December 2002 TN Nurse Feature Article – Tennessee Nurses Association

Health Policy: A Critical Call for Nursing Involvement

By Joan Thomas, PhD, RN, APRN, BC

In July 1996, Tennessee implemented a managed behavioral health program called TennCare Partners. This publicly funded experiment in behavioral health care started chaotically and soon became a debacle. Many people with mental illnesses and/or chemical dependency disorders did not receive care or lost continuity of care. The traditional “safety net” behavioral health care system rapidly deteriorated (Chang, 1998). “No other state should try and replicate this (TennCare Partners) model. It is a prescription for failure,” said Dr. William Applegate, former chairman of the University of Tennessee Preventative Medicine Department (Powers, 1998). Had TennCare Partners received greater input from nurses during its development, many of its design flaws would likely have been decreased.

A report released by Tennessee state auditors in March 2001 indicated that more mentally ill Tennesseans are being hospitalized or jailed because they lack sufficient treatment options due to TennCare Partners not working properly. The auditors’ report stated the conceptual idea underlying the TennCare Partners program was to decrease hospitalization by enhancing community based services. However, the increased community services failed to materialize. Without the community based services and treatment programs, mentally ill individuals had increased difficulties with law enforcement resulting in more individuals with mental illness entering Tennessee jails (Downing, 2001).

A survey of Tennessee county jails in 1998 found 1,890 inmates in pretrial custody with some form of mental illness. The increased number of mentally ill in jails is due to Tennessee lacking both community mental health services as well as a statewide diversion plan for the mentally ill. Furthermore, according to the auditors’ report, there is a lack of TennCare coverage for discharged jail inmates due to TennCare’s rule of not providing coverage to people convicted of crimes. Therefore, reapplication for TennCare coverage must occur upon an inmate’s release from jail, but the reapplication process may take several months to complete. During this time period, the former inmate is not receiving treatment and frequently returns to jail as a result of committing another crime, which may have a direct or indirect relationship to their mental illness. (Downing, 2001).

Not only has TennCare Partners resulted in an influx of the mentally ill into the jail system, but also many mentally ill have come to comprise the homeless population. Approximately 20-25% of the single adult homeless population has been diagnosed with some form of severe and persistent mental illness. Despite the large proportion of mentally ill adults among the homeless population, the increase in homelessness is not attributable to the discharge of mentally ill people from institutions.

Most mentally ill people were released from the institutions in the 1950s and 1960s, however, increases in homelessness did not occur until the 1980s. It was during this time that income and housing options for many Americans began to decrease. The advent of TennCare Partners and its denial of services or premature and unplanned discharge from treatment facilities have probably resulted in the increasing presence of the severely and persistently mentally ill patient population among the homeless (National Coalition for the Homeless, 1999).

The suffering of the mentally ill and their families that resulted from the TennCare Partners debacle is a wake-up call for nursing to become increasingly involved in health policy development. “Envision how things would be if the voice and visibility of nursing were commensurate with the size and importance of nursing in health care.” (Buresh & Gordon, 2000, p. 11). As a matter of fact, nursing is by far the largest health care profession. In this country, nurses outnumber physicians more than three to one with some 2,161,700 registered nurses employed in nursing during 1996. If only 10 percent of nurses actively sought involvement in health policy matters, that would mean conscious activism by 250,000 nurses in the US. (Buresh & Gordon, 2000). Can you imagine nursing’s ability to impact the current public mental health crisis?

The Gallup poll in 1999 indicated that the American public viewed nursing as the nation’s most honest and ethical profession. The unfortunate paradox is that Americans hold nurses in the highest regard, but have little knowledge regarding what nurses actually do. The general public is not the only group lacking knowledge about nursing. Journalists report that information about nursing rarely comes their way. While medical researchers are usually called upon to discuss the implications of their work, nurses are rarely asked to express an informed opinion. Reluctance to make their voices heard is especially unfortunate during this time when journalists are demonstrating an increasing willingness to pay attention to nurses. Journalists covering health care have airtime and print space to fill. Journalists need good stories from strong, reliable sources. In short, journalists need nursing’s stories. But where are they? (Buresh & Gordon, 2000)

If journalists find nurses difficult to access, it is reasonable to assume that health policy makers experience the same reluctance on the part of nurses to influence health policy decisions. This resistance to participating in the health policy formulation process is especially unfortunate during this time when the federal government is actively seeking nursing input in improving health care quality. For example, nurses have been given a key role in the research agenda of the federal Agency for Healthcare Research and Quality. Nursing’s involvement is being sought by this federal agency in the areas of quality of care, outcomes research, primary care, and translation of research into practice (AHRQ Research activities, 2001). All of these areas of nursing research directly influence health policy.

