heAlth PoliCy and PolitiCs

heAlth PoliCy and PolitiCs

Introduction In 2010, the Institute of Medicine* (IOM) issued a report, The Future of Nursing: Advancing Health, Leading Change, that challenged nurses to work with other healthcare professionals in two ways: to learn from them and to help them learn from nurses. In this spirit of interprofessional cooperation and leadership, this text will incorporate a variety of healthcare provider professionals (HCPs) into the discussion of public policy, case studies, discussion points, and reader activities.

▸ How Is Public Policy Related to Clinical Practice?

It is the authors’ belief that nurses and other HCPs are ideally positioned to participate in the policy arena because of their history, education, practice, and organizational involvement.

In this chapter, policy is an overarching term used to define both an entity and a process. The purpose of public policy is to direct problems to the government’s attention and to secure the government’s response.

The definition of public policy is important because it clarifies common misconceptions about what constitutes policy. In this text, the terms public policy and policy are interchangeable. The process of creating policy can be focused in many areas, most of which are interwoven. For example, environmental pol- icy deals with determinants of health such as hazardous materials, particulate matter in the air or water, and safety standards in the workplace. Education policies are more than tangentially related to health—just ask school nurses. Regulations define who can administer medication; state laws dictate which type of sex education can be taught. Defense policy is related to health policy when developing, investigating, or testing biological and chemical weapons. There is a growing awareness of the need for a health-in-all-policies approach to strategic thinking about policy.

Statutes: Written laws passed by a legislative body. Statutes differ from “common law” in that common law (also known as case law) is based on prior court decisions. Statutes may be enacted by both federal and state governments and must adhere to the rules set in the Constitution.

System (capital “S”): The U.S. healthcare delivery and finance system (usage specific to this text).

system (lowercase “s”): A group of hospitals and/or clinics that form a large healthcare delivery organization (usage specific to this text).

* The name of the Institute of Medicine was changed to the National Academy of Med- icine in 2016.

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Health policy directly addresses health problems and is the specific focus of this text. In general, policy is a consciously chosen course of action: a law, regulation, rule, procedure, administrative action, incentive, or voluntary practice of governments and other institutions. By comparison, politics is the process of influencing the allocation of scarce resources.

Policy as an Entity Official government policies reflect the beliefs and values of elected members, the administration in power, and the will of the American people. Official policies provide direction for the philosophy and mission of government organizations. Some policies, known as position statements, report the opinions of organizations about issues that members believe are important. For example, state boards of nursing (government agencies created by legislatures to protect the public through the regulation of nursing practice) publish advisory opinions on what constitutes competent and safe nursing practice.

Laws (or statutes) are one type of policy entity that serve as legal directives for public and private behavior. Laws are made at the international, federal, state, and local levels and are considered the principal source in guiding conduct. Lawmaking usually is the purview of the legislative branch of government in the United States, although presidential vetoes, executive orders, and judicial interpretations of laws also have the force of law.

Judicial interpretation occurs in three ways: (1) through courts’ interpre- tation of the meaning of broadly written laws that are vague regarding details; (2) by determining how some laws are applied—that is, by resolving questions or settling controversies; or (3) by interpreting the Constitution and declaring a law unconstitutional, thereby nullifying the entire statute (Litman & Robins, 1991). For example, the 1973 Rehabilitation Act prohibited discrimination against people with handicaps by any program that received federal assistance. Although this may have seemed fair and reasonable at the outset, courts adjudicated questions of how much accommodation is “fair and reasonable” (Wilson, 1989). In general, courts are idealized as being above the influence of political activity that surrounds the legislature. The court system, especially the federal court system, may also resolve conflicts between levels of government (state and federal).

Regulations and rules are another policy entity discussed elsewhere in this text. Although they often are included in discussions of laws, regulations differ from statutes. Once the legislative branch enacts a law, the executive branch of government administers that law’s implementation. The executive branch consists of the president, the White House staff, multiple agencies, commissions, and departments that carry out the work of implementing and monitoring laws for the public benefit. Government agencies formulate regulations that achieve the intent of the statute. Overall, laws are written in general terms, and regulations are written more specifically to guide the interpretation, administration, and enforcement of the law. The Administrative Procedures Act, enacted in 1946, ensures a structure and process that is published and open, in the spirit of the founding fathers, so the average constituent can participate in the process of public decision making.

All these policy entities evolve over time and are accomplished through the efforts of a variety of actors or players. Although commonly used, the terms

How Is Public Policy Related to Clinical Practice? 3



position statement, resolution, goal, objective, program, procedure, law, and reg- ulation really are not interchangeable with the word policy. Rather, they are the formal expressions of policy decisions. For the purposes of understanding just what policy is, nurses must grasp policy as a process.

Policy as a Process For purposes of analysis, policymaking comprises five processes:

■ Agenda setting ■ Government response (usually legislation and regulation) ■ Policy design ■ Implementation ■ Evaluation of the policy outcomes ■ Economics and finance of policy

The steps in the policy process are not necessarily sequential or logical. For example, the definition of a problem, which usually occurs in the agenda-setting phase, may change during fact-finding and debate. Program design may be altered significantly during implementation. Evaluation of a policy or program (often considered the last phase of the process) may propel onto the national agenda (often considered the first phase of the process) a problem that differs from the originally identified issue. For the purpose of organizing one’s thoughts and conceptualizing the policy process, we will examine the policy process from a linear perspective in this text, but you should recognize that this path is not always strictly followed.

The opportunities for nurse input throughout the policy process are unlim- ited. Nurses are articulate experts who can address both the rational shaping of policy and the emotional aspects of the process. Nurses cannot afford to limit their actions to monitoring bills; they must seize the initiative and use their con- siderable collective and individual influence to ensure the health, welfare, and protection of the public and healthcare professionals.

Why You Are the Right Person to Influence Health Policy Nursing’s education requirements, communication skills, rich history, leadership, and trade association involvement, as well as our practice venues, uniquely qualify nurses to influence thought leaders and policymakers. Nursing and nurses have an ongoing impact on health and social policies. FIGURE 1-1 illustrates some aspects of nurses’ impact on the health and well-being of populations.

Advanced studies build on education and experience and broaden the arena in which nurses work to a systems perspective, including both regional health systems and the overall U.S. System of healthcare delivery and finance. Nurses not only are well prepared to provide direct care to persons and families but also act as change agents in the work environments in which they practice and the states/nations where they reside.

Nurses have developed theories to explain and predict phenomena they encounter in the course of providing care. In their practice, nurses also in- corporate theory from other disciplines such as psychology, anthropology, education, biomedical science, and information technology. Integration of all

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FIGURE 1-1 Historical timeline of nurses who influenced policy. (continues)

1852 Florence Nightingale used statistics to advocate for improved education for nurses, sanitation, and equality.

1861 Clarissa “Clara” Barton was a hospital nurse in the American Civil War. She founded the American Red Cross.

1879 Mary Mahoney was the first African American nurse in the United States and a major advocate for equal opportunities for minorities.

1903 North Carolina creates first Board of Nursing in nation and licenses the first registered nurse.

1906 Lillian D. Wald, nurse, humanitarian, and author. She was known for contributions to human rights and was the founder of Amer- ican Community Nursing. She helped found the NAACP.

1909 The University of Minnesota bestows the first bachelor’s degree in nursing.

1916 Margaret Higgins Sanger was an American birth control activist, sex educator, writer, and nurse. Sanger popularized the term “birth control” and opened the first birth control clinic in the United States (later evolved into Planned Parenthood).

1925 Frontier Nursing Service was established in Kentucky with ad- vanced practice nurses (midwives).

1955 RADM Jessie M. Scott, DSc, served as assistant surgeon general in the U.S. Public Health Service; led division of nursing for 15 years; testimony before Congress on the need for better nursing training led to the 1964 Nurse Training Act, the first major legislation to provide federal support for nurse education during peacetime.

