CASE STUDY 2-3: The Veterans Health Administration Ruling on APRN Practice

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CASE STUDY 2-3: The Veterans Health Administration Ruling on APRN Practice

CASE STUDY 2-3: The Veterans Health Administration Ruling on APRN Practice
CASE STUDY 2-3: The Veterans Health Administration Ruling on APRN Practice

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CASE STUDY 2-3: The Veterans Health Administration Ruling on APRN Practice In December 2016, the U.S. Department of Veterans Affairs (VA) announced its final rule regarding APRN practice within the Veterans Health Administration national health system. The decision allows nurse practitioners, certified nurse–midwives, and clinical nurse specialists to practice without physician supervision. This change will facilitate broader access to health care within the VA system (American Association of Colleges of Nursing [AACN], 2016). During 2016, nurses nationally were encouraged to post advocacy messages to the appropriate webpage (https:// for changing such rules and regulations. This use of the media was an example of promoting advocacy by the four professional associations representing APRNs, the American Nurses Association, and other nursing groups at national and state levels. By the time the Final Rule was released in May 2016, more than 179,734 comments had been posted (J. Thew, personal communication, 2017). This large number of comments reflects advocacy behaviors of nurses.

CASE STUDY 2-4: The National Center for Nursing Research Amendment A classic example of agenda setting was the initiation of federal legislation in 1983 that increased the funding base for nursing research. An amendment to the 1985 Health Research Extension Act, which created the National Center for Nursing Research (NCNR) on the campus of the National Institutes of Health (NIH), was the focus of this national example of agenda setting.

Creation of the NCNR came about because a group of nurse leaders wanted to create a national institute of nursing within the NIH. To help pass the legislation in 1985, a political compromise was made with congressional legislators to create a center instead of an institute (a lesser agency in the hierarchy). In 1993, however, the NCNR was turned into an institute, and today the agency continues as the National Institute of Nursing Research (NINR). The discussion here regarding the NCNR amendment focuses on the agenda setting and policy formulation that occurred from 1983 to 1985. Achievement in getting the NINR funded was an especially notable accomplishment because no other health profession has such an institute.

The Influence of National Nurse Groups The creation of the National Center for Nursing Research on the campus of the National Institutes of Health in Bethesda, Maryland, was a policy victory for national nurse organizations. Although nurses’ groups traditionally have not been considered strong political actors, these groups recognized the importance of political activity to bring about public policies that enhanced patient care (Warner, 2003). In the last decade of the 20th century, nurse groups were just emerging as actors in policy networks; however, “a full cadre of nurse leaders who are knowledgeable and experienced in the public arena, who fully understand the design of public policy, and who are conversant with consumer, business and provider groups [did] not yet exist” (DeBack, 1990, p. 69). In a study of national health organizations that play a key role in the health policymaking area (Laumann, Heinz, Nelson, & Salisbury, 1991), no nurse organizations were cited. APRNs are well aware of this absence because state legislative and regulatory activity affects their professional practice on a daily basis.

Research on the NCNR amendment has been important because it studied political actors who were not generally studied (e.g., nurse interest groups); this research contributes to public policy scholars’ knowledge of all actors in policy networks. Laumann et al. (1991) acknowledged that “we may even run a risk of misrepresenting the sorts of actors who come to be influential in policy deliberation” (p. 67). The significance of policy research becomes obvious when the Schneider and Ingram (1993a) model of social construction of target populations in policy design is applied to nurse interest groups. For example, how nurses were viewed by policymakers—the social construction of nurses as a target population—influenced not only the policy in which nurses were interested but also the passage of the total NIH reauthorization bill.

Dohler (1991) compared health policy actors in the United States, Great Britain, and Germany and found that it is much easier to have new political actors in the United States because there are multiple ways to become involved. Dohler has written of the great increase in new actors since 1970. Baumgartner and Jones (1993) also described multiple paths of access to becoming involved.

▸ Overview of Models and Dimensions Several researchers have developed models of agenda setting and policy formulation (Baumgartner & Jones, 1993; Cobb & Elder, 1983), alternative formulation, and policy design (Schneider & Ingram, 1993a). Data analysis reveals the importance of the Schneider and Ingram (1993a) model of the social construction of target populations and of the classic Kingdon (1995) model for an understanding of the agenda-setting process for the amendment described in Case Study 2-4 to the NIH-reauthorizing legislative bill. Analysis of this legislation over the period of a decade also underscores the importance of Dryzek’s (1983) classic definition of policy design. An analysis of the legislation supported the importance of study- ing the contextual dimension that has been advocated by Bobrow and Dryzek (1987), Bosso (1992a), DeLeon (1988–1989), Ingraham and White (1988–1989), May (1991), and Schneider and Ingram (1993b). The value of other models— institutional, representational communities and an institutional approach, and the congressional motivational model—is addressed as well, as these models contribute to an understanding of this example. These findings are discussed in detail in this analysis. For example, during the study of interest groups opposed to this legislation, this researcher noted two occurrences of an iron triangle in the early 1980s, in which legislators and their staff and agency bureaucrats worked with interested parties to resolve issues (FIGURE 2-2).

Kingdon Model One model that served as an explanatory focus for this research was the Kingdon (1995) model, which explains how issues get on the political agenda and, once there, how alternative solutions are devised (FIGURE 2-3). The four important

Overview of Models and Dimensions 23