Assignment – Policy and Advocacy for Improving Population Health
I need 4 pages… 2 first ones on the provide template.
To Prepare:
- Review the agenda priorities of the current/sitting U.S. president and the two previous presidential administrations.
- Select an issue related to healthcare that was addressed by each of the last three U.S. presidential administrations.
- Reflect on the focus of their respective agendas, including the allocation of financial resources for addressing the healthcare issue you selected.
- Consider how you would communicate the importance of a healthcare issue to a legislator/policymaker or a member of their staff for inclusion on an agenda.
Part 1: Agenda Comparison Grid – 1- to 2-page Comparison Grid
Use the Agenda Comparison Grid Template Attachment – complete the Part 1: Agenda Comparison Grid based on the current/sitting U.S. president and the two previous presidential administrations and their agendas related to the public health concern you selected. Be sure to address the following:
- Identify and provide a brief description of the population health concern you selected and the factors that contribute to it.
- Describe the administrative agenda focus related to the issue you selected.
- Identify the allocations of financial and other resources that the current and two previous presidents dedicated to this issue.
- Explain how each of the presidential administrations approached the issue.
Part 2: Agenda Comparison Grid Analysis – 1-Page Analysis
Using the information, you recorded in Part 1: Agenda Comparison Grid on the template, complete the Part 2: Agenda Comparison Grid Analysis portion of the template, by addressing the following:
- Which administrative agency would most likely be responsible for helping you address the healthcare issue you selected?
- How do you think your selected healthcare issue might get on the agenda for the current and two previous presidents? How does it stay there?
- Who would you choose to be the entrepreneur/ champion/sponsor of the healthcare issue you selected for the current and two previous presidents?
- At least 2 outside and 2-3 course resources are used.
Part 3: Narrative – 1-page Fact Sheet
Using the information recorded on the template in Parts 1 and 2, develop a 1-page narrative that you could use to communicate with a policymaker/legislator or a member of their staff for this healthcare issue. Be sure to address the following:
- Summarize why this healthcare issue is important and should be included in the agenda for legislation.
- Justify the role of the nurse in agenda setting for healthcare issues.
- At least 3 resources are used.
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Rubric Detail
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Excellent Good Fair Poor
Part 1: Agenda
Comparison Grid-
-Identify a
population health
concern
-Describe the
Population Health
concern you
selected and the
factors that
contribute to it.
5 (5%) – 5 (5%)
The response clearly and
accurately identi�es and
describes a population health
concern.
4 (4%) – 4 (4%)
The response
vaguely identi�es
and describes a
population health
concern.
3.5 (3.5%) – 3.5
(3.5%)
The response
inaccurately
identi�es and
describes a
population health
concern.
0 (0%) – 3 (3%)
Identi�cation and
description of a
population health
concern is missing
or incomplete.
Part 1: Agenda
Comparison Grid-
– Describe the
administrative
agenda focus
related to this
issue for the
current and two
previous
presidents.
– Identify the
allocations of
�nancial and
other resources
that the current
and two previous
presidents
dedicated to this
issue.
– Explain how each
of the presidential
administrations
approached the
issue.
18 (18%) – 20 (20%)
The response clearly and
accurately describes the
presidential administrations’
focus related to the concern, the
�nancial and resource allocation
dedicated to the concern, and
explains how each of the
presidential administrations
approached the issue. At least 3
resources are used.
16 (16%) – 17 (17%)
The response
vaguely describes
the presidential
administrations’
focus related to
the concern, the
�nancial and
resource
allocation
dedicated to the
concern, and
explains how each
of the presidential
administrations
approached the
issue. Only 2
resources are
used.
14 (14%) – 15 (15%)
The response
inaccurately
describes the
presidential
administrations’
focus related to
the concern, the
�nancial and
resource
allocation
dedicated to the
concern, and how
each of the
presidential
administrations
approached the
issue. Only 1
resource is used.
0 (0%) – 13 (13%)
The description of
the presidential
administrations’
focus related to
the concern,
�nancial and
resource
allocation
dedicated to the
concern, and
explanation for
how each of the
presidential
administrations
approached the
issue is missing.
No resources are
used.
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Grid View List View
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Excellent Good Fair Poor
Part 2: Agenda
Comparison Grid
Analysis- Address
the following:
-Which
administrative
agency would
most likely be
responsible for
helping you
address the
healthcare issue
you selected?
-How do you think
your selected
healthcare issue
might get on the
agenda? How does
it stay there?
-Who would you
choose to be the
entrepreneur/
champion/sponsor
of the healthcare
issue you selected
for the current
and two previous
presidents?
23 (23%) – 25 (25%)
-The response clearly and
accurately identi�es an
administrative agency most likely
to be responsible for addressing
the selected healthcare issue.
-Response clearly and accurately
explains how the healthcare
issue gets on the agenda and
remains there.
– The response clearly and
accurately identi�es the
entrepreneur/champion/sponsor
of the healthcare issue selected.
20 (20%) – 22 (22%)
-The response
vaguely identi�es
an administrative
agency which may
be responsible for
addressing the
selected
healthcare issue.
-Response
adequately
explains how the
healthcare issue
gets on the
agenda and
remains there.
-Identi�cation of
the entrepreneur/
champion/sponsor
of the healthcare
issue selected is
vague.
18 (18%) – 19 (19%)
-Identi�cation of
an administrative
agency
responsible for
addressing the
selected health
care issue is
inaccurate.
-Explanation of
how the
healthcare issue
gets on the
agenda and
remains there is
vague or
inaccurate.
-Identi�cation of
the entrepreneur/
champion/sponsor
of the healthcare
issue selected is
inaccurate or does
not align with the
healthcare issue.
0 (0%) – 17 (17%)
-Identi�cation of
an administrative
agency
responsible for
addressing the
selected
healthcare issue is
missing.
-Explanation of
how the
healthcare issue
gets on the
agenda and
remains there is
vague and
inaccurate or is
missing.
-Identi�cation of
the entrepreneur/
champion/sponsor
of the healthcare
issue selected is
vague and
inaccurate or is
missing.
Narrative:
Based on your
Agenda
Comparison Grid
for the healthcare
issue you selected,
develop a 1-2-page
narrative that you
could use to
communicate with
a policy-
maker/legislator
or a member of
their sta� for this
healthcare issue.
-Summarize why
this healthcare
issue is important
and should be
included in the
agenda for
legislation.
-Justify the role of
the nurse in
agenda setting for
healthcare issues
32 (32%) – 35 (35%)
Creates a well-developed,
accurate, and narrative.
The response provides a
complete, detailed, and speci�c
synthesis of two outside
resources reviewed on why this
healthcare issue is important
and should be included in the
agenda for legislation. The
response fully integrates at least
2 outside resources and 2-3
course speci�c resources that
fully supports the summary
provided.
Responses accurately and
thoroughly justify in detail the
role of the nurse in agenda
setting for healthcare issues.
28 (28%) – 31 (31%)
Creates an
accurate and
thorough
narrative.
The response
provides an
accurate synthesis
of at least one
outside resource
reviewed on why
this healthcare
issue is important
and should be
included in the
agenda for
legislation. The
response
integrates at least
1 outside resource
and 2-3 course
speci�c resources
that may support
the summary
provided.
Responses
accurately justify
the role of the
nurse in agenda
setting for
healthcare issues.
25 (25%) – 27 (27%)
Creates a narrative
that is partially
accurate or
incomplete.
The response
provides a vague
or inaccurate
summary of
outside resources
reviewed on why
this healthcare
issue is important
and should be
included in the
agenda for
legislation. The
response
minimally
integrates
resources that
may support the
summary
provided.
The responses
partially justi�es
the role of the
nurse in agenda
setting for
healthcare issues.
0 (0%) – 24 (24%)
The response
provides a vague
and inaccurate
summary of no
outside resources
reviewed on why
this healthcare
issue is important
and should be
included in the
agenda for
legislation, or is
missing. The
response fails to
integrate any
resources to
support the
summary
provided.
Responses
justifying the role
of the nurse in
agenda setting for
healthcare issues
is inaccurate and
incomplete or is
missing.
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Excellent Good Fair Poor
Written
Expression and
Formatting –
Paragraph
Development and
Organization:
Paragraphs make
clear points that
support well
developed ideas,
�ow logically, and
demonstrate
continuity of
ideas. Sentences
are carefully
focused–neither
long and rambling
nor short and
lacking substance.
A clear and
comprehensive
purpose
statement and
introduction is
provided which
delineates all
required criteria.
5 (5%) – 5 (5%)
Paragraphs and sentences follow
writing standards for �ow,
continuity, and clarity.
A clear and comprehensive
purpose statement, introduction,
and conclusion is provided which
delineates all required criteria.
4 (4%) – 4 (4%)
Paragraphs and
sentences follow
writing standards
for �ow,
continuity, and
clarity 80% of the
time.
Purpose,
introduction, and
conclusion of the
assignment is
stated, yet is brief
and not
descriptive.
3.5 (3.5%) – 3.5
(3.5%)
Paragraphs and
sentences follow
writing standards
for �ow,
continuity, and
clarity 60%- 79% of
the time.
Purpose,
introduction, and
conclusion of the
assignment is
vague or o� topic.
0 (0%) – 3 (3%)
Paragraphs and
sentences follow
writing standards
for �ow,
continuity, and
clarity < 60% of the
time.
No purpose
statement,
introduction, or
conclusion was
provided.
Written
Expression and
Formatting –
English writing
standards:
Correct grammar,
mechanics, and
proper
punctuation
5 (5%) – 5 (5%)
Uses correct grammar, spelling,
and punctuation with no errors.
4 (4%) – 4 (4%)
Contains a few (1-
2) grammar,
spelling, and
punctuation
errors.
3.5 (3.5%) – 3.5
(3.5%)
Contains several
(3-4) grammar,
spelling, and
punctuation
errors.
0 (0%) – 3 (3%)
Contains many (≥
5) grammar,
spelling, and
punctuation errors
that interfere with
the reader’s
understanding.
Written
Expression and
Formatting – The
paper follows
correct APA
format for title
page, headings,
font, spacing,
margins,
indentations, page
numbers,
parenthetical/in-
text citations, and
reference list.
5 (5%) – 5 (5%)
Uses correct APA format with no
errors.
4 (4%) – 4 (4%)
Contains a few (1-
2) APA format
errors.
3.5 (3.5%) – 3.5
(3.5%)
Contains several
(3-4) APA format
errors.
0 (0%) – 3 (3%)
Contains many (≥
5) APA format
errors.
Total Points: 100
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Title
First Name Last Name
Walden University
Policy and Advocacy for Improving Population Health
NURS 6050
Date
Title of Paper
(add an introduction in this space)
Agenda Comparison Grid and Fact Sheet or Talking Points Brief Assignment Template for Part 1 and Part 2
Part 1: Agenda Comparison Grid
Use this Agenda Comparison Grid to document information about the population health/healthcare issue your selected and the presidential agendas. By completing this grid, you will develop a more in depth understanding of your selected issue and how you might position it politically based on the presidential agendas.
You will use the information in the Part 1: Agenda Comparison Grid to complete the remaining Part 2 and Part 3 of your Assignment.
|
Identify the Population Health concern you selected. |
|||||||
|
Describe the Population Health concern you selected and the factors that contribute to it. |
|||||||
|
Administration (President Name) |
President Trump |
President Obama |
President Bush |
||||
|
Describe the administrative agenda focus related to this issue for the current and two previous presidents. |
|||||||
|
Identify the allocations of financial and other resources that the current and two previous presidents dedicated to this issue. |
|||||||
|
Explain how each of the presidential administrations approached the issue. |
Part 2: Agenda Comparison Grid Analysis
Using the information you recorded in Part 1: Agenda Comparison Grid, complete the following to document information about the population health/healthcare issue your selected
|
Which administrative agency would most likely be responsible for helping you address the healthcare issue you selected? |
|
How do you think your selected healthcare issue might get on the agenda for the current and two previous presidents? How does it stay there? |
|
Who would you choose to be the entrepreneur/ champion/sponsor of the healthcare issue you selected for the current and two previous presidents? |
Narrative with the Facts
Conclusion
References
Agenda Comparison Grid Template
© 2020 Walden University
2
American Academy of Nursing on Policy
Policy agenda for nurse-led care coordination
Gerri Lamb, PhD, RN, FAAN, Co-Chaira,
Robin Newhouse, PhD, RN, NEA-BC, FAAN, Co-Chairb,
Claudia Beverly, PhD, RN, FAANc, Debra A. Toney, PhD, RN, FAANd,
Stacey Cropley, DNP, RNe, Charlotte A. Weaver, PhD, RN, FAANf,
Ellen Kurtzman, MPH, RN, FAANg, Donna Zazworsky, MS, CCM, RN, FAANh,
Marilyn Rantz, PhD, RN, FAANi, Brenda Zierler, PhD, RN, FAANj,
Mary Naylor, PhD, RN, FAAN, Expert Reviewerk,
Sue Reinhard, PhD, RN, FAAN, Expert Reviewerl, Cheryl Sullivan, MSES, Staffm,*,
Kim Czubaruk, Esq, Staffm, Marla Weston, PhD, RN, FAAN, Staffn,
Maureen Dailey, PhD, RN, CWOCN, Staffn, Cheryl Peterson, MSN, RN, Staffn, and
Task Force Members
aArizona State University
bUniversity of Maryland
c John A. Hartford Center of Geriatric Nursing Excellence
dNevada Health Centers Inc.
eTexas Nurses Organization
fGentiva Health Services Inc.
gGeorge Washington University
hCarondelet Health Network
iUniversity of Missouri-Columbia
jUniversity of Washington
kUniversity of Pennsylvania
lAmerican Association of Retired Persons
mAmerican Academy of Nursing
nAmerican Nursing Association
I. Introduction and Statement of Policy
Priorities
The Care Coordination Task Force (CCTF) was
convened in mid-2014 by the leadership of the Amer-
ican Nurses Association (ANA) and the American
Academy of Nursing (AAN) to review major position
papers and policy briefs on care coordination pub-
lished between 2012 and 2013 by expert panels of both
organizations, and to recommend specific and action-
able federal policy priorities to advance nursing’s
contributions to effective care coordination. Nurses
have been and continue to be pivotal in the develop-
ment and delivery of innovative care coordination
practice models. The 2011 Institute of Medicine Report
on the Future of Nursing (Institute of Medicine, 2011)
emphasized the nursing profession’s long-term
strength in improving the quality, access and value of
* Corresponding author: Cheryl Sullivan, American Academy of Nursi
E-mail address: cheryl_sullivan@aannet.org (C. Sullivan).