1966 NP role created by Henry Silver, MD, and Loretta Ford, RN. 1967 Luther Christman, PhD, became the first male dean of a School

of Nursing (at Vanderbilt University). Earlier in his career, he had been refused admission to the U.S. Army Nurse Corps because of his gender. He was the founder of the American Association for Men in Nursing, as well as a founder of the National Student Nurses Association.

1971 Idaho statutorily recognizes advanced practice nursing. 1978 Faye Wattleton, CNM, was elected president of the Planned Par-

enthood Federation of America—the first African American and youngest person ever to hold that office. First African American woman honored by the Congressional Black Caucus.

1987 Ada S. Hinshaw, PhD, became the first permanent leader at the National Institute of Nursing Research at the National Institutes of Health.

1989 Geraldine “Polly” Bednash, PhD, headed the American Associ- ation of Colleges of Nursing’s legislative and regulatory advocacy programs as director of government affairs. She became CEO of AACN in 1989 and co-authored AACN’s landmark study of the financial costs to students and clinical agencies of baccalaureate and graduate nursing education.

How Is Public Policy Related to Clinical Practice? 5



1992 Eddie Bernice Johnson, BSN, was the first nurse elected to the U.S. Congress (D-TX). Strong voice for African Americans and pro-nursing policies.

1996 Beverly Malone, PhD, elected president of the American Nurses Association; President Clinton appointed her to Advisory Com- mission on Consumer Protection and Quality in the Health Care Industry and to the post of deputy assistant secretary for health within the Department of Health and Human Services.

1998 Lois G. Capps, BSN, California Representative to the U.S. House from 1998–2017, where she founded the Congressional Nursing Congress.

2001 Major General Irene Trowell-Harris, EdD, RN, USAF (Ret.), director of Department of Veterans Affairs, Center for Women Veterans. Instrumental in establishing fellowship for military nurses in the office of Senator Daniel K. Inouye (D-HI).

2009 Mary Wakefield, PhD, became the first nurse appointed as di- rector of the Health Resources and Services Administration. In 2015, she became the Acting Deputy Secretary for the Department of Health and Human Services. Served as Chief of Staff for U.S. Senators Quentin Burdick (D-ND) and Kent Conrad (D-ND).

2010 Mary D. Naylor, PhD, a member of the Medicare Payment Ad- visory Commission influenced health policy with membership on the RAND Health Board, the National Quality Forum Board of Directors, and as pastchair of the Board of the Long-Term Quality Alliance.

2013 Joanne Disch, PhD, influenced health policy as chair of the na- tional board of directors for the American Association of Retired Persons and the American Academy of Nursing.

FIGURE 1-1 Historical timeline of nurses who influenced policy. (continued)

this information reflects the extreme complexity of nursing care and its provi- sion within an extremely complex healthcare system. Nurses understand that partnerships are valued over competition, and that the old rules of business that rewarded power and ownership have given way to accountability and shared risk. Transformation of today’s broken healthcare system will require a radical, cross-functional, futuristic change in the way people think. Observing patterns in personal behavior can be useful when working with policymakers as they try to figure out the best or most cost-effective way to address public problems. Creative ways of examining problems and innovative solutions may cause discomfort among policymakers who have learned to be cautious and go slowly. Nurses and other professionals can help officials employ new ideas to reach their policy goals by sharing stories and interpreting data to show how those data affect patients and professionals.

Communication skills are integral to the education of nurses, who often must interpret complex medical situations and terms into common, understandable, pragmatic language. Nurse education programs have formalized a greater focus

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on communications than is present in any other professional education program. From baccalaureate curricula through all upper levels of nurse education, major segments of nursing courses focus on individual communications and group processes. Skills include active listening, reflection, clarification, assertiveness, role playing, and other techniques that build nurse competence levels. These same skills are useful when talking with policymakers. Other chapters in this text discuss the differences in nurses’ communication with patients/colleagues and with nonclinician policymakers.

Nursing care is not only a form of altruism but also incorporates intentional action (or inaction) that focuses on a person or group with actual or potential health problems. The education of nurses puts them in the position of discover- ing and acknowledging health problems and health System problems that may demand intervention by public policymakers. For these many reasons, accrediting agencies require policy content within nurse education programs.

Practice and Policy Evidence and theory provide the foundation for nursing as a practice profession. Nurses stand tall in their multiple roles—provider of care, educator, adminis- trator, consultant, researcher, political activist, and policymaker. In their daily practice, nurses spot healthcare problems that may need government interven- tion, although not all problems nurses and their patients face in the healthcare System are amenable to solutions by government. Corporations, philanthropy, or collective action by individuals may best solve some problems. Most nurses are employees (as are most physicians today) and must navigate the organizations in which they work. By being attuned to systems issues, nurses have developed the ability to direct questions and identify solutions. This ability is reflected in the relationships that nurses can develop with policymakers.

Nurses bring the “power of numbers” when they enter the policy arena. Ac- cording to a 2017 report from the National Council of State Boards of Nursing, there are 3,913,805 registered nurses (RNs) in the United States. Collectively, nurses represent the largest group of healthcare workers in the nation.

Nurses have many personal stories that illustrate health problems and patients’ responses to them. These stories have a powerful effect when a nurse brings an issue to the attention of policymakers. Anecdotes often make a problem more understandable at a personal level, and nurses are credible storytellers. By ap- plying evidence to a specific patient situation, nurses may also bring research to legislators in ways that can be understood and can have a positive effect.

Nurses live in neighborhoods where health problems often surface and can often rally friends to publicize a local issue. Nurses are constituents of electoral districts and can make contacts with policymakers in their districts. Nurses vote. It is not unusual for a nurse to become the point person for a policymaker who is seeking information about healthcare issues. A nurse does not have to be knowledgeable about every health problem, but she or he has knowledge of a specific patient population as well as a vast network of colleagues and resources to tap into when a policymaker seeks facts. The practice of nursing prepares the practitioner to work in the policy arena. The public policy process (FIGURE 1-2), after all, involves the application of a decision-making model in the public sector.

How Is Public Policy Related to Clinical Practice? 7



FIGURE 1-2 The policy process. Reproduced from Centers for Disease Control and Prevention. (2012). Overview of CDC’s Policy Process. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Serivces. Retrieved from

I. Problem Identification


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Stakeholder Engagement

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All facets of nursing practice and patient care are highly regulated by po- litical bodies. State boards of nursing and other professional regulatory boards exert much influence in interpreting the statutes that govern nursing. Scope of practice is legislated by elected members but then defined in the rules and reg- ulations by boards. Because each state and jurisdiction defines the practice of nursing differently, there is wide variation in the nursing scope of practice across the specific states. A fear expressed by many boards is that their decisions may interfere with Federal Trade Commission (FTC) rules that restrict monopoly practices. In 2014, the FTC published a policy paper addressing the regulation of the advanced practice registered nurse (APRN) that includes five key findings with important implications for policymakers:

1. APRNs provide care that is safe and effective. 2. Physicians’ mandatory supervision of and collaboration with advanced

nurse practice is not justified by any concern for patient health or safety. 3. Supervision and collaborative agreements required by statute or

regulation lead to increased costs, decreased quality of care, fewer innovative practices, and reduced access to services.

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4. APRNs collaborate effectively with all healthcare professionals without inflexible rules and laws.

5. APRN practice is “good for competition and consumers” (“FTC Policy Paper,” 2014, p. 11).

Professional nurses who are knowledgeable about the regulatory process can more readily spot opportunities to contribute or intervene prior to final rule making.

