DEPARTMENT
OF CLINICAL
IMMUNOLOGY, ALLERGOLOGY
AND
GENERAL PATIENT CARE
Lecture 3
Influences
on Health Care Delivery and Community Health Nursing
After studying this chapter, you should be able to:
·
Identify
essential elements of health care ethics.
·
Seven ethical
principles.
·
Discuss the
different types of policy.
·
Describe the
process of health policy development and the interface of politics.
·
Explain how
community health nurses can contribute to health policy.
·
Apply the
steps of policy development.
·
Partner with
community groups to form healthy public policy.
What Is Ethics?
Ethics is a philosophical pursuit originating in an
ancient discourse on the definition of “the good.†To maintain a clear focus on ethics, it is helpful to
contrast its domain to that of law. In so doing, you may be able to avoid the
tendency to confuse the two or to simplify the moral struggle to do the right
thing by seeking a legal reason for action. The essential points of comparison
are the following:
- Whereas ethics considers
people as inherently good, law presumes them to be basically bad;
- Therefore, ethics
proposes what a person should do, whereas law specifies what one must do;
- In fact, although one may
be chastised if found in violation of ethical principles, there are no
definite sanctions for violations of its precepts, whereas law imposes
penalties in terms of fines and imprisonment.
Another point of confusion arises because the popular
press often confuses the two terms or at least uses them interchangeably. Press
coverage of the “ethics violations†of public officials actually
deals with infractions of laws intended to bridge the gap between the two
arenas and influence people to act in the “correct†way.
The law is often seen as a way to enforce the current ethical values of a
society because it responds more quickly to changing circumstances (O'Keefe,
2002).
Finally, ethics includes many levels of discourse, but
the division of ethics most useful to health care decision making is that of
applied ethics. The function of applied ethics is to provide a systematic,
logical framework for analysis, discourse, and decision making that helps
ensure that decisions are grounded in the philosophy of “goodâ€
actions.
Seven Principles Essential in Health Care Ethics
The process of
ethical decision making involves analysis of alternative actions in light of
moral and ethical principles. In health care ethics, seven pervasive principles
are useful in making conscientious decisions. These are the principles of
autonomy, respect for people, beneficence, nonmaleficence,
justice, veracity, and fidelity (
Autonomy
The right of
individuals to self-determination (autonomy) is the core value of western
European and American law and ethics. In application to health care, it means
that decisions should be made by those most affected, be they individuals,
families, groups, or communities. Clearly, autonomy is the umbrella concept of
the community-as-partner model. Particularly in community health, it is
important to understand that many health care professionals will come and go,
and any outside program, no matter how worthy, will endure only as long as
those professionals remain, unless the community makes an autonomous investment
to endorse and adopt the idea behind the program.
Ethical Principles in Health Care
|
1.
Autonomy 2.
Respect for persons 3.
Beneficence 4.
Nonmaleficence 5.
Justice (distributive and retributive) 6.
Veracity |
The
altruistic nature of health care professionals presents a central challenge to
the autonomy of those who receive their care. Often, the desire to care is so
strong, and the appreciation of those who benefit from that caring so rewarding
for the provider, that the result is a system of giving and taking that leads
to increased dependency over time. It is striking to visit a remote community
after a community assistance project of some kind has been operating there and
be greeted with, “Who are you and what are you going to give us?â€
For some community health care providers, it seems that the urge to help is so
strong that it can get in the way of empowering people to do things for
themselves. The classical field of community development, as exemplified by the
Peace Corps and other relief organizations, assists people in developing the
skills needed to improve their own circumstances. Thus, in contrast to programs
focused on providing goods or services, these programs operate at the
grass-roots level. Outside helpers work as catalysts with people in communities
to discover their potential, and as advocates to help the community learn how
to access resources needed to move toward their goals.
Respect for People
The second
essential ethical principle, respect for people, recognizes that every person
and community has intrinsic value. Applying this principle to community health
directs health care professionals to evaluate the effect of proposed
initiatives in light of their implications for all who might be affected.
One example of applying the principle of respect for
people might be to encourage a community to reevaluate
its proposal to resolve its solid waste or toxic waste problem by transporting
this waste to another community. The benefit to people in one community creates
potential harm for those in another. Another example would be to give careful
consideration before introducing western medical practices and ideals that
might conflict with a community's cultural norms and folk-healing practices.
Other examples will be discussed in more detail in the next sections in
relation to justice issues and programs that are restricted to serve only a
portion of the community in need.
