Overview and Summary: Healthcare Reform: Nurses Impact Policy

Healthcare Reform. These words – this ideal – has been flung across every media platform for decades. Everyone has an opinion or policy stance about healthcare since every individual is at some point on the wellness-illness continuum. The political factions leverage it to gain support for their views on how healthcare can be accessed, provided, and funded. In this OJIN: The Online Journal of Issues in Nursing topic, what we add to the mix is Nurses – us, the largest group of healthcare professionals in the United States and globally: Nurses Impact Policy.

As professionals, we contribute nursing expertise in every setting and at every level of care delivery and policy development. Recent evidence of this is the appointment of Rear Admiral Sylvia Trent-Adams, PhD, RN, FAAN (an OJIN coauthor in the January 2017 topic on emerging global health concerns) as the Acting Surgeon General in the United States Department of Health and Human Services (2017). Less evident, but just as important, is the work of all nurses each day to impact healthcare reform. We witness outcomes that lead to joy, despair, transformations, hope; equally so, these experiences impact us. We must not lose these emotional impacts that grip us as stories unfold before us in our communities, and nationally. We must utilize what we learn from our experiences and make a vow to keep focused to improve access and healthcare delivery for everyone.

It is our stories that can make the difference. Quoted here is a short narrative by one father, The Honorable Senator Creigh Deeds of the General Assembly of the Commonwealth of Virginia, whose son was unable to access a hospital during a mental health crisis (used with permission):

My life changed forever with my son’s death. He did not exhibit outward signs of mental illness until after he was 20 years old. In the brief years that remained, I struggled to figure out how best to help him. My difficulty stemmed in part from not having a background in mental health and not taking the time to learn everything I could. This was complicated by his health care professionals refusing to talk to me either because they did not feel like they could because of the law or some other reason. In any event, I did the best I could, hospitalizing him twice during 2011, and making sure he was on medication, stable and oriented forward.

When Gus returned to the College of William and Mary [Williamsburg, Virginia] in the fall of 2012, I felt like things were on the right path. Still he struggled. He told me “Dad, those kids just don’t like me”. I knew that the old Gus, the life of every party he ever went to, would have fit into any circle at school. Even with the medication, the old Gus was gone. He still made good grades and seemed to do well. Apparently he slipped off his medication during the spring semester. When he returned [home] that summer, there were stark changes.

Nevertheless, he returned to his work at The Nature Camp, earning honors that summer, the last of his life, as an outstanding counselor. Gus loved the outdoors, and he loved children. Even though when I went to visit him at camp, he was clearly off his medication and laughing at the illusions that danced around my head while we ate, he related well to the kids there.

I have spent a large portion of my time since he died to make sure he is remembered, to make sure that Gus is remembered for more than the way his life ended, and to make sure that others who struggle as he did, do not suffer needlessly. I have worked to create a system of public mental health in Virginia that meets the needs of every community and to ensure that we are taking positive steps to improve the quality of life of people with mental illness in Virginia. I have also worked to bring awareness to the issue and to beat back the stigma that keeps so many people from treatment and that drives families and those who suffer underground. There is still so much work to do.

Very truly yours,
R. Creigh Deeds, Senator
25th Senatorial District
Commonwealth of Virginia

Senator Deeds courageously wrote this passage for the OJIN Healthcare Reform topic, knowing he could reach many nurses and health professionals. His words poignantly implore us to use our compassion, our knowledge, and professional commitments to make an impact on policy. This OJIN topic is initiated by five articles that consider healthcare reform in the lens of the national political arena, in several specific areas of reform, and in the context of global healthcare. In each of them, nurses are making a difference.

In the 2017 national political arena, the swirl of news about healthcare and reform is dizzying. In her article, "The State of Play: Healthcare Reform in 2017," Suzanne Miyamoto, PhD, RN, FAAN, Chief Policy Officer at the American Association of Colleges of Nursing (AACN), presents a summary of the major streams of policy, law, and policy-proposals that have come together to form The State of Play: Healthcare Reform in 2017. Miyamoto’s factual review includes the Congressional Committees’ work on the American Health Care Act as well as input from independent stakeholders such as the Congressional Budget Office, advocacy health-professionals’ organizations, health organization coalitions, and constituents. Additionally, she presents essential reminders to the readers of our tenets of democracy based on debate, discourse, and the understanding that change is a constant challenge and we must be flexible and open to it.

In an applauded collaboration among health experts, Joelle T. Fathi, DNP, RN, ANP-BC; Hannah E. Modin, MHA, B.A; and John D. Scott, MD, MSc, FIDSA report in their article, "Nurses Advancing Telehealth Services in the Era of Healthcare Reform," about information and communication technologies (ICT) – which affords us telehealth services as a viable means for healthcare access in primary and acute care settings. What today appears to be ‘innovative’ technology actually began in 1905 – more than 110 years ago – and its evolution through interactive technology expands the possibilities for access, patient-centered care, healing, education, and collaboration. The authors dispel the belief that the focus of telehealth services is only for underserved in rural areas. In fact, telehealth is used more broadly, to include urban settings, since transportation can be cumbersome and limit patient access to care. In the current era of healthcare reform, Fathi, Modin, and Scott emphasize that nurses and other professionals are positioned to influence policy to advance the use of telehealth services as strategies to deliver timely, efficient, quality, effective care. They urge nurses to become educated about recommendations from major policy stakeholders (e.g., IOM, IHI-Triple Aim; Macy Report, NCSBN) to support full scope of practice and to seek appropriate reimbursement for any services provided through telehealth.

