AN EXAMINATION OF FACTORS INFLUENCING DEVELOPMENT

OF HEALTH CARE POLICY AND PROGRAMS IN A

STATE HEALTH DEPARTMENT

by

Urla Jeane Maxfield

A thesis submitted to the faculty of The University of Utah

in partial fulfillment of the requirements for the degree of

Master of Science

College of Nursing

The University of Utah

August 1984

THE UNIVERSITY OF UTAH GRADUATE SCHOOL

SUPERVISORY COMMITTEE APPROVAL

of a thesis submitted by

Urla Jeane Maxfield

This thesis has beel! read by each member of the following supervisory committee and by majority vote has been found to be satisfactory.

Chairman:verla B. Collins, Ph.D.

dC � A.E. Rothermick, Ph.D.

THE U;\IIVERSlTY OF UTAH GRADUATE SCHOOL

FINAL READING APPROVAL

To the Graduate Council of The University of Utah:

I have read the thesis of Urla Jeane Maxfield in its

final form and have found that (I) its format. citations. and bibliographic style are

consistent and acceptable; (2) its illustrative materials including figures. tables. and

charts are in place; and (3) the final manuscript is satisfactory to the Supervisory

Committee and is ready for submission to the Graduate School.

Verla B. Collins

A�a;� Linda K. Amos

Ch:lIrm:Jn De:Jn

Approved for the Graduate Council

Copyright @ 1984 Urla Jeane Maxfield

All Rights Reserved

ABSTRACT

This research examined the comparative perceptions

of professional nurses and a selected group of other

health care professionals relative to the importance of

key factors identified as influencing development and

implementation of health care policy and programs. Any

differences in perception could be significant and

influence choices made among alternatives during the

process of making decisions. With the change of empha­

sis of the current administration in Washington and

shift of responsibility to the states, health program

policy and planning becomes a provocative issue. Maxi­

mization'of resources through deliberate planning efforts

is essential as is utilization of professional judgment

and expertise of a broad range of health care profes­

sionals. The extent of nurses' involvement in this

process is unknown but crucial because of the patient

advocacy perspective nurses have that few others in­

volved in health care policy decision making demonstrate.

The effort to show nurses to be equally knowledgeable

and comparable to other health care professionals in

considering the importance of key factors influencing

health care policy development should serve as a consid-

eration to further the involvement of nurses in this

vital health care process.

v

CONTENTS

ABSTRACT . . .

LIST OF TABLES

ACKNOWLEDGMENTS.

Chapter

I . INTRODUCTION.

Problem . . . . . Problem Statement . Purpose . . . . Definitions . . . . .

II. LITERATURE REVIEW.

III. METHODOLOGY . . . . .

iv

vii

viii

1

13 16 16 17

20

53

Sample and Setting. . . . . . . . . 54 Ins t r urn en t. . . . . . . . . .. .... 5 7 Pilot Test. . . . . . . . . .. 58 Method. .. .............. 60

IV. FINDINGS AND DATA ANALYSIS ..

V. DISCUSSION ...

Implications. . Limitations . Recommendations for Future Research .

Appendices

61

73

78 79 80

A. QUESTIONNAIRE - PILOT TEST FORMAT . . . .. 83 B. PARTICIPANT DEMOGRAPHIC INFORMATION . . 98 C. QUESTIONNAIRE - DATA COLLECTION FORMAT. .. 100 D. RELATIONSHIP OF KEY FACTORS TO

STATEMENTS 108

SELECTED BIBLIOGRAPHY. 110

LIST OF TABLES

1 . Profile of Participants .. 62

2. Length of Time Employed at utah Department of Health. . . . . . . . . . . . . . . . . . . .. 64

3. Length of Time With Present Job Responsibility. 64

4. Participants Included in the Survey. . . 66

5. Comparison of Key Factor Mean Scores . 68

6. Ranking of The Key Factors by Total Mean Score. 70

ACKNOWLEDGMENTS

I am indebted to many people for their support and

contribution to development and completion of this pro­

ject. A few of them deserve special acknowledgment.

My sincere appreciation is extended to Dr~ Verla B.

Collins. Her advice and encouragement kept me committed

to completing this project.

I also wish to thank the other members of my super­

visory committee, Dr. G. Manny Gunne whose suggestions

and editorial assistance have been exceptional, and

Dr. A. E. Rothermich.

Special appreciation is extended to Dr. John

Sullivan for his assistance in developing the survey

questionnaire used to collect data, and for his assis­

tance in analyzing the data and discussing the various

ways it could be presented.

CHAPTER I

INTRODUCTION

Contemporary health care is both a major industry

and a public institution, a product of changing techno­

logy and narrowing specialization. It is also increas­

ingly shaped by government intervention and official

control fostered by the current federal fiscal crisis

and changing federal priorities. Continued change in

health care policy and programs seems fairly certain at

this point. In his discussion of the issues, Kohlert

(1982) emphasized that the "rate of change in the health

care industry is greater and is accelerating at a more

rapid pace than at any time since early 1900" (p. 68).

Health care was originally believed to be the

responsibility of individuals or organizations in the

private sector. Furthermore, through the years, develop­

ment of health care policy in the united States has

neither been planned nor directed toward any long-term

solutions. Health-related programs have developed

reactively in response to erratic phenomena and short

term needs. The advent of government programs and

changes in the administrative philosophy in Washington

have contributed to an awareness of the need for a more

rational approach to health care planning. Yesterday's

solutions do not meet the needs of today's health care

recipients.

Health care planning efforts and the participants

in planning have changed through the years. The current

emphasis in health care can be partially understood by

looking at the relationships between national policy,

social settings and their impact on hospitals and health

care through the years. In the 1940s, the emphasis was

on voluntary efforts at planning. The participants in

planning at that time were hospital trustees, business

leaders, and physicians. Financial contributions were

solicited from business and industry to support the pro­

vision of health care in the community.

2

The Hill-Burton program of 1946 brought the begin­

ning of federal intervention and external control to

hospital construction. The Hill-Burton act provided

monies for construction or expansion of community hos­

pitals. The Hill-Burton formula estimated bed need by

state and community and then allocated construction funds

accordingly.

established.

As a result, thousands of beds were

One condition of the Hill-Burton grants

was assurance that a specified percentage of indigent

patients would be treated free of charge. Guaranteed

access to care was initiated, and there was a dramatic

increase in the amount of care provided in hospital

settings. Expansion in the health care industry had

begun. Increased length of stay, coupled with increased

utilization, added emphasis to the need for expansion

of facilities and purchase of more sophisticated equip­

ment. Hospital administrators and physicians joined the

trustees and business leaders in planning efforts.

Later, President Johnson's Great Society movement

3

of the 1960s mandated consumer participation, and compre­

hensive health planning was established. The initial

emphasis at that time was on developing new services and

avoiding duplication. "Guaranteed access" continued as

part of our national policy. Needs of a rising number

of elderly became evident, due in part, according to

Spitzer and Grace (1981), to erosion of the extended

family and a shift to hospitals of the responsibility

for care of the elderly and the chronically ill. In

response to these needs, Medicare (Title 18) of the

Social Security Act was passed in 1966 to provide care

for those over 65 years of age. In 1968, additional

legislation provided for state programs with federal

support to provide health care for the poor and needy.

Medicaid (Title 19) provided increased utilization of

health care services when costs were already rising.

Cost containment became an issue toward the end of the

1960s, and closing of surplus facilities and services

also became a concern. Spitzer and Grace (1981) further

noted that cost containment is a "social force" result­

ing from earlier policy emphasis on expansion of hos­

pitals, emphasis on in-hospital care, changes in the

acuity level of the illness being treated, and the

growing number of elderly who become dependent on public

programs.

National health care policy in the 1970s continued

to emphasize cost containment. Health Systems Agencies

(HSAs) developed in response to the National Health

Planning and Development Act of 1974. The basic goals

of the HSAs, according to Rorie and Dearman (1980), were

achievement of better access to health care and improved

utilization of available resources with cost as an

overriding concern. These goals were to be achieved

by developing less costly alternatives to care which

would also gain Third Party Liability (TPL) reimburse­

ment, promotion of healthier lifestyles and safe

environments, development of community alternatives for

the elderly, and increased access to primary care,

especially for rural underserved areas or for economi­

cally deprived populations. "Certificate of Need" laws

were implemented to control proliferation of health care

facilities and duplication of costly equipment. Rate

commissions developed in some states for the specific

purpose of containing spiraling health care costs. Ulin

4

(1982) notes that consumers continued to be the major

participants in planning and decision making by mandate

of the Health Planning and Resources Development Act of

1974. In the late 1970s, hospitals and commercial

insurance companies began to see the need for becoming

involved in HSA planning activities.

The federal government has played a continuing role

in providing funding for health care since the mid-1940s.

Health care reforms now being developed by the Depart­

ment of Health and Human services place emphasis on

control of health care expenditures in the federal bud­

get, relaxing of federal regulation and controls,

legislative proposals to introduce competition into the

health care industry, and increased emphasis on disease

prevention and health promotion. The 1980s, again

according to Spitzer and Grace (198l), emphasize health

care policy which continues to stress cost containment

made effective through planning, implementation, and

evaluation.

The key questions become: What will be the locus

of planning, and who will be the participants in the

future? It appears that there will have to be some

continuing program to provide health care to those in

need. Health and social issues are basic to the human

welfare of all people. However, priorities for dealing

with these issues may be very different in separate

5

states and localities. Policies will reflect consumer

demands, the available resources, the local conditions,

and the institutions available to deal with the issues.

Ultimately, "we must recognize that Ipeople carel needs

can be almost infinite, and the resources from which

they can be met remain finite" (Snoke, 1982, p. 1029).

Some type of regulation must exist. In the face of

competition, deregulation free market incentives,

decreased federal funding, continued emphasis on cost

containment, and shifts in responsibility to the states,

there seems to be an even greater need to maximize

resources through policy decisions and planning based on

professional judgment and effort by those with expertise

in the health care field. Effective delivery of health

care must be provided through planning, quality control

measures, and modification of systems for providing

and charging fairly for health care services. Health

planning and policy development seem extremely critical

at this point in order to manage the growing complexity

and increased costs of health care.

6

Aiken (1981) asserts that there must be some changes

developed in the organization and management of health

care in order to deal with that growing complexity of

health care issues. Following the years which emphasized

expansion in health care, the present task is priority

setting and cost containment. The challenge is to

develop innovations which will utilize reduced resources

to the benefit of the majority of consumers. Aiken

(1981) further notes that change is not easy, "especially

when it challenges traditional assumptions and vested

interests" (p. xvi). Utilization of objective data

when managing limited resources becomes essential.

Uncertainty, according to Snoke (1982), marks the current

effort to provide for those in need of health care.

Even in the private sector, third party reimbursement

agencies are facing the same dilemma as public agencies

in establishing policies for financing health care.

Snoke (1982) further indicates that the uncertainty is

complicated by not knowing the role the federal govern­

ment and states will play in regulation and reimbursement

of health care. However, Slavin (1982) point~ out that

"it is apparent the Federal Government no longer chooses

to participate financially in local health planning"

(p. 35). Slavin (1982) cites the planned phase out of

Health Systems Agencies as one point of evidence, the

policy emphasis of the Reagan Administration on cost

containment for the Medicare and Medicaid programs as a

second point of evidence, and emphasis on competition,

deregulation and free market incentives as a third point

of emphasis.

Providing responsibly and humanely for the poor may

become a sensitive and stressful issue against a back-

7

8

drop of the federal fiscal exigency, changing federal

priorities, and a deepening national economic crisis.

Rogers, Blendon and Moloney (1982) indicate that Medicaid

has long been recognized as the public sector health

program that pays for the medical care of many of the

nation's poor. Whatever the inadequacies of the Medi­

caid program are perceived to be, it has played a very

important, conscientious role in our society in the 17

years since Medicare and Medicaid programs were signed

into law.

As pressures mount to reduce federal and state

expenditures, it is inevitable that Medicaid will suffer

cuts to some degree. Those responsible for policy

decisions and planning for public sector health programs

face an impressive challenge. Planning for the pro­

vision of vital medical services to the poor who need

them will necessitate time, research, and the active

participation of a broad range of professionals in the

health care field to develop policy and discriminating

ways of organizing and changing some of the current

arrangements for providing health care to the poor while

using substantially fewer resources. The regulatory

approach to health care policy is being questioned while

incentive-based proposals are gaining recognition.

Models designed to change the incentive structure in the

delivery and financing of health care which also encour-

age providers and recipients to be cost conscious par­

ticipants in the health care system are very essential

to future programs.

9

Ulin noted in her discussion of the international

nursing challenge, "Resources alone will not bring health

to people," (1982, p. 534). Wealth alone cannot

determine the health status of a population, but organi­

zation and distribution of resources is a vital factor.

Ulin (1982) further noted that accessibility of health

care is determined by availability, convenience, and

affordability. Contemporary debate tends to focus on

cost and cost containment as a paramount issue according

to Morgan (1981) and Vladeck (1981). Aiken (1981) is

quoted as stating that "the single most important con­

cern to health policy makers in 1980 is the cost of

health care" (p. 4). The literature does support cost

and cost containment in health care as a leading issue.

Other issues also have a great deal of significance

in health care policy development. Brandt (1982)

reported that the Department of Health and Human Services

published the Surgeon General's report on Health Pro­

motion and Disease Prevention in 1979 and "announced

that 'prevention' had been accorded top billing in

federal health policy •.. " (p. 1040). The report advances

quantified goals relative to health promotion and

disease prevention that "we ought to be able to achieve

10

by 1990" (p. 1040).

