Holy Angel University Graduate School of Nursing Angeles City

A written report on: Nursing in a Political Era & Issues within a managed care environment

Submitted to: Prof. Christopher Guarin, MAN, RN Submitted by: Noriel P. Calaguas, BSN Submitted on: August 18, 2011

Nursing in a Political Era

Nursing then, now and tomorrow Historical View of Nursing 1633 The founding of the Sisters of Charity by St. Vincent de Paul and Louise de Merillac. Nursing went out of the convent in the homes of the poor. This expanded into a hospital in Angers, France & Phillipines. 1654 and 1656 SOC care for the wounded on the battlefields by 1660 over 40 houses of the SOC exist in France and several other countries. 18th Century Rabia Choraya HN in the Moroccan Army traveled with Gen Braddock, highest paid women in service. 1783 James Derham, a slave from New Orleans buys his freedom from $ made as a nurse. 1820- Jensey Snow, slave, opens a hospital In 1836 The Nursing Society of Philadelphia opens a school for nurses. The need for nurses flourished during the Crimean War 1853 and the civil war 1865. The Army Nursing Corp began in 1872. People of all races entered the nursing field during these years. 1844- Dorothea Dix, report to legislature 1850 Florence Nightingale begins her training at the St Vincent de Paul in Alexadria, Egypt. 1853 FN visits the Sisters of Charity in Paris to learn their methods. 1860 FN is published What is it and What its Not

Current Views of Nursing Nursing is viewed a stressful, impossible job Nurse have no control over what is required to provide good patient care (Steinbrook, 2002). There is less one on one personal care, focus on admitting, discharging, and teaching patients to care for themselves As nurses stand at a crossroad of leadership or followership practice, a consideration of nursing theory may provide the professional foundation necessary for growth, excellence and survival (Gonzalez,2008).

The Nurses of the Future The nurse of the future a highly educated, well-informed, fully practicing and empowered practitioner is needed now. Nurses know that and they are serving on national organizations, regional committees, grass-roots task forces and consumer-based coalitions with new commitment and a sense of urgency. (McCauley, 2011)

Tomorrows most successful nurses will be educated, passionate, and politically aware and prepared to assume their rightful place as collaborators in improving health care. (Beall, 2011) The future of nursing is here. Its just not everywhere, (Hinman, 2011)

Public perception In the annual 2008 Gallop survey, nurses are in the #1 position on honesty and ethics. Eighty four percent of Americans report that the ethics of nurses as very high or high compared with 20 other professions, earning us the top spot for the 7th consecutive year.

Negative stereotypes Angel of mercy Hand maiden Glorified waitress Naughty nurse TV and media image Behaviors/appearance Appearance-unkempt Negative attitude Not respecting others/self Not accounting for actions Criticizing others Being mean to patients Backstabbing/gossiping co-workers Poor communication skills Not competent and does not want to learn anything new

Autonomy, power and empowerment Autonomy is defined as the amount of control that we have over our practice. (Cohen and Bartholomew, 2008). Power is the ability to influence others through the possession of knowledge or skills that are useful to others(Manojlovich,2007). Empowerment- develops over time and is through to occur when and organization sincerely engages people with mutual interest with an intention to promote growth ( Erickson et al., 2003). Accountability-willingness to invest in decision making and to assure responsibility for individual and collective performance( Larkin et al., 2008). The relationship between clinical credibility and the image of nursing

Clinical credibility is the impression of the performance of a nurse. This is created by a consumer or another health care provider after they observe or interacts with the nurse in a clinical setting

Force of Magnetism: Image of nursing Nurses must be viewed as integral to the organizations ability to provide patient care (ANCC, 2005).

The purpose of shared governance is to provide an organizational frame which increases the obligation and opportunity of professional members of the nursing staff to make decisions that affect their work and to be fully involved in implementing and evaluating the effectiveness of those decisions in order to increase professional accountability for them (ANCC, 2005). Politics

Policy

is a process by which groups of people make collective decisions (Wikipedia.com, 2011) Process of influencing the allocation of scarce resources (Mason, Leavitt, and Chafee, 2007) Also refers to the methods and tactics used to make and apply policy (Roux and Halstead, 2009)

is a plan to guide action or decisions (Roux and Halstead, 2009) Mason, Leavitt, and Chafee (2007) differentiated policy into five categories: o Public Policy o Social Policy o Health Policy o Institutional Policy o Organizational Policy Is Nursing, Political in Nature?