0029-6554/$ – see front matter
http://dx.doi.org/10.1016/j.outlook.2015.06.003
health care through care coordination. The rapid
changes transforming health care today and increased
demand for care coordination require immediate
action to enable nurses and other qualified health
professionals to deliver outstanding care coordination
to achieve the nation’s quality agenda as outlined in its
National Quality Strategy (NQS; Agency for Healthcare
Research and Quality [AHRQ], 2011). Recognizing this
urgent need, ANA and AAN charged the CCTF with
translating seminal documents crafted by their mem-
bers into a blueprint for policy action.
Members of the CCTF prioritized policy recommen-
dations to support and reduce barriers for nurses to
practice the full scope of their care coordination
expertise.
They acknowledged that members of other profes-
sional and nonprofessional groups also are instru-
mental in the implementation of care coordination
interventions. Their approach was to generate general
ng, 1000 Vermont Avenue, NW, Suite 910, WA.
Nur s Out l o o k 6 3 ( 2 0 1 5 ) 5 2 1e 5 3 0522
overarching policy priorities that may be aligned with
interprofessional colleagues with supporting short-
term (within one year) and longer-term (within three
years) strategies thatmaximize nursing’s contributions.
The task force supports implementation of the
following policy recommendations and short-term
strategies to contribute to effective care coordination
in traditional and community settings. Long-term
strategies to support and advance the short-term
strategies also are discussed.
Policy priorities
Policy priority #1: Payment should be expanded for
consistency across all qualified health professionals
delivering high-value care coordination activities,
including bachelor’s-prepared nurses.
Short-term strategy #1: Create provisions for pay-
ment of care coordination based on a set of common
tasks delineating qualifying providers for payment
and providing payment with supporting docu-
mentation.
Short-term strategy #2: Advocate for inclusion of
team-based accountability and transparency.
Short-term strategy #3: Advocate for full scope of
practice of advanced practice registered nurses
(APRNs).
Short-term strategy #4: Identify bachelor’s-prepared
registered nurses (RNs) as qualified providers of care
coordination services.
Policy priority #2: Accelerate the design, endorsement
and use of rigorously tested care coordination mea-
sures, including those central to the domains of nurse
care coordination.
Short-term strategy #1: Solicit promising care coor-
dination measures from the nursing community.
Short-term strategy #2: Convene a national group to
identify effective strategies to increase funding
streams for the development and testing of care co-
ordinationmeasures central to the domains of nurse
care coordination practice.
Short-term strategy #3: Refine and strengthen stra-
tegies to seat expert nurses on national care coor-
dination measure development and review panels.
II. Background and Guiding Principles
The CCTF was convened by ANA and AAN to prioritize
policy options for advancing care coordination and to
propose actionable strategies and leadership to
advance their implementation. As an initial step in
drafting policy recommendations, task force members
reviewed seminal policy and position papers on care
coordination prepared by AAN and ANA expert panels
and work groups:
� The imperative for patient-, family- and population-
centered interprofessional approaches to care coor-
dination and transitional care: A policy brief by the
American Academy of Nursing’s CCTF, Nursing
Outlook 60 (2012), 330-333. (Cipriano, 2012).
� The importance of health information technology in
care coordination and transition care,Nursing Outlook
61 (2013), 475-479. (Cipriano et al., 2013).
� The value of nurse care coordination: A white paper
of the ANA, Nursing Outlook 61 (2013), 490-501.
(Camicia et al., 2013).
� Framework for measuring nurses’ contributions to
care coordination, ANA Care Coordination Quality
Measures Professional Issues Panel, October 2013.
Following review of these papers, CCTF members
gathered information about recent developments
in care coordination practice, measurement and pay-
ment. With the assistance of project staff, they gener-
ated a comprehensive list of potential priority areas for
advancing care coordination, including payment for all
qualified health professionals, payment for team-
based care, performance measurement, health infor-
mation technology, development and expansion of
best practice models, workforce development, com-
mon definitions and service scope, outcome research,
incentives for patient and family engagement, and
standardization of competencies for accreditation and
maintenance of certification.
Task force members then ranked these areas ac-
cording to importance for advancing care coordination
practice and its outcomes, alignment with current and
pending policies relevant to care coordination, and
feasibility of short-term success in policy change and
funding. They reached a consensus on two key priority
areas on which to initially focus their policy recom-
mendations: (1) expanding payment at an equitable
and consistent rate for care coordination provided by
all qualified health professionals; and (2) developing,
implementing and evaluating performance measures
to accelerate high-value care coordination provided by
the United States health care system.
Members of the task force believe that these two
priority areas are consistent with recommendations
from ANA and AAN position papers and are core to
advancing the quality of care coordination practice and
outcomes by nurses and other qualified health pro-
fessionals. While the policy recommendations for care
coordination payment and performance measurement
are presented separately, task force members viewed
them as highly interdependent and supported by evi-
dence, much of which emanates from high-value care
coordination models provided by nurses that have
been developed, implemented, and evaluated for de-
cades (see Figure 1).
As a first step, the CCTF members established
guiding principles in which to situate their policy
recommendations. They emphasized the importance
of removing barriers to effective care coordination by
supporting APRNs and RNs in their ability to practice
Figure 1 e Task force framework for care
coordination policy recommendations.
Nur s Ou t l o o k 6 3 ( 2 0 1 5 ) 5 2 1e 5 3 0 523
to the full extent of their education and training. The
ability to accurately attribute the unique contributions
of nurses working independently or as members of a
team was viewed as central to professional practice
and all policy recommendations. Without linkages to
attribution, nursing’s contributions are silent, and the
ability to examine activities and interventions of the
nurse is limited. The value of nursing interventions
on patient health must be examined and known to
promote transparent accountability and advance both
payment and performance measurement.
Drawing from the work of the ANA panel, the CCTF
identified additional principles that ground their policy
recommendations: accessible (i.e., that payment opti-
mizes access to care), equitable, rational, evidence-
based, patient-/family-centered, interprofessional,
inclusive, accountable, and efficient (or resourceful).
Somemembers cited theneed for comprehensible rules
and transparency in public reporting of data regarding
care coordination outcomes to enhance consumer
selection of higher-value health care.
III. Policy Priority #1: Payment Should Be
Expanded for Consistency across All
Qualified Health Professionals Delivering
High-Value Care Coordination Activities,
Including Bachelor’s-Prepared Nurses
Reimbursement to all qualified health professionals
who deliver care coordination services is needed to
promote high-quality/value care coordination and
facilitate patient choice to better achieve patient-/
family-centered outcomes. Payment has the best op-
portunity to stimulate value when constrained only by
performance expectations. Payment should be directed
to the highest-performing care coordination practice
d regardless of which health care professional pro-
vides these services. Evidence suggests nurse-led care
coordination or team-based models in which nurses
play a central role are effective. Nurses will then need
to emphasize the knowledge and skills they bring
to care coordination, as will all eligible health
professionals.
Expanding payment to all qualified professionals
will actualize an interprofessional health care work-
force inwhich the health professionalmost qualified to
deliver the highest-performing care coordination
practice to meet the needs of patients/families delivers
care coordination services for peoplewith complex and
chronic conditions. These services are often needed in
challenging settings, working with vulnerable pop-
ulations in which nurses often lead care coordination
teams. While our recommendation starts with pay-
ment for all qualified health professionals, develop-
ment of a long-term payment strategy for team-based
accountability is in order. We should support value-
based purchasing that promotes flexibility in how
payment is made and enables nurses to receive pay-
ment for high-quality, efficient care coordination.
The first policy strategy focused on payment is
viewed as urgent and foundational to advance nurs-
ing’s contributions to effective care coordination. As
noted previously, nurses serve a central role in diverse
models of care coordination for people with complex
illnesses across health care settings, demonstrating
impressive health care quality and lower costs
(Camicia et al., 2013). Yet most of the current and
proposed payment models focus on physicians and
APRNs and do not recognize the significant contribu-
tions of bachelor’s-prepared RNs or the efforts of other
health professionals who contribute to care coordina-
tion as members of interprofessional teams.
Currently, there are a few initiatives and pieces of
legislation that may offer an opportunity to introduce
payment for all qualified health professionals. The
Department of Health and Human Services recently
announced that it will be creating a Health Care Pay-
ment Learning and Action Network (Centers for
Medicare and Medicaid Services [CMS], n.d.) to spread
value-based payment models, which may provide a
venue to test innovative care coordination models
nationally. Additionally, CMS proposed changes to the
payment policy under the Physician Fee Schedule for
chronic caremanagement (CCM; Department of Health
and Human Services, 2014). Coordination of care ser-
vices that are non-face-to-face will be reimbursed for
Medicare beneficiaries with two or more chronic con-
ditions expected to last at least 12 months. APRNs will
be eligible for reimbursement, but, as yet, non-APRN
nurses working to the full scope of their education,
training and licenses, and other health professionals
beyond physicians, will not.
Policy Priority #1: Short-Term Strategies
Four short-term strategies are priorities for achieving
policy priority #1. These strategies are aimed at speci-
fying performance expectations for care coordination
Nur s Out l o o k 6 3 ( 2 0 1 5 ) 5 2 1e 5 3 0524
and recognizing and measuring contributions of all
qualified health professionals who contribute to care
coordination individually and as members of an
interprofessional team.
Short-Term Strategy #1: Create Provisions for Payment
of Care Coordination Based on a Set of Common Tasks
Delineating Qualifying Providers for Payment and
Providing Payment with Supporting Documentation
Specification of high-value care coordination activities
is central to payment policy. While this work is un-
derway and represented in ANA and AAN documents
reviewed by the task force, it is not complete and de-
mands immediate attention.
ANA and AAN should appoint a task force to identify
professional organizations that represent providers
that may be eligible for reimbursement for care coor-
dination; develop a taxonomy of structures, processes,
and outcomes for care coordination; and work with
CMS to advocate for a common taxonomy and to
harmonize definitions for use inmeasure development
and evaluation. The taxonomy should be matched to
RN and APRN tasks as qualified providers.
Short-Term Strategy #2: Advocate for Inclusion of Team-
Based Accountability and Transparency
Emerging delivery models including accountable care
organizations (ACOs) and patient-centered medical
homes (PCMHs) rely on effective teamwork and
collaboration to ensure professional practice at full
scope and achievement of NQS priorities, including
care coordination. Current payment models do not
recognize the high-value care coordination activities
provided by health professionals other than those
identified as qualified providers. Along with clear
specification of high-value care coordination activities,
paving the way for equitable payment for care coordi-
nation requires advocating and developing the infra-
structure for:
� Team-based accountability for high-value care coor-
dination: Providers must recognize that care coordi-
nation activities require contributions of team
members best-prepared to carry out these activities.
� Transparency: National Provider Identifier data
should be collected for all teammembers and include
bachelor’s-prepared RNs and APRNs to ensure attri-
bution and commensurate payment. Transparency
related to care coordination activities is needed to
determine the optimal mix of clinicians with the
right staffing/skill mix to yield the best outcomes for
specific populations at risk.
ANA should take the lead on developing and
implementing advocacy tactics for team-based
accountability and transparency and should partner
with ANA organizational constituencies and affiliates,
including AAN expert panels, specialty nursing orga-
nizations, and other stakeholders.
Short-Term Strategy #3: Advocate for Full Scope of
Practice of APRNs
Current care coordination payment models include
provisions for APRN payment. Short-term strategy #3 is
aimed at better positioning APRNs to lead and influ-
ence the development, implementation and evaluation
of high-value care coordination models. To date, a few
APRNs have successfully formed PCMHs. Their impact
on care coordination activities and relevant outcomes
in these settings should be closely monitored.
In addition, strategies should be undertaken to
include APRNs at the highest levels of other emerging
practice models, such as ACOs. There is a shortage of
primary care providers limiting access to care for
vulnerable populations to the right care, at the right
time, with the right clinician team (e.g., timely
palliative/end-of-life care, chronic care, etc.). Lack of
timely access reduces patient-/family-centered care
and increases cost due to avoidable adverse events
(e.g., avoidable emergency department admissions and
readmissions).
