Advanced Practice Nurses - Questions

How do advanced practice nurses incorporate healthcare economics into clinical decision-making with their patients and influence value-based care models with cost-effective quality outcomes? How can nurses become more engaged at the grassroots level to impact health policy (state or national) despite challenges such as time, lack of health policy knowledge or lack of access to policymakers? How can advanced practice nurses advocate beyond the bedside at the legislative level to better represent nursing and affect change to the healthcare system? If cost is placed at the forefront of healthcare policies how do nurses handle ethical conflicts with providing quality patient care? Shreejana Khanal How do health policy and economic factors influence clinical decision-making and patient outcomes in advanced nursing practice, and why is it essential for advanced practice nurses to understand these concepts? Policy changes clinical practice and affects patient outcomes in advanced practice. Policies impact budgets, decide what gets reimbursed, and determine who gets access to care services. Since health care functions under artificial scarcity, clinical decisions are made based on money available and what the payers allow. Politics is the allocation of scarce goods and services, directly affecting care and outcomes (Groenwald & Eldridge, 2020). APRNs should know these concepts to advocate for patients but need to understand how services are paid for under cost-containment measures. Mason et al. (2021) go on to state that “economic factors such as reimbursement mechanisms and payment models, as well as financing systems, drive what kind of care gets priority” (p.81). As nurses who care for patients day in and day out, APRNs must be familiar with health policy to understand how we can help our patients influence better outcomes. In my ICU/ER setting, policies related to hospital throughput and maximizing reimbursement drive some decisions made about patients, such as pushing early discharge, need for admission, rapid response activation, etc., that directly affect patient safety and outcomes. In what ways can nurses actively participate in the development and implementation of health policy at local, state, and national levels, and what barriers might limit their involvement? Nurses have many opportunities to be engaged at local, state and national levels to help formulate health policy but face barriers. Some examples include professional organizations, committee work related to policy, research, and contacting legislators. Nurses also play a role in setting the agenda by contributing information regarding aspects of healthcare that require policy development (Groenwald & Eldridge, 2020) . Lack of time, knowledge, political efficacy, and power are barriers to nurses becoming engaged in policymaking (American Nurses Association, 2019). Some stakeholders have more say than nurses when it comes to healthcare policy development due to power structures within the healthcare microcosm (Mason et al., 2021). Groenwald and Eldridge (2020) mention how nurses have a great deal of power in numbers and trust from the public but fail to translate that to leverage politically 17. In critical care, I feel nurses are on the frontline of seeing where systems fail patients. Whether it be delayed escalation of care or absence of early warning scoring systems, nurses can identify these areas but may not feel empowered or know how to carry these concerns to policy agenda setters. How can nurses engage in political and legislative advocacy to advance the nursing profession, and what strategies are most effective in influencing healthcare policy at a broader level? Nurses have many opportunities to be engaged at local, state and national levels to help formulate health policy but face barriers. Some examples include professional organizations, committee work related to policy, research, and contacting legislators. Nurses also play a role in setting the agenda by contributing information regarding aspects of healthcare that require policy development (Groenwald & Eldridge, 2020). Lack of time, knowledge, political efficacy, and power are barriers to nurses becoming engaged in policymaking (American Nurses Association, 2019). Some stakeholders have more say than nurses when it comes to healthcare policy development due to power structures within the healthcare microcosm (Mason et al., 2021). Groenwald and Eldridge (2020) mention how nurses have a great deal of power in numbers and trust from the public but fail to translate that to leverage politically 17. In critical care, I feel nurses are on the frontline of seeing where systems fail patients. Whether it be delayed escalation of care or absence of early warning scoring systems, nurses can identify these areas but may not feel empowered or know how to carry these concerns to policy agenda setters. Advocating politically and through the legislature for nursing is possible through concrete efforts. Ways nurses can help change or create policy include building coalitions, getting active in political action committees (PAC), lobbying, and “knowing” your politician. Nurses can also use expert power by providing clinical information related to patient outcomes or healthcare experiences. Expertise is one of the most potent sources of power nurses have (Groenwald & Eldridge, 2020). Nursing is not the only profession that will agree with your position on a policy, so it is vital to build relationships and collaborate with other groups that align with your goals. Mason et al. (2021) state that advocacy should not only focus on individual issues but ensure they fit the larger goals of the public and politicians’. Lastly, you must be willing to be engaged over the long term to create sustainable change. I think QI projects are one-way nurses can help implement changes in practice that may reach policy level decisions. For example, in the ER/ICU, we helped implement an early warning score system and sepsis bundle to improve patient safety. 