Nursing apathy toward participation in the political process is pandemic. Never more so than today has the profession needed a strong united stand within the political arena. Political involvement encompasses being knowledgeable about issues, laws, and health policy. Barriers to political activism are thought to encompass several spectra including heavy workloads, feelings of powerlessness, time constraints, sex issues, and lack of understanding of a complex political process. The implementation of a political role for a nurse is based on three levels of commitment including survival, success, and significance. Survival includes individual involvement within communities. Success accepts challenges in addressing injustices especially within the health-care arena. Significant involvement uses visionary nurses toward the betterment of the nurse profession. Strategies for involvement include political awareness, incorporation of course/program expectations on both undergraduate and graduate levels and teamwork. As patient advocates, nurses cannot continue to be spectators in the political arena. o http://www.professionalnursing.org/article/S8755-7223(04)00179-6/abstract

Nurses and Political Action Influence can be exerted on: the workplace by affecting the development of institutional policies, the community through activities on local boards professional organizations by participating on committees or serving as an officer, and government through involvement in campaigns, letter writing, and voting Who are we again? Nurses hold a level of stature that is highly respected and trusted. They are viewed as professionals who truly are interested in the welfare of others. The role of nurses in health promotion is recognized by international, national, and state organizations. Organized support of these issues can greatly affect world health, so nurses have a duty to investigate their role and increase their level of participation.

This type of empowerment broadens nursing's political focus and increases respect for the profession on all political levels. Who are we again? Nurses, as individuals, frequently do not address political issues that affect the profession. A lack of knowledge of the legislative process causes them to be overwhelmed by the complexity of public policy. Nurses focus on clinical care and sometimes ignore larger issues, partially due to a heavy workload, but also due to a lack of understanding of how to influence public policy. Is Health Care, Political?

Yes, it is. Health and health care are inextricably intertwined with social, economic, and political systems. Health care is political because it involves limited resources, important needs, and varied ideas on how to match resources with needs. Health is political because health care is expensive. Someone somewhere must decide about the allocation of resources that go to health and health care. How should Nursing, Health Care and Politics Mix, Nurses need to be involved in those political decisions. Nurses need to be vocal about the policies and politics that affect their practice. Nurses may forget that, as the largest group of health care professionals, they could generate enough power to successfully reform the health care system based on numbers alone. Nurses and Politics: Should We or Shouldn't We? So, the answer to the question is yes, unequivocally yes, nurses should get involved in politics to improve working conditions and provide patients with quality care. (Smith, 2003) o http://findarticles.com/p/articles/mi_qa4090/is_200303/ai_n9180434/

Why Should Nurses Be Involved? Politics influences: where nurses work what they do and how they do it ability or organize professionally nurses professional status through licensure and certification Nurses have always been involved in politics. Florence Nightingale used her contacts with powerful men in government to obtain supplies and the personnel she needed to care for wounded soldiers in the Crimea. Hannah Ropes was able to fight incompetence and obtain decent care for wounded Civil War soldiers because she understood who the influential people in Washington were. Today, with many interests competing to be heard in the decision-making circles of our nation, the person who understands power and politics is the one most likely to obtain the resources needed to accomplish desired ends.