ANA and AAN should
advocate to have the final rule
amended to authorize APRNs as eligible providers to
certify plans of care across all care settings, prioritizing
post-acute care/long-term care settings (specifically
home health care, nursing homes, assisted living and
skilled nursing facilities) as a beginning to improve
patient-centered care outcomes (e.g., reduce rehospi-
talization). ANA and AAN should identify organiza-
tions that are already working on authorizing APRNs to
certify plans of care across all care settings, prioritizing
post-acute care/long-term care settings.
Short-Term Strategy #4: Identify Bachelor’s-Prepared
RNs as Qualified Providers of Care Coordination
Services
Bachelor’s-prepared nurses have led and contributed to
care coordination models for decades. Care coordina-
tion is an essential competency for all bachelor’s-pre-
pared nurses (American Association of Colleges of
Nursing, 2008; ANA, 2010). Bachelor’s-prepared nurses
have the education and experience to (1) direct care
coordination across settings and among caregivers,
including oversight of licensed and unlicensed
personnel in any assigned or delegated task; and (2)
partner with other clinicians and caregivers in inter-
disciplinary teams to promote positive patient out-
comes (ANA, 2010). Yet their care coordination
activities are not recognized or included in any current
or proposed payment model. For the most part, high-
value care coordination activities delivered by bache-
lor’s-prepared nurses are attributed and paid to pro-
fessionals currently designated as qualified providers.
ANA should advocate for bachelor’s-prepared
nurses to practice to the full extent of their education
and experience, and for their designation as qualified
providers; their payment should not be rolled into
payment for other providers (similar to being included
in bed-and-board in hospitals). ANA’s regulatory team
Nur s Ou t l o o k 6 3 ( 2 0 1 5 ) 5 2 1e 5 3 0 525
should work with constituencies to ensure that final
rules include team-based accountability, transparency
and appropriate health professionals (including bach-
elor’s-prepared nurses) in the reimbursement for CCM.
Longer-Term Considerations
Task force members identified several longer-term
initiatives to support and advance achievement and
maintenance of the short-term payment priorities.
� Monitor and evaluate the transition from fee-for-
service to capitation and optimize the benefits of
capitation to support care coordination.
Evaluation will be of primary importance as com-
mons sets of tasks are identified (short-term strategy
#1), team-based accountability is enhanced (short-
term strategy #2), and APRNs’ and bachelor’s-prepared
nurses’ full scope of practice is realized (short-term
strategies #3 and #4). As capitated payment for care
coordination is implemented, ANA and AAN should
evaluate the impact of changing reimbursement on
economic and patient outcomes. They should advocate
for permember permonthmodels, which are capitated
models of reimbursement, as they will reduce clinician
burden for billing (e.g., CPT codes for CCM) and reduce
the opportunity for gaming.
� Support and advocate for testing of innovative nurse-
led and interprofessional high-value care coordina-
tion models.
There is mixed evidence supporting various models
of care coordination. The Community-based Care
Transitions Program funded by CMS evaluation is still
underway. A generation of new, innovative models of
care coordination that are both nurse-led and inter-
professional is needed. For example, research indicates
that family members recognize the need and take re-
sponsibility for many care coordination activities.
Consumer-drivenmodels of care to pay for needed care
coordination services and to reimburse family mem-
bers and significant others for high-value care coordi-
nation activities will likely involve APRNs and
bachelor’s-prepared nurses in care coordination ser-
vices. Funders will need to commit to a program of
research to test the efficacy and effectiveness of these
new models of care.
ANA and AAN shouldworkwith CMS to advocate for
testing care coordination interventions in all relevant
Center for Medicare and Medicaid Innovation (CMMI)
initiatives, including the Bundled Payments for Care
Improvement initiative. They also should work with
AHRQ and the Patient-Centered Outcomes Research
Institute (PCORI) to encourage funding for multisite
cluster trials of nurse-led care coordination in-
terventions, including those with consumer-driven
options.
IV. Policy Priority #2: Accelerate the Design,
Endorsement, and Use of Rigorously Tested
Care Coordination Measures, Including
Those Central to the Domains of Nurse Care
Coordination
The importance of robust measures of care coordina-
tion practice was highlighted in each of the founda-
tional papers reviewed bymembers of the CCTF. AAN’s
policy briefs on patient-, family- and population-
centered interprofessional approaches to care coordi-
nation and transitional care and health information
technology recommended immediate policy action to
“expedite funding to develop, implement and evaluate
performance measures that address gaps in effective
and efficient care coordination” (Cipriano, 2012) and
harmonize data elements and standards requirements
for a single patient-centered, consensus-based, longi-
tudinal plan of care that is interoperable and accessible
to patients, families, and all providers across all set-
tings (Cipriano et al., 2013). ANA’s white paper on the
value of nurse care coordination and its framework for
measuring nurses’ contributions to care coordination
specified principles to guide measurement develop-
ment, including transparency, parsimony, evidence-
based, comprehensiveness, and interprofessional
teamwork, as well as measurement domains associ-
ated with effective nurse care coordination practice.
In the short period since these papers were pub-
lished and widely disseminated, there have been a few
promising advances in care coordination performance
measurement. In 2013, as part of its reorganization,
NQF established a standing committee on care coor-
dination performance measures with a nurse as co-
chair. NQF also convened a new work group to
address measurement gaps in care coordination. This
work group proposed a new definition of “care coordi-
nation” to guide measure development and revisions
to the 2006 NQF measurement domains, thereby
bringing them into close alignment with the goals and
strategies of the national quality agenda (Table 1). The
ANA framework for performancemeasurement of care
coordination was one of the source documents used to
inform these changes.
In addition to these definition and framework re-
finements, CMS, AHRQ and the National Committee for
Quality Assurance (NCQA) have embarked on funded
initiatives to develop new care coordination measures.
CMS has been a significant leader in closing the mea-
sures gap through its Measure Management System
Blueprint. AHRQ has funded the American Institutes
for Research to develop a new Care Coordination
Quality Measure for Primary Care as part of its Care
Coordination Measures Development Phase III pro-
gram. NCQA is currently convening work groups to
develop new care coordination measures for Medicare
Advantage Plans. PCORI has an interest in health sys-
tem interventions and has funded a major national
Table 1 e Changes in NQF’s Care Coordination Definition and Measurement Domains, 2006 and 2014
Topic 2006 2014
Definition of “care
coordination”
A function that helps ensure that the patient’s
needs and preferences for health services and
information sharing across people, functions
and sites are met over time.
The deliberate synchronization of activities and
information to improve health outcomes by
ensuring that care recipients’ and families’
needs and preferences for health care and
community services are met over time.
Measurement
domains
� Health care home.
� Proactive plan of care and follow-up.
� Communication.
� Information systems.
� Transitions or handoffs.
� Joint creation of a patient-centered plan of care.
� Use of a health neighborhood to execute plan of
care.
� Achievement of outcomes.
Sources: National Quality Forum, 2006; National Quality Forum, 2014b.
Nur s Out l o o k 6 3 ( 2 0 1 5 ) 5 2 1e 5 3 0526
study to investigate which transitional care services
are most effective in improving patient-centered out-
comes. Results will provide evidence supporting
structure and process measures for care coordination.
Although the launch of each of these initiatives
suggests greater interest in developing a robust set of
care coordination measures that reflect changes in
health care and evolving care coordination practice
models, there is still a paucity of endorsed care coor-
dination performance measures. Only one new care
coordination measure was submitted to NQF for
endorsement in the previous two review cycles. Most
of the currently endorsed measures are setting- or
“eligible provider”-specific and are limited to a very
small set of the refined NQF measurement domains.
Measure development activities convened by AHRQ,
and NCQA are in the very early stages. Most existing
measures are low-level (e.g., check box) process mea-
sures. The right mix of high-impact structure, process
and outcome measures is needed. Patient-reported
outcomes also are needed.
While there is considerable discussion of the
shortcomings of the current care coordination mea-
surement set, there also is recognition that develop-
ment and testing of new measures are expensive and
time-consuming, with few sources of funding. In
addition, the feasibility of capturing data for more
robust measures is a challenge. Significant gaps
remain in domains of care coordination integral to
nurse care coordination practice, including shared
decision-making in the patient-/family-centered plan
of care, shared accountability among team members
for the plan of care, timeliness and accountability of
services, care recipient and family experience of care
coordination, and impact on quality outcomes and
costs of care.
Setting the Stage for Performance Measurement Policy
Strategies
Task force members identified several issues affecting
the current context andpolitical environment for policy
recommendations and strategies related to advancing
care coordination performance measurement.
Definition of “care coordination”: Definitions of “care
coordination” driving performance measurement
continue to evolve. Different definitions are being used
to guide measure review, endorsement and regulation.
The CCTF reviewed the variety of definitions available
and evaluated their alignment with domains proposed
in the ANA’s Framework for Measuring Nurses’
Contributions to Care Coordination (ANA Care
Coordination Quality Measures Professional Issues
Panel, 2013). Recognizing that the ANA framework
informed NQF’s most recent changes to its care coor-
dination definition and domains, the task force mem-
bers proposed that their policy recommendations build
on the 2014NQF consensus definition and highlight key
aspects central to nursing in the development of the
care coordination measurement set. Task force mem-
bers affirmed the importance of patient-/family-
centeredness, patient engagement, integration of care,
the full continuum of care and payment in NQF’s defi-
nition and measurement domains, and recommended
that each of these elements be made more explicit in
future revisions. Policy strategies for advancing care
coordination performance measurement must be
guided by a strong patient-centric model that empha-
sizes patient and family engagement and collaboration
with providers across the care continuum of care
planning and evaluation. There needs to be an
emphasis on the human interaction that is founda-
tional to effective care coordination intervention as
well as the workflow and sequencing components
included in the definition.
Priority measures: The current set of care coordi-
nation performance measures has significant gaps in
areas that are central to nurse care coordination
practice and to core competency areas required for
payment to all qualified health professionals. Imme-
diate priorities for filling these gaps identified by task
force members include:
� As feasible, a harmonized set of care coordination
measures across the full continuum of care,
including primary care, acute care, post-acute and
long-term care, hospice, assisted living, and com-
munity services.
Nur s Ou t l o o k 6 3 ( 2 0 1 5 ) 5 2 1e 5 3 0 527
� Screening and risk assessment measures that cap-
ture evidence-based risk assessment at each point of
care.
� Implementation of endorsed medication reconcilia-
tion measures.
� Advanced care planning.
� Patient engagement competencies for care coordi-
nation and transitional care.
eMeasures: As recommended in the AAN paper on
health information technology, the development of
care coordination measures needs to anticipate re-
quirements for eMeasures that support standards and
interoperability and accessibility to patient-/family-
centered care coordination data.
Team-based care coordination measures: Care co-
ordination is commonly defined and operationalized in
the context of interprofessional teamwork, shared
accountability and collaboration. The processes of care
coordination require expert integration and synchro-
nization between and among patients, families, pro-
fessional and lay providers, and health care and
community settings, as reflected in current definitions
and frameworks. Translating shared accountability
and determining attribution of care coordination to the
individuals and groups that have the requisite com-
petencies and actually do the work are significant is-
sues and tension points in the care coordination
payment dialogue. The members of the CCTF support
team-based measures for care coordination in philos-
ophy; they believe that considerably more analysis and
discussion are required before team-based measures
are proposed as a policy priority.
Policy Priority #2: Short-Term Strategies
Three short-term strategies are priorities for achieving
policy priority #2. These strategies are aimed at
creating a wider pool of potential care coordination
measures from nurses in practice, generating funding
for measure development and testing, and positioning
nurses on key committees guiding selection of care
coordination performance measures.
Short-Term Strategy #1: Solicit Promising Care
Coordination Measures from the Nursing Community
There is no question that nurses are leading and
participating in the development and refinement of
care coordination models in all practice settings. Ex-
amples of the range of nurse-led models for patient-
centered medical homes, post-acute and long-term
care, and transitional care are evident in published
literature as well as the numerous conferences on
care coordination, continuity of care, care across the
continuum, and other related topics. Many of the
preferred practices that are used to guide develop-
ment and support NQF’s care coordination perfor-
mance measures derive from programs and models
developed by nurses in which nurses lead and pro-
vide the majority of the care coordination
interventions in multiple roles. It is likely that many
nurse care coordination programs are using home-
grown and/or standardized performance measures to
capture structures, processes and outcomes of care
coordination. Few, if any, of these measures are being
developed to meet rigorous endorsement criteria.
Since only one new care coordination measure was
submitted for NQF review in the previous two review
cycles, it is questionable whether nurses are aware of
the need and opportunity to develop nascent mea-
sures or the process needed to submit them for
endorsement.
Nurse-developed and -led care coordination pro-
grams may be a rich and untapped source of measures
to fill the care coordination measurement gap, particu-
larly in the domains of care coordinationmost reflective
of nursing interventions and contributions to care co-
ordination. As a first step in moving toward perfor-
mance metrics, the state of development of care
coordinationmeasures should be established.Measures
should capture the actual practice work of care coordi-
nation and can be used to define competencies and
payment for all qualified health professionals. The task
force recommends that ANA and AAN develop a work-
ing group with the Nursing Alliance for Quality Care
(NAQC) and membership from all nursing specialty
groups to conduct a national campaign to solicit care
coordination measures being used in nurse care coor-
dination programs. ANA, AAN and nursing specialty
organizations should survey research-intensive mem-
bers (including AAN Edge Runners) to determine if care
coordination measures have been developed and used
within nurse-scientist-conducted research studies.
