needed for policy decisions. For these reasons, several chapters in this text address aspects of these three health policy directives.
The Affordable Care Act Policy Directive
The ACA consists of two different public laws signed by President Barack Obama in 2010: the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act (National Council of State Boards of Nursing, 2014). Obviously, the purpose of the ACA is to enhance the accessibility and affordability of health care to all Americans. An additional purpose evident in the provisions of the program is the improvement of health care and health systems. Because the goal is to provide access to health care for 32 million additional low-income working individuals in this country, the ACA has considerable implications for the health professional workforce and those workers’ ability to function at the full scope of their education, given the increased number of people to be included in health care (National Council of State Boards of Nursing, 2014).
The provisions in the ACA are numerous and complex, as they are designed to guide national programs with multiple goals. The provisions include (a) change in payment regulations by the government, such as restricting payments to hospitals for unnecessary readmissions, value-based purchasing programs for hospitals and providers, and bundled payment plans; (b) changes in the organization of health care delivery models (e.g., accountable care organizations and shared health savings plans); and (c) primary care transformations, with, for example, increased emphasis on preventive services, community-based care, and health homes for low-income individuals with different ethnic backgrounds. The ACA also recognizes the need for evaluation and research focused on public health issues and outcomes for individuals in order to assess progress on improving health care (supplement to Blumenthal, Abrams, & Nuzium, 2015a).
According to Jost (2016), the ACA has led to or contributed to a series of successes. Economically, there are between 7.0 and 14.6 million fewer uninsured low-income working individuals. This number is larger when students who are now covered on their parents’ insurance policies through age 25 and individuals who are no longer excluded from insurance due to existing preconditions of disease are considered. The early research data suggest that both access to and affordability of health care have been improved (Shartzer, Long, & Anderson, 2016). In addition, the annual rate of increase in health costs has slowed. Changes in the health care delivery system and quality indicators cannot be clearly evaluated, because most of these initiatives did not begin until later, around 2013 (Blumenthal, Abrams, & Nuzium, 2015b). However, there is a trend toward a decrease in hospital readmissions and reported high satisfaction of individuals with their insurance coverage and health care (Jost, 2016).
There is strong potential that nursing research can shape the many delivery-system and quality initiatives of the ACA. The research of Naylor and others and repeated testimonies to Congress and the National Academy of Medicine are already evident in the provisions on hospital readmissions (Naylor et al., 2013). Grey’s study of self-management of teens with diabetes (Grey, Knafl, Schulman-Green, & Reynolds, 2015) and Hill’s investigation (Allen et al., 2011) of adult management of chronic illness have strong policy implications for the quality initiatives of the ACA. These are just a few examples of the potential of nursing research to influence and shape the quality initiatives relating to the primary care, preventive services provisions of the ACA.
The Future of Nursing Policy Directive
The Future of Nursing: Leading Change, Advancing Health (IOM, 2011) study and policy report, a collaborative endeavor of the Institute of Medicine (IOM, now NAM or National Academy of Medicine) and the Robert Wood Johnson Foundation (RWJF), is the second major health policy directive to be discussed. The RWJF and IOM initiative is directly linked to the ACA legislation passed in 2010, as it opens health care access to an additional 32 million individuals and families. Such an influx will require extensive renovation of the health care system through interprofessional cooperation and leadership in order to provide patient-centered, quality, evidence-based, and safe care. Nursing, as the largest major health profession, needs to prepare for providing health care and leadership in enhancing the health care system in the United States. The Future of Nursing report (IOM, 2011) provided a blueprint and a set of recommendations for the nursing profession’s movement into its roles participating in and leading the redesigned health care system. According to the ACA, the U.S. health care system needs to advance a strong community and public health system in addition to acute care and palliative care systems that cross the life span of individuals and families.
