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.

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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.

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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

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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

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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.

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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.

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� 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

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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.pdf.

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, ANP1, Sybil L. Crawford, PhD1, Nancy S. Morris, PhD, ANP1, and Joyce Pulcini, PhD, RN, PNP-BC, FAAN2

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

1University of Massachusetts Medical School, Worcester, MA, USA 2George 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

Reprints and permissions:

sagepub.com/journalsPermissions.nav

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 (n¼ 884); 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 (n¼ 915). 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’ (N¼ 632) 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 (N¼ 632).

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 certificationa

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

aSome 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 (N¼ 622)a.

Characteristic n % Mean SD pb

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

aTotal numbers differ from Table 1 due to missing data on efficacy measurement. bANOVA.

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 (N¼ 620)a.

Characteristic n (%) Mean (SD) pb

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

aTotal numbers differ from Table 1 due to missing data on efficacy measurement. bANOVA.

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 from4 .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 (N¼ 631).

Internal efficacy

Mean (SD) pb External efficacy

Mean (SD) pbPolitical activity na %

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)

PAC¼ political action committee. an reflects totals for Internal Efficacy Scale. bANOVA.

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 thatNPshave lowpolitical efficacy, labeling themas ‘‘poli- tically alienatedAmericans.’’ 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.

References

American Association of Colleges of Nursing (AACN). (1996). The essentials of master’s education for a advanced practice nursing. Retrieved from http://www.aacn.nche.edu/educa-

tion-resources/MasEssentials96.pdf

American Association of Nurse Practitioners. (n.d.). Fellows

mentorship program. Retrieved from https://www.aanp. org/fellows-program/faanp-mentorship-program

American Association of Nurse Practitioners. (2017a). Historical timeline. Retrieved from https://www.aanp.org/

all-about-nps/historical-timeline

American Association of Nurse Practitioners. (2017b). State

practice environment. Retrieved from https://www.aanp. org/legislation-regulation/state-legislation/state-practice- environment

Associated Press. (n.d.). Health sign ups top 12 million. Retrieved from http://interactives.ap.org/2017/health-over-

haul-map/?utm_campaign=SocialFlow&utm_source= Twitter&utm_medium=AP_Interactive

Barrett-Sheridan, S. (2009). A quantitative correlational study of political behavior and attitudes of nurses toward macro-social

patient advocacy (Order #305127506). Retrieved from http://gradworks.proquest.com/3384630.pdf

Barton, J., Castillo, M., & Petrie, R. (2016). Negative cam- paigning, fundraising, and voter turnout: A field experi- ment. Journal of Economic Behavior & Organization, 121,

99–113. Retrieved from http://dx.doi.org/10.2139/ssrn. 2280214

Boys, J. D. (2016). Hijacks, hijinks, history and Hillary: The 2016 presidential election. Political Insight, 7(2), 24–26. Retrieved from http://pli.sagepub.com/content/7/2/24.full

Burden, B. C., & Neiheisel, J. R. (2013). Election administra- tion and the pure effect of voter registration on turnout. Political Research Quarterly, 66(1), 77–90. http://proxygw.

wrlc.org/login?url=http://search.proquest.com/docview/ 1445174652?accountid=11243

Caprara, G. V., Vecchione, M., Capanna, C., & Mebane, M. (2009). Perceived political self-efficacy: Theory, assessment, and applications. European Journal of Social Psychology,

39(6), 1002–1020. Retrieved from http://dx.doi.org/10. 1002/ejsp.604

Casey, S. (2009). State political participation of North Carolina

nurse anesthetists (Masters’ thesis). Available from ProQuest Dissertations and Theses database. (UMI No. 1465674).

Center for Information and Research on Civic Learning and Engagement (CIRCLE), Tufts University. (2016). Updated- total youth votes in 2016 primaries and caucuses. Retrieved

from http://civicyouth.org/total-youth-votes-in-2016-pri- maries-and-caucuses/

Condon, M. (2015). Voice lessons: Rethinking the relationship between education and political participation. Political

Behavior, 37(4), 819–843. Retrieved from http://dx.doi.org/ 10.1007/s11109-015-9301\

Craven, G., & Ober, S. (2009). Massachusetts nurse practi-

tioners step up as one solution to the primary care access problem a political success story. Policy, Politics, & Nursing Practice, 10(2), 94–100. Retrieved from http://doi:10.1177/

1527154409344627 Desilver, D. (2016, March 8). So far, turnout in this year’s

primaries rivals 2008 records. Retrieved from ww.pewre- search.org/fact-tank/2016/03/08/so-far-turnout-in-this-

years-primaries-rivals-2008-record/ Dillman, D. A., Smyth, J. D., & Christian, L. M. (2014).