4. How should ethical principles guide the development and implementation of healthcare policies, particularly when balancing cost, access, and quality of care? Ethics should be considered when developing healthcare policies affecting patient care, access, and payment. Justice, beneficence, and nonmaleficence are guiding principles when determining if a policy will provide safe and equitable care to our patients. Other than our patients, there are other stakeholders when developing policy, so we must understand how our decision will affect others. Power differentials between stakeholders can increase healthcare disparities, so we must identify who will be affected when decisions are made (Groenwald & Eldridge, 2020). Mason et al. (2021) add that we must be transparent when decisions are made and hold ourselves accountable for our actions. In addition, we should allow everyone who will be affected by the policy to have a voice when decisions are made. APRNs have the background and clinical expertise to provide a voice when it comes to healthcare policies. Cost-containment is one thing we often face when caring for patients in critical care. I have seen firsthand where we may not get patients the level of care they need because there is no longer ICU bed availability. Policies like these make us question if we are providing equitable care to our patients. References Alyse Singleton How do policy changed around insurance coverage or reimbursement affect the patients you care for? Changes to insurance coverage/reimbursement have measurable effects at the bedside more than many think. Many times, coverage limitations/reimbursement being tied to certain metrics can directly affect admission/discharge decisions/timing. Politics decide how scarce healthcare resources get allocated which directly affects patient care (Groenwald & Eldridge, 2020). Mason et al. (2021) further stated that reimbursement determines how organizations value specific care priorities. I spend most of my time in the ICU/ER setting and see it frequently with patients who have avoided care due to inability to pay or lack of insurance. They come in so much sicker than they would have been if they were able to receive preventative care or lower levels of care before becoming so unstable. How can nurses share their clinical experience around staffing, pay, or workforce conditions in a way that actually connects with policymakers? I believe nurses have an incredible opportunity to engage with policymakers; we just aren’t taking full advantage of it. One thing I have learned is pairing patient stories with facts. Policymakers love statistics but hearing how it directly affects patients from a nurse allows them to understand it that much better. Nursing carries clinical credibility and when talking to lawmakers and involved parties, our clinical background provides “expert power” which is a very strong form of power (Groenwald & Eldridge, 2020). Mason et al. (2021) adds that communication and relationship building are vital when engaging with policymakers. “For example, speaking to legislators about unsafe nurse staffing isn’t as impactful as explaining how it prevents nurses from catching changes in patients’ conditions or leads to more adverse events” (p. 13). What are some ways to stay informed about current legislative issues affecting nursing? The best piece of information I can think of when it comes to staying informed is that you do not have to know every policy going through Congress. Follow the ANA, sign up for policy alerts, or even just take notice of laws that affect healthcare when reading the news. The ANA (2019) addresses how one of the biggest barriers to nurses getting involved is knowing what’s going on. Learning about one new policy a week can really help and over time you’ll start to recognize keywords that pop up a lot in policies. Mason et al. (2021) discusses how it is also important to continue to engage with the policies you learn about. Personally, scrolling through social media I see little healthcare/political posts that my nursing organizations share. Just seeing them bite sized keeps my mind thinking about them so when I have the opportunity to read further or reach out to my local legislators I can. Another bonus is these updates usually only take a few minutes. How can nurses help ensure policies are fair and don’t unintentionally widen existing gaps in healthcare? Ensuring policies are equitable can be difficult, but I believe nurses are at such an advantage because we understand what is missing. Justice and beneficence should be used when creating policies that target vulnerable populations (Groenwald & Eldridge, 2020). Mason et al. (2021) discuss how it is also important to understand whose perspective is being considered when the policies are made. In critical care, I have had patients who do not have follow-up care, cannot get their medicines, have no transportation, etc. affect their recovery. If things like that are not kept in mind when making policies regarding a specific disease/condition, you may unintentionally be increasing the gap between populations. Nurses can use their voice to express what we are actually seeing. References Mason, D. J., Dickson, E. L., McLemore, M. R., Perez, G. A., Trent-Adams, S., & Underwood, L. (2021). Policy & Politics in Nursing and Health Care. Elsevier. (Mason et al., 2021)