Organizational Involvement Professional organizations bring their influence to the policy process in ways that a single person may not. There are a myriad of nurse-focused organizations, including those in specialty areas, education-related organizations, and leadership-related organizations. For example, the American Nurses Association, National League for Nursing, and Sigma Theta Tau International state a commitment to advancing health and health care in the United States and/or on a global scale, as noted in their mission statements and goals, and offer nurses opportunities to develop personal leadership skills. The Oncology Nurses Society, American Association of Critical Care Nurses, American Association of Nurse Anesthetists, Emergency Nurses Association, and many other specialty organizations focus on policies specific to certain patient populations and provide continuing education. Participating on committees within trade associations provides opportunities to learn about the organization, its mission, and its outreach efforts in more depth.

Professional associations afford their members experiences to become knowledgeable about issues pertinent to the organization or the profession. These groups can expand a nurse’s perspective toward a broader view of health and professional issues, such as at the state, national, or global level. This kind of change in viewpoint often encourages a member’s foray into the process of public policy. Some nurses are experienced in their political activity. They serve as chairs of legislative committees for professional organizations, work as cam- paign managers for elected officials, or present testimony at congressional, state, or local hearings; a few have run for office or hold office.

Political activism is a major expectation of most professional organizations. Many organizations employ professional lobbyists who carry those organizations’ issues and concerns forward to policymakers. These sophisticated activists are skilled in the process of getting the attention of government and obtaining a response. Nurses also have an opportunity to voice their own opinions and provide information from their own practices through active participation in organizations. This give-and-take builds knowledge and confidence when nurses help legislators and others interpret issues.

Taking Action Nurses cannot afford to limit their actions in relation to policy. Instead, nurses need to share their unique perspectives with bureaucrats, agency staff, legislators, and others in public service regarding what nurses do, what nurses and their patients need, and how their cost-effectiveness has long-term impacts on health care in the United States.

How Is Public Policy Related to Clinical Practice? 9



Many nurses are embracing the whole range of options available in the various parts of the policy process. They are seizing opportunities to engage in ongoing, meaningful dialogues with those who represent the districts and states and those who administer public programs. Nurses are becoming indispensable sources of information for elected and appointed officials, and they are demonstrating lead- ership by becoming those officials and by participating with others in planning and decision making. By working with colleagues in other health professions, nurses often succeed in moving an issue forward owing to their well-recognized credibility and the relatively fewer barriers they must overcome.

Addressing Nursing Shortages Nurses can bring research and creativity to efforts geared toward solving public policy issues such as the nursing shortage and the most efficacious use of RN and APRNs. Aiken and colleagues have reported repeatedly that hospitals with higher proportions of baccalaureate-prepared nurses demonstrate decreased patient morbidity and mortality (Aiken et al., 2003, 2012, 2014; Van den Heede et al., 2009; Wiltse-Nicely, Sloane, & Aiken, 2013; You et al., 2013). Aiken’s research includes studies in the United States and in nine European countries. Although the National Council of State Boards of Nursing has stated that it is not ready to support legislation or regulation that requires a bachelor of science in nursing (BSN) degree as the entry level into practice as a registered nurse, the marketplace is moving in a different direction. Many healthcare agencies are limiting new hires to those with a BSN and have developed policies that require RNs with associate’s degrees or diplomas to complete a BSN within 5 years of employment. Academic institutions have expanded or created RN-to-BSN programs in response to the demand from the accrediting agency for Magnet status, the American Nurses Credentialing Center.

Second-degree nurse education programs, reminiscent of similar programs initiated during World War II, have flourished at the bachelor’s and master’s degree levels. These programs were created to accept applicants with college degrees in fields other than nursing and provide students with an opportunity to graduate with a degree in nursing in an abbreviated time period; graduates are eligible to sit for the National Council Licensure Examination (NCLEX-RN) to become registered nurses. These popular programs provide new avenues that address the nurse shortage.

Perhaps the greatest potential for change in the education of nurses will be the effect of the IOM (2010) report, The Future of Nursing: Leading Change, Advancing Health. Developed under the aegis of and funded by the Robert Wood Johnson Foundation, this report explicitly recognized that nurses (the largest healthcare workforce in the United States) must be an integral part of a healthcare team. Its authors emphasize four key messages (IOM, 2010, pp. 1–3):

1. Nurses should practice to the full extent of their education and training. 2. Nurses should achieve higher levels of education and training through

an improved education system that promotes seamless academic progression.

3. Nurses should be full partners with physicians and other healthcare professionals in redesigning health care in the United States.

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4. Effective workforce planning and policymaking require better data collection and an improved information infrastructure.

A consortium of professional organizations has moved forward together to address common problems. The Josiah Macy Jr. Foundation (2014) developed recommendations that support working together in five areas: (1) engagement, (2) innovative models, (3) education reform, (4) revision of regulatory standards, and (5) realignment of resources.

▸ Healthcare Reform at the Center of the Public Policy Process

Starting with the Harry Truman administration in the 1940s, every U.S. pres- ident’s administration has struggled to reform the healthcare System to meet the needs of all U.S. residents. President Barack Obama declared early in his administration that a major priority would be health care for all, and in 2010, the Patient Protection and Affordable Care Act (commonly known as the ACA and “Obamacare”) was established, a huge first for the United States. Seven years after the passage of the ACA, however, more than one-third of U.S. residents were unable to identify that Obamacare and the ACA were one and the same (Advisory Board, 2017).

The Affordable Care Act was being debated and amended as this text was being revised; no one can predict how health care for the nation will be addressed by the Trump administration. Public uncertainty about personal coverage and methods of financing care are major issues; the former solutions may not fit new program designs. Most care providers recognize the problems inherent in offering care to the uninsured and underinsured. The disparities in care seen in low-socioeconomic groups and vulnerable populations (e.g., children, the elderly) and groups with specific health concerns (e.g., persons with diabetes, smokers) present enormous challenges. Nurses have proffered solutions that have been taken seriously by major policy players.

Expanding the historical boundaries of nursing will require skills in negotia- tion, diplomacy, assertiveness, expert communication, and leadership. Sometimes physician and nurse colleagues are threatened by these behaviors, and it takes persistence and certainty of purpose to proceed. Nurses must speak out as artic- ulate, knowledgeable, caring professionals who contribute to the whole health agenda and who advocate for their patients and the community. All healthcare professions have expanded the boundaries of practice from their beginnings. Practice inevitably reflects societal needs and conditions; homeostasis is not an option if the provision of health care is to be relevant.

▸ Developing a More Sophisticated Political Role for Nurses

In addition to being clinical experts, nurses are entrepreneurs, decision makers, and political activists. Many nurses realize that if they are to control practice and

Developing a More Sophisticated Political Role for Nurses 11



move the profession of nursing forward as major players in the healthcare arena, they must be involved in the legal decisions about the health and welfare of the public—decisions that often are made in the governmental arena.

For many nurses, political activism used to mean letting someone else get involved. Today’s nurses often tune in to bills that reflect a particular passion (e.g., driving and texting), disease entity (e.g., diabetes), or population (e.g., childhood obesity). Although this activity indicates a greater involvement in the political process, it still misses a broader comprehension of the whole policymaking process that provides many opportunities for nurse input before and after legislation is proposed and passed.

Nurses who are serious about political activity realize that the key to establish- ing contacts with legislators and agency directors is to forge ongoing relationships with elected and appointed officials and their staffs. By developing credibility with those active in the political process and demonstrating integrity and moral purpose as client advocates, nurses are becoming players in the complex process of policymaking.

Nurses have learned that by using nursing knowledge and skill, they can gain the confidence of government actors. Personal stories drawn from professional nurses’ experience anchor altruistic conversations with legislators and their staffs, creating an important emotional link that can influence policy design. Nurses’ vast network of clinical experts produces nurses in direct care who provide persuasive, articulate arguments with people “on the Hill” (i.e., U. S. congressional members and senators who work on Capitol Hill) during appropriations committee hearings and informal meetings.

