NR442 - STUDY GUIDE NO. 4

*LEADERSHIP BY EXAMPLE* REPORT ON QUALITY ENHANCEMENT PROCESS - CONCLUSIONS

There is a lack of consistent performance measurement across and within programs. The usefulness of quality information has been questioned. There is a lack of a conceptual framework to guide the evaluation. There is a lack of computerized clinical data. There is a lack of commitment to guide decisions. There is a lack of a systematic approach for assessing the quality enhancement activities.

HOW VOLUNTARY HEALTH AGENCIES FIT INTO THE OVERALL HEALTH CARE SYSTEM

They support research, education, and services for particular groups of patients Voluntary health agencies are committed to specific diseases, organ or body structures, health and welfare of special groups, or particular phases of health

WHY NURSES SHOULD BE KNOWLEDGEABLE ABOUT HEALTH CARE FUNDING

To better serve as patient advocates in policy making for funding that provides appropriate care for the greatest good

MAJOR CHANGE AFTER MEDICARE DRUG BENEFIT WAS INTRODUCED

Use of drugs and their cost immediately increased ** sick people = profit

KLUCKHOHN & STRODTBECK - FIVE QUESTIONS THAT ADDRESS VALUES & NORMS

What is the character of innate human nature (human nature orientation)? What is the relationship of the human to nature (person-nature orientation)? What is the temporal focus (i.e., time sense) of human life (time orientation)? What is the mode of human activity (activity orientation)? What is the mode of human relationships (social orientation)?

USE OF SILENCE - NURSING CONSIDERATION

Wide cultural variation exists when interpreting silence. Some individuals find silence uncomfortable, whereas others use silence to show understanding and respect. *The only way to know the meaning of the silence is to ask*

CORRECT PROCESS A BILL MUST TAKE BEFORE FINAL APPROVAL BY THE PRESIDENT

a bill must succeed through two legislative bodies - House of Representatives - Senate Once the bill is approved by the House and the Senate, it can be submitted to the President for approval

ASIAN CULTURE - EXPECTED BEHAVIORS MAY INCLUDE...

a client being quiet and compliant, asking few questions a client averting his/her eyes during the conversation a client may provide nurse with answers he/she thinks the nurse wants to hear

CULTURAL IMPOSITION

a person's tendency to impose his or her own beliefs, values, and patterns of behavior on individuals from another culture

LOBBYIST

a person, who voluntarily or for a fee, represents himself/herself, or another individual, organization, or entity for the purpose of influencing policy or legislation

HEALTH POLICY - DEFINED

a statement of a decision regarding a goal in health care and a plan for achieving that goal

PERSONAL HEALTH CARE MODELS - COMMUNITY HEALTH CENTERS

addresses broader inputs into health such as education and housing

PATIENT PROTECTION AND AFFORDABLE CARE ACT

aka "Health Care Reform Act" requires all U.S. citizens to have qualifying health care coverage expands eligibility for Medicaid subsidizes premiums for lower/middle income families requires coverage for dependent children up to age 26 eliminates restrictions on coverage for pre-existing conditions eliminates lifetime limits on coverage requires plan to include preventive care/screening without consumer cost sharing

DIETARY PRACTICES - HINDUISM

all meats are prohibited

YIN-YANG THEORY

all organisms and objects in the universe consist of yin or yang energy forces origin of the energy forces is within the autonomic nervous system, where balance between the opposing forces is maintained during health yin energy represents the female and negative forces (e.g., emptiness, darkness, and cold), yang forces are male and positive, emitting fullness, light, and warmth.

CRITICAL THEORY

an approach that raises questions about oppressive situations involves community members in the definition and solution of problems facilitates interventions that reduce health-damaging effects of environments

BARRIERS TO HEALTH CARE

any condition that prevents an individual from seeking desired health care presents a barrier *Examples* inability to communicate pre-existing conditions non-participating physician financial burden/inability to pay lack of transport to/from facility

PUBLIC SECTOR POLICIES

are slow and *reactive* economics is just one of many factors involved public policies are determined by voting shifts, electoral realignment, and term limits

ALTERNATIVE QUESTION TO ASSESS FOR SOCIOECONOMIC STATUS (SES)

ask patient about their education or employment position *Rationale* SES may be determined by examining income, occupation, and educational level. If that is not possible, age, gender, possessions, location of residence, religion, and race may also be considered.

STRATEGY USED BY INDUSTRY GIANTS TO REDUCE COSTS OF HEALTH INSURANCE FOR THEIR EMPLOYEES

assemble their own health care programs *Example* Kaiser Permanente Problem: enrolles/employees had limited choice; preventive care was covered and encouraged, but care was restricted. Cost reduction was driven by the idea that fewer services = less cost

CORE ENVIRONMENTAL HEALTH COMPETENCIES

assessment management communication

NEW NATIONAL HEALTH GOALS

attain high quality, longer lives free of preventable disease, disability, injury, and premature death achieve health equity, eliminate disparities, and improve the health of all age groups create social and physical environments that promote good health for all promote quality of life, health development, and health behaviors across all life stages.

NURSE WHO REPRESENTS THE STATE PROFESSIONAL ASSOCIATION - ACTION REQUIRED WITH RESPECT TO LEGISLATION

be prepared to provide testimony and comment on relevant issues important to nursing

NURSE LOBBYIST - CRUCIAL TASK TO ACHEIVE

be seen as a reliable and credible source of accurate information

PERSONAL HEALTH SERVICES

care for individuals and families in: - clinics - schools - correctional facilities (prisons)

NOTABLE CHANGE OF THE OMNIBUS BUDGET RECONCILIATION ACT

changed from process evaluation to outcome evaluation when evaluating care established guidelines for the use of restraints added prescription drug benefits for Medicaid recipients

LEAST EXPENSIVE APPROACH TO TREATING CHRONIC DISEASES

choose health lifestyle behaviors to retain health healthy lifestyles can modify or even prevent most chronic illnesses

ADVANCED PRACTICE NURSE THAT DOES NOT HAVE ADVANCED EDUCATION IN A CLINICAL SPECIALITY

clinical nurse leader

GRASSROOTS COOPERATION

communication from individual constituents via email, telephone, or postal mail can have great influence *Example* a nurse, who is unable to be actively involved at the state level, can still communicate her position (with rationales) through direct/personal communication to a legislator

