Politics is the use of relationships and power to gain ascendancy among competing stakeholders to influence policy and the allocation of scarce resources. Because inevitably there are competing interests for scarce resources, policymaking is done within a political context.
The definition of politics contains several important concepts. Influencing indicates that there are opportunities to shape the outcome of a process. Allocation means that decisions are being made about how to distribute resources. Scarce implies the limits to available resources and that all parties probably cannot have all they want. Finally, resourcesare usually considered to be financial but could also include human resources (personnel), time, or physical space such as offices (Mason, Leavitt, & Chaffee, 2012). Engaging in the political context of policymaking includes knowing the positions of key stakeholders and political parties, as well as the electoral process, public opinion, the influence of media coverage, and more (see Chapter 9 for an in-depth discussion of political analysis and strategies). Understanding politics is an invitation not to misuse power, people, or information but rather to align the health of the public with the interest of the policymaker. For example, a Congresswoman may have run her campaign focused on improving the economy. She may not have linked the rising obesity epidemic as a threat to the larger macroeconomy and American productivity. Nurses could link obesity to the economy by describing the catastrophic direct and indirect costs of the obesity epidemic and how it is making the United States less competitive in a global market. This is a way for nurses to use their power to create more urgency about the most pressing public health issues.
Policy Analysis and Analysts
Analysis is the examination of an object or a process to understand it better. Policy analysis uses various methods to assess a problem and determine possible solutions. This encourages deliberate critical thinking about the causes of problems, identifies the ways a government or other groups could respond, evaluates alternatives, and determines the most desirable policy choice. (See Chapter 7.) Policy analysts are individuals who, with professional training and experience, analyze problems and weigh potential solutions. Citizens can also use policy analysis to better understand a problem, 11alternatives, and potential implications of policy choices (Kraft & Furlong, 2010).
Advocacy and Activism
Advocacy of one patient at a time has long been a central role for nurses. But nurses can be advocates on a larger scale by working in policy and politics, which is endorsed in “nursing’s social policy statement” (American Nurses Association [ANA], 2003), a document that defines nursing and its social context. Political activism may be associated with protests but has grown to include additional diverse and effective strategies such as blogging, using evidence to support policy choices, and garnering media attention in sophisticated ways.
Interest Groups and Lobbyists
Interest groups advocate for policies that are advantageous to their membership. Groups often employ lobbyists to advocate on their behalf and their power cannot be underestimated. In 2009, 1814 U.S. businesses and organizations spent $554,566,269 on lobbying and employed 3527 lobbyists to advocate for their interests in the health care reform debate and other issues (Center for Responsive Politics, n.d., a). This was a peak year that coincided with interest groups’ attempts to influence the ACA. In 2013, 1299 organizations spent $483,078,712 on lobbying and used 2918 lobbyists to advance their interests, including over $1.6 million by the ANA and $940,000 by the American Association of Nurse Anesthetists (Center for Responsive Politics, n.d., b).
The power of media is demonstrated in political and issue campaigns, whether through paid political advertisements or the “talking heads” on “news” programs that present polarized views. The aim is to deliver messages that resonate with the values and emotions of a target audience to support or oppose a candidate or proposed policy. The strategic use of media is imperative in today’s cacophony of information. Gaining the attention of a target audience is power. Persuading that audience to behave the way you want is ultimate power.
In this information age, nurses must proactively use media to influence policy and make themselves available to speak with journalists about policy matters. However, nurses have not always been eager to enter the media spotlight (see Chapter 14 on using media as a policy and political tool), particularly when it comes to talking with journalists. Social media is a tool for influencing policymakers (Grande et al., 2014) and provides nurses with an opportunity to control their message. Nurse bloggers such as Barbara Glickstein are getting visibility as “media makers.” Theresa Brown writes for the Opinionator column for The New York Times. Both are bringing nursing perspectives on policy matters to the public’s attention.
Science and Research
The information age has created an emphasis on evidence-based practice and policies. Scientific findings play a powerful role in the first step of the policy process: getting attention to particular problems and moving them to the policy agenda. Research can also be valuable in defining the size and scope of a problem and substantiating policy recommendations. This can help to obtain support for a proposed policy and in lobbying for support of it. Evidence should be used to inform policy debates and shape policy choices to help ensure that the solution will be effective. That said, evidence is essential but may not be sufficient to advance policies. Values and politics can trump evidence, as has been apparent in recent debates over two issues: climate change and decreasing rates of vaccinations. Despite the evidence showing that humans are contributing to potentially devastating changes in the earth’s climate or that childhood vaccinations do not cause autism, debates about these issues continue and affect whether policies are or are not adopted to address the problems.