McManis warned the forum of the American Asso-

ciation for Hospital Planners that "quality assurance

will surpass cost containment as the nation's major

health issue by 1990" (A.H.A. Convention Briefs, 1983,

p. 40). Abdellah (1975), Crow (1981), Aday and Anderson

(1981), and Donabedian, Wheeler and Wyszewianski (1982)

all addressed the quality issue. Quality assurance

will undoubtedly be receiving increased attention in

the literature, in policy, and in practice in the next

few years.

The trend in health care policy for the 1980s and

early 1990s appears to be set. Given (1979) summarized

it very well:

Policy decisions during the 1980s will continue to be directed toward containing costs, improving the distribution and utilization of manpower resources, and improving accountability •.. At present, it appears that the primary focus of these decisions will be programs that emphasize the prevention of illness, health maintenance services, and appro­priate access to primary care services (p. 24).

Quality assurance added to Given's summary estab-

lishes the key factors and the challenge to be considered

by planners concerned with developing health care policy

and programs in the next few years.

Participants involved in health care policy de-

cis ions must take a broadly-based approach to decision

11

making and must have some expertise and skill in identi­

fying problems, setting a course of action to deal with

the problems, evaluating the action, reviewing the pro­

cess, and facing change. The power and the ability to

influence policy and shape programs does not rest with

a single individual or agency but with mUltiple levels

of government and organized professional and consumer

groups.

Mitsunaga (1981) identifies health policy formula­

tion as the consequence of a political process. She

further identifies the participants of the process as

public and private agencies, special interest groups,

health care professionals, and consumers. The extent

to which nurses participate in policy and planning is

unknown. Conway (1981) stated, "Nursing as a profession

could and should have a voice in shaping the nature

and delivery of services to be provided" (p. 15). Ac­

cording to Aiken (1981), nursing's influence on health

care policy in the past has not been proportional to

their numbers. Ulin (1982) indicates that nurses con­

tinue to believe in involvement but emphasize individual

freedom of choice rather than cooperative effort toward

health policy decisions or community action. Conway

(1981) believes that leaders in the nursing profession

must "define what essential components of nursing ought

to be included" (p. 17) in health care policy which will

12

be developed by professional planners or legislative

action. Whether or not nursing will be given the

opportunity to provide such definitions, largely depends

on the ability of nurses to form a strong coalition and

provide a unified proposal. Nurses should participate

in health care policy decisions from a professional per-

spective as well as a patient care perspective. The

educational preparation of nurses to deal with patient

care from a physiological, biological and emotional

perspective places nurses in an advocacy role that few

others involved in health care policy decisions will

have. In addition to the basic educational preparation

and skill development through daily experience with

recipients of health care, nurses have established a

strong political base in the last few years and gained

power within the health care system. As a result,

nurses are in a position to exert a great deal of influ-

ence on policy decisions and legislation. As early as

1978, the American Academy of Nursing advanced this

belief. Aiken (1981) and Mitsunaga (1981) both wrote

about nurses' increased repertoire of political behaviors

and activities. Mitsunaga (1981) further stated,

... accordingly, we have a stronger power base, and we do exert influence on policy decisions. But given current social, political and economic forces in society, it is even more critical that we bring objective data to the policies we advo­cate (p. 6).

13

Williams (1983) stated, "All nurses should be concerned

about this relative lack of involvement in policy for­

mUlation." She reasoned that the ability to provide

patient care is influenced by policies that determine

how health care is to be financed and the settings in

which it can be provided. Preparation as well as par­

ticipation is essential for nurses to effectively influ­

ence policy.

Problem

Despite numerous public and private sector efforts,

health care costs, including those of Medicaid, continue

to rise at an alarming rate. The escalation of health

care costs constitutes a critical problem for most

states. Changing federal priorities, decreased federal

funding, continuing emphasis on cost containment, shift

of responsibility to the states, deregulation, competi­

tion, free market incentives and balanced budget demands

add to the growing complexity in the health care indus­

try. If the cost of health care continues to escalate

at the current recorded rate, resources could be unavail­

able within a few years. There is a growing concern in

both the public and private sectors and a recognized

need for a systematic, coordinated approach to find a

viable solution to the problem of affordable, quality

health care acceptable to both consumers and providers.

14

The problem is complex and creates stressful issues.

The result of escalating health care costs is reduction

of other essential programs and diversion of private

sector resources in order to pay for health care costs.

It has become clearly evident that there is a need for

some creative planning, carefully designed innovations,

intriguing new ideas, incentive-based programs, and a

broadly developed policy leading to reforms especially

in Medicaid and other programs for the poor and needy.

The need for highly competent health care professionals

with expertise in health care delivery to be involved in

making the necessary policy decisions also becomes

increasingly evident. In this time of limited resources,

priority setting and cost containment must be an issue

in the development of carefully designed innovations

and approaches to health care. Nurses have an obligation

to be counted among the professionals involved in any

health care planning effort. Nurses have a unique per­

spective of health care needs based on a holistic ap­

proach to patient care responsibilities and long term

experience with assessment of needs, establishing

priorities, making judgments, planning care and evalua­

ting outcomes which would lend itself very effectively

to the decision making process leading to health care

policy development.

At one time, public policy decisions on health care

15

were centered in Washington. Today, more and more of

these decisions are made at the state and local levels.

State and local governments have been given more auton­

omy, more responsibility, but less money to operate

health care programs for the needy. There is no way to

know what the eventual outcome of this changing admini­

strative philosophy will be; how the changing admini­

strative philosophy will affect participants involved in

making policy decisions; or how it will eventually affect

patient care. The resulting pressure on state and local

government budgets has created problems relative to the

amount, duration, and scope of such programs. The prob­

lems are heightened by the prevalence of balanced budget

requirements. This new challenge to state and local

governments has also created opportunities for innova­

tions in structure and reform in health care and cost

containment programs. Short term actions to limit

eligibility, scope of benefits, and reimbursement need

to be replaced by policy alternatives which maintain

needed levels of benefits and allocate resources more

efficiently. With this shift in emphasis and the accom­

panying responsibility to make prudent decisions about

utilization of available resources, there is an ever­

growing need for health care policy decisions and plan­

ning to be based on professional judgment and fort by

planners with expertise in the health care field. The

admonition of Conway (1981) and Williams (1983) is

appropriate; nurses could and should be involved in

health policy formulation as a way to influence health

care services and the public welfare.

Problem Statement

Are factors which influence the development of

health care policy and programs perceived differently

16

by professional nurses and other health care profession­

als in a State Department of Health?

Purpose

The purpose of this study was to compare the per­

ceptions of professional nurses and other health care

professionals on the importance of factors which influ­

ence health care policy development. Differences in

perception could influence the choices made among alter­

natives in the decision making process. The special

skills and expertise which nurses gain from basic train­

ing and education and from providing patient care, con­

stitute a special quality dimension others do not bring

to the policy decision making process.

The concepts and ideas which appear repeatedly in

current health care literature are defined by this

author as key factors influencing the development of

health care policy and programs in the future, and are

used as the basis for this study to determine whether

17

there is a perceived difference in the importance of

these factors as considered by professional nurses and

other health care professionals who are involved in

various phases of policy and program development or

operation. The ultimate purpose would be to show that

nurses are equally competent with other health care pro-

fessionals to participate in health care policy

decisions.

Definitions

For the purpose of this study the following defini-

tions apply:

1. Appropriate Access to Primary Care: the oppor­tunity to seek and receive a basic level of "essential" health care which includes education and appropriate preventive and curative services.

2. Competition: influencing behavior of consumers and providers of health care through develop­ment of favorable terms and incentives for making cost conscious decisions.

3. Consumer: an individual who receives health care through utilizing the services of providers or health care programs. (Could also be called a client, a recipient or a patient) .

4. Cost Containment: control of the increase in cost of human, physical, and technical resources utilized in the delivery of health care ser­vices.

5. Deregulation: removal of restrictions or regu­lations which govern practice" program or activity.

6. Health Care: diagnosis and/or treatment of health problems in the horne, office, or hos­pital. Includes physician services, nursing

care and service, and ancillary services under the direction or supervision of a physician.

7. Health Care Planning: establishing goals, policies, and procedures directed toward pro­viding health care for specified population groups.

8. Health Care Policy: a statement defining the parameters of programs and services providing access to health care.

9. Health Promotion and Maintenance: seeking regular health care, following advice, and practicing positive patterns of behavior to assure healthy lifestyles, increased life expectancy and productivity.

10. Incentive: a stimulus to encourage action toward a positive result -- to save money, to conserve resources, to control services, or to control utilization.

11. Indigent: impoverished, with insufficient resources.

12. Medicaid: a program administered by the State to pay medical bills for eligible people who have low incomes and cannot afford the cost of health care.

13. Medicare: a Federal program of health insur­ance for people age 65 years and over and some disabled people.

14. Planning: establishing goals, policies and procedures directed toward a specific purpose.

18

15. Prevention of Illness: establishing practices and habits of daily living which promote healthy lifestyles and reduce risk factors, thus, avoid­ing health problems which would threaten indi­vidual well being and decrease life expectancy.

16. Prospective Reimbursement: payment based on price per case utilizing Diagnosis Related Groups (DRGs). The payment rate is determined in advance and paid regardless of the length of individual stay. The standards, case mix, and groupings have been determined nationally. The index to determine payment is based on local

cost data.

17. Provider: one who provides service or care -- physician, dentist, therapist, nurse.

19

18. Provider Accountability: having responsibility for completing a specific task or providing a specific service and being responsible to answer to "someone" for the quality and cost of the task or service and the manner in which it is completed.

19. Quality Assurance: assessment of patient health outcomes, process outcomes, and cost outcomes as a result of care and service given. Quality assurance includes use of the results of assess­ment to recommend corrective action to secure improvement in the outcomes when indicated.

20. Regulatory Policies: usually take the form of requirements imposed upon the health care market place.

21. Third Party Liability (TPL): responsibility of an insurance plan or organization separate from the employee or employer for payment for medi­cal services in exchange for a monthly fee from subscribers.

22. utilization and Distribution of Manpower Resources: the utilization of health care pro­fessionals (manpower) prepared to effectively provide service in a safe and competent manner where and when needed in traditional or alter­native settings.

CHAPTER II

LITERATURE REVIEW

The current health care crisis in America touches

the lives of everyone -- rich, poor, young and old.

Society has been changed by decades of rapid growth and

expansion of knowledge, ingenuity and technology. So­

phisticated communication systems and easy mobility have

added to the crisis that is now apparent in this century.

Americans are poorly served by a health care system that

has not adequately met the challenge of a growing popu­

lation, growing expectations, or a faltering economic

state. Those responsible for contemporary policy

decisions in health care are faced with aggravating

concerns over rising costs, access to care, quality of

care, and availability of prevention and maintenance pro­

grams. An additional concern is that adequately prepared

health care providers are available to meet an ever­

growing need.

The current concern relative to health care centers

on the cost of health care, and the rapid rise of costs

over the last few years. The rise in health care costs

has been at a rate much higher than the costs of other

21

goods and services during the same period of time. As

a result, the cost of health care is a paramount con-

cern. Aiken (1981) supports this belief with this

statement, "Economic considerations have been dominant

in public policy formulation in health" (p. 4). She

further indicates that three major issues -- magnitude,

inflation and cost effectiveness -- are involved in the

economic considerations. According to Aiken (1981) the

trend points to less money in the corning decade. "Insti-

tutions will respond to the dilemma by formulating

priorities and reallocating resources accordingly" (p.

9). Collins (1982) supports Aiken by using a statement

from Levin,

The reductions in federal support will mean that states will completely reevaluate reimbursement rates, eligibility, and services with an eye toward restricting the scope of the program (p. 34).

Collins (1982) adds that

... by the end of the decade, it [the nation's health care delivery system] may bear little resemblance to the "Great Society's" vision of medical assistance for the poor and elderly (p. 39).

This transition in the health care delivery system

was initiated by the current administration in Washington

which views the proposed changes as contributing to a

more efficient delivery of care while lowering federal

expenditures accordingly. Hyman (1982) tells us that

"The inauguration of President Ronald Reagan signified a

22

new direction in the way health services are to be pro-

vided in the united States" (p. 563). He noted three

distinct agendas through which the Administration

intends to deal with health care issues: a)stimulation

of competition among health care providers as a means of

controlling costs, b) assumption by the states of more

responsibility for providing for the needy, and c) trans-

ference of block grants as the means of federal funding.

This intent is supported in the report published by the

President's Commission in A National Agenda for the

Eighties, and reported by Hyman (1982):

The commission feels, on balance, that an expansion of the role of competition, consumer choice, and market incentives rather than government control is more likely to create the much needed stimulus toward greater efficiency, cost con­sciousness, and responsiveness to consumer preferences so visibly lacking in our present arrangement for providing medical care (p. 563).

There is no way to know what the eventual outcome

of this changing administrative philosophy will be: how

the changing marketing concepts all relate to health

planning: how the changing administrative philosophy will

affect participants involved in making policy decisions;

or how it will affect patient care. One thing is cer-

tain, those who design health care policy playa key

role and face a monumental challenge to develop and

implement creative strategies for health care delivery

23

in the face of reduced resources.

"The subject of debate is not whether cuts will

occur, but in what form and to what degree," according

to Rogers, Blendon and Moloney (1982, p. 17). They

further suggest that the only strategies available to

planners to control costs are to reduce eligibility, to

limit the number of people who are covered for services,

and to limit the scope of programs. The second strategy

is selective program reform and alternative, less costly

ways of providing care.