Short-Term Strategy #2: Convene a National Group to
Identify Effective Strategies to Increase Funding Streams
for the Development and Testing of Care Coordination
Measures Central to the Domains of Nurse Care
Coordination Practice
Growth of the care coordination measurement set is
severely limited by the lack of funding for measure
development and testing. The few measure develop-
ment initiatives currently funded are targeted to spe-
cific practice settings (e.g., primary care), eligible
providers and/or specific populations (Medicare
Advantage members). Expanding funding streams for
measure development and testing is essential to
improve the state of performance measurement for
care coordination.
The CCTF recommends that ANA and AAN convene
a national task force with the major funders of care
coordination measure development and testing,
including CMS, AHRQ and major organizations influ-
encing the selection and endorsement of care coordi-
nation measures used for payment guidelines, such as
NCQA, the Measurement Application Partnership
(National Quality Forum, 2014a) and NQF, to review
measurement gaps in care coordination and propose
initiatives to fund development and testing of care
coordination measures that align with core nursing
Nur s Out l o o k 6 3 ( 2 0 1 5 ) 5 2 1e 5 3 0528
domains and achievement of the national quality
agenda goals.
Short-Term Strategy #3: Refine and Strengthen Strategies
to Seat Expert Nurses on National Care Coordination
Measure Development and Review Panels
Key decisions about development, evaluation and se-
lection of measures for national payment programs
like value-based purchasing are initiated and influ-
enced within expert panels, task forces and standing
committees. The nursing community has made
tremendous strides in the past several years in seating
nurse experts on care coordination on committees at
CMS, AHRQ and NQF.
The CCTF recommends that ANA and AAN convene
a task force to review and strengthen current processes
to identify andplacenurse experts on care coordination
performance measurement committees in order to in-
crease the number of nurses on these committees and
to prepare for succession planning.
Longer-Term Consideration
� Evaluate the value and feasibility of team-based care
coordination measures.
As already discussed, CCTFmembers acknowledged
potential advantages of team-based measures for
capturing the actual delivery of care coordination ser-
vices and addressing accountability and attribution
issues. The current state of team performance mea-
surement is not well-developed, and there is no
consensus about how these measures may be feasibly
operationalized or implemented within payment pol-
icy. The CCTF recommends further analysis of the
value and feasibility of these measures.
r e f e r e n c e s
Agency for Healthcare Research and Quality (AHRQ). (2011).
National strategy for quality improvement in health care. Retrieved
from http://www.ahrq.gov/workingforquality/.
American Association of Colleges of Nursing. (2008). The essentials
of baccalaureate education for professional nursing practice.
Retrieved from http://www.aacn.nche.edu/education-
resources/BaccEssentials08 .
American Nurses Association (ANA). (2010). Nursing: Scope
and standards of practice (2nd ed.). Silver Spring, MD:
ANA.
ANA Care Coordination Quality Measures Professional Issues
Panel. (2013). Framework for measuring nurses’ contributions to
care coordination. Retrieved from http://nursingworld.org/
Framework-for-Measuring-Nurses-Contributions-to-Care-
Coordination.
Camicia, M., Chamberlain, B., Finnie, R. R., Nalle, M., Lindeke, L. L.,
Lorenz, L., . McMenamin, P. (2013). The value of nursing care
coordination: A white paper of the American Nurses
Association. Nursing Outlook, 61(6), 490e501.
Centers for Medicare and Medicaid Services (CMS). (n.d.). Health
care payment learning and action. Retrieved from http://
innovation.cms.gov/initiatives/Health-Care-Payment-
Learning-and-Action-Network/
Cipriano, P. (2012). The imperative for patient-, family- and
population-centered interprofessional approaches to care
coordination and transitional care: A policy brief by the
American Academy of Nursing’s Care Coordination Task
Force. Nursing Outlook, 60(5), 330e333.
Cipriano, P. F., Bowles, K., Dailey, M., Dykes, P., Lamb, G., &
Naylor, M. (2013). The importance of health information
technology in care coordination and transitional care. Nursing
Outlook, 61(6), 475e489.
Department of Health and Human Services. (2014). Federal register
proposed rules (No. CMS-1612-P). Baltimore, MD: Centers for
Medicare and Medicaid Services.
Institute of Medicine. (2011). The future of nursing: Leading change,
advancing health. Washington, DC: The National Academies
Press.
National Quality Forum. (2014a). Measure applications partnership.
Retrieved from http://www.qualityforum.org/setting_
priorities/partnership/measure_applications_partnership.
aspx.
National Quality Forum. (2014b). Priority setting for healthcare
performance measurement: Addressing performance measure gaps
in care coordination. Retrieved from. http://www.
qualityforum.org/Publications/2014/08/Priority_Setting_for_
Healthcare_Perf.ormance_Measurement__Addressing_
Performance_Measure_Gaps_in_Care_Coordination.
aspx.
National Quality Forum. (2006). NQF-endorsed definition and
framework for measuring care coordination. Retrieved from www.
qualityforum.org.
Summary of Care Coordination Policy Priorities, Short-Term Strategies and Longer-Term Considerations
Care Coordination Policy Strategies Lead Organizations
Payment Short-term strategies
Payment should be expanded for
consistency across all qualified
health professionals delivering
high-value care coordination
activities, including bachelor’s-
prepared nurses.
1. Create provisions for payment of
care coordination based on a set of
common tasks delineating quali-
fying providers for payment and
providing payment with support-
ing documentation.
2. Advocate for inclusion of team-
based accountability and
transparency.
ANA and AAN should appoint a task
force in the private sector to
develop the taxonomy of common
tasks, match tasks to qualified
providers (RNs and APRNs), and
advise CMS and other payers on
evidence from research.
Representatives from CMS, AHRQ,
PCORI and other payers may be
invited to participate in the task
force.
ANA should take the lead on
developing and implementing
advocacy tactics for team-based
accountability and transparency,
and partner with ANA
organizational constituencies
(organizational affiliates and other
specialty nursing organizations,
such as geriatric nursing groups
and AAN expert panels) and other
stakeholders (e.g., payers,
consumers) as buy-in is solidified.
3. Advocate for full scope of practice
of APRNs.
Specifically, ANA and AAN should
advocate to have the final rule
amended to authorize APRNs as
eligible providers to certify plans of
care across all care settings, priori-
tizing post-acute care/long-term care
settings (specifically home health
care, nursing homes, and assisted
living and skilled nursing facilities)
as a beginning to improve patient-
centered care outcomes (e.g., reduce
rehospitalization).
ANA and AAN should identify
organizations that are already
working on this (there is proposed
legislation with bipartisan
support). Begin with Robert Wood
Johnson Foundation, AARP
(Campaign for Action) and Johnson
& Johnson.
4. Identify bachelor’s-prepared RNs
as qualified providers of care co-
ordination services.
ANA and AAN should employ
multiple strategies, resources,
levers and constituencies.
Consumers Union may be a
potential partner.
Longer-term considerations
1. Monitor and evaluate the transi-
tion from fee-for-service to
capitation, and optimize the
benefits of capitation to support
care coordination.
ANA and AAN should evaluate the
impact of changing
reimbursement on economic and
patient outcomes.
2. Support and advocate for testing
of innovative nurse-led and
interprofessional high-value care
coordination models.
ANA and AAN should work with CMS
to advocate for testing care
coordination interventions in all
relevant CMMI initiatives,
including the Bundled Payments
for Care Improvement initiative.
They also should work with AHRQ
and PCORI to encourage funding
for multisite cluster trials of nurse-
led care coordination
interventions.
(continued on next page)
Nur s Ou t l o o k 6 3 ( 2 0 1 5 ) 5 2 1e 5 3 0 529
(Continued )
Care Coordination Policy Strategies Lead Organizations
Performance measurement Short-term strategies
Accelerate the design, endorsement
and use of rigorously tested care
coordination measures, including
those central to the domains of
nurse care coordination.
1. Solicit promising care coordina-
tion measures from the nursing
community.
ANA, AAN, NAQC and nursing
specialty organizations should
determine the state of
development of care coordination
measures. A survey of research-
intensive members, including AAN
Edge Runners, should be
conducted to determine if care
coordination measures have been
developed and used within nurse-
scientist-conducted research
studies.
2. Convene a national group to
identify effective strategies to in-
crease funding streams for the
development and testing of care
coordination measures central to
the domains of nursing care co-
ordination practice.
ANA and Academy to work with
CMS, AHRQ, NQF, NCQA, Office of
the Assistant Secretary for Health,
key stakeholder groups, e.g.,
consumers and other purchasers.
Start with CMS.
3. Refine and strengthen strategies
to seat expert nurses on national
care coordination measure devel-
opment and review panels.
ANA, Academy, and NAQC to
convene a working group to review
current procedures and processes
and propose strategies for timely
appointments.
Longer-term consideration
1. Evaluate the value and feasibility
of team-based care coordination
measures.
The AAN expert panel should work
with CMS and the Physician
Consortium for Performance
Improvement.
Nur s Out l o o k 6 3 ( 2 0 1 5 ) 5 2 1e 5 3 0530
Article
Political Efficacy and Participation
of Nurse Practitioners
Nancy C. O’Rourke, PhD, ANP
1
, Sybil L. Crawford, PhD
1
, Nancy
S. Morris, PhD, ANP
1
, and Joyce Pulcini, PhD, RN, PNP-BC,
FAAN
2
Abstract
Twenty-eight states have laws and regulations limiting the ability of nurse practitioners (NPs) to practice to the full extent of
their education and training, thereby preventing patients from fully accessing NP services. Revisions to state laws and
regulations require NPs to engage in the political process. Understanding the political engagement of NPs may facilitate
the efforts of nurse leaders and nursing organizations to promote change in state rules and regulations. The purpose of this
study was to describe the political efficacy and political participation of U.S. NPs and gain insight into factors associated with
political interest and engagement. In the fall of 2015, we mailed a survey to 2,020 NPs randomly chosen from the American
Academy of Nurse Practitioners’ database and 632 responded (31% response rate). Participants completed the Trust in
Government (external political efficacy) and the Political Efficacy (internal political efficacy) scales, and a demographic form.
Overall, NPs have low political efficacy. Older age (p4.001), health policy mentoring (p4.001), and specific education
on health policy (p4.001) were all positively associated with internal political efficacy and political participation.
External political efficacy was not significantly associated with any of the study variables. Political activities of NPs are largely
limited to voting and contacting legislators. Identifying factors that engage NPs in grassroots political activities and the
broader political arena is warranted, particularly with current initiatives to make changes to state laws and regulations
that limit their practice.
Keywords
political efficacy, political participation, nurse practitioners, health policy
Given the rapid and turbulent changes to the U.S. health-
care system following the 2016 elections, nurse practi-
tioners’ (NPs) political efficacy and participation are
important for securing affordable, high-quality care for
millions of Americans. The 2016 presidential campaign
set the stage for disarray within the Republican party
(Jacobson, 2016), while the Democratic party experi-
enced unprecedented division in its voter base (Boys,
2016; Wang, Li, & Luo, 2016). Campaigns were conten-
tious, unconventional, and disruptive. Political unrest is
at its highest since 2000 (Boys, 2016; Wang et al., 2016).
The implementation of the Patient Protection and
Affordable Care Act was a concern during the 2016 cam-
paigns. As of January 31, 2017, 12 million newly insured
individuals were added to an already strained health-care
system (Associated Press, 2017).
Central to the health-care debate is a well-documen-
ted shortage of primary care providers, predicted to
become critical by 2020 (Graves et al., 2016). Both the
Institute of Medicine (IOM, 2011) and the National
Governors Association (2012) recommended removal
of restrictive state regulations to enhance access to NP
services as a necessary step to address the provider short-
age. The Federal Trade Commission (2014) ruled that
physician supervision clauses in NP state practice acts
create anticompetitive environments and should be
removed. Revising outdated laws or regulations to
allow NPs to practice to the full extent of their education
1
University of Massachusetts Medical School, Worcester, MA, USA
2
George Washington University, DC, USA
Corresponding Author:
Nancy C. O’Rourke, University of Massachusetts Medical School, 55 Truell
Road, Worcester, MA 01655-0112, USA.
Email: nancyc.orourke@gmail.com
Policy, Politics, & Nursing Practice
2017, Vol. 18(3) 135–148
! The Author(s) 2017
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DOI: 10.1177/1527154417728514
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would ensure patients have full access to NP services
(Poghosyan, Boyd, & Clarke, 2016).
Historically, many NPs have not been politically
engaged or able to effectively create and sustain political
change (Craven & Ober, 2009; Kung & Rudner-Lugo,
2014; Moran, 2014; Oden, Price, Alteneder, Boardley, &
Ubokudom, 2000). Understanding political efficacy, and
factors associated with political efficacy, of NPs may
facilitate the efforts of nurse leaders and nursing organ-
izations to promote change in state rules and regulations.
This article presents the findings of a study examining
NP political efficacy and participation. We explain the
historical involvement of NPs’ engagement in health
policy, evidence of their political efficacy, and describe
Sharoni’s (2012) framework on political efficacy, which
was used to structure this study. Methods and data ana-
lysis follow with a discussion of our findings and the
study’s implications for practice, policy, and professional
organizations.
