A nurse's experience in Washington

Sister Rosemary Donley, R N

A nurse’s experience in Washington

Nurses now believe that their political and social role extends beyond being a good neighbor and good citizen to policy development and legislative activism. One way to explore your “greening” as a nurse-politician is to find a starting point on a continuum from interest to information to involvement.

To help you define your position, let me share my experiences in politics. From September 1977 through August 1978, I was the second nurse and the third woman to serve in Washington, DC, as a Robert Wood Johnson Health Policy Fellow. This was a major step along the continuum for me. Each year,

Sister Rosemary Donley, R N , PhD, is associate professor in the School of Nursing, Uni- versity of Pittsburgh. A diploma graduate of Pittsburgh Hospital School of Nursing, she re- ceived a bachelor’s degree in nursing from St Louis University and master’s and PhD de- grees from the University of Pittsburgh.

This article is adapted from a speech given at the 26th AORN Congress in St Louis.

six outstanding midcareer academic health professionals are brought to Washington to learn about health legislation, politics, and policy. Established in the early 1970s by the Institute of Medicine, a unit of the National Academy of Sciences, the Fellowships are financed by the private Robert Wood Johnson Foundation.

The personal growth of the Fellow is the main purpose of the program, but one expectation is that there will be a ripple effect among one’s colleagues and students. The ultimate goal is that the next generation of health professionals will be more aware of health policy than their teachers and mentors.

For me, the Fellowship was the out- growth of a long interest in and study of politics. I was born into a political fam- ily. My father held a political job for 30 years, and his brother ran unsuccess- fully five times for the Pittsburgh City Council. While I was teaching a t the University of Pittsburgh School of Nursing in the early 1970s, I became aware of the impact of federal health legislation on health care services and health education. I spent several years tracing the influence of Medicare on hospital and nursing home construc- tion, medical practice, and health services. I learned to explain laws, to check the Federal Register for rules and regulations, and to read the Congressional Record.

During my year as a Robert Wood

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Johnson Fellow, I spent time in both the executive and legislative branches of government. The other Fellows in 1977 were a nephrologist from Tufts Univer- sity School of Medicine, Boston; a pri- mary care physician from Harvard Uni- versity, Cambridge, Mass; a community health physician from the University of Arizona, Tucson; a biochemist and associate dean from the University of Mas- sachusetts Medical School, Worcester; and a dentistlphysiologistlassociate dean from the University of Iowa, Iowa City.

We spent the first several months of our experience literally walking through the programs in the US De- partment of Health, Education, and Welfare (HEW). HEW is really four departments; Health, Education, Welfare, and the central administration of HEW. I t i s directed by Secre ta ry Joseph Califano. Our focus was the “H” in HEW. The health offices are located in buildings on Capitol Hill; in Rockville, Md; on the campus of the National In- stitutes of Health in Bethesda, Md; in the Parklawn Buildings in Hyattsville, Md; in the Center for Disease Control in Atlanta; and in ten regional centers around the country.

The mix of employees in the health area is similar to military organizations. There are health professionals who are commissioned officers in the Public Heal th Service; professional, technical, and clerical workers em- ployed under the civil service system; and political appointees. The largest group of employees is in the civil service system. They are the career personnel, bureaucrats whose job tenure is inde- pendent of who sits in the White House or the Office of the Secretary of HEW. Among them are experts in service programs who are able to discuss the impact of federal legislation on health care delivery in detail and with national perspectives. However, in the intricate

organization of HEW, these program or operations experts are usually low in the chain of command.

Although expertise in a particular subject may be va lued wi th in t h e agency and recognized by t h e congressional staff on the Hill, information is diluted as it weaves its way from the program staff to the decision makers in the upper echelon of HEW. Often valu- able data are lost or washed out in the information referral process. Coupled with the low esteem and public ridicule of bureaucrats, this contributes to low risk-taking behavior and resistance to change on the part of the civil service staff.

The first commissioned corps of public health officers, similar to the military, developed out of a sense of battle. The enemy was infectious or communicable disease. Today there is still a commissioned corps of public health officers in HEW. This is another phenomenon of a bureaucracy. Structures and organizations persist long after the reasons for their being have disappeared.

If you were to name a person within HEW, you would probably recall one of the political appointees who heads the agency. The most visible employees, they a re appointed by the President or the Secretary. They have access to the Administration and a strong commitment to the policy and program direc- tives framed by the President and his domestic policy staff. Depending on the political milieu, a program may be fa- vored and supported with budget and personnel or stripped of its staff and given a low profile and little money.