Health care is costly, and public dollars can be and are spent in many ways to provide health care. Legislative and administrative decisions of governmental agencies determine what part of the federal and state budget is allocated to health care, how much is used for preventive health programs, how much for research, how much for care & treatment, how much for education, and what diseases are targeted for investigation. Decisions are also made in health care agencies. What positions will be funded, what equipment purchased, what programs should be adopted and which of the current programs should be dropped. Knowing where decision making occurs, who makes the decisions, and being familiar with how you can influence that process is important. POLITICS INFLUENCES NURSES PROFESSIONAL STATUS THROUGH LICENSURE AND CERTIFICATION Nurses practice is controlled by the Nurse Practice Act of each state. The NPA legally defines nursing and the scope of nursing practice is outlined in that document. Nurses experience effects of government regulation directly: o nurse/patient ratio o advance practice prescriptive privileges o decrease in the number of nurses employed in hospitals http://old.texarkanacollege.edu/~sdroske/ch16.htm Public policy formation There are four main steps in the process of public policy formation: 1. setting an agenda 2. government response 3. policy design 4. and program implementation Timing is a crucial aspect in politics. If a group of nurses want to introduce legislation supporting a higher nurse-to-patient ratio, the time to press forward on the issue might be after a negative outcome occurs related to a low level of professional nurses on staff. Nurses need to recognize the factors that can potentiate change. It always is wise to take a step back from the issue at hand and determine whether the time is right, or whether the cause might be better served by increasing resources and waiting for a more opportune moment.

Factors: POWER: "that force that enables persons or groups to realize their will even against opposition." Nurses become empowered through education, leadership, and collective action. Power in nursing is based on four facets: o expertise and reputation o position or profession

o o o

personality connections to influential people, such as major corporations, organizations, and politicians Nurses and Political Action

Political-ethical conflict = conflict between one's ethical belief system and what one feels compelled to do or is told to do by someone in a position of power. Many conflicts exist in the nursing profession, which are of concern because quality patient care and public health are at stake, e.g.: o the difference between historical ideas of what nursing was and the new image of what nursing has become, o the contrast between the perceived weakness of the female gender and the strength of the nursing profession as a whole (eg, the largest single sector of the health care industry), and o the inconsistency between the goals of the physician and institutional sectors of the health care industry with goals of the nursing profession. Political-ethical conflict is defined as the conflict between one's ethical belief system and what he or she feels compelled to do or is told to do by someone in a position of power. (Jardin, 2001) http://findarticles.com/p/articles/mi_m0FSL/is_5_74/ai_81161374/

Visionary leaders can bring nursing to the next level of professionalism and involvement.

Nurses are in an ideal profession to articulate a higher vision of leadership. If nurses can rid themselves of their traditional tunnel vision, they can participate in the promotion and election of visionary leaders. Having visionary nursing leaders in strategic positions in health care facilities; professional organizations; and national offices significantly increases the influence of nurses and, therefore, their objectives in the health care political arena. WHO's key focus on policy development encompasses many nursing philosophies. The organizations' policies for action include: integrating health and human development into public policies ensuring equitable access to health services promoting and protecting health preventing and controlling specific health problems

Are we (here in the Philippines), Political Active? 1987 Philippine Constitution

Article II., Section 15. The State shall protect and promote the right to health of the people and instill health consciousness among them.

ANG NARS is a non-profit, non-stock organization with Securities and Exchange Commission (SEC) Registration No. CN200900208.

Our VISION We envision ANG NARS as an advocate organization ensuring and promoting the socioeconomic- political- professional rights of Nurses with the responsibility and accountability to provide safe quality Nursing care to the Filipino people. Our MISSION a. Promote the rights and welfare of the many marginalized Filipino Nurses both local and abroad; b. Work with all sectors and professionals in the health care system in lobbying for, and in advancing the many concerns of the Nurses and other health professionals that their human dignity are, at all times, protected; c. Unify Nurses both local and abroad into a solid organization that can be a potent sector and active partner in advocating for effective and efficient health delivery systems. d. Have a representation in Congress who will be our voice in the august halls of our country's legislature Our MOTTO: KARAPATAN, KALUSUGAN, at KABUHAYAN!

Our ANG NARS General Plan of Actions: Tamang Trabaho! Tamang Sweldo! Tamang Solusyon!

Implementation of Republic Act 9173s Salary Grade 15 for all Nurses working in the country. It shall secure the proper treatment and remuneration of nurses; Uphold the working conditions of Nurses here and abroad; Monitor and implement an effective and efficient program of the Philippine Health Care Delivery System; Encourage and motivate Nurses to become politically and socially responsible.