Internet, phone, mail, and mixed-mode surveys: The

Tailored design method. New York, NY: John Wiley & Sons.

Dittmar, K. E. (2015). Women and the vote: From enfranchise-

ment to influence. In K. Kreider & T. Baldino (Eds.), Minority voting in the United States (pp. 99–126). Denver, CO: Praeger.

Dower, C., Moore, J., & Langelier, M. (2013). It is time to restructure health professions scope-of-practice regulations to remove barriers to care. Health Affairs, 32(11), 1971–6. Retrieved from http://content.healthaffairs.org/content/32/

11/1971.full Federal Trade Commission. (2014). Policy perspectives:

Competition and the regulation of advanced practice nurses.

Retrieved from https://www.ftc.gov/system/files/docu- ments/reports/policy-perspectives-competition-regulation- advanced-practice-nurses/140307aprnpolicypaper.pdf

File, T. (2013a). The diversifying electorate—Voting rates by race and Hispanic origin in 2012 (and other recent elec- tions). Retrieved from http://hstrial-iinfo879.homestead. com/Census_-_Voting_in_2012.pdf

File, T. (2013b). Young-adult voting: An analysis of presiden- tial elections, 1964–2012. Retrieved from http://census.gov/ content/dam/Census/library/publications/2014/demo/p20-

573.pdf File, T., & Chrissy, S. (2012, July). Voting and registration in

the election of November 2008. Retrieved from https://www.

census.gov/prod/2010pubs/p20-562.pdf Graves, J. A., Mishra, P., Dittus, R. S., Parikh, R., Perloff, J.,

& Buerhaus, P. I. (2016). Role of geography and nurse prac-

titioner scope-of-practice in efforts to expand primary care system capacity: Health reform and the primary care

146 Policy, Politics, & Nursing Practice 18(3)

workforce. Medical Care, 54(1), 81–89. Retrieved from http://dx.doi.org/10.1097/mlr.0000000000000454

Harrington, R., & Gould, S. (2016, December 21). Americans

beat one voter turnout record-here’s how 2016 compares with past elections. Retrieved from http://www.businessinsider. com/trump-voter-turnout-records-history-obama-clinton-

2016-11 Henn, M., & Foard, N. (2012). Young people, political partici-

pation and trust in Britain. Parliamentary Affairs, 65,

47–67. Retrieved from http://dx.doi.org/10.1093/pa/gsr046 Henry J. Kaiser Family Foundation. (2016, April). Total

number of nurse practitioners, by gender. Retrieved from

http://kff.org/other/state-indicator/total-number-of-nurse- practitioners-by-gender/

Hillygus, D. S. (2005). The missing link: Exploring the relation- ship between higher education and political engagement.

Political Behavior, 27(1), 25–47. Retrieved from http://dx. doi.org/10.1007/s11109-005-3075-8

Institute of Medicine. (2011). The future of nursing: Leading

change, advancing health. Retrieved from http://books.nap. edu/openbook.php?record_id=12956&page=R1

Jacobson, G. C. (2016). Polarization, gridlock, and presidential

campaign politics in 2016. The ANNALS of the American Academy of Political and Social Science, 667(1), 226–246. Retrieved from http://ann.sagepub.com/content/667/1/226. full.pdf+html

Kahne, J., Crow, D., & Lee, N. J. (2013). Different pedagogy, different politics: High school learning opportunities and youth political engagement. Political Psychology, 34(3),

419–441. Retrieved from http://www.civicsurvey.org/sites/ default/files/publications/Different_Pedogogy-Diff_ Politics_062013.pdf

Kahne, J., & Westheimer, J. (2006). The limits of political effi- cacy: Educating citizens for a democratic society. Political Science & Politics, 39(02), 289–296. Retrieved from http://

citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.506. 8895&rep=rep1&type=pdf

Kung, Y. M., & Rudner Lugo, N. (2014). Political advocacy and practice barriers: A survey of Florida APRNs. Journal

of the American Association of Nurse Practitioners, 27, 145–151. doi:10.1002/2327-6924.12142.

McDonald, Michael P. (2016). Voter Turnout Demographics.

United States Elections Project. Retrieved from http:// www.electproject.org/home/voter-turnout/demographics (accessed 16 January 2017).