Since political climates change more rapidly than politicians, strong commitment to a program by political appointees is uncommon. When present, commitment often leads to insecurity and defensiveness. Success for t h e politician in the agency depends on favor with the Administration and the

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cultivation of a unique ability to scan the environment and anticipate new political directions. The Monopoly- board geography of the health section of HEW and the mix of politicians, health officers, and bureaucrats offer a man- agement challenge.

When the Fellows came to Washington in the fall of 1977, the health section of HEW was undergoing another reorganization. Two major divisions were operating: the Health Care Financing Administration (HCFA), then directed by a hard-hitting municipal hospital administrator, Robert Derzon, ar-d the Office of the Assistant Secretary for Health, headed by Julius Richmond, MD, the gentle pediatrician from Head Start. (Derzon has since resigned and his place taken by Leonard D Schaeffer, a former vice-president of Citibank.) In assuming office, Dr Richmond adopted not only the political appointment of Assistant Secretary for Health but also the title Surgeon General, which described his professional link with the Public Health Service. Shortly after Dr Richmond assumed the desk of Assis- tant Secretary, he began his own reorganization. He moved the Center for Health Statistics and the Center for Health Services Research from the Health Resources Administration, a di- vision within the Public Health Service, directly into his office. Realignment of people, programs, and budgets con- sumes energy and engages the atten- tion of those in the bureaucracy.

One of the perplexing questions for me centered around the purpose of the reorganizations. I came to several un- validated conclusions. Given the more or less stable nature of a bureaucratic system, reorganization becomes a sur- vival tool for the political appointee. Coming from outside the system and often from outside government, he can more rapidly orient himself if he estab- lishes new patterns of authority. As

new coalitions develop and the system is temporarily unbalanced, the “new kid in town” can establish himself while the old-timers regroup. Reorganization serves the purposes of orientation, co- alition and loyalty building, and time buying. The time-buying concept is linked with another bureaucratic phenomenon called institutional mem- ory. This quality of mind and heart is usually vested in the old-timers. In periods of transition, the person who remembers (and tells) what it was like under Presidents such as Kennedy, Johnson, Ford, and Nixon is invaluable. Ths shrewd political appointee tunes in to this information until he feels grounded in the system.

Meanwhile, the Washington media monitor and analyze realignments of power and authority and give these undertakings a sense of importance. Because scenes change rapidly, it becomes important to know which actor is currently on stage. Social introductions in Washington are sensitive to this job shuming. I learned to give work his- tories in lieu of introductions.

What are some practical outcomes of interest, information, and involvement in government bureaucracy? Most of you would find similarities between HEW and the organizational behavior within hospitals, schools of nursing, or churches. Sensitize yourself to your organization and determine what patterns you can transfer to working with Washington.

The health bureaucracy in Wash- ington has characteristics of all liv- ing organisms. Understand the structure of the agency with which you wish to interact.

What is its jurisdiction? How does it relate organizationally to other agencies within the divi- sion or department? Who heads the agency? What is his source of expertise and authority?


Who within the agency holds the key to the information you seek, such as grants, contracts, and regu- lation development?

0 What is the political rating of this agency and its programs?

Homework is essential. Take time to identify and contact the right person. Some professions refer to their established informal contacts as “old-boy networks.” Nurses have been slow to develop communication chains, but this is changing. One expression of the grow- ing sophistication within nursing is the realization that nurses can decode and use complex systems. The bureaucracy in Washington may surprise you. It may be less intricate than your work environment.

Unfortunately, our orientation did not permit us to explore the health pro- grsms outside the jurisdiction of HEW. This was a serious but understandable omission. During the year in Wash- ington, I looked for the agencies that had developed around various laws. I found that the US Departments of Labor, Defense, and Agriculture, to name a few, have executive responsibility in overseeing health dollars and major health programs. They cannot be discounted in any analysis of the federal health bureaucracy.

My first introduction to Capitol Hill and the legislative branch of government occurred when I joined the health staff of Rep Doug Walgren (D), a freshman congressman from the 18th District in Pennsylvania. Walgren is a member of the House Interstate and Foreign Commerce Committee and sits on i t s two heal th subcommittees: Health and the Environment and Over- sight and Evaluation.