Beneficence
The desire to act in the best interest of others,
beneficence, is perhaps the strongest guiding ethical principle of health care
professionals. Most people who enter the helping professions
do so because of an altruistic desire to help others. Because of the
desire to help people, to take care of them, and to alleviate their suffering,
health care professionals often find themselves faced with conflicts between
their desire to help (beneficence) and their respect for the other person's
right to choose (autonomy). In fact, the principles of beneficence and autonomy
are so often at odds that it is all but impossible to imagine an uncomplicated
example of beneficence as applied to community health nursing. Even a community
health initiative as apparently benign as an immunization campaign to protect
community members from a communicable disease may conflict with the autonomy of
people whose religious beliefs do not support the practice.
The complexity of communities makes it unlikely that any community-wide
activity will be uniformly beneficial to all sectors.
Nonmaleficence
Nonmaleficence, the avoidance of harm, is the silent partner of
beneficence. Often, health care decisions may offer no really good option that
will provide positive results, but at least there may be a choice that does not
cause any outright harm. When proposals are considered for community health
initiatives, it is important to evaluate not only what positive good
(beneficence) may come from the activity, but also what harm might result,
particularly if, as in the example above of solid waste and respect for people,
the same initiative may well be beneficial for some community members and
harmful to others. If a community attracts more industry to the area, the
results may include increased job opportunities and better economic conditions
for its residents, but there may be counterbalancing health risk factors such
as environmental harm and decreased water and air quality.
Justice
The principle
of justice has two aspects, both of them applicable to health care decision
making. Most often, discussions of health-related justice center
on distributive justice, the fair distribution of rights and resources. These
discussions often center on allocation of scarce
resources in ways that are fair and of greatest benefit to the most people. In
this context, community health care providers and advocates argue for increased
governmental support for preventive health programs that lead to better quality
of life (beneficence) for the greatest number of people in the community
(respect for people).
Well-meaning community programs to improve access to
health services raise issues of distributive justice. In one example, a community
coalition of diverse clinical providers and health care organizations developed
a series of community health fairs in different neighborhoods
in and near a small city. Initiated as a means of improving child immunization
rates, in the early years the fairs were small and community oriented,
combining health services and some aspects of a street fair, including games,
food, raffles, and children's activities. Events were held three times a year,
and the late summer fair was always the largest, because many children needed
immunizations or athletic physicals before the start of school. Civic groups
joined in to provide school supplies for the back-to-school fair and other
incentives for the other fairs. Incentives brought an ever-increasing number of
people to the health fairs, including many people who came because of their
need for the supplies (paper, pens, food, and blankets) rather than a need for
health services. Because the intent of the organizers was to provide health
services, there was often a requirement that participants receive a certain
number of services to be eligible for the incentives. Service records from the
fairs indicate that a number of participants traveled
to health fairs in several communities and participated in repeated health screenings
to receive the incentives.
Grant-funded community health projects also raise
issues of distributive justice when a project selects random houses in a
particular neighborhood. A neighbor
may be visiting on the porch at the time the field investigator visits and
offers members of the selected household a stipend in return for blood pressure
screening. Culturally sensitive, caring field researchers who are invested in
the community are known to dip into their own pockets and provide equal
treatment to the neighbor even though the data will
never be included as part of the study.
There is a second branch of the principle of justice,
that of retributive justice, the arena of reward and punishment. Because of
their generally altruistic nature, health care professionals may be reluctant
to address this principle. However, the application of this darker side of
justice is often tied closely to distributive justice. Allocation of resources
is very often determined politically, and resources are awarded to those who
have provided their support to those in control of the resources. Thus, in poor
communities everywhere, we see political candidates who provide transportation
to the polls along with assurances of improved living conditions should they be
elected. At the same time, grants and projects often come to communities that
have demonstrated a strong voting record for those in power.
Many community health programs are funded by local,
state, or federal government grants. Often, communities are selected to receive
grant-funded services through the political and legislative process. Therefore,
it is important for community health nurses to be active in the political arena
and to help community residents establish a voice within the local, state, and
national political arena. Starting with knowing their own city, county, and
state representatives, effective community health nurses can serve as a link
between the community and its elected representatives and can facilitate
interaction and support as a two-way process. Unless the community (including
the nurse) can find ways to support politicians (photo opportunities, voting,
attending rallies), it is unlikely that politicians will reciprocate by funding
needed programs.