The Power of Presidents and Other Leaders
The president embodies the power of the executive branch of government and is the only person elected to represent the entire nation. As the most visible government official, the president is able to propel issues to the top of the nation’s policy agenda. Although the president cannot introduce legislation, he or she can provide draft legislation 12and legislative guidance. The president can also issue executive orders when he or she cannot get support for policy change from Congress. President Obama has done so in the face of a paralyzed Congress, as did his Republican and Democratic predecessors. This force also applies to the leaders of many public and private entities. Never underestimate the power of the official leader or of those who seek to remove or thwart the leader.
The Framework for Action
Nursing has a covenant with the public. The profession’s practice laws, standards, and ethics have roots in its history of activism for social justice. A social contract with society demands professional responsibility. Thus, every nurse must continuously consider the policy context of daily practice in any setting. The solutions to today’s most intractable health care problems, including perverse payment mechanisms, deeply disturbing social injustice, and shocking ethnic and racial disparities, are not simple to solve. But, according to the annual Gallup poll (Gallup, 2013), the public regards nurses’ “honesty and ethical standards” more highly than those of any other profession. This public trust places a moral imperative on nurses to vigorously engage in influencing policy. Nurses see close up how policies get played out in patient care and can report on unintended consequences. This imperative requires nurses to expand their involvement in policy decisions at the institutional, community, state, federal, or international realm and need not be restricted to any one setting.
The Framework for Action (Figure 1-5) illustrates that nurses operate in four spheres: government, workplace, interest groups (including professional organizations), and community to influence policies that affect health and health care and core/social determinants of health.
FIGURE 1-5 A framework: Spheres of influence for action. Nurses need to work in multiple spheres of influence to shape health and social policy. Policies are designed to remedy problems in the health system and to address social determinants of health; both of which aim to improve health.
Spheres of Influence
The four spheres of influence provide a visual medium for understanding the policy arena. These spheres are not discrete silos. Policy can be shaped in more than one sphere at a time, and action in one sphere can influence others. To achieve greater 13access to care for the uninsured, for example, nurses may work in their own organization to alter policy to increase access to services. They may also use political strategies in the media, such as blogging or being interviewed on television, to express their support for better access to care. They may work with a professional association or an interest group to communicate their views to policymakers. Additional context (the who, what, where, when, and why of nursing’s policy influence) is provided in Figure 1-6.
FIGURE 1-6 The who, what, where, when, and why of nursing’s policy influence.
Government action and policy affect lives from birth until death. It funds prenatal care, inspects food, controls the safety of toys and cars, operates schools, builds highways, and regulates what is transmitted on airwaves. It provides for the common defense; supplies fire and police protection; and gives financial assistance to the poor, aged, and others who cannot maintain a minimal standard of living. The government responds to disaster, subsidizes agriculture, and licenses funeral homes.
Although most U.S. health care is provided in the private sector, much is paid for and regulated by the government. So, how the government crafts health policy is extremely important (Weissert & Weissert, 2012). Government plays a significant role in influencing nursing and nursing practice. States determine the scope of professional activities considered to be nursing, with notable exceptions of the military, veterans’ administration, and Indian health service. Federal and state governments determine who is eligible for care under specific benefit programs and who can be reimbursed 14for providing care. Sometimes government provides leadership in defining problems for both the public and private sectors to address. There are more than a dozen House and Senate committees and subcommittees that shape policy on health, and many more committees address social problems that affect health. In the House of Representatives, the Congressional Nursing Caucus, an informal, bipartisan group of legislators who have declared their interest in helping nurses, lobbies for federal funding for nursing education (Walker, 2009).
Abraham Lincoln’s description of a “government of the people, by the people, for the people” (Lincoln, 1863) captures the intricate nature of the relationship of government and its people. There are many ways nurses can influence policymaking in the government sphere, at local, state, and federal levels of government. Examples include:
• Obtaining appointment to influential government positions
• Serving in federal, state, and local agencies
• Serving as elected officials
• Working as paid lobbyists
• Communicating positions to policymakers
• Providing testimony at government hearings
• Participating in grassroots efforts, such as rallies, to draw attention to problems
The Workforce and Workplace
Nurses work in a variety of settings: hospitals, clinics, schools, private sector firms, government agencies, military services, research centers, nursing homes, and home health agencies. All of these environments are political ones; resources are finite, and nurses must work in each to influence the allocation of organizational resources. Policies guide many activities in the health care workplaces where nurses are employed. Many that affect nursing and patient care are internal organizational policies such as staffing policies, clinical procedures, and patient care guidelines. External policies are operative in the health care workplace also; for example, state laws regulating nursing licensure. Federal laws and regulations are evident in the nursing workplace such as Occupational Health and Safety Administration regulations regarding worker protection from bloodborne pathogens.