LOCAL HEALTH DEPARTMENT SERVICE CATEGORIES INCLUDE...

community health services environmental health services personal health services mental health services

PERSONAL HEALTH CARE MODELS - SINGLE SPECIALTY GROUP

consists of physicians in the same specialty who pool expenses, income, and offices

COMMUNITY HEALTH SERVICES

control of communicable disease - surveillance - immunizations maternal/child health programs nutrition services health promotion education

LEININGER'S NURSING DECISION & ACTION MODELS

culture care preservation and maintenance culture care accommodation and negotiation culture care repatterning and restructuring

ACTION THAT WOULD HELP DECREASE TOTAL HEALTH CARE COSTS IN THE UNITED STATES

decrease fraud and abuse

PRIVATE SECTOR - HEALTH CARE POLICIES

deliver, insure, or fund health care services outside government control insurance company (fully-insured) or employers (self-insured) draft policies that determine: - what illnesses to cover - what drugs to include in the formulary - how much to charge for coverage

COST CONTAINMENT - RATIONING

determining the most appropriate use of health care or directing the health care where it can do the most good treatment outcomes are highly variable what appears to be the best course of action for one client is not the best course of action for another health care decisions need to incorporate many variables in order to ensure the best outcome

CULTURE-BOUND SYNDROMES

disorders found only in particular cultures

ENGAGING COMMUNITY PROBLEMS OF THE ENVIRONMENT - FIRST STEP

educate the public about environmental health hazards

ENVIRONMENTAL CORE COMPETENCY - COMMUNICATION

education communication conflict resolution marketing environmental/public health as a service

SINGLE PARENT

either mother or father and at least one child

THE PRIVATE SECTOR INCLUDES...

employers professional organizations - American Hospital Association non-profit health care organizations - American Heart Association for-profit health care organizations - Weiss Memorial Hospital@Uptown

CULTURAL CARE - IMPORTANT NURSING ACTION REQUIRED BEFORE PROVIDING CARE

establish rapport gain trust/confidence

LINEAL RELATIONSHIPS

exist by virtue of heredity and kinship ties. relationships follow an ordered succession and have continuity through time *Example* a patient may seek assistance from other members of the family and allow a relative to make decisions about health care matters

DAY OF WORSHIP - MUSLIM

extends from sunset on Thursday to sunset on Friday

LEVEL OF GOVERNMENT THAT ESTABLISHES REGULATIONS AND PROVIDES FUNDING FOR HEALTH CARE

federal government

PROVIDES CARE FOR MILITARY PERSONNEL, THEIR FAMILIES, AND VETERANS AS WELL AS NATIVE AMERICANS

federal government

COLLATERAL RELATIONSHIPS

focus is primarily on group goals, and family orientation is important *Example* many Asian clients describe family honor and the importance of working together toward an achievement of the group versus a personal goal

ENVIRONMENTAL HEALTH SERVICES

food hygiene/food safety - inspection of processing plants - inspection of restaurants protection from hazardous substances control of waste, air, noise, and water pollution occupational health

SMALL COMMUNITY GROUP WHO HOPES TO ACCOMPLISH GOALS AGAINST A LARGE POWERFUL CORPORATION - WHAT ACTION CAN THEY TAKE

form coalitions with other groups who have similar interests

"TRANSCULTURAL NURSING" - DEFINED BY LEININGER

formal area of study and practice focused on a comparative analysis of different cultures and subcultures in the world with respect to cultural care, health and illness beliefs, values, and practices with the goal of using this knowledge to provide culture-specific and culture-universal nursing care to people

NURSE REINVESTMENT ACT OF 2003

funding initiatives that were created in response to a critical nursing shortage in the U.S. funding is provided to increase nursing school enrollments and the number of practicing nurses

COMMUNAL FAMILY

group of men and women with/without children

HOW THE POPULATION OF THE UNITED STATES IS CHANGING

growth will occur because of ongoing immigration

PERSONAL HEALTH CARE MODELS - INTEGRATED HEALTH MAINTENANCE MODEL

has prepaid multi-specialty physicians

HOW HEALTH CARE COSTS ARE SPREAD OVER A PERSON'S LIFETIME - WHAT CONCLUSION CAN BE DRAWN

health care expenditures increase with age

CURRENT TREND RELATED TO HEALTH CARE SERVICES

health care organizations are offering services low in cost and higher in reimbursement.

SERVICES PROVIDED AT THE PRIVATE SUBSYSTEM LEVEL INCLUDE...

health promotion prevention and early detection of disease diagnosis and treatment of disease with a focus on cure rehabilitative-restorative care custodial care

WHEN ASSISTING SPECIFIC AGGREGATES - COMMUNITY NURSE OUTCOME

help people learn from their own experience and analyze the world with the intention to change it

NUCLEAR DYAD

husband and wife with no children (or no children living at home)

NUCLEAR FAMILY

husband, wife and child/children

BLENDED FAMILY

husband, wife, and children from previous relationships

PERSONAL HEALTH CARE MODELS - SOLO PRACTICE

independent physician in private practice only physician in the office

HEALTH CARE SERVICES THAT ARE PROVIDED BY PHILANTHROPICAL GROUPS

informational and research groups *Rationale* Philanthropic funding, whose services are typically research or disease oriented, pays a limited amount of health care Services are limited to the specific disease or population of interest. Informational and research activities constitute the majority of services provided, although some give direct care or meet ancillary needs such as housing, transportation, or wigs

REGISTERED NURSE SAFE STAFFING ACT OF 2013

introduced in Congress to address concerns of inadequate and inappropriate staffing, which threatens patients' safety and the nurses' health the act would encourage development of staffing systems that require the input of direct care registered nurses, as well as protection for RNs who speak out about patient care issues *note*: this act has not been passed yet

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

issues covered by the law include: - privacy/confidentiality - portability of coverage - limits on coverage due to preexisting conditions

PRIVATE SECTOR POLICIES

largely influenced by theories of *economics* and business management, including consumerism and *market trends* such policies can react quickly and are often *proactive*

CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA)

law requires all hospitals with emergency services that participate in Medicare to treat any client in their emergency services, whether or not that client is covered by Medicare or has the ability to pay law that allows a severed employee and/or their family members to continue health coverage for a specified period of time

ACCORDING TO SIR EDWARD TYLOR, CULTURE HAS FOUR BASIC CHARACTERISTICS

learned from birth through the processes of language acquisition and socialization shared by members of the same cultural group adapted to specific conditions related to environmental and technical factors and to the availability of natural resources culture is dynamic