I realized early in December 1977 that my orientation to the Hill was going to be like some of my nursing experiences. The staff person who worked with Walgren on health issues was ill,

so the day after arriving in the office, I became Walgren’s legislative assistant for health.

During the 95th Congress (1976- 19781, the Subcommittee on Health and the Environment had jurisdiction over all health legislation except the Medi- care Act.’ During 1977-1978, most public health legislation was to be revised and amended. Examples were t h e Nurse Training Act (Title VIII), the Health Planning Act (Title XV), the Health Services Act (Title I), and the Health Maintenance Organization (HMO) Act (Title XIII).

In the winter of 1978, the Subcommit- tee also held oversight hearings and introduced bills on the biological effects of low-level radiation, the protection of human subjects, teenage pregnancy, developmental disabilities, and the food and drug law.

While I was with Walgren, my major areas of work were the health planning bill, the nurse training act, the health services bill, and the health effects of low levels of radiation. I became in- formed and more interested in the impact of health legislation on southwest- ern Pennsylvania, which Walgren represented. I had the opportunity to repre- sent the Congressman in speaking to the Allegheny County Medical Society, to work closely with the staff of the Health Systems Agency of Southwest- ern Pennsylvania, and to meet with various hospital administrators about the Health Planning Act and the cost con- tainment bills. I was able to pursue my interest in long-term care, particularly in developing support for alternatives to institutionalization through increased federal support for home health services. I also worked on hospice legislation, introduced by Walgren in April 1978.

It was not all work, however. In April 1978, I was sent by the American Politi- cal Science Association as a delegate

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The Structure of HEW The initials HEW seem to be synonymous with government bureaucracy. The Department is a bewildering maze of offices, agencies, and subunits. This is a capsule description of how the health section of HEW is organized.

At the top of HEW is Secretary Joseph Califano, a cabinet member who reports directly to the President. Two agencies are the umbrellas for the Department’s health activities: the Public Health Service (PHS) and the Health Care Financing Administration (HCFA).

1786 when Congress established the Marine Hospital Service to care for merchant seamen, the PHS now has 30,000 employees nationwide.

The largest is the National Institute of Health (NIH), made up of 11 research centers. NIH also funds research by other hospitals, medical schools, and nonprofit research centers. The Food and Drug Administration is a consumer protection agency that studies and regulates a wide variety of substances. Another PHS subunit, the Center for Disease Control in Atlanta, combats communicable disease and conducts a number of other health and safety activities.

Public Health Service. Dating back to

Within the PHS are six major subunits.

The Health Resources Administration is responsible for health manpower and training. The agency also supports and works with health systems agencies, the local planning units. The focus of the Health Services Administration (HSA) is bringing health care to citizens. Within HSA are programs for community health centers, rural health, and migrant health. HSA also operates the National Health Service Corps to recruit health professionals for medically underserved rural and urban areas. The sixth subunit, the Alcohol, Drug Abuse, and Mental Health Administration, administers programs designed to prevent or reduce these problems.

Health Care Financing Administration. This new HEW agency was established in 1977 to streamline and control the burgeoning Medicare and Medicaid programs. Today the budget of these two programs is $45 billion. HCFA also oversees the writing of rules and regulations pertaining to health. Another HCFA function is developing standards for quality assurance programs such as professional standards review organizations (PSRO). Formerly, Medicare was under the Social Security Administration, which administers Supplemental Security Income (SSI), and Medicaid was under the Aid to Families with Dependent Children (AFDC) program.

to t h e Canadian Par l i amen t . In t h e l ove l y ci ty o f O t t a w a , I m e t P r i m e M in i s te r P ier re Trudeau, l is tened to the f o r m a l presentat ion o f t h e n a t i o n a l budget, and realized t h a t t he Canadian centra l government invests l i t t l e t i m e or energy in hea l th mat ters because the hea l th plans are administered by t h e prov inc ia l governments.

U p o n r e t u r n i n g f r o m Canada, I walked across the Capi to l l a w n to j o i n the ma jo r i t y s ta f f o f t h e Senate Hu- man Resources Commit tee. There i s a wisdom o n Capi to l Hill that every member o f t h e House eventual ly wants to run for t he Senate. My decision t o j o i n

the ma jo r i t y s ta f f o f t h e H u m a n Re- sources Commit tee was based o n a de- sire t o observe t h e legis lat ive process in the “other body” and to part ic ipate in the pol i t ica l process f rom a posi t ion of p o w e r . C h a i r e d by S e n H a r r i s o n Wi l l iams, Jr (D-NJ), t he Human Re- sources Commit tee i s a parent committee with jur isd ic t ion over heal th, science, education, labor, t h e humanit ies, migrant workers, human development, and alcoholism and drug abuse.

