Because We Made VowsEileen T. O’Grady, PhD, RN, ANP-BC

“…that to the brim my heart was full; I made novows, but vows were then made for me; bondunknown to me was given, that I should be, ...adedicated Spirit.” William Wordsworth

When Florence Nightingale defined nursing, she sawthat influencing policymakers was core to the role. Shemarched up and down the halls of Parliament with scatterplots and piecharts showing the undeniable impact thatnursing care was having on the Crimea War soldiers’ mor-tality rates. She worked tirelessly to reform Victorian-eraLondon by promoting health policies to improve the plightof the poor, maternal-child care, and a host of other issues.

When I was asked to write an essay on why NPsshould care about being engaged in health care pol-icy, what came to mind was that we made vows.When each of us graduated with our first nursingdegree, we said Nightingale’s solemn promise,pledge, and personal commitment to “take myshare of responsibility in promoting the health andwelfare of the community” and “to be active inassisting others in safeguarding and promoting thehealth and happiness of mankind.”

When we make vows in our life, we must saythem again and again not to forget. What is mostimportant to us must be spoken out loud and madereal in our outer worlds. I speak from prior experi-ence of feeling strangled by a work environment inwhich I could not or would not take my share ofresponsibility in changing the system. I was doingwork that brushed up against what was mostimportant to me, and I did not take responsibility fornaming or changing the problem. It became a con-fining, imprisoning way to live in a world in whichwe were meant to be free.

We NPs are in a mission-driven profession. Wewant to impact individuals and communities on alarger scale. When we work in clinical settings that

deliver perverse, unjust, or undignified care and wedo nothing about it, we are complicit. Our currenthealth care model is not meeting the needs ofpatients and communities. After decades ofdebate, monumentally ambitious reform is on thehorizon. As highly skilled and knowledgeable mem-bers of the health workforce, we have a duty, anobligation really, to engage in policy in a fierce way.

We must pay fiercer attention to the care weare delivering and notice if there is a disallowing oflarger or stronger ideals for ourselves. Determinewhat gives you grace as an NP. Pay attention tothe parts that make you feel fully alive and noticethe parts that make you feel confined, restricted,or small. Identify a situation in your clinical settingthat needs to be changed, stopped, or started.What is beckoning you? What calls to you on adeep level that needs to be addressed? Seek tounderstand why you are not taking action. Is it toobig? Too overwhelming? Or too frightening?

The word responsibility simply means the abilityto respond. It need not carry any burden at all. Aswe work in our institutions, communities, and fed-eral arenas, we must speak up, become visible, andbring our sensible solutions and ideas to the fore.We must offer a more compelling vision of whatreformed health care could look like. This does notrequire acknowledgment or reaction to our opposi-tion, but simply the ability to respond to policymak-ers and the public in a more thoughtful, patient-cen-tered, and imaginative way. We NPs must individu-ally and collectively respond to policy ideas with anintense patient-centeredness. You must care aboutthis. Remember why we became nurses—becausewe made vows.

Dr. Eileen O’Grady is a certified adult nurse practitionerand wellness coach living near Washington, DC.

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Note: As of December 2009.As part of its mission, ACNP advocates federal poli-cies and programs to enhance access to care, pro-vide options for health care consumers, and sup-port nurse practitioners (NPs). Each year ACNPupdates its Public Policy Agenda as an advocacyeffort and encourages Congress and theAdministration to ensure that NPs are enfranchisedin legislative and regulatory policymaking efforts.Specifically, in the 2nd Session of the 111thCongress, ACNP calls upon Congress and theAdministration to:

• Provide full reimbursement and empanelmentfor all NPs in all settings

• Include provider-neutral language in all federallegislation, regulation, and other policies

• Recognize NPs’ authority to order home healthand hospice services and to admit patients toskilled nursing facilities

• Support development of a national NP databaseand tracking mechanism

• Support policies that recognize NPs as primarycare providers in all settings, including medicalhomes and accountable care organizations

•Appropriate increased funding for nursingfaculty, advanced practice nursing, and basicnursing education and research

• Ensure inclusion of NPs in the development ofhealth IT policy and infrastructure

• Include the NP perspective in national healthcare reform strategy

2010 ACNP Public PolicyAgenda

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The knowledge, perspectives, and experi-ences of involved NPs can have an impact onthe changes that will continue to confront usas part of the health care transformationprocess. Several emerging models of carehave been discussed in the context of healthcare reform and could potentially impactaccess to care or reimbursement foradvanced practice nurses.

Transitional Care, as introduced in the“Medicare Transitional Care Act” (H.R.2773/S.1295) provides for a transitional carebenefit designed to support and coordinatecare for beneficiaries as they move from thehospital setting to their homes, skilled nursingfacilities, or rehabilitation centers. This bene-fit targets Medicare beneficiaries who are atparticularly high risk for hospital admissionsand readmissions. The services under thebenefit are inclusive of medication reviews,care coordination, and home visits. The legis-lation is modeled after the Transitional CareModel developed by the University ofPennsylvania and has shown to improvehealth outcomes and increased patient satis-faction. Hospitals will be rewarded for estab-lishing evidence-based transitional care serv-ices and APRNs have an opportunity to be akey stakeholder in this process.

Accountable Care Organization (ACO)

entered the policy spotlight early in 2009 andhas gained momentum since. The ACO isdesigned to eliminate unnecessary medicalservice, spur the teamwork of providers to deliv-er efficient care, and ensure payment that is

focused on the provision of high-quality care.The redesigned reimbursement method wouldbe based on the creation of “savings” bydecreasing duplication of services and eliminat-ing procedures and referrals that are of uncer-tain value. ACOs would be accountable for theoverall quality and cost of care for the popula-tions they serve. It is anticipated that theywould foster affiliations of providers such ashospitals and primary care practices, yet anoth-er opportunity for APRNs to actively participatein the creation of this new model.