ENVIRONMENTAL HEALTH ASSESSMENT SHOULD INCLUDE...

living patterns work risks atmospheric quality water quality housing food quality waste control radiation risks

HEALTH CARE PROVIDER ORGANIZATION THAT IS SEEING INCREASE IN DEMAND FOR THEIR SERVICES

long-term care facilities *Rationale* decreased hospital stays result in more home care admissions and more discharges to long-term care facilities for short-term recovery and rehabilitation

MENTAL HEALTH PARITY AND ADDICTIONS EQUITY ACT OF 2008

mandates that group health plan benefits, coverage, and limitations that apply to medical-surgical services must also apply to mental health services equally mental health coverage cannot be more restrictive *example* no lifetime max on in-patient hospital stay vs. 30-day limit on in-patient mental health stay

PROVISIONS OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT

mandating that all citizens obtain health insurance expanding Medicaid eligibility subsidizing insurance premiums for low income purchasers prohibiting denial of coverage for preexisting conditions establishing health insurance exchanges

DAY OF WORSHIP - ROMAN CATHOLIC

may worship in the late afternoon or evening on Saturday or all day Sunday

*TO ERR IS HUMAN: BUILDING A SAFER HEALTH CARE SYSTEM* REPORT - FINDINGS & RECOMMENDATIONS

medication errors contribute to 44,000 - 98,000 deaths each year errors are largely the result of system failures health care systems must focus on error prevention and promote changes to improve processes that will promote safety

STATE PUBLIC HEALTH DEPARTMENT - NURSING ACTIVITY

monitor the incidence of influenza in the state

NURSE INVOLVEMENT IN POLICY INCLUDES...

monitoring the quality ratings of health care organizations and suggesting changes that would improve care conducting/supporting health policy research working with health care professionals to influence change in the quality of health care writing letters to educate legislators about health care issues

EXTENDED FAMILY

nuclear family pluse other blood relatives

WHY FEDERAL GOVERNMENT IS UNABLE TO DO WHATEVER POLITICIANS WANT

only actions authorized by the constitution are legitimate

INDEMNITY PLANS

paid all the costs of covered services provided to the enrollee enrollee enjoyed free choice of provider and services plan preserve the enrollee's right of choice and allow the person to manage his or her own health care *Example* Art Buchwald - retired Times Mirror employee who had his own retiree indemnity plan

LEININGER'S TERM "CULTURE SPECIFIC"

particularistic values, beliefs, and patterning of behavior that tend to be special, local, or unique to a designated culture do not tend to be shared with members of other cultures

PERSON/NATURE ORIENTATION - HARMONY

people and nature exist together as a single entity *Example* "If I follow the diet described and use medication to lower my blood pressure, I can restore the balance and harmony that were upset by this illness. The emotional stress I've been feeling indicates an inner lack of harmony that needs to be balanced."

PERSON/NATURE ORIENTATION - MASTERY

people are intended to overcome natural forces and to put them to use for the benefit of humankind *Example* "I will overcome this hypertension no matter what. By eating the right foods, working toward stress reduction, and conquering the disease with medication, I will take charge of the situation and influence the course of my disease."

PERSON/NATURE ORIENTATION - DESTINY

people are subjugated to nature in a fatalistic, inevitable manner *Example* "Why should I bother watching my diet, taking medication, and getting regular blood pressure checks? High blood pressure is part of my genetic destiny and there is nothing I can do to change the outcome. There is no need to waste money on prescription drugs and health checkups."

ETHNOCENTRISM

person's tendency to view his or her own way of life as the most desirable, acceptable, or best and tendency to act in a superior manner toward individuals from another culture

SICK BUILDING SYNDROME

phenomenon in which public structures and homes cause occupants to experience a variety of symptoms, such as headache, fatigue, and exacerbation of allergies

WELFARE REFORM ACT OF 1996

placed restrictions on eligibility for AFDC Medicaid, and other federally funded welfare programs law decreased the number of people on welfare forced many individuals to take low-paying jobs, many of which did not offer health insurance

FLAW OF INDEMNITY PLANS

plans lacked incentives to retain costs

CRITICAL ISSUES IN HEALTH CARE ADDRESSED BY HIPAA

portability of insurance coverage and pre-existing conditions Insurance companies setting limits on coverage of longer than 12 months

HOW LOCAL GOVERNMENT IS PROVIDED AUTHORITY

power is delegated by the state states may delegate powers to the local government

ENVIRONMENTAL CORE COMPETENCY - MANAGEMENT

problem solving economic/political issues organizational knowledge/behavior managing work computer/information technology reporting/documentation/record keeping partnering

USING DRGs TO DETERMINE REIMBURSEMENT - UNFORTUNATE CONSEQUENCES

providers had strong incentive to undertreat and underuse health resources high quality care was no longer assured

HOW COMPLIMENTARY/ALTERNATIVE THERAPIES DIFFER FROM TRADITIONAL HEALTH CARE

providers vary in training and licensure reimbursement is often unavailable

PERSONAL HEALTH CARE MODELS - MULTISPECIALTY GROUP PRACTICE

provides for interaction among specialty areas

STATE CHILD HEALTH IMPROVEMENT ACT (SCHIP) OF 1997

provides insurance for children and families who cannot afford health insurance law was extended, not renewed by the Bush administration, and then renewed by the Obama administration where it became the Children's Health Insurance Reauthorization Act of 2009

PUBLIC POLICY DECISIONS ARE MADE BY WHICH PART OF THE FEDERAL GOVERNMENT

public policy refers to decisions made by legislative, executive, or judicial branches at the local, state, or federal levels of government.

LEADING CAUSE OF LUNG CANCER AMONG NON-SMOKERS

radon gas *Rationale* Radon exposure is the leading cause of lung cancer among nonsmokers in the United States. It is estimated that radon causes an estimated 21,000 lung cancer deaths every year.

LIFESTYLE BEHAVIORS THAT CAN PREVENT CHRONIC ILLNESS

reducing stress maintaining an optimal body weight smoking cessation exercise regularly

INDIVIDUAL RELATIONSHIPS

refer to personal autonomy and independence individual goals dominate, and group goals become secondary

CULTURAL NEGOTIATION

refers to the process in which messages, instructions, and belief systems are manipulated, linked, or processed between the professional and lay models of health problems and preferred treatment. in each act, the nurse gives attention to eliciting the client's views regarding a health-related experience (e.g., pregnancy, complications of pregnancy, or illness of an infant).

