Week 1: Barriers to Practice

  1. Identify and describe practice barriers for all four APNs roles in your state and discuss these barriers on a state and national level. The four roles include the nurse midwife, nurse anesthetist, nurse practitioner and clinical nurse specialist. 
  2. Identify forms of competition on the state and national level that interfere with APN’s ability to practice independently. 
  3. Identify the specific lawmakers by name at the state level (i.e., key members of the state’s legislative branch and executive branch of government) 
  4. Discuss interest groups that exist at the state and national levels that influence APN policy. 
  5. Discuss methods used to influence change in policy in forms of competition, state legislative and executive branches of government and interest groups. 
  6. A scholarly resource must be used for EACH discussion question each week.

Key Points

  • Barriers to APN practice identified in the readings this week and from outside reliable sources.
  • Barriers that are particular to your state and nationally.
  • Forms of competition that exist
  • Law makers at the state level, i.e. state senate and house, governor
  • Interest groups are there at the state and national level
  • Methods you can use to influence a change to eliminate barriers

Week 1: Policy Making, Healthcare and Professional Nursing



Stethoscope and Gavel

Welcome to the first week of healthcare policy! During this first week, the focus is on types of policies and their relationship to healthcare policy. Next there will be a review of the relationship of values to politics and consideration of political action spheres applied to nursing. It also is important to examine the history of policy development and policy making in nursing. Finally, ethical principles will be considered in relationship to healthcare policy.

As you begin this course, notice that the conclusions of several chapters in the textbook contain special features, such as Vignettes, Policy Spotlights, and Taking Action. Some of these features are assigned as reading that serve to provide specific life examples of the topics discussed in the individual chapters. Take a look at the contents of these special features, whether assigned or not, and you may see that some apply directly to your chosen policy priority. The assigned journal articles further enhance the content of the readings and lesson. The many websites for various professional organizations found in the web resource section will help you with tracking various policy concerns, and they will list important contact information, as well as examples of position statements and briefs. Finally, the video links provide presentation examples and ideas, as well as the video clips that give you a broad understanding of healthcare policy concerns impacting the United States and the global community.

When you think about policy, and especially healthcare policy, what comes to mind? It is important to remember that healthcare is a multifaceted system that is highly convoluted with many interrelated elements. Changing a policy in one area may have intentional or unintentional impact upon other areas. For example, changing access to healthcare may result in the need for additional advanced practice nurses or could overwhelm already crowded emergency departments. Consider possible changes to our American healthcare policies with new leadership in Washington D. C. In addition, consider the impact of new policies upon nursing practice in your community, state, and country, as well as the global community.

Historical Development of Advanced Practice Nursing

The road to advanced practice for nurses in the United States has required patience, dedication, and advocacy (Barker, 2009). The historical development of the role dates back to 1965 when nurse Loretta Ford and physician Henry Silver, from the University of Colorado, suggested that a nurse practitioner (NP) could best alleviate the primary care shortage (especially in the area of pediatrics) and developed a pediatric nurse practitioner plan of study. Their efforts were met with much resistance from both the nursing and medical communities (Hain & Fleck, 2014). Nurses thought such a role was “playing doctor,” whereas physicians thought such a role was “practicing medicine without a license.” However, the early work by Ford and Silva paved the way for advanced practice nursing (Buppert, 2011). Eventually four advanced practice nursing (APN) roles emerged, that of the Certified Nurse Midwife/CNM (Avery, Germano, & Camune, 2010; Kelley, & Klopf, 2008), Certified Nurse Practitioner/CNP (Baker, 2010; Dierick-van Daele et al., 2010; Frisch et al., 2010; Goroll, & Mulley, 2009; O’Neill, Moore, & Ryan, 2008), Clinical Nurse Specialist/CNS (LaSala, Connors, Pedro, & Phipps, 2007), and Certified Nurse Anesthetist/CRNA (Galvin, Dewan, & Rockoff, 2009). In 2017, APNs can further specialize within these roles to include expertise in Mental Health, Geriatrics, Acute Care, and Palliative Care (Hain & Fleck, 2014).

Some important professional organizations that contributed to early role development include the American Association of Nurse Anesthetists (AANA) and the American Association of Nurse Practitioners (AANP), both with a largely clinical focus; the American College of Nurse Practitioners (ACNP), with a largely legislative focus; and the National Organization of Nurse Practitioner Faculty (NONPF), with a largely educative focus. Initially, many nurse practitioners were actually prepared through certificate programs, much like the nurse anesthetist of that day. Historically, nurses would complete intensive diploma nursing programs at a given hospital and then move on to complete hospital-based certificate programs as a nurse clinician or nurse anesthetist. As nurse clinician programs grew in popularity, and as the minimum level of entry began to move to university-based education, the hospital certificate programs moved as well, leading to specialty education at the graduate level in order to obtain advanced practice credentials. Despite the movement from generalist to specialist education, the commitment remains first to nursing, then to specialization such as the advanced practice role, and then to sub-specialty role development such as the role of the nurse practitioner (Kass-Wolff & Lowe, 2009). In addition, a wide and differing variety of professional preparation requirements, continuing education mandates, and/or standards of practice exist that are unique to each state (Yoder-Wise, 2012). Credentialing remains a confusing discussion among APNs and even more confusing to laypersons, other healthcare professionals, legislators, and payers (Bishop, 2014).