Policy influences the size and composition of the nursing workforce. The ACA authorizes increased funding for scholarships and loans for nursing education, potentially augmenting existing workforce programs funded under Title VII and Title VIII of the Public Health Service Act. The nongovernmental Commission on Graduates of Foreign Nursing Schools is authorized by the federal government to protect the public by ensuring that nurses and other health care professionals educated outside the United States are eligible and qualified to meet U.S. licensure, immigration, and other practice requirements (Commission on Graduates of Foreign Nursing Schools, 2009). The National Council of State Boards of Nursing is a not-for-profit organization that brings together state boards of nursing to act on matters of common interest affecting the public’s health, safety, and welfare, including the development of licensing examinations in nursing (National Council of State Boards of Nursing, 2009). These are just a few examples of the external forces that shape workforce and workplace policy.
Associations and Interest Groups
Professional nursing associations have played a significant role in influencing practice. Many associations have legislative or policy committees that advocate policies supporting their members’ practice and advance the interests of their patient populations. Working with a group increases the effectiveness of advocacy, provides for the sharing of resources, and enhances networking and learning. In fact, these associations can be excellent training grounds for novice nurses to learn about policy and political action (see Chapter 4). Nurses can be effective in association policy activities by serving on public policy or legislative work groups, providing testimony, and preparing position statements.
When nursing organizations join forces through coalitions, their influence can be multiplied. For example, The Nursing Community (www.thenursingcommunity.org) is an informal coalition of national nursing organizations that formed to speak with one voice on matters important to national policy and political appointments (see 15Chapter 75). The Coalition for Patients’ Rights (www.patientsrightscoalition.org) is a group of more than 35 national organizations representing health care professionals that is working to fight the American Medical Association’s attempts to limit patients’ access to nonphysician providers. Twenty members are nursing organizations.
Nurses can be influential, not just in nursing associations, but by working with other interest groups such as the American Public Health Association or the Sierra Club. Some interest groups have a broad portfolio of policy interests, whereas others focus on one disease (e.g., National Breast Cancer Coalition) or one issue (e.g., driving while intoxicated, the primary focus of Mothers Against Drunk Driving). Interest groups have become powerful players in policy debates; those with large funding streams are able to shape public opinion with media advertisements.
A limited number of nurses will have the opportunity to influence policy at the highest levels of government, but extensive opportunities exist for nurses to influence health and social policy in communities. Nursing has a rich history of community activism with remarkable examples provided by leaders such as Lillian Wald, Harriet Tubman, and Ruth Lubic. This legacy continues today with the community advocacy efforts of nurses such as Cora Tomalinas, Mary Behrens, Ellie Lopez-Bowlan, the Nightingales who took on Big Tobacco, and the nurses who are a part of the Canary Coalition for Clean Air (their stories appear in this book).
A community is a group of people who share something in common and interact with one another, who may exhibit a commitment to one another or share a geographic boundary (Lundy & Janes, 2001). A community may be a neighborhood, a city, an online group with a common interest, or a faith-based network. Nurses can be influential in communities by identifying problems, strategizing with others, mobilizing support, and advocating change. In residential communities (such as towns, villages, and urban districts), there are opportunities to serve in positions that influence policy. Many groups, such as planning boards, civic organizations, and parent-teacher associations, offer opportunities for involvement.
The Framework for Action includes health as an element of the model to represent that optimal health is viewed as the goal of nursing’s policy efforts. Optimal health (whether for the individual patient, family, a population, or community) is the central focus of the political and policy activity described in this book. This focus makes it clear that the ultimate goal for advancing nursing’s interests must be to promote the public’s health.
Nursing embraces a broad definition of health that aligns with the World Health Organization (1948): “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” It incorporates the concept of positive health, not just ill health (Greene et al., 2014). This definition requires a focus on creating communities that thrive economically, have safe environments, and use resources to ensure that their members have access to good nutrition and other elements that can promote health.
Health and Social Policy
This definition of health leads to the focus on health and social policy as key elements in the Framework for Action. Many factors that affect health are social ones, such as income, education, and housing. Although nurses involved in policy often focus on health policies, the emphasis on upstream factors requires a broader focus on the socioeconomic factors that affect health, including labor policy, laws that can stimulate job creation, or local ordinances on smoking bans.