As all politics are local, so are our tragic stories of mental health struggles (see Deeds above) and the untold victims of the spiraling opiate crisis and epidemic. Weekly we find ourselves in moments of solitude, prayer, spiritual reflection, perhaps questioning ourselves as professionals when we learn of tragedies close to us and our network circle of associates. Almost all nurses care for patients with addiction issues. We cannot become inured to these events; we must force ourselves to feel the emotion and pain again and again for ourselves and for our families, friends, and associates. We must work to eliminate the stigma associated with addiction specifically and mental health disorders in general. In her review for nurses, "Opiate Crisis and Healthcare Reform in America: A Review for Nurses," Susan G. Painter, DNP, PMHNP-BC, provides insight into this blight on our localities and our nation. Painter notes that nurses are in front line positions to provide assessment for patients with opioid use histories and subsequently connect them to evidence-based resources that can save lives. She describes how nurse engagement can influence positive outcomes when individuals with opioid abuse disorder seek resources and treatment. Painter describes federal, state, and local policy initiatives, often having bipartisan support, to facilitate healthcare reform to address this epidemic. Finally, she offers considerations for nurses to effect change, noting the urgency to positively impact and reverse this crisis as policy is considered, debated, and decided.

Healthcare reform readers have targeted large sectors of care delivery and seek greater control of the costs of care and insurance coverage options. We have experienced a paradigm shift to the value of the care provided over the volume (fee for service) payments; promotion of innovation through financial incentives; treatment in ambulatory settings; increasing focus on preventive care; and greater attention to how social determinants of health impact health and the care system. In "Nurse Led Reform: Is It Time to Rethink the Nursing Unit," author Mark McClelland, DNP, RN, CPHQ, who has served as both a Quality Director and Nurse Scientists for a worldwide health system, posits the question as part of healthcare reform and nursing impact, is it time to rethink the nursing unit? – does it need reform also? McClelland outlines the transformation in healthcare delivery since the early 1900s, the institutions and legislation that brought about enormous changes in how individuals receive healthcare coverage, access to care, and the strong measures in place to assure quality based on evidence based research and practices. In this article, McClelland asks: What has changed in the model of organization for nursing care delivery on a typical general nursing care unit that addresses nursing complexity, level of skills, specialization, and alignments with reforms in healthcare? McClelland presents a proposed Service Line Model (SLM) that incorporates elements of the functional, team, and primary nursing models. He provides assumptions, categorizes domains of nursing practice and its supporting roles, and describes the functions and characteristics of the SLM model. He projects potential benefits including reduced clinical variations and a greater ability to identify and measure the nursing contribution to each patient encounter.

The United States is not alone on the journey for healthcare reform as it seeks to transform the delivery and financing of healthcare to all members of society. To assist us in diving into the global perspectives and nursing impact in healthcare transformation, three nurse scientists provide us a wide-angle view through the methodologic lens of the multi-layered bibliometric methods analysis. David C. Benton PhD, RGN, FRCN, FAAN; Deborah E. Trautman, PhD, RN, FAAN; and Maureen Swick, PhD, RN, NEA-BC note in "Healthcare Transformation: A Bibliographic Analysis of a Global Endeavor" that nursing-focused articles on exploring healthcare transformation number nearly eight thousand authored since 1969, aggregated among four major countries (USA, UK, Canada, and Australia). This article steps into methodology, an area infrequently addressed in OJIN; however, it underscores the wide-spread interest of nurses globally about reform and the impact that nurses have on policy. The authors provide insight into the bibliometric methodology, adding graphic depictions of how subject matter and relationships evolve to varying lines of inquiry sourced from renowned authorities who were cited frequently and became the origin-locus for new insights and innovation. The readers will discover interesting mappings (akin to the popular word-clouds) and discussions revealing the influence and significance of scholarly journals in advancing articles focused on the multiple concepts in healthcare policy transformation at the global level.

This OJIN topic focuses on healthcare reform and nurses’ impact on policy. The articles clearly demonstrate the breadth of settings and discovery that nurses experience and advocate for as they strive to make healthcare reform equitable, affordable, and accessible to all members of society. The journal editors invite you to share your response to this OJIN topic addressing healthcare reform either by writing a Letter to the Editor or by submitting a manuscript which will further the discussion of this topic which has been initiated by these introductory articles.

Jennifer Matthews, PhD, RN, CNS, FAAN
Email: jmatthewsrn@comcast.net