My mentor, Becky Beauregard, a n associate counsel for t he Committee, worked closely with Sen Edward Ken- nedy’s (D-Mass) subcommittee o n heal th


Getting involved: Resources If you are interested in getting involved in politics, these are sources you may wish to consult.

Congressional Directory. Revised each year, this is a comprehensive guide to Congress and the bureaucracy, with biographies, committee assignments, telephone numbers, and addresses. Available at your public library or request an order form from the Superintendant of Documents, US Government Printing Office, Washington, DC 20402. There is a charge.

This Is HEW, Bewildered by the bureaucratic maze of HEW? This booklet explains the major agencies in the Department and their functions. A simplified organization chart helps you to visualize jurisdictions. Write Public Affairs Office, HEW, 200 Independence Ave SW, Washington, DC 20201.

ANA legislative activities from 1922 to ANA in Washington. A brief history of

1972. Includes a summary of legislation of interest to nurses. ANA publication number GR-1. Request an order form from t h e Publications Office, American Nurses’ Association, 2420 Pershing Rd, Kansas City, Mo 64108. There is a charge.

publishes a directory of nursing organizations in the federal government. For the latest edition, see Nursing Outlook (April 1978), pp 264-265. The 1979 directory will appear in July.

American Journal of Nursing. An annual directory of national and state nursing organizations and nursing agencies in the federal government. See American Journal of Nursing (April 1979).

comprehensive guide to key officials, committees, and agencies on federal and state health issues. For the 1979 edition, write Science & Health Publications, Inc, Suite 51 1, 1129 20th St NW, Washington, DC 20036. Price is $24.95 prepaid.

Nursing Outlook. Each year, this journal

National Health Directory. A

legislation. The heal th bills had reached the level of the full committee when I arrived in the Senate. I was able to follow “my bills”-health planning, nurse training, the health services bill, and the HMO bill-at full committee “mark up” and on to the floor of the Senate. During mark up, bills may be edited and amended.

In the Senate, we developed a “prevention package” as an amendment to the health services bill. This was an at- tempt to stimulate financially the development of prevention programs beyond immunization in state health departments. The amendment mentioned politically taboo subjects: alcohol labeling, food labeling, and cigarette tax.

What happened to this prevention package could be the subject of another paper. Briefly, what happened is that the amendments were deleted before the bill reached the Senate floor. A com-

bination of political factors explain the demise of the prevention package: committee jurisdiction, the tobacco lobby, and unwillingness to underwrite financially public education for personal health habits.

The most intriguing experience of my Senate career was observing the Senate reaction to California’s tax-cutting Proposition 13 and to watch the beginning of the 1980 race to the White House.

The Fellowship experience was re- warding. As time passed, I realized my opinions were respected and my political instincts were accurate. Was this to be explained by my Irish genes and childhood memories of the politics of Al- legheny County? Did it have something to do with years in nursing?

The modern word politics, derived from an ancient Greek word for city or state, means the sharing of limited re-

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sources. Compromise and the sharing of resources are skills nurses use in practice. The political arena is an area where nurses will feel at home.

In asking you t o locate your position in political action, my emphasis has been on movement from interest, to information, to involvement in the political process. Practice is a recognized way ofdeveloping and testing skill. Over the year, I thought about strategies, based on an insight into the democratic system. Simply, the good politician is al- ways running for election. Name recog- nition and the development of constit- uencies around a variety of issues are important factors in winning an election. Using this principle, I suggest developing skills in the following areas.

1. Become known by name to your representatives and senators. Develop personal and professional relationships with them and their staffs.

2. Visit their district offices. If you are going to Washington, make plans to visit the office of your political association and the offices of your representatives and senators.

3. Write brief notes t o your congressmen. Someone, usually the staff person who has responsibility in the area, reads and answers the letters. Often the congressman is looking for a health issue. Your letter may focus his energy.

4. Clarify your purpose and your communication. What do you want? (a) to acquaint the congressman with you and your interests? (b) to obtain information about or request a copy of a law, bill, or hearing report? (c) to express your concern and give a viewpoint about an issue that is being ignored or is before a committee of the House or Sen- ate? (d) to ask your congressman to explore a question at a hearing? (e) to ask him to introduce a n amendment or introduce a bill on a subject? (0 to ask for his vote on a particular issue?

