Chapter 5: Advance Equitable Population Health Policy
This chapter will cover:
- Vulnerable Populations
- Stages of the Policy Development Process
- Nurses’ Role in Advancing Health Care Policies
- Social Responsibility as a Global Citizen
5.1 Vulnerable Populations
Structural barriers within society and in the health care system place vulnerable populations, also known as disadvantaged groups, at higher risk for poor health. Multiple social factors, such as living in unsafe neighborhoods, being unable to access quality education, and working in low-wage occupations, put vulnerable populations and communities at a disadvantage, perpetuating their low socioeconomic position. Nurses can meaningfully intervene and improve health outcomes by assessing these populations through the lens of the social determinants of health (SDOH). Nurses have a duty to ensure equitable and culturally competent care. Disadvantaged populations are often subject to significant health disparities.
While no defined set of factors exists to determine whether a population or a community is disadvantaged, one or more of the following characteristics are often used to identify vulnerability (Bhatt & Bathija, 2018):
- Income and education
- Access to primary health care services
- Age
- Gender and sexual orientation
- Social, cultural, and linguistic needs
- Race and ethnicity
- Chronic illness or disability
- Alcohol or substance misuse
- Homelessness
- Human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS)
- Veteran status
- Migrant status
- Rural residency
Since nursing is founded on the principle of social justice, nurses are well positioned to care for vulnerable populations and advocate for systemic changes. Ensuring access to essential health care services, advocating for culturally and linguistically appropriate care, and educating community partners on health needs are steps toward improving the health ou.tcomes of vulnerable populations (Bhatt & Bathija, 2018).
5.2 Stages of the Policy Development Process
The term policy development process (also referred to as health policy process) describes the steps or stages that are followed as a specific problem or concern generates a plan of action intended to correct it. Think of this as an umbrella term that captures all stages from the idea for a new policy to the evaluation of the policy. This is similar to the steps of the nursing process, so this should feel familiar. There are many models that describe the steps of policy development, but one of the most commonly used in creating public health policy is the stage-sequential model, illustrated in Figure 5.1
Again, these steps likely look familiar as in this model the policy development process is very similar to the nursing process. Let’s review each stage and its parallel in the nursing process.
The first stage is agenda setting. This stage combines two steps of the nursing process: assessment and diagnosis. Before a policy addressing an issue can be created, it is first necessary to define the problem clearly. For example, if a clinic does not allow children to be present during their caregiver’s appointment, this policy might lead to canceled or skipped appointments when childcare plans fall through, negatively influencing the caregiver’s health. This particular situation can be dealt with by changing the existing policy. Having identified the problem, the next step would be to bring it to the attention of those with the power to change the policy. In this example, the policy directors may be the health care providers, nurses, and the clinic manager, and the individual who identified the problem could send these individuals an e-mail or talk to them directly about their concerns (Coughlin et. al, 2022).
The second stage, policy formulation, means developing a plan to solve the previously identified problem. This is the same action as the planning stage of the nursing process. This step of policy development should result in a tangible outcome: a fully completed proposal for a new or amended policy. Returning to the previous example of the clinic, the plan to solve this problem might be proposing new guidelines for when children may be present at a parent or caregiver’s medical appointment.
The third stage, policy adoption, is when the policy or change in existing policy becomes official. Adoption can be as informal as a facility-wide memorandum indicating the new policy and the date it will be in effect. For example, “as of July 1, children under the age of 5 are permitted to be in the examination room with a parent or caregiver.” Notifying others, such as clients, customers, or other community partners, about the new policy may also be part of the adoption process, depending on who the policy will affect. Policy adoption can also be handled formally; for example, a federal health care policy is adopted when Congress passes legislation. There is no step that corresponds directly to this stage in the nursing process.
Stage four, or policy implementation, is when the policy is implemented into action. Some policies do not require money or resources to implement. In the clinic example, this policy is a purely behavioral change and costs nothing to implement. However, if people or material resources are needed to enact a policy, obtaining the money to pay for them can make the implementation process much slower.
Stage five, policy evaluation, is the same in policy development and in the nursing process. For both, it means determining how well a policy is working. If a policy makes substantial changes to a process, involves many people, and is implemented over a long period of time, evaluation can be surprisingly difficult to accomplish. To gain an objective view of the policy’s success, it is necessary to collect data on its outcomes. In the clinic example, evaluation of the new policy would require tracking data to know whether giving flexibility in bringing children to appointments resulted in fewer cancellations or rescheduled visits. It would also assess if the policy resulted in any unforeseen effects, such as slowing the office and clinical staff down. Finally, if the policy evaluation determines that the new or revised policy has created another problem, the whole process will begin again.
5.3 Nurses’ Role in Advancing Health Care Policies
When nurses work to defend policies that improve health care outcomes, they are ultimately advocating for their clients. Nurses experience the daily influence of policy and politics in health care. As the largest group in the global health care workforce, nurses are uniquely positioned to observe the ways in which health policy affects clients and their communities (Kovner, 2023). Nurses are crucial to defending health policy because they spend much of their time interacting with clients and understanding their needs. Nurses can relay successes and limitations to policymakers, whether directly through contact with their legislators or through the collective voice of a nursing organization like the ANA (Pollack-Porter et al., 2018).