Vladeck (1981) discusses cost containment from a

slightly different perspective. "True cost containment,

can restrain cost increases without damaging access, but

is politically more difficult to accomplish than measures

that reduce access" (p. 69). "Prom a technical per­

spective it is easier, not harder, to control total hos­

pital revenues or total long term care expenditures than

the expenses of a single payerll (p. 76).

Cost containment is accorded a great deal of space

in the literature and undoubtedly is the issue of prime

concern, as Aiken (1981) acknowledged. The other factors

of concern to those responsible for health care policy

are related to the cost containment issue, directly or

indirectly, and must be considered in the decision making

process.

The Surgeon General's report on health promotion

24

and disease prevention released in 1979 announced that

"Prevention" had been given top billing in federal health

policy. It does seem reasonable that efforts and

monies expended in prevention programs may, in the long

run, be cost effective and contribute to cost contain-

ment. Kohlert (1982) believes that emphasis on disease

prevention and health promotion was stimulated by the

legislative action to bring about competition in health

care. Conway (1981) believes that "while the need for

tertiary medical care will not be eliminated, the greater

need now and for the future is to assist people to modify

their lifestyles in more healthful ways" (p. 16).

In discussion prevention, the issue of consumer

participation becomes a very real factor. Prevention

cannot be effected without consumer cooperation or

involvement in improved health care practices. This

cooperation comes through education and change in habits

and lifestyle. Abdellah (1975) indicates that the

patient must become an active partner in the health care

system with responsibility for his own care. Planners

must provide for the education necessary to support this

participation. Given (1979) supports this premise by

indicating that

... there is an emerging concensus, supported through legislation and consumer movements, that consumers can assume greater responsi­bility for their own health; further, that consumers hold the key to preventing disease,

promoting health, reducing morbidity and mortality, and lowering the costs of health care (p. 24).

Consumers no longer believe that pro­fessionals are the front of all health care wisdom. Consumers in fact, may be beginning to veer away from care that is autocratic, dogmatic and expensive toward care that is democratic, shared, and less expensive (Given, 1979, p. vii).

According to Ulin (1982), the curative role is more

25

easily recognized by the client as a bonified service ...

therefore, she asserts that "a burden is placed on plan-

ners to devise a reimbursement system that will reward

prevention on an equal basis with cure" (p. 535).

Michael (1982) advances the belief that

Prevention is an idea whose time has come ... Improvement in the health of our citizens will not be made predominantly through treatment of disease, but rather through its prevention ... Prevention programs should concentrate on modifying practices that lead to disease rather than the disease itself ... (p. 937). The obvious lesson is that all citizens must assume a much greater personal responsibility for main­taining their health (p. 938).

Conway (1981) believes the ultimate prevention pro-

gram should be found at the place of employment and

provided by employers. A program of this kind would

allow for early detection of health problems and provide

for early intervention. It would save the individual

time and effort in seeking someone to provide care when

it is necessary. The real asset, Conway (1981) believes,

is in a well-developed program for reducing job related

26

stress which in turn will prevent stress induced i11-

ness at a later time.

Chen and Jones (1982) support the concept of employ-

ee health programs and emphasize the belief that,

The most popular programs provide for fitness, hypertension control~ smoking cessation, reduction of alcohol and drug dependence, stress management, and nutrition and weight control ...

Chen and Jones further assert that

Employee fitness programs have been associated with improved job performance and work attitudes, improved stamina, sounder sleep, reduced vulnerability to accidents, fewer doctor visits, and lower morbidity (p. 6).

Closely associated with the concepts of prevention

and consumerism is the concept of health promotion and

maintenance. In the literature, the concepts are often

discussed together. Clearie, Blair and Ward (1982) note

that there is less reward and prestige for health pro-

moted than for illness treated. They further note that

patients recognize a gap in the care they receive from

their physicians in the area of education, especially

in the area of healthy lifestyles with discussion of

risk factors. Clearie et ale (1982) further note that

this lack of advice becomes significant

... when it is realized that a way to successful adaptive behavior change is patient education, and that consumers have shown a desire for timely, perti­nent health information (p. 504).

27

A dilemma is identified by the fact that current methods

of medical practice do not lend themselves to edu-

cation in an effort to promote healthy lifestyles.

As early as 1975, Abdellah suggested that new

delivery systems "must emphasize prevention, health

maintenance and outreach efforts ... " She further indi-

cated that "health testing, health care activities and

preventive medicine tasks should be performed by non-

physician staff under medical supervision" (p. 6).

Clearie et al. (1982) quote Rabin (1981) as suggesting

... that physicians refer patients in need of lifestyle changes to health paraprofessionals who are skilled in assisting patients to sustain changes in areas such as dietary patterns, stress reduction and exercise behav­iors (p. 504).

Clearie et al. (1982) also suggest that behavioral pre-

scriptions as well as pharmacologic prescriptions should

be part of a physiciads clinical training. Ulin (1982)

and Abdellah (1975) note that controlling disease and

promoting health can only succeed where there is an

individual and a community who are motivated participants.

Health education is a vital intervention comparable to

management of health problems.

Abde11ah (1975) indicated that ninadequate and

poorly used manpower contribute to a major part of the

failure of present health delivery systems to meet

needs ... " (p. 4). liThe need to organize each profes-

28

sion's collective efforts to a full range of health

services is fully recognized" (p. 5). Abdellah (1975)

recognized that much needed to be done in development

and utilization of manpower resources to the benefit of

those in need of health care. Years later, Mullan (1982)

stated that "maximization of resources would be of

great benefit throughout a medical system haunted by

continually escalating costs" (p. 1077). Hanson (1982)

believes that "a central objective should be to maximize

the use of human resources toward the achievement of

maximum production" (p. 17). Rogers et ale (1982)

suggest changing

... some of our current arrangements for providing health care to the poor .•. Strategies involve more emphasis on care in the ambulatory setting, better coordi­nation of services, the use of less expensive personnel for different tasks, and incentives for physicians to be more restrictive in the use of high cost technologies (p. 17).

From the literature, it appears that a need for more

effective utilization of manpower resources in providing

health care has been recognized for a number of years

but not adequately addressed. In any discussion of

the utilization of manpower resources, the contribution

which nurses are capable of making cannot be overlooked.

According to Aiken (1981) "The 1980s offer a promise of

exciting contributions by nurses to the nation's health

and health care system •.. " (p. 4).

Fagin (1982) asserts that "nursing should be

actively involved in the design of programs of health

promotion and disease prevention that will ultimately

reduce reliance on higher cost technological interven~

tions ll (p. 11). According to Spitzer and Grace (1981)

nurses have a "capability of playing a major role in

'wellness' rather than 'illness' care" (p. 79). Given

(1979), reporting on research done at Michigan State

University, expressed the hope that evidence from this

research would show policy makers the "unique and

valuable II contribution that nurses make to health

status, lIa contribution that compliments and enhances

29

the diagnosing and prescribing activities of physicians. 1I

Given further expressed the belief that "as evidence

begins to emerge, nurses can rationally appeal to policy

makers to implement financial and manpower policies that

more appropriately recognize and provide for nursing

practice II (p. 29).

Primary health care is a concept which has been

addressed in medicine and nursing practice in recent

years. Several definitions have evolved over time. Ulin

(1982) reports that an international meeting held in 1978

with representatives of 127 nations and 72 international

organizations dealt with the issue of primary care as

the only

... viable means of achieving more equitable

distribution of health resources enabling all people to attain a level of health that will permit them to live socially and economically productive lives (p. 531).

Ulin (1982) further discussed "essential health care"

and a minimum set of primary health care needs as

30

directed toward both prevention and cure. These minimum

or basic needs include appropriate care for illness

or injury, appropriate medication when indicated, edu-

cation to support improved lifestyle, and concern for

basic sanitation and the environment. One further

aspect presented in this conference and discussed by

Ulin (1982) is the World Health Organization (WHO)

support for the concept of appraising community health

needs as a means of planning for the provision of health

care.

Mullan (1982) discussed the changing landscape of

health services and focused on the community medicine

and primary care movements. The two developing special-

ties share some common ground but have remained rela-

tively independent of each other. Community medicine

is tied to the concept of public health and is directed

at marginally served populations. Primary care is basic

in clinical practice and has survived in the main stream

of medical practice. Mullan (1982) suggests that the

two should come together with a discipline developed

which would be called "Community Oriented Primary Care"

(p. 1076). This approach includes provision of primary

31

clinical care for individual patients and families as

well as a special focus on the community and its sub-

groups, the planning of services, and evaluation of

the effects of care. Mullan (1982) further comments

that Community Oriented Primary Care would incorporate

clinical as well as epidemiologic skills in a way that

the skills would complement each other; would establish

programs in the community to be administered with a

primary care approach; would define a specific population

within a geographic area and would then plan for

accessibility of the population to care; and finally,

he suggests that the community would be involved in the

implementation and operation of the program. Mullan

(1982) envisions continuous feedback of data and infor-

mation which would influence the practice. He stated,

Any activities designed to promote health and prevent disease should stem from a data base. Community Oriented Primary Care practice systematically develops such data for use by practitioners and the practice. The small, prospective investment in community assessment suggested by Community Oriented Primary Care would make many primary care practices more responsive to community needs and at the same time more cost effective (p. 1077).

In March of 1982, the Institute of Medicine held a

conference where practitioners, policy makers, community

leaders and academic leaders from the medical community

documented the various forms of Community Oriented Pri-

mary Care groups in operation in this country and abroad.

32

The group concluded that the idea of Community Oriented

Primary care is not outside the American experience,

but it has never been incorporated into the educational

experience of recent practitioners. Mullan (1982)

charges that "this educational gap needs to be closed

if the full potential of primary care is to be realized"

(p. 1078). In further discussion, Mullan (1982) advances

the belief that the Community Oriented Primary Care

practice promotes sound principles for any practice form,

but is "particularly timely for the health care dilemmas

we are currently facing ... " (p. 1077). Problem identifi-

cation followed by carefully planned solutions offer

more effective use of resources than the traditional

medical response offers.

One additional aspect of primary care addressed in

the literature is that of the primary care giver. The

physician in primary care practice is an accepted role,

and the physician is seen as the principal provider of

health care. Ramsay, McKenzie and Fish (1982) report

that

Studies about the nurse as a provider of primary care have investigated both health outcome variables and process variables. Health outcomes obtained by nurses have not been found to be inferior to those obtained by physicians ... (p. 55).

Other research has shown that care is provided

differently by nurses than by physicians, and nurses

usually see fewer patients, spend more time with each

patient and usually schedule more appointments for

followup.

Fagin (1982) states that,

A great deal of evidence has also accumu­lated with regard to the nurse in primary care showing successful outcomes as meas­ured by standards of cost and quality. The most recent data summarizing all the studies indicate that nurse practitioners alter the production of medical services in a way that both improves access and reduces cost (p. 5).

Ulin (1982) believes that "It is not surprising

33

that empirical evidence should validate nursing practice

in primary care u (p. 535). According to Ulin (1982),

the nurse practitioner model which originated at the

University of Colorado in 1966 has evolved to mean prac-

tice of nursing in ambulatory settings. Fagin (1982)

further suggests that the nurse must be given more

opportunity to provide care in ambulatory settings

involving children, teenagers, pregnant women, care in

the home and care of the elderly. This concept is

supported by Spitzer and Grace (1981) who assert that

nursing is capable of playing a "major role in wellness

rather than illness care" (p. 79). Fagin (1982) supports

continued development of a nursing role in primary care

by concluding that the

... predominantly nursing interventions under nursing management and design {i.e., health teaching, support for the

family, and care in the home) in colla­boration with physicians and other appro­priate consultants will bring about short and long term savings (p. 12).

A final aspect of primary care deals with access

to care. Vladeck (1981) reports that,

..• access to health care for the poor and elderly has improved dramatically over the last 15 years, largely as a result of Medicare, Medicaid, and other federal initiatives (p. 69).

The poor currently consume roughly equal amounts of

34

health care as the nonpoor, but access is still a problem

for minorities, for those with chronic disease, and for

those who live in inner city and rural areas. Vladeck

(1981) asserts that people who need medical care are

unable to receive it because barriers still exist in

the form of costs of care, inability to get to the

place care is provided, continuing discrimination pat-

terns or complete lack of service availability. Health

care financing programs cannot realistically solve the

problems which contribute to the lack of access. Society

has some obligation, but as the President's Commission

appointed to explore ethical and legal issues in health

care (1983) pointed out, there is limitation on society's

resources. The commission further reported that "the

achievement of equitable access is an obligation of

sufficient moral urgency to warrant devoting the neces-

sary resources to it" (p. 35). Furthermore, Vladeck

(1981) believes the broader concern is that gains

in access to health services for the poor and elder­

ly over the past 15 years are threatened today by

spiraling health care costs. Any reduction in reim­

bursement provided by public programs will enhance

the problem because providers will choose to serve

private pay patients or those with insurance cover­

age which can serve only to exacerbate the access

problems. Conway (1981) believes that "the ongoing

debate over access to care versus how much care an

individual is entitled to will continue" (p. 14).

Policy makers will be faced with making decisions

which, in one way or another, address access issues.

Hopefully, alternatives can be considered which

will preserve access to care for all who need

care.

35

The health care delivery system is exceedingly

complex. Health and social issues surface with attempts

to design delivery systems which also insure quality.