Veracity
Veracity is the commitment to tell the truth. In
application to community health nursing, it centers
on honesty about who you are and what you bring to the community. In some
communities, many programs and researchers have come and gone and a cynical
materialism has arisen in the community. Community health nurses may find
themselves entering communities that have become accustomed to outsiders
bringing in programs, goods, or services. It is difficult but necessary to be
clear from the beginning that, in the spirit of community as partner, the only
gift brought by the nurse is the gift of self, offering advocacy and energy in
support of the community.
Community health research raises issues of veracity.
Many communities, particularly those with underrepresented population groups,
are frequently visited by teams of researchers who screen residents for any
number of health conditions or risk factors, including chronic illness and
toxic exposure. Community health nurses, as community
advocates, should help ensure that these researchers are honest with the
community about exactly what is to be provided. All too often, residents do not
understand that the only benefit from participation in a research study is the
screening itself. Access to the results of health screening raises a separate
issue of veracity, as well as issues of beneficence and nonmaleficence.
It does not benefit anyone to know they have a serious health condition if they
have no access to treatment for it.
Fidelity
The last of the seven essential principles is
fidelity, or faithfulness. To work with communities or individuals, the health
care professional must be careful in making promises and steadfast in keeping
them. This obligation may be embodied as simply as making and keeping
appointments. It also may extend to a pledge to report back to community
leaders on the outcome of a project.As discussed
above in the section on veracity, community health
research raises especially serious questions of fidelity as well as veracity in
projects that involve health screening. To be effective on a long-term basis in
a community, a community health nurse needs to network with health care
providers in the community to obtain treatment for people made aware of serious
health conditions by community health screenings. Much of the work of the community
health nurse, then, involves building relationships to advocate effectively for
treatment for community members diagnosed with serious health conditions. It is
important to be aware of the reciprocal nature of this relationship and how it
relates to issues of retributive justice and political involvement. Thus, if
the community health nurse expects another health care professional to respond
to a community and its needs, the time will come that the health care
professional is entitled to ask for a favor in
return. An effective approach is to consider what one's
community, one's associates, or oneself might have to offer in advance
of asking the favor. It is also good to know about
tax incentives, public relations, referrals, and other nonaltruistic
motives as well.
Advocacy in community health nursing.
New roles of the health care professional within the
framework of community as partner reflect an increasingly balanced
participation between providers and recipients of health care. One role,
developed and elaborated by nurse ethicist Sally Gadow,
is that of advocacy. In her
philosophical discourse, advocacy
involves understanding the world view, life circumstances, and priorities of
those requesting or receiving care and exploring the possible options with them
in light of their preferences. In contrast to a strict contractualist
or consumerist approach, however, the health care professional tries to imagine
experiencing the situation of the person seeking care and offers an opinion of
the best choice in full consideration of the other party's individuality (Gadow, 1990).
Another conception of the role of the health care
professional, particularly applicable to community health nursing, is that of
catalyst. In this model, the community is seen as containing
all the necessary qualities and resources for change, and the role of the
health care professional is to provide the spark that will initiate change, as
desired or needed by the community and on its terms.
Both of these models clearly establish the primacy of
the community and the fact that lasting change depends on the investment of the
community. However, it is important to underscore that the health care
professional is an active, concerned, supportive, sometimes challenging
participant in the process. As an advocate or catalyst, the community health
nurse can make the difference between success and failure of a community's
efforts to improve the quality of life of its members.
Nurses work
with communities to promote population health. To promote the health of the
community, health policy development is required. This chapter discusses the
process of health policy development and why policy development is a part of
the role of a community health nurse. Examples of nurses who have worked with
communities to influence and develop policy are reviewed. Additionally,
information is given on how to become part of the policy development process in
a community and how politics is part of the policy development process.
Finally, we use concepts of health policy development to analyze community
health issues and derive an action plan.
Policy Comes in Different Forms
Policy is defined as a plan or course of action, as of
a government, political party, or business, intended to influence and determine
decisions, actions, and other matters (American Heritage Dictionary, 2000).
Other authors describe policy as “the principles that govern
action directed towards given ends†(Titmus,
1974, p. 23) and “a consciously chosen course of action (or inaction)
directed toward some end†(Kalisch & Kalisch, 1982, p. 61). The development of policy includes
the choices that a society, organization, or group makes regarding their goals
and priorities, including how they will allocate their resources. The
development and use of policies gives the entity a goal or a plan of action.
The policy formed should reflect the values, beliefs, and attitudes of those
who are designing the policy.
Policy is often explained further by describing its
various types. The types we describe in this chapter are public policy, social
policy, institutional policy, organizational policy, and health policy. When
describing the different types of policy, often we find that a policy may fit
several different types depending on the perspective of the person describing
it. For example, public policy regarding assault laws may become part of health
policy as we make laws for victims' rights to health care compensation
following intentional injury.