The ANA has worked to defend provisions of the ACA (Affordable Care Act), since it was introduced in 2010. One of the policies it has focused on is the information technology initiative. The ANA has advocated for electronic health records (EHRs) to promote client safety, joined health information technology alliances such as the Healthcare Information and Management Systems Society and the Alliance for Nursing Informatics, and developed educational products for e-health campaigns. Not all nurses were happy about the change from paper charting to EHRs, so the ANA worked to defend that policy by educating nurses about the improvements in client safety offered through the use of computerized client charts (American Nurses Association [ANA], 2023).
The information obtained by collecting data on a group of interest can be used by policymakers to tailor planned activities and interventions to directly target the members of that group (Leal, 2022). Nurses can support this process by keeping careful records of health needs and barriers to improved health in the selected client group. Nurses can also act as advocates for policy development when they identify a health gap in a client population.
An example of this is nurse Judith Haber’s work to create interest in policies aimed at whole-person care for people who use Medicare. Dental care is not a covered benefit for these individuals unless the issue is related to very specific effects of medical treatment (such as pulling teeth that are loosened by treatment for cancer). Sixty percent of Americans aged 65 and older are enrolled in Medicare, and unless they purchase a private dental coverage policy, they must pay for all dental treatment out of pocket. Dr. Haber and her colleagues in the Oral Health Nursing Education Practice (OHNEP) program (a national nursing oral health initiative) have worked with the Centers for Medicare and Medicaid Services to improve access to dental care for several years. While dental care is not yet completely covered, through the efforts of these nurses, Medicare has been expanded to include benefits to clients with medical conditions (like artificial heart valves) that are impacted by oral health (Kovner, 2023).
Some applicable advocacy strategies for any nurse include joining a national nursing organization to draw attention to health disparities with a collective voice. Politics and policy are at the core of health care planning and improvements to population health, and by using the power of organized lobbying, nurses can create awareness of issues that will drive the development of policies to address these issues (Brokaw, 2016).
5.4 Social Responsibility as a Global Citizen
The role of nurses as global citizens goes beyond providing local health care. Nurses must embrace their responsibility to contribute to positive global health outcomes, promote health equity, and address global health challenges. Nurses are prepared to interact with populations from around the world. Being culturally competent and sensitive allows nurses to provide care that respects cultural beliefs, practices, and values. Global citizenship in nursing involves advocating for equal access to quality health care for all individuals regardless of their geographical location, socioeconomic status, or cultural background. Nurses can advocate for policies that address health disparities and promote health equity globally. They also promote global health by educating individuals and communities about disease prevention, hygiene, nutrition, and healthy lifestyles. This knowledge can have a positive impact on public health outcomes worldwide. Additionally, nurses are often at the forefront of responding to disasters and humanitarian crises around the world, providing emergency medical care, supporting displaced populations, and delivering essential health care services.
Global citizenship encourages nurses to collaborate with health care professionals and policymakers across borders, fostering international partnerships that facilitate knowledge-sharing, capacity-building, and skill-sharing projects. Nurses can contribute to global health by participating in educational initiatives and training programs in undeserved areas such as third-world communities, helping to strengthen health care systems and empower local health care professionals. They can also engage in global public health initiatives, such as promoting sanitation, safe drinking water, and hygiene practices to prevent spreading infectious diseases. Above all, nurses must prioritize the well-being of clients and communities, even in challenging and resource-limited.
Nurses must continuously learn about and adapt to global health issues, emerging diseases, and evolving health care practices. They should advocate for health equity, promote global health initiatives, collaborate internationally, and provide health care services in diverse settings to improve global health outcomes.
References
American Nurses Association. (2023). Health system transformation. https://www.nursingworld.org/practice-policy/health-policy/health-system-reform/
Bhatt, J., & Bathija, P. (2018). Ensuring access to quality health care in vulnerable communities. Academic Medicine, 93(9), 1271–1275. doi: 10.1097/ACM.0000000000002254
Brokaw, J. (2016). The nursing profession’s potential impact on policy and politics. American Nurse Journal. 11(9), 43–46.
Coughlin, C. G., Bovell-Ammon, A., & Sandel, M. (2022). Extending the child tax credit to break the cycle of poverty. JAMA Pediatrics, 176(3), 225–227. https://doi-org.ezp.twu.edu/10.1001/jamapediatrics.2021.4603
Kovner, C. (2023). Together we can influence policy changes. Policy, Politics & Nursing Practice 24(1). https://doi-org.ezp.twu.edu/10.1177/15271544221147446
Leal, M. (2022). Public health and economic development: The case of Medicaid . . . Does “economic growth” result in better “population health”? Journal of Public Health, 44(4), 727.
Pollack-Porter, K. M., Rutkow, L., & McGinty, E. E. (2018). The importance of policy change for addressing public health problems. Public Health Reports, 133(1_suppl), 9S–14S. doi:10.1177/0033354918788880
Content in this chapter is an adaptation of chapter sections Introduction chapter 27, 34.3, 34.4, 35.3, Population Health Nursing by Jessica Ochs, Sherry L. Roper, and Susan M. Schwartz in OpenStax, licensed CC BY.