As early as 1975, Abdellah wrote that "Regulation is

necessary to assure accountability for expenditure of

public funds" (p. 6). Abdellah (1975) saw the need for

regulation in relation to costs, distribution and quality

of care, and protection of consumers. She further saw

regulation as a protection of the public from fraud,

abuse, incompetence, or exploitation by providers, injury,

infectious diseases, and as a means to insure adequate

utilization of scarce resources.

36

According to Hull (1982) accountability has the

aspect of "task responsibility" and "answerability.1f

Task responsibility involves the responsibility to com­

plete a task. The responsibility can be gained by

assignment from a supervisor or someone else in a

position of authority; by assumption of the task without

real assignment; or by being "saddled" with the task

for lack of someone else to accept the responsibility.

Answerability means being held responsible by someone

for completion of the task responsibility. Hull (1982)

further indicates that statutory definitions and pro­

fessional standards become involved in any discussion

of responsibility and accountability. Task responsi­

bility is associated with education. Licensure and

certification requirements establish the limits of task

responsibility and accountability which define pro­

fessional practice. Arndt and Huckaby (1980) have

stated that "Accountability is always associated with

responsibility and authority" (p. 79).

The final factor to be considered as important to

health care policy development is quality. Quality is

involved in all of the factors previously discussed.

However, McManis has predicted that "Quality assurance

will surpass cost containment as the nation's major

health care issue by 1990" (A.H,A. Convention Briefs,

1983, p. 40). Donabedian, Wheeler and Wyszewianski

(1982) assert that the quality of health care services

37

has attracted increasing attention in the last 10 years.

With increasing expenditures for health care, there has

been increasing pressure to determine that there is

adequate quality associated with the services being pro-

vided and reimbursed. Donabedian et al. (1982)

.•. specifically define the highest quality of care as that which yields the greatest expected improvements in health status, health being defined broadly to include physical, physio­logical and psychological dimensions. (p. 976).

Crow (1981) defines quality of care as having

several meanings which are not unitary but which in

their own right, can apply to the quality of health

care -- a degree of excellence, a skill, accomplishment,

trait or attribute, or the characteristic of a substance

contrasted to the quantity of a substance.

An editorial in 'Modern Health Care October, 1983

states that,

The best way to ensure high quality health care is to encourage competition among free standing emergency and primary care centers, established physicians, and hos­pital emergency departments. Consumers are smart. They will go where the quality is high and the prices are right (p. 5).

Donebedian et al. (1982) believe that the Social

Security amendments of 1972 which mandated Professional

Standards Review Organizations (PSROs) manifested con­

cern for quality of care in relation to the rapidly

escalating health care expenditures. The federal

government had become a major third party payer by 1972

and the intent of the PSRO legislation was to insure

that reimbursement would only be made for "care that

38

was necessary, provided at the least costly site, and of

satisfactory quality ..• This legislation did not,

indeed could not, define what was necessary care of

good quality beyond stipulating that it comply with

practices and standards that were acceptable to the pro­

fession itself" (p. 975-976).

In the face of decreased federal funding, changing

federal priorities, continuing emphasis on cost contain­

ment, shift of responsibility to the states, and the

growing complexity of the health care industry, the

emphasis on quality assurance can only increase, perhaps

to fulfill the prediction made by McManis (A.H.A., 1983).

The challenge for planners is evident. Change in

the health care industry is more certain today than it

has ever been. The mUltiplicity of factors to be con­

sidered in today's health care market makes planning and

policy development exceptionally difficult but increas­

ingly necessary. The rising cost of health care must be

addressed along with the clear message from consumers

and third party payers that lower cost alternatives must

39

be sought. Introduction of competition into the health

care market brings a completely new challenge requiring

well planned programs just to stay in the arena. The

changing medical practice patterns manifested by prepaid

group plans, preferred provider panels, and the develop-

ment of freestanding care centers makes planning and

marketing strategies essential. Changing technology

creates stress on the health care system requiring

planning for adequate utilization. And finally, changing

reimbursement mechanisms demand flexibility and crea-

tivity in planning in order to manage with decreased

income.

An editorial in Hospitals (November, 1981) suggested

that in past planning efforts, there has been

... conflict between those who believe that the goal of planning is cost containment, first and foremost, and those who see it as a mUltipurpose activity that can expand, as well as contract service (p. 61).

Conflicts are likely to continue unless the role of

health planning can be more clearly defined and coopera-

tion achieved among participants. Snoke (1982) agrees

that problems must be solved by cooperative efforts of

the various levels of government and the private sector.

Demands on resources within states and towns must be

resolved through a coordinated approach to planning and

policy development that meets the needs of providers and

consumers.

Ackoff (1982) has characterized planning,

... as a participative way of dealing with a set of interrelated problems where it is believed that unless something is done, a desirable future is not likely to occur; and that if appropriate action is taken, the likelihood of such a future can be increased (p. 35).

The literature generally discusses health planning

as it relates to comprehensive health planning, region-

alized planning, health systems agencies, and institu-

tional planning. For several reasons, planning as it

relates specifically to programs for the needy has not

40

been an issue. The public has many misconceptions about

public assistance programs and the population these

programs serve. Planning and policy development for

the provision of health care through public programs has

largely been left to individual states and their respon-

sible agencies with major constraints from federal rules,

regulations and guidelines, and from state legislative

actions determining the limitations of program planning

and service delivery. Therefore, the scope of service

and reimbursement is not consistent among states. A

worsening economic situation and the changing policies

of the current administration in Washington have called

attention to public assistance programs, especially

Medicaid. As various social and health programs struggle

for survival in the face of cost containment efforts,

the literature is beginning to explore programs directed

41

at providing health care to the nation's poor, aged,

and disabled.

Relative to planning in general, the literature

suggests that planning is a political process, a vital

process especially in today's health care market, and

it means many things to many people. Vasu (1979) stated

it most pointedly,

While a strong political consensus on the need for some form of planning exists, there are a variety of different per­spectives on just what planning is or what is the best method to achieve it. Indeed, much of the consensus on the need for planning thoroughly collapses at that juncture at which one moves from some abstract and amorphous notion about planning's necessity to any concrete expression of its reality ... (p. 4).

Vasu (1979) further indicates that planning has two

distinct aspects: economic and political. Mitsunaga

(1981) agrees, stating that "Health policy formulation

is the consequence of a political process influenced

by other social, political and economic forces" (p.

3). Vasu (1979) believes that economists approach plan-

ning from the perspective of controlling goods and ser-

vices while the political aspect of planning addresses

people and the organizations to which they belong.

Planning efforts can be undertaken in a variety

of settings and for a variety of reasons. Planners

are directed by the goals they seek to achieve, or by

the goods and the services they seek to allocate, or

by the associations or people they must serve. The

participants in health care planning can be representa­

tives of public or private agencies; health care pro­

fessionals -- physicians, nurses, therapists, dentists,

dietitians; consumers of health care; special interest

groups -- insurance companies, business leaders; and

others interested in reform of the system either for

public or private interests. The priorities and objec­

tives of the various participants differ, but each one

is competing for the same set of available resources.

The number of participants in the health care planning

arena intensifies the problems of health care policy

development. Any decision affecting the system or any

attempt to regulate it creates tension for one partici­

pant or another. Planning is not a technical process;

it involves a determination of priorities and selection

from among those priorities. Value judgments become

42

an issue in this respect, and the question of which

values planners will reflect must be resolved. Planning

has a significant effect on policy decisions which are

based on different kinds of information at different

stages. "Policy is a posture, or attitude or a set

of values, opinions, and actions that influence decision

making in certain directions" (Mitsunaga, 1981, p. 2).

Public policy is defined as an ordering of priorities

within certain constraints.

Medicaid has long been recognized as the program

that pays for the medical care of many of the nation's

poor. There are not many choices for Medicaid Policy

makers. As Rogers et ale (1982) point out, lilt seems

inevitable that Medicaid will suffer substantial cut-

backs. The subject of debate is not whether cuts will

occur, but in what form and to what degree" (p. 17).

Rogers et ale (1982) further recognize that a dilemma

exists in the need to control the escalating costs of

Medicaid services while maintaining essential services

for those low-income citizens in need of medical care.

The same dilemma was noted in an editorial in Hospitals

(1981),

Being charged with increasing access to health care and with cutting costs, is a rather difficult assignment; so is trying to serve as a local agency when final decision making rests with the state and most of the funding is coming from the federal government (p. 61).

Rogers et ale (1982) assert that the dilemma can only

be met by two general strategies for cutting costs.

The first,

... to reduce substantially the number of poor covered by public sector health programs, and to reduce the comprehensive­ness of the health benefits currently provided to these recipients. The second strategy is to make highly selective, professionally determined cuts where they will do the least harm, and to change some of our current arrangements for providing health care to the poor (p. 17).

43

Neither alternative is without a negative aspect.

Problems are likely to surface with any program option

that may be chosen. No one wants to be responsible

for providing less service or denying vital medical

services to the poor as the first strategy suggests.

44

The second strategy, although it appears to be the most

logical, will involve time, research, and active partici­

pation of health care providers who will support the

changes that will be necessary in the health care de-

livery system to make it work. Proposed changes empha-

size ambulatory care, careful coordination of services,

use of less expensive personnel to complete some tasks,

and incentives which would encourage physicians to con­

trol the use of expensive tests and equipment.

Several programs which could be classified under

either of these strategies mentioned by Rogers et al.

(1982) have been implemented and are operating with

varying degrees of success throughout the country_

Restricting eligibility may be quick and simple

to implement and may initially appear to save money,

but those clients needing assistance will seek it some­

where and will eventually gain assistance at one point

or another in state or local programs that do not have

the benefit of federal matching funds. The result of

reduced federal and state Medicaid expenditures may

be increased health care expenditures for local govern-

45

ments.

Restricting services is also considered a quick

and easy cost containment strategy, but for some states,

eliminating federally supported services may again mean

shifting this responsibility to states and localities,

and the potential exists for clients to postpone neces­

sary care, leading eventually to more costly care.

Utilization control programs to monitor provider

and client services are gaining popularity as a cost

containment measure as well as a quality assurance meas­

ure. Significant cost savings have been realized from

this effort. Most of the utilization control programs

target improper use of services rather than reduction

of all services. Less political resistance develops

from participants when a utilization control program

is used. However, misapplication of utilization control

programs can create barriers to accessing necessary

services.

Case management, Health Maintenance Organizations,

and preferred practice groups where providers share

the financial risks seem to encourage use of primary

care and control of service levels. Client freedom

of choice is somewhat limited, but clients can gain

access into the health care system with these programs

and there is a significant potential for cost contain­

ment.

46

Competitive bidding for program design and cost

control also stimulates an element of quality assurance

and is one of the newer strategies available to planners.

There is no model available on which to base such pro­

grams so policy makers are moving slowly to build proper

provider and consumer incentives into such programs.

Prospective reimbursement methodologies have been

very successful in cost containment where specific pro­

blem areas could be targeted. The most recent prospec­

tive payment program to be implemented as a cost contain­

ment program is the Diagnosis Related Group methodologies

(DRGs). The complexities of this program are not fully

known, and there is some disagreement on the value of

such a program or the ability to design it so it will

be acceptable to the industry.

Future policy and planning decisions will undoubted­

ly continue to implement programs designed to provide

essential health care while maintaining quality and

cost effectiveness. Prevention of illness and mainte­

nance of health along with appropriate access to care

will be major issues in policy decisions. Such program

development must be based on objective data gained by

careful study and research.

The literature supports the trend of less federal

intervention, both regulatory and financial, fewer

resources and more responsibility by the states to meet

47

health care needs of the poor, aged, and disabled.

This trend noted in the literature suggesting fewer

resources and more autonomy for the states in deciding

how the resources will be utilized, supports the belief

that there is a greater need than ever before for health

planning and policy decisions to be shared by highly

skilled health care professionals with expertise in

health care delivery, who can assess needs, determine

priorities, and develop plans of care. Nurses have

this expertise with added skills in research and experi-

ence in evaluation of individual care and programs.

These added dimensions could greatly enhance the nurse's

role in the policy and planning process and in improving

decisions on how resources are to be allocated.

Unfortunately, nurses have not seen themselves

in an active role in the community in decision making

and health planning. Only recently have nurses begun

to assert themselves and show interest in being part

of the world beyond daily patient care so that their

voice can be heard and their ideas respected. Mitsunaga

(1981) concurs,

During the last decade we in nursing have increased our repertoire of political behaviors and our political activities, significantly. Accordingly, we have a stronger power base, and we do exert influence on policy dec ions (p. 6).

Aiken (1981) asserts that the

Influence of nursing on national health care policy in the past has not been com­mensurate with numbers, important changes have occurred in the past two decades, both within nursing and in society that may dramatically affect the role of nursing in health care in the 1980s ... Nurses now represent over 58% of all health pro­fessionals (p. 3).

48

This fact alone suggests that nurses have a responsibil-

ity to be involved in resolving policy and planning iss-

ues and to help determine where emphasis will be placed,

where resources will be allocated, and how services will

be delivered. The American Academy of Nursing (1979)

noted:

Important changes in the delivery and fi­nancing of health care services seem inevit­able ... Emphasis is placed on the need for nursing to ally itself with consumers and to develop strategies necessary for nursing's voice to be heard and for nurses' expertise to be used in health care decision making of the 1980s (p. vii).

Aiken (1981) further supports the idea that nurses

need to be a part of this vital policy and planning

process, to bring expertise. She writes,

When faced with limited resources, it be­comes more important to base resource allo­cation on objective data. Nurses can influ­ence how resources are allocated in several ways. One is the development of demonstra­tion programs that are objectively studied to determine their benefit to patients and their costs to society (p. xvi).