Health Systems and Social Determinants of Health
The health care system is the focus of most discussions of health policy to date. Much of this book focuses on understanding the complex and sometimes chaotic U.S. health care system, the ACA’s role in augmenting the system’s performance, and other 16policies needed to achieve the Triple Aim. It also addresses the powerful impact that upstream factors have on the health of populations. A singular focus on the health care system is limited in the extent to which it can lead to higher levels of health for individuals, families, and communities.
Nursing has also developed a competency-based educational curriculum supporting future nurses’ involvement in policy. The American Association of Colleges of Nursing (AACN) publishes the necessary curriculum content and expected competencies of all nursing school graduates from baccalaureate, master’s, doctor of nursing practice, and research doctorate (PhD) programs. These documents serve as a framework for twenty-first-century nursing and ground the profession in the direct and indirect care of individuals, families, communities, and populations. The content builds on nursing knowledge, theory, and research and derives knowledge from a wide array of fields and professions.
A study by Byrd and colleagues (2012) found that undergraduate nursing students for the most part are largely unaware of the importance of political activity for nurses. After participating in a robust and active public policy learning activity, students measured high on a political astuteness scale. This study suggests that political skills can be learned when presented with relevance to nursing and used to hone skills such as inquiry, critical thinking, and complex problem solving. These results highlight the importance of increasing students’ awareness of how to participate in the political process, as well as encouraging their participation in student and professional organizations.
For each level of nursing education—BSN, MSN, DNP, and PhD—there is a clear expectation that graduates will have policy competency, with increasing emphasis on policy leadership as nursing students progress academically, although this is less well defined for PhD graduates (AACN, 2006; AACN Task Force, n.d.). These essentials make it clear that health policy directly influences nursing practice and every aspect of the health care system. It is understood that patient safety and quality cannot be addressed outside of the context of policy. The broader policy context is emphasized throughout nursing degree programs. It is expected that DNP graduates are able to design, implement, and advocate health policies that improve the health of populations. The powerful practice experiences of nurses can become potent influencers in policy formation. Additionally, a DNP graduate integrates these practice experiences with two additional skill sets: the ability to analyze the policy process and the ability to engage in politically competent action (AACN, 2006). See Table 1-1 for a summary of the policy competencies in successive nursing education programs.
AACN’s Nursing Essentials Series: Policy Competencies for Nurses
Policy Essential: All Nurses at This Level Must Have Expertise in:
BSN Policy Essential VI1
Health care policy, finance, and regulatory environments
Health care policies, including financial and regulatory, directly and indirectly influence the nature and functioning of the health care system and thereby are important considerations in professional nursing practice.
MSN Policy Essential VI1
Health policy and advocacy
Recognizes that the master’s-prepared nurse is able to intervene at the system level through the policy development process and to employ advocacy strategies to influence health and health care.
DNP Policy Essential V1
Health care policy for advocacy in health care
The DNP graduate has the capacity to engage proactively in the development and implementation of health policy at all levels, including institutional, local, state, regional, federal, and international levels.
DNP graduates, as leaders in the practice arena, provide a critical interface among practice, research, and policy.
Preparing graduates with the essential competencies to assume a leadership role in the development of health policy requires that students have opportunities to contrast the major contextual factors and policy triggers that influence health policymaking at various levels.
Research-Focused Doctorate in Nursing (PhD)2
Curricular elements include:
Communicate research findings to lay and professional audiences and identify implications for policy, nursing practice, and the profession
Strategies to influence health policy.
Leadership related to health policy and professional issues.
1The American Association of Colleges of Nursing. Essentials Series. Baccalaureate (2008); Masters (1996); DNP (2011). Retrieved from www.aacn.nche.edu/education-resources/essential-series.
2The American Association of Colleges of Nursing. (2010). The Research-Focused Doctoral Program in Nursing: Pathways to excellence. Report from the AACN Task Force on the Research-Focused Doctorate in Nursing. Retrieved from www.aacn.nche.edu/education-resources/phdposition.pdf.
Policy and Political Competence
Competence is being adequately prepared or qualified to perform a specific role. It encompasses a combination of knowledge, skills, and behaviors that improve performance. Nurses are often reluctant to become involved in policy because of the “politics.” Political skill has a bad reputation; for some, it conjures up thoughts of manipulation, self-interested behavior, and favoritism (Ferris, Davidson, & Perrewe, 2005). “She plays politics” is not generally considered to be a compliment, but true political skill is critical in health care leadership, advocating for others, and shaping policy. It is simply not possible to succeed in any decision-making arena by ignoring the political realm. Ferris, Davidson, and Perrewe (2005) consider political skill to be the ability to understand others and to use that knowledge to influence others to act in a way that supports one’s objectives. They identify political skill in four components: