Week 2: Lesson
Policy Making Process: How Nurses Can Make an Impact
Last week, the course included an overview of policy, healthcare policy, and policy making. In addition key historical figures in nursing and their important contributions to the profession and to healthcare in general were reviewed. Finally, ethical principles were reviewed with application to healthcare policies and policy making. This week, you will need to carry those concepts and insights forward as you learn about the processes involved in advocacy and policy making. Examples of levels of involvement will be described in addition to careful analysis of policy development and strategies for implementation. As you incorporate this lesson into your own knowledge and experiential base, consider your professional development and what policy issue you wish to impact.
Starting the Policy Process
If you have worked as a nurse, regardless of the practice environment, you most likely have had an “aha” moment, when you realized that something can and should be changed in order to improve healthcare. For example, a personal event (healthcare of an elderly parent) or a professional event (you believe that staffing ratios should be regulated) could all be events that trigger interest in health care policy. You may already be involved in professional organizations, but perhaps your level of involvement has been limited; until now. Have you felt overwhelmed even considering how to approach the situation, but then, in that moment, something clicked that caused you to act? So how can a concern or problem become a policy?
A problem can be explained to be a gap between what currently exists and what you desire to exist. In healthcare there are many problems that individuals want to change. But do all of these problems merit a healthcare policy? While your textbook identifies multiple factors that can help determine if a problem should become a healthcare policy, of specific emphasis is if the problem generates public interest. For example, the recent outbreak of measles has generated significant public interest in the required vaccinations of children. Should parents be able to opt out of providing childhood immunizations because of fear related to autism? What responsibility do parents have to the other children at a daycare or school to protect children unable to receive vaccines due to health reasons? While public interest can increase and decrease on a specific topic, it is public interest and concerns about public health that often drives policies.
Within Mason, Gardner, Outlaw, and O’Grady (2016), three sources of healthcare policy were noted. Click on each of the following to learn more about these sources.
Sources of Healthcare Policy
3. Community Stakeholders
Let’s review each step of the policy making process and consider the role of a professional nurse.
Define the problem, and get it on the agenda.
1. Define the problem, and get it on the agenda.
2. Develop policy option
3. Involve interest groups and stake holders
4. Implement the selected policy
5. Evaluate the impact of the policy
6. Modify, repeal, or leave the policy alone
7. Communicate policy options
8. Modify, repeal, or leave the policy alone
9. Define the problem, and get it on the agenda.
10. Develop policy option
11. Involve interest groups and stake holders
12. Implement the selected policy
13. Evaluate the impact of the policy
14. Modify, repeal, or leave the policy alone
15. Communicate policy options
16. Modify, repeal, or leave the policy alone
When a problem needs a health care policy, the next question is what level should the policy be implemented? Reconsider the examples previously noted, what level (workplace, local, state, federal) would be most effective for a healthcare policy to be implemented for an effective change to occur. A question to consider, is if all healthcare problems/concerns should become a health care policy?
Policy Development and Analysis
It is important to understand that there are two types of policy: public and private. Healthcare institutions are examples of the private policy arena. By contrast, public policies pertain to local, state, and federal legislation and regulation in addition to court rulings that impact individual and institutional behaviors. Institutional (private) policy often reflects public policy in that implementation and compliance concerns are handed down from public policy rulings and regulations. In other words, no private institution operates in isolation from public policy oversight and regulations. Therefore, healthcare policy refers to both public and private policies that directly relate to healthcare services. For this course, the goal is to encourage graduate-level nursing students to step out into the public policy arena, actively meeting and interacting with legislators. The ripple effect of this action can certainly be felt in the private sector as well.
Policy analysis closely resembles the nursing process. When assessing a potential policy concern, one needs to examine the background, purpose, content, and the anticipated or actual effects of the proposed policy. It is critical to consider the relevant social, economic, and political factors that impact or may be impacted by the policy concern. The officials and organizations involved in shaping a policy, as well as those with a stake in the policy concern, must also be taken into account. Remember that complex adaptive systems theory? Each piece affects all of the other pieces, and the dynamic is always changing and evolving. In addition, please consider the applicability of middle-range theories in nursing. These theories apply to quality of life, social-support systems, and health-promotion concerns. Middle-range nursing theories are easily applied to public policy-related concerns. Think about how you can apply theory to your policy-priority concern.
There are four basic models or approaches to policy making: (a) the rational approach, (b) incrementalism, (c) the policy-stream model, and (d) the stage-sequential model. Like the various nursing-theory models, a model that serves as a framework for approaching policy and policy making provides critical structure to this process. A model is selected depending upon the particular policy and its context.