Background
Political efficacy is ‘‘an activity that has the intent or effect
of influencing government action – either directly by
affecting the making or implementation of public) policy
or indirectly by influencing the selection of people who
make those policies’’ (Verba, Schlozman, Brady, &
Brady, 1995, p. 38). It is associated with political partici-
pation and often referred to as one’s sense of being able to
influence the political process (Caprara, Vecchione,
Capanna, & Mebane, 2009; Sharoni, 2012). Political effi-
cacy has two distinct constructs: a personal sense of effi-
cacy (internal) and a system-oriented component of
efficacy (external) (Neimie, Craig, & Mattei, 1991).
Internal efficacy is one’s sense of being able to understand
and participate in politics. External efficacy is one’s trust
that the government will be responsive to the demands of
citizens (Neimie et al., 1991; Sharoni, 2012).
Electorate politics are increasingly complex, especially
in highly competitive elections (Barton, Castillo, &
Petrie, 2016). Understanding campaign and electoral
dynamics and learning about candidates require initiative;
many eligible voters may feel inadequate to the task
(Burden & Neiheisel, 2013). Some state and federal laws
enacted since 2012 impose new policies on voters.
Restrictions include requiring a photo identification to
vote, curtailing voter registration times and early voting
periods, and enforcing stricter rules for those with past
criminal convictions (Wang, 2012; Weiser & Opsal, 2014).
Campaigns and elections that are controversial and
competitive are associated with increased voter turnout,
usually measured as a percent of registered voters who
actually vote (Barton et al., 2016). In the first 12 national
primary elections of 2016, 17.3% of eligible Republican
voters turned out to vote. This is the highest rate of GOP
primary voting since the 1980 elections. In 2016,
Democrats had the highest rate (11.7%) of primary elec-
tion voting since 1992, with one exception, the unusually
high turnout in 2008 when the rate was 30.4% (Desilver,
2016; File & Chrissy, 2012). Harrington and Gould
(2016) state that rates of eligible voters participating in
presidential elections have decreased from approximately
64% in 2004 and 2008 to 61.8% in 2012. In 2016, only
60% of eligible voters cast a ballot (Harrington &
Gould, 2016).
Age, gender, race, socioeconomic status (SES), and
education are all associated with political participation,
and education in the development of civic skills is
strongly predictive of political participation (Hillygus,
2005). Schlozman, Verba, and Brady (2012) associated
higher income with increased political activity, especially
with regard to monetary donations toward political cam-
paigns. Voting data from 2012 indicate that adults older
than 65 years of age have higher rates of voting (69.7%)
than adults 18 to 24 (38%) or 25 to 44 years of age
(49.5%; File, 2013b).
Historically, younger voters report feeling isolated or
excluded, as political parties have been reluctant to
engage and represent their interests (Zukin, Keeter,
Andolina, Jenkins, & Carpini, 2006; Henn & Foard
2012). Recent studies report increased interest among
younger voters, with 18 to 24 years olds casting 19.9
%
of ballots in the 2014 election (Center for Information
and Research on Civic Learning and Engagement, 2016).
The racial demographics of voters also shifted in 2012,
showing increased racial and ethnic diversity; 64.1% of
eligible non-Hispanic Whites, 48% of eligible Hispanics,
and 66.2% of eligible Blacks voted (File, 2013a). While
women are more likely to vote than men (63.7% vs.
59.8%), in all other aspects of political participation,
men consistently participate in political activities at
higher rates than women (Dittmar, 2015; Schlozman
et al., 2012).
Higher education leads to higher rates of voting, with
the voting rate of college graduates as high as 70%,
compared with 27% of those with high school education
(‘‘Voting,’’ n.d.). Based on several single state studies,
certified registered nurse anesthetists and other advanced
practice registered nurses (APRNs) consistently vote at
rates greater than 90%, which is higher than general
population voting rates (Casey, 2009; Moran, 2014;
Oden et al., 2000; McDonald, 2016).
Political Efficacy and Political Participation of NPs
Research on the political efficacy and participation of
NPs is limited. Studies of registered nurses (Barrett-
Sheridan, 2009; Vandenhouten, Malakar, Kubsch,
Block, & Gallagher-Lepak, 2011), NPs, certified regis-
tered nurse anesthetists, and certified nurse midwives
136 Policy, Politics, & Nursing Practice 18(3)
report voting to be the predominate form of political
participation (Casey, 2009; Moran, 2014; Oden et al.,
2000). With the exception of 2008 elections, self-reported
voting rates for NPs (89%) are higher than those of
the general population (62%) (File, 2013b, Oden et al,
2000). Among NPs, lack of time, knowledge, interest,
family obligations, and financial constraints are cited
as barriers to other types of political participation
(Casey, 2009; Kung & Rudner-Lugo, 2014; Moran,
2014; Oden et al, 2000).
Recent studies show mixed results on political efficacy
and political engagement of NPs in areas other than
voting (Kung & Rudner-Lugo, 2014; Moran, 2014;
Oden, 2000; Ryan, 2015). Oden et al. (2000) report
results of a mailed survey of public policy involvement
sent to members of the American Academy of Nurse
Practitioners (AANP). Time, money, and civic skills
were identified as barriers to political participation for
the 440 AANP members who responded (74% response
rate). Voting was the most common political activity
reported; 87% of the participants reported consistent
voting patterns (Oden et al., 2000). There was a strong
positive correlation between self-rated involvement in
political activities and political efficacy (p< .001) with a
majority reporting that they received policy education
from professional organizations and journals.
Age, socioeconomic resources, and prior engagement
in political activities were significant predictors of polit-
ical participation among a study of 170 advanced prac-
tice nurses in Louisiana (Moran, 2014). Kung and
Rudner-Lugo (2014) surveyed APRNs in Florida
(n¼884); 23% reported being active in policy, despite
acknowledging significant barriers to practice in their
state. This differs from Ryan (2015), who surveyed 875
NPs practicing in convenient care clinics from 44 states
and Australia and reported political involvement in 70%
of the NPs, defined as membership in state or national
professional nursing organizations. There was wide vari-
ation in the level of political engagement, with less
involvement in political activities by NP students, unem-
ployed, and retired NPs compared with those still
employed. Ryan (2015) also reported that 43.1% of
NPs practicing less than 2 years reported having had
education or coursework in health policy.
In 1996, healthcare policy was identified as essential
core content for master’s education for advanced prac-
tice nursing (American Association of Colleges of
Nursing (AACN), 1996). The purpose of including
health policy content was to help students understand
‘‘how health policy is formulated, how to affect this pro-
cess, and how it impacts clinical practice and health care
delivery’’ (AACN, 1996, p. 7). Despite the addition of
this content into educational programs, voting remains
NPs’ primary and most consistent form of political par-
ticipation (Kung & Rudner- Lugo, 2014; Moran, 2014;
Oden, 2000) with fewer NPs reporting involvement with
local, state, and national organizations and their legisla-
tive activities.
The Future of Nursing: Leading Change, Advancing
Health (IOM, 2011) called on the profession to enhance
its political efficacy and presence in the policy arena. NP
organizations across the country are working to revise
their state laws and regulations to include the IOM’s
recommendation for NPs to practice to the full extent
of their education and training. Despite revisions to state
laws or regulations, many states still have rules and regu-
lations that restrict NPs from practicing to their full
potential, thereby limiting patients’ access to primary
care. In the 2012 to 2014 legislative sessions, over a
dozen states introduced legislation to modernize licen-
sure laws for NPs. Only three of these states were
successful in making changes that led to full scope of
practice (Phillips, 2015). As of 2017, 23 states and the
District of Columbia have eliminated restrictive regula-
tions legislative or regulatory restrictions on practice
(AANP, 2017b).
The NP role was first established in the late 1960s
and early 1970s (AANP, 2017a). Nearly 50 years
later, NPs still face challenges to their professional
practice. As legislation continues to drive changes to
health-care delivery, it is imperative that NPs have a
political voice. The extant literature is limited and
lacks the depth of information required to success-
fully engage the NP population in political activities
(other than voting) and advance the political agenda
of the profession.
Theoretical Framework
Recognized as an important motivational variable, self-
efficacy is an appropriate concept to frame this study on
political efficacy and engagement. Sharoni (2012)
describes internal and external political efficacy and
defines them respectively as ‘‘the average American’s
feelings of political empowerment and his or her percep-
tion of the government’s receptiveness to public political
participation’’ (p. 119). This framework denotes charac-
teristics predictive of internal and external political
efficacy which lead to political interest, knowledge,
engagement, and trust in the government and was used
as a framework for this study (Figure 1).
Personal characteristics (age, gender, SES, race, eth-
nicity education, and educational experiences in nonpo-
litical environments about self-governance) are factors
associated with achieving internal political efficacy in
the general public (Sharoni, 2012). Education about
self-governance refers to teaching the general public
they have a duty to participate, that their participation
counts, and they have some control over their political
destiny by participating in the process. Sharoni’s (2012)
O’Rourke et al. 137
conceptualization that education about self-governance
in a nonpolitical environment is a form of political
socialization, which leads to a sense of increased internal
efficacy, is supported by the literature (Kahne, Crow, &
Lee, 2013; Schlozman et al., 2012; Zukin et al., 2006).
Specifically, higher education, higher SES, older age
(>65 years), race (White), and gender (male) are predict-
ive of a higher sense of political efficacy (Schlozman
et al., 2012; Zukin et al., 2006).
In addition to the variables in Sharoni’s model
(Figure 1), we have added NP specialty and practice set-
tings. We hypothesize that these factors will impact NP
internal political efficacy. Kahne et al. (2013) have also
shown that external political efficacy is influenced by
one’s direct political activity. Mentoring by someone
more knowledgeable in health policy was included in
direct political participation, as we hypothesized this
may impact external political efficacy. Sharoni (2012)
proposes a typography based upon high and low levels
of internal and external political efficacy. She suggests a
person with high internal and external political efficacy is
an ‘‘Empowered American Citizen,’’ a person with high
internal and low external political efficacy is an ‘‘Engaged
Grassroots Activist,’’ a person with low internal and high
external political efficacy a ‘‘Complacent American
Citizen’’ and a person with low internal and external pol-
itical efficacy a ‘‘Politically Alienated American’’
(Sharoni, 2012). Each category is indicative of varying
political engagement. Use of this framework will yield
valuable insights to achieve the goal of this study and to
provide a foundation to spur further research to improve
the political position of the NP profession.
Study Aims
Using a political efficacy framework, the purposes of this
study were to evaluate the political efficacy and political
participation of NPs across the United States and to
better understand factors associated with political inter-
est, knowledge, and engagement. The specific aims of
this study were to: (a) describe internal and external pol-
itical efficacy of NPs in the United States; (b) examine
the association of select NP characteristics (age, gender,
race, ethnicity, education, income, NP population foci,
full practice authority, and relationship with a health
policy mentor or role model) and health policy education
in nonpolitical environments (academic coursework or
continuing education offering on health policy) with
internal political efficacy; (c) examine the association of
select NP characteristics (age, gender, race, ethnicity,
education, income, NP population foci, full practice
authority, and relationship with a health policy mentor
or role model) and previous political participation (direct
political participation or mentoring by another with
this experience) with external political efficacy; and (d)
examine the relationship between internal and external
political efficacy and NP political interest, knowledge,
participation, and likelihood to vote.
Methods
Design, Sample, and Setting
A descriptive cross-sectional survey design was used to
explore the political efficacy and participation of a
random national sample of NPs. The sample was
drawn from the American Association of Nurse
Practitioners (AANP) database which includes all
AANP members licensed in the United States (76,000)
and is inclusive of all specialties (acute care, adult,
family, geriatric, neonatal, pediatric, women’s health,
and psychiatric NPs).
The AANP database allows for systematic
sampling, minimizing sampling error, and supporting
Educa�on in a non-poli�cal
environment about self-governance
Direct Poli�cal Par�cipa�on
Educa�on
Socioeconomic Status
Gender
Ethnicity
Race
Specialty
State of Prac�ce
Internal Poli�cal Efficacy
External Poli�cal Efficacy
Poli�cal Interest,
Knowledge,
Engagement
Trust in Government,
Likelihood to Vote
Figure 1. Adapted from Sharoni, 2012.
138 Policy, Politics, & Nursing Practice 18(3)
the generalizability of the findings. We used geographic-
ally stratified data to identify a relationship between pol-
itical efficacy and practice in states with full practice
authority; we also wanted to have NPs representative
of all 50 states.
Sample size was calculated based on a confidence level
of 95%, confidence interval of half-width 0.05, standard
deviation of 0.5, a 2015 population of 182,000 NPs,
based on a 40% or less response rate. To address Aim
1, a required sample size of 385 was calculated for esti-
mating mean internal and external efficacy to within plus
or minus 0.05 points with 95% confidence, assuming a
standard deviation of 0.5. For Aims 2 through 4 invol-
ving associations with efficacy, using two-sided hypoth-
esis testing, a Type 1 error rate of 0.05, and 80% power,
this sample size also allows a mean detectable between-
group difference in efficacy of at least 0.3 standard
deviations for two approximately equally sized groups.