Nurses regularly participate in formal, short-term internship programs with elected officials and in bureaucratic agencies. Most of these internships were created by nursing organizations convinced of the importance of political involvement. Interns and fellows learn how to handle constituent concerns, how to write legislation, how to argue with opponents yet remain colleagues, and how to maneuver through the bureaucracy. They carry the message of the necessity of the political process to the larger profession, although the rank-and-file nurses still are not active in this role.

Nurses who have been reluctant to become active in the political arena cannot afford to ignore their obligations any longer. Each nurse counts, and collectively, nursing is a major actor in the effort to ensure the United States’ healthy future. Many nurses have already expanded their conception of what nursing is and how it is practiced to include active political participation. The process is similar at the federal or state level: Identify the problem and become part of the solution.

Working with the Political System Many professional nurses and APRNs develop contacts with legislators, appointed officials, and their staffs. Groups that offer nurse interaction include the House Nursing Caucus and Senate Nursing Caucus (their membership shifts with the election cycle). Members hold briefings on the nurse shortage, patient and nurse safety issues, vaccination, school health, reauthorization of legislation (e.g., the Emergency Medical System, the Ryan White Act), preparedness for bioterrorism, and other relevant and pertinent issues and concerns.

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Nurses must stay alert to issues and be assertive in bringing problems to the attention of policymakers. It is important to bring success stories to legislators and officials—they need to hear what good nurses do and how well they practice. Sharing positive information will keep the image of nurses positioned within an affirmative and constructive picture. Legislators must run for office (and U.S. representatives do so every 2 years), so media coverage with a local nurse who is pursuing noteworthy accomplishments is usually welcomed.

▸ Conclusion Healthcare professionals must have expert knowledge and skills in change man- agement, conflict resolution, active listening, assertiveness, communication, negotiation, and group processes to function appropriately in the policy arena. Professional autonomy and collaborative interdependence are possible within a political system in which consumers can choose access to quality health care that is provided by competent practitioners at a reasonable cost. Professional nurses have a strong, persistent voice in designing such a healthcare system for today and for the future.

The policy process is much broader and more comprehensive than the legislative process. Although individual components can be identified for ana- lytical study, the policy process is fluid, nonlinear, and dynamic. There are many opportunities for nurses in advanced practice to participate throughout the policy process. The question is not whether nurses should become involved in the political system, but to what extent. Across the policy arena, nurses must be involved with every aspect of this process. By knowing all the components and issues that must be addressed in each phase, the nurse in advanced practice will find many opportunities for providing expert advice. APRNs can use the policy process, individual components, and models as a framework to analyze issues and participate in alternative solutions.

▸ Discussion Points 1. Identify a problem you have encountered in school or in practice (e.g., “My

patients all have dental problems and have no means of paying for dental care”). Discuss how the diagram of the policy process (Figure 1-2) can help inform how you approach finding a solution to this problem. Reflect on which level of government might address this problem and why. Identify the stakeholders in this issue.

2. Discuss the role of research in nursing/healthcare practice as it affects health policy. What has been the focus over the past century? What is the pattern of nursing research vis-à-vis topic, methodology, and relevance? To what extent do you think the current focus on evidence-based practice has influenced research? Cite examples.

3. Trace the amount of federal funding appropriated for nursing or HCP re- search over specific year(s). Do not limit your search to federal health-related agencies; that is, investigate departments (e.g., commerce, environment,

13Discussion Points



transportation), military services, and the Department of Veterans Affairs. Which funding opportunities exist for nurse scientists/HCP scientists?

4. Read books and articles about the changing paradigm in healthcare delivery systems. Discuss the change in nursing or another healthcare profession as an occupation versus a profession.

5. Consider a thesis, graduate project, or dissertation on a specific topic (e.g., clinical problems, healthcare issues) using the policy process as a framework. Identify policies within public agencies and determine how they were developed. Interview members of a government agency’s policy committee to discover how policies are changed.

6. Review official governmental policies. Which governmental agency is responsible for developing the policy? For enforcing the policy? How has the policy changed over time? What are the consequences of not complying with the policy? What is needed to change the policy?

7. Identify nurses and healthcare professionals who are elected officials at the local, state, or national level. Interview these officials to determine how the nurses and HCPs were elected, what their objectives are, and to what extent they use their nursing knowledge in their official capacities. Ask the officials if they tapped into nurses groups during their campaigns. If so, what did the nurses and HCPs contribute? If not, why?

8. Discuss the fluidity among the major components of the policy process. Point out how players move among the components in a nonlinear way. How can this knowledge facilitate entrance into the policymaking process?

9. Watch television programs in which participants discuss national and international issues. Analyze the patterns of verbal and nonverbal commu- nication, pro-and-con arguments, and other methods of discussion used on the program. Position your analysis within the framework of gender differences in communication and utility in the political arena.

10. List ways in which healthcare professionals can become more knowledgeable about the policy process. Choose at least three activities in which you will participate. Develop a tool for evaluating the activity and your knowledge and involvement.

11. Select at least one problem or irritation in a clinical area, and brainstorm with other healthcare professionals or graduate students on how to approach a solution. Who else could you bring into the discussion who could become supporters? Discuss funding sources—be creative.

12. Attend a meeting of the state board of your health profession or a profes- sional convention. Identify issues discussed, resources used, communication techniques, and rules observed. Evaluate the usefulness of the session to your practice.

13. Discuss which skills (e.g., task, interpersonal) and attitudes are required for the nurse in the policy arena. Who is best prepared to teach these skills, and which teaching techniques should be used? How will the skills be evaluated? Develop a worksheet to facilitate planning. Discuss at least five strategies for helping nurses integrate these skills into their practices.

14. Convene a group of healthcare professionals and discuss common problems, potential solutions, and strategies to move forward.

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References Advisory Board. (2017, February 7). Many Americans think repealing Obamacare won’t repeal

the ACA, survey finds. Retrieved from /many-americans-think-repealing-the-aca#

Aiken, L. H., Clarke, S. R., Cheung, R. B., Sloane, D. M., & Silber, J. H. (2003). Educational levels of hospital nurses and surgical patient mortality. Journal of the American Medical Association, 290(12), 1617–1623.

Aiken, L. H., Cimotti, J. P., Sloane, D. M., Smith, H. L., Flynn, L., & Neff, D. E. (2012). Effects of nurse staffing and nursing education on patient deaths in hospitals with different work environments. Medical Care, 49(12), 1047–1053.

Aiken, L. H., Sloane, D. M., Bruyneel, L., Van den Heede, K., Griffiths, P., Busse, R., . . . Sermeus, W. (2014). Nurse staffing and education and hospital mortality in nine European countries: A retrospective observational study. Lancet, 383(9931), 1824–1830.

Centers for Disease Control and Prevention. (2012). Overview of CDC’s policy process. U.S. Department of Health and Human Services. Retrieved from /analysis/process/docs/cdcpolicyprocess.pdf

FTC policy paper examines competition and the regulation of APRNs. (2014). American Nurse, 46(3), 11.

Institute of Medicine (IOM). (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press.

Josiah Macy Jr. Foundation. (2014). Publications. Retrieved from http://www.macyfoundation .org/publications/publications/aligning-interprofessional-education

CASE STUDY 1-1: The Addiction Epidemic You are an acute care nurse practitioner who works in an urban emergency room (ER). You see many people who come to the ER who have overdosed (OD) on heroin. Emergency medical services personnel may administer a drug that might reverse the overdose such as naloxone (Narcan). You may see three ODs during each 12-hour shift; some of these patients are admitted to the hospital, and others are sent home with a consultation for psychiatric followup. You are becoming hardened to the issue and have begun to question what you can do to address this epidemic.

Discussion Points 1. You hear that the state health director is convening a task force. List four

actions you can take to be invited to participate in this task force. 2. Which other healthcare professionals should be included on the task force? 3. Which state agencies and regulatory boards could add value to the

discussion? 4. Which information/experience could the APRN use to lead a discussion

about widespread addiction? 5. Identify three issues that might be brought up at a meeting that could

derail a focus on public safety. Which tactics can the nurse use to bring the discussion back to the issue of safety?