Public policy applies to all members of a society and
includes prescribed sanctions for failure to comply, such as fines for driving
while intoxicated or fines for factories that do not comply with emission regulations.
Public policy is formulated by governmental bodies and frequently restricts
personal choice to improve public welfare, such as fines for unsafe driving.
Additional examples of public policy include seat belt laws for both children
and adults and legislation that regulates where and to whom tobacco products
may be sold and the fines or penalties that apply with failure to comply.
Policy that promotes the welfare of the public is
termed social welfare policy. Examples of social welfare policy include child labor laws and income assistance, such as Social Security.
Social welfare policy tends to focus on the nation's minorities and vulnerable
populations. Aid to Families with Dependent Children (AFDC) as well as
Temporary Assistance for Needy Families (TANF) and Supplemental Security Income
(SSI) are examples of public welfare programs. Further information is offered
about TANF in Table 1.
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Table 1 Examples of Legislated Health Services |
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Institutional policy governs work sites. Institutional
policies are based on the institution's mission and goals, and they determine
how the institution will function and relate to employees. Institutional
policies state when the work shifts begin and end, the location and rules of
smoking environments for employees and clients, and criteria for paid sick
leave and vacation time.
Organizational policy is formed and applies to groups
who have similar interests or special interests, such as professional associations.
An example of organizational policy is a state nurses' association or a
specialty nursing organization that determines governing rules for membership,
such as designated credentialing or registration.
Health policy includes the laws to promote the health
of citizens. Often health policy is considered a part of public policy when it
is directly related to legislated health care services and reimbursement
(Mason, Leavitt, & Chaffee, 2002), such as Medicare and Medicaid. Health
policy is established in many ways including legislation, rules and
regulations, and institutional mission and goals. Health policies determine
what services are paid for and by whom, who is eligible to receive care, and
who qualifies for financial assistance. Examples of health programs that are
guided by health policy are described in Table 1.
Policy can be made in any organizational system and at
many levels including community agencies, state organizations, and national and
international groups. Health policy may also be characterized by the level
(i.e., community, state, national, or international) at which the policy
development occurs. For example, health care policy decisions made on a
community level, such as a new health clinic for low-income families, is funded
with budget allocations from local city and county governments. State funding
for health care policies may also focus on the provision of health care as well
as policies related to the licensure of health care professionals and the
regulation of health care institutions. At both state and local levels,
policies may be formulated in legislation or emanate from regulations that
control health-related behavior by citizens, such as
state laws and local ordinances that limit smoking in public
places. National health policy focuses on issues of concern to all citizens,
such as legislation and regulations that focus on patient safety in hospitals
and ensure access to public health care.
If policy reflects the needs of the public, then the
public must assist in the development of the policy. How can community health
nurses assist citizens to be part of health policy formulation? Community
health nurses who work with community residents have a unique perspective for
health policy decision making because of their nursing knowledge, their role as
an advocate for community health, and their understanding of the political
process. We begin with a brief historical overview of how nurses have partnered
with communities and populations of need to form healthy public policy.
Nurses Involved With Policy: Some Exemplars
Florence
Nightingale was active in setting policy to implement organizational changes
including hand washing and cleanliness procedures in the military hospitals in
which she practiced during the Crimean War (Palmer, 1977). Nightingale believed
that once she determined a course of action to be beneficial to the patients,
it was then her responsibility to make sure that the policy
continue to be followed. Even after Nightingale's health declined and
she could not practice nursing, she worked from her bed to see that health care
policies were implemented throughout the
Another
pioneer nurse in public health policy making was Lillian Wald,
who practiced in the early 20th century in the tenements of
Margaret
Sanger was another nurse who saw policies that needed to be changed and worked
to improve the life of her community residents. Sanger sought to increase
the use and availability of birth control measures, such as condoms and spermicides. Sanger's dedication to changing contraception
policies began when she connected her mother's premature death to having
experienced 18 pregnancies. Sanger helped to change laws that prohibited
education about, use of, and sending information through the mail about
contraception (Wardell, 1980).
Today, community health nursing is guided by the
American Nurses' Association (ANA) Code of Ethics with Interpretive Statements
(2001) and the ANA Social Policy Statement (2003). Both of these documents
include sections on nurses' responsibility to the public and threats to the
health and safety of the community. The ANA Code of Ethics also specifically
states that nurses “participate in institutional and legislative efforts
to promote health and meet national health objectives …
support initiatives that address barriers to health such as poverty,
homelessness, unsafe living conditions, abuse and violence, and lack of access
to health services†(ANA Code of Ethics, 2001, 8.2).
