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					Running Head: HEALTH POLICY CRITIQUE                                        1

                                 Health Policy Critique


                                      Janet Reeves

                                        A Paper

                 Submitted in partial fulfillment of the requirements for
                         NURS 740 Health Policy and Politics
                 University of Alabama Birmingham School of Nursing

                                 Birmingham, Alabama

                                  September 14, 2009
Running Head: HEALTH POLICY CRITIQUE                                                                 2

       In the midst of both primary care provider and nursing shortages, state regulations

continue to restrict the practice of nurse practitioners (NP). Milstead asserts the quest for

autonomy in advanced practice nursing is “one of many political and legislative concerns faced

by nurse practitioners” (2008, p.42). This paper examines a policy restricting the practice of NPs

in Alabama and the effects of the policy on the health of the state’s residents. The identified

model used to critique the policy will be described and recommendations will be discussed.

       Policy 34-21-84 refers to the section of the Nurse Practice Act for the Alabama Board of

Nursing (ABN) designating the joint committee to recommend rules and regulations for

advanced practice. The policy maintains certified registered nurse practitioner (CRNP) or a

certified nurse midwife (CNM) in Alabama may not practice medicine unless that person

possesses a certificate of qualification issued by the Board of Nursing and practices as indicated

by written protocols approved by the State Board of Medical Examiners and the Board of

Nursing. Furthermore, the CRNP and CNM must have an agreement with these protocols signed

by a qualified collaborating physician or physicians (Alabama Board of Nursing, 1975).

       Infirmities and mortalities in this state are among the highest in the nation. Health care

disparities in Alabama are directly affected by practice restrictions placed on nurse practitioners.

According to the Alabama Department of Public Health (2006), sixty-two of Alabama’s counties

are now designated as shortage areas for primary care physicians. An additional 180 primary

care physicians would be required to eliminate the provider shortage designations for

underserved residents (Alabama Department of Public Health 2006).

        The ADPH also cites Alabama ranks fourth in the nation for deaths due to heart disease.

The report found a relationship between the infant mortality rate and the teen pregnancy rate.

Teen pregnancies and births to teenage mothers in Alabama have risen within the past two years.
Running Head: HEALTH POLICY CRITIQUE                                                                   3

On average 21.7 births per day in Alabama are to teenage mothers. Infant mortality in the state is

9.3 infant deaths per 1,000 live births. Sexually transmittable diseases in the state are ranked as

some of the highest in the nation. Alabama’s rates of early syphilis ranked second nationwide

with gonorrhea and chlamydia ranking fourth (2006).

       The Schneider and Ingram Model, an appropriate analytical model to critic Alabama’s

policy, suggests that “social constructions” are just as influential as well-substantiated rationale

in establishing the policy agenda. Furthermore, social constructions that become embedded in

public policy are then communicated to the electorate and substantial affect their political

affiliation and participation (1993). According to Schneider and Ingram the theory of social

constructions— “stereotypes about particular groups of people that have been created by politics,

culture, socialization, history, the media, literature, religion, and the like”—is used to explain

why some groups possess more political power than others and how enacted policy reflects the

influences of the groups in power at the time (1993). For example, those groups in power—those

who have positive social constructions, such as “honesty” and “integrity”—will have possess

more political power because of their positive social constructions, and thus, find it relatively

easy to pass their legislative agenda. For groups that have the resources to shape their own

constructions, they will have no problem portraying positive social constructions and will be able

combat any attempt to label them with negative constructions. Thus, financially resourceful

groups will have little hindrance enacting their legislative agenda because they will be able to

target new groups or form alliances with old groups because of their ability to create positive

social constructions (Schneider & Ingram, 1993). Accordingly, groups without the resources will

be stigmatized during the policy process and will not be able to mobilize the citizenship with

positive constructions. Therefore, they will face a great challenge in enacting their legislative
Running Head: HEALTH POLICY CRITIQUE                                                              4

agenda (1993). According to Schneider and Ingram, “Social constructions enhance their power,

whereas it detracts from the power of the disadvantaged groups.” (1993). Because of this

whimsical dynamic, policies are not technically illogical simply because of political power

considerations (1993). Therefore, social constructions must be used to determine which policies

are sound and which are illogical (Schneider & Ingram,1993)