*LEADERSHIP BY EXAMPLE* REPORT

requested by Congress that recommended a more systematic approach to promote quality and to use technology in government-funded programs

EXECUTIVE ORDER 12898

required all federal agencies to develop comprehensive strategies for achieving environmental justice. directive has served to increase public participation and access to information as well as provision of education about multiple risks and cumulative exposures

APPROPRIATE TERM FOR INTOXICATED DRIVERS, SECONDHAND SMOKE, URBAN CROWDING, NOISE, AND MECHANIZATION

risks in the built environment

GAY FAMILY

same-gender couple with/without children

MENTAL HEALTH SERVICES

services are supported by funds offered by local and regional mental health and mental retardation facilities and programs

THIS IS ACCOMPLISHED THROUGH PUBLIC POLICY

solutions to problems of public concern are developed

COST CONTAINMENT - CAPITATED REIMBURSEMENT

statistical norms, practice parameters, and population data determine the capitated, or maximum, payment for services this is the maximum reimbursement amount that the health care provider will receive for the provision of care *example* accepting a payment of $50 as "payment in full" even though the actual cost of service was higher

ADVISORY COMMISSION ON CONSUMER PROTECTION AND QUALITY IN THE HEALTH CARE INDUSTRY REPORT - KEY OUTCOME

stimulated the Institute of Medicine to explore quality in more depth known as the *Quality Chasm Series*

DAY OF WORSHIP - JEWISH/SEVENTH DAY ADVENTIST

sunset on Friday to sunset on Saturday

HOW TO INFLUENCE INTERNAL PRIVATE HEALTH POLICY - NURSING ACTION

support nursing research done that demonstrates positive clinical and economic outcomes

CULTURAL STEREOTYPING

tendency to view individuals of common cultural backgrounds similarly and according to a preconceived notion of how they behave

MEDICARE MODERNIZATION ACT OF 2003 - KEY BENEFIT

the addition of prescription benefits for seniors and people living with disabilities

FEDERAL LEVEL SUBSYSTEM TARGETS...

the general population special populations international health

GLOBAL WARMING

the gradual increase in the average temperature of Earth's near-surface air and oceans since the mid-twentieth century and its projected continuation

USE OF FOLK HEALER - NURSING CONSIDERATION

the nurse should be aware of alternative practices and folk healers that are used by the groups for which they care nurse should also be aware that most indigenous healing practices are innocuous, regardless of whether they are effective It is usually helpful to include any behaviors that may be helpful or neutral in effect

WHEN A BILL IS PASSED BY THE LEGISLATURE, BUT IS NOT ENDORSED BY THE PRESIDENT - WHAT HAPPENS?

the president may sign it so it becomes law however, if he neither signs nor vetoes it, the bill becomes law by default

PUBLIC POLICY - DEFINED

the study of specific policy problems and governmental responses to them

FACTOR THAT HAS LED TO COOPERATION BETWEEN STATE AND FEDERAL LEVEL WITH REGARD TO PUBLIC HEALTH

the threat of bioterrorism

BIOMEDICAL PERSPECTIVE

theory of illness causation based on the following beliefs: all events in life have cause and effect human body functions more or less mechanically all life can be reduced to smaller parts (i.e. human = body, mind, and spirit) all of reality can be observed and measured

WHY EMPLOYERS DECIDE TO SELF-INSURE

to reduce administrative costs charged by insurance companies

CULTURAL CARE - NURSING CONSIDERATION

unless an action is harmful, the nurse should engage in culture care preservation and maintenance *Example* A nurse observes a client wrapping a tummy band around her newborn's abdomen. Nurse: "Can you explain to me the purpose of wrapping a band around the baby's tummy?"

COHABITATION

unmarried man and woman sharing a household with/without children

CRITICAL THEORY - HOW THIS THEORY IS USED BY NURSES

used to help community health nurses think about social, cultural, economic and political factors of health allows nurses to attack the problem at its source and alter community-wide precursors of poor health

WHEN A HEALTH CARE ORGANIZATION RECEIVES FEDERAL FUNDING FOR A SPECIAL HEALTH CARE NEED

when the funding is no longer provided, the programs cease results in a lack of continuity of care

USING ENVIRONMENTAL PERSPECTIVE - MOST IMPORTANT QUESTION FOR NURSE TO ASK WHEN ASSESSING POTENTIAL HEALTH PROBLEMS

"Can you tell me what you do at work?" *Rationale* Because 25% of worldwide preventable illnesses are caused by poor environmental quality, nurses need to ask critical questions about their clients' work and home environments to help discern the contributions of specific hazards to their health.

BUILDING A COLLECTIVE STRATEGY - QUESTION THAT THE COMMUNITY NURSE SHOULD ASK

"who is affected by the problem?" *Rationale* Dialogue from critical thinking should facilitate community involvement and is not focused on a single individual

WHY SO MANY AMERICANS CONTINUE TO ENGAGE IN UNHEALTHY BEHAVIORS

*Americans believe that most illnesses can be cured with insurance footing the bill* Society sees insurance as an economic shield protecting against all disease and illness. The belief in cure rather than prevention, combined with this financial safety net, encourages society to become a passive participant in health care.

NURSE-MIDWIFE WHO CRUSADED FOR FREESTANDING BIRTH CENTERS

*Dr. Ruth Watson Lubic* developed model through the Maternity Center Association in New York City

*HEALTH PROFESSIONS EDUCATION* REPORT - KEY SUGGESTIONS

*Five Core Competencies* provide patient-centered care work in interdisciplinary teams employ evidence-based practice apply quality improvement use informatics

ENVIRONMENTAL HEALTH MNEUMONIC - *I PREPARE*

*I* - Investigate potential exposures *P* - Present work *R* - Residence *E* - Environmental concerns *P* - Past work *A* - Activities *R* - Referrals and Resources *E* - Educate

THIS NURSE FOUGHT TO HAVE NURSES CONTROLLED BY NURSES RATHER THAN PHYSICIANS

*Lavinia Dock* political activist who waged a campaign for legislation to allow nurses to control the nursing profession

THIS NURSE USED POLITICAL EXPERTISE TO INFLUENCE THE FEDERAL GOVERNMENT TO DEVELOP A CHILDREN'S BUREAU

*Lillian Wald* her work recognized the connection between social conditions and health

*FUTURE OF NURSING* REPORT - FOUR KEY MESSAGES

*Nurses should practice to the full extent of their education and training* Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States Effective workforce planning and policy making require better data collection and an improved information infrastructure

UNDERSTANDING OF "FAMILY" - NURSING CONSIDERATION

*Patient* How do you define family? *Nurse* Whoever you tell us is your family. the definition of "family" is widely varied. Ask your patient.