To accommodate a participation rate of at least 20%
(conservative estimate), we randomly selected 2,020
NPs for our sample. Inclusion criteria included the
following: (a) current licensure as an NP in the United
States, (b) ability to read and write English, and (c) inclu-
sion in the AANP database. There were no additional
exclusion criteria.
Procedures
The names and addresses of a geographically stratified
random sample of 2,020 NPs were purchased from
AANP in 2015. To increase response rates, a postcard
announcing the delivery of the survey was sent one week
prior to survey mailing, as recommended by Dillman,
Smyth, and Christian (2014). The survey mailing con-
tained a letter of introduction, a survey containing the
Political Efficacy and Trust in Government indices, a
demographic questionnaire, a postage paid return enve-
lope, and an Opt-Out postage paid postcard for those
who chose not to participate. Approval was obtained
from the University of Massachusetts Medical School
Institutional Review Board. We piloted the survey with
a random sample of 20 NPs to evaluate the survey instru-
ments for ease of use, understandability of the directions,
time for completion, and overall acceptability. No issues
were identified. These data were included in the final
sample. Completed surveys were accepted up to six
weeks after the initial mailing.
Measures
The Efficacy Index (Sharoni, 2012) was used to assess
internal political efficacy. Sharoni (2012) tested this
index in a study on Internet use and trust in government
with a sample of 924 adults. It is composed of 13 ques-
tions, derived from the American National Elections
Study and political efficacy theory. This index uses a 1
to 5 Likert scale and ranks agreement or disagreement
with each statement. An overall higher score indicates a
higher sense of internal political efficacy. Analysis of the
data showed a range from 0 to 44, mean score of 24.3, a
skewness of �.389, and Cronbach’s alpha of 0.775,
demonstrating good reliability (Sharoni, 2012).
The Trust in Government Index, used to assess external
political efficacy, includes 10 scale questions, based on a
Gallup poll on ‘‘Trust in Government.’’ These 10 ques-
tions were designed to evaluate an individual’s trust and
confidence in government. The Likert type scale has par-
ticipants rate their opinions on a scale of 1 to 5. Greater
trust in government is demonstrated by high overall
score. Sharoni (2012) tested the scale in a study on inter-
net use and trust in government (n¼915). In her study,
the scale had a range of scores from 0 to 41, a mean score
of 17.6, a skewness of �.034, and a standard deviation of
7.2. Cronbach’s alpha of 0.881 indicated high reliability
(Sharoni, 2012).
A researcher developed demographic questionnaire
was used to obtain data on characteristics thought to
influence political efficacy, as described in Sharoni’s
framework. Characteristics included age, gender, ethni-
city, SES, race, and education. Data on NP population
foci and years of NP practice were also included.
The following three additional variables were included:
(a) relationship with a politically active mentor or role
model, (b) specific education either during initial NP
education program or focused continuing education on
health policy, and (c) state where employed.
Statistical Analysis
Data analysis was performed using IBM SPSS statistics
for Macintosh version 22. Descriptive statistics were cal-
culated for all study variables as appropriate to the level
of data. For continuous variables, mean, median, skew-
ness, standard error of the mean, standard deviation,
and histograms were calculated. Frequencies were run
on all categorical variables. All continuous variables
were checked for normal distribution by calculating
Fisher’s measure of skewness. Internal consistency and
reliability were estimated using Cronbach’s alpha for all
multi-item scales.
Characteristics of the sample were summarized using
frequencies for categorical variables and means (stand-
ard deviations) for continuous variables. Descriptive
statistics for internal and external political efficacy
are presented (Specific aim 1). To identify unadjusted
associations of the outcomes internal and political
efficacy with demographic characteristics (Specific aims
2–3) and political activities (Specific aim 4), one-way
analysis of variance (ANOVA) was used for each pre-
dictor of interest. For Aims 2 and 3, multiway ANOVA
O’Rourke et al. 139
was employed to estimate adjusted associations of par-
ticipant characteristics with efficacy, including all
predictors that were statistically significant in unad-
justed analyses.
For Specific aim 4, analysis by one way between-sub-
jects’ ANOVA was conducted to compare the associ-
ation of political activities with internal and external
efficacy. Multiway ANOVA including all predictors
that were statistically significant in unadjusted analyses
was also performed.
Results
Characteristics of the Participants
Six hundred thirty-two NPs participated, representing
49 states and all 11 of the AANP’s regions. This was
a 31% response rate. Participants’ (N¼632) character-
istics are summarized in Table 1. Participants were
predominately White (87.6%), female (91.2%), and
1/3 were older than the age of 55 years. Most
(98.4%) held a master’s degree or higher and 86%
reported an annual income of over $80,000. The major-
ity (72.5%) were certified as family NPs and practicing
in states without full practice authority (76.5%).
Almost 94% voted in the 2012 presidential election
and 95% anticipate voting in the 2016 presidential elec-
tion. Just under half (48%) reported contact with a
legislator. Fifteen percent reported working with state
or national organizations to advance the political
agenda. NP participation in other forms of political
activity is described in Table 4.
Political Efficacy
Political efficacy was assessed with two instruments; the
Efficacy Index was used to measure internal efficacy, and
the Trust in Government Index was used to measure
external efficacy (Sharoni, 2012). With this sample,
Cronbach’s alpha for the efficacy (internal) and trust
(external) indices were .648 and .892, respectively, indi-
cating good reliability. Factor analysis was used to deter-
mine if reliability could be improved by removing low
performing items. However, reliability did not improve
when items were removed, therefore original scales were
used. Internal efficacy scores ranged from 0 to 65 with a
mean score of 44.3 (standard deviation of 5.9) and
a median of 45. External efficacies ranged from 10 to
50, with a mean of 29.4 (standard deviation of 7.1) and
a median of 30.
We divided the Trust and Efficacy Indices into high
and low scores, based upon the median possible
score, as suggested by Sharoni (2012). According to
Sharoni’s (2012) Trust in Government and Political
Efficacy typology, NPs in this sample have low internal
and external political efficacy and are categorized as
‘‘politically alienated Americans.’’ The sample was
one point short of being classified as ‘‘empowered
American citizens.’’
Table 1. Characteristics of Nurse Practitioners (N¼632).
Characteristic n %
Age
20–35 years 102 16.9
36–45 years 137 22.7
46–55 years 160 26.5
56–65 years 176 29.1
>65 years 29 4.8
Gender
Female 572 91.4
Male 54 8.6
Race
American Indian or Alaskan 1 0.2
Hawaiian or Pacific Islander 6 1.0
Mixed 16 2.5
Asian 25 4.0
Black or African American 32 5.1
White 549 87.3
Ethnicity
Hispanic 18 2.9
Non-Hispanic 601 97.1
Income
4 $80,000 73 12.8
> $80,000–4 $120,000 373 65.3
> $120,000 125 21.9
Highest level of education
Certificate 9 1.4
Master’s degree in nursing 529 83.7
Nonnursing master’s or doctoral degree 21 3.3
Doctor of nursing practice (DNP) 55 8.7
Doctor of philosophy in nursing (PhD) 17 2.7
NP certification
a
Family 458 72.5
Adult or adult-gero primary care 155 24.5
Gerontology 37 5.9
Adult or adult-gero acute care 29 4.6
Pediatric 12 1.9
Psychiatric 11 1.7
Other 37 5.9
Not certified 9 4.6
Practice in state with full practice authority
Health policy education 142 23.5
During NP program or continuing education 436 72.3
No formal health policy education 167 27.7
a
Some NPs reported > 1 certification.
140 Policy, Politics, & Nursing Practice 18(3)
Variables Associated With Internal and
External Political Efficacy of NPs
In univariate analysis older age, graduate education,
education in health policy, and relationship with a
health policy mentor all had a statistically significant
association with internal efficacy (p < .001) (Table 2). To estimate the effect of the statistically significant predictors on the dependent variable, with other pre- dictors held constant, we ran multivariate statistical analyses. Graduate education was no longer statistic- ally significant, but the other predictors in the model
Table 2. Relationship Between NP Characteristics and Internal Political Efficacy (N¼622)
a
.
Characteristic n % Mean SD p
b
Age <.001
20–35 years 102 17.1 41.4 6.5
36–45 years 137 22.4 43.5 6.1
46–55 years 159 26.7 45.6 5.8
56–65 years 173 29.1 45.3 5.0
> 65 years 28 4.7 45.2 5.1
Gender .141
Female 563 91.2 44.1 5.9
Male 54 8.8 45.4 5.6
Race .798
American Indian or Alaskan 1 0.2 44.0 –
Hawaiian or Pacific Islander 6 1.0 45.0 1.6
Mixed 16 2.6 45.9 1.7
Asian 25 4.0 45.5 1.1
Black or African American 29 4.7 44.5 1.2
White 543 87.6 44.2 0.3
Ethnicity .272
Hispanic 18 3.0 42.8 8.1
Non-Hispanic 592 97.0 44.3 5.7
Income .115
4$80,000 71 12.6 44.1 4.5
>$80,000–4 $120,000 371 65.8 44.0 6.1
>$120,000 121 21.5 45.2 5.5
Highest level of education <.001
Certificate 8 1.3 44.1 3.3
Master’s degree in nursing 526 84.6 43.8 6.0
Nonnursing master’s or doctoral degree 19 3.1 46.1 5.2
Doctor of nursing practice (DNP) 52 8.4 49.1 4.7
Doctor of philosophy in nursing (PhD) 17 2.7 46.9 3.9
Health policy mentor <.001
Yes 111 18.4 46.9 5.2
No 492 81.6 43.6 5.9
Practice in state with full practice authority .932
Yes 139 23.2 44.2 5.6
No 460 76.8 44.2 6.0
Health policy education <.001
During NP Program or continuing education 430 72.3 45.0 5.7
No formal health policy education 165 27.7 42.2 6.0
a
Total numbers differ from Table 1 due to missing data on efficacy measurement.
b
ANOVA.
O’Rourke et al. 141
(age, health policy education, and association with a
health policy mentor) remained statistically significant
with p values < .001. None of the variables examined
were significantly associated with external political
efficacy (Table 3).
NP Political Activity and Internal and
External Political Efficacy
Voting in the last election, intent to vote in 2016
fall election, working on or donating to a political
Table 3. Relationship Between NP Characteristics and External Political Efficacy (N¼620)
a
.
Characteristic n (%)
Mean (SD) p
b
Age .090
20–35 years 102 17.2 29.9 6.5
36–45 years 136 22.9 30.1 6.9
46–55 years 156 26.3 28.2 7.1
56–65 years 172 29.0 29.9 7.4
> 65 years 27 4.5 30.4 7.0
Gender .150
Female 562 91.2 29.5 7.1
Male 54 8.7 28.1 6.5
Race .259
American Indian or Alaskan 1 0.2 29.0 –
Hawaiian or Pacific Islander 6 1.0 33.0 2.7
Mixed 16 2.6 25.8 1.2
Asian 25 4.0 28.4 1.8
Black or African American 30 4.9 30.1 1.4
White 540 87.4 29.5 0.3
Ethnicity .481
Hispanic 17 2.8 30.6 8.9
Non-Hispanic 592 97.2 29.4 7.0
Income .707
4 $80,000 71 12.6 28.9 6.8
> $80,000–4 $120,000 369 65.7 29.6 7.0
> $120,000 122 21.7 29.2 7.3
Highest level of education .082
Certificate 9 1.5 29.1 7.3
Master’s Degree in Nursing 520 83.8 29.4 7.0
Nonnursing master’s or doctoral degree 21 3.4 30.6 6.5
Doctor of nursing practice (DNP) 53 8.5 28.0 7.9
Doctor of philosophy in nursing (PhD) 17 2.7 30.6 6.5
Health policy mentor .399
Yes 111 18.4 46.9 5.2
No 492 81.6 43.6 5.9
Practice in state with full practice authority .679
Yes 139 23.2 44.2 5.6
No 460 76.8 44.2 6.0
Health Policy Education .973
During NP program or continuing education 430 72.3 45.0 5.7
No formal health policy education 165 27.7 42.2 6.0
a
Total numbers differ from Table 1 due to missing data on efficacy measurement.
b
ANOVA.
142 Policy, Politics, & Nursing Practice 18(3)
action committee, working on campaigns, attending
fundraisers or political meetings, meeting with
legislators and contacting legislators, publicly speaking
about health policy issues, attending health policy
meetings or conferences, and working with a state
or national NP organization, all had statistically signifi-
cant associations with internal efficacy, with p values
ranging from 4 .001 to .008 (Table 4). None of the
factors we assessed were significantly associated with
external efficacy.
Table 4. NP Political Activities and Association With Political Internal and External Efficacy (N¼631).
