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This article will discuss different routes by whichnurses can enter health policy work, describe

one nurse’s experience, and offer some caveats for EDnurses contemplating a move from clinical to policywork.

So there you are, working overtime during onemore short-staffed shift in the emergency department.You are dealing with a host of federal and state regu-latory mandates, a high volume of patients who havegreat needs, inadequate resources to meet thoseneeds, and a lack of on-call specialty physicians. Thewaiting room is packed, and EMS units are en route toyou—with luck, you will even know they are coming.Your holding area is full, too—your hospital and othersare worried about revenues, and some of your sickestand most disadvantaged patients have become “hotpotatoes” who are difficult to place. A host of managedcare requirements confound your efforts to do whatyou came into ED nursing to do in the first place—takecare of people at a time when their condition is theleast predictable and perhaps the most depressing todeal with. Furthermore, any one of your patients maydecide, months or years later, to name you in a com-plaint or lawsuit that you never saw coming. That thecomplaint is ultimately found to have no merit (we allhope!) does not make it any easier to stomach. Ahealth care business or law course you recently tookhas convinced you that you can stop the madness.You have an unexpected moment of epiphany, and the“Ah-ha!” explodes on you in a burst of clear light.

Alternatively, perhaps after years of experienceand education, while actively working in the emer-

gency department or not, you quietly make a decisionthat you want to take your career in a different direc-tion—you want to affect health care delivery systemsfor the greater good of the public. You think that youwill be comfortable with incremental change, delayedsatisfaction, losing some battles along the way evenwhen you are right, being misquoted in the media asoften as not, and being seen as a threat by people andinstitutions with which you have previously been as-sociated. Perhaps the combination of your profession-al insights and that newly minted master’s of busi-ness administration degree has convinced you thatyou can make this system run better—either from apublic position of some sort, or from a position with aregulatory or accrediting agency, or as a consumeradvocate. Perhaps you want to engage in this workfor a specific period of time as a career-broadeningmove, with a plan to re-enter the provider side of thehealth care industry later. These different motivationsare all valid.

Whether this insight comes to you in a flash orafter lengthy deliberations, I am tempted to warn youthat a skinny man in a dark suit who looks remarkablylike Rod Serling is waiting for you up ahead, standingby the signpost at the intersection of 2 roads. Not toworry—you are not actually heading into the Twilight

Ken Simpson is Director of Professional Services at Phoenix IndianMedical Center, Phoenix, Ariz. He has earned associate’s and bach-elor’s degrees in nursing, master’s and doctoral degrees in businessadministration, and USAF Flight Nurse wings. He is a career UnitedStates Public Health Service officer, holding the rank of Commander.For reprints, write: Kenneth W. Simpson, 8434 North 17th Dr,Phoenix, AZ 85021; E-mail: Ken.Simpson@pimc.ihs.gov.J Emerg Nurs 2000;26:615-7.Copyright © by the Emergency Nurses Association.0099-1767/2000 $12.00 +0 18/9/111067doi:10.1067/men.2000.111067

Policy PerspectivesOne RN’s journey into policy workAuthor: Kenneth Simpson, RN, DBA, Phoenix, Ariz

The date was October 22,1997, and the issue wasconcern over the number ofemergency departments thatwere closing in California,particularly in the northernpart of the state, in the wakeof a disastrous flu season.

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Zone, but you have arrived at the border of a new ter-ritory. You have made a decision to take a road lesstraveled, to find a way to personally influence healthcare policy. That road will be a bumpy one. Welcome,colleague.

How do you go about taking this road less trav-eled? That depends on what you want to do. First,consider Thoreau’s advice and “probe the earth andsee where your main roots run.” If your passion lies inchampioning the cause of a specific group of peoplewho are perhaps afflicted by a particular disease ordanger (eg, nursing home residents, the urban work-ing poor, patients with HIV/AIDS, underprivilegedwomen needing prenatal care, homeless people withmental illness, staff nurses at risk for needlesticks orlatex allergy, or the citizenry of a rural area faced withlosing their only hospital or at risk of exposure to pes-ticides and other toxins), then you should go the routeof advocacy. Advocacy allows you to challenge thestatus quo directly, draw attention to your cause, andenlist like-minded people to assist you. It also freesyou to make demands of government agencies andprivate facilities alike. Many of these causes are al-ready espoused by organizations, and you maychoose to ally yourself with one of them or become asolo advocate at a grassroots level. You may be able toadvocate in your off-duty time if your advocacy workis not a paid position. If you work, however, be mind-ful of securing employment that will not be jeopar-dized by your advocacy efforts. The reason that youare an advocate is to effect change in health care pol-icy. That takes time, and you have to be able pay yourbills if you are going to be around long enough to dosome good.

I was an ED nurse who became involved in healthcare policy. How did I make this transition? My first

job as a registered nurse was as a staff ED nurse in1976, an experience that has shaped much of my pro-fessional life and outlook. Later, I was commissionedas an officer in the Air Force Nurse Corps and report-ed to a training base hospital in West Texas in late1977. While assigned to the general 21-bed wardthere, I picked up an additional duty as the “ER advi-sor” based on my civilian experience. Our little emer-gency department was staffed only by medics, andpatients who were not treated by the medics wereseen by the house physician who was on call. Afterreturning to civilian life in 1981, I spent 6 years in avariety of jobs—cardiovascular ICU, telemetry, homehealth, director of nurses in long-term care, and staffnurse on a state mentally retarded/developmentallydisabled campus. In 1987 I returned to federal serviceas a US Public Health Service officer, in an assign-ment to an Indian Health Service (IHS) hospital inrural Arizona. This initial assignment with the IHSput me in charge of the clinic and emergency depart-ment at a rural hospital on the Gila River Indian Reser-vation. This experience was one of richest I have everhad—not easy or routine, but rich.