CULTURAL CARE - AN EXAMPLE

*Patient* female immigrant from the Middle East attends clinic for the first time with two female friends. A male nurse is assigned to her, but the patient refuses to answer questions. *Nursing Action* Since the female patient is not comfortable with the male nurse, it would be appropriate for the male nurse to ask a female nurse to attend to the client.

PRIVATE SECTOR POLICY VS. PUBLIC SECTOR POLICY

*Private Sector* influenced by theories of economics and business management *Public Sector* influenced by social and political theories

MAJOR INFLUENCE ON STUDENT NURSES AND BECOMING POLITICALLY ACTIVE

*Role models* *Example* attending a local district nurses association meeting where your professor serves as an officer nurses most often identify positive role models as the major influence that assisted them to become politically active

ENTITY THAT HAS THE AUTHORITY TO ACT IN EVERY AREA EXCEPT THOSE SPECIFICALLY MENTIONED IN THE CONSTITUTION

*State Government* Any powers not delegated to the federal government are reserved for the states

COMMUNITY PRESENTATION ABOUT ASTHMA - NURSING CONSIDERATION

*The nurse included...* - causes of asthma - how to identify triggers - how to use an inhaler *The nurse SHOULD HAVE ALSO INCLUDED...* actions that can be taken to improve air quality *Rationale* Research suggests that changing individual behaviors does not lead to significant reductions in overall morbidity and morality in the absence of basic social, economic, and political changes.

MAJOR CAUSE FOR THE RISE IN HEALTH CARE COSTS

*a demand for complex and advanced services* fueled by the presence of very rapid technological advances, society's sense of entitlement to these therapies, a guaranteed payer, and the prevailing medical orientation toward curative measures

BASIS FOR AMERICAN CITIZENS TO FEEL COMFORTABLE EXPRESSING AN OPINION ON A POLITICAL ISSUE

*amendments to the Constitution* aka "The Bill of Rights" these amendments protect individuals' rights and freedoms

MOST IMPORTANT FACTOR IN LEGISLATION

*beliefs, attitudes, and values of the policy* public policy encompasses the choices made regarding goals, priorities, and how resources are allocated policy choices reflect the values, beliefs, and attitudes of those designing the policy

POVERTY GUIDELINE FOR A FAMILY OF FOUR IN MAINLAND US IN 2013

*below $23,550* A four-person household must make less than $23,550 to be considered under the poverty guideline according to the U.S. Department of Health and Human Services.

HEALTH CARE PROVIDERS DURING THE GREAT DEPRESSION

*hospitals and physicians went bankrupt* With 25% of the population out of work, the number of patients capable of paying their medical bills was reduced. Because public financing was limited, hospitals, physicians, and other providers went bankrupt.

WHAT HAPPENED TO HOSPITALS BUILT OR EXPANDED BY HILL-BURTON

*many hospitals have either consolidated or closed* high cost of health care combined with decreasing length of stay and increased use of primary care services, many hospitals are now closing

FORCES FOR A PROPOSED BILL VS. FORCES OPPOSED TO A BILL - WHO HAS THE ADVANTAGE?

*opposition always has the advantage* it is far easier to defeat a bill than get one passed

HOW GOVERNMENT CONTROLS CONDITIONS THAT INDIVIDUALS CANNOT

*passes and enforces law* *Rationale* government regulates conditions that individuals cannot control and provides individual protection through a population-wide focus tasks are accomplished through passage and enforcement of laws laws control individuals' behaviors, which may lead to the establishment of social mores and common sense related to the laws that have been established

CLIENT IN 1920 - THIS WAS HOW THEY PAID FOR HEALTH CARE SERVICES

*patients paid out-of-pocket whatever the provider charge* until the 1930s, the predominant method of health care financing was self-payment

HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA) - ASSISTS NURSING WORKFORCE DEVELOPMENT BY...

*providing grants to provide for education and recruitment* nursing workforce development programs administered by the HRSA through Title VIII provide federal support for nurses' workforce development HRSA does not establish nursing schools but provides federal funding for nursing education at the undergraduate and graduate levels favors institutions that educate nurses for practice in rural and medically underserved communities

ECONOMICS - DEFINED

*science of allocation of resources* resources can be goods or services

CHANGING THE PARADIGM OF HEALTH CARE FROM DISEASE ORIENTATION TO PROMOTING HEALTH ORIENTATION - REASON IT IS SO DIFFICULT

*serious reallocation of resources would have to occur* *Rationale* because the vast majority of health spending is currently directed to medical care and biomedical research reflects a viewpoint of health care as a commodity *the allocation of resources has the most influence on creating a paradigm shift*

STATE LEVEL SUBSYSTEM - NURSING CONSIDERATION

*the organization and activities of public health services vary widely among states* states are responsible for the health of their citizens and are the central authorities in the public health care system

MOST PERSONAL HEALTH CARE SERVICES ARE PROVIDED HERE

*the private sector* includes - clinics - physician office - hospitals - hospital ambulatory centers - skilled care facilities - homes

WHY DID EMPLOYERS OFFER HEALTH INSURANCE AS A BENEFIT?

*to obtain and retain the limited number of persons available to work* During World War II, faced with a limited workforce and governmental restrictions on wages, employers began to see health insurance as a means of supplying workers' benefits without granting a wage increase

FOOD DESERT

A neighborhood with little to no access to healthy foods There are significant disparities in access to healthy and fresh food supplies, with poor minority families being more likely to live in a food desert

CARVE-OUT SERVICE

A particular service that is offered only by a designated provider or group. *Example* A carve-out service (for example, mental health care) is provided within a standard benefit package but delivered exclusively by a designated provider or group.