Issues in a Managed Care Environment

As managed care continues to grow, the relationships among providers, hospitals, physicians and other healthcare professionals are undergoing change and, in many cases, strain. Emanual and Dobler(21) cogently argue that managed care is producing a major change in the physician-patient relationship which has traditionally been based on what they term the six Cs. I.E.: (1) The patient's ability to choose their physician; (2) provider competence (3) physician-patient communication (4) compassion (5) continuity of care and most importantly (6) That there is no conflict of interest on the part of the health care provider. They warn that when managed care restricts patients' choices of physicians; controls their access to care, limits the treatments their physicians can prescribe; limits their doctors' ability to refer them to specialists, and erodes the patients' trust in their doctors by creating a persistent, corrosive conflict of interest; it will ultimately destroy the doctor-patient relationship. Finally, they argue that many of the currently employed salary schemes which reward physicians and hospitals for not providing needed medical services produce a serious, inescapable and pernicious conflict of interest. Emanual and Dobler Many managed care plan executives insist on hiring only recently graduated physicians who are more willing to accept the new corporate managed care culture and who rapidly become dependent upon it. But the "culture of minimums" often conflicts with striving for excellence. An optimal health delivery system must: (1) be patient responsive (2) provide adequate and compassionate care (3) encourage physician excellence (4) be accessible (5) reduce bureaucracy to a minimum (6) provide humane treatment based on scientific merit and (7) be accountable to the patient. Failure to meet these goals has prompted an increasing number of law-suits which may in fact limit the seemingly capricious decisions that so many fear. Many of these suits spring from the cost containment strategies employed by managed care corporations which include: (1) controlling the use of medical services wherever possible (2) limiting treatment (3) reducing follow up visits (4) limiting diagnostic studies (5) controlling formularies (6) eliminating the use of costly medications and treatments wherever possible (7) reducing visits to specialists (8) reducing or eliminating laboratory procedures, (9) reducing or eliminating expensive measures to preserve life (10)providing care using the least expensive "professionals" (11)making patients work through gatekeepers (12)placing healthcare providers at financial risk

(13)rewarding providers for limiting their services through salary increases, bonuses, paybacks, etc (14)dropping sick patients from panels at the time of contract renewal (15)forcing providers to follow rigidly defined protocols (16)limiting physician judgement (17)using utilization review techniques in an arbitrary manner which may define appropriate treatment as "medically unnecessary (18)requiring cumbersome pre-certification (19)mandating the use of a rigid treatment hierarchy before more expensive care can be offered (20)insisting on the use of mail-order pharmacies, and; (21)limiting the services of ancillary care providers such as nurses, physical therapists, special nursing assistants, sitters, etc.

Sample Case suit concerning managed care.

The 1981 Georgia case of Stewart v Midani defined what these crucial elements of employment

were. In this important case, the court ruled that the factors to be used in determining whether an institution affected a physician's judgement or behavior depended upon the specific elements of the relationship that existed between the physician and the employing institution, specifically whether the institution had (1) the right to directly oversee the physician's work, (2) a contract with the physician to perform a specific service or task, (3) the authority to control the time during which a physician worked, (4) the right to inspect a physician's work product, (5) contracted to provide facilities or supplies to the physician, (6) a right to terminate the physician's contract, (7) the ability to determine the degree of skill necessary for the physician's employment and (8) control of the method by which the physician was paid. The court felt that if a preponderance of these elements were present, that there was a masterservant relationship between the physician and the institution and under such terms that the hospital or corporation would be at least partially accountable for the results of the physician's work. Applying Midani (40) subsequent courts have ruled that staff model HMOs which employed physicians on a salaried basis and who directly control the physician's work product are liable for the doctor's behavior because they fulfill all the terms of the "master-servant" relationship. Other cases have expanded Midani to apply to IPA model HMOs and in some cases even PPOs where financial arrangements or protocols define practice.

(Richard C. W. Hall, M.D. ,2002)

List of Law suits concerning Managed Care available at: http://www.drrichardhall.com/ethical.htm