The rational-approach model is good when sweeping policy is necessary. This approach takes time for thorough analysis so it’s not appropriate for crisis situations when due diligence cannot be applied. Policy concerns best approached using this model are large in scope, affect multiple players, and involve layers of stakeholders. The rational approach is involved, because it applies to situations that are multifaceted (like spokes in a wheel) and have taken years to reach a point where drastic change is needed.
Incrementalism, or the pilot method, is called for when policy making needs to be approached in pieces or steps. Breaking a situation down into smaller bits makes it much easier to approach and apply, and the pilot method may be the best initial approach. It is also much easier to regulate and even discontinue a policy that is smaller in scope. Are you aware of policies that were started as pilot approaches or taken in small pieces initially? The policy-stream model contains a series of policy components that float around, so to speak (like soup), waiting for the joining of any two of the major streams to come together and link at the right time. The three streams are problem stream, policy stream, and political stream. The political stream is especially sensitive. During the current economic crisis in the United States and indeed, the global community, the policy-stream model has pulled together the three policy-component streams in a time-sensitive way. What factors or streams can you identify that went into the current economic crisis? Because these streams came together as they did, will effective policy making result?
The stage-sequential model most closely resembles the nursing process. Its stages are policy-agenda setting, policy formation, program implementation, and policy evaluation (Anderson, 1990); like the nursing process, it is cyclical and dynamic. The policy process always undergoes tweaking and re-evaluation. Your basic nursing education prepared you well for healthcare-policy advocacy!
Transcript (Links to an external site.)Links to an external site.
Regardless of which model is selected for approaching policy making, the policyconcern itself needs careful analysis. A policy-concern paper lays out the policy concern in a carefully delineated way, providing all of the necessary pieces for thoroughly analyzing the cocnern. Components examined include context, goals, and options; evaluation of these goals and options (including alternatives); and recommended solutions. A policy analysis scorecard is used to compare alternatives by assigning each alternative a total score. By carefully examining all aspects of a particular policy, one can then select the best approach.
Policy Analysis and Strategies
A solid nursing education prepares an individual for analyzing policies and strategizing for action. Nurses are taught to care for human beings in a bio-psycho-social-spiritual framework. Nurses understand people systems and are experts in specialty areas of practice. It is these characteristics that make nurses the perfect resource to assist in policy analysis and development of strategies.
As nursing and politics continue to interact, it is important to understand and appreciate the concerns that may arise. Careful preparation, acquisition of pertinent knowledge, and confidence in oneself and the presentation of the concern will greatly level the playing field in the political arena. A fundamental step in the analysis of any policy is to first determine the nature of the problem.
Questions to ask when framing a concern are:
· What is the scope, history, and duration of the problem, and what or whom is affected?
· Where does this concern currently stand, and how can I access information about it?
· Is quality data currently available?
· Are there gaps in the existing data?
· Is additional research required?
In framing a concern, it’s vital to pinpoint the target audience. If the identified problem is institutional (private sector), consider how the institution will react if you call attention to inadequate staffing. Even if the institution is part of the private sector, as most are, will public-sector policy regulations impact the situation? For example, take a look at the tremendous strides made by the California Nurses Association. Through tireless work, it was able to hold its ground against a new governor and maintain safe nurse-to-patient ratios. What about that infamous peanut company in Georgia that was responsible for the salmonella outbreak that sickened and killed people all across the country? Although it was a private company, it was held to public health regulation standards that ultimately shut it down.
Take all possible solutions to a given problem into account, as well as the resources that are needed to address it. How much will it cost? How practical is it? How long will it take? Has this concern been tackled before? If so, how did that go? Who needs to be involved? Many concerns require a mix of public and private-sector players. If the problem involves public policy, the level of government (state, federal, or local) and branch of government (legislative, executive, or judicial) need to be clarified. It is critical to know the stakeholders involved as well; sometimes, important stakeholders are not initially identified.
Do not forget to consider important aspects of a problem concern, such as values, resources, cultural influences, and power. Values are an important consideration in policy. Depending on your policy concern, you need to consider the values of the organization, community, state, region, or nation. It is important to research the values of important stakeholders in your policyconcern, as well. Resources can include money, human resources, and time, as well as the support of powerful individuals and organizations. Moreover, cultural influences impact healthcare concerns. It is important to understand the cultural needs of those involved in your policy-priority concern. Cultural considerations include beliefs, behaviors, attitudes, and practices. Lastly, power is important in policy. Power is difficult to define freely in the policy-making process. It is important that you analyze those that have power in your policy concern. Identify those who are in favor of and against your proposed policy. Some forms of power are obvious and direct, but others are more subtle and indirect. Think of sources of power as sources of influence in your policy concern. Do you perceive yourself as having power? A good place to start is by empowering yourself with knowledge and a clearly defined concern and plan.