On the individual level, what can you do to “tell the world what you do”? Buresh & Gordon (2000) put forth several directives to make your nursing voice known.

First, introduce yourself to patients, family members, other health care professionals, and any person involved in health policy decision making with your first and last names and credentials as a registered nurse. Your introduction “is an important moment that has lasting consequences for you as an individual professional and for nursing as a whole” (Buresh & Gordon, 2000, p. 50). Your introduction lets people know you are a nurse and therefore, a serious professional with valuable experience and knowledge (Buresh & Gordon, 2000).

Second, adopt a style of dress that encourages others to treat you professionally. Clothing with teddy bears, hearts, flowers, and smiley faces may tell patients they have no reason to fear you but it also suggests that you, the nurse, should not be taken seriously. Lab coats and solid-color scrubs with a name-pin that gives your full name and credentials can clearly identify you as the professional nurse.

Third, in discussions with patients and their families, the media, and health policy decision makers, describe the complexity of the work you do and the clinical/scholarly judgments you make. Nurses rarely acknowledge relying on their own knowledge and judgment. Therefore, the public views nursing as simply following the doctor’s orders (Buresh & Gordon, 2000).

Fourth, prepare a minimum of three anecdotes about your work. People can better comprehend the challenges and complexity of nursing through the stories nurses tell about their work. Story telling allows listeners to enter into the world of nursing and comprehend its importance. When developing your anecdotes, make them come alive with rich detail while also avoiding professional jargon (Buresh & Gordon, 2000).

Fifth, be aware of the patient confidentiality issue, but do not allow it to silence you about nursing. Patient privacy and confidentiality need not be violated by nurses making their work with patients known. The issue of confidentiality can be successfully managed by changing details that might reveal the identity of patients or by describing a general group of patients and avoiding the details of a particular patient. When describing a specific patient situation, you can make it known that some facts have been altered for the purpose of confidentiality, but that the essence of the story is unchanged. Some nurses have expressed concern that talking about their work will result in an exploitation of their patients. In fact the opposite is true. It is critical to describe the work of nursing and how essential nursing is to quality health care (Buresh & Gordon, 2000).

Sixth, appearing engaged or emotional when describing your nursing experiences enhances your stories. Allow your enthusiasm and commitment to nursing to be reflected in both your body language and voice. Furthermore, when discussing health policy issues that require change, do not resist expressing moral outrage. As long as you are not out of control or blatantly offensive, expressing profound concern is appropriate and justified (Buresh & Gordon, 2000). Remember, as a nurse you are “on the front line” of health care and any concerns you express to policy makers are likely to make a significant impression.

Finally, many nurses have expressed fear that they will make mistakes when discussing nursing and professional issues. They are concerned about being misinterpreted or generating anger and controversy. In this situation, nurses must think realistically. Errors in your discussion content can be rectified. Many issues are debatable as opposed to being absolutely right or wrong. It is totally acceptable to convey to individuals and groups that your information represents your perspective as a nurse. Others may disagree, but that does not mean your perspective is “wrong.” Furthermore, remember that no matter how much knowledge you gather, no person has perfect knowledge. In other words, you will never be guaranteed that you or anyone else will not make a mistake. If you are waiting until you have all information and knowledge about nursing and important health policy issues before you speak out, you will remain forever silent (Buresh & Golden, 2000).

Returning to the issue of the TennCare Partners debacle and the crisis in mental health care that ensued, what can we as nurses do now? The following is a list of activist options for professional nurses and their organizations.

1. Educate yourself as much as possible about TennCare Partners and the state mental health crisis. Newspapers, journals, Internet Web sites and psychiatric nurses are good sources of information. However, remember you do not need “perfect” knowledge in order to speak out on this or other issues.