Interpretation and communication of findings and results

of various studies are often overlooked by nurses as

a vital step in influencing public opinion and policy.

49

Rational decision making based on knowledge is essential

to health policy development. Aiken (1981) lists Ita

second important way to influence resource allocation

as involvement in decision making at the institutional

level" (p. xvi).

Planning is essential to the success of any en­

deavor. If the challenge of rising health care costs

is to be successfully addressed, then planning must

be the process through which it is achieved. The par-

ticipants in the planning process are important. Plan-

ning requires a certain amount of expertise, objectivity

and experience with the problem solving process and

group interaction in order to make judgments which will

maintain necessary levels of benefit and allocate resour­

ces efficiently. Planning involves determination of

priorities and selection from among those priorities.

Value judgments become an issue and the question of

which values planners will reflect must be resolved.

The participants cannot be totally self-service nor

seek to force recognition of one preferred category

of service over another. A balance must be reached.

From all indications there will be less money in the

coming years to provide essential service and care.

Planners must look beyond tradition and vested interests.

Creatively designed innovations in utilization of re­

sources and provision of care are essential.

50

With less money available, critical decisions will

involve setting priorities, reevaluating reimbursement

rates, eligibility and services leading to a restricted

Medicaid program. The advent of competition and free

market incentives will require new directions. Emphasis

must be placed on finding alternatives in the delivery

of health care which will control costs, provide access

to quality care and primary care services and involve

consumers in developing more healthy lifestyles. Several

writers agree. Aiken (1981) believes that different

challenges are ahead in the 1980s because of the economic

state of the country. Emphasis will be placed on deter

mining priorities and reducing the scope of health pro-

grams. Fagin (1982) believes that in an effort to

develop alternatives to high cost technological care,

restructuring of the reimbursement system will occur

and substitutes for hospital and institutional care

will surface. Fagin (1982) further believes that these

substitutes will be family support systems, health

teaching, home health services, and other programs "under

nursing management and design, in consultation with

physicians and appropriate others" (p. 12). Given (1979)

stated,

The social changes and trends for increasing patients r active involvement in their care and emphasizing preventive care and health maintenance will necessitate policy and structural change in the health care delivery

system. Consumers in concert with nurses may yet evolve a viable health care delivery model that has implications for health policy decisions in the 1980s (p. 29).

Abdellah, in 1975, discussed new delivery systems in

51

relation to meeting social, emotional and biologic needs

through approaches involving prevention, maintenance,

and outreach efforts.

Kuntz (1983) credits McManis with stating that

"By the 1990s, 90% of all health care will be provided

under some kind of contractural arrangement between

providers and payers" (p. 26).

Friedman (1982) credits George Caldwell, President,

Lutheran General Hospital, with advancing the bel f,

"that most health care activity in the next 20 years

will take place outside of the hospital." Caldwell

further emphasized that not to respond to this challenge

"is not to respond to what the consumer really wants,

and is not to serve the community in terms of what it

needs" (p. 71).

What are the implications of nursing? The American

Academy for Nursing (1979) noted that important changes

in financing and distribution of health services seems

inevitable. These inevitable changes only serve to

emphasize the need for nursing (nurses) to become in-

volved and to work in concert with consumers for "nurs-

ing's voice to be heard and for nurses' expertise to

52

be used in health care decision making in the 1980s"

(p. vii). Conway (1981) suggests that moving to a social

model of care where the home and the community become

the locus of patient care should be of interest to nurses

because of the potential for nurses to provide a good

share of that care. "In addition, nursing as a profes-

sion could and should have a voice in shaping the nature

and the delivery of the services provided" (p. 15).

The literature supports the belief that the direc­

tion of future planning and policy decisions seems to

be set. With less money available, decisions will be

critical with program structure a vital issue. Partici-

pants in the planning process must be creative, seeking

alternatives which provide access to quality, cost effec­

tive care for the greatest number of people. The liter­

ature also points to nurses as one of the principal

participants in this vital process.

Therefore, the purpose of this study was to deter­

mine what the comparative perspectives of nurses and

other health care professionals are on the various fac­

tors relevant to health care planning and policy making.

This information will serve as a consideration to further

the involvement of nurses in this vital health care

process.

CHAPTER III

METHODOLOGY

The emphasis of this study was on the comparative

perceptions of professional nurses and a selected group

of other health care professionals relative to the impor­

tance of the seven factors which influence the develop­

ment and implementation of health care policy and

programs.

A questionnaire with a rating scale was developed

by the investigator to gather the data. An initial

pilot test of the questionnaire preceded the actual

study and resulted in a revision of some of the state­

ments. After minor editing of the second pilot test,

the instrument was prepared for distribution to the

selected participants.

A cover letter was prepared to explain the purpose

of the questionnaire, to advise the selected staff mem­

bers that participation was completely voluntary, and

to assure the participants that their responses would

be confidential. The questionnaire packets were person­

ally delivered to the selected staff participants.

Self-addressed envelopes were included in the packet

for return of the questionnaire by mail.

54

Evidence of previous research on this subject could

not be found in the literature. Therefore, it was neces­

sary to develop a tool to collect the data. Surveys

are a flexible and useful exploratory tool when study

of a topic is in the developmental stages. The sample

in this survey was expected to be small, and the time

element was critical. A survey questionnaire to be

distributed to participants, self-administered, and

returned seemed most appropriate within the time avail­

able. The survey questionnaire offered anonymity to

the participants with no risk of bias by a face to face

contact or a personal interview.

Four statements related to each of the seven key

factors. Scores were totaled for each of the profes­

sional groups, the mean computed, and a profile drawn.

A t-test was run on the data to determine if there was

a significant difference between the groups. A descrip­

tive analysis was carried out on the data since the

survey dealt with participants perceptions and opinions.

Description is one of the basic functions of a survey.

Sample and Setting

The sample for this exploratory study was drawn

from the Utah Department of Health where various divi­

sions, bureaus, and offices are assigned specific respon­

sibility to promote and protect the health and well

being of residents of the state. Planning and policy

decisions are essential for the Department of Health

to meet the assigned responsibility to administer and

enforce state and federal regulations, and to develop

and carry out reasonable health programs and practices

deemed necessary to protect the public health of Utah

citizens.

55

Two divisions within the Department of Health were

selected to participate in the study (i.e., the Division

of Community Health Services and the Division of Health

Care Financing). These divisions were selected because

of their emphasis on providing health care to the in­

dividual.

The major focus of the Division of Community Health

Services is prevention through measures directed at

changing unhealthy behavior. If not corrected, unhealthy

behavior could result in long-term ill health and expen­

sive medical care. Offices and bureaus within the

Division deal with policy and programs for Community

Health Nursing, Chronic Disease Control, Communicable

Disease Control, Health Promotion and Risk Reduction,

and Emergency Medical Services. Professional nurses,

other health care professionals, some paraprofessionals,

technicians, business professionals, accountants, and

secretaries constitute the working force of the Division

of Community Health Services. The impact of the agency

reaches all parts of the state through local health

56

departments.

The Division of Health Care Financing the agency

designated by the Utah Department of Health as the Med­

ical Ass tance Unit, assigned by federal regulation,

as responsible for administration of the Title XIX

Medicaid program. The Health Care Financing Policy

and Planning Unit serves as staff to the division direc­

tor. Policy and programs developed by the unit staff

and subsequently approved by the division director are

bas to the functioning of the bureaus within the

Division responsible for policy implementation, program

operation, utilization review, and program review.

The working force of the Division is essentially the

same as that of the Division of Community Health Services

with professional nurses, other health care profession­

als, some paraprofessionals, technicians, business

managers, accountants, and secretaries.

Other health care professionals are designated

as health educators, social workers, health care admini­

strators, pharmacists, physical therapists, dietitians,

and emergency medical technicians. Business profession­

als and accountants specializing in health care manage­

ment and financing are also considered health care pro­

fessionals for the purpose of this study.

Other paraprofessionals and technicians are staff

members who do not have a definite medical orientation,

57

but who have worked in the agencies for a long period

of time and have presumably developed an expertise in

certain programs enabling them to handle specified health

related responsibilities. The findings of this study

may be generalized with caution to other public and

private agencies where decisions governing health care

policy are developed.

Instrument

In the literature, several concepts and ideas

appeared repeatedly and were discussed from the aspect

of their influence on health care policy decisions and

health care programs of the future. For the purpose

of this study, those concepts and ideas have been defined

as key factors and include the following:

1. Cost Containment

2. Utilization and Distribution of Manpower Resources

3. Provider Accountability

4. Quality Assurance

5. Prevention of Illness

6. Health Promotion and Maintenance

7. Appropriate Access to Primary Care.

Statements related to these key factors were identi-

fied and noted during the literature review. A question-

naire was developed from the statements. The question-

naire was designed as a tool to measure any variance

58

in viewpoint and emphasis relative to the factors identi

fied as influencing contemporary health care policy

and program development. The perceived difference in

the importance of these factors as considered by pro­

fessional nurses and other health care professionals

was to be determined by the weight of opinion expressed

in relation to each factor. Responses were recorded

on the rating scale along a continuum from 1 to 7, with

the number 1 indicating strong disagreement and the

number 7 indicating strong agreement. Any differences

in perception could be significant and influence choices

made among alternatives considered by participants in

the process of policy development and implementation.

The questionnaire contained 28 statements; 4 state­

ments for each of the seven key factors. Initially,

the statements were to be equally divided with potential

positive and negative responses. However, after pilot

testing and revising the instrument, the majority of

the statements required a positive phrasing.

Pilot Test

For the pilot test of the instrument, the question­

naire was submitted to a select group from the Division

of Health Care Financing consisting of the Director,

Division of Health Care Financing; Director, Policy

and Planning Unit; Director, Bureau of Facility Manage­

ment; Director, Bureau of Provider and Client Services;

59

Director, Bureau of Program Review; and the Medicaid

Operations Manager. From the Division of Community

Health Services, the Director and Nursing Consultant

were asked to respond. The rationale for selecting

these people as a panel of experts was that all of them

had interest and expertise in either development or

utilization of policy_ Eventually, selected staff from

each of these bureaus would comprise the sample respond­

ing to the questionnaire as the major data generators

of the study. In addition to responding to the basic

statements, the pilot group was asked to identify which

of the seven key factors was reflected by each statement.

Finally, the expert participants were asked to rank

the seven key factors in order of importance. The par­

ticipants in this pilot group were asked to comment

and suggest any changes they would recommend or any

additional questions they deemed appropriate.

The response to the first pilot test of the ques­

tionnaire revealed the need to revise, simplify and

clarify some of the statements and to add a list of

definitions of the key factors. Changes were made and

the questionnaire submitted to a second panel of 9 par­

ticipants comprised of selected members of the utili­

zation review staff of Blue Cross - Blue Shield of Utah

and to the Policy and Planning Staff of the Office of

Health Planning and Policy Development, an agency desig-

nated to coordinate the overall health planning and

policy development of the Utah Department of Health.

Method

60

To complete the data collection, the revised ques­

tionnaire was distributed to 65 selected staff members.

Selection was based on responsibility for policy develop­

ment, policy implementation, program operation, utili­

zation review, and program review. The Director of

Community Health Services selected 17 participants from

that Division. This investigator selected 48 partici­

pants from the Division of Health Care Financing.

The questionnaire packets were personally delivered

to the selected participants. Self-addressed envelopes

were included for return of the questionnaire by mail.

CHAPTER IV

FINDINGS AND DATA ANALYSIS

Survey questionnaires were distributed to 65 par­

ticipants. Seventeen were selected from the Division

of Community Health Services and 48 from the Division

of Health Care Financing. Thirty-five or 53.8% of the

survey questionnaires were completed and returned (Table

1). Since anonymity was assured it is not known how

many participants responded from each Division.

Seventeen participants were registered nurses com­

prising 49% of the sample. The remaining 18 participants

were other health care professionals comprising 51%

of the sample. Twenty-four of the participants (69%)

were female. Eleven of the participants (31%) were

male. Seventeen of the participants (49%) were Master's

level prepared, while 14 (40%) were Bachelor's level

prepared. Four of the participants (11%) were Associate

Degree prepared. The Associate Degree category included

any nurse with a diploma in nursing.

Many of the participants indicated responsibility

for more than one area of policy. Of the sample, 25.9%

indicated responsibility for policy implementation,

24% indicated responsibility for program operation,

62

Table 1

Profile of Participants

Percent Number S!-o

Profession: Registered Nurse 17 49 Health Care Administrator 8 23 Social Worker 5 14 Health Educator 2 6 Business Professional 2 6 Pharmacist 1 3

35

Gender: Female 24 69 Male 11 31

Age: 25-30 4 11 31-35 10 29 36-40 4 11 41-50 8 23 Over 50 9 26

Education: Associate Degree

(Including Diploma) 4 11 Bachelor's Degree 14 40 Master's Degree 17 49

Emphasis of Policy: Development 10 18.5 Implementation 14 25.9 Program Operation 13 24 Utilization Review 6 11 Program Review 7 12.9 Other (survey) 4 7.4

and 18.5% of the sample indicated responsibility for

policy development. Responsibility for program review

was indicated by 12.9% of the sample, for utilization

review by 11% and for survey by 7.4%.

Length of time employed at the Utah Department

of Health as reported by participants in the survey

sample ranged from 1 month to 20 years (Table 2). The

median of the sample was 3 years. Eighteen (51.5%)

63

of the participants, had been employed between 2.5 years

and 4 years. Eight participants (22.8%) had been with

the Health Department for more than 4 years, and 9 of

the participants (25.7%) had been with the Health Depart­

ment less than 2 years.

