PPACA Nurse The Patient Protection and Affordable Care Act's Impact on Evidence-Based Practice in Nursing: The National Quality Strategy

The recently enacted Patient Protection and Affordable Care Act (PPACA), a landmark and controversial piece of legislation still years away from coming into full effect and currently being challenged (at least in part) in the nation's courts, is primarily seen by the public as impacting upon healthcare payment systems and insurance practices. These are certainly the areas of the legislation that have received the most significant amount of media attention, and they do represent the widest departure from current practices and institutions in the healthcare system, according to many perspectives. The PPACA is not solely concerned with improving access to healthcare and the affordability of care, however; the legislation contains directives and policy measures aimed at directly improving the overall quality of healthcare throughout the country through explicitly empirical means.

One of the most significant pieces of the PPACA in this regard is the call for a National Health Care Quality Strategy and Plan, created by a select council headed by the Surgeon General and under the auspices of the Department of Health and Human Services (McCurdy 2010). The Plan, often simply called the National Quality Strategy, was developed by the council after input was sought from the public and any interested stakeholders, and is meant to directly address the healthcare concerns of communities and healthcare workers alike (McCurdy 2010). It is through this strategy that much of the direct impact of the PPACA on nursing can be seen.

There are of course many pieces of the PPACA that will impact the practice of nursing, and that in some ways already are (Webb & Marshall 2010; Newman 2011; Groszkruger 2011). When it comes to the primary concern of nursing, however, namely the direct care and quality of life/health experienced by nursing patients, the direct implications of the National Quality strategy and its formation are unmatched in the rest of the legislation. Though not explicitly stated as such, the overall goal of the National Quality Strategy -- or its overall function, perhaps, depending on one's perspective -- is to ensure that evidence-based practice becomes more efficiently, effectively, and comprehensively incorporated into the methods and skill sets of all medical and nursing practitioners (McCurdy 2011; HHS 2011). This paper will examine the direct and explicit impacts on evidence-based practice in nursing that have occurred and/or are expected to occur as a result of the National Quality Strategy, as well as exploring the deeper implications of the strategy's formation and the philosophy of the legislation that led to its creation.

The National Quality Strategy

The National Health Care Strategy and Plan, National Strategy for Quality Improvement in Health Care, or simply National Quality Strategy, was officially released on March 21, 2001 (HHS 2011). Though relatively brief at approximately ten-thousand words, this strategy outlines plans for the improvement of the quality of care at the local, state, and national levels (HHS 2011). A key means for accomplishing this is through a focus on evidence-based practice.

It is true that the National Quality Strategy addresses the issue of healthcare quality through a variety of means, including greater social awareness, patient education, and other factors not directly related to the provision of specific care services (HHS 2011; National Strategy for Quality Improvement in Health Care 2011). According to the National Quality Strategy, however, it is through research and the use of evidence that the development of all of these methods as well as the direct and explicit medical and nursing interventions recommended both for practice and for further study in the National Quality Strategy should occur (NSQIHC 2011). This is quite clearly outlined in the executive summary of the document in addition to being further detailed in various portions throughout this policy recommendation and congressional report: "The National Quality Strategy will promote quality health care [and] will incorporate the evidence-based results of the latest research and scientific advances in clinical medicine, public health,...

From the outset, then, it is clear that this is a piece of the PPACA legislation that is directly relevant to nursing practice and evidence-based decision making.
Delving deeper into the language of the National Quality Strategy yields further information on how this policy might impact evidence-based practice in nursing. In one specific item, the strategy calls for greater national and local attention to the prevention treatment of the leading causes of mortality, specifically cardiovascular disease (NSQIHC 2011). Citing research and calling for more, and for more widespread implementation of the results, the National Quality Strategy is demanding that all health care workers incorporate evidence-based practice into overall health assessments of communities and individual patients, and that specific care practices based on solid and ongoing research be implemented (NSQIHC 2011).

The National Quality Strategy also calls for the greater use of evidence-based practices in achieving greater community health, making recommendations not only for the development of evidence but for educational policies and priorities to ensure that these practices are actually incorporated by the communities of the nation and the healthcare providers that serve these communities (NSQIHC 2011). This has many complex impacts on nursing practice, as it influences not only direct care practices but also overall methods of patient and community interaction. As primary healthcare providers, educators, and observers n many communities across the nation, nurses will ultimately shoulder a great deal of the burden in carrying evidenced-based practices into the homes and lives of their patients, which is the only way they will make any meaningful change in the quality of health of the nations citizens.

These affects of the PPACA legislation generally and the National Quality Strategy as well as the overall role of the nurse as a central healthcare in many communities has been well documented, and this role is only likely to increase as the National Quality Strategy becomes more comprehensively and purposefully implemented (Webb & Marshall 2010; Groszkruger 2011; Jennings & Lamb 2011; Powell 2011; Dailey 2011). In a variety of ways, then, the National Quality Strategy that has been created as called for in the PPACA directly impacts the practice of nursing and the use of evidence-based practices.

Evidence of Impact on Nursing Practice

Though a great deal of attention has been paid to the financial impacts of the PPACA as a whole in the year since it was signed into law -- and to the potential financial impacts that are expected to occur when all of the provisions of the law come into effect, if the law is not struck down first -- there has also already been some investigation as to the impact of the legislation on the practice of medicine and nursing (Groszkruger 2011; Dailey 2011). The research is not entirely conclusive at this point, which is hardly surprising given how recently the legislation was passed and even more recently it began to be implemented in any meaningful and functional way. It demonstrates, however, that the nursing community as well as other medical practitioners and researchers are noting the potential impacts of the legislation and are already attempting to implement changes (Dailey 2011; Webb & Marshall 2010; Newman 2011; Shelton & Saigal 2011; Berkman 2011).

That the nursing community has been able to incorporate the legislation at all given its scope and complexity is a testament to the level of preparedness and eagerness of ongoing improvement and providing a fix to the broken healthcare system is in the nursing community. More impressive is the fact that, while there is still a long way to go, there has been a discernible impact on the use of research and evidence-based practices from nursing fields on social policy and social work (Berkman 2011). The National Quality Strategy cannot claim all of the credit for this, to be sure, but the institution of a direct national mandate for increased reliance on evidence-based practices is certainly a step in the right direction.

Evidenced-based practice in nursing has been part of a major push by the National Institute of Health and other federal agencies for quite some time, but the passage of the PPACA and specifically the development of the National Quality Strategy have done a great deal to cement this drive and to call for explicit ways in which to bring a greater use of evidence-based practice about (Melnyk & Fineout-Overholt 2010; NSQIHC 2011). By outlining specific practices or areas of concern and citing research regarding these issues and concerns, the National Quality Strategy has made a direct call for nurses and other healthcare workers to look to evidence to guide their practices and changes in these practices (NSQIHC 2011). Geriatric care and attention has been specifically cited in the National Quality Strategy as an area that would benefit both from greater research and from a greater implementation of current research, and this call is already being answered by practical research regarding methods for achieving more widespread evidence-based practices, while the same improvements are crossing into other areas of healthcare, as well (NSQIHC 2011; Berkman 2011;…