2. Become involved in the Tennessee Nurses Association (TNA) and make the TennCare Partners issue an agenda item. Remember, all patients have mental health and/or psychosocial concerns and therefore, this issue impacts all involved in the health care system.

3. With TNA membership comes automatic opportunity to become active in the American Nurses Association (ANA), the organization whose primary mission includes establishing the political and legislative agenda for nursing (Cramer, 2002). Becoming involved in the ANA can also enhance your opportunity to advocate for the mentally ill population.

4. Join your local chapter of the National Alliance for Mentally Ill (NAMI). This is an excellent advocacy organization with a wide array of resources that will enhance your grasp of this issue. Also, NAMI provides numerous opportunities to make your voice heard with policy makers in matters related to mental health care.

5. Register to vote and vote in every election. Voting alone, however, is not enough. Become an informed voter by reading the newspaper, legislative newsletters, and studying policy makers’ voting records on mental health issues (Cherry & Jacob, 1999).

6. Work in the political campaigns of candidates who support strengthening the state’s response to its mentally ill population. Participating in political campaigns will provide opportunity to further educate and inform the candidates regarding mental health issues (Cherry & Jacob, 1999).

7. Attend “Meet the Candidates” town hall meetings and make your concern about TennCare Partners known. Ask questions to determine the candidates’ position on TennCare issues (Cherry & Jacob, 1999).

8. Visit lawmakers and communicate your concerns about the state’s treatment of its mentally ill population. Nothing is more effective in communicating your position than personal contact between a policy maker and a well-informed nurse(s). Most lawmakers desire information that will help them plan for future health care policy (Cherry & Jacob, 1999).

9. Writing letters to lawmakers can be an effective if timed properly. Letters should be written before the legislator has committed to a particular position. It is easier to persuade an uncommitted lawmaker than it is to change a lawmaker’s decision once a public position has been taken (Cherry & Jacob, 1999).

10. Telephoning health policy makers is a useful technique when time is critical and you desire to make you opinion known about a particular piece of legislation. However, it is not an effective method of educating a legislator about an issue (Cherry & Jacob, 1999).

If ever a time for nursing’s involvement in health policy decisions existed, it is now. Since July 1, 2002, TennCare has been requiring its enrollees to go through “redetermination” to find out if they are eligible to remain enrolled in TennCare. Current TennCare enrollees with access to private insurance will no longer remain eligible for TennCare. On the face of it, that may appear reasonable. However, having access to insurance is not the same as having access to affordable insurance. Therein lies the problem. Thousands of Tennesseans will lose their TennCare eligibility due to having access to insurance but few will be able to afford it. The numbers of uninsured people will soar, resulting in an ever-increasing health care crisis for Tennesseans and Tennessee’s healthcare providers.

References

AHRQ Research Activities. (2002). Nurses have important role in improving health care, AHRQ Research Activities, June 2001 (No. 250). Silver Springs, MD: Author.

Buresh, B., & Gordon, S. (2000). From silence to voice: What nurses know and must communicate to the public. Ottawa: Canadian Nurses Association.

Chang, C. F., Kiser, L. J., Bailey, J. E., Martins, M., Gibson, W. C., Shaberg, K. A., et al. (1998). Tennessee’s failed managed care program for mental health and substance abuse services. Journal of the American Medical Association, 279, 864-869.

Cherry, B., & Jacob, S. R. (2001). Contemporary nursing: Issues, trends, & management. St. Louis: Mosby.

Cramer, M. E. (2002). Factors influencing organized political participation in nursing. Policy, Politics, & Nursing Practice, 3, 97-107.

Downing, S. (2001, March 26). Mentally ill jailed for lack of care: State audit says TennCare plan hasn’t worked. The Commercial Appeal: B1-2.

National Coalition for the Homeless. (1999, April). Mental illness and homelessness. Retrieved November 4, 2002, from http://ww.national homeless.org/mental.html

Powers, M. (1998, March 18). TennCare Partners flawed, study says: Program’s design blamed for managed care crisis. The Commercial Appeal: A1.

Joan Thomas PhD, RN, APRN, BC is an assistant professor at the Loewenberg School of Nursing, University of Memphis, where she teaches psychiatric nursing and nursing research. Thomas, an ANCC certified Clinical Nurse Specialist in Adult Psychiatric and Mental Health Nursing, has published in the area of health policy.