The formal charge (IOM, 2011, p. 3) of The Future of Nursing initiative was broad and encompassing. The committee was asked to consider the “capacity of the nursing workforce” to respond to the reformed health care system and public health system, including the delivery of nursing services; the structure and changes needed in nursing education; policy changes required in national, state, and local public institutions; and how to handle current and future nursing workforce shortages.
The Future of Nursing report (IOM, 2011) advanced four key messages that spawned a number of recommendations:
• First, nurses should practice at the full extent of their education and training (IOM, 2011, p. 4).
• Second, nurses should complete higher levels of education and training through an improved educational system that encourages and enhances progression through different levels (IOM, 2011, p. 6).
• Third, nurses should be fully involved as partners with physicians and other health professionals in redesigning the health care systems in the United States (IOM, 2011, p. 7).
• Fourth, effective workforce planning and policy making require better data collection and improved information infrastructure (IOM, 2011, p. 8).
These four key messages were based on a number of professional issues and led to several recommendations for policy makers and public institutions.
The first key message pertains to nurses with various types of degrees and preparation being able to practice at the full scope of their education and training. The most obvious example with this message is the practice of advanced practice registered nurses (APRNs). There are multiple barriers to their practice; for example, the state regulations for the practice of APRNs that are more restrictive in some states than others. Another example of not reaching full scope of practice is the nurse with his or her first professional degree who, because of transition problems from school or work, drops out of nursing within a short time. Several of the report’s recommendations focused on this message.
• Recommendation 1: Remove scope of practice barriers (IOM, 2011, p. 9). This recommendation was specifically focused on the practice of APRNs. As such, there were subrecommendations for Congress, state legislatures, the Centers for Medicare and Medicaid Services (CMS), the Office of Personnel Management (OPM), and the Federal Trade Commission.
• Recommendation 2: Expand opportunities for nurses to lead and diffuse interprofessional efforts in redesigning health systems (IOM, 2011, p. 11). This concept is targeted at APRNs as partners and leaders with physicians and other health professionals as the health care systems are redesigned to accommodate an additional 32 million individuals and families.
• Recommendation 3: Implement nurse residency programs as standard practice in health systems (IOM, 2011, p. 11). Nurse residency programs have been shown to enhance new graduates’ transition from school to work and have evidenced a decrease in turnover rates for these new professionals.
The second key message focuses on nurses being educated at higher levels within an educational system that advances academic progression for students. Reviewing the increasing complexity of health care, and the knowledge and skills required for practice, the report suggested that higher levels of education are needed. Hence, three recommendations were provided:
• Recommendation 4: The basic education of nurses needs to be enhanced with 80% prepared at the baccalaureate level by 2020 (IOM, 2011, p. 12). This is in response to the increasing complexity involved with health care knowledge, skills, and technology.
• Recommendation 5: Double the number of nurses with a doctorate by 2020 (IOM, 2011, p. 13). This recommendation reflects a major professional challenge; that is, the consistent faculty shortage reported by schools of nursing in this country. Nursing needs additional professionals with earned doctoral degrees for education, practice, research, and leadership purposes.
• Recommendation 6: Ensure that nurses engage in lifelong learning (IOM, 2011, p. 13). To advance the recommendation of The Future of Nursing report, lifelong learning will be a requirement; for example, leading and partnering in redesigning the country’s health care systems and improving the quality, safety, and evidence base under patient-centered health care, specifically nursing care.
The third key message flows from the two prior messages and the call for greater scope of practice and higher education to meet changing dynamics and the increasing complexity of health care. Such conditions also recognize the need for nurses to be leaders and partners in changing and designing the reformed health care system. Thus, the third key message: Nurses should be fully involved as partners with physicians and other health professionals in designing the health care system for the United States.
• Recommendation 7 simply reinforces this key message; that is, prepare and enable nurses to lead change to advance health (IOM, 2011, p. 14).
The fourth key message addresses effective workforce planning and policy making related to current and future nursing shortages. Workforce shortages occur in all the health professions; thus, the workforce planning and policy-making initiative should be broader and more inclusive. However, the implementation of this recommendation is hampered by the lack of standardized data collection processes at the national and state levels and an adequate information infrastructure to handle such data and the reports needed. The eighth recommendation focuses on this need.