       Senate Bill 483, drafted by the Nurse Practitioner Alliance of Alabama (NPAA), was

introduced to the Alabama Senate Health Committee (SHC) in the February 2009 session. This

bill would have granted the practice of nursing certified registered nurse practitioners (CRNP)

and certified registered nurse midwives (CNM) to be regulated only by the Board of Nursing,

thereby abolishing collaborative practice with a physician. Additionally the bill would have

authorized CRNPs and CNMs to prescribe controlled drugs in Schedules III through V (Nurse

Practitioner Alliance of Alabama, 2009). The bill never made it out of the committee and

subsequently died. At the same session the Medical Association of the State of Alabama

(MASA) and Alabama Physician Assistant (PA) supported bill granting PAs the authority to

prescribe Controlled Substances Schedule III-V drugs under the supervision of a physician was

introduced. The bill was signed into law in May 2009 (Medical Association of the State of

Alabama, 2009).

       In applying the Schneider and Ingram model to this policy both MASA and the NPs are

positively viewed targets. This author assumes MASA, having more power than the NPs, used

their influence to also introduce a bill granting more privileges to PAs. The NPs, having less

power could appear overzealous and avaricious in requesting more freedoms than those being

proposed by the more powerful population for their interest group.
Running Head: HEALTH POLICY CRITIQUE                                                                5

       Plummets in the present economy are causing a rise in the number of uninsured persons

(Pearson, 2008). Policies in states lagging behind on health care need to be revisited to benefit

the patient. Lugo, O’Grady, Hodnick, and Hanson conducted a study and ranked states by

consumer choice (2007). Alabama ranked 51 while, on the opposite end of the spectrum, Arizona

ranked number one (2007). The Pearson Report (2008) was used to compare legislation between

the two states. Alabama’s NPs are regulated by a joint committee of the Board of Nursing (BoN)

and the Board of Medical Examiners (BoME). The NP is required to have a collaborating

physician in order to practice. The practice is governed by written protocols. Employees of the

BoME inspect collaborative physician sites to ensure compliance. Also noted in the report is PAs

are not subject to these inspections. The NP may prescribe medications as written in the

individual protocol but they are not authorized to prescribe controlled substances. To the

contrary, Arizona NPs are solely governed by the BoN and may practice independently. They

also have full prescriptive privileges and are authorized to prescribe schedule II-V drugs

(Pearson, 2007).

       Milstead contends progress in policies reaching the formal agenda are likely to depend on

how congress views the target population (2008, p61). An integral part of the solution is to

educate lawmakers with regard to the positive impact policy would have on the voters in their

district. Politicians need to be enlightened on the educational requirements as well as the NP’s

scope of practice. This author had personal conversation with her districts legislators. Of the

three, only one was vaguely familiar with the designation of NPs as health care providers. As

individuals, NPs must take a proactive approach for our profession in addition to being abreast of

current issues and trends in healthcare. Awareness of where NPs stand in political issues and
Running Head: HEALTH POLICY CRITIQUE                                                         6

becoming active in professional organizations is paramount. We must approach our lawmakers

armed with the evidence that policy change is necessary.
Running Head: HEALTH POLICY CRITIQUE                                                               7


Alabama Board of Nursing (1975). Statutory authority: Code of Alabama. Retrieved September

       11, 2009 from

Alabama Department of Public Health (2006). Alabama Center for Vital Statistics. Retrieved

       September 8, 2009 from h HealthStatistics/


Ingram, H. and Schneider, A. (1993). Social construction of target populations: implications for

       politics and policy. American Political Science Review 87 (2):334-347.

Medical Association of the State of Alabama (2009). PA prescriptive bill becomes law.

       Retrieved September 9, 2009 from


Milstead, J (2008).Health policy and politics: a nurse’s guide. Sudberry, Massachusetts: Jones

       and Bartlett Publishers.

Nurse Practitioner Alliance of Alabama (2009). Nurse Practitioner and Nurse Midwife

       Legislation for 2009 Session. Retrieved September 11, 2009 from: http://enp-

Pearson, L. (2008). The Pearson Report. The American Journal for Nurse Practitioners12 (2),


Lugo, N., O’Grady, E., Hodnicki, D., Hanson, C. (2007). Ranking state regulation: practice

       environment and consumer healthcare choice. The American Journal for Nurse

       Practitioners 11(4), 8-23.

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