More recently, Healthy People 2010 (HP 2010) directs
providers of care, including community health nurses, to work toward the
achievement of two overarching goals: to increase the quality and years of
healthy life and to eliminate health disparities (U.S. Department of Health and
Human Services, 2005). Health care providers are encouraged to work with
communities to implement health programs to further the health of the community
and to use the HP 2010 goals to set an agenda for community health
improvements. Setting an agenda for health improvements involves using
knowledge, expertise, and experience to work with local organizations and
officials to enact health policies and set goals for the individual
communities.
Florence Nightingale, Lillian Wald,
and Margaret Sanger addressed community issues for community health. Today, our
challenge is to work with community residents to identify the health issues of
concern and collaborate to form an action plan.
Policy or Politics?
How is policy affected by politics? How does politics
shape policy? Politics is defined as “the process of influencing the
allocation of scarce resources†(Mason, Leavitt, & Chaffee, 2002, p. 9). However,
politics is a word that has assumed a meaning much broader and much less
neutral than the definition. When a discussion of politics occurs, often the
context determines the meaning. A person's perception of politics will depend
on his or her experiences and knowledge of politics. Politics occur within all
organizations whether they are for-profit businesses, not-for-profit service
agencies, social gatherings, faith communities, health care settings, or
governmental agencies. The manner in which politics operate, positively or
negatively, in an organization will depend on the rules that have been
established as acceptable within that organization, whether the goals are
important to the participants, and whether one person is in a position to
change the rules of the organization (Mason, Leavitt, & Chaffee, 2002).
The community health nurse lobbies for the allocation
of resources and shapes policies by analyzing the impact of the policy on
community health. Lobbying for resources and analyzing the impact of policy on
health defines politics. The community health nurse is a politician for health.
Politics is sometimes portrayed negatively when it appears that the politicians
will do whatever is necessary to achieve their goals. Now is a good time to
review Chapter 4 and consider the connection between politics and ethical
quandaries. Consider the following potential ethical quandary. Schools in a geographic
area with a high tax base fund a full-time school nurse for each public school.
Schools in the same geographic area with a low tax base cannot afford a nurse
for any of the schools. Should the taxpayers living in the geographic area with
school nurses share their revenue to budget school nurses for schools without a
nurse? Defend your answer. Describe how you could bring citizens together to
discuss the issue. What health data would you want to gather about the students
(in both the schools with and without a nurse) before the meeting? What would
be the goal of the meeting?
Policy-Making in Action
Policy-making occurs in many settings and among many
people. Any system involving people will necessitate policy-making.
Policy-making systems include governmental organizations, such as state,
county, and city public health departments; federal and state legislatures;
offices of the governor and mayor; as well as local and state regulatory
agencies, such as public utilities, housing, and zoning. Additionally, private,
not-for-profit organizations, such as faith communities, the American Red
Cross, the Shriners,
The Process
The
basic building blocks of nursing, the steps of the nursing process, are similar
to the process used in policy-making. Please refer to Table 7-2 as
we discuss this process.
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Table 7-2 Steps of the Nursing Process and
Policy-Making Process |
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Step 1: Problem Recognition and Definition
Policy-making begins with recognizing and defining the
problem of interest to the policy makers. We can use as an example a frequently
encountered problem in urban community health—paved walkways (i.e.,
sidewalks) in disrepair. Broken or uneven paved walkways are a danger to all pedestrians.
For example, pedestrians may be forced to walk around broken paved walkways and
into the street, putting them at increased risk for a motor vehicle accident.
The community health nurse may become aware of the problem of inadequate paved
walkways through observation; conversations with community members and business
owners; and reports from local police, hospital, or emergency aid workers who
file accident reports. The community health nurse would confirm the problem by
gathering information on the number of accidents that have occurred to
different age groups. Next, the community health nurse would compare the number
of accidents on inadequately paved walkways to the number of accidents on
adequately paved walkways.
Step 2: Policy Formulation
Once the problem has been clearly defined, the policy
maker (i.e., the community health nurse) determines what type of policy is
required and who has jurisdiction over the problem. A policy would be proposed
to maintain safe paved walkways. Or in nursing process terms, a diagnosis is
made. Returning to the example of the paved walkways, the community health
nurse would determine which agency and persons were responsible for the
construction and maintenance of the paved walkways. Paved walkways on public
property are usually the responsibility of public (i.e., city) government.