Medical home, also known as Patient-

Centered Medical Home (PCMH) or AdvancedPrimary Care Model, is defined as “an approachto providing comprehensive primary care... thatfacilitates partnerships between individualpatients, and their personal primary careproviders, and when appropriate, the patient’sfamily.” The advancement of medical homesmay allow better access to health care, increasesatisfaction with care, and improve health. ThePatient-Centered Primary Care Collaborative hasled this effort through establishment of a varietyof projects to evaluate the effectiveness of thismodel. In early 2008, the NP Roundtable devel-oped talking points on the medical homes issue;for details, visit the ACNP position statementwebpage (http://bit.ly/6yDZeX) and click on “NPRoundtable Nurse Practitioners: MedicalHome/Coordinated Primary Care Providers.”

Now is the time to get involved, to become iden-tified as a key healthcare provider, and demonstrateleadership in the drive to decrease costs andimprove quality of care, and to be accountable.

Critical Health Policy Leadershipfrom ACNP Public Policy

Committee

Keeping with the focus of the journal’s issue on policy,ACNP would like to showcase the public policy issuesand priorities of several state affiliates. The leadership ofsome ACNP state affiliate organizations were asked thefollowing questions: What are the three major issues fornurse practitioners in your state? What are your statepolicy priorities in the upcoming year? What type of col-laboration went into your last successful policy effort?

Their responses are outlined below; for more informa-tion on individual state affiliate organizations, please visittheir respective websites.

Texas Nurse Practitioners

www.texasnp.org

The three major issues in Texas are changing diagno-sis from physician delegated to granted by theTexas Board of Nursing, changing prescribing fromphysician delegated to granted by the Texas Board ofNursing, and removing site-based restrictions related toprescribing so APNs can prescribe II-IV classes of med-ications throughout Texas.

The Texas State policy priorities for the upcoming yearare funding RN/APN PAC and supporting Texans who arerunning for state office positions; supporting the gover-nor’s race for reelection, using grassroots efforts to dis-cuss APN common goals with candidates at local andstate levels, and working on campaigns to garner sup-port; supporting Senators and House Representativeswho have filed bills for APNs on nursing board-grantedprescriptive authority and are willing to present theseagain next session; and targeting those state offi-cials sitting on House Health and Senate Health andHuman Services committees.

In terms of collaboration within Texas, there is theCoalition of Nurses in Advanced Practice, whichincludes all APNs, NPs, CRNAs, CNMs, and CNSs.Using grassroots efforts, APNs are meeting locally andat the Capitol with House Representatives andSenators and their staff to discuss APN issues.Leadership of the Texas Nursing Association, TexasAssociation of Nurse Anesthetists, and Texas NursePractitioners regularly collaborate and share commongoals to move forward in the Texas legislature.

Massachusetts Coalition

of Nurse Practitioners

www.mcnpweb.org

Three major issues facing the Massachusetts Coalition ofNurse Practitioners (MCNP) are payment reform to equal-ize the reimbursement rate between physicians and NPs,medical homes, and recognition of our primary careprovider legislation and enforcement of those regulations.

The policy priorities for the upcoming year are tacklingthe major issues described above. Additionally, the organ-ization is actively lobbying for inclusion of NPs in alldemonstration projects and payment reform language.

The organization collaborates with many differentgroups and has great support from community groupswhen meeting with them. MCNP regularly attends

and is a member of the Chamber of Commerce.Relationships have been forged with theMassachusetts Group Insurance Commission and theState Attorney General’s office, as well as the StateDirectors of Medicaid, the League of CommunityHealth Centers, and the Commissioner at the StateDepartment of Public Health.

California Association

for Nurse Practitioners

www.canpweb.org

One major issue for the California Association forNurse Practitioners (CANP) is a lack of an NP scope ofpractice separate from that of the registered nurse(RN). Currently, California’s NPs are able to practice ata level above that of the RN through the use of stan-dardized procedures. Each practice setting must havea set of standardized procedures that specify theaspects of management of a patient condition that aNP has proven competency to perform.

Another issue is NPs’ inability to be recognized as apatient’s primary care provider, which makes it impos-sible to be listed on insurance plans for reimburse-ment. Finally, not having hospital admitting privileges isa major concern of California NPs.

The main public policy priority for the upcoming yearwill be obtaining a Nurse Practitioner Scope of Practicefor California’s Nurse Practitioners.

CANP has been working hard at building alliancesboth with other advanced practice nursing groups andthe California Medical Association (CMA). During theprocess for passage of SB 294, an act to add Section2835.7 to the California State Business and ProfessionsCode relating to nurse practitioners, the organizationwas able to get a neutral position letter from CMA,which was helpful.

Pennsylvania Coalition

of Nurse Practitioners

www.pacnp.org

The major issues facing the PCNP are updating thestate regulations for NPs and the passage ofPennsylvania Senate Bill 441, which would allow NPsto perform physicals on teachers seeking certificationwithin the state. Most importantly, the organization isworking toward recognition of NPs as primary careproviders with insurer and payer recognition.

The policy priorities for the upcoming year are thecreation of a published White Paper that illustrates thebarriers for NPs still exist in Pennsylvania, the elimina-tion of the collaborative agreement between physi-cians and NPs, and ultimately striving toward inde-pendent practice for NPs throughout the state.

PCNP readily collaborates with many associatedorganizations at local, state, and national levels. ThePennsylvania Medical Society and the PennsylvaniaIndependent Regulatory Review Commission weretwo groups that the organization successfully workedwith to push through the new CRNP regulations.

Issues and Priorities for ACNP State Affiliates in the Upcoming YearA

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