The participants reported their present responsi­

bility for policy ranging from 1 month to 11 years

(Table 3). The median of the sample was 2 years 6 months

and the mode was 3 years. Seventeen participants (48.5%)

had been in their present positions for 1 year 6 months

to 3 years. Ten participants (28.5%) had been with

their present jobs for 1 year and 4 months or less.

Eight of the participants (22.8%) had their present

job responsibility for more than 3.3 years.

While organizing the data for analysis, it was

determined that the responses from the 2 health edu­

cators, the 2 business professionals and the 1 pharmacist

could not be included. The numbers were not large enough

64

Table 2

Length of Time Employed at Utah Department of Health

1 month

25.7%

1 2 month years

n 9

Range Median

3 Years

2.5 years

51.5%

4 years

Table 3

20 years

22.8%

6 20 years years

n=8

Length of Time with Present Job Responsibility

1 month

28.5%

1 1.3 month years

n 10

Range Median

2.5 years

1.5 years

48.5%

n=17

3 years

11 years

22.8%

3.3 11 years years

n=8

to provide an adequate comparison and data analysis.

As a result, the sample size was reduced to 30. The

17 registered nurses comprised 56.6% of the sample.

The 8 health care administrators represented 26.6% of

the sample, and the 5 social workers represented 16.6%

of the sample.

The emphasis of responsibility for policy changed

with the change in sample size (Table 4). The percen­

tage of those having responsibility for policy develop­

ment decreased by 4%, while the percentage of those

with responsibility for program operation decreased

by 1.1%. The percentage of those having responsibility

for policy implementation increased by 1.1%.

65

The survey questionnaire had 28 statements; 4 state­

ments for each of the seven key factors. The option

for response was on a continuum. At one end of the

continuum the participant could indicate strong agreement

with the statement. At the other end of the continuum

the choice was for strong disagreement with the state­

ment. Any of the 7 points along the line could be

marked.

For each professional group, the scores relating

to each key factor were summed. For example, the first

key factor was appropriate access to primary care ser­

vices. Seventeen registered nurses responded. The

responses of the nurses to all four statements related

66

Table 4

Participants Included in the Survey

Number Percent ( % )

Profession:

Registered Nurse 17 56.6% Health Care Administrator 8 26.6% Social Worker 5 16.6%

30

Emphasis of Policy:

Development 7 14.5% Implementation 13 27% Program Operation 11 22.9% Utilization Review 6 12.5% Program Review 6 14.5% Other (Survey) 4 8.3%

to that factor were summed. The mean score was deter-

mined and a profile drawn (Table 5 and Figure 1). This

process was completed for each key factor and for each

professional group.

67

The mean scores for the separate professional groups

for each of the key factors were similar. The profile

of the means demonstrates that the groups are homogeneous

in their orientation or their opinions about the key

factors which influence health care policy development.

A !-test applied to the data determined there was no

significant differences among the groups.

Although the participants were not asked to rank

the key factors by order of importance, a ranking can

be determined by looking at the total mean scores for

each factor (Table 6).

The profile presented by plotting the mean scores

of the study group presents an interesting picture.

Quality assurance, purported by McManis (A.H.A., 1983)

to become the number one issue in health care, appears to

be given a very low priority by this group of profes­

sionals.

Health promotion and maintenance was given the next

lowest mean score by all groups. The rating of this fac­

tor becomes even more notable in light of the fact that

prevention of illness received the highest mean score of

all the factors among all of the professional groups. The

Category Number

R.N. 17

Health Care Adm. 8

Social Worker 5

Table 5

Comparison of Key Factor Mean Scores

Primary Health Prevent Quality Provider Care Pro/Main Illness Assur. Account.

20.23 16.76 22.70 16.47 19.58

19.87 15.62 22.12 15.87 19.00

21.80 17.00 22.60 16.20 20.80

Man-power

22.76

20.25

22.20

Cost Contain

19.88

17.50

20.60

0"\ co

30

20

10

s.w. H.C.A.

R.N.

'.7'",,/" .. _ ~ ........... . " .. ;.----..... '"-.... ~ "{ > -...:p

Health Promotion I Quality & Maintenance Assurance

Utilization and Distribution of Resources

Provider Appropriate Prevention of Access to Illness Accountability Prbnary Care

Figure 1. Comparison of key factor mean scores.

Cost Containment

O"l 1.0

Rank

1

2

3

4

5

6

7

70

Table 6

Ranking of The Key Factors by Total Mean Score

Key Factor

Prevention of Illness

Utilization and Distribution of Manpower Resources

Appropriate Access to Primary Care

Provider Accountability

Cost Containment

Health Promotion and Maintenance

Quality Assurance

Total Mean Score

67.42

65.21

61.90

59.38

57.98

49.38

48.54

two factors are very closely related, in fact, they

are interrelated. Health promotion is a part of pre­

venting illness.

Cost containment was placed fifth in the ranking

according to the mean score of the groups. This rating

is remarkable in view of the emphasis placed on cost

containment in the media and by federal, state, and

local governments.

71

Provider accountability was ranked fourth according

to the mean scores of the groups, and perhaps shows some

indication that it is important to expect some level of

responsibility from within the professions. Regulation

and legislation cannot solve the crisis which exists

in health care.

Providing appropr e access to primary care is

given number 3 ranking and demonstrates a recognition

of the need to assure some level of health care to all

people. Alternative methods of providing primary care

are certainly a part of the issue, but it is not known

to what extent participants considered the issue in

the responses they gave to the statements.

Utilization and distribution of manpower resources

was ranked as number 2 according to the mean scores

of the groups. This factor can be related to all other

factors to some degree. It is a matter of great interest

that it is ranked ~n this position. However, it could

be a reflection of the times and the trend which depict

a growing interest in integrating change in the health

care delivery system.

72

Prevention of illness is ranked as the number one

factor to be considered in developing health care policy_

These professionals apparently support the Surgeon

General's report of 1979 which accorded "prevention"

top billing for the 1980s. New technologies, research,

improved treatment methodologies, education, and access

to care make prevention of illness a goal it is possible

to achieve.

CHAPTER V

DISCUSSION

In examining the data and findings, some general

observations were made about the sample. The first

notable observation was in the number of survey question­

naires returned. It is generally accepted by researchers

that one of the disadvantages of survey research is

the low rate of return of the questionnaires. The 53.8%

return rate for this study represents a significant

response.

The number of registered nurses responding to the

study questionnaire was of interest since this investi­

gator had not anticipated that number of nurses employed

in policy related roles in the Department. The 17

registered nurses comprising 49% of the sample offered

a significant opportunity to assess the perspectives

of registered nurses in relation to the importance of

factors influencing the development of health care

policy.

The third telling observation was found in the

length of time the respondents had been employed at

the Health Department, and the length of time the par­

ticipants indicated they had been in their present

positions. Of those responding to the survey, 77.2%

indicated that they had been employed at the Health

Department for 4 or less years. Seventy-seven percent

of those participating in the study reported that they

had been in their present positions with responsibility

for some aspect of policy for less than 3-1/2 years.

This seems like a relatively short period of time.

No knowledge of previous employment or responsibility

is available in order to determine what influence pre­

vious experience may have had in shaping opinions.

The crisis in health care has been an issue for several

years and perhaps sufficient emphasis and urgency has

been given to the issues that a short period of time

74

is all that is necessary for priorities to be established

in the minds of those involved with policy issues.

The agreement in the responses of the three profes­

sional groups which were compared is somewhat remarkable.

One observer reviewing these data commented that it dem­

onstrated homogeneity within the work setting and could

be evidence of good communication or commitment to goals

which had been cooperatively established. That obser­

vation cannot be supported because the work environment

does not require that all of the participants work

together or even communicate at length. The fact that

one group invited to participate in the study was selec­

ted from an entirely different Division of the Health

75

Department which is housed in a different building would

discount the effect of the working relationship on

homogeneity. It is not known what percentage of the

participants responded to the questionnaire from the

two divisions.

One common thread which can be identified is the

fact that both divisions are within the Utah Department

of Health. Therefore, there would be some common philo­

sophy, goals, purpose and direction. But again, the

Division of Health Care Financing, the Medicaid Agency,

deals with policy and programs for the poor and needy.

The Division of Community Health Services is concerned

with the general population and the public health.

The ranking of the key factors which was established

by summing the mean score for each key factor, is another

notable aspect of the study. The groups invited to

participate in the pilot test of the questionnaire were

specifically asked to rank the 7 factors in order of

their importance. No common order could be established

from either one of those tests. There was no agreement.

One cannot help but question whether the participants

who generated the final data would have ranked the key

factors in the same order had they been specifically

requested to rank the factors.

The research question posed for this study was

answered. Are factors which influence the development

76

of health care policy and programs perceived differently

by professional nurses and other health care profes­

sionals in a State Department of Health? The results

of the study showed that there is little difference

in the perceptions of the various health care profes­

sionals relative to the key factors which influence

the development of health care policy.

Nurses appear to be equally knowledgeable and com­

parable to other health care professionals in consider­

ing the importance of key factors which influence health

care policy development. This conclusion gives credence

to one of the basic tenets underlying the development

of this study. Nurses should be a part of the policy

and planning effort leading to policy development.

Nurses are an essential group of health care providers

and should not shun the responsibility to be involved.

Ulin (1982) indicates that nurses continue to believe

in involvement but emphasize individual freedom of choice

rather than cooperative effort toward health policy

decisions or community action. That commitment needs

to be examined.

Historically, nurses have not been involved in

decision making in any proportion equal to their numbers.

Nurses have traditionally been content to follow the

path which for years was their role, to follow written

orders without question. Recently, nurses have been

77

encouraged to assess, to evaluate, to speak up and let

their voices be heard, to form opinions, and to become

involved in the political process. Most of the current

authors in nursing literature are addressing the issue

of nurses' participation in the community and in public

activities with varying degrees of emphasis. The message

is clear: nurses must assign a higher priority to in-

volvement in public policy decisions. Williams (1983)

in discussing Community Health Nursing stated,

Policy formulation is one of the most important modes by which the health of populations is affected. Accordingly, it may be one of the most crucial prac­tice domains of Community Health Nursing (p. 226).

This author proposes that policy development is indeed

one of the crucial domains of ALL nursing practice.

Nurses have an obligation to be counted among the pro-

fessionals involved in any health care planning effort.

Unfortunately, nurses who leave the bedside to venture

into the domain of management and policy making are

viewed as leaving nursing. However, most of the policy

decisions affecting nursing occur outside the traditional

role of nursing. If nurses are to be involved, they

will have to move beyond traditional roles.

Nurses have a unique perspective of health care

needs based on a holistic approach to patient care

responsibility and long term experience with assessment

of needs, establishing priorities, making judgments,

planning care and evaluating outcomes which would lend

itself very effectively to the decision making process

leading to health care policy development. Becoming

involved in policy making is one way of supporting nur­

sing to assure that nursing and the special value of

nursing care does not get discounted in the pressure

of other issues in the process of policy decisions.

Implications

During development of this study a question was

posed: What will be the locus of planning and who will

be the participants in the future? With the change

78

of emphasis of the current administration in Washington

and the shift of responsibility to the states, more

and more responsibility will fall to the states and

the major part of planning will be the prerogative of

state agencies and state legislatures. The need to

maximize resources through policy decisions and planning

based on professional judgment and expertise of a broad

range of health care professionals appears to be essen­

tial in order to maximize the resources available.

The broad range of health care professionals must assur­

edly include nurses. This study shows nurses to be

comparable to other health care professionals when con­

sidering the key factors important to health care plan­

ning and policy making. In addition, nurses have an

added advantage. They have a special skill and expertise

gained from basic training and education and from pro­

viding patient care which constitutes a special quality

dimension others do not bring to the policy decision

making process. The educational preparation of nurses

to deal w£th patient care from a physiological, bio­

logical, and emotional perspective places nurses in

a patient advocacy role that few others involved in

health care policy decisions will have.

As indicated in the literature, one additional

supporting factor for nurses' involvement in health

79

care planning and policy decision making is that nurses

have established a strong political base in recent years

and are in a position to exert influence on policy

decisions and legislation.

This study has shown nurses to be comparable to

other health care professionals involved in health care

policy development. This information should serve as

a consideration to further the involvement of nurses

in this vital health care process.

Limitations

One limitation of the study was the inability to

adequately test and refine the questionnaire for data

collection. The groups with sufficient knowledge and

experience in health care planning and policy development

who are available to devote time to respond to such

questionnaire testing are limited. Test of the instru-

ment by a larger panel with evidence of agreement among

the groups participating in the tests would assure

validity of the instrument and reliability of the data

collected.

A larger sample in numbers of participants gener-

ating data would increase analytical accuracy of the

data, as Polit and Hungler (1978) concur. With a low

response rate or limited numbers of participants it

is difficult to consider the responses representative,

and it may not be appropriate to generalize the results

of the study to a larger population. In addition to

a larger sample, equal numbers of professionals in each

group to be studied would be an asset to generalization

of the study results. Other professional groups could

be included as part of the study sample to allow for

more comparison and the establishment of a stronger

position from which to analyze any variance in study

results.

Recommendations for Future Research

80

Evidence of previous research on this subject could

not be found in the literature. However, research is

indicated. Objectively-determined data to support the

role of nursing in health care planning and policy

development could serve to encourge participation of

nurses in this vital process. Health care policies

determine practice conditions and the settings in which

nurses function. Policy decisions must become a major

concern and part of the practice domain of nurses in

the future, not only to keep the profession viable,

but to influence the public's welfare.