Therefore, the appropriate place to begin a discussion about the need for safe
paved walkways is city government, often city council members. Now is a good
time to stop and learn who the city government
representatives are where you live. What are their names? When were they
elected? Where are their offices? How can you contact government
representatives to discuss community problems affecting health and public
safety, such as paved walkways in disrepair and the related information on
accidents?
Continuing with Step 2, policy formulation, a group of
concerned community members, including the community health nurse, must write a
proposal to be presented to the responsible city government officials. The
proposal is usually a brief statement about the problem and the need for action
(i.e., a policy) to correct the problem. The goal of the proposal is have the
walkway issue placed on the agenda for consideration by city government policy
makers when a meeting is convened. In order to bring the issue of inadequately
maintained paved walkways to the attention of the authorities, increased public
awareness is necessary. The community health nurse and interested citizens can
increase public awareness by writing letters to the editor of the local
newspaper regarding the lack of safe walkways and associated accidents.
Detailing incidents of persons injured as a result of the walkway condition and
presenting the information to local faith-based, service, and civic
organizations as well as at public forums is an excellent way to inform the
public about the problem.Now is a
good time to take a break, get a beverage, and review today's newspaper. What
issues affecting the public's health are discussed in the newspaper? What
further information would you need to gather to document the extent of this
problem? How would you identify the responsible agency? What strategies do you
suggest to increase public awareness about the problem?
Step 3: Adoption of the Policy
The third step of the policy-making process, which
coincides with planning in the nursing process, is the adoption of the policy
by the appropriate agency. Once a policy proposal has been presented to
responsible officials and the policy has been adopted, governing rules and
regulations are formulated to administer it. For example, the department
responsible for paved walkways will be specified, along with a schedule for
routinely assessing the condition of walkways and completing necessary
maintenance. It is important for the community health nurse and interested
community residents to be present during the discussion of the policy proposal
by the public officials. The nurse and citizens must always request an
opportunity to testify as to the importance of safe walkways and be prepared to
offer the names of specific walkways needing immediate repair. Finances will
need to be allocated to begin the fourth step, the process of implementation.
Step 4: Implementation
Following approval from the appropriate agency and
allocation of a budget, the policy can be implemented. For the paved walkway
example, implementation is the completion of paved walkway repairs. Frequently
during Step 4, public education programs are necessary to increase awareness of
the new policy, especially if the new policy requires a change in citizen behavior, such as seat belt use or no smoking in public
places.
Step 5: Evaluation
After the policy had been implemented, the final step
is evaluation of the new policy of paved walkway repair and maintenance. When
the goals of the policy—routine walkway maintenance and repair—are
being met, then the policy for safe walkways is effective. However, if the
evaluation determines that paved walkway maintenance and repair is not
completed, then the public policy process would begin again. The community
health nurse must continue to collect data on the occurrence of accidents on
pedestrian walkways. Accident data can help determine the efficacy of the new
walkway policy. If accidents and injuries continue to occur at paved walkways,
then the community nurse would collect data to determine the association of the
injury to the condition of the walkway. The data may indicate that the cause of
the pedestrian accidents is not associated with the condition of the walkway
but rather with the lack of paved walkways. If the problem is lack of paved
walkways as opposed to our first problem of paved walkways in disrepair, then
the community health nurse begins the policy-making process anew with the goal
being a policy for the construction of new paved walkways.
You may be asking, “What is the difference between
a ‘program,’ funded by local
government, to repair paved walkways and a ‘policy,’
formed and funded by local government, to repair walkways?â€
Programs are usually a set of actions to achieve a goal, such as a program to
build paved walkways around all schools in an area. In contrast, policy is a
set of principles, frequently formally agreed on, such as those that govern the
construction and routine maintenance of walkways. Frequently, paved walkways
are required to be built for all new construction as part of a city building
code; however, the maintenance and repair of the walkways is not formulated
into a policy or code. Therefore, a community may confront the need for
additional public policy regarding the maintenance of paved walkways. Let's
discuss another public policy action that began with community action.
