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