Moran, V. J. (2014). Political participation among Louisiana advanced practice nurses (Doctoral dissertation). (Order no. 3583255). Retrieved from http://search.proquest.com/doc- view/1552485329

National Academy of Medicine. (n.d.). Health policy educational programs and fellowships. Retrieved from https://nam.edu/pro- grams/health-policy-educational-programs-and-fellowships/

National Governors Association. (2012). The role of nurse prac- titioners in meeting increasing demand for primary care. Retrieved from file:///C:/Users/morrisn/Downloads/

1212NursePractitionersPaper.pdf Neimie, R. G., Craig, S. C., & Mattei, F. (1991). Measuring

internal political efficacy in the 1988 national election study.

The American Political Science Review, 85(4). doi: 10.2307/ 1963953.

Oden, L. S., Price, J. H., Alteneder, R., Boardley, D., & Ubokudom, S. (2000). Public policy involvement by nurse practitioners. Journal of Community Health, 25(2), 139–155.

Retrieved from http://dx.doi.org/10.1023/A:1005181724388 Persson, M. (2015). Education and political participation. British

Journal of Political Science, 45(03), 689–703. Retrieved from

http://dx.doi.org/10.1017/s0007123413000409 Phillips, S. J. (2015). 27th Annual APRN Legislative update:

Advancements continue for APRN practice. The Nurse

Practitioner, 40(1), 16–42. Retrieved from http://dx.doi. org/10.1097/01.NPR.0000457433.04789.ec

Poghosyan, L., & Aiken, L. (2015). Maximizing nurse practi-

tioners’ contributions to primary care through organiza- tional changes. Journal of Ambulatory Care Management, 38(2), 109–117. doi:10.1097/JAC.0000000000000054.

Poghosyan, L., Boyd, D. R., & Clarke, S. P. (2016). Optimizing

full scope of practice for nurse practitioners in primary care: A proposed conceptual model. Nursing Outlook, 64(2), 146–155.

Ryan, S. F. (2015). Nurse practitioners and political engage- ment: Findings from a nurse practitioner advanced practice focus group & national online survey. Retrieved from https://c.

ymcdn.com/sites/www.thenpa.org/resource/resmgr/Headline_ News/NursePractitionersandPolitic.pdf

Schlozman, K. L., Verba, S., & Brady, H. E. (2012). The unhea- venly chorus: Unequal political voice and the broken promise

of American democracy. Princeton, NJ: Princeton University Press.

Sharoni, S. (2012). E-Citizenship: Trust in government, polit-

ical efficacy, and political participation in the internet era. Electronic Media & Politics, 1(8), 119–135. Retrieved from https://static1.squarespace.com/static/

55cb6d37e4b060e9216ba489/t/55df0c3de4b0ba506ce26a86/ 1440681021049/eCitizenship.pdf

Sharp, D. B., & Monsivais, D. (2014). Decreasing barriers for

nurse practitioner social entrepreneurship. Journal of the American Association of Nurse Practitioners, 26(10), 562–566. doi: 10.1002/2327-6924.12126.

Vandenhouten, C. L., Malakar, C. L., Kubsch, S., Block, D.

E., & Gallagher-Lepak, S. (2011). Political participation of registered nurses. Policy, Politics, & Nursing Practice, 1(3), 159–167. Retrieved from http://dx.doi.org/10.1177/

1527154411425189 Verba, S., Schlozman, K. L., Brady, H. E., & Brady, H. E.

(1995). Voice and equality: Civic voluntarism in American

politics. Cambridge, MA: Harvard University Press. Wang, T. A. (2012). The politics of voter suppression: Defending

and expanding Americans’ right to vote. Ithaca, NY: Cornell University Press.

Wang, Y., Li, Y., & Luo, J. (2016). Deciphering the 2016 US presidential campaign in the twitter sphere: A comparison of the Trumpists and Clintonists. Retrieved from http://

arxiv.org/pdf/1603.03097.pdf Weiser, W., & Opsal, E. (2014). The state of voting in 2014.

Retrieved from http://www.brennancenter.org/sites/

default/files/analysis/State_of_Voting_2014.pdf Zukin, C., Keeter, S., Andolina, M., Jenkins, K., & Carpini, M.

X. D. (2006). A new engagement? Political participation, civic

life, and the changing American citizen. New York, NY: Oxford University Press.

O’Rourke et al. 147

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)

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.

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

Narrative with the Facts

Conclusion

References

Agenda Comparison Grid Template