When I transferred to the San Francisco office ofthe Health Care Financing Administration in 1992 asa fledgling surveyor, the bulk of my work consisted ofinspecting nursing homes and serving as a case re-viewer and regulatory consultant to the states. Othertypes of health care providers—hospitals, homehealth agencies, and others—were assigned to me asadditional duties. In 1994, after 8 years on the backburner, the “Emergency Treatment And Labor Act”(EMTALA) burst on the scene, with HCFA’s publica-tion of the first edition of the EMTALA InterpretiveGuidelines, which spell out requirements for screen-ing and transfer of emergency patients. My ED back-ground was directly relevant to these issues, and I be-came the lead interpretation and enforcement officerfor these regulations for HCFA Region 9. In this role, Ihad the opportunity to propose interpretive languagethat was eventually adopted verbatim in the third(5/98) edition of the EMTALA guidelines. This lan-guage remains in effect as I write this article in Au-gust 2000, which is a source of personal satisfaction.

As EMTALA’s Region 9 lead interpretation andenforcement officer, as in any federal surveyor posi-tion, I became involved in the national debate sur-rounding my areas of regulatory expertise, and re-mained so even after leaving HCFA in 1999. As asurveyor, you can expect to perform a certain numberof the surveys yourself, accompany many state surveyteams on site, travel a lot, field angry calls from thepublic, write defensible Statements of Deficiency thatfacilities must address, and judge the adequacy of a

You must be able to setaside your individualconvictions and look at ahealth care organizationfairly and dispassionately,regardless of how outrageousthe facts or how tragic thecircumstances. This task isnot easy and is not for thefaint of heart.

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health care facility’s plan of correction. Such policy-related positions offer the opportunity to directly influ-ence or create regulations and guidelines that becomethe standards that facilities participating in Medicaremust meet on a national basis. With EMTALA in par-ticular, I found myself interacting extensively withhospitals and medical associations—sometimes in therole of explaining the EMTALA requirements, some-times in the role of advising the hospital that its planof correction for the problems found during anEMTALA survey was not adequate and that the hos-pital was facing termination from the Medicare/Med-icaid program. During a period of 7 years, I was in-volved in regulation of nursing homes, hospitals ingeneral (and EMTALA enforcement in particular),dialysis facilities (end-stage renal disease facilities),and in the development and enforcement of surveyprotocols for organ procurement organizations.

Besides testifying as a government witness in anadministrative law hearing, one of the more interest-ing experiences I had while at HCFA was to give tes-timony on behalf of the Agency before the CaliforniaState Assembly’s Committee on Health. The date wasOctober 22, 1997, and the issue was concern over thenumber of emergency departments that were closingin California, particularly in the northern part of thestate, in the wake of a disastrous flu season charac-terized by widespread ED overloading and some pa-tient deaths. It was an experience that left me with asense of awe and quiet pride. I had done somethingthat would contribute to the public good. It washeady stuff.

In 1999 I returned to IHS. My position includedextensive involvement in risk management, compli-ance, medical staff, evolution of the organization, and,of course, ED issues. I continue my broader EMTALAinvolvement through contributions to an emergencymedicine trade publication and Arizona hospital andAmerican College of Emergency Physicians semi-nars, and I provide consultation throughout IHS as an“additional duty.” Of late, opportunities for consultingand expert witnessing (on my own time, not repre-senting the government) have developed.

Affecting public policy via the regulatory routemakes some specific demands: you cannot act as anadvocate for a specific cause, and you are tasked toensure facility compliance with the laws of the land.

To be successful, you must be able to set aside yourindividual convictions and look at a health care orga-nization fairly and dispassionately, regardless of howoutrageous the facts or how tragic the circumstances.This task is not easy and is not for the faint of heart.Besides the professional knowledge a nurse brings tothe job, he or she must be an expert practitioner ofcritical thinking and be able to establish what thefacts were at a specific point in time. You must ac-cept that anything you say or do may wind up in ahearing with testimony under oath, and that no mat-ter what you decide, somebody will still be mad atyou—a complainant, a family member, an advocate,or people at a facility that you threaten with decertifi-cation, loss of revenues, bad press, and possible civilor criminal sanctions.

If a federal position is not your cup of tea, you cando much the same thing as a surveyor for a state sur-vey agency. Generally this is the State Department ofHealth Services, Division of Licensure and Certifica-tion, or an agency with a similar name. “Licensure”indicates state licensure of the facility to operate, and“certification” means the facility meets the require-ments for billing the federally funded Medicare andMedicaid programs. State employees may not havetravel requirements as extensive as those of a federalsurveyor. State surveyors must be able to keep stateand federal requirements separate, because theyoften differ. State surveyors also have the unique op-portunity to affect policy on the state level, an oppor-tunity federal surveyors do not have.

Getting into policy work via state or federalroutes, over time, creates the opportunity to positive-ly influence the health of the public—and not just inthe context of emergency care. It is not for every-body—but if it is a good fit for you, few endeavors aremore rewarding.

Submissions to this column are welcomed and en-couraged. Contributions may be sent to Ruth E.Malone, PhD, RN, Institute for Health PolicyStudies, Box 0936, Laurel Heights Campus, Uni-versity of California, San Francisco, San Francisco,CA 94143, phone (415) 476-3273; E-mail: rmalone@itsa.ucsf.edu.