6. Which design tactics could be considered when writing a policy to address this issue?

7. How can information about this issue be disseminated within the profession and to those outside the profession?




Litman, T. J., & Robins, L. S. (1991). Health politics and policy (2nd ed.). Albany, NY: Delmar. National Council of State Boards of Nursing. (2017). Active RN licenses. Retrieved from http:// Patient Protection and Affordable Care Act of 2010. (2010). Pub. L. No. 111-148, 124 Stat. 119. Van den Heede, K., Lesaffre, E., Diya, L., Vleugels, A., Clarke, S. P., Aiken, L. H., & Sermeus, W.

(2009). The relationship between inpatient cardiac surgery mortality and nurse numbers and educational level: Analysis of administrative data. International Journal of Nursing Studies, 46, 796–803.

Wilson, J. Q. (1989). American government institutions and policies (4th ed.). Albany, NY: Delmar. Wiltse-Nicely, K. L., Sloane, D. M., & Aiken, L. H. (2013, June). Lower mortality for abdominal

aorta aneurysm repair in high volume hospitals contingent on nurse staffing. Health Systems Research, 48(3), 972–991.

You, L.-M., Aiken, L. H., Sloane, D. M., Liu, K., He, G-P, Hu, Y.,  .  .  . Sermeus, W. (2013). Hospital nursing, care quality, and patient satisfaction: Cross-sectional survey of nurses and patients in hospitals in China and Europe. International Journal of Nursing Studies, 50(2), 154–161.

16 Chapter 1 Informing Public Policy: An Important Role for Registered Nurses



© Visions of America/Joe Sohm/Photodisc/Getty


Contextual dimensions: Studying issues in the real world, in the circumstances or settings of what is happening at the time.

Iron triangle: Legislators or their committees, interest groups, and administrative agencies that work together on a policy issue that will benefit all parties.

Streams: Kingdon’s classic research on agenda setting noted a streams metaphor—the concept of the interaction of public problems, policies, and politics that couple and uncouple throughout the process of agenda setting.

Window of opportunity: Limited time frame for action.

Agenda Setting: What Rises to a Policymaker’s Attention? Elizabeth Ann Furlong

▸ Introduction This chapter emphasizes the agenda-setting aspect of policymaking by using exemplar case studies at local, state, and national levels. Agenda setting is the process of moving a problem to the government’s attention so that solutions can be considered. Registered nurses (RNs), advanced practice registered nurses (APRNs), and other interprofessional healthcare workers (IPHCWs) can apply the knowledge from these case studies to the many current concerns they face. The author acknowledges the older dates of many of the references cited in this chapter. These classic political science references on agenda setting are retained in this chapter to further the historical knowledge of the nurse policy advocate. Agenda setting can happen in legislative settings and in private organizations.





The local example in this chapter demonstrates what can be done in the latter venue. By seeking and obtaining a grant from a national organization, nurse leaders are initiating and furthering a new policy practice in a health organization. The outcomes of this new agenda policy can have potential implications for furthering agenda setting at governmental levels.

FIGURE 2-1 illustrates the various levels of the political agenda: ■ Agenda universe: All ideas that could possibly be brought up and discussed

in a society. ■ Systemic agenda: All issues that are commonly perceived as meriting public

attention within the legitimate jurisdiction of the existing governmental authority.

■ Institutional agenda: Items that have risen to the attention of a governing body. ■ Decision agenda: Items about to be acted on by a governing body.

APRNs and other IPHCWs, as well as policymakers and citizens, are interested in the best public policies to address society’s concerns. Early political science researchers mainly studied the later steps of policymaking—implementation and evaluation—to gain an understanding of public policy and knowledge that could be used by policymakers to create better public policies. Although all stages of the policy process have been studied, the need for more research on the earlier parts of policymaking—agenda setting, policy formulation, and policy design—has been the subject of more discussion in recent times (Bosso, 1992a; Ingraham, 1987; May, 1991). Research interest in these latter areas grew during the 1980s and 1990s and continues into the 21st century.

As noted earlier, this chapter presents examples of agenda setting at the local, state, and national levels. The first example demonstrates how nurse and interprofessional health leaders are changing practice interventions at the organi- zational level with use of a grant. By seeking and obtaining a grant from a national organization, nurse leaders can initiate new practices in a health organization. The outcomes of this new agenda policy can have potential implications for fur- thering agenda setting at governmental levels. Changing policies and processes in the delivery of healthcare services in an ambulatory health center in a nonprofit

FIGURE 2-1 Levels of the political agenda.

Agenda Universe

Systemic Agenda

Institutional Agenda

Decision Agenda

“Getting on” or creating this level of agenda setting is the

goal of nurse leaders

18 Chapter 2 Agenda Setting: What Rises to a Policymaker’s Attention?



health organization is not only a policy end unto itself but also has implications for other nurse leaders to set such agendas in their respective organizations.

APRNs and other IPHCWs also need to learn how issues get on legislative agendas. The state-level example presented in the second case study involves a nurse practitioner bill that was passed in Nebraska. The first national example in this chapter focuses on an event that had just occurred as this text was being written. The second national-level case study is a classic national legislative ex- ample; research and analysis for this second national example were performed by this author. Following that analysis, those same theories are applied to the Nebraska nurse practitioner bill.

CASE STUDY 2-1: A Local Example Policies can be changed in organizations as well as legislatively. This first example demonstrates nurse and interprofessional health leaders changing practice interventions with use of a grant. Specifically, they are setting an agenda in an ambulatory health center, with this planning and intervention facilitated by a grant.

Two departments in Omaha Creighton University’s College of Nursing and the Center for Interprofessional Practice, Education, and Research are furthering interprofessional health care and education by their 2016 receipt of a $50,000 grant from the National Center for Interprofessional Practice and Education (Blue News [daily e-newsletter, Creighton University], 2016). The grant at Creighton, titled “Accelerating Interprofessional Community-Based Education and Practice,” will assist in developing a nurse practitioner–led interprofessional team to be utilized in Creighton’s healthcare-affiliated system, Catholic Health Initiative (CHI). In addition to the grant, both Creighton University and CHI donated $25,000 to the endeavor. Dean Catherine Todero of the College of Nursing noted, “Nurse practitioners are increasingly taking lead roles in a number of clinical and educational health care situations” (Blue News, 2016). This grant will further the practice, education, and research of a nurse practitioner–led interprofessional team for a national agency.

CASE STUDY 2-2: A Nurse Practitioner– Initiated Bill in the Spring 2014 Nebraska Unicameral Legislature An example of agenda setting in 2014 was an effort by the Nebraska Nurse Practitioners (NNP), a state nursing association, to find a state senator who would introduce a bill into the Nebraska unicameral legislative session to eliminate the Integrated Practice Agreement (IPA) from the Nurse Practitioner Practice Act (Nebraska Legislature, 2014). The public hearing for the bill was held on January 31, 2014; the sponsoring state senator’s goal was for the bill to emerge from the seven- member Health and Human Services Committee with support from all or most of the members (Senator S. Crawford, personal communication, January 2014).


Introduction 19



Prior to the bill’s introduction, the NNP had to undergo review by the Nebraska Credentialing Review (407) Program. This state-level review program had been created to evaluate current Nebraska health professionals who are seeking to expand their scope of practice or to evaluate the scope of practice of a new type of provider (Nebraska Department of Health and Human Services, n.d.). As part of its review, the NNP submitted extensive documentation to three review bodies—an ad hoc Technical Review Committee appointed by the director of the Nebraska Division of Public Health, a second review by the State Board of Health, and a third review by the director of the Division of Public Health. These reviews represented input from the Department of Health and Human Services (DHHS) about possible concerns for Nebraskans in either public health or safety. Although the recommendations at the three levels are advisory, they serve to inform state senators when considering and voting on proposed legislation (D. Wesley, lobbyist, personal communication, June 2013). The NNP proposal received support at the first two levels; at the second level, the vote was 12–5 to eliminate the IPA requirement (Whitmire, 2013). There also were recommendations with this second vote to (1) have practice requirements for the new graduate nurse practitioner (NP) and (2) have ongoing competency evaluations of all NPs. At the third level of review, the director and chief medical director of the DHHS were strongly opposed to the NNP proposal (Ruggles, 2013).