Policymakers are both elected and appointed public officials who are responsible for directly or indirectly influencing public policy. If a policymaker can be convinced that a problem needs to be addressed in some way, he or she can work to change public policy or allocate funds in ways that will address the problem. Policymakers will be most interested in concerns that are popular or those perceived as beneficial to the public good and the policymaker. For example, a school lunch nutrition campaign is a good health promotion strategy from a nursing perspective. Evidence clearly demonstrates that good nutrition has a positive impact on health indicators. Therefore, an interested nurse advocate would research this concern and bring it to the attention of the appropriate policymaker(s). The nurse advocate anticipates questions from the policymaker, such as: What specifically are you saying is the problem? What’s the evidence? What specifically do you believe needs to be done?
For the purpose of this course, how would you lay out this concern for your policymaker? What stories could you present to make the policy concern compelling? What evidence supports the policy concern? Are you considering potential costs? Remember, you are only required to discuss your identified policy-priorityconcern (after thoroughly researching and analyzing it) with a policymaker, ask or recommend a course of action, and reflect upon that process. Whether or not (and to what extent) the concern ultimately gets addressed or implemented is not within the scope of this course. The intent of this course is to get students active in the public policy-making process. In order for that to occur, a student must fully understand the concepts inherent in healthcare policy.
To gather the necessary information needed to transfer a healthcare problem or concern into a policy, a policy concern paper or policy analysis is used. This document explains a healthcare problem/issue, describes its background/impact and presents an objective evaluation of various options. The paper should conclude with one recommended action. This information is used by a policymaker to resolve the problem or concern A well-written policy-concern paper can spell the difference between success and failure at the end of this course. As a student in NR506, your graded assignments are a simplified policy-concern paper that clearly defines the policy concern, analyzes it, and carefully factors in various elements involved or potentially involved with the problem while considering options and solutions. Elements of this simplified policy-concern paper include:
· Description of the context and importance of the problem;
· Discussion of a range of policy options; and
· The policy recommendation.
Persistence is essential in this overall process, because it may take a long time to fully implement change, especially on a larger scale. Changes may be incremental rather than revolutionary. A pilot approach may be wise. You may want to follow up on the recommended changes to your policymaker/legislator long after this course is concluded. Pay careful attention to evaluate proposed policies and avoid getting bogged down in details that seem important at the time but are not that important in the larger scheme of things.
It’s always a good idea to stay focused and updated on concerns that may have an impact on your identified problem. Practice how to deliver your message in a clear, concise way, taking into consideration the stakeholders involved. Weigh every statement made in response to your policy-concern statement, as well as what is not said. Understand the importance of building networks and coalitions that will support and augment your power base. Do not be afraid to take advantage of quid pro quo (almost an expectation in the world of politics), and learn to strike while the iron’s hot (timing can be everything). Anticipate concenrs that may arise and plan proactively for them. After all, nothing ventured, nothing gained!
Learning the ropes of the political process is exciting, but at the same time, it involves a rigorous and systematic approach and the determination to see it through. This week’s content provided information on political development, suggestions for advocacy, approach models, and problem analysis and strategies. Clarifying and defining your problem is the first (and most important) step. The time and effort spent in this process will benefit you and the patient population you’re seeking to serve.
Remember, a problem that is clearly stated is one half solved. Take a look at the example policy-concern paper in your textbook and use the discussions to gain a deeper understanding of the processes involved and for clarification and guidance. Take the necessary time to thoroughly analyze your policy-priority concern so that you will feel confident in your presentation and your recommendations. Next week, we will examine ways in which nurses can form strong political alliances, utilize research in the policy process, and effectively manage conflict. All of these areas will greatly assist you in your journey in becoming a stronger policy advocate.
Transcript (Links to an external site.)Links to an external site.
Anderson, J. E. (1990). Public policymaking. Boston, MA: Houghton-Mifflin.
Mason, D. J., Gardner, D. B., Outlaw, F. H., & O’Grady, E. T. (2016). Policy & politics in nursing and healthcare (7th ed.). Retrieved from http://online.vitalsource.com
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