EFFECTS OF MEDICARE AND MEDICAID

A previously unseen rise in demand for services occurred Many persons previously without access now receive health care Medicare reimbursement rates became the standard for all insurance carriers Indemnity insurance plans were offered

REASON TO JOIN AMERICAN NURSES ASSOCIATION (ANA)

ANA has full time lobbyists on staff to help represent the interests of nurses and society nurses should be encouraged to participate in organizations, even if it is through paying dues, so that their voice can be represented

THIS MINORITY GROUP HAS A 35% HIGHER MORTALITY RATE FROM CANCER THAN NON-MINORITY GROUPS

African-Americans

DIETARY PRACTICES - MORMONISM

Alcohol, tobacco, and beverages containing caffeine (e.g., coffee, tea, colas, and select carbonated soft drinks) are prohibited.

COST CONTAINMENT - ACCESS LIMITATION

All third-party payers, or insurance plans, control access to health care through designation of covered services (i.e. eligible services) MCO/HMO designate type of service and specify conditions under which the service is covered some services require referral and/or pre-authorization from a primary care provider or "gatekeeper" managed care plans tend to be fiscally conservative and support less costly modalities, treatments, and medications

HOW THE FEDERAL GOVERNMENT DETERMINES WHICH PROJECTS ARE AWARDED SPECIAL FUNDING FOR HEALTH CARE

Allocation of federal resources is based on societal priorities *Example* 2020 Health Objectives

CURRENT LEGISLATION ACTS THAT LIMIT WHAT MCOs ARE ALLOWED TO DO

Allowing patients to see a specialist without having to obtain approval from their primary care provider Allowing patients to go to the emergency department without first telephoning for approval Allowing patients the right to choose a physician

MESSAGE THAT PUBLIC HEALTH LEADERS ARE TRYING TO EMPHASIZE TO THE PUBLIC

Assume responsibility for your own health by choosing healthy behaviors

HOW ELIGIBILITY FOR MEDICAID SERVICES IS DETERMINED

Baseline eligibility is established by the federal government, but states may be more lenient Children in low-income families are eligible for free care Eligibility depends on family size and total family income

WHY HEALTH CARE PROVIDERS ARE CONCERNED WITH MASS TRANSIT, CLEAN POWER, AND THE FARMING INDUSTRY

Because air pollutants are contributors to asthma and other health problems *Rationale* All three (mass transit, clean power, and industry) emit air pollutants, which result in smog, the most common outdoor air pollutant in the United States. Atmospheric pollutants cause or contribute to asthma, allergic reactions, bronchitis, lung cancer, chronic respiratory disease, and death.

ORIGINAL PRIVATE HEALTH INSURANCE PLANS - UNFORTUNATE CONSEQUENCES

Because providers were paid for any service they gave, it was economically advantageous for them to give as much care as possible Health care costs increased very rapidly Health education and health promotion interventions were not included in the idea of health insurance Patients wanted any and all care that might help, regardless of how expensive it was There was no limit on what care could be sought and given

HOW HOSPITALS COPED WITH WHEN MEDICARE REIMBURSEMENT BECAME BASED ON DRGs

Charged more for patients whose care was paid by insurance *Rationale* Hospitals developed cost shifting to supplement losses caused by Medicare funding. Because private insurance reimbursements were cost based, hospitals included the loss in their total costs; therefore private insurance paid for covering care to both their enrollees and Medicare patients.

PERSUADED CONGRESS CONGRESS TO RATIFY THE TREATY OF GENEVA WHICH ALLOWED THE RED CROSS TO PERFORM HUMANITARIAN EFFORTS IN TIMES OF PEACE

Clara Barton

RESPONSIBLE FOR ORGANIZING RELIEF EFFORTS DURING THE U.S. CIVIL WAR

Clara Barton

STATEMENT THAT BEST SUMMARIZES ALL OF THE CHANGES RESULTING FROM ATTEMPTS TO CONTROL COSTS

Conflict between providers, patients, employer, and insurance plans raged

LAWS THAT ALL MUST OBEY INCLUDE...

Court decisions related to legislative law Laws passed by your state or the federal government Rules and regulations from agencies, such as the state board of nursing

ACTIONS THAT REPRESENT A SHIFT IN PHILOSOPHY AT THE CENTERS FOR DISEASE CONTROL AND PREVENTION

Creating integrated health information systems Encouraging partnerships and strategic alliances Leveraging resources to steer the larger health system

SIGNIFICANCE OF HEALTH PLAN EFFECTIVENESS DATA AND INFORMATION SET (HEDIS)

Data are used to measure performance in the accreditation of managed care organizations (MCOs) The National Committee for Quality Assurance accredits MCOs and uses HEDIS to measure performance and consumer satisfaction.

MOST CRUCIAL STEP IN POLICY FORMATION

Defining the issue and placing it on the agenda for possible action

FUNCTIONS THAT ARE RESPONSIBILITIES OF THE STATE

Delegating power to localities and holding them accountable for results Licensure of professional health care providers Overseeing all insurance programs Providing access to necessary health services

FEDERAL AGENCY RESPONSIBLE FOR WIC, FOOD STAMPS, AND SCHOOL-BASED NUTRITION PROGRAMS

Department of Agriculture

FEDERAL AGENCY RESPONSIBLE FOR ADMINISTERING MOST OF THE FEDERAL HEALTH-RELATED ACTIVITIES

Department of Health and Human Services (DHHS)

ACTIVITIES THAT ARE RESPONSIBILITIES OF LOCAL HEALTH DEPARTMENTS

Determining the safety of residents' wells Providing free health screenings Providing health education programs on proper nutrition Inspecting restaurants

WHAT INSURANCE COMPANIES DID TO DECREASE THEIR CONSTANTLY INCREASING COSTS

Did not cover any illnesses that were diagnosed before the person (or his or her employer) purchased insurance Limited coverage to only certain services, eliminating any that were experimental, nontraditional, or too costly Reimbursed only the care that was requested by the patient's primary physician Required pre-approval before expensive services were used Ceased coverage on any person who used an exorbitant number of services, whenever possible

PRINCIPLE FACTOR BEHIND ONGOING LEGISLATION ON THE FEDERAL LEVEL RELATED TO HEALTH CARE

Efforts must be put in place to control constantly increasing costs

WHY ENVIRONMENTAL HEALTH IS MORE CHALLENGING THAN OTHER VARIABLES RELATED TO AN INDIVIDUALS HEALTH

Environmental health requires social, economic, and political changes to improve

CURRENT ISSUES THAT ARE LEADING THE WORLD HEALTH ORGANIZATION TO RECONSIDER ITS DEFINITION OF HEALTH

Environmental issues such as industrial toxins or carcinogenic commercial products Global, not local, problems such as spread of antibiotic-resistant bacteria Need to move from containment and treatment to social intervention Realization that government actions influence the basic human right of health Worldwide pandemics such as human immunodeficiency virus (HIV) and swine flu, which require a different approach

CONCLUSION THAT CAN BE DRAWN CONCERNING EFFORTS TO DECREASE ENVIRONMENTAL POLLUTION

Federal policies have been weakened, and enforcement lacks funding. *Rationale* Legislation in the 1970s was aimed toward a comprehensive national environmental policy. The momentum slowed in the 1980s, with policies being reversed and regulation losing its funding. This trend has continued. The EPA sets rules but lacks resources to accomplish the goals.