APRNs in Nebraska set the agenda with four goals in mind:

■ Decrease barriers to their full scope of practice ■ Provide more and needed access to health care (especially primary care and

mental health care) in rural parts of the state ■ Meet the emerging primary healthcare needs associated with an increased

Nebraska population having health insurance because of the Affordable Care Act

■ Decrease the exodus of APRNs to contiguous states that did not have such IPA agreements (Sundermeier, 2013/2014)

In seeking passage of this bill, Nebraska NPs wanted to join the 17 other states and the District of Columbia that had facilitated full scope of practice availability for nurse practitioners. As noted by Bobrow and Dryzek (1987), this case study underscores the importance of contextual dimensions furthering agenda setting. As noted previously, there were four important contexts in setting this agenda topic at this time in this state.

This agenda, which was based on evidence-based practice studies and the promotion of all nurses working to their full potential, is also advocated by the National Academy of Medicine (Institute of Medicine, 2010). By providing

CASE STUDY 2-2: A Nurse Practitioner– Initiated Bill in the Spring 2014 Nebraska Unicameral Legislature (continued)

20 Chapter 2 Agenda Setting: What Rises to a Policymaker’s Attention?



Before presenting two national case studies, the reader should take note of some salient concepts. Congress may pass a law that directs an agency to take action on a certain subject and set a schedule for the agency to follow in issuing rules. More often, an agency surveys its area of legal responsibility and then decides which issues or goals have priority for rulemaking. A few of the many factors that an agency may consider are presented here:

■ New technologies or new data on existing issues ■ Concerns arising from accidents or various problems affecting society ■ Recommendations from congressional committees or federal advisory

committees ■ Petitions from interest groups, corporations, and members of the public ■ Lawsuits filed by interest groups, corporations, states, and members of the

public ■ Presidential directives ■ “Prompt letters” from the Office of Management and Budget (OMB) ■ Requests from other agencies ■ Studies and recommendations of agency staff (https://www.federalregister


legislative language to a state senator to introduce a bill, APRNs set the agenda in Nebraska.

A variety of strategies were implemented to further the agenda goal. This chapter’s author served as chair of the Nebraska Nurses Association’s Legislative Advocacy and Representation Committee (LARC). This committee worked in unison and collaboratively with the NNP, its lobbyist, the NNA lobbyist, and the sponsoring state senator to serve as the lead strategists and voices. APRNs used public media to promote their perspectives. For example, following a negative review from the Nebraska DHHS, one APRN educated the public via an op-ed article about APRNs in the state’s largest newspaper (Holmes, 2013). She noted several of the previously made arguments as support for why APRNs wanted the IPA eliminated.

The bill passed by a 43–0 vote during the last day of the 2014 unicameral session. However, the governor vetoed the legislation, and there was not time for the unicameral legislature to enact an override.

In early 2015, the bill was reintroduced, passed, and signed by the new governor on March 5, 2015 (Lazure, Cramer, & Hoebelheinrich, 2016). Other factors facilitating its passage included (1) education regarding APRN capabilities along with advocacy during the campaigns of 17 new state senators; (2) obtaining commitments from both gubernatorial candidates that they would not veto the bill if reintroduced in 2015; (3) ongoing advocacy by the earlier noted nursing groups; and (4) interprofessional health groups that both supported the bill and said they would testify at a public hearing. Nebraska is now one of 21 states in which nurse practitioners have full practice authority (Pohl, Thomas, Barksdale, & Werner, 2016).

Introduction 21



CASE STUDY 2-3: The Veterans Health Administration Ruling on APRN Practice In December 2016, the U.S. Department of Veterans Affairs (VA) announced its final rule regarding APRN practice within the Veterans Health Administration national health system. The decision allows nurse practitioners, certified nurse–midwives, and clinical nurse specialists to practice without physician supervision. This change will facilitate broader access to health care within the VA system (American Association of Colleges of Nursing [AACN], 2016). During 2016, nurses nationally were encouraged to post advocacy messages to the appropriate webpage (https:// for changing such rules and regulations. This use of the media was an example of promoting advocacy by the four professional associations representing APRNs, the American Nurses Association, and other nursing groups at national and state levels. By the time the Final Rule was released in May 2016, more than 179,734 comments had been posted (J. Thew, personal communication, 2017). This large number of comments reflects advocacy behaviors of nurses.

CASE STUDY 2-4: The National Center for Nursing Research Amendment A classic example of agenda setting was the initiation of federal legislation in 1983 that increased the funding base for nursing research. An amendment to the 1985 Health Research Extension Act, which created the National Center for Nursing Research (NCNR) on the campus of the National Institutes of Health (NIH), was the focus of this national example of agenda setting.

Creation of the NCNR came about because a group of nurse leaders wanted to create a national institute of nursing within the NIH. To help pass the legislation in 1985, a political compromise was made with congressional legislators to create a center instead of an institute (a lesser agency in the hierarchy). In 1993, however, the NCNR was turned into an institute, and today the agency continues as the National Institute of Nursing Research (NINR). The discussion here regarding the NCNR amendment focuses on the agenda setting and policy formulation that occurred from 1983 to 1985. Achievement in getting the NINR funded was an especially notable accomplishment because no other health profession has such an institute.

The Influence of National Nurse Groups The creation of the National Center for Nursing Research on the campus of the National Institutes of Health in Bethesda, Maryland, was a policy victory for national nurse organizations. Although nurses’ groups traditionally have not been considered strong political actors, these groups recognized the importance of political activity to bring about public policies that enhanced patient care (Warner, 2003). In the last decade of the 20th century, nurse groups were just emerging as actors in policy networks; however, “a full cadre of nurse leaders who are knowledgeable and experienced in the public arena, who fully understand the design of public policy, and who are conversant with consumer, business and

22 Chapter 2 Agenda Setting: What Rises to a Policymaker’s Attention?



provider groups [did] not yet exist” (DeBack, 1990, p. 69). In a study of national health organizations that play a key role in the health policymaking area (Laumann, Heinz, Nelson, & Salisbury, 1991), no nurse organizations were cited. APRNs are well aware of this absence because state legislative and regulatory activity affects their professional practice on a daily basis.

Research on the NCNR amendment has been important because it studied political actors who were not generally studied (e.g., nurse interest groups); this research contributes to public policy scholars’ knowledge of all actors in policy networks. Laumann et al. (1991) acknowledged that “we may even run a risk of misrepresenting the sorts of actors who come to be influential in policy deliberation” (p. 67). The significance of policy research becomes obvious when the Schneider and Ingram (1993a) model of social construction of target populations in policy design is applied to nurse interest groups. For example, how nurses were viewed by policymakers—the social construction of nurses as a target population—influenced not only the policy in which nurses were interested but also the passage of the total NIH reauthorization bill.

Dohler (1991) compared health policy actors in the United States, Great Britain, and Germany and found that it is much easier to have new political actors in the United States because there are multiple ways to become involved. Dohler has written of the great increase in new actors since 1970. Baumgartner and Jones (1993) also described multiple paths of access to becoming involved.