Internal efficacy
Mean (SD) p
b
External efficacy
Mean (SD) p
b
Political activity n
a
%
Worked or donated to PAC .000 .324
Yes 144 23.3 46.8 (5.1) 29.9 (7.1)
No 478 76.8 43.5 (5.9) 29.3 (7.1)
Worked on political campaigns .000 .612
Yes 160 25.8 47.0 (4.7) 29.2 (7.2)
No 461 74.2 43.4 (6.0) 29.5 (7.1)
Attended fundraiser or town meetings .000 .252
Yes 105 16.9 47.2 (4.3) 30.1 (7.1)
No 515 83.1 43.7 (6.0) 29.3 (7.1)
Met with legislator(s) .000 .817
Yes 129 20.7 47.1 (4.5) 29.6 (7.2)
No 493 79.3 43.6 (4.5) 29.4 (7.1)
Mail, e-mail, phone contact with legislator(s) .000 .599
Yes 297 47.8 45.6 (5.2) 29.6 (6.8)
No 325 52.3 43.1 (6.2) 29.3 (7.4)
Provided education to legislator(s) .000 .845
Yes 55 8.9 48.0 (4.4) 29.6 (7.1)
No 565 91.0 43.9 (5.9) 29.4 (7.1)
Public speaking re: political issues .008 .274
Yes 30 4.8 47.1 (5.4) 28.0 (5.8)
No 591 95.2 44.2 (5.9) 28.5 (7.2)
Attended health policy conference
.000 .901
Yes 169 27.2 46.3 (4.8) 29.5 (7.2)
No 453 72.8 43.6 (6.1) 29.4 (7.2)
Worked with state or national
organizations on political issues
.000 .901
Yes 94 15.1 46.9 (5.2) 29.5 (7.2)
No 527 84.9 43.8 (5.9) 29.4 (7.2)
Had health policy mentor or role model .000 .399
Yes 110 18.3 46.9 (5.2) 30.0 (6.3)
No 492 81.7 43.6 (5.9) 29.3 (7.2)
Voted in 2012 Presidential Election .004 .439
Yes 584 93.7 44.5 (5.8) 29.4 (7.1)
No 39 6.3 41.7 (6.4) 30.3 (7.1)
Anticipate voting in 2016 Presidential Election .000 .191
Yes 603 95.6 44.5 (5.8) 29.5 (7.1)
No 28 4.4 39.4 (5.8) 27.7 (5.8)
PAC¼political action committee.
a
n reflects totals for Internal Efficacy Scale.
b
ANOVA.
O’Rourke et al. 143
Discussion
Studies of the general public identify gender, race,
income, and ethnicity as factors positively associated
with one’s sense of internal and external political efficacy
(Schlozman et al., 2012; Sharoni, 2012). This is in con-
trast to our findings, which showed that gender, race,
income, and ethnicity were not associated with political
efficacy. In our study, NPs were predominately White,
middle aged, educated with a master’s degree, and in a
middle- to high-income bracket. These characteristics
different from those of the general population and may
account for the differences seen in our results.
In this study, older age, health policy mentoring, and
specific education on health policy were all positively
associated with increased internal political efficacy, as
demonstrated in previous studies (Hillygus, 2005;
Schlozman et al., 2012; Sharoni, 2012) and supportive
of Sharoni’s (2012) framework. The working hypothesis
is that education fosters skills and efficacy levels that
support the ability to participate in political interactions
with confidence and ease (Condon, 2015; Hillygus, 2005;
Persson, 2015; Schlozman et al., 2012; Sharoni, 2012).
Education, in general, is widely accepted as a well-estab-
lished predictor of political participation (Condon, 2015;
Hillygus, 2005; Persson, 2015; Schlozman et al., 2012).
Hillygus (2005) noted that programs that concentrate on
developing civic skills strongly predicted increased polit-
ical participation. In our unadjusted analysis, education
was significantly associated with internal political effi-
cacy, with NPs holding a master’s degree in a field out-
side of nursing having the highest internal efficacy.
Graduate education, however, was no longer significant
in our multivariate analysis when we controlled for other
factors.
Eighty-four percent of respondents in this study had
not worked with state or national organizations to
advance a political agenda, nor did they participate in
many other political activities aside from voting or con-
tacting a legislator. This is consistent with findings from
Kung and Rudner-Lugo’s (2014) study, where 23% of
APRNs in Florida reported being active in policy. Ryan
(2015) reported different findings, with greater than 70%
of NPs being involved in political activity (measured by
membership in state and national professional nursing
organizations). These findings are in stark contrast to
our findings and those of Oden et al. (2000).
Considering membership in a professional organization
as a reflection of political activity yields a high percent-
age of politically engaged NP and leads to questions of
the limitations of this as a measure of engagement.
Applying Sharoni’s (2012) framework to our results,
NPs have low internal and external political efficacy, as
well as limited active political participation beyond
voting and contacting legislators. Given technologic
advances and the national organizations’ coordination
of letter or e-mail writing campaigns, contacting legisla-
tors is an easily accessible method of engagement for
many NPs. We did not specifically measure political
donations made to a national organization, which like
membership in a professional organization may repre-
sent indirect political participation and may yield a
higher percent of NP involvement. However, indirect
involvement does not necessarily increase grassroots
involvement on critical issues. Less than 25% of NPs
in this study engaged in a political activity such as meet-
ing with a legislator, working on a campaign, or attend-
ing a fundraiser or town hall meeting. Political efficacy is
not the same as one’s sense of civic responsibility (Kahne
& Westheimer, 2006), and it may not be the primary
driving force behind NP participation in broader polit-
ical activities.
Implications for Policy and Practice
NPs face barriers to practice, reimbursement, and pro-
fessional recognition. Efforts to advance practice have
been met with steep resistance in many states, and our
grassroots efforts fall short many times (Dower, Moore,
& Langelier, 2013; Phillips, 2015). In many organiza-
tions, institutional policies and by-laws hinder our abil-
ities to practice to our full potential (Poghosyan &
Aiken, 2015). Some insurers continually refuse to creden-
tial, reimburse, and recognize our contributions to the
health-care system (Sharp & Monsivais, 2014). Each
state determines the scope of practice for NPs in its jur-
isdiction, making action at the local and state level
imperative. Advocating for policy change through legis-
lation and regulation can influence NP practice
environments.
Making legislators aware that over 90% of NPs
report regular voting could allow our voice to be
heard. Although technologic approaches (e.g., mass
e-mail campaigns) to communicate with legislators may
be increasing frequency of NP contact with policy-
makers, lack of engagement on other levels is a concern.
The findings from this study reveal that we are not ade-
quately engaging the NP population in political activities
(beyond voting and letter writing) that can sway legisla-
tive initiatives. Barriers to participation include time,
financial resources, civic skills, and lack of education
(Casey, 2009; Kung & Rudner-Lugo, 2014; Moran,
2014; Oden et al, 2000). Identification of successful stra-
tegies that inspire NPs to address practice issues through
the legislative arena is clearly needed.
Implications for Education
The 1996 recommendation to add health policy content
to NP curricula was intended to improve political
144 Policy, Politics, & Nursing Practice 18(3)
knowledge and engagement (AACN, 1996). Based on
our results, perhaps curricular reform is not enough
to broaden NP political participation beyond voting
and contacting legislators. Ryan (2015) noted that of
NPs in practice for less than 2 years, 43% reported
participating in any formal health policy education.
Eighty-one percent wanted more formal educational
opportunities on political activism. Our findings indi-
cate 46.6% reported receiving formal health policy edu-
cation during their initial NP program. Although some
NPs in our sample were educated prior to the 1996
recommendation to incorporate health policy content
into curricula, having less than half the sample recall
this content is concerning. The quality and effectiveness
of teaching health policy content warrant further
review. Kahne and Westheimer (2006) note education
that targets external efficacy does not impact one’s
sense of internal efficacy or one’s sense of civic respon-
sibility and actually may hinder the development of
internal efficacy.
It is important for educators to discern desired out-
comes of curricular content. For example, is the goal
to have NP graduates be knowledgeable about health
policy and the impact they might have on policy? Or,
is it for them to become politically active and engage
in the formation of health policy? Educators should
find a way to incorporate health policy and political
socialization throughout the curricula, to motivate and
engage the ‘‘rank and file’’ NPs in the political pro-
cesses that impact their work. Ryan (2015) suggests
that adding political and policy questions to the
national certification examinations may stimulate
interest.
Implications for Professional Organizations
In this study, our sample falls into the ‘‘politically
alienated’’ group, but only by one point. Given the
sample are all members of the national organization,
they may be more politically engaged and informed
those who are not members. This holds significant
implications for organizations to advance their legisla-
tive agendas. Organizing and mobilizing grassroots
NPs are key to advancing the profession’s political
agenda. This is an important issue when the profession
is seeking to obtain full practice authority across the
country and substantially influence the changing
health-care system.
Identification of barriers to NP engagement in health
policy is clearly needed. Examining states that have cre-
ated and sustained successful grassroots engagement,
and duplicating these efforts, is one strategy to consider.
Another option may be to create a database of NP activ-
ists for each state with the potential of linking interested
NPs with mentors to develop expertise and foster new
leaders. Although each state’s context, political culture,
and demographics are unique, the skill set to work with
legislators and to mobilize NPs may be transferable.
Expanding existing mentorship programs, such as the
AANP Fellows Mentorship (AANP, n.d.), is another
way to promote leadership development.
The association between political mentoring and pol-
itical efficacy and participation challenges professional
organizations to develop and increase opportunities
for student and practicing NPs. Ryan (2015) reported
that survey respondents identified a formal mentoring
program as the most desirable way to promote engage-
ment and that over 35% of the NPs were interested
in participating in such a program. It is important
for nurse leaders in practice, academia, and nursing
professional organizations to engage NPs at the grass-
roots level. Increasing nurses’ involvement in programs
like the Robert Wood Johnson Foundation Health
Policy Fellows is another option to increase knowledge
and awareness (National Academy of Medicine, n.d.).
Strengths and Limitations
Demographics of the study population are consistent
with AANP’s 2016 membership database, which includes
76,000 NPs from across the United States. AANP demo-
graphic data report an average age of 49 years, White,
predominately female, holding a graduate degree
and practicing in primary care (AANP, 2016b). The
NP demographics from the Kaiser Family Foundation
(Henry J. Kaiser Family Foundation, 2016) are similar,
suggesting our sample is representative of the U.S. NP
population. The strengths of a random, geographically
stratified sample with similar demographic characteris-
tics of the overall NP population, as validated by
AANP and Kaiser Family Foundation, are important
and support generalizability of the results. This study
also used reliable indexes to measure political efficacy,
adding to the credibility of the findings.
The study had several limitations. Using a cross-sec-
tional design provides information specific to this popu-
lation at one point in time. Moreover, the survey relied
on self-reporting. Underreported or overreported polit-
ical participation due to inaccurate recall or perceived
social desirability could pose a threat to the internal val-
idity of the findings. Although external validity may be
affected by nonresponse, as those choosing to respond to
a mailed survey may be different in some ways from the
nonrespondents, our sample was similar to the general
NP population suggesting little nonresponse bias. The
AANP database comprised NPs who are members in a
professional organization and thus, we may have tar-
geted those NPs more likely to be politically engaged
and who have a higher sense of political efficacy than
those who are not.
O’Rourke et al. 145
Conclusion
Using Sharoni’s (2012) typology, our findings indicate
that NPs have low political efficacy, labeling them as ‘‘poli-
tically alienated Americans.’’ Older age, health policy edu-
cation, and mentoring are associated with internal
political efficacy and political engagement of NPs. The
political activity of NPs in the United States is largely
limited to voting and contact with legislators. Identifying
strategies to engage NPs in the broader political arena is
warranted, particularly with current initiatives to change
state laws and regulations that limit NP practice.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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Author Biographies
Nancy C. O’Rourke is a clinical faculty at the George
Washington University, teaching health policy and
maintains a full time clinical practice. She is an expert
on reimbursement and the evolving role of nurse practi-
tioners, specifically focused on advocacy, engagement,
and the impact of nurse practitioners on health policy
and scope or practice.
Sybil L. Crawford, PhD, is an associate professor in the
Biostatistics Research Group, Division of Preventive
Medicine, Department of Medicine at the University of
Massachusetts Medical School. Dr. Crawford has con-
ducted research in women’s health for more than 17
years, with a particular focus on menopause. Her
research interests include women’s health, particularly
menopause, ethnic differences in health and health care
utilization, and applied statistical techniques such as
longitudinal analysis.
Nancy S. Morris is a faculty at the Graduate School of
Nursing at the University of Massachusetts Worcester.
She completed a Fellowship in the Program Research in
Medical Outcomes at the University of Vermont College
of Medicine and continues her efforts at understanding
health literacy and its relationship to health and health
behaviors and outcomes. In addition, she holds an
appointment as an external faculty nurse scientist at
the Yvonne L. Munn Center for Nursing Research at
Massachusetts General Hospital in Boston.
Joyce Pulcini, PhD, RN, PNP-BC, FAAN, is a professor
and the chair of George Washington University School
of Nursing (GW Nursing) Acute and Chronic Care
Community and the director of GW Nursing
Community and Global Initiatives. She is an expert on
the evolving roles of nurse practitioners throughout the
world, focusing on nurse practitioner education, reim-
bursement, political advocacy, and removal of barriers
to practice. Over the course of more than 30 years as a
pediatric nurse practitioner, educator, and author, she
has become a leader in health care and nursing policy
at local, state, and national levels and is known for her
work in the global development of advanced practice
nursing and survey research she and an international
team conducted on education, practice, and regulation
of advanced practice.
148 Policy, Politics, & Nursing Practice 18(3)
American Academy of Nursing on Policy
The mechanics of writing a policy brief
Rosanna DeMarco, PhD, RN, PHCNS-BC, APHN-BC, ACRN, FAANa,*,
Kimberly Adams Tufts, DNP, WHNP-BC, FAANb
aDepartment of Nursing, College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA
bCommunity and Global Initiatives, School of Nursing, College of Health Sciences, Old Dominion University, Norfolk, VA
According to Nannini and Houde (2010), reports
addressing the interests and needs of policy makers
are frequently referred to as policy briefs
.