81

Comparison of nurses with other health care pro­

fessionals in policy development roles is not the only

avenue available for study. Nurses function in practice

settings under policies developed by nurses. Demon­

stration programs could be developed and outcomes objec­

tively studied to determine benefits of such programs

to patients and to society. Research designed to explore

the direct result of policy developed by nurses could

enhance support for nurses' involvement in policy and

planning roles as a viable practice option.

The community offers an opportunity for additional

research. This study could be replicated with emphasis

on comparing the perceptions of nurses working in prac

t settings providing patient care with nurses working

in an agency at a level where policy development occurs.

Nurses in a practice setting may view the factors influ­

encing health care policy development from an entirely

different perspective based on a relationship with

patients d for delivery of care.

Consumers of health care in the community could

also provide an interesting group for study. Their

views about the factors influencing health care policy

development could be compared with the care givers' and

with those involved in health care policy development.

82

APPENDIX A

QUESTIONNAIRE - PILOT TEST FORMAT

Dear Colleague:

You are being invited to participate in a research study conducted by a graduate nurse at the University

84

of Utah. I am interested in finding out whether nurses perceive factors influencing health care policy develop­ment differently than other health care professionals.

The attached questionnaire must be tested by a "panel of experts" to determine if it can effectively measure the data collected and answer the questions identified for study. Since you have major responsi­bility for Health Planning and Policy Development you qualify to be part of the panel.

Participation in this study is completely voluntary and you are under no obligation to respond. Should you choose to participate, it will take less than one hour of your time, and your response will be confiden­tial. Completion and return of these forms will be considered your informed consent to participate in this study.

Within a few weeks, a similar questionnaire will be distributed to selected participants in the Division of Health Care Financing. The conclusions and recom­mendations of the study will be completed by May of 1984.

A self-addressed stamped envelope is included for your convenience in returning the questionnaire. On March 12, 1984, seven (7) days after distribution of this questionnaire, it will be assumed that all who wish to participate will have responded, and the data will be analyzed.

Thank you for your cooperation.

Urla Jeane Maxfield, R.N.

For the purpose of this study the following definitions apply:

85

Health Care Policy is a statement defining the parameters of programs and services providing access to health care.

Cost Containment means control of the increase in cost of human, physical, and technical resources utilized in the delivery of health care services.

Utilization and Distribution of Manpower Resources means the utilization of health care professionals (manpower) prepared to effectively provide service in a safe and competent manner where and when needed in traditional or alternative settings.

Provider Accountability means having responsibility for completing a specific task or providing a specific service and being responsible to answer to "someone" for the quality and cost of the task or service and the manner in which it is completed.

Quality Assurance means assessment of patient health outcomes, process outcomes, and cost outcomes as a result of care and service given. Quality assurance includes use of the results of assessment to recommend corrective action to secure improvement in the outcomes when indicated.

Prevention of Illness means establishing practices and habits of daily living which promote healthy lifestyles and reduce risk factors, thus, avoiding health problems which would threaten individual well being and decrease life expectancy.

Health Promotion and Maintenance means seeking regular health care, following advice, and practicing positive patterns of behavior to assure healthy lifestyles, increased life expectancy and productivity.

Appropriate Access to Primary Care means the opportunity to seek and receive a basic level of "essential" health care which includes education and appropriate preventive and curative services.

Instructions:

Read the statement. On a continuum of 1 to 7, circle the number which best represents the weight of your opinion. Determine which of the factors listed at the far right of the page is reflected by the statement. Check the appropriate column.

Only one factor should be chosen for each statement.

A blank page is provided at the end of the questionnaire for your convenience in making any comments or suggestions about the questionnaire you would like to make.

1. Access to some quantity of Primary Health Care is a basic right rather than a privilege for every individual.

Strongly Disagree

1 2 3 4 5

Strongly Agree

6 7

2. Health Care policy defines the scope of service available to clients. Health care providers (physicians, dentists etc.) are accountable for all aspects of care and service provided.

Strongly Agree

7 6 5 4 3

Strongly Disagree

2 1

3. Health care policy has social, economic and political aspects. The economic aspect, cost containment, is the major factor to be considered in policy development.

Strongly Agree

7 6 5 4 3

Strongly Disagree

2 1

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4 • Quality Assurance is achieved by carefully developed health care policy.

Strongly Strongly Disagree Agree

1 2 3 4 5 6 7

5. A comprehensive health program provided at the place of employment would be an advantage to both employer and employees, because it would encourage health maintenance activities and improve the health status of employees.

Strongly Strongly Agree Disagree

7 6 5 4 3 2 1

6. The quality and amount of health care available to the poor and the elderly would improve with improved access to primary care services.

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Strongly Strongly Disagree Agree

1 2 3 4 567

7. The current emphasis on cost containment is a social force in response to previous expansion of hospitals, emphasis on in­hospital services, increased demand on the system by long term care, and the apparent increase in acuity of care.

Strongly Strongly Agree Disagree

7 6 5 4 321

8. Knowledgeable health care professionals are the best qualified individuals to build provider accountability into health care policy as it is developed.

Strongly Strongly Disagree Agree

1 2 3 4 5 6 7

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Strongly Strongly Agree Disagree

7 6 5 4 3 2 1

1 o . Current social changes and trends emphasizing health promotion and maintenance will stimulate policy development leading to structural changes in the method and location of health care delivery in the future.

Strongly Strongly Agree Disagree

7 6 5 4 3 2 1

1 1. Provider accountability can be assured by physician partici-pation in health care policy development.

Strongly Strongly Disagree Agree

1 2 3 4 5 6 7

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1 2 • In the future, consumers will be less dependent on hospitals for care, because health care policy will permit more effec-tive utilization of manpower resources to provide care in the community.

Strongly Strongly Disagree Agree

1 2 3 4 5 6 7

1 3 . The greatest potential for assuring quality care can be achieved through health care policy developed as a result of highly selective choices made among possible alternatives.

Strongly Strongly Agree Disagree

7 6 5 4 3 2 1

1 4 • Health care policy will give major emphasis to prevention of illness in the next few years. Strongly Strongly

Agree Disagree 7 6 5 4 3 2 1

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15. Tradition and professional dominance hamper development of policy that would creatively utilize manpower resources in health care delivery systems.

Strongly Disagree

1 2 3 4 5

Strongly Agree

6 7

16. Specialized ambulatory surgery centers, birthing centers, and emergency care centers have developed in recent years with little regard for the quality of care clients will receive.

Strongly Strongly Agree Disagree 765 432 1

17. Effective utilization and distribution of manpower resources could be accomplished by health care policy promoting direct care, supervision and education by skilled primary care practitioners if federal restrictions did not prevent reim­bursement for such services.

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1 2 3 4 5 6 7

1 8. Many consumers are capable of taking an active part in pro-moting and maintaining their own health if given proper education and support.

Strongly Strongly Disagree Agree

1 2 3 4 5 6 7

1 9. Prevention of illness and disease is an important concept to consider in health care policy development.

Strongly Strongly Agree Disagree

7 6 5 4 3 2 1

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2 o. Appropriate access to primary care services could be achieved for greater numbers of el ible people by changing some of o'Ur current emphasis and arrangements for providing health care.

Strongly Strongly Disagree Agree

1 2 3 4 5 6 7

2 1 . In tOday's health care market, consumers have an opportunity to seek quality assurance in health care because of the choices available in the community.

Strongly Strongly Disagree Agree

1 2 3 4 5 6 7

2 2. The parameters of careful developed health care policy encourage provider accountability; however, the potential for fraud and abuse is always present. Strongly Strongly

Agree Disagree 7 6 5 4 3 2 1

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2 3 . Health care policy which encourages utilization of primary care networks, preferred provider organizations and case management providers appropriate access to primary care services.

Strongly Strongly Agree Disagree

7 6 5 4 3 2 1

2 4 • Consumers are interested in participating in programs or pro-jects aimed at prevention of illness.

Strongly Strongly Disagree Agree

1 2 3 4 5 6 7

2 5. Access to health promotion and maintenance services will increase in the future because providers will see a need for this emphasis.

Strongly Agree

Strongly Disagree

7 6 5 4 3 2 1

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6. Consumerism and change of public attitudes have played an important role in the development of alternatives allowing effective utilization of manpower resources in providing health care.

Strongly Strongly Disagree Agree 123 4 567

7. Development of health care policy supporting prevention of illness is necessary because of social trends of increased longevity, increasing proportions of women and nonwhites in the population, mobility of the population and tendency toward early retirement.

Strongly Strongly Disagree Agree

1 2 3 4 5 6 7

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Strongly Strongly Agree Disagree

7 6 5 4 3 2 1

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97

The following factors are important in influencing Health Care Policy Development. Please rank the factors accor­ding to your opinion about their importance.

Place the number 1 in front of the factor which, in your opinion, should be given the most consideration when health care policy decisions are made.

Place the number 7 in front of the factor which, in your opinion, should be given the least consideration when health care policy decisions are made.

Match the remaining numbers and factors.

Provider Accountability

Quality Assurance

Effective Utilization and Distribution of Manpower Resources

Cost Containment

Prevention of Illness

Access to Health Promotion and Maintenance Services

Access to Primary Care Services.

Thank you for your cooperation!

APPENDIX B

PARTICIPANT DEMOGRAPHIC INFORMATION

Gender:

Female Male

Age:

25 - 30 31 - 35 36 - 40 41 - 50 Over 50

Profession:

Health Care Administrator Registered Nurse Pharmacist Business Other (Specify)

Education:

High School Associate Degree B.S. Degree (Major) Graduate Degree

Specialty M. S.

B.A. Degree (Major) Ph. D. M. A. :

Length of Time With the Utah Department of Health

Length of Time in present position

Main Emphasis of Policy for your job responsibility:

Development Implementation Program Operation Utilization Review Program Review Other (Specify)

99

APPENDIX C

QUESTIONNAIRE - DATA COLLECTION FORMAT

101

Dear Colleague:

You are being invited to participate in a research study being conducted by a graduate nurse at the Univer sity of Utah. I am interested in finding out whether nurses perceive factors influencing health care policy development differently than other health care pro­fessionals.

Participation in this study is completely voluntary and you are under no obligation to respond. Should you choose to participate, it will take less than one hour of your time, and your response will be confiden­tial. Completion and return of these forms will be considered your informed consent to participate in this study. Conclusions and recommendations of the study will be completed by April of 1984 and available for your review if you desire to know the outcome.

To protect the confidentiality and anonymity of your response, please complete the following page with requested information. Place the completed page in the small envelope which has been provided and seal the envelope. Return'the sealed envelope separately from the remaining part of the questionnaire. By Friday March 30, 1984, it will be assumed that all who wish to participate will have responded, and the data will be analyzed.

Phone: 571-1862

Thank you for your cooperation.

Urla Jeane Maxfield, R.N.

102

For the purpose of this study the following definitions apply:

Health Care Policy is a statement defining the parameters of programs and services providing access to health care.

Cost Containment means control of the increase in cost of human, physical, and technical resources ut ized in the delivery of health care services.

Utilization and Distribution of Manpower Resources means the utilization of health care professionals (manpower) prepared to effectively provide service in a safe and competent manner where and when needed in traditional or alternative settings.

Provider Accountability means having responsibility for completing a specific task or providing a specif service and being responsible to answer to "someone" for the quality and cost of the task or service and the manner in which it is completed.

Quality Asurance means assessment of patient health outcomes, process outcomes, and cost outcomes as a result of care and service given. Quality assurance includes use of the results of assessment to recommend corrective action to secure improvement in the outcomes when indi­cated.

s means establishing practices and --~~--~~~~--~~~ which promote healthy lifestyles and reduce risk factors, thus, avoiding health problems which would threaten individual well being and decrease life expectancy.

Health Promotion and Maintenance means seeking regular health care, following advice, and practicing positive patterns of behavior to assure healthy lifestyles, increase life expectancy and productivity.

Appropriate Access to Primary Care means the opportunity to seek and receive a basic level of "essential" health care which includes education and appropriate preventive and curative services.

Instructions:

Read the statement. On a continuum of 1 to 7, circle the number which best represents the weight of your opinion.

1. Access to some quantity of Primary Health Care is a basic right rather than a privilege for every individual.

Strongly Disagree

1 2 3 4 5

Strongly Agree

6 7

103

2. Health care policy defines the scope of service available to clients. Health care providers (physi­cians, dentists etc.) are accountable for all aspects of care and service provided.

Strongly Agree

7 6 5 4 3

Strongly Disagree

2 1

3. Health care policy has social, economic and politi­cal aspects. The economic aspect, cost containment, is the major factor to be considered in policy development.

4 •

Strongly Agree

7 6 5

Quality Assurance is health care policy.

Strongly Disagree

1 2 3

4 3

achieved by

4 5

Strongly Disagree

2 1

carefully developed

Strongly Agree

6 7

5. A comprehensive health program provided at the place of employment would be an advantage to both employer and employees, because it would encourage health maintenance activities and improve the health status of employees.

Strongly Strongly Agree Disagree 765 4 3 2 1

6. The quality and amount of health care available to the poor and the elderly would improve with im­provied access to primary care services.

Strongly Disagree

1 2 3 4 5

Strongly Agree

6 7

104

7. The current emphasis on cost containment is a social force in response to previous expansion of hospitals, emphasis on in-hospital services, increased demand on the system by long term care, and the apparent increase in acuity of care.

Strongly Agree

7 6 5 4 3

Strongly Disagree

2 1

8. Knowledgeable health care professionals are the best qual ied individuals to build provider account­ability into health care policy as it is developed.

