After reviewing the memberships of several federal policymaking bodies on mental health issues, I detected a theme: nursing was underrepresented. In April 2002 President Bush established the President's New Freedom Commission on Mental Health to address issues that limit patients' access to mental health care. There were 22 members on the president's commission, designed to outline a national, long-term redesign of the mental health system. None was identified as a nurse. These commissioners appointed chairpeople to 15 subcommittees to explore other important issues. Not one nurse was chosen to serve on the president's commission or to chair a subcommittee.
The Substance Abuse and Mental Health Services Administration (SAMHSA) underscores this point. It's the federal agency that will implement the commission's Federal Mental Health Action Agenda and consists of three centers and six national advisory councils. A review of the membership of these bodies was discouraging. On six advisory boards, only one member of one council is identified as a nurse, and no nurse holds a position in SAMHSA's administration.
Further, in 2004 the Institute of Medicine created the Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders. Its final report, completed in October 2005, contained a national agenda for improving mental health treatment. The 26-member committee included two consumers, one of whom was an RN. Otherwise, there was no nursing representation.
The implications are staggering: the nation's mental health system is being transformed without the nursing profession's perspective and contribution. And the lack of nursing representation in mental health policymaking is not an anomaly; nurses are absent from other areas of health care policy, as well.
With a few notable exceptions, such as the Joint Commission and the Institute for Healthcare Improvement, this phenomenon appears pervasive. Physicians, lawyers, social workers, and other professionals are well represented on these policymaking committees. So why are nurses absent? Is it that the public and other professionals view nurses as subordinates rather than autonomous practitioners and leaders in health care? Perhaps nurses' perceptions of themselves relegate them to policy sidelines. Many hypotheses exist. For instance, it's because nursing is a mostly female profession or because political acumen and the characteristics required to be a nurse (being nurturing and caring) are somehow mutually exclusive. Perhaps we aren't asking the correct questions. Whatever the cause, the truth remains that no one is banging down nursing's door for policy advice. And nurses are not standing up to give their opinion.
Nurses will, however, rally for better pay and better staffing-motivated by here-and-now issues. For many nurses, health care policy holds no interest and appears to have little practical value-it's not within their direct control and seems to have no immediate impact on everyday practice. Yet think about the 1990s, when financial constraints and reduced reimbursement spurred policy decisions that were heralded as the answers to the nation's costly health care system. Managed care, organizational reengineering, and hospital mergers marked that time. As part of the cost-efficient initiatives, RNs were let go from hospitals and replaced by less skilled workers. The consequences of that decision are still felt today and underscore the vital importance of nurses' participation in health care policy, if only to ensure future employment.
I can't help but wonder: if nurses had been involved in the policy decisions of the past, would those efforts in the 1990s have been more successful? If nurses continue to remain absent from policymaking and advisory tables, what will the future of health care look like for them?