▸ Overview of Models and Dimensions Several researchers have developed models of agenda setting and policy formulation (Baumgartner & Jones, 1993; Cobb & Elder, 1983), alternative formulation, and policy design (Schneider & Ingram, 1993a). Data analysis reveals the importance of the Schneider and Ingram (1993a) model of the social construction of target populations and of the classic Kingdon (1995) model for an understanding of the agenda-setting process for the amendment described in Case Study 2-4 to the NIH-reauthorizing legislative bill. Analysis of this legislation over the period of a decade also underscores the importance of Dryzek’s (1983) classic definition of policy design. An analysis of the legislation supported the importance of study- ing the contextual dimension that has been advocated by Bobrow and Dryzek (1987), Bosso (1992a), DeLeon (1988–1989), Ingraham and White (1988–1989), May (1991), and Schneider and Ingram (1993b). The value of other models— institutional, representational communities and an institutional approach, and the congressional motivational model—is addressed as well, as these models contribute to an understanding of this example. These findings are discussed in detail in this analysis. For example, during the study of interest groups opposed to this legislation, this researcher noted two occurrences of an iron triangle in the early 1980s, in which legislators and their staff and agency bureaucrats worked with interested parties to resolve issues (FIGURE 2-2).

Kingdon Model One model that served as an explanatory focus for this research was the Kingdon (1995) model, which explains how issues get on the political agenda and, once there, how alternative solutions are devised (FIGURE 2-3). The four important

Overview of Models and Dimensions 23



FIGURE 2-2 Iron triangle of politics.


Interest Groups


Agencies of the executive branch of the federal government

Lobbyists, healthcare professionals, manufacturers, other governments, constituency factions

FIGURE 2-3 Kingdon model.

Problem stream

Policy stream

Politics stream

Policy window Agenda

concepts of this model are the three streams (problem, policy, and politics) and the window of opportunity. A problem stream can be marked by systematic indicators of a problem, by a sudden crisis, by feedback that a program is not working as intended, and by the release of certain important reports. A practi- cal application for APRNs and other IPHCWs is that they can be attentive to these indicators and maximize such opportunities to get an issue on the agenda. A policy stream relates to those policy actors and communities who attach their solutions (policies) to emerging problems. This concept also relates to the actual policy being promoted: APRNs and other IPHCWs can be attentive to identi- fying problems and framing their solutions to such concerns. The third stream of Kingdon’s model is the political stream, which consists of the public mood, pressure group campaigns, election results, partisan or ideological distributions in Congress, and changes in administrations. Other factors include congressio- nal committee jurisdictional boundaries and turf concerns among agencies and government branches.

APRNs and other IPHCWs need to be constantly attentive to all these po- litical factors, which can be integrated with the fourth concept, the window of

24 Chapter 2 Agenda Setting: What Rises to a Policymaker’s Attention?



opportunity. This window opens when the three streams become integrated at a time that is favorable to solve a problem with the preferred policy and with the least resistance.

Interview data and a review of the literature showed many ways in which the Kingdon model explained the agenda setting for the NCNR legislation. For example, for the problem stream, the following were variables: (1) the need for nursing research was recognized by many (e.g., Rep. Madigan [Republican‒Illinois], legislative staffers, and national nurse leaders); (2) data were available regarding the financial disparity in research funding for nurses; and (3) an Institute of Medicine (IOM) report (Cantelon, 2010) on this problem was released in 1983. There were two variables for the political stream: (1) the policy would be valuable for Rep. Madigan’s re-election and (2) the policy proposal was an important way for the Republican party to secure increased votes from women. In terms of the policy stream, it was sound public policy. The window of opportunity opened with the release of the 1983 IOM report in conjunction with the election cycle, the singular presence of many national nurse leaders who were knowledgeable about both policy and politics, and a U.S. representative who initiated the idea for this bill—all these factors came together quickly and at an opportune time. In summarizing these findings in relation to the Kingdon model, this example validated the importance of the political and problem streams.

Ultimately, the NCNR amendment was passed without meeting the policy stream processes described by Kingdon, in that it did not go through a softening-up phase. This concept refers to several revisions being made to a particular policy as compromises are made and negotiations take place. As stated, the NCNR amendment was articulated once and moved forward; there was no tweaking or change in the legislation’s language.

Professional nurses and other IPHCWs may be able to apply the Kingdon model to ongoing priority practice issues with which they are concerned. For example, APRNs and other IPHCWs can be attentive to the three streams (policy, problem, and political) and recognize the existence of a window of opportunity in which to move their agenda forward. APRNs and other IPHCWs also need to be aware that taking part in political activity in regulatory agencies could be an ideal way to problem solve. Case Study 2-3, for example, addressed changes to a Final Rule and regulations within the VA system for three types of APRNs. Another example occurred in the early part of the 21st century when nurse practitioners encountered increased difficulty in having mail-order pharmacies recognize and fill their prescriptions (Edmunds, 2003). Two nurse practitioners from New York and South Carolina addressed this problem stream by working with the Food and Drug Administration and the Federal Trade Commission. The NPs recognized that working through regulatory agencies was the best initial solution for solving this problem (Edmunds, 2003).

Importance of Contextual Dimensions Some authors, notably Bobrow and Dryzek (1987), Bosso (1992a), DeLeon (1988–1989), Ingraham and White (1988–1989), May (1991), and Schneider and Ingram (1993b), have emphasized the need to analyze the political context in which policies get on the agenda, alternatives are formulated, and policies are put into effect. Although neither a definitive nor an exhaustive list, five contextual

Overview of Models and Dimensions 25



dimensions are suggested by Bobrow and Dryzek (1987) for studying the success or failure of any designed policy:

■ Complexity and uncertainty of the decision–system environment ■ Feedback potential ■ Control of design by an actor or group of actors ■ Stability of policy actors over time ■ Stirring the audience into action

DeLeon (1988‒1989) writes that sometimes researchers, because of their unstructured environment, have chosen to study approaches and methodolo- gies that may meet scientific rigor better, but in doing so, come “dangerously close to rendering the policy sciences all-but-useless in the real-life political arenas” (p. 300).

DeLeon (1988–1989) notes that it is nearly impossible for researchers to “structure analytically the contextual environment in which their recommended analyses must operate” (p. 300). Whether analyzing the 1983 case study or the 2014‒2015 case study, APRNs and other IPHCWs must analyze the context in which they find themselves, apply theory, and evaluate the outcome later for theory application. Researchers and advocacy activists today must work in a world characterized by great social complexity, extreme political competition, and limited resources. Of these writers, Bosso and May are especially strong in their advocacy of this contextual approach to the study of public policy. Bosso (1992b) echoes DeLeon’s concern:

In many ways, the healthiest trend is the admission, albeit a grudging one for many, that policymaking is not engineering and the study of policy formation cannot be a laboratory science. In policy making, contexts do matter, people do not always act according to narrow self-interest and decisions are made on the basis of incomplete or biased information. (p. 23)

For many healthcare professionals, this “messy” process is very uncom- fortable. Nevertheless, data from congressional documents, archival sources, and personal and telephone interviews highlight the importance of the political context to all aspects of policy design for the NCNR—how the policy arrived on the agenda, how policy alternatives were formulated, the legislative process, implementation, and redesign of the legislation eight years later, resulting in new legislation within two years to accomplish the original goal (Bobrow & Dryzek, 1987; Bosso, 1992b; DeLeon, 1988–1989; Ingraham & White, 1988–1989; May, 1991; Schneider & Ingram, 1993b).

Examples of Political Contextual Influence Sixteen variables are analyzed here in regard to their contribution to the 1985 passage of the NCNR and the 1993 change of the NCNR to the NINR (TABLE 2-1).

26 Chapter 2 Agenda Setting: What Rises to a Policymaker’s Attention?



TABLE 2-1 Variables Contributing to Passage of Legislation Creating the National Center for Nursing Research

Partisan political conflict between legislators

Influenced the initial agenda setting of the amendment and the legislative process throughout the two years. Opposition to Rep. Waxman’s (Democrat–California) NIH bill in the spring and summer of 1983 resulted in Rep. Madigan’s initiating a substitute policy. An impetus for Rep. Madigan’s bill was a perception that Rep. Waxman yielded too much power with NIH legislation. As noted by two congressional staffers, this was an example of partisan conflict.