An additional policy that has followed the
policy-making process and has impacted the health and well-being of children is
that of mandatory child safety seat laws. The first step of the policy-making
process, problem recognition, began when the incidence of children being killed
or severely injured in motor vehicle accidents was associated with the injured
or deceased children being unrestrained on vehicle impact. Citizens (i.e.,
policy makers) gathered data, consulted experts, and formulated a policy to
address the issue. The policy was then presented to the appropriate governing
body, which in this case was the state legislature. The requirement of child safety
seats was discussed, debated, and approved by majority vote. A date for
implementation was determined. Once the policy was implemented, the policy
makers continued to measure the effectiveness of the policy and determine if
fewer deaths and injuries to children occurred following the policy. The answer
has been yes, but the policy makers continue to adjust the policy to make
children safer, such as increasing the age of children that are included in the
child restraint law.
Important Health Policy Issues for All Communities
Over
the past several decades, three areas of greatest concern in health care have
been 1) access to care; 2) cost of care; and 3) quality of care. These concerns
have taken center stage in national health care and
are issues of great concern on the community level. There has been much debate
over the financing of health care and the health care delivery system in the
In 2005, the American Nurses' Association (ANA)
legislative initiatives included the issues of access, cost, and quality at a
level at which action can be implemented. For instance, access to care now
includes access to health coverage, health plans, and Medicare reform. Cost of
care includes advanced practice nurse coverage, health plans, Medicaid cost
containment, medical errors, medical malpractice liability/tort reform,
and Medicare reform/prescription drugs. Finally, quality of care now includes
adequate and appropriate nurse staffing, mandatory overtime, safe health care
reporting, “whistle-blowing†protection for nurses, and
safe patient handling. It is now the role of the community health nurse to be
aware of these issues, to learn how they affect the community, and to partner
with the community to become a united voice for the citizens. These issues will
not be solved easily and may never be completely solved, but they must be
addressed for the health of the community.
How Can a Nurse Affect
Healthy Public Policy?
Nurses can and do influence health policy.
- Learn the legislative
process. To influence and initiate changes in the health care system, the
nurse needs to know about the legislative process. Nurses can learn about
the legislative process by visiting websites of local, state, and federal
governments. Many of these websites exist to educate the public on the
legislative process and to inform constituents on how to be more involved.
Information may also be obtained from government Internet sites which
inform and educate citizens on how to participate in local/city government
by serving on boards or committees.
- Stay informed on current
issues. It is important that community health nurses stay informed on
issues that are important to the profession of nursing, to the community
members we serve, and to the community at large. Without remaining current
on the issues it is impossible to know what information to collect, with
whom to share the information, and when to speak out. Reading the local
newspaper with attention to local community issues is an excellent way to
stay informed.
- Identify government
representatives. Most government websites have links to enable
constituents to identify their representatives and provide addresses and
phone numbers for contacting representatives.
Be an active constituent. Nurses can be active members
of a constituency by writing letters, making visits, or calling
representatives. Nurses as professionals may also choose to provide nursing
expertise as policies and programs are being designed and to work with
coalitions who have similar interests in the issues.
- Speak out. Community
health nurses can also be advocates for the people with whom they work.
Being an advocate involves speaking for those who cannot speak for
themselves. An additional role of a community health nurse is to be
knowledgeable of new programs, evaluate whether targeted groups are being
served as proposed, and keep policy makers aware of progress or lack of
progress toward goals.
What Can a
Nurse Do to Influence Health Policy?
|
1.
Learn the legislative process 2.
Stay informed on current issues 3.
Identify government representatives
4.
Be an active constituent 5.
Speak out |
Finally, remember that successful policy-making
depends on you. To be a part of a successful policy-making process and healthy
policy formation, stay focused on the needs of the citizens. Listen
attentively. Personal relationships are the currency by which things happen. Be
persistent. Show that you are concerned and will remain involved. Be prepared
with data to demonstrate the effect of the problem on community health. Be
positive. People are drawn to positive people. Positivity
is a low-cost investment that has a high return. Be patient with the
policy-making process, whether it occurs through a legislative body or a
smaller organization. Time to reflect on the policy is part of the process, so
patience is vital. Exhibit passion for the health issue.
Your commitment will make a memorable impression on the community and policy
makers. Lastly, be professional in every way and in everything you do. A lack
of professionalism will always be remembered long after the issue is forgotten.
Applying Your New Knowledge in Healthy Public
Policy
To apply your new knowledge in forming healthy public
policy, please complete the following scenario. You read and hear news reports
documenting an increase in the number of children drowning in your city. You
ask, “What can I do?†Remembering the
steps of the policy-making process, you begin with data collection. You need to
know the actual number of children drowned this year compared to previous
years. Has the number of deaths increased or decreased? Learn what the death
rate from drowning is for children younger than 5 years this year compared to
the last five years. Establish the death rate from drowning for children older
than 5 years and younger than 18 years this year compared to previous years.