These reports
are intended to be short and easy to use, containing
information that can be reviewed quickly by policy
makers. The contents of these reports are based on
systematic reviews of the literature addressing
refereed, rigorously evaluated science to advance pol-
icy making based on the best evidence. In a very
important way, policy briefs give policymakers context
to the issues that are intended to be addressed in their
roles. Policy brief writers typically used this genre of
communicating ideas and opinions when they argue a
specific solution to a problem while addressing the
audience outside of their organization or common
worldview. Today, policy briefs have become popular
tools for corporations and professional organizations,
especially on the Internet but also in other readily
accessible written formats, in that they promote the
mission and vision of organizations through public
sharing of ideas based on compelling evidence (Colby,
Quinn, Williams, Bilhelmer, & Goodell, 2008).
Typically, the purpose of a policy brief is to create a
short document providing findings and recommenda-
tions to an audience who may not be experts in an area
of interest. The brief serves as a vehicle for providing
policy advice; it advocates for the desired solution to a
particular problem or challenge. The audience for a pol-
icy brief can be the general public or particular entities of
interest that seek solutions to problems or needs or who
may require to be convinced of a different way of looking
at an area of interest (i.e., exposure to a new paradigm).
In order to persuade the targeted audience, the brief
must focus on their needs. If the brief addresses prob-
lems that readers want to solve, they will read the policy
brief looking for a newway to view a solution. Otherwise,
the policy brief may not be read and may even be
ignored. It is important to emphasize the readers’ in-
terests rather than those of the writer when composing
this type of document while supplying credible evidence
to support change in policy (Pick, 2008).
Students in policy courses, professional organiza-
tions, policy institutes (i.e., “think tanks”), and
* Corresponding author: Rosanna DeMarco, 100 Morrissey Boulevard,
ton, Boston, MA 02135.
E-mail address: rosanna.demarco@umb.edu (R. DeMarco).
0029-6554/$ – see front matter � 2014 Elsevier Inc. All rights reserved
http://dx.doi.org/10.1016/j.outlook.2014.04.002
legislators are among those who most often write
policy briefs for the purpose of giving succinct evidence
to support actions that ideally should be taken to
address an issue. The main purpose of giving the evi-
dence in a succinct form is to make a convincing
argument to inform policy making while considering
all the salient aspects of an issue from a position of
expertise. Policy briefs are written to inform others of a
specific viewpoint, to frame discussions, and to show
credibility and expertise on a certain subject matter
(Chaffee, 2007).
There are many examples of policy briefs. We focus
on one policy brief that was produced by the American
Academy of Nursing’s expert panel addressing
emerging and infectious diseases (DeMarco, Bradley
Springer, Gallagher, Jones, & Visk, 2012) (Figure 1).
Other examples are readily available outside of the
American Academy of Nursing and can be accessed for
comparison, such as a policy brief on the consolidation
of school districts that was written by the National
Education and Policy Center (Howley, Johnson, & Petrie,
2011) and a policy brief that was generated as the end
product of a funded research project addressing rural
considerations related to globalization (DERREG, 2011).
Each of these policy briefs shows the structure of a
typical brief with some key variations that will be
addressed and explained. What is often lacking in the
literature is guidance on how one creates effective pol-
icy briefs (i.e., the structure and mechanics of devel-
oping the brief itself) and how there may be differences
in the physical presentation across business and pro-
fessional groups aswell as national versus international
approaches. This article highlights the overall frame-
work for crafting an effective policy brief by using the
three briefs mentioned previously as examples.
Step 1: Considerations before Writing a Policy
Brief
The informed writer of a policy brief gives attention
to two major considerations before drafting the brief:
301-22 Science Center Building, University of Massachusetts Bos-
.
Figure 1 e Excerpts from Executive Summary, Background and Significance, and Position Statement (DeMarco
et al., 2012).
Nur s Out l o o k 6 2 ( 2 0 1 4 ) 2 1 9e 2 2 4220
(1) the interests and expertise of the target audience
and (2) the timing of delivery for the brief. Consider-
ationmust be given to the target audience for the brief
so that the level of writing, explanations, and exam-
ples will be geared to the needs of that group. For
example, a policy brief focusing on infectious disease
transmission that is directed to a nonscientific group
interested in volunteerism will require more expla-
nation of terms than would be the case with a scien-
tific research group. Do research to determine how
knowledgeable the group is about the topic. This
research is highly significant because if readers are
highly knowledgeable, simplified concepts may be
interpreted as patronizing. The writer must consider
how much persuasion is needed in order to convince
the reader of the policy brief to take the endorsed
approach and/or action. The readermay bemore open
to the message and the message viewed as more ur-
gent during times of crisis (e.g., gun control when an
episode of gun violence has made national news). At
other times, the writer may need to provide more
evidence and more carefully consider alternative
perspectives.
This approach is highlighted in the examples pre-
sented in this article. In Figure 1, the authors discuss
HIV testing at a critical point wherein the Centers for
Disease Control and Prevention had recently released
information about transmission trends and related
those trends to individuals who did not know their
status and therefore might be transmitting infectious
diseases unknowingly. Thus, there was a perceived
immediate need to protect individuals from height-
ened vulnerability and to decrease the prospective
health and personal costs related to chronic disease
Figure 1 e (continued).
Nur s Ou t l o o k 6 2 ( 2 0 1 4 ) 2 1 9e 2 2 4 221
care through policy change. Finally, a balanced brief
shows both sides of a complex issue. Including the
benefits and advantages or barriers and facilitators to a
solution is very important as can be seen in Figure 1. It
underscores the position but also embodies a sense of
fairness in putting forth that position.
Step 2: Four Sections to a Policy Brief
Generally, there are four sections to a policy brief: (1) an
executive summary; (2) background and significance;
(3) a position statement highlighting the actions the
reader should take; and (4) a timely, reputable refer-
ence list. One of the challenging issues of writing a
policy brief is that it should be brief. A policy brief
should be a “stand-alone” document focused on a
single topic that is no more than two to four pages in
length or 1,500 words (International Development
Research Center, 2013) (Figure 2). The example in
Figure 1 (DeMarco et al., 2012) is a good example of how
to achieve brevity.
Executive Summary
This section represents the distillation of the policy
brief. It provides an overview for busy readers and
should be written last. The executive summary is
similar to an abstract. It should be a paragraph or two
and only take up half of a double-spaced page. It
should stand alone and help the reader to understand
the background, significance, and position taken in a
short brief statement. The executive summary should
answer the following question: What is the policy
brief really about? In Figure 1, in the case of universal
testing for HIV, the authors include statements that
summarize the need for testing from the perspective
of not knowing one’s testing status and how
dangerous this is while explaining the difficulty in
Figure 1 e (continued).
Nur s Out l o o k 6 2 ( 2 0 1 4 ) 2 1 9e 2 2 4222
harnessing real data regarding the incidence and
prevalence of infection and coinfections (DeMarco
et al., 2012).
Background and Significance
This section creates curiosity for the rest of the brief. It
explains the importance and urgency of the issue and
answers “why?” In addition, it describes issues and
context and should not be overly technical. The rule of
thumb is to progress from the general to the specific.
The purpose and/or focus of the policy brief must
immediately be apparent to the reader. This is essen-
tial to crafting an effective and persuasive brief.
Therefore, limiting the supporting evidence to one or
two paragraphs is critical as shown in Figure 1.
If available, it is also important to include references
from lay publications with a wide sphere of influence
(e.g., The New York Times, The Washington Post, and so
on). The use of such references informs the reader that
the topic is current and in the public purview. Using
current references defines the challenge and facilitates
Figure 2 e Key elements of a policy brief.
Nur s Ou t l o o k 6 2 ( 2 0 1 4 ) 2 1 9e 2 2 4 223
an understanding of the extent of the challenge. Cur-
rent references also elucidate why this challenge is
perhaps more important than other challenges. Using
statistics from respected published sources that are
current, reputable, and peer reviewed is an effective
way to accomplish this. Statistics are frequently used
in the examples in Figure 1. These data highlight that
many people are affected or potentially affected by
these infections, and particular health care costs are
either mentioned or identified by naming states that
have instituted changes in these areas of interest. In
the examples, the Centers for Disease Control and
Prevention and the European Commission are quoted
as foundational national and international authorities.
After presenting the context and background in the
opening paragraphs, the writer can then move on to
“bring home the point” by highlighting the key con-
cerns surrounding the issue in the next section of the
document.
Highlight the key concerns via bulleted points
(Figure 1). This is the place to illustrate the broad
impact of the issue to focus attention on multifaceted
aspects. The impact of an issue, whether it be positive
or negative, is rarely limited to one facet. The ramifi-
cations are frequently multifaceted, with health, the
economy, professional autonomy of providers, human
rights of care recipients, environmental consider-
ations, and social implications being among them.
Consider the case for promoting universal testing for
HIV infection. Although universal testing for HIV will
result in increased numbers of persons being aware
they are infected, lead to decreased community levels
of HIV because of decreased transmission, and facili-
tate earlier enrollment in HIV care and treatment
(DeMarco et al., 2012; Figure 1), there are also other
implications in addition to the impact on health out-
comes. A more persuasive argument might also
include information about increased labor productivity
and quality of life. A well-written policy brief presents
a variety of consequences related to the issue at hand.
Hence, clearly explicated key concerns are easily
linked to the writer’s recommendations for addressing
the issue (i.e., position statement). The position state-
ment constitutes the third section of the policy brief.
Position Statement Directing Policy
This section expresses ideas that are balanced and
defensible but with strong assertions. One of the key
approaches is to let the reader know what could
happen if something does not change. In every case,
this section needs to be supported by evidence and be
replete with referenced sources. The position state-
ment sectionmust also be clear and concise and is best
written without inflammatory language (Chaffee,
2007). The writer should use the active voice. Active
language can be quite persuasive, giving the impres-
sion that this issue is important. Keeping the focus of
the statement narrow also facilitates its effectiveness
by avoiding a potential dilution of the issue (Foley,
2007). Parsimony is a must; white space and bullets
are very useful techniques.
The position statement section of a policy brief
highlights the writer’s recommendations using clear,
concise, appropriate, and directly actionable language.
If writing a policy brief that is directed to a policymaker
(e.g., a congressman, city council member, and so on),
speak their language. Use policy-related language
when drafting recommendations for action. For
example, “write new guidelines to oversee the practice
of advanced practice nurses” might be more effectively
written as “promulgate new rules to regulate the
practice of advanced practice nurses.” For recommen-
dations that are directly actionable (Longest, 2010), one
might write, “Ensure that all FDA [Food and Drug
Administration]-approved prescription medications
must be available on all insurance company formulary
lists.” The term ensure leaves a lot to interpretation.
How might the availability of medications be ensured?
Will the availability be ensured by asserting pressure
on employers who provide insurance coverage, by
enlisting the assistance of consumers, or via
Nur s Out l o o k 6 2 ( 2 0 1 4 ) 2 1 9e 2 2 4224
authoritative agency oversight? A clearer and more
directive recommendationmight read, “Draft new CMS
[Centers for Medicare & Medicaid Services] regulations
mandating that all FDA-approved prescription medi-
cations be made available on all insurance company
formulary lists.”
Reference List
The formatting and style of references should also be
considered. The use of superscripts saves room in the
text of a policy brief, and sequential numeric refer-
encing in the reference list allows for an easy review of
the references as the reader examines the contents of
the brief. Figure 1 gives examples of the use of super-
scripts with sequential referencing to maximize space.
In addition to a reference list that encompasses
cited sources, an effective position statement should
be accompanied by an extensive bibliography. This is
where the writer of the statement is able to show his or
her in-depth grasp of the background for, context of,
and trends related to the issue. The bibliography
should be comprised of entries from journals, news-
papers, and books in addition to online sources.
Including this section goes a long way in creating
goodwill with staffers and agency personnel. A diverse
and comprehensive bibliography is especially helpful if
the recipient of the policy brief decides to investigate
the issue and potentially take action.
Design Choices
As has been discussed earlier, the use of bullets to
emphasize key sections of the policy brief, such as
specific policy suggestions made in the position state-
ment section, enables the reader to focus. However, the
bullets must express a complete thought and not be so
abbreviated that it is difficult to understand the point
being made (Figure 1). Using subtitles to break up text
or bold, underlined, or shaded/color-highlighted font
enhancements is also helpful. Boxing in areas to
emphasize examples or issues can create a focus in the
document as will using graphs and figures if they are
easy to read and labeled accurately. All verbs need to be
dynamic and allow the reader to feel propelled to do
something or think in a different way (Figure 1).
Conclusion
A well-written policy brief is a very effective advocacy
tool. Nurses are credible and respected authorities
who enjoy the public’s trust and confidence. Har-
nessing that expertise and using it to draft policy
briefs is a fantastic strategy for impacting health care
policy and health outcomes. Essentially, a well-crafted
policy brief takes a position, backs up that position
with solid evidence, is clear and succinct, and speaks
to potential objections before they surface (Chaffee,
2007). Hence, the policy brief is an excellent tool for
exerting influence in the increasingly complex health
policy arena.
Acknowledgments
The authors gratefully acknowledge themembers of the
American Academy of Nursing Emerging & Infectious
Diseases Expert Panel for their guidance and assistance.
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