Election cycle A U.S. representative’s concern with his re-election chances influenced the initial agenda setting because of the congressional perception that nurses were a target population who could help his re-election chances. Several respondents noted that this was an important factor in the initial decision for this type of public policy

Bipartisan negotiation— presence versus absence

Bipartisan negotiations between Rep. Waxman and Rep. Madigan in early fall 1983 resulted in a firm resolve during the 97th and 98th Congresses to stay with the proposed NINR policy and during the 99th Congress to accept a compromise on the NCNR. Another example of bipartisan negotiation was the early committee work by Rep. Madigan, Rep. Broyhill (Republican–North Carolina), and Rep. Shelby (Democrat- Alabama) to forge a simple bipartisan four-line amendment. The bipartisan effort of these three representatives smoothed the way for passage of this amendment by the subcommittee.

Interest-group unity

Unity by nurse groups was considered by many interviewees to be a crucial factor in the bill’s passage, and this unity also was important in explaining why no other policy alternatives were pursued. Because the decision to support Rep. Madigan was officially made by the Tri-Council (the American Nurses Association [ANA], the National League for Nursing [NLN], the Association of Nurse Executives, and the American Association of Colleges of Nursing) in the summer of 1983, and although other policy alternatives were considered after that point, the priority of presenting a united front with Rep. Madigan was maintained by nurse organizations.

Non-interest- group unity

Prior disunity by the American Association of Medical Colleges had disillusioned Rep. Madigan and increased his interest in initiating the NINR policy with the nurse providers’ groups.


Overview of Models and Dimensions 27



Partisan conflict between the White House and an interest group

The White House and nursing organizations (which had generally supported Democratic presidential and vice presidential candidates) had an influence on this legislation’s history. The 1984 campaign support by the ANA for Democratic candidates was the reason for the Republican presidential veto of a NINR amendment and the NIH bill.

Ideological and partisan conflicts over current issues

Concerns about fetal tissue research and animal rights research caused much difficulty in the early 1980s. Concerns about immigration laws and immigrants with human immunodeficiency virus (HIV) infection raised concerns in the 1990s and affected compromises and passage of the bills. These issues, although not directly addressed in the NINR amendment, had a major effect on the bill’s legislative history.

Federal or state budget deficit concerns

There was opposition to the creation of new federal entities because of the deficit concern, and President Ronald Reagan consistently used this argument as a reason not to create an NINR.

Timing of passage during the president’s “lame-duck” term

The NIH bill with the NCNR amendment was passed in 1985, when President Reagan was beginning his second term. The number of Republican members of Congress, the lack of any constraint to vote along party lines that was reflected in the 1985 legislative vote, and the ability to override the president’s veto were all factors. The timing of this vote in President Reagan’s lame-duck term helped the bill’s passage.

History of legislators with administrative agencies

Rep. Waxman’s attempts to exert control over NIH was a factor in Rep. Madigan’s initiation of NIH legislation during the summer of 1983. Data support the perspective that, of all administrative agencies, the NIH consistently was regarded positively by members of Congress, and this positive perception was reflected in ample funding levels on a consistent basis. Contrary to this usual positive regard was the negative situation between Rep. Dingell (Democrat– Michigan) and the NIH. Rep. Dingell had “captured” letters sent by NIH officials to research scientists asking them to lobby their congressional representatives for increased funding—an example of the internal workings of an iron triangle. Rep. Dingell reminded NIH officials that this activity violated law.

TABLE 2-1 Variables Contributing to Passage of Legislation Creating the National Center for Nursing Research (continued)

28 Chapter 2 Agenda Setting: What Rises to a Policymaker’s Attention?




The relationship of Congress, administrative agencies, and the Office of Management and Budget

NIH officials became anxious when the OMB dictated that NIH develop a last-minute revised budget to honor a 1980 promise to fund 5,000 new grants yearly. This mandated division of NIH’s economic pie contributed to NIH officials not wanting new research entities on their campus that would further erode existing programs and projects. A second similar budgetary crisis occurred at NIH in spring 1985 that, again, caused much consternation for NIH officials and research scientists.

Internal political dynamics and relationships in Congress

Rep. Waxman was a member of the Congressional class of 1974, when the dynamic in Congress was a decentralization of power with a large new congressional class. (A congressional class refers to that cohort of officials elected in a certain year.) The data show that Rep. Waxman was interested in gaining more power and control over NIH. Although his committee had authorizing power over the NIH, it did not have the greater power of the Appropriations Committee, which was responsible for funding. However, through his ability to authorize legislation, Rep. Waxman had leverage to gain more power. Rep. Waxman’s attempt to micromanage the NIH resulted in Rep. Madigan’s initiating a substitute policy.

Communication between the White House and Congress

President Reagan publicly vetoed the legislation in 1984, although he could have allowed its passage quietly by not signing the bill. The veto was intended to alert Congress to expect conflict the following year if the bill’s provisions were not changed. An example of the negative relationship between the White House and Congress can be seen with the congressional override vote in 1985. Members of Congress (and many members of the president’s political party) felt betrayed over their work on this legislation and over what they thought their communication had been with the president about passing this policy and putting it into effect. This sense of betrayal spurred their work in securing the veto override.

International politics

During the fall of 1985, the Senate waited until the Geneva Summit was finished before beginning the veto-override vote. This was done to keep President Reagan from losing any credibility regarding his leadership ability during the summit meeting because the Soviet leader would be aware of the veto override.

Overview of Models and Dimensions 29



The skills and abilities of an interest group

In the early 1980s, many factors influenced the ability of nurse interest groups to promote this policy once it was on the agenda: (1) the formation of the Tri-Council, (2) a special interest in public policy by the executive director of the NLN, (3) the anticipated need to reauthorize the Nurse Education Act, (4) the policy orientations of many deans of nursing education programs, (5) a combination of people who saw the need, (6) much networking by nurses, (7) the presence of highly motivated people who were interested in furthering the nursing profession, (8) nurses appointed to positions within the White House, (9) more nurses working on Capitol Hill, and (10) the study conducted by Dr. Joanne Stevenson (personal communication, 1990) on nurse researchers’ inability to obtain NIH grants.

The wit of “all politics is personal” and the importance of personal relationships

Data revealed the importance of personal relationships in getting the idea on the agenda, in obtaining strategic information, in sharing needed information, and in making requests. For example, strategic networking at certain cocktail parties helped with the legislation’s acceptance, as did carpooling with selected political actors. Savvy nurse leaders facilitated other nurses in meeting with legislators and legislative aides in these settings so nurses could lobby effectively. The importance of congressional staffers to the initiation and passage of legislation must be emphasized: Several interviewees spoke of the importance of certain staffers in their tenacity to ensure that the NCNR amendment was passed. Clearly, the adage that “all politics is personal” influenced the legislation at various points.

TABLE 2-1 Variables Contributing to Passage of Legislation Creating the National Center for Nursing Research (continued)

Control and Stability Factors Two of Bobrow and Dryzek’s (1987) five contextual dimensions were in evidence and contributed to the success of this policy, both because the NCNR was passed as legislation in 1985 and because the NCNR became the National Institute of Nursing Research in 1993. The two criteria—namely, the control of design by an actor or group of actors and the stability of policy actors over time—were related in this instance.

Once this policy was on the agenda and once nurses were united, the nurse interest groups were committed to the legislation. The nurse interest groups showed unity in working with Representative Madigan and staying the course. Although other policy alternatives were discussed, they were never vigorously pursued by the nurse interest groups. Once the compromise on the NCNR was made in 1985, the nurse interest groups found the deal acceptable because they knew they had a “foot in the door” and because they planned to accomplish their original design (i.e., a nursing institute rather than a nursing center) at a later date.

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