What are the circumstances surrounding the deaths, such as time of day, day of
the week? What are the specific ages and genders of the children who drown?
Were the children unattended at the time of drowning? How many children drown
in public pools? How many in private pools? What type of policy regulates pools
in your city? Is there a policy for fences around pools? If yes, how high must
the fence be? Must the fence be locked? Are lifeguards
required at public pools? What about alarms for trespassers after pool operation
hours? Are there regulations about having private pools in your city? Are there
penalties for not complying with the policy? How often are the policies
reviewed?
The next step would be to decide if there is a problem
and if a new or revised policy is needed. If a problem exists, then it would be
necessary to determine who has jurisdiction for the problem. Is it a local
issue or a state issue? This distinction may depend on the location of the drownings and who has the authorization to implement and enforce
the policies.
After determining that there are an increased number
of children drowning or being injured at pools, and determining who has
jurisdiction for the problem, then a policy would be formulated to address the
identified issue. To address the problem, the policy might institute
regulations on fencing of pools, minimum height of fences, closure and locking
of gates, penalties for noncompliance, and
determination of who monitors compliance. Included in the policy proposal might
also be a request for funding to educate the public on the dangers associated
with pools and pool safety. Public awareness could be increased through school
education, workplace meetings, highway billboards, or mailings. The policy
proposal would then be presented to the appropriate legislative group. When a
policy proposal is presented to a governing council, a presentation by the
community health nurse and citizens in support of the policy is very helpful.
Personal accounts of a family that lost a child to drowning are powerful
testimony. You may also solicit support from other health care providers and
request they offer expert testimony on the issue of pool safety and child
drowning. If the policy is approved, then financial resources must be allocated
for the implementation of the policy. Setting a date for implementation is the
next step. Included in the policy is the importance of public education on the
health problem of children drowning and the new policy. After the policy has
been implemented, the community health nurse needs to review the statistics on
child drowning at pools each year to compare with previous years and to learn
if the new pool policy is effective in decreasing the number of children drowning.
This example is intended to encourage you to examine your local newspaper
frequently and consider opportunities for you to act to form healthy public
policy.
Summary
We have discussed the different types of policy and
spent considerable time describing the process of healthy policy development,
including the role of politics. We have stressed the importance of the
community health nurse and community residents forming a partnership to enact
healthy public policy, and we have described the specific steps of the policy
development process. You are now ready to begin the dynamic process of
partnering with community groups for healthy public policy.
References
Annerino, J. (1994). The wild country
of
Burkhardt, M., & Nathaniel, A. (2002). Ethical theory. In M. Burkhardt
& A. Nathaniel (Eds.), Ethics & issues in contemporary nursing (2nd
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Fisher,
R., et al. (2001).
Gadow, S. (1990). Existential advocacy:
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& S. Gadow (Eds.), Nursing images and ideals:
Opening dialogue with the humanities (pp. 79–101).
Gottschalk,
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Maslow, A. (1970). Motivation and
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law (pp. 58–93).
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Department of Health and Human Services. (2000). Healthy People 2010:
Understanding and improving health (2nd ed.). Washington, DC: U.S. Government Printing Office.
The
American Heritage® Dictionary of the English
Language (4th ed.). (2000).
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(2003). Social policy statement (2nd ed).
Buhler-Wilkerson, K. (1993).
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D. J., Leavitt, J. K., & Chaffee, M. W. (2002). Policy & politics in
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Internet
Resources
http://www.nursingworld.org, The official website of the American Nurses'
Association. The site provides access to member benefits, career choices,
credentialing information, continuing information, and current nursing issues
and publications. Of particular interest is the Nursing Issues and Programs
link. From there choose the Government Affairs link where links to resources
for both state and federal legislation and participation can be located.
http://www.apha.org, This is the home page of the American Public
Health Association (APHA). APHA has been influencing policies and setting
priorities in public health for over 125 years. Current legislation, advocacy,
and policy information is provided.
http://www.communityhlth.org, The Association for Community Health Improvement sponsors this site. The
mission of the association is to strengthen community health through education,
peer networking, and the dissemination of practical
tools. The website provides resources and information to assist in the mission.
http://www.florence-nightingale.co.uk, This site provides information on the
http://www.healthypeople.gov, The Healthy People site provides information on the history of Healthy
People, the current goals and objectives for Healthy People 2010 and progress
toward the goals.
http://www.firstgov.gov, This is the U.S. Government's official web
portal. This site provides online information, services, and resources from the
U.S. Government.