With the emergence of these APN roles, delivery of healthcare in the year 2017 has progressed past augmenting care in traditional MD/DO practices. APNs are now practicing in such diverse settings from the operating room to owning their own practices where the delivery of care is independent of physician oversight. Even with the diversity of care delivery models, state governance of APN practice continues to differ widely with regard to scope of practice, level of autonomy and individual certification requirements (IOM, 2011).

Policy and Healthcare Policy

Political definition

It is important to consider a basic definition of policy when embarking upon any discussion of policy in general and healthcare policy in particular. Policy is a defined course of action identified by individuals or groups in order to resolve a concern. Although this represents a fairly broad definition of policy, it is important to realize that policies can change, and in fact must change as situations or concerns change.

Consider for a minute an example of a positive and negative policy you have experienced and its consequences. Public policies are specific because they are identified and enforced by public or governmental officials. For example, requiring specific immunizations of school age children can come from local school district officials or state government or even both. Healthcare policies have far-reaching effects. Consider the ripples that emerge when a pebble is dropped into a pool of standing water. When the pebble is dropped into the water, small ripples begin developing around where the pebble was dropped, and a series of larger ripples follows with an increasingly wider radius. Consider the wide reaching impact if the minimum age for Medicare coverage was raised to 70 years of age! What if the policy was lowered to 60 years of age?

As noted earlier, healthcare is a complex, convoluted system that must adapt to changes. The crisis facing the healthcare system currently are very different from the 1960’s. Take a minute and identify three current healthcare crisis or concerns and then compare to the list noted below.

The Question

Identify three healthcare crisis or concerns.

Your Answer

Compare Answers

Professional Nursing’s History of Healthcare Policy Making

As nurses, we have been consistently judged as one of the most trusted professions. Strong nurse leaders, such as Lillian Wald, Margaret Sanger, and Lavinia Dock, worked tirelessly to promote health and change the lives of millions of people in this country. Yet, their actions occurred in spite of being women at a time in our history when women’s roles were those of homemaker and mother without the right to vote! Oftentimes, these women were persecuted and even risked jail in order to pursue their agendas of public health, social welfare, and community service.

Professional nursing as we know it today was started by Florence Nightingale in the mid-1800s. Her well known healthcare policy work in the Crimean War reduced the death rate at one hospital from 42% to 2%. The healthcare policies that she implemented focused on sanitation and environmental controls. She opened the nurse-training program in England with the intention to promote health, as well as the autonomy of nursing and women. When Nightingale’s model was first applied to schools in the United States a few years later, the intent was the same. It is her work to change healthcare policy at the workplace/workforce level that resulted in her recognition.

Nurse leaders at this time fully realized that their mission of public health and professional autonomy needed the strength found only in organizing. If they remained isolated and alone in their work, they were essentially powerless against the forces of entrenched medical groups and hospital boards. The founding editor of the American Journal of Nursing, Sophia Palmer, specifically used the journal as a means of enlightening nurses (women) about the importance of policy and politics. Nurse leaders, such as Isabel Hampton Robb, organized nurses and began to take control of the training schools within hospitals so that students would receive the type of education Nightingale had intended, instead of the hard-labor model that had evolved.

Within the public-health sector in the early 1900s, nurse leaders in the United States worked to improve appalling sanitary conditions, especially in poor urban areas. Lillian Wald organized a group of nurses living within the community they served and focused on community health concerns. Today, it is difficult to imagine the social conditions of that time: Sanitation was nonexistent, overcrowding was rampant, and poverty was pervasive. Often, it was the women and children who bore the brunt of the lack of even the most basic healthcare. Margaret Sanger fought to promote access to birth control education, fully understanding and using political strategies in advocating for women’s health. Lavinia Dock worked to organize nurses and involve them in the suffrage movement, realizing that this political action would significantly strengthen nursing’s voice in all areas of healthcare policy. Appealing to nurses as women and citing the social plight of underfed school children in New York, Dock noted that this translated into the political power to change not only that situation but countless others that affect the health and social conditions of all individuals.

Out of the efforts of these women came health and social policies that transformed the quality and quantity of life in this country, and the ripple effect impacted the global community, as well. Consider each of these and other nurse leaders from history in terms of the four spheres of political action and political development. These women understood the critical importance of politics and policy making and the impact of policy on their advocacy agendas. Their focus was on the political process, and their goal was to impact health promotion and wellness in order to prevent illness, rather than simply treating what already existed. In this way, they understood that they could help far more people and promote the health of generations to come.

Throughout the intervening decades, nurse leaders in all areas of nursing followed in the footsteps of early activists and learned from their strategies. Ponder the fact that nurses have a significant way to go in terms of nursing leadership in the government sphere. What do you think needs to change or improve in order for nurses to get more politically active in the government sphere? Will you be an active participant at this level? How can you move in this general direction?

Ethics and Healthcare Policy


One cannot possibly discuss politics and policy making without first reviewing the basics of ethics. Healthcare policy ethics is one of the most hotly debated and hard-fought concerns in politics, especially here in the United States. With the rising costs and limited resources involved in healthcare services in this country, ethical problems and dilemmas appear on every horizon. When discussing ethics and healthcare policy, it is good to review basic ethical principles

Review the ethical principles and see a description of each.

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