• Recommendation 8: Build an infrastructure for the collection and analysis of interprofessional health care workforce data (IOM, 2011, p. 14).
Following the publication of The Future of Nursing report in 2011, a Campaign for Action Initiative was formed through collaboration between the AARP and the RWJF to facilitate the implementation of the recommendations. The initiative is housed in the Center to Champion Nursing in America at the AARP. Fifty-one coalitions were formed, by state, under the campaign initiative.
In 2015, a follow-up report was published by the IOM, titled Assessing Progress on the Institute of Medicine Report: The Future of Nursing (IOM, Altman, Butler, & Shern, 2015). Ten recommendations were suggested by the assessment report, all intended to advance the campaign’s endeavors in implementing the original eight recommendations of the 2011 report.
The goals of the assessment report reflect the recommendations of the initial report, The Future of Nursing: Leading Change, Advancing Health. They include:
• Addressing educational transformation
• Leveraging nursing leadership
• Removing barriers to practice and care
• Fostering interprofessional collaboration
• Promoting diversity
• Bolstering workforce data
The 10 recommendations of the assessment report provide data when available and address general issues as to how to further the implementation of the original report. For example, under the Scope of Practice recommendation the report suggests that progress is evident, as eight additional states now allow full scope of practice for APRNs (for a total of 21 states). However, additional effort is needed, as 29 states still have reduced or restricted practice. On the interprofessional collaboration recommendation, general issues are cited. However, the assessment report strengthens the initial recommendation by addressing the need for wider, more inclusive collaboration through leadership and a focus on communication. The assessment report also strengthens the initial report by adding a recommendation on diversity. The statistics cited for nursing education programs and workforce groups show that nursing does not meet the diverse population percentage data for the country.
Given the extensive thought and study addressing the report, The Future of Nursing: Leading Change and Advancing Health, it is evident how nursing research provides a base for the issues and could be influenced by the need for data in some areas. Several chapters in this text speak to redesigned ways of providing health care, such as Chapters 12 and 13, addressing aging in place.
Genomic Nursing Science Blueprint Policy Directive
The third health policy directive is more specific to the discipline and has the potential to shape nursing research just as a review of current research informed the blueprint. The genomic nursing science blueprint (Calzone et al., 2013) was developed by the Genomic Nursing State of the Science Advisory Panel, which was organized by two coordinators, Dr. Kathleen Calzone and Dr. Jean Jenkins, under the sponsorship of the National Institute of Nursing Research (NINR) at the National Institutes of Health (NIH). The blueprint is a policy statement from the experts on the advisory panel and not a formal federal document.
The aim of the genomic nursing science initiative was “to establish the Genomic Nursing Science Blueprint through analysis of the evidence and expert evaluations of the current state of the science and public comments” (Calzone et al., 2013, p. 98). Using this process, the blueprint was developed to merge with four of the NINR strategic plan areas, identifying a number of potential genomic nursing research opportunities within the areas of health promotion/disease prevention, quality of life, innovations, and investigator training. In addition, the blueprint outlined two foci for genomic nursing research: the client defined as individual, family, community, or population and the context of the genomic nursing situation that was to be studied. Several cross-cutting themes were also suggested that would have to be considered in any genomic nursing investigation.
Genomic nursing research opportunities flow from the practice of genomic nursing. Calzone, Jenkins, and colleagues define genomic nursing as “broad, encompassing risk assessment, risk management, treatment options and treatment decisions” (2013, p. 99). Due to the complexity of genomic nursing practice and research, both are usually interdisciplinary in nature.
Aligning the genomic nursing science blueprint with the NINR strategic plan helped nurse scientists and others understand how genomic nursing research would strengthen nursing science, as well as the reverse. Genomic nursing research opportunities suggested by the advisory panel will be cited for each of the NINR strategic areas and subareas.