ESTABLISHED THE FIRST NURSE CORPS

Florence Nightingale

FIRST NURSE TO EXERT POLITICAL PRESSURE ON A GOVERNMENT

Florence Nightingale

HELPED ESTABLISH HOSPICE CARE IN THE UNITED STATES

Florence Wald

YIN-YANG THEORY APPLIED TO FOOD

Foods are classified as hot and cold in this theory foods are transformed into yin and yang energy when metabolized by the body Yin foods are cold while yang foods are hot cold foods are eaten when one has a hot illness hot foods are eaten when one has a cold illness

WHAT DOES IT MEAN TO BE "KOSHER"

Foods should be kosher (meaning "properly preserved"). All animals must be ritually slaughtered by a shochet (i.e., quickly with the least pain possible) to be kosher

APPROACHING HEALTH AT THE AGGREGATE LEVEL IS THE INITIATIVE OF WHICH AGENCY/DOCUMENT

Healthy People 2020

NURSING ACTION THAT IS MOST HELPFUL TO A COMMUNITY'S LONG TERM HEALTH

Helping the community create political change through organization, use of media, legislative lobbying, and mass demonstrations

COMMUNITY CLEAN UP DAY - NURSING ACTION

Hold a dialogue with community members about the problem and its effects *Rationale* An important nursing goal is to help people learn from their own experiences and analyze the world with an intention to change it It is essential that those affected participate in the process of identifying and working to solve environmental problems. The nurse's role is to ask critical questions and help groups reflect on the environmental realities of their lives

DIRECT RESULT OF GLOBAL WARMING

Increased number of parasites and insects *Rationale* Rising global temperatures may enhance the quantity and distribution of parasites, insects, and other disease vectors, potentially increasing the prevalence of a variety of infectious diseases.

WHY RISKS ASSOCIATED WITH VARIOUS EMPLOYMENT POSITIONS ARE INACCURATE

Individuals assume it is a personal problem, not an employment issue. *Rationale* Statistics do not reflect unreported health problems. Collective problems related to employment or occupation are often perceived as individualized injuries, and no one "connects the dots."

MAJOR PROBLEM WITH U.S. HEALTH CARE SYSTEM

Large number of underinsured and uninsured citizens

WHAT HAS HAPPENED TO AIR QUALITY SINCE THE U.S. OUTLAWED CHLOROFLUOROCARBONS, HALONS, AND CARBON TETRACHLORIDE

Little change occurred because these chemicals remain in the atmosphere

DISCRIMINATORY LAND USE

Locating industrial hazards in low-income communities members of these communities are at risk for illness and injury

MOST COMMON ORGANIZATION FOR RECEIVING PERSON HEALTH CARE IN THE UNITED STATES

Managed care organization with capitated payments to providers, both professionals and organizations

PROBLEMS WITH U.S. WATER SUPPLY

Many aquifers are contaminated with pesticides and fertilizers More than 45 million Americans drink untreated water Sediment from construction, agriculture, and deforestation is often present Underground water, if contaminated, cannot be cleansed

FOUNDER OF FRONTIER NURSING SERVICE

Mary Breckenridge

HOW HAVING HEALTH INSURANCE HAS AFFECTED LIFESTYLE BEHAVIORS

Medications and medical treatment are relied on for cure *Rationale* Funding for behavioral changes is limited, inadequate, or unavailable. Weight loss programs or smoking cessation programs are not reimbursable treatment regimens, although more expensive pharmaceutical interventions are reimbursable

ISSUE THAT EXISTS WITH COMMUNITIES USING SOLID WASTE LANDFILLS TO DISPOSE OF TRASH FROM PRIVATE RESIDENCES

Methane gas may move through the soil to cause fire or explosions nearby. *Rationale* Solid waste landfills accumulate methane gas, a by-product of decomposing organic wastes. Without proper venting, this volatile gas can move through soil and cause fires and explosions in nearby areas.

OVER 13 % OF RESIDENTS IN THE UNITED STATES WERE BORN IN OTHER COUNTRIES. MORE THAN HALF (52%) OF THESE INDIVIDUALS WERE BORN IN...

Mexico and Latin America

A COMMUNITY HEALTH NURSE IS CARING FOR A CLIENT WHO OFTEN STARES AT THE FLOOR WHILE THE NURSE IS TALKING. THIS CLIENT IS LIKELY FROM WHAT ETHIC GROUP

Native American *Rationale* there are certain ethnic groups who avoid eye contract; these groups include: - Asian - Native American - Arab - Indochinese - Appalachian

*CROSSING THE QUALITY CHASM* REPORT - CONCLUSIONS

Need for evidence-based, planned care Reorganization of practices to meet the needs of patients who require more time, a broad array of resources, and closer follow-up Systematic attention to patients' need for information and behavioral change Ready access to necessary clinical expertise Supportive information systems

WHY NURSES ARE NOT MORE EFFECTIVE IN CREATING POLITICAL CHANGE

Nurses do not act or do not agree on what changes are needed *Rationale* nurses know how to communicate, collaborate, negotiate, and serve as leaders who can make themselves heard However, the various nursing subgroups do not agree on public policies

WHY NEW HEALTH CARE MODELS CANNOT BE TESTED WITH SMALL GROUPS

Offering a service establishes a precedent and a sense of entitlement, so it is difficult to discontinue the program.

