The importance of health policy to individual nurses and the discipline of nursing was recently highlighted by Parse. She stated:
Currently, health policies focus primarily on efficiency, technological advances, and cost containment as priorities related to healthcare delivery. To be sure, these are important considerations for all concerned. But there is little evidence to suggest that these priorities are likely to change to include consideration for human dignity and free choice, without some overt commitment with action from a discipline with a vested interest in the quality of life of citizens. Is nursing that discipline? Will nurses rise to the occasion and demand health policy changes that include a focus on humanly lived experiences of health that fortify quality of life by honoring dignity and choice. Only time will tell.1
The purpose of this article is to discuss the integration of nursing and the health policies that influence physical and mental healthcare. The word “integration” refers to the bringing together, mixing, combining, or uniting of parts to form a larger whole.2
Prior to integration, each part must be clearly defined. The parts of particular interest in this discussion are nursing and health policy. Nursing was defined by Martha Rogers as “A magnificent epic of service to [human]kind.”3 Thirty years later, the American Academy of Nursing Expert Panel on Nursing Theory-Guided Practice defined nursing as “A human health service to society.”4 The striking similarity between the 2 definitions indicates that there is consensus that nursing is a healthcare service.
A definition of policy that seems relevant to policy as the term is used by members of the American Academy of Nursing and others interested in policy analysis and evaluation is: A principle or course of action adopted or proposed as desirable, advantageous, or expedient.5 Policies are expressed as goals, programs, proposals, laws, and regulations that reflect beliefs and values of those who develop the policies.6 Although an explicit definition of health policy could not be located, it seems reasonable to conclude that the term refers to a desirable course of action addressing the health of human beings. Health policies typically address the quality of services, the cost of services, and/or access to those services.
Ellenbecker and colleagues maintained that a focus on health policy “expands Henderson’s definition of the nursing function from nurses contributing to individuals’ health to the broader function of contributing to societal health.”7 Henderson defined the unique function of nurses as assisting “individual[s], sick or well, in the performance of activities contributing to health or its recovery (or to a peaceful death) that [they] would perform un-aided if [they] had the necessary strength, will, or knowledge. And to do this in such as way as to help [them] gain independence as rapidly as possible.8
Some nurses and policy analysts may ask why members of the American Academy of Nursing are interested in health policy. The answer is that the Academy has identified a reason for its existence through what may be thought of as the integration of health policy knowledge and nursing knowledge. Accordingly, the Academy’s mission “is to serve the public and nursing profession by advancing health policy and practice through the generation, synthesis, and dissemination of nursing knowledge.”9
Knowledge encompasses the metaparadigm of each discipline, philosophies, conceptual models, theories, and methods of inquiry.10 Knowledge grows through continuing development of new ways of viewing each knowledge component, as well as evolution of existing knowledge. Health policies may be viewed as theories that reflect White’s idea of sociopolitical knowing,11 which also is viewed as a type of theory.12 Theories of sociopolitical knowing are used to guide nursing practice in the sense that the cultural context of nurse-patient interactions and the context in which nursing and health care occur are understood and taken into account.
Theories do not arise spontaneously but rather are derived from broader conceptual models. Furthermore, theories are not fully understood outside the context of their parent conceptual model. Indeed, Popper asserted that it is “absurd”13 to think that some conceptual model—or what he called “a horizon of expectation”13—is not the starting point for theory development. Two nursing conceptual models explicitly address health policy—the Conceptual Model of Nursing and Health Policy (CMNHP)14, 15 and the Clouterbuck Minimum Data Matrix Model (CMDMM).16
The CMNHP was designed to extend substantive knowledge of health policy within the discipline of nursing and addresses the intersection of nursing and health policy. The model takes 3 types of health policies into account. Public policies are those health policies formulated by governmental entities, such as the federal government, state governments, and city and town governments. Organizational policies are those health policies formulated by organizations, such as hospitals and home healthcare agencies. Professional policies are those health policies formulated by professional societies and associations, such as the American Academy of Nursing, the American Nurses’ Association, and various specialty practice associations, such as the Oncology Nursing Society and the American Association of Critical Care Nurses.
According to the CMNHP, each health policy may address one or more of 3 components. Personnel refers to those people who provide the services. The health policy specifies who those people should be, including educational preparation and other credentials. Services refers to the types of activities provided. The health policy specifies what services should be provided and the amount of service that should be provided. Expenditures refers to the cost of services. The health policy specifies how much should or can be spent on the services.
Russell and Fawcett15 identified 4 levels of nursing and health policy focus and outcomes. The 4 levels are increasingly broad and not meant to be viewed as a hierarchy. Each level interacts with all other levels. Level 1 focuses on the quality of nursing practice processes; the outcome is efficacy. Level 2 focuses on the quality and cost of nursing practice delivery systems. The outcomes are effectiveness and efficiency. Level 3 focuses on access to health care; the outcome is equity of access. Level 4 focuses on the quality and cost of and access to world health practices; the outcome is social justice.
The CMDMM was designed as “a teaching mechanism to generate a comprehensive base of consumer information prerequisite to the in-depth level of critical analysis and synthesis needed to produce [high] quality health care outcomes in the 21st century.”16 Three dimensions of variables—personal, situational, structural—are “known to influence consumer health status, behavior, and outcomes.”16 The variables are used to create a “comprehensive consumer profile reflecting … subjective and objective realities.”16 The structural dimension variables include health policy and regulations. Thus, the CMDMM includes health policy as one of many variables that are needed to understand the health-related experiences of human beings. Unlike the CMNHP, health policy is not a central focus but rather one important variable to consider.
The American Academy of Nursing has recognized the need for nurses to be involved in the development of health policies because, as Hughes pointed out, “our consumers, patients and clients need us to be. Who better than nurses understand the practical reality of health care that spans numerous settings, involves people at their most vulnerable, and provides a view of health from multiple perspectives?”17 Two nursing conceptual models—the CMNHP and the CMDMM—provide a distinctive nursing context for health policy development. A major challenge to the advancement of nursing knowledge is to derive theories of health policy from the CMNHP and the CMMDM. Another major challenge is to use the 2 conceptual models as guides for the analysis and evaluation of existing health policies. Members of the American Academy of Nursing are urged to undertake that work. For only when health policies are developed, analyzed, and evaluated within a distinctive nursing context will the integration of nursing and health policy occur.
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