Strongly Strongly Disagree Agree

1 2 3 4 567

9. Health care policy designed to selectively restrict services will have a measurable effect on cost con­tainment.

Strongly Agree

7 6 5 4 3

Strongly Disagree

2 1

10. Current social changes and trends emphasizing health promotion and maintenance will stimulate policy development leading to structural changes in the method and location of health care delivery in the future.

Strongly Agree

7 6 5 4 3

Strongly Disagree

2 1

11. Provider accountability can be assured by physician participation in health care policy development.

Strongly Strongly Disagree Agree

1 2 3 4 567

12. In the future, consumers will be less dependent on hospitals for care, because health care policy will permit more effective utilization of manpower resources to provide care in the community.

Strongly Disagree

1 2 3 4 5

Strongly Agree

6 7

105

13. The greatest potential for assuring quality care can be achieved through health care policy developed as a result of highly selective choices made among possible alternatives.

Strongly Agree

7 6 5 4 3

Strongly Disagree

2 1

14. Health care policy will give major emphasis to pre­vention of illness in the next few years.

Strongly Agree

7 6 5 4 3

Strongly Disagree

2 1

15. Tradition and professional dominance hamper develop­ment of policy that would creatively utilize manpower resources in health care delivery systems.

Strongly Disagree

1 2 3 4 5

Strongly Agree

6 7

16. Specialized ambulatory surgery centers, birthing centers, and emergency care centers have developed in recent years with little regard for the quality of care clients will receive.

Strongly Agree

7 6 5 4 3

Strongly Disagree

2 1

17. Effective utilization and distribution of manpower resources could be accomplished by health care policy promoting direct care, supervision and education by skilled primary nurse practitioners if federal restrictions did not prevent reimbursement for such services.

Strongly Disagree

1 2 3 4 5

Strongly Agree

6 7

18. Many consumers are capable of taking an active part in promoting and maintaining their own health if given proper education and support.

Strongly Disagree

1 2 3 4 5

Strongly Agree

6 7

19. Prevention of illness and disease is an important concept to consider in health care policy develop­ment.

Strongly Agree

7 6 5 4 3

Strongly Disagree

2 1

20. Appropriate access to primary care services could be achieved for greater numbers of eligible people

106

by changing some of our current emphasis and arrange­ments for providing health care.

Strongly Disagree

1 2 3 4 5

Strongly Agree

6 7

21. In today's health care market, consumers have an opportunity to seek quality assurance in health care because of the choices available in the commun­ity.

Strongly Disagree

1 2 3 4 5

Strongly Agree

6 7

22. The parameters of carefully developed health care policy encourage provider accountability; however, the potential for fraud and abuse is always present.

Strongly Agree

7 6 5 4 3

Strongly Disagree

2 1

23. Health care policy which encourages utilization of primary care networks, preferred provider organi­zations and case management provides appropriate access to primary care services.

Strongly Agree

7 6 5 4 3

Strongly Disagree

2 1

24. Consumers are interested in participating in programs or projects aimed at prevention of illness.

Strongly Disagree

1 2 3 4 5

Strongly Agree

6 7

25. Access to health promotion and maintenance services will increase in the future because providers will see a need for this emphasis.

Strongly Agree

7 6 5 4 3

Strongly Disagree

2 1

107

26. Consumerism and change of public attitudes have played an important role in the development of alter­natives allowing effective utilization of manpower resources in providing health care.

Strongly Disagree

1 2 3 4 5

Strongly Disagree

6 7

27. Development of health care policy supporting pre­vention of illness is necessary because of social trends of increased longevity, increasing proportions of women and nonwhites in the population, mobility of the population and tendency toward early retire­ment.

Strongly Disagree

1 2 3 4 5

Strongly Agree

6 7

28. Cost containment can be promoted by health care policy that provides for service to be performed by personnel prepared to provide that service in a safe and competent manner at the lowest cost.

Strongly AGree

7 6 5 4

This questionnaire was completed by:

Health Care Administrator

Registered Nurse

Pharmacist

Business Professional

Other (specify)

3

Strongly Disagree

2 1

Thank you for your cooperation!

APPENDIX D

RELATIONSHIP OF KEY FACTORS

TO STATEMENTS

Statements related Factor to the

Appropriate Access to Primary Care Services.

Health Promotion and Maintenance Services

Prevention of Illness

Quality Assurance

Provider Accountability

Utilization and Distribution of resources

Cost

* 7 1

Containment

Agree Disagree

Manpower

1 6

20 23

5 10 18 25

14 19 24 27

4 13 16 21

2 8

11 22

12 15 17 26

3 7 9

28

factor

109

Ideal Answer*

7 1 7 7

7 7 7 1

7 7 7 7

1 7 1 7

7 7 1 7

7 7 7 6

1 7 7 7

SELECTED BIBLIOGRAPHY

III

A chance to start over for hospital planning. (1981, November). Hospitals, 61-62.

Abdellah, F.G. (1975). Models for health care systems. Models for health care delivery: Now and for the future, American Academy of Nursing, 3-19.

Ackoff, R.L. (1982, October). Our changing concept of planning. The Journal of Nursing Administration, 35-40.

Aday, L. & Anderson, R.M. (1981, December). Equity of access to medical care: A conceptual and empir­icaloverview. Medical Care, XIX(12), 4-26.

A.H.A. convention briefs. (1983, September). Modern Health Care, 40, 49.

Aiken, L. H. (Ed.), (1981). practice. New York:

Health policy and nursing McGraw-Hill, Inc.

Anderson, J.E. (1979). Public policy-making (2nd ed.). New York: Holt, Rinehart and Winston.

Archer, S.E. & Goehner, P.A. cal force. Belmont, CA:

( 1982 ). _N_u_r_s_e_s_: __ A----'p_o_l_i_t_i_­Wadsworth, Inc.

Arndt, C. & Huckaby, L.M.D. (1980). Nursing administra­tion -- Theory for practice with a systems approach (2nd ed.). St. Louis: The C.V. Mosby Company.

Benjamin, A.E., Jr. & Downs, G.W. (1982, Fall). Evalu­ating the national health planning and resources development act: Learning from experience? Journal of Health Politics, Policy and Law, 2(3), 707-722.

Benner, P. & Wrubel, J. (1982, May). Skilled clinical knowledge: The value of perceptual awareness, part I. The Journal of Nursing Administration, 28-33.

Blendon, R.J. & Moloney, T.W. (1982, December 22). Medicaid is vital to the poor: Cut with care. The New York Times.

Blendon, R.J. & Moloney, T.W. (Eds.). (1982). New approaches to the Medicaid crisis. New York: F & S Press, A Division of Frost and Sullivan, Inc.

Brandt, E.N., Jr. (1982, September). Prevention policy and practice in the 1980s. American Psychologist,

112

22(9), 1038-1042.

Brasfield. J.M. (1982. Winter). Health planning reform: A proposal for the eighties. Journal of Health politics. policy and Law. ~(4). 718-738.

Brown. J.H.U. (1978). The politics of health care. Cambridge: Ballinger Publishing Company.

Chen. M.S .• Jr. & Jones. R.M. (1982. June). Establishing priorities in the wellnesS program. occupational

Health and safety, ~(7), 36.

Clearie, A.F., Blair, S.N. & Ward. W.B. (1982, september). The role of the physician in health promotion: Findings from a community telephone survey. The Journal of South Carolina Medical Association~ 503-505.

Cohen, 0.1., Littenberg, B., wetzel, C. & Neuhauser, D.B. (1982. october). Improving physician compli-ance with preventive medicine guidelines. Medical Care, XX(10), 1040-1045. --

Collins, J.A. (1982, January). Medicare and medicaid: Cuts and concerns. Geriatrics, }2(1), 33-39.

Conway, M.E. (1981). The impact of changing resources on he~lth care of the future. In The impact of changlng resour~es of health policy, American Academy of Nurslng, 3-18.

Crow, R .. A. (1981). Research and the standards of nursinl

care: What is the relationship? Journal of Nurslng, 6, 491-496. Advanc

Cunningham, R.M., Jr. (1981 Nov some new dimensions H' ,ember). Planning has . ospltals, 70-72.

Davis, C.K 0 kl ., a ey, D. & Sochalski J Leadership for expand' " .A. (1982, Januar'

P l' lng nurslng . fl

o lCY. Journal of Nursin . 7n uenee on heal . . g Admlnlstration. 15-21

Dletrlch A J . , .. & Marton K I continuous care f' .. (1982, February) 0 rom a ph ' . . oes ence? The Journal of F YSlclan make a differ-937. amlly Practice, 15(5), 929·

Donabedian A Wh 1 , ., ee er J R C October). Qualit' ... & Wyszewianski, L. (19 model. Medical c y , cost and health: An ' ____ ~=-~a~r~e, XX(10), 975-991. lntegrat

&

113

Epstein. R.L. (1981). Antitrust aspects of future health planning. Issues in Health Car~. ~(l). 36-41.

Fagin. C.M. (1982). Nursing's pivotal role in achieving competition in health care. In From accomodation to self determination: Nursing's role in the deve­~ment of health care policy. American Academy

of Nursing, 3-15. Ferguson. D.L. & Brunner, N.A. (1982. october). Balanc­

ing priorities to attain quality care. Nursin~ Management, 13(10), 67-69.

Foley, H.A. (1981. April). sounding board: Health planning __ demise or reformation? The New England Journal of Medicine, lQ!(16), 969-972.

Friedman, E. (1982, December 1). Access to care.

Hospitals, 83-90.

Friedman, E. (1982, october 16). Slicing the pie thinner

Hospitals, 62-74.

F ' d r~e man, E. (198~, November). Voluntary community-wide

health plannlng. Hospitals, 63-66.

GeUderHO

' L: (1982, December 16). Health plannJ.'ng. spltals, 81-84.

Given, B. (1979)' , , f . Patlent part' , ~~nl~~~~e on health POliCy~~~ia~~on. ,In Nursing's emy of Nursing 24 30 e elghties ~. . ,. ' r'>.m~r~-

Graham, R. (1982) , . Pollcy' l' study of the lmp lcations f Jo content of f' 0 the national __ u_r_n~a=1~o~f~F~a~m~i~1~l2~~i.~~aml1Y practi y Practlce, 15(4 ceo The

Green, L H . - ), 735-737-.-. ., Wllson R W

Data requireme~t .. & Bauer, K G (1 objectives for t~ to m~asure pr~g;ess983. January) d~sease preven . e nat~on in health on the Health 73(1} tlon. American Jo promotion and , _ ' 18-23. urnal of Public

Hanson, R.Lo Journal

(1982, December). ' of Nursing Adm' . Managlng human resourc' Hefferin E A lnlstration, 17-23. '

, 0., Horsle Promoting r y, J. & Ventur administrat~S~arch-based nursine

: M.R. (1982, May Admini t r s role Th J g. The nurse

s ration, 34-410

• e ournal of N ursing

'c lic ol~ of ub rceS.

The art and -reSou T.1 \ 1 982 ) . ul at ion sIn c .

p • V'4 • f r e . ons , d HoUse. ~ena 0 bl~cat~ , 'ty an The a~ e pu ~ ib~l~ 101-

HillS: sag Respon~ outlOOk, December). ~

R T. \ 19 82 ,. analyzed. Hull, . ntabil~tY'

aCcou 712. ." ~ nlannin

. Healtl.J. .t' d. . \ 1982) . Marylan .

Hyman f H ·.~~ch \ 2nd ed.)· . report: ~, h pol~CY corporat~on. b r). He~alt En land

septem e. The Ne\tJ J K. \1982, the poor. 40

Inglehard, l·policies and 307(13), 836-8 . Federa f Medicine, --- . report: Journal 0 Health pol~cy of

(1982, AU9ust)·ew England Journ~ Inglehard, J.K. f HMOs. !?e N

The future 0 (7) 451- 456 • Medicine, l22 ' .' d planning: - ) Organ~ze 1 67-69

(1982, November. b fore. Hospita~, Kohlert , S·d 't more than ever e - ,

We nee ~ '. that start the~r ) Hosp~tals .

Kuntz, E.F. (1983~ october. , ations ease st~ng own P

referred provider organ~z 26-27. Modern Health Care,

of discounts. t The second revolution

Michael, J.M. (1982, Augus ~~otion and its environmen­in health -- he~lth ppr holog ist , 37(8), 936-941. tal base. Amerlcan syc --

Mi 1 io, N. (1981). Philadelphia:

Promoting health through public poli' F.A. Davis Company.

Mitsunaga, B.K. (1981, Summer). The use of knowledge and health policy planning: Forms and functions oi the relationships. Western Journal of Nursing Research, 1, 1-8.

Morgan, S. (1981, December). "access and distribution. 1-3.

Introduction: Equity, Medical Care, XIX(12),

Mullan, F. (1982, October 21). Community oriented pri· mary care, an agenda for the '80s. The New England Journal of Medicine, 307(17), 1076-1078.

Nursing's influence on health policy for the eighties. (1979). American Academy of Nursing.

Peterson, K. (1981). Public planning and regulation.

Spitzer, R. & Grace, H.K. (1981). Cost containment: Impact on nursing service and nursing education The impact of changing resources on health poli~ Amerlcan Academy of Nursing. 65-87. - Y

Steve~s, R. & Stevens, R. (1974). W If l A . e are medicine n merlca: A case study of me~d~i~c~a~i~d~.~~~~~

The Free Press. New York:

Think of the pat Care,S.

s. (1983, October). Modern Healtt

Ulin, P.R. (1982, November nursing challenge N~De~ember). International

. rSlng Outlook, 531-535.