STRENGTHS OF THE AMERICAN HEALTH CARE SYSTEM

Offering the availability and use of technological advances in equipment and procedures Leading the world in laboratory and clinical research

WHAT PHYSICIANS DID TO COMPETE WITH NEW COMPETITION FROM HMOs

Organized preferred provider organizations (PPOs) to negotiate with insurance companies *Rationale* In an effort to compete with HMOs, physicians and hospitals organized the independent practice model, which provided services to enrollees of one insurance company. This model evolved into the PPO, which offered services at a reduced rate in exchange for a guaranteed increase in consumers.

WHY NURSES SHOULD CONTRIBUTE TO THEIR STATE NURSING ASSOCIATION PAC

PACs are a reality of political life nurses need to recognize their power and support those that are committed to electing candidates sympathetic to health care issues the contribution of money will support the current nursing practice initiatives which will change as nursing practice changes

POLITICAL ACTION COMMITTEES - PURPOSE

PACs attract candidates who are sympathetic to particular health care issues *rationale* PACs are nonpartisan entities that promote the election of candidates believed to be sympathetic to their interests. The purpose of specific PACs could be to promote certain health care issues or health care reform or to obtain financing for certain professional organizations.

HOW PARTICIPATORY ACTION RESEARCH DIFFERS FROM OTHER RESEARCH METHODS

Participatory action research poses solutions to the problem *Rationale* Participatory action research calls for nurses, community members, and other resource people to work together in identifying health problems, designing the studies, collecting and analyzing the data, disseminating the results, and posing solutions to the problems.

FIRST GOVERNMENT STEP IN TRYING TO STOP CONSTANTLY RISING COSTS

Payment reimbursement based on diagnosis and client characteristics rather than on treatment given *Example* first efforts to control costs were made by the federal government when Medicare hospital reimbursement was based on a prospective payment system Payment would be based on a classification system that identified costs according to diagnosis and client characteristics.

BEST EXPLANATION ON WHY IT IS DIFFICULT TO GET OTHERS INTERESTED IN ENVIRONMENTAL HEALTH

People respond more to an acute crisis than chronic environmental problems

WHO MAY RECEIVE BENEFITS UNDER MEDICARE?

Persons with end-stage renal disease (ESRD) Those over 65 years of age, if eligible for Social Security benefits Those with permanent disabilities

DIETARY PRACTICES - ISLAM

Pork and intoxicating beverages are prohibited.

DIETARY PRACTICES - SEVENTH DAY ADVENTIST

Pork, certain seafood (including shellfish), and fermented beverages are prohibited. A vegetarian diet is encouraged

DIETARY PRACTICES - JUDAISM

Pork, predatory fowl, shellfish, other water creatures and blood by ingestion are prohibited Mixing dairy and meat dishes at the same meal is prohibited

HOW PROVIDERS CAN LEGALLY IMPROVE THEIR PROFIT UNDER THE CURRENT REIMBURSEMENT PROCESS

Practice conservatively to earn an incentive payment *Rationale* As a reward for conservative medical practices, health care providers may receive a specified amount of money or a percentage of the agreed reimbursement if services are delivered below the limit set by the third-party payer.

WHEN WAS THE IDEA OF NATIONAL HEALTH CARE FIRST DEBATED?

President Theodore Roosevelt advocated such national medical coverage in 1916

THE FORMATION OF A COALITION

Professional groups often form coalitions to advance their shared interests *For Example* a nursing association and a medical association disagree on advanced practice nursing reimbursement. instead of fighting, the two groups form a coalition to collaborate on a bill that would benefit patients

HOW THE GOVERNMENT WAS SUCCESSFUL AT CONTAINING COSTS

Prospective payments were based on diagnosis-related groups (DRGs) *Rationale* Prospective payment based on DRGs proved to be effective. The cost reduction that resulted gave rise to the managed care revolution as providers searched for the most cost-effective mechanism of care provision.

*UNEQUAL TREATMENT: CONFRONTING RACIAL AND ETHNIC DISPARITIES IN HEALTH CARE* REPORT - PRIMARY CONCLUSION

Provider bias and stereotyping contribute to inequalities

PURPOSE OF PROFESSIONAL SOCIETIES SUCH AS THE AMERICAN NURSES ASSOCIATION (ANA)

Providing control and oversight of the occupation Establishing standards for practice Protecting the interests of the practitioners Safeguarding the public trust

ENVIRONMENTAL CORE COMPETENCY - ASSESSMENT

Research Data analysis and interpretation Evaluation

STATEMENT THAT BEST DESCRIBES RELATIONSHIP BETWEEN THE ENVIRONMENT AND HEALTH

Research shows that a healthy environment increases quality of life and years of healthy living

CULTURALLY APPROPRIATE DISTANCE

Sense of spatial distance is significant because culturally appropriate distance zones vary widely Many cultures stand closer for important conversations, whereas the others may step back because being too close is uncomfortable

STANDARDS OF CULTURALLY COMPETENT CARE

Social Justice Critical Reflection Knowledge of Cultures Culturally Competent Practice Cultural Competence in Health Care Systems and Organizations Patient Advocacy and Empowerment Multicultural Workforce Education and Training in Culturally Competent Care Cross-Cultural Communication Cross-Cultural Leadership Policy Development Evidence-Based Practice and Research

MAJOR EVENT IN 1960s THAT AFFECTED HEALTH CARE

Social Security Act was amended to create Medicare and Medicaid legislation Titles XVIII and XIX of the Social Security Act created Medicare and Medicaid

ARDENT AND ELOQUENT ADVOCATE FOR ABOLISHING SLAVERY AND SUPPORTING WOMEN'S RIGHTS

Sojourner Truth

APPROACH TO HEALTH CARE USED BY STATES

States frequently develop new programs as federal funds become available to pay for them.

DAY OF WORSHIP - PROTESTANT

Sunday is the usual day of worship

ESTABLISHED NATIVE AMERICAN NURSES ASSOCIATION

Susie Walking Bear Yellowtail walked from reservation to reservation to improve health services for Native Americans

1979 REPORT *HEALTHY PEOPLE: THE SURGEON GENERAL'S REPORT ON HEALTH PROMOTION AND DISEASE PREVENTION* - KEY OUTCOMES

The Health Objectives Planning Act of 1990 was passed The federal government began to identify and monitor national health care goals. Healthy People 2000, Healthy People 2010, and Healthy People 2020 are also results of this Act.

LEININGER'S TERM "CULTURE UNIVERSAL"

The commonalities of values, norms, and life patterns that are held in all cultures