Conceptual Basis for Policymaking

The policy process consists of a series of actions, each critical to resolving a problem through analysis and formulation of solutions and can involve many organizations and individuals as well as requiring multiple steps. Two models from political scientists are relevant to nurses’ understanding of the policy process. The purpose of reviewing these models is to provide two different yet complementary approaches for readers to see how the seemingly chaotic policymaking process has a form, rhythm, and predictability.

Longest’s Policy Cycle Model

Health policy is a cyclical process. Longest (2010) mapped out an interrelated model to capture how U.S. policymaking works. It is a continuous, highly dynamic cycle that captures the incremen­talism inherent in U.S. governmental decision making (Figure 7-1). In its simplest form, there are three phases to the policy process: a policy formulation phase, an implementation phase, and a policy modification phase. Each phase contains a set of actions and activities that produce outcomes or products that influence the next stage. Although simple in design, this model is deceptively complex. Defining the policy problem with adequate clarity so that it gains the attention of policymakers and stakeholders is challenging; each policy problem has many solutions and competitors seeking a place on the policy agenda. Although policymaking is dependent on good data and evidence about what works, data and evidence may not be enough to outweigh the influence of the political environment.

FIGURE 7-1 Longest’s Policy Framework. (Redrawn from Longest, B. [2010]. Health policymaking in the United States [5th ed.]. Chicago: Health Administration Press.)

Policy formulation includes all of the activities that are involved in policy design, including those activities which inform the legislators. It is in this phase that nurses can serve as a knowledge source to legislators in helping frame the problem and bringing nursing stories and patient narratives to illustrate how health problems play out with individual constituents/populations. The most effective 66time to influence legislation is before it is drafted, so that nurses can help frame the issues to align with their desire for policy outcomes that are patient-centered.

Policy implementation comprises the rule-making phase of policy development. The legislative branch passes the law to the executive branch which is charged with implementation. This includes adding specificity to the law and may also include, for example, defining the provider to include advanced practice nurses. The writing of rules after legislation is passed is a crucial and often overlooked aspect of policymaking. At this juncture, nurses with appropriate expertise can monitor and influence how the rules are written. Once written, federal regulations are published in the daily Federal Register for 60 days to receive public comment. States also have regulation processes that provide designated times for public input.

Stakeholder groups can exert enormous influence during the implementation phase (, 2013). When strong letter-writing campaigns are employed, the rulemaking agency may be forced to publish those comments and make adjustments according to their volume and scientific rigor. It is not unusual for the intent of a policy to get lost in the translation to program development. This rule-making phase is an important leverage point for nurses to closely monitor and respond to regulations through grassroots campaigns.

Two important aspects of American democracy are at play during the public comment phase: (1) informed citizenry: the democratic process only works if its citizenry is informed; and (2) government is not all-knowing: the government acknowledges it does not hold all of the expertise, it must solicit that expertise from the public (, 2013). An example of rule making that limited nursing occurred when the Georgia legislature revised its scope of practice law for nurses. The law had many benefits for APNs, but the executive branch of the Georgia state government made the rules and regulations more restrictive than they were before the legislation was passed. The restrictions caused many APNs to avoid practicing under the new scope of practice but to continue to work under the old scope of practice that is still in effect as it is less restrictive (Center to Champion Nursing in America, 2010).

Policy modification allows all previous decisions to be revisited and modified. Polices that are wholly pertinent at one time may, over time, become inappropriate. Almost all policies have unintended consequences which is why many stakeholders seek to modify policies continuously.