(g) to inform him of the impact that a bill or an issue would have on his con- stituents?

5 . In your communication, suggest positive approaches. Convey respect, information about the legislator’s past record on the subject, and your sophistication about political realities.

6. Identify yourself with the political action arm of your professional association. Invite the legislator or his repre- sentative to meetings where you can get publicity.

7. Read the Washington commen- taries from various points of view. Ob- tain the political commentary from your associations.

8. Volunteer and help in election campaigns.

9. Be patient. Politics, like love, takes time.

There is a classic stereotype of a politician. He smiles, kisses babies, smokes cigars, and shakes hands. Try to construct situations that are positive, and allow the legislator to do something for you. While in Washington, I learned something from the lobbyists. My fa- vorite lobbyist would give us the position of his association; then he would smile and offer an option we could buy. By the time he had seen all the members and staffs of the Subcommittee on Health and the Environment, he had commitments for most of his package. The message is, play to win something.

A wise woman who represented a financially powerful lobby told me, “I never punish them when they vote against us. Anyone can make a mistake. Any bill is like a commuter train. There will be another one by in several hours.” This good advice helped me gain perspective on how to deal with the congressmen and staffs.

I believe the key to effectiveness in the legislative process lies in the development of interpersonal relationships. In the Anglo-Saxon systems, laws


develop out o f experience. Cult ivate a work ing and t rust ing relationship w i t h your legislators and the i r staffs. Share your experience w i t h them.

It i s possible in Washington to have access to computerized information systems and to review abstracts o f the lit- erature. These are readi ly available to Congressmen and the i r staffs. Repre- sentatives need the local, human touch. Information about the impact o f a program o n a distr ict or region, data to sup- por t the need for federal intervention, and facts that indicate government pro-

grams are being misused are pol i t ical ly vi tal. You can offer this.

I le f t Washington, DC, proud to be American. I respect the pol i t ical process because, although it i s somewhat chao- t ic , i t i s u l t imate ly fair. I also realized the government needs me. I think it needs you, too. 0 Notes

1. House Committee on Interstate and Foreign Commerce, Compilation of Selected Acts within the Jurisdiction of the Committee on Interstate and Foreign Commerce (Washington, DC: US Govern- ment Printing Office, Vol 1-4, 1977) 22.

Improved CAT scan data pinpoint brain tumors A new method has been developed to pinpoint the location of deep brain tumors using computerized axial tomography (CAT) scanning. Developed by scientists at Rush-Presbyterian-St Luke’s Medical Center, Chicago, the method allows use of biopsy techniques that greatly reduce the risk of injuring the patient’s brain.

The new technique is described in an article in Neurosurgery by Richard D Penn, MD, associate professor of neurosurgery, and Walter W Whisler, MD, professor and chairman of the Department of Neurosurgery.

Although CAT scans provide three-dimensional pictures of various parts of the body, until now it has been difficult to determine precise spatial information to locate the site of a brain tumor. Beginning research in 1977, Dr Penn developed a series of computer programs to extract additional data from CAT scans. Using an image processing technique, Dr Penn’s programs allow him to produce a greatly enhanced picture of the brain. With this additional visual information, it is possible to pinpoint the exact location of a suspected deep tumor, and perform a biopsy of it through stereotaxic surgery.

In stereotaxic surgery, a small biopsy needle is inserted to the predetermined part of the brain, using special surgical and x-ray equipment. The procedure can be

done under local anesthesia, with little or no injury to surrounding tissue. This contrasts to regular biopsies of brain tumors, which require conventional surgery. Such biopsies risk causing severe brain damage while trying to locate and reach the tumor.

stereotaxic surgery for biopsy of deep brain tumors, using a mathematical approximation technique to locate the tumor. The newly developed image processing method allows easier and more precise locating of tumors.

coordinates to pinpoint suspected tumor sites, Dr Whisler has biopsied 21 patients using stereotaxic surgery. No patient died or suffered any untoward effects as result of the surgery. Two patients were found to have abscesses rather than tumors. Dr Whisler reported without this procedure, their conditions would have remained undiagnosed.

programs expand the usefulness of the CAT scanner. He said use of the CAT scanner with stereotaxic surgery will further neurosurgeons’ understanding of brain tumors and their treatment.

Since 1975, Dr Whisler has used

Using